What is the immediate treatment for an asthma acute exacerbation?

Immediate Treatment for Asthma Acute Exacerbation

The immediate treatment for an asthma acute exacerbation includes high-dose inhaled beta-agonists (salbutamol 5 mg or terbutaline 10 mg), systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg), and oxygen therapy to maintain SaO₂ >90%. 1, 2

Initial Assessment and Recognition

• Recognize features of severe asthma exacerbation: inability to complete sentences in one breath, respiratory rate >25 breaths/min, PEF <50% of predicted/best, heart rate >110 beats/min 1
• Life-threatening features include: PEF <33% of predicted/best, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 1
• Arterial blood gas markers of severe, life-threatening attack: normal/high PaCO₂ in a breathless asthmatic, severe hypoxia (PaO₂ <8 kPa), low pH 1

Immediate Management Algorithm

Step 1: Oxygen and Bronchodilator Therapy

• Administer oxygen through nasal cannulae or mask to maintain oxygen saturation >90% (>95% in pregnant patients or those with heart disease) 2, 3
• Give high-dose inhaled beta-agonist: salbutamol 5 mg or terbutaline 10 mg via nebulizer (oxygen-driven) or multiple actuations of MDI with spacer (2 puffs 10-20 times) 1, 4
• For children: salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses in very young children) 1

Step 2: Systemic Corticosteroids

• Immediately administer prednisolone 30-60 mg orally or IV hydrocortisone 200 mg (or both if very ill) 1, 2
• For children: prednisolone 1-2 mg/kg body weight orally (maximum 40 mg) 1

Step 3: Additional Measures for Life-Threatening Features

• Add ipratropium bromide 0.5 mg nebulized to the beta-agonist 1, 2
• Consider IV aminophylline (250 mg over 20 minutes) or IV salbutamol/terbutaline (250 μg over 10 minutes) 1
• Caution: Do not give bolus aminophylline to patients already taking oral theophyllines 1

Monitoring and Reassessment (15-30 minutes after starting treatment)

• Measure PEF or FEV₁ and assess symptoms and vital signs 2, 3
• Monitor oxygen saturation continuously 2, 3
• If patient is improving: continue oxygen, prednisolone 30-60 mg daily or IV hydrocortisone 200 mg every 6 hours, and nebulized beta-agonist every 4-6 hours 1
• If patient is not improving after 15-30 minutes: continue oxygen and steroids, give nebulized beta-agonist more frequently (up to every 15-30 minutes), add ipratropium 0.5 mg to nebulizer and repeat 6-hourly 1

If Patient Still Not Improving

• Consider aminophylline infusion (monitor blood concentrations if continued >24 hours) 1
• Consider salbutamol/terbutaline infusion as an alternative to aminophylline 1
• Consider magnesium sulfate (2 g IV over 20 minutes) for patients with severe refractory asthma 2
• Transfer to intensive care if there is deteriorating PEF, worsening/persistent hypoxia or hypercapnia, exhaustion, feeble respirations, confusion, or drowsiness 1

Common Pitfalls and Caveats

• The severity of an asthma attack is often underestimated by patients, relatives, and doctors due to failure to make objective measurements 1
• Do not administer sedatives of any kind to patients with acute asthma exacerbation 1
• Response to treatment is a better predictor of hospitalization need than initial severity 2, 3
• Early administration of systemic corticosteroids is essential and may reduce hospitalization rates 2, 5
• For children, blood gas estimations are rarely helpful in deciding initial management 1
• Children with severe attacks may not appear distressed; assessment in the very young may be difficult 1