What is the initial management for an acute exacerbation of asthma?

Initial Management for Acute Asthma Exacerbation

The initial management for an acute asthma exacerbation should include oxygen therapy to maintain saturation >90%, short-acting beta-agonists (SABA) such as albuterol, and early administration of systemic corticosteroids. 1, 2

Initial Assessment and Oxygen Therapy

• Assess severity based on symptoms, signs, and lung function (PEF or FEV1), classifying as mild, moderate, severe, or life-threatening 2
• Administer oxygen through nasal cannulae or mask to maintain oxygen saturation >90% (>95% in pregnant patients or those with heart disease) 1, 2
• Monitor oxygen saturation continuously until a clear response to bronchodilator therapy occurs 1

Bronchodilator Therapy

• Administer albuterol (short-acting β2-agonist) as first-line treatment via nebulizer or metered-dose inhaler (MDI) with spacer 1, 2
  • Nebulizer dosing: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 3, 1
  • MDI dosing: 4-8 puffs every 20 minutes for up to 3 doses, then as needed 1
• For severe exacerbations (FEV1 or PEF <40% predicted), continuous administration of albuterol may be more effective than intermittent dosing 4
• Add ipratropium bromide for severe exacerbations to increase bronchodilation 3, 1
  • Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 3, 1
  • The combination of a beta-agonist and ipratropium bromide has been shown to reduce hospitalizations, particularly in patients with severe airflow obstruction 3, 1

Systemic Corticosteroids

• Administer systemic corticosteroids early for all moderate-to-severe exacerbations 1, 2
  • Oral prednisone 40-60 mg in single or divided doses for adults 1, 2
  • For children: 1-2 mg/kg/day (maximum 60 mg/day) 1
• Oral administration is as effective as intravenous administration and less invasive 1
• The total course typically lasts 3-10 days, with no tapering needed for courses less than 1 week 1

Monitoring and Reassessment

• Reassess the patient 15-30 minutes after starting treatment 1, 2
• Measure PEF or FEV1 before and after treatments 1
• All patients should undergo repeat assessment after the initial dose of inhaled bronchodilator treatment 3
• Response to treatment is a better predictor of hospitalization need than initial severity 3, 1

Adjunctive Therapies

• Consider intravenous magnesium sulfate (2g IV over 20 minutes) for patients with severe refractory asthma or life-threatening exacerbations 3, 1, 2
• Antibiotics are not generally recommended unless there is strong evidence of bacterial infection (e.g., pneumonia or sinusitis) 3
• Aggressive hydration is not recommended for older children and adults but might be appropriate for some infants and young children 3

Recognition of Impending Respiratory Failure

• Monitor for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO2 ≥42 mm Hg 3
• Do not delay intubation once it is deemed necessary 3
• Consider other treatments such as intravenous magnesium, heliox, and other therapies before resorting to intubation 3

Common Pitfalls and Caveats

• The severity of an asthma attack is often underestimated due to failure to make objective measurements 1
• Do not administer sedatives of any kind to patients with acute asthma exacerbation 1
• Paradoxical bronchospasm can occur with inhaled albuterol and may be life-threatening; discontinue immediately if it occurs 5
• Excessive use of inhaled sympathomimetic drugs has been associated with fatalities in patients with asthma 5
• Do not delay patient transport to the hospital while administering bronchodilator treatment 2