What is the management of acute asthma exacerbation?

From the Guidelines

Management of acute asthma exacerbation requires prompt intervention with bronchodilators and anti-inflammatory medications, with the goal of reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study 1 recommends that all patients presenting with an asthma exacerbation should be evaluated and triaged immediately, with treatment instituted promptly based on the severity of the exacerbation.

Key Components of Management

• Primary treatment consists of administration of oxygen, inhaled β2-agonists, and systemic corticosteroids, with the dose and frequency of administration dependent on the severity of the exacerbation.
• For mild to moderate exacerbations, start with albuterol (salbutamol) via metered-dose inhaler with spacer, 4-8 puffs every 20 minutes for the first hour, then every 1-4 hours as needed, and add oral prednisone 40-60 mg daily for 5-7 days to reduce inflammation.
• For severe exacerbations, administer oxygen to maintain saturation ≥92%, continuous nebulized albuterol plus ipratropium bromide, and intravenous methylprednisolone 40-80 mg in divided doses.

Monitoring and Discharge

• Monitor response with peak flow measurements, oxygen saturation, and clinical assessment, and hospitalization is indicated for patients with severe symptoms, oxygen saturation <90%, peak flow <40% predicted, or inadequate response to initial treatment.
• Patients can generally be discharged if FEV1 or PEF results are 70% or more of predicted value or personal best and symptoms are minimal or absent, with a prescription for 3 to 10 days of corticosteroid therapy to reduce the risk of recurrence, as recommended by 1.

Special Considerations

• Infants are at greater risk for respiratory failure, and clinicians should be familiar with special considerations in the assessment and treatment of infants experiencing asthma exacerbations, as noted in 1.
• The goal of treatment is to improve airflow and oxygenation by relaxing bronchial smooth muscle, reducing airway inflammation, and decreasing mucus production.

From the FDA Drug Label

Adults and Children 2 to 12 Years of Age: The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy.

The management of acute asthma exacerbation with albuterol (INH) involves administering 2.5 mg of albuterol by nebulization three to four times daily. If a previously effective dosage regimen fails to provide relief, medical advice should be sought immediately as it may indicate worsening asthma requiring reassessment of therapy 2.

From the Research

Management of Acute Asthma Exacerbation

The management of acute asthma exacerbation involves several key components, including:

• Assessment of the severity of the attack and evaluation of the response to treatment 3
• Maintenance of adequate arterial oxygen saturation with supplemental oxygen 3, 4, 5
• Relief of airflow obstruction with repetitive administration of short-acting beta-2 agonists (SABA) 3, 4, 5, 6, 7
• Treatment of airway inflammation with systemic corticosteroids (CS) to prevent future relapses 3, 4, 5, 6, 7
• Consideration of adjunctive therapies such as short-acting muscarinic antagonists, magnesium sulfate, and helium/oxygen combination gas 4, 5, 6, 7

Treatment Options

Treatment options for acute asthma exacerbation include:

• Inhaled corticosteroid/formoterol combination for patients 12 years and older who are not using an inhaled corticosteroid/long-acting beta2 agonist inhaler for maintenance 4
• Short-acting beta2 agonist for patients using an inhaled corticosteroid/long-acting beta2 agonist inhaler that does not include formoterol 4
• Inhaled corticosteroid/formoterol inhaler for children four to 11 years of age to reduce the risk of exacerbations and need for oral corticosteroids 4
• Oral or parenteral corticosteroids for patients who do not rapidly respond to SABA/SAMA inhalation 6
• Intravenous magnesium sulfate for selected cases, particularly in severe exacerbations 7

Hospitalization and Discharge

Patients with severe exacerbations should be transferred to an acute care facility and treated with oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids 4

• Improvement in symptoms and forced expiratory volume in one second or peak expiratory flow to 60% to 80% of predicted values helps determine appropriateness for discharge 4
• The addition of inhaled corticosteroids, consideration of stepping up asthma maintenance therapy, close follow-up, and education on asthma action plans are important next steps to prevent future exacerbations 4