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 b2-agonists, and systemic corticosteroids, with the dose and frequency of administration dependent on the severity of the exacerbation.
• For mild to moderate exacerbations, treatment may include albuterol (salbutamol) via metered-dose inhaler with spacer, and oral prednisone to reduce inflammation.
• For severe exacerbations, treatment may include continuous nebulized albuterol, ipratropium bromide, and intravenous methylprednisolone.

Discharge Criteria

• 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.
• Before discharge, patients should be prescribed 3 to 10 days of corticosteroid therapy to reduce the risk of recurrence, as recommended by 1.

Important 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 1.
• Hospitalization is necessary for patients with severe symptoms, oxygen saturation <90%, or poor response to initial treatment.

Monitoring and Follow-up

• Close monitoring of lung function and oxygen saturation is crucial in the management of acute asthma exacerbation.
• After the acute phase, review and adjust the patient's maintenance therapy, ensure proper inhaler technique, and develop a written asthma action plan to prevent future exacerbations.

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 three to four times daily by nebulization for adults and children weighing at least 15 kg. If symptoms persist or worsen, medical advice should be sought immediately for 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
• Treatment of airway inflammation with systemic corticosteroids (CS) to prevent future relapses 3, 4, 5, 6
• Consideration of adjunctive therapies such as short-acting muscarinic antagonists, magnesium sulfate, and helium/oxygen combination gas 4, 5, 6

Treatment Strategies

Different treatment strategies may be employed, including:

• "As-needed" inhaled corticosteroids for patients with asthma 7
• Combination ICS-formoterol in a single inhaler, ICS and short-acting beta2-agonists in separate inhalers, and combination ICS-albuterol in a single inhaler 7
• Inhaled corticosteroid/formoterol combination for home management of asthma exacerbations 4
• Short-acting beta2 agonist and oxygen therapy in the office setting, with repeated doses of the short-acting beta2 agonist every 20 minutes for one hour and oral corticosteroids 4

Patient Care

Patient care involves:

• Assessment of exacerbation severity and beginning treatment with a short-acting beta2 agonist and oxygen to maintain oxygen saturations 4, 5
• Transfer to an acute care facility for patients with severe exacerbations, with treatment including oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids 4, 5
• Monitoring and systemic therapy similar to treatments used in the emergency department for patients requiring hospital admission 4
• Education on asthma action plans and consideration of stepping up asthma maintenance therapy to prevent future exacerbations 4