What is the recommended treatment for an asthma exacerbation?

Management of Asthma Exacerbations

The recommended first-line treatment for asthma exacerbations consists of oxygen supplementation to maintain saturation >90%, short-acting beta-agonists (SABA) such as albuterol/salbutamol, and early administration of systemic corticosteroids. 1

Initial Assessment and Treatment

• Administer oxygen through nasal cannulae or mask to maintain oxygen saturation >90% (>95% in pregnant patients or those with heart disease) 1, 2
• Provide inhaled short-acting beta-agonists (SABA) as first-line bronchodilator treatment 1, 2:
  • Via nebulizer: 2.5-5 mg albuterol/salbutamol every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed
  • Via MDI with spacer: 4-12 puffs every 20 minutes for up to 3 doses, then as needed
• Administer systemic corticosteroids early in the treatment 1, 2:
  • Oral prednisone 40-60 mg daily in adults (1-2 mg/kg/day, maximum 60 mg/day in children)
  • Oral administration is as effective as intravenous for most patients 3

Adjunctive Therapies

• Add ipratropium bromide for severe exacerbations 1, 2:
  • Via nebulizer: 0.5 mg every 20 minutes for 3 doses, then as needed
  • Via MDI with spacer: 4-8 puffs every 20 minutes for 3 doses, then as needed
• Consider intravenous magnesium sulfate (2g IV over 20 minutes) for patients with severe refractory asthma 1
• For severe exacerbations, continuous administration of albuterol may be more effective than intermittent dosing 2

Monitoring and Reassessment

• Reassess the patient 15-30 minutes after starting treatment 1
• Measure peak expiratory flow (PEF) or FEV₁ before and after treatments 1
• Monitor oxygen saturation continuously until a clear response to bronchodilator therapy has occurred 1, 2
• Response to treatment is a better predictor of hospitalization need than initial severity 1, 2

Duration of Treatment

• Systemic corticosteroids should typically be continued for 5-10 days 1, 2
• For courses less than 1 week, no tapering is needed 2, 4
• A 1-week course of oral corticosteroids appears to be as effective as a 2-week course for most patients 4

Common Pitfalls and Considerations

• The severity of asthma exacerbations is often underestimated due to failure to make objective measurements 1
• Avoid sedatives of any kind in patients with acute asthma exacerbations 1
• Antibiotics are not generally recommended unless there is strong evidence of bacterial infection 1
• While short courses of systemic corticosteroids are essential for treating exacerbations, be aware that even brief courses (3-7 days) can have adverse effects including impacts on bone density, blood pressure, and mental health 5
• Inhaled corticosteroids alone are not recommended as primary treatment for acute exacerbations, as oral corticosteroids are significantly more effective in preventing hospitalizations and improving lung function 6

Signs of Impending Respiratory Failure

• Monitor for signs including inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO₂ ≥42 mm Hg 1
• Do not delay intubation once it is deemed necessary 1
• Consider other treatments such as intravenous magnesium before resorting to intubation 1