What is the initial treatment protocol for acute exacerbations of bronchial asthma in the Emergency Room (ER)?

Initial Treatment Protocol for Acute Asthma Exacerbations in the Emergency Room

The initial treatment protocol for acute asthma exacerbations in the emergency room should include oxygen administration to maintain saturation >90%, inhaled short-acting beta-agonists (albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses), early systemic corticosteroids, and ipratropium bromide for severe exacerbations. 1, 2

Initial Assessment and Severity Classification

• Assess severity based on symptoms, signs, and lung function (PEF or FEV1) 2:

  • Mild: Dyspnea only with activity, PEF ≥70% of predicted/personal best
  • Moderate: Dyspnea interfering with usual activity, PEF 40-69% of predicted
  • Severe: Dyspnea at rest, PEF <40% of predicted
  • Life-threatening: Confusion, drowsiness, silent chest, cyanosis 2

• Monitor for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO2 ≥42 mm Hg 1

Primary Treatment Components

Oxygen Therapy

• Administer oxygen through nasal cannulae or mask to maintain oxygen saturation (SaO₂) >90% (>95% in pregnant patients or those with heart disease) 1, 2
• Monitor oxygen saturation continuously until clear response to bronchodilator therapy 1

Bronchodilator Therapy

• Administer albuterol (short-acting β2-agonist) as first-line treatment 1, 2:
  • Nebulizer: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed
  • MDI with spacer: 4-8 puffs every 20 minutes for 3 doses, then as needed
• For severe exacerbations (FEV1 or PEF <40%), continuous administration of albuterol may be more effective 2
• Lower doses of albuterol (2.5 mg) are as effective as higher doses (7.5 mg) for most patients 3

Corticosteroids

• Administer systemic corticosteroids early in all moderate-to-severe exacerbations 1, 4:
  • Oral prednisone: 40-60 mg in single or divided doses for adults
  • IV hydrocortisone: 200 mg if unable to take oral medication
  • Early administration may reduce hospitalization rates 5, 1

Ipratropium Bromide

• Add ipratropium bromide to albuterol for severe exacerbations 5, 1, 2:
  • Nebulizer: 0.5 mg every 20 minutes for 3 doses, then as needed
  • MDI: 8 puffs every 20 minutes for 3 doses, then as needed
• The combination of albuterol and ipratropium has been shown to reduce hospitalizations, particularly in patients with severe airflow obstruction 5, 1

Monitoring and Reassessment

• Reassess patients 15-30 minutes after starting treatment 1, 2
• All patients should undergo repeat assessment after the initial dose of inhaled bronchodilator treatment 5
• All patients, regardless of exacerbation severity, should be assessed after 3 doses of inhaled bronchodilator treatment (60-90 minutes after initiation of therapy) 5
• Response to treatment is a better predictor of hospitalization need than initial severity 5, 2
• Repeat assessments should include 5:
  • Patient's subjective response to treatment
  • Physical findings
  • FEV1 or PEF measurements
  • Arterial blood gas measurements or pulse oximetry in patients with suspected hypoventilation, severe distress, or FEV1/PEF <25% of predicted

Adjunctive Therapies

• Consider intravenous magnesium sulfate (2g IV over 20 minutes) for patients with life-threatening exacerbations or those whose exacerbations remain severe after 1 hour of intensive conventional treatment 5, 1, 2
• Antibiotics are not generally recommended unless there is strong evidence of bacterial infection (e.g., pneumonia or sinusitis) 5, 1
• Aggressive hydration is not recommended for older children and adults but might be appropriate for some infants and young children who may become dehydrated 5, 1
• The following treatments are NOT recommended 5:
  • Methylxanthines
  • Chest physiotherapy
  • Mucolytics
  • Sedation

Common Pitfalls and Caveats

• The severity of an asthma attack is often underestimated due to failure to make objective measurements 1
• Do not delay intubation once it is deemed necessary in patients with impending respiratory failure 5, 1
• Patients who initially demonstrate a poor bronchodilator response to albuterol may benefit from more frequent treatments (every 30 minutes) 6
• MDI with spacer is as effective as nebulized therapy with appropriate administration technique and coaching 5, 7
• Sedatives of any kind should not be administered to patients with acute asthma exacerbation 1