What is the recommended treatment for an asthma exacerbation?

Management of Asthma Exacerbation

The recommended first-line treatment for asthma exacerbation includes oxygen supplementation to maintain saturation >90%, inhaled short-acting beta-agonists (SABA) such as albuterol, and systemic corticosteroids administered early in the course of treatment. 1, 2

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 albuterol (short-acting β2-agonist) as first-line bronchodilator treatment via nebulizer or metered-dose inhaler (MDI) with spacer 1
  • Nebulizer dosing: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1, 2
  • MDI dosing: 4-8 puffs every 20 minutes for up to 3 doses, then as needed 1
• Administer systemic corticosteroids early in treatment 1, 2
  • Oral prednisone 40-60 mg in single or divided doses for adults 1, 2
  • Oral route is as effective as intravenous administration and less invasive 1, 3
  • Duration typically 5-10 days with no tapering needed for courses less than 1 week 1, 2

Adjunctive Therapies

• Add ipratropium bromide to albuterol therapy for severe exacerbations 1, 2
  • Nebulizer dosing: 0.5 mg every 20 minutes for 3 doses, then as needed 1, 2
  • MDI dosing: 8 puffs every 20 minutes for 3 doses, then as needed 1
  • The combination of a beta-agonist and ipratropium has been shown to reduce hospitalizations in patients with severe airflow obstruction 1, 2
• Consider intravenous magnesium sulfate (2g IV over 20 minutes) for patients with severe refractory asthma 1
• Antibiotics are not generally recommended unless there is strong evidence of bacterial infection (e.g., pneumonia or sinusitis) 1, 4

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

Treatment Based on Severity

Mild Exacerbation

• SABA via MDI with spacer (2-10 puffs) 4
• Consider oral corticosteroids 4

Moderate Exacerbation

• SABA via nebulizer or MDI with spacer 4
• Oral corticosteroids (recommended in 11 guidelines) 4
• Oxygen supplementation to maintain saturation >92-95% 4
• Consider adding ipratropium bromide 4, 1

Severe Exacerbation

• SABA via nebulizer (continuous administration may be more effective than intermittent dosing) 1, 2
• Systemic corticosteroids (oral or IV if unable to take oral) 4
• Oxygen supplementation (recommended in 15 guidelines) 4
• Ipratropium bromide added to SABA therapy 1, 2
• Consider IV magnesium sulfate (recommended in 9 guidelines) 4

Common Pitfalls and Caveats

• Montelukast (Singulair) is not indicated for use in the reversal of bronchospasm in acute asthma attacks 5
• The severity of an asthma attack is often underestimated by patients, relatives, and doctors due to failure to make objective measurements 1
• Do not administer sedatives of any kind to patients with acute asthma exacerbation 1
• Monitor for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO2 ≥42 mm Hg 1
• While short courses of systemic corticosteroids are very effective for resolving acute asthma symptoms, they can still cause adverse effects including hypertension, gastrointestinal ulcers/bleeds, and impacts on mental health 6

Medication Dosages

• Oral prednisone: 40-60 mg daily for 5-10 days (no tapering needed for short courses) 1, 2
• Methylprednisolone: 1-2 mg/kg IV 4
• Hydrocortisone: 4-7 mg/kg IV every 8 hours 4
• Dexamethasone: dosage for 3-5 days 4
• Albuterol nebulizer: 2.5-5.0 mg up to three times every 20 min over the first hour 4, 1
• Ipratropium bromide: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses 1