What is the treatment for asthma exacerbation?

Management of Asthma Exacerbation

The primary treatment for asthma exacerbation consists of oxygen therapy, inhaled short-acting beta-agonists (SABAs), and systemic corticosteroids, with adjunctive therapies like ipratropium bromide and magnesium sulfate for severe cases. 1, 2

Initial Assessment and Severity Classification

• Assess severity based on symptoms, signs, and lung function (PEF or FEV1), with mild exacerbation defined as dyspnea only with activity (PEF ≥70% predicted), moderate exacerbation as dyspnea interfering with usual activity (PEF 40-69% predicted), and severe exacerbation as dyspnea at rest (PEF <40% predicted) 1, 2
• Life-threatening features include silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 1
• In infants, assessment depends more on physical examination, with serious distress signs including accessory muscle use, wheezing, paradoxical breathing, cyanosis, and respiratory rate >60 breaths/min 3

Primary Treatment Components

Oxygen Therapy

• Administer oxygen through nasal cannulae or mask to maintain oxygen saturation >90% (>95% in pregnant women and patients with heart disease) 4, 1, 2
• Monitor oxygen saturation continuously until clear response to bronchodilator therapy occurs 1, 2

Bronchodilator Therapy

• Administer albuterol (short-acting β2-agonist) as first-line treatment via nebulizer or metered-dose inhaler (MDI) with spacer 1, 2, 3
• 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, 5
• MDI dosing: 4-8 puffs every 20 minutes for up to 3 doses, then as needed 1, 3
• For severe exacerbations (FEV1 or PEF <40%), continuous administration of albuterol may be more effective than intermittent administration 4, 2
• EMS providers should not delay patient transport while administering bronchodilator treatment, with treatment repeated during transport to a maximum of 3 bronchodilator treatments during the first hour and then 1 per hour 4, 3

Systemic Corticosteroids

• Administer systemic corticosteroids early in the treatment for all moderate-to-severe exacerbations 1, 2, 3
• Oral prednisone 40-60 mg in single or divided doses for adults 1, 2
• For children: 1-2 mg/kg/day (maximum 60 mg/day) 1, 3
• Oral administration is as effective as intravenous administration and less invasive 1

Adjunctive Therapies

Ipratropium Bromide

• Add ipratropium bromide to beta-agonist therapy for severe exacerbations 1, 2, 3
• Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2
• The combination of a beta-agonist and ipratropium has been shown to reduce hospitalizations in patients with severe airflow obstruction 1, 3

Magnesium Sulfate

• Consider intravenous magnesium sulfate (2g IV over 20 minutes) for patients with severe refractory asthma 1, 2, 3
• Most effective when administered early in the treatment course 2

Monitoring and Reassessment

• Reassess the patient 15-30 minutes after starting treatment 1, 2
• Measure PEF or FEV₁ before and after treatments 1, 2, 3
• Assess symptoms and vital signs 1, 2
• Response to treatment is a better predictor of hospitalization need than initial severity 1, 2

Common Pitfalls and Caveats

• The severity of an asthma attack is often underestimated by patients, relatives, and doctors due to failure to make objective measurements 1
• Avoid sedatives of any kind in patients with acute asthma exacerbation 1, 2
• Monitor for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO2 ≥42 mm Hg 1, 3
• Fatalities have been reported with excessive use of inhaled sympathomimetic drugs 5
• Albuterol can produce paradoxical bronchospasm, which can be life-threatening; if it occurs, discontinue the preparation immediately and institute alternative therapy 5

Hospital Admission Criteria

• Consider hospital admission for any life-threatening features, features of acute severe asthma present after initial treatment, and lower threshold for admission with history of recent nocturnal symptoms, recent hospital admission, or previous severe attacks 3
• In infants, lack of response to short-acting β2-agonist therapy indicates need for hospitalization 3

Discharge Planning

• Continue oral corticosteroids for 5-10 days 1
• Consider initiating or increasing inhaled corticosteroids at discharge 1, 3
• Provide a written asthma action plan 3
• Recent evidence suggests that a fixed-dose combination of albuterol and budesonide as rescue medication might reduce the risk of severe asthma exacerbation compared to albuterol alone in patients with uncontrolled moderate-to-severe asthma 6