What medications should be given to a patient presenting to the Emergency Room (ER) with severe asthma?

Medications for Severe Asthma in the Emergency Room

For patients presenting with severe asthma to the emergency room, immediate treatment should include oxygen therapy (40-60%), nebulized beta-agonists (salbutamol 5 mg or terbutaline 10 mg), systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg), and ipratropium bromide 0.5 mg for severe cases. 1, 2

Initial Assessment of Severity

• Assess for features of severe asthma: inability to complete sentences in one breath, respiratory rate >25/min, pulse >110/min, and peak expiratory flow (PEF) <50% of predicted 1
• Look for life-threatening features: silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 1
• Measure oxygen saturation and PEF to objectively assess severity 1, 3

First-Line Medications

• Oxygen therapy: Administer 40-60% oxygen in all cases of severe asthma 1
• Beta-agonists: Give nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1
  • If nebulizer unavailable, administer 2 puffs of beta-agonist via large volume spacer and repeat 10-20 times 1
  • Monitor response 15-30 minutes after nebulizer treatment 1
• Systemic corticosteroids: Administer early in treatment 2
  • Oral prednisolone 30-60 mg or intravenous hydrocortisone 200 mg 1
  • Clinical benefits may not be apparent for 6-12 hours, making early administration crucial 4, 5

Additional Medications for Severe Cases

• Ipratropium bromide: Add 0.5 mg to nebulized beta-agonist for severe exacerbations 1, 2
  • Combination with beta-agonists decreases time in the emergency department and hospitalization rates 5
  • Benefits are not sustained after hospital admission 5
• Aminophylline: Consider 250 mg administered intravenously over 20 minutes for life-threatening features 1
  • Use with caution if patient is already taking theophyllines 1
• Epinephrine (adrenaline): Reserved for catastrophic, sudden severe asthma when other treatments have failed 2
  • Administer 0.5 mg via subcutaneous injection 2

Medication Administration Considerations

• Beta-agonists can be administered by continuous nebulization (CN) or bolus nebulization (BN) with equal efficacy 6
• Standard dosing of albuterol (2.5 mg) every 20 minutes is as effective as higher doses (7.5 mg) for most patients 7
• Pressurized metered-dose inhalers (pMDI) with spacers can be as effective as nebulizers when used with appropriate dosing schemes 8
• Monitor for paradoxical bronchospasm with beta-agonists, which can be life-threatening and requires immediate discontinuation 9

Monitoring Response and Follow-up

• Reassess 15-30 minutes after nebulizer treatment 1
• If signs of acute severe asthma persist:
  • Arrange hospital admission 1
  • Repeat nebulized ipratropium 0.5 mg or give subcutaneous terbutaline 1
• For patients with improving symptoms but PEF still 50-75% of predicted:
  • Continue treatment with beta-agonists 1
  • Ensure prednisolone has been administered 1
  • Observe for at least 60 minutes before considering discharge 1

Common Pitfalls and Caveats

• Underuse of corticosteroids is a common factor in preventable asthma deaths 1
• Physicians' subjective assessments of airway obstruction are often inaccurate; rely on objective measures like PEF 4
• Patients who subsequently require admission typically show a diminished response to the first beta-agonist administration 7
• Fatalities have been reported with excessive use of inhaled sympathomimetic drugs 9
• Patients with decreased responsiveness to initial treatment may need admission regardless of medication adjustments 7