What is the recommended treatment for an asthma exacerbation?

Management of Asthma Exacerbation

The recommended treatment for an asthma exacerbation includes administering oxygen to maintain saturation >90%, short-acting beta-agonists (albuterol) via nebulizer or metered-dose inhaler with spacer, early systemic corticosteroids, and adding ipratropium bromide for severe exacerbations. 1, 2

Initial Assessment and Treatment

• 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 a clear response to bronchodilator therapy has occurred 2
• Administer albuterol as first-line bronchodilator treatment via nebulizer (2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed) or metered-dose inhaler with spacer (4-8 puffs every 20 minutes for up to 3 doses) 1, 2, 3
• For severe exacerbations (FEV1 or PEF <40% predicted), continuous administration of albuterol may be more effective than intermittent dosing 2

Systemic Corticosteroids

• Administer systemic corticosteroids early in the treatment course for moderate to severe exacerbations 1
• Oral prednisone 40-60 mg in single or divided doses is recommended for adults 1, 2
• Oral administration is as effective as intravenous administration and less invasive 1, 4
• The total course of systemic corticosteroids typically lasts 3-10 days, with no tapering needed for courses less than 1 week 2, 5

Adjunctive Therapies

• Add ipratropium bromide to albuterol therapy for severe exacerbations (0.5 mg 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, 2
• Consider intravenous magnesium sulfate (2g IV over 20 minutes) for patients with severe refractory asthma 1

Monitoring and Reassessment

• Perform initial assessment within the first 15-30 minutes, including administering oxygen, giving the first dose of inhaled albuterol, and administering systemic corticosteroids 1
• Reassess the patient 15-30 minutes after starting treatment, measuring peak expiratory flow (PEF) or FEV₁, and assessing symptoms and vital signs 1
• Response to treatment is a better predictor of hospitalization need than initial severity 1, 2
• Measure PEF or FEV₁ before and after treatments 1

Recognition of Severe or Life-Threatening Features

• Severe features include inability to complete sentences in one breath, respiratory rate >25 breaths/min, PEF <50% of predicted/best, and heart rate >110 beats/min 1
• Life-threatening features include PEF <33% of predicted/best, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 1
• Monitor for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO2 ≥42 mm Hg 1

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
• Do not delay administration of systemic corticosteroids as early administration may reduce hospitalization rates 1
• Avoid sedatives of any kind in patients with acute asthma exacerbation 1
• Antibiotics are not generally recommended unless there is strong evidence of bacterial infection (e.g., pneumonia or sinusitis) 1
• Regular use of short-acting beta-agonists four or more times daily can reduce their duration of action, highlighting the need for careful management 1
• Aggressive hydration is not recommended for older children and adults but might be appropriate for some infants and young children 1

Discharge Planning

• Ensure patients have appropriate maintenance therapy and a written self-management plan before discharge 1
• Continue oral corticosteroids for 3-10 days 1, 6
• Arrange follow-up with primary care within 1 week 1