What is the management for an acute exacerbation (AE) of bronchial asthma?

Management of Acute Exacerbation of Bronchial Asthma

The management of acute asthma exacerbation requires immediate administration of oxygen to maintain SaO₂ >90%, short-acting beta-agonists (SABA) such as albuterol every 20 minutes for 3 doses, and early systemic corticosteroids for all moderate-to-severe exacerbations. 1, 2

Initial Assessment and Treatment

• Assess severity based on symptoms, signs, and lung function (PEF or FEV1), classifying as mild, moderate, severe, or life-threatening 1
• Administer oxygen through nasal cannulae or mask to maintain SaO₂ >90% (>95% in pregnant patients or those with heart disease) 1, 2
• Provide albuterol (short-acting β2-agonist) as first-line treatment via:
  • Nebulizer: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1, 3
  • MDI with spacer: 4-8 puffs every 20 minutes for 3 doses, then as needed 1, 2
• Administer systemic corticosteroids early for moderate-to-severe exacerbations:
  • Adults: Oral prednisone 40-60 mg in single or divided doses 2, 4
  • Children: 1-2 mg/kg/day (maximum 60 mg/day) 2

Adjunctive Therapies

• Add ipratropium bromide to β2-agonist therapy for severe exacerbations:
  • 0.5 mg via nebulizer or 4-8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2
• Consider magnesium sulfate for patients with severe refractory asthma:
  • Standard adult dose: 2 g IV administered over 20 minutes 1, 2
• Antibiotics are not generally recommended unless there is strong evidence of bacterial infection (e.g., pneumonia or sinusitis) 2

Monitoring and Reassessment

• Reassess patient 15-30 minutes after starting treatment 1, 2
• Measure PEF or FEV₁ before and after treatments 1, 2
• Monitor oxygen saturation continuously until clear response to bronchodilator therapy 1
• Response to treatment is a better predictor of hospitalization need than initial severity 5, 2

Recognition of Impending Respiratory Failure

• Watch for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO2 ≥42 mm Hg 5, 2
• Do not delay intubation once it is deemed necessary 5
• Consider other treatments such as intravenous magnesium or heliox before resorting to intubation 5, 2

Hospital Admission Criteria

• Admit patients with any life-threatening features 1, 2
• Admit patients with features of acute severe asthma present after initial treatment 1, 2
• Lower threshold for admission with history of recent nocturnal symptoms, recent hospital admission, or previous severe attacks 1

Discharge Criteria

• Clinical stability with improved oxygen saturation and lung function (FEV1 and PEF) 1
• Normal breath rate and absence of chest wall indrawing 1
• Appropriate home care and written asthma action plan arranged 1

Special Considerations

• For children, assessment depends more on physical examination than objective measurements 1
• Blood gas estimations are rarely helpful in deciding initial management for children 2, 6
• EMS providers should not delay patient transport while administering bronchodilator treatment 1

Common Pitfalls and Caveats

• The severity of an asthma attack is often underestimated due to failure to make objective measurements 2
• Do not administer sedatives of any kind to patients with acute asthma exacerbation 2
• Intravenous magnesium sulfate has no apparent value in patients with exacerbations of lower severity but might be considered in those with life-threatening exacerbations 5
• Regular use of SABAs can lead to reduced effectiveness, highlighting the need for careful management 2