What is the recommended management for acute asthma exacerbation?

Management of Acute Asthma Exacerbation

The recommended management for acute asthma exacerbation includes oxygen therapy, short-acting beta-agonists (SABAs), systemic corticosteroids, and consideration of adjunctive therapies based on severity, with continuous monitoring and reassessment to guide treatment decisions. 1, 2

Initial Assessment and Severity Classification

• Assess severity based on symptoms, signs, and lung function (PEF or FEV1), classifying as mild, moderate, severe, or life-threatening 1
• Features of severe exacerbation include inability to complete sentences, respiratory rate >25/min, heart rate >110/min, and PEF <50% of predicted/best 2
• Life-threatening features include PEF <33% of predicted/best, silent chest, cyanosis, feeble respiratory effort, confusion, or coma 2

Primary Treatment Components

Oxygen Therapy

• Administer oxygen through nasal cannulae or mask to maintain SaO₂ >90% (>95% in pregnant patients or those with heart disease) 1, 2, 3
• Monitor oxygen saturation continuously until clear response to bronchodilator therapy 1, 2

Bronchodilator Therapy

• Administer albuterol (short-acting β2-agonist) as first-line treatment for all asthma exacerbations 1, 2, 4
• Administration options:
  • Nebulizer: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1, 2, 4
  • MDI with spacer: 4-12 puffs every 20 minutes for 3 doses, then as needed 1, 2
• For severe exacerbations, continuous administration of albuterol may be more effective than intermittent dosing 3

Systemic Corticosteroids

• Administer early systemic corticosteroids for all moderate-to-severe exacerbations 1, 2, 3
• Adult dosing: oral prednisone 40-60 mg in single or divided doses 1, 2
• Child dosing: 1-2 mg/kg/day (maximum 60 mg/day) 1, 2
• Clinical benefits may not occur for 6-12 hours after administration 5, 6
• Total course typically lasts 3-10 days, with no tapering needed for courses less than 1 week 2, 3

Adjunctive Therapies

Ipratropium Bromide

• Add ipratropium bromide to β2-agonist therapy for severe exacerbations 1, 2, 3
• Dosing: 0.5 mg via nebulizer or 4-8 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 2, 3, 6

Magnesium Sulfate

• Consider magnesium sulfate for patients with severe refractory asthma 1, 2, 3
• Standard adult dose: 2 g IV administered over 20 minutes 1, 2

Treatment Strategy and Monitoring

• Initial assessment and treatment within first 15-30 minutes, including oxygen, first dose of albuterol, and systemic corticosteroids 1, 2, 3
• Reassess patient 15-30 minutes after starting treatment 1, 2
• Measure PEF or FEV₁ before and after treatments 1, 2
• Response to treatment is a better predictor of hospitalization need than initial severity 2, 3

Hospital Admission Criteria

• Any life-threatening features 1, 2
• 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
• In infants, lack of response to short-acting β2-agonist therapy 1

Discharge Criteria

• Clinical stability 1
• 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

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 2
• Do not administer sedatives of any kind to patients with acute asthma exacerbation 2
• Antibiotics are not generally recommended unless there is strong evidence of bacterial infection (e.g., pneumonia or sinusitis) 2
• Monitor for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO2 ≥42 mm Hg 2
• Do not delay intubation once it is deemed necessary 2