What is the appropriate prescription for a patient with a moderate asthma exacerbation?

Management of Moderate Asthma Exacerbation

For a moderate asthma exacerbation, prescribe short-acting beta-agonists (SABA) such as albuterol via nebulizer or metered-dose inhaler (MDI) with spacer, plus oral systemic corticosteroids, and consider adding ipratropium bromide. 1

Initial Assessment and Treatment

• A moderate asthma exacerbation is characterized by deterioration in symptoms, deterioration in lung function, and increased rescue bronchodilator use lasting for 2 days or more 2
• Administer oxygen through nasal cannulae or mask to maintain oxygen saturation (SaO₂) >90% (>95% in pregnant patients or those with heart disease) 1
• Monitor oxygen saturation until a clear response to bronchodilator therapy has occurred 1

Bronchodilator Therapy

• Administer albuterol via nebulizer (2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed) or MDI with spacer (4-8 puffs every 20 minutes for up to 3 doses, then as needed) 1
• Add ipratropium bromide to beta-agonist therapy for moderate to severe exacerbations (0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed) 1
• Be aware that albuterol can produce paradoxical bronchospasm, which can be life-threatening; if this occurs, discontinue the medication immediately and institute alternative therapy 3

Systemic Corticosteroids

• Administer systemic corticosteroids early in the treatment of moderate asthma exacerbations 1
• For adults, prescribe oral prednisone 40-60 mg in a single or divided doses for 5-10 days 1
• For children, prescribe 1-2 mg/kg/day (maximum 60 mg/day) for 3-10 days 1
• Tapering is not necessary for courses of less than 10 days 2
• Single-dose dexamethasone may be an alternative to prednisone for improved compliance, particularly in settings where adherence is a concern 4

Monitoring and Reassessment

• Measure peak expiratory flow (PEF) or FEV₁ before and after treatments 1
• Reassess the patient 15-30 minutes after starting treatment, measuring PEF or FEV₁, and assessing symptoms and vital signs 1
• Response to treatment is a better predictor of hospitalization need than initial severity 1

Criteria for Hospital Admission

• Consider hospital admission for patients with life-threatening features or features of a severe attack that persist after initial treatment 1
• Patients should not be discharged until symptoms have stabilized with PEF above 75% of predicted value or best level 1

Common Pitfalls and Caveats

• The severity of an asthma exacerbation is often underestimated by patients and healthcare providers due to failure to make objective measurements 1
• Albuterol should be used with caution in patients with cardiovascular disorders, convulsive disorders, hyperthyroidism, or diabetes mellitus 3
• Repeated dosing with albuterol can cause significant hypokalemia in some patients, which has the potential to produce adverse cardiovascular effects 3
• Do not administer sedatives of any kind to patients with acute asthma exacerbation 1
• Short courses of systemic corticosteroids, even brief dosing periods (3-7 days), can cause adverse events including loss of bone density, hypertension, gastrointestinal ulcers/bleeds, and impacts on mental health 5

Discharge Planning

• Ensure patients have appropriate maintenance therapy and a written self-management plan before discharge 1
• Arrange follow-up with primary care within 1 week 1
• Consider initiating or increasing inhaled corticosteroids at discharge for patients not already receiving them 1