What is the treatment for an asthma exacerbation?

Treatment for Asthma Exacerbation

The primary treatment for asthma exacerbation consists of oxygen therapy, inhaled short-acting beta-agonists (albuterol), and systemic corticosteroids, with the intensity and frequency of administration determined by the severity of the exacerbation. 1, 2

Initial Assessment and Severity Classification

• Assess severity based on symptoms, signs, and lung function (PEF or FEV1):
  • Mild: Dyspnea only with activity, PEF ≥70% of predicted/personal best
  • Moderate: Dyspnea interfering with usual activity, PEF 40-69% of predicted
  • Severe: Dyspnea at rest, PEF <40% of predicted
  • Life-threatening: Silent chest, cyanosis, feeble respiratory effort, confusion 1, 2

Primary Treatment Components

Oxygen Therapy

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

Inhaled Short-Acting Beta-Agonists (SABA)

• Albuterol is the first-line treatment for all asthma exacerbations 1, 3
• 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, 3
  • MDI with spacer: 4-8 puffs every 20 minutes for up to 3 doses, then as needed 1
• For severe exacerbations (FEV1 or PEF <40%), continuous administration may be more effective than intermittent administration 4, 2

Systemic Corticosteroids

• Administer early in the treatment of moderate to severe exacerbations 1, 2
• Oral prednisone: 40-60 mg in single or divided doses for adults 1, 2
• For children: 1-2 mg/kg/day (maximum 60 mg/day) 2
• Oral administration is as effective as intravenous and less invasive 2

Adjunctive Therapies

Ipratropium Bromide

• Add to beta-agonist therapy for severe exacerbations 1, 2
• Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2
• The combination of beta-agonist and ipratropium has been shown to reduce hospitalizations in patients with severe airflow obstruction 2

Magnesium Sulfate

• Consider for patients with severe refractory asthma 1, 2
• Standard adult dose: 2 g IV administered over 20 minutes 1, 2
• Most effective when administered early in the treatment course 1

Treatment Strategy and Monitoring

• Initial assessment and treatment within first 15-30 minutes: oxygen, first dose of albuterol, and systemic corticosteroids 2, 5
• 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 1, 2

Common Pitfalls and Caveats

• Regular use of short-acting beta-agonists (four or more times daily) can reduce their duration of action 1, 2
• Monitor for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue 1, 2
• Avoid sedatives of any kind in patients with acute asthma exacerbation 1, 2
• Fatalities have been reported with excessive use of inhaled sympathomimetic drugs 3
• Paradoxical bronchospasm can occur with inhaled beta-agonists and can be life-threatening 3

Prehospital Management

• EMS providers should administer supplemental oxygen and inhaled short-acting bronchodilators 4, 5
• Treatment can be repeated while transporting the patient to a maximum of 3 bronchodilator treatments during the first hour and then 1 per hour 4
• EMS providers should not delay patient transport to the hospital while administering bronchodilator treatment 4, 5

Hospital Admission Criteria

• Life-threatening features present
• Features of severe asthma persisting after initial treatment
• History of recent nocturnal symptoms or previous severe attacks 2, 5