What is the treatment for status asthmaticus?

Treatment of Status Asthmaticus

The treatment of status asthmaticus requires immediate administration of high-flow oxygen, inhaled short-acting beta-agonists (salbutamol 5 mg or terbutaline 10 mg via nebulizer), and systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg). 1

Initial Assessment and Management

Recognition of Status Asthmaticus

• Unable to complete sentences in one breath 1
• Respiratory rate >25 breaths/min in adults, >50 breaths/min in children 1
• Heart rate >110 beats/min in adults, >140 beats/min in children 1
• Peak Expiratory Flow (PEF) <50% of predicted or best 1
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, poor respiratory effort, exhaustion, confusion, or coma 1

Immediate Treatment

• High-flow oxygen (40-60%) via face mask to maintain SaO₂ >92% 1, 2
• Nebulized short-acting beta-agonists: salbutamol 5 mg or terbutaline 10 mg (half doses for young children) 1
• Systemic corticosteroids: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1, 3
• Add ipratropium bromide 0.5 mg to nebulizer (100 μg in children) and repeat every 6 hours 1

Ongoing Management

For Patients Showing Improvement

• Continue high-flow oxygen 1, 3
• Prednisolone 1-2 mg/kg daily (maximum 40 mg in children) 1
• Nebulized beta-agonists every 4 hours 1
• Monitor PEF before and after bronchodilator treatment 1

For Patients Not Improving After 15-30 Minutes

• Continue oxygen and steroids 1
• Increase frequency of nebulized beta-agonists up to every 15-30 minutes 1
• Consider IV magnesium sulfate for life-threatening exacerbations or those remaining severe after 1 hour of intensive treatment 1, 4
• For life-threatening features in children: IV aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion of 1 mg/kg/h (omit loading dose if already on oral theophyllines) 1

Criteria for ICU Transfer

• Deteriorating PEF despite treatment 1
• Persistent or worsening hypoxia 1, 5
• Hypercapnia (PaCO₂ ≥42 mm Hg) 1, 5
• Exhaustion, confusion, drowsiness 1
• Respiratory arrest or coma 1

Mechanical Ventilation Considerations

• If pharmacological therapy fails to reverse severe airflow obstruction, mechanical ventilation may be required 6, 5
• Ventilation strategy should avoid excessive lung inflation by limiting minute ventilation and prolonging expiratory time, despite resulting hypercapnia 6, 5
• Sedation may be required but paralytic agents should be avoided if possible due to risk of ICU myopathy 6, 5

Discharge Criteria and Follow-up

• Patient should be on discharge medication for 24 hours with inhaler technique checked and recorded 1
• PEF >75% of predicted or best with diurnal variability <25% 1
• Treatment plan should include oral and inhaled corticosteroids, bronchodilators, and a written self-management plan 1
• Follow-up with primary care within 1 week 1
• Specialist respiratory clinic follow-up within 4 weeks 1

Common Pitfalls to Avoid

• Delaying corticosteroid administration - should be given immediately as effects take 6-12 hours to manifest 3, 7
• Using sedatives in asthmatic patients - contraindicated due to risk of respiratory depression 2, 6
• Administering antibiotics without clear evidence of bacterial infection 2, 6
• Underestimating severity - many deaths occur due to failure to recognize severity 1, 6
• Discharging patients too early - ensure adequate response to treatment and appropriate follow-up plans 1