What are the recommended treatments for managing asthma exacerbations according to the Global Initiative for Asthma (GINA) guidelines?

GINA Guidelines on Asthma Exacerbation Management

Severity Classification

Classify asthma exacerbations immediately based on objective lung function and clinical parameters to guide treatment intensity. 1, 2

• Mild exacerbation: Dyspnea only with activity, PEF ≥70% predicted, speaks in sentences 1
• Moderate exacerbation: Dyspnea interfering with usual activity, PEF 40-69% predicted, speaks in phrases 1
• Severe exacerbation: Dyspnea at rest, PEF <40% predicted, respiratory rate >25/min, heart rate >110/min, speaks in words 1, 2
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, altered consciousness, bradycardia, or PaCO₂ ≥42 mmHg 1, 2

Immediate Treatment Protocol (First 15-30 Minutes)

Initiate oxygen, bronchodilators, and systemic corticosteroids simultaneously within the first 15-30 minutes for all moderate-to-severe exacerbations. 1, 2

Oxygen Therapy

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

Bronchodilator Therapy

• Albuterol (first-line): 2.5-5 mg via nebulizer OR 4-12 puffs via MDI with spacer every 20 minutes for 3 doses 1, 2
• MDI with spacer is equally effective to nebulizer and may be superior in severe exacerbations 3
• After initial 3 doses, continue 2.5-10 mg every 1-4 hours as needed 1

Systemic Corticosteroids

• Administer within the first hour—this is critical for reducing hospitalization rates 1, 2
• Oral route is preferred and equally effective as IV 1
• Adults: Prednisone 40-60 mg orally in single or divided doses 1, 2
• Children: 1-2 mg/kg/day (maximum 60 mg/day) 1, 2
• Alternative: IV hydrocortisone 200 mg or methylprednisolone 1-2 mg/kg 1

Adjunctive Therapies for Severe Exacerbations

Ipratropium Bromide

Add ipratropium to albuterol for all severe exacerbations—this combination reduces hospitalizations, particularly in patients with severe airflow obstruction. 1, 2

• Dosing: 0.5 mg via nebulizer OR 8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2
• Combination therapy is more effective than albuterol alone in severe cases 1, 3

Magnesium Sulfate

Consider IV magnesium sulfate for patients with severe refractory asthma or life-threatening exacerbations, particularly after 1 hour of intensive conventional treatment. 1, 4

• Dosing: 2 g IV over 20 minutes 1, 4
• Moderately improves pulmonary function and reduces hospital admissions in severe exacerbations 4
• Should be used as adjunct, not replacement, for standard therapy 4
• Minor side effects include flushing and light-headedness 4

Reassessment and Monitoring

Reassess the patient 15-30 minutes after starting treatment—response to treatment is a better predictor of hospitalization need than initial severity. 1, 2

• Measure PEF or FEV₁ before and after each treatment 1, 2
• Monitor vital signs, oxygen saturation, and clinical symptoms continuously 1, 2
• If improving: Continue oxygen, oral corticosteroids, and nebulized beta-agonist every 4-6 hours 1
• If not improving after 15-30 minutes: Give nebulized beta-agonists more frequently (up to every 15 minutes) 1

Hospital Admission Criteria

Admit patients with any of the following features: 1, 2

• Life-threatening features present at any time 2
• Features of severe attack persisting after initial treatment 1, 2
• PEF <33% predicted or best value after initial treatment 1
• Lack of response to short-acting β₂-agonist therapy (especially in infants) 2
• Lower threshold for admission if: afternoon/evening presentation, recent nocturnal symptoms, previous severe attacks, or concerning social circumstances 1

Discharge Criteria and Planning

Do not discharge until clinical stability is achieved with PEF >75% predicted or personal best and diurnal variability <25%. 1

• Ensure improved oxygen saturation, lung function, normal respiratory rate, and absence of chest wall indrawing 2
• Continue oral corticosteroids for 5-10 days (adults: 40-60 mg prednisone; children: 1-2 mg/kg/day, maximum 60 mg/day) 1
• No tapering necessary for courses <10 days 1
• Initiate or increase inhaled corticosteroids at discharge 1
• Provide written asthma action plan 1, 2
• Arrange follow-up with primary care within 1 week and specialist within 4 weeks 1

Critical Pitfalls to Avoid

• Never underestimate severity—patients, relatives, and doctors often underestimate severity due to failure to make objective measurements 1
• Never administer sedatives to patients with acute asthma exacerbation 1
• Do not delay intubation once deemed necessary—monitor for inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO₂ ≥42 mmHg 1
• Antibiotics are not generally recommended unless strong evidence of bacterial infection (pneumonia or sinusitis) 1, 2
• Aggressive hydration is not recommended for older children and adults 1
• Be aware of paradoxical bronchospasm with SABA formulations—consider ipratropium as rescue inhaler if this occurs 5

Special Considerations for Infants

• Assessment depends more on physical examination than objective measurements 2
• Signs of serious distress: accessory muscle use, wheezing, paradoxical breathing, cyanosis, respiratory rate >60/min 2
• Blood gas estimations rarely helpful in deciding initial management 1
• Consider half doses of medications in very young children 1