What is the initial treatment for acute exacerbation of bronchial asthma?

Initial Treatment for Acute Exacerbation of Bronchial Asthma

Administer oxygen to maintain saturation >90% (>95% in pregnant patients or those with heart disease), immediately give albuterol 2.5-5 mg via nebulizer every 20 minutes for 3 doses, and start systemic corticosteroids (prednisone 40-60 mg orally) within the first 15-30 minutes of presentation. 1, 2, 3

Immediate Assessment and Oxygen Therapy

• Assess severity immediately using symptoms, peak expiratory flow (PEF), and oxygen saturation to guide treatment intensity 1, 3
• Mild exacerbation: dyspnea only with activity, PEF ≥70% predicted 1, 3
• Moderate exacerbation: dyspnea interfering with usual activity, PEF 40-69% predicted 1, 3
• Severe exacerbation: dyspnea at rest, PEF <40% predicted 1, 3
• Life-threatening features: confusion, drowsiness, silent chest, cyanosis, inability to speak, PaCO₂ ≥42 mmHg 2, 3

Administer supplemental oxygen through nasal cannula or mask immediately to maintain oxygen saturation >90% (>95% in pregnant patients or those with heart disease) 1, 2, 3

• Monitor oxygen saturation continuously until clear response to bronchodilator therapy occurs 1, 2, 3

First-Line Bronchodilator Therapy

Albuterol (short-acting beta-agonist) is the cornerstone of initial treatment and should be administered within the first 15-30 minutes 1, 2, 3

Dosing 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, 3, 4
• Metered-dose inhaler (MDI) with spacer: 4-8 puffs every 20 minutes for up to 3 doses, then as needed 1, 2
• For severe exacerbations (PEF <40%): Consider continuous nebulization of albuterol, which may be more effective than intermittent dosing 1, 2

Systemic Corticosteroids - Critical Early Intervention

Administer systemic corticosteroids early (within the first 15-30 minutes) to all patients with moderate to severe exacerbations 1, 2, 3

Dosing:

• Adults: Prednisone 40-60 mg orally in single or divided doses 1, 2, 3
• Children: 1-2 mg/kg/day (maximum 60 mg/day) 1, 2
• Alternative for adults: Dexamethasone 16 mg daily for 2 days 3
• Alternative for children: Dexamethasone 0.3 mg/kg (maximum 12 mg) as single dose, or 0.6 mg/kg/day (maximum 16 mg/day) for 2 days 3

Oral administration is as effective as intravenous and less invasive - reserve IV hydrocortisone 200 mg for patients unable to take oral medications 2

• Treatment duration should be 5-10 days for outpatient "burst" therapy 2
• Tapering is not necessary for courses less than 10 days 2

Adjunctive Therapies for Severe Exacerbations

Ipratropium Bromide (Short-Acting Anticholinergic)

Add ipratropium bromide to albuterol for all moderate-to-severe exacerbations - this combination reduces hospitalizations, particularly in patients with severe airflow obstruction 1, 2, 3

• Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2, 3

Intravenous Magnesium Sulfate

Consider magnesium sulfate for patients with severe refractory asthma or life-threatening exacerbations - most effective when administered early in the treatment course 1, 2, 3

• Dosing: 2 g IV over 20 minutes 1, 2, 3

Reassessment and Treatment Response

Reassess the patient 15-30 minutes after starting treatment by measuring PEF or FEV₁ before and after treatments, and assessing symptoms and vital signs 1, 2, 3

• Response to treatment is a better predictor of hospitalization need than initial severity 1, 2
• If no improvement after 15-30 minutes, give nebulized beta-agonists more frequently (up to every 15 minutes) 2
• After 3 doses of bronchodilator (60-90 minutes), perform comprehensive reassessment including subjective response, physical findings, and objective measurements 2

Critical Pitfalls to Avoid

• Never administer sedatives of any kind to patients with acute asthma exacerbation 1, 2
• Do not delay corticosteroid administration - early use impacts immediate need for ICU or hospital admission 1, 2
• Avoid methylxanthines (theophylline) due to increased side effect profiles without superior efficacy 5, 2
• Do not routinely prescribe antibiotics unless there is strong evidence of bacterial infection (pneumonia or sinusitis) 2
• Monitor for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue, PaCO₂ ≥42 mmHg 1, 2

Hospital Admission Criteria

Admit patients with any of the following: 2, 3

• Life-threatening features (confusion, drowsiness, silent chest, cyanosis) present at any time 3
• Features of severe attack persist after initial treatment, especially PEF <33% predicted 2, 3
• Recent nocturnal symptoms, recent hospital admission, or previous severe attacks (lower threshold for admission) 3
• Patients not responding significantly after 1-2 hours of maximum therapy 2, 3