What is the recommended treatment for an asthma exacerbation?

Asthma Exacerbation Treatment

For acute asthma exacerbations, immediately administer oxygen to maintain SaO₂ >90%, high-dose inhaled albuterol (2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses), and systemic corticosteroids (prednisone 40-60 mg orally for adults or 1-2 mg/kg for children, maximum 60 mg/day) within the first 15-30 minutes. 1

Initial Assessment and Oxygen Therapy

• Administer supplemental oxygen via nasal cannula or mask to maintain oxygen saturation >90% (>95% in pregnant patients or those with cardiac disease) 1
• Monitor oxygen saturation continuously until a clear response to bronchodilator therapy occurs 1
• Measure peak expiratory flow (PEF) or FEV₁ before treatment to establish baseline severity 1

Primary Bronchodilator Therapy

• Administer albuterol as first-line treatment with the following dosing options: 2, 1
  • Nebulizer: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed
  • MDI with spacer: 4-8 puffs every 20 minutes for up to 3 hours, then as needed
• Both delivery methods (nebulizer vs MDI with spacer) are equally effective when properly administered 2

Systemic Corticosteroids - Critical Early Intervention

• Administer systemic corticosteroids early in all moderate to severe exacerbations - this is one of the most important interventions and may reduce hospitalization rates 1
• Adult dosing: Prednisone 40-60 mg orally in single or divided doses 2, 1
• Pediatric dosing: 1-2 mg/kg/day (maximum 60 mg/day) 2, 1
• Oral administration is as effective as intravenous and should be preferred unless gastrointestinal absorption is impaired 2, 3
• If IV route is necessary, use hydrocortisone 200 mg every 6 hours or methylprednisolone 1-2 mg/kg 2, 1
• Duration: 5-10 days for outpatient "burst" therapy 2, 1
• No tapering is necessary for courses less than 10 days, especially if patients are concurrently taking inhaled corticosteroids 2, 1

Adjunctive Ipratropium Bromide

• Add ipratropium bromide to albuterol for all moderate to severe exacerbations - this combination reduces hospitalizations, particularly in patients with severe airflow obstruction 2, 1
• Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 2, 1
• Important limitation: Ipratropium provides benefit only during the first 3 hours in the emergency department and has not been shown to provide further benefit once the patient is hospitalized 2

Reassessment Timeline

• First reassessment at 15-30 minutes after starting treatment: measure PEF or FEV₁, assess symptoms, and check vital signs 1
• Second reassessment at 60-90 minutes (after 3 doses of bronchodilator): response to treatment is a better predictor of hospitalization need than initial severity 1

Severe or Refractory Exacerbations

• For severe exacerbations not responding to initial therapy, consider intravenous magnesium sulfate 2 g over 20 minutes (adults) or 25-75 mg/kg up to 2 g maximum (children) 2, 1
• Consider continuous nebulization of albuterol for life-threatening exacerbations 1
• Recognize signs of impending respiratory failure: inability to speak, altered mental status, intercostal retractions, worsening fatigue, and PaCO₂ ≥42 mmHg 1

Common Pitfalls to Avoid

• Do not administer sedatives of any kind during acute asthma exacerbations 1
• Avoid methylxanthines (theophylline) - they have increased side effects without superior efficacy 1
• Do not routinely prescribe antibiotics unless there is strong evidence of bacterial infection such as pneumonia or sinusitis 1
• Avoid aggressive hydration in older children and adults (may be appropriate for infants and young children) 1
• Do not delay intubation once it is deemed necessary - it should be performed semi-electively before respiratory arrest occurs 2

Monitoring Parameters

• Continuously monitor oxygen saturation 1
• Measure PEF or FEV₁ before and after treatments 1
• Assess respiratory rate, heart rate, ability to speak in complete sentences, and use of accessory muscles 1

Discharge Criteria and Follow-up

• Ensure PEF reaches 70% of predicted or personal best before discharge 2
• Continue oral corticosteroids for the full 5-10 day course 1
• Initiate or increase inhaled corticosteroids at discharge 1
• Arrange follow-up within 1 week with primary care 1

Important Consideration Regarding Steroid Safety

While systemic corticosteroids are essential for managing exacerbations, even short courses (3-7 days) are associated with adverse events including bone density loss, hypertension, gastrointestinal complications, and mental health impacts 4. However, the immediate benefits in treating acute exacerbations outweigh these risks, making their use mandatory in moderate to severe cases.