What is the recommended treatment for an asthma exacerbation?

Asthma Exacerbation Treatment

Immediate Management Algorithm

For any asthma exacerbation, immediately administer oxygen to maintain saturation >90% (>95% in pregnant patients or those with heart disease), give albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses, and start systemic corticosteroids (prednisone 40-60 mg orally for adults) within the first 15-30 minutes. 1

First-Line Bronchodilator Therapy

• Albuterol (short-acting β2-agonist) is the cornerstone of acute treatment, administered either via nebulizer (2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed) or MDI with spacer (4-8 puffs every 20 minutes for up to 3 doses, then as needed). 1

• Both delivery methods are equally effective when properly administered, so choose based on patient ability and available equipment. 1

• For severe exacerbations not responding to intermittent dosing, consider continuous nebulization of albuterol. 1

Systemic Corticosteroids - Critical Early Intervention

• Administer oral prednisone 40-60 mg immediately for adults with moderate to severe exacerbations; this is as effective as intravenous administration and less invasive. 1, 2

• For children, dose at 1-2 mg/kg/day (maximum 60 mg/day). 1

• Oral administration is preferred over IV unless the patient is vomiting or unable to take oral medications - studies demonstrate equivalent efficacy between oral prednisolone and IV hydrocortisone. 1, 2

• Duration should be 5-10 days, with no tapering necessary for courses less than 10 days. 1

• Higher doses (0.6 mg/kg) show superior efficacy compared to lower doses (0.2-0.4 mg/kg), supporting the 40-60 mg recommendation for adults. 3

• While short courses are effective, be aware that even brief systemic corticosteroid exposure (3-7 days) carries risks including bone density loss, hypertension, gastrointestinal bleeding, and mental health impacts - consider cumulative annual exposure. 4

Adjunctive Ipratropium Bromide

• Add ipratropium bromide 0.5 mg via nebulizer or 8 puffs via MDI to albuterol for all moderate to severe exacerbations - this combination reduces hospitalizations, particularly in patients with severe airflow obstruction. 1

• Dose every 20 minutes for 3 doses, then as needed. 1

Reassessment Protocol

• Reassess 15-30 minutes after starting treatment by measuring peak expiratory flow (PEF) or FEV₁, assessing symptoms, and checking vital signs. 1

• Response to treatment is a better predictor of hospitalization need than initial severity. 1

• Continue monitoring oxygen saturation continuously until clear response to bronchodilator therapy occurs. 1

Escalation for Severe or Refractory Exacerbations

Severity Recognition

• Severe exacerbation features include: inability to complete sentences in one breath, respiratory rate >25 breaths/min, PEF <50% predicted/best, heart rate >110 beats/min. 1

• Life-threatening features include: PEF <33% predicted/best, silent chest, cyanosis, altered mental status, PaCO₂ ≥42 mmHg, inability to speak. 1

Additional Interventions

• For severe refractory asthma or life-threatening exacerbations, administer IV magnesium sulfate 2 g over 20 minutes for adults (25-75 mg/kg up to 2 g maximum for children). 1

• If no improvement after initial treatment, increase nebulized beta-agonist frequency to every 15 minutes. 1

• Consider chest X-ray to exclude complications such as pneumothorax, consolidation, or pulmonary edema in patients not responding to initial therapy. 1

Critical Pitfalls to Avoid

• Never administer sedatives of any kind to patients with acute asthma exacerbation. 1

• Do not delay intubation once deemed necessary - it should be performed semi-electively before respiratory arrest occurs. 1

• Avoid methylxanthines (theophylline), chest physiotherapy, mucolytics, and aggressive hydration in older children and adults. 1

• Do not routinely prescribe antibiotics unless there is strong evidence of bacterial infection such as pneumonia or sinusitis. 1

• Recognize that severity is often underestimated by patients, relatives, and physicians due to failure to make objective measurements. 1

Disposition Criteria

Hospital Admission Indicated For:

• Life-threatening features or severe attack features persisting after initial treatment. 1

• PEF <33% predicted or best value after initial therapy. 1

• Lower threshold for admission if patient presents afternoon/evening, has recent nocturnal symptoms, previous severe attacks, or concerning social circumstances. 1

Discharge Criteria:

• PEF reaches ≥70% of predicted or personal best. 1

• Symptoms have stabilized with diurnal variability <25%. 1

• Ensure patient has appropriate maintenance therapy, written self-management plan, and follow-up arranged within 1 week with primary care and within 4 weeks with specialist. 1

• Continue oral corticosteroids for the full 5-10 day course and consider initiating or increasing inhaled corticosteroids at discharge. 1