What is the best course of treatment for a patient experiencing prolonged asthma exacerbation?

Treatment of Prolonged Asthma Exacerbation

For a patient experiencing prolonged asthma exacerbation, immediately initiate high-dose systemic corticosteroids (prednisolone 30-60 mg daily or IV hydrocortisone 200 mg), oxygen therapy (40-60%), and frequent nebulized bronchodilators (salbutamol 5 mg or terbutaline 10 mg), with reassessment every 15-30 minutes to determine need for hospitalization. 1

Immediate Assessment and Severity Classification

Assess severity objectively using peak expiratory flow (PEF) and clinical parameters rather than relying on clinical impression alone 1:

Severe exacerbation features:

• Cannot complete sentences in one breath 1
• Pulse >110 beats/min 1
• Respirations >25 breaths/min 1
• PEF <50% of predicted or personal best 1

Life-threatening features requiring immediate intensive care consideration:

• Silent chest, cyanosis, feeble respiratory effort 1
• Bradycardia, confusion, exhaustion, or coma 1
• Hypoxia (PaO2 <8 kPa) despite 60% oxygen or hypercapnia (PaCO2 >6 kPa) 1

Initial Treatment Protocol

Bronchodilator Therapy

• Administer nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1
• Reassess response 15-30 minutes after nebulization 1
• If inadequate response, repeat nebulized bronchodilators every 15 minutes (up to every 15 minutes for severe cases) 1
• Add ipratropium 0.5 mg to nebulized β-agonist if life-threatening features present 1

Systemic Corticosteroids

Critical intervention that must not be delayed:

• Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg immediately 1, 2
• Oral administration is equally effective as IV unless patient is vomiting or severely ill 2
• Continue prednisolone 30-60 mg daily or IV hydrocortisone 200 mg every 6 hours for hospitalized patients 1, 2
• Anti-inflammatory effects take 6-12 hours to become apparent, making early administration essential 2

Oxygen Therapy

• Administer 40-60% oxygen in all cases of severe exacerbation 1
• Continue oxygen therapy throughout treatment and monitoring 1

Monitoring and Reassessment

Measure PEF 15-30 minutes after initial treatment and continue monitoring according to response 1, 2:

If PEF remains <33% predicted after initial treatment:

• Arrange immediate hospital admission 1
• Consider aminophylline 250 mg IV over 20 minutes OR salbutamol/terbutaline 250 µg IV over 10 minutes 1
• Obtain chest radiography to exclude pneumothorax or pneumonia 1

If PEF 50-75% predicted:

• Continue frequent nebulized bronchodilators (every 4 hours if improving, more frequently if not) 1
• Continue systemic corticosteroids 1
• Consider hospital admission if multiple severe features persist 1

Hospital Admission Criteria

Admit if any of the following present:

• Any life-threatening features 1
• PEF <33% predicted after initial treatment 1
• Features of acute severe asthma persist after initial treatment 1

Lower threshold for admission if:

• Attack occurs in afternoon or evening 1
• Recent nocturnal symptoms or worsening symptoms 1
• Previous severe attacks or recent hospital admission 1
• Concern about patient's ability to assess severity or poor social circumstances 1

Duration and Follow-Up for Prolonged Exacerbations

Systemic Corticosteroid Course

• Continue prednisolone 30-60 mg daily for 1-3 weeks (or longer for chronic asthma) 1
• Total course typically 3-10 days, but may require up to 21 days until lung function returns to previous best 1, 2
• No need to taper courses <7 days, especially if patient taking inhaled corticosteroids 2
• Higher doses beyond 60-80 mg/day provide no additional benefit 2

Discharge Criteria

Patients should not be discharged until 1:

• PEF >75% predicted or personal best 1
• Diurnal variability <25% 1
• No nocturnal symptoms 1

Post-Discharge Management

• Continue inhaled corticosteroids (or initiate if not already prescribed) 1
• Schedule follow-up within 24-48 hours for severe exacerbations 1
• Provide written self-management plan 1
• Monitor symptoms and PEF on chart 1

Additional Considerations for Refractory Cases

If patient deteriorates despite maximal treatment:

• Transfer to intensive care unit 1
• Consider IV aminophylline (if not already on oral theophyllines) or parenteral β-agonists 1, 3
• IV magnesium sulfate may be beneficial in severe exacerbations 3
• Prepare for possible intubation and mechanical ventilation 1

Common Pitfalls to Avoid

• Underuse of corticosteroids is a major factor in asthma deaths 1
• Delaying systemic corticosteroid administration leads to poorer outcomes 2
• Relying on clinical impression alone without objective PEF measurement 1
• Using sedation (absolutely contraindicated) 1
• Prescribing antibiotics unless bacterial infection confirmed 1
• Unnecessary tapering of short corticosteroid courses 2

Patients requiring >2 bursts of oral corticosteroids in one year should be referred to asthma specialist 1