What is the treatment regimen for a severe exacerbation of asthma in the Emergency Room (ER)?

From the Guidelines

The management of severe asthma exacerbation in the emergency room involves prompt administration of oxygen to maintain saturation above 92%, along with repeated short-acting beta-agonists (albuterol/salbutamol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for the first hour) and early administration of systemic corticosteroids, typically prednisone 40-60 mg orally or methylprednisolone 60-125 mg IV 1, 2, 3, 4.

Key Components of Management

• Administration of oxygen to maintain saturation above 92%
• Repeated short-acting beta-agonists (albuterol/salbutamol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for the first hour)
• Early administration of systemic corticosteroids, typically prednisone 40-60 mg orally or methylprednisolone 60-125 mg IV
• Addition of ipratropium bromide (0.5 mg nebulized or 4-8 puffs via MDI) to the first few beta-agonist treatments for severe exacerbations
• Consideration of magnesium sulfate (2 g IV over 20 minutes) for patients not responding adequately, and epinephrine (0.3-0.5 mg IM) in severe cases ### Monitoring and Supportive Care
• Continuous cardiac monitoring
• Frequent reassessment of respiratory status
• Arterial blood gas measurement
• IV fluids if the patient is dehydrated ### Discharge and Admission Criteria
• Patients should be monitored for at least 60 minutes after the last treatment to ensure stability before considering discharge
• Those with persistent symptoms or high-risk factors may require admission for continued treatment and monitoring 1, 2, 3, 4

From the FDA Drug Label

The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm During this time most patients gain optimum benefit from regular use of the inhalation solution. If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy. Ipratropium bromide inhalation solution can be mixed in the nebulizer with albuterol or metaproterenol if used within one hour but not with other drugs.

For severe exacerbation of asthma in the ER, the regimen may involve the use of albuterol and ipratropium bromide.

• Albuterol can be administered as needed to control recurring bouts of bronchospasm 5.
• Ipratropium bromide can be mixed with albuterol in a nebulizer for administration 6. It is essential to seek medical advice immediately if a previously effective dosage regimen fails to provide the usual relief, as this may indicate seriously worsening asthma 5.

From the Research

Severe Exacerbation of Asthma Regimen in the ER

• The management of severe asthma exacerbations in the emergency department (ED) involves early recognition and intervention, continuous monitoring, and appropriate disposition 7.
• Treatment may include the use of inhaled magnesium sulfate as an adjunct to standard therapy, which has been shown to improve lung function and reduce hospital admissions 8.
• Ipratropium bromide is a quaternary anticholinergic bronchodilator that can be used as adjunctive therapy for the emergency treatment of acute asthma exacerbation, and its addition to inhaled beta2-agonist therapy has been associated with improved lung function and reduced hospitalization rates 9.
• The use of combination ipratropium/beta2-agonist therapy is recommended for acute asthmatic exacerbation, as it provides physiological evidence of benefit without risk of adverse effects 9.
• Effective management of an exacerbation requires rapid assessment of severity, and most therapies are directed at alleviating bronchospasm and decreasing airway inflammation, with treatments such as inhaled short-acting beta-agonists, systemic corticosteroids, and supplemental oxygen being commonly used 10.
• Adjunctive therapy with intravenous magnesium and Heliox-driven nebulization of bronchodilators should be considered for patients presenting with severe and very severe exacerbations 10.
• Disposition should be determined based on serial assessments of the response to therapy over the first 4 hours in the ED, and patients stable for discharge should receive medications, asthma education, and follow-up scheduled by ED staff 10.
• The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations, and patients needing admission to the hospital require continued monitoring and systemic therapy similar to treatments used in the ED 11.