What is the recommended treatment for an asthma exacerbation?

Asthma Exacerbation Treatment

For acute asthma exacerbations, 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 early with oral prednisone 40-60 mg (or IV hydrocortisone 200 mg if unable to take oral medication). 1

Initial Assessment and Oxygen Therapy

• Assess severity within the first 15-30 minutes by evaluating symptoms, vital signs, and measuring peak expiratory flow (PEF) or FEV₁ if possible 1
• Severe exacerbations are characterized by dyspnea at rest, PEF <40% predicted, respiratory rate >25 breaths/min, heart rate >110 beats/min, and inability to complete sentences in one breath 1
• Life-threatening features include PEF <33% predicted, silent chest, cyanosis, altered mental status, PaCO₂ ≥42 mmHg, or exhaustion 1
• Administer supplemental oxygen immediately via nasal cannula or mask to maintain oxygen saturation >90% (>95% in pregnant patients or those with heart disease) 1
• Monitor oxygen saturation continuously until a clear response to bronchodilator therapy occurs 1

Primary Bronchodilator Treatment

• Administer albuterol as first-line bronchodilator therapy with the following dosing options: 1
  • Nebulizer: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1
  • MDI with spacer: 4-8 puffs every 20 minutes for up to 3 doses, then as needed 1
• Both nebulizer and MDI with spacer are equally effective when properly administered 1
• For severe exacerbations not responding to initial treatment, consider continuous nebulization of albuterol 1

Systemic Corticosteroids - Critical Early Intervention

• Administer systemic corticosteroids early in all moderate to severe exacerbations - this is essential and should not be delayed 1
• Oral prednisone 40-60 mg in single or divided doses for adults 1
• Pediatric dosing: 1-2 mg/kg/day (maximum 60 mg/day) 1
• Oral administration is as effective as intravenous and is preferred when the patient can tolerate oral medication 1, 2
• If oral route is not feasible, give IV hydrocortisone 200 mg initially, then 200 mg every 6 hours 1
• Continue treatment for 5-10 days for outpatient "burst" therapy; no tapering is necessary for courses less than 10 days 1, 3

The evidence strongly supports oral over IV steroids when possible - a randomized controlled trial showed equivalent efficacy between oral prednisolone 100 mg daily and IV hydrocortisone 100 mg every 6 hours 2. This makes oral administration preferable due to ease of use and lower cost.

Adjunctive Ipratropium Bromide

• Add ipratropium bromide to albuterol for all moderate to severe exacerbations 1
• Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 1
• The combination of beta-agonist and ipratropium reduces hospitalizations, particularly in patients with severe airflow obstruction 1

Reassessment and Monitoring

• Reassess the patient 15-30 minutes after starting treatment by measuring PEF or FEV₁ and assessing symptoms and vital signs 1
• Response to treatment is a better predictor of hospitalization need than initial severity 1
• Measure PEF or FEV₁ before and after treatments to guide ongoing management 1
• Continue monitoring oxygen saturation continuously 1

Severe or Refractory Exacerbations

• For severe exacerbations remaining after 1 hour of intensive treatment, consider IV magnesium sulfate 2 g over 20 minutes 1, 4
• Magnesium sulfate is particularly beneficial for life-threatening exacerbations or when FEV₁/PEF remains <40% predicted after initial treatments 4
• The greatest benefit occurs in patients with FEV₁ <20% predicted 4
• Magnesium causes bronchial smooth muscle relaxation independent of serum magnesium level and has only minor side effects (flushing, light-headedness) 4

Critical Pitfalls to Avoid

• Do NOT delay intubation once it is deemed necessary - it should be performed semi-electively before respiratory arrest occurs 1
• Monitor for signs of impending respiratory failure: inability to speak, altered mental status, intercostal retraction, worsening fatigue, and PaCO₂ ≥42 mmHg 1
• Do NOT administer sedatives of any kind to patients with acute asthma exacerbation 1
• Avoid methylxanthines (theophylline), chest physiotherapy, and mucolytics - they provide no benefit and increase side effects 1
• Antibiotics are not generally recommended unless there is strong evidence of bacterial infection such as pneumonia or sinusitis 1
• Aggressive hydration is not recommended for older children and adults 1

Montelukast Has No Role in Acute Exacerbations

• Montelukast (Singulair) is NOT indicated for use in the reversal of bronchospasm in acute asthma attacks, including status asthmaticus 5
• Patients should be advised that oral montelukast is not for the treatment of acute asthma attacks 5
• Therapy with montelukast can be continued during acute exacerbations, but it does not treat the exacerbation itself 5

Disposition Criteria

• Discharge criteria: PEF ≥70% of predicted or personal best, minimal symptoms, oxygen saturation stable on room air 1
• Observe patients for 30-60 minutes after the last bronchodilator dose to ensure stability before discharge 1
• Hospital admission criteria: PEF <50% predicted after 1-2 hours of treatment, life-threatening features, or severe attack features persisting after initial treatment 1

Discharge Planning

• Continue oral corticosteroids for 5-10 days after discharge with no taper needed for courses <10 days 1
• Initiate or continue inhaled corticosteroids at discharge 1
• Provide a written asthma action plan and review inhaler technique 1
• Arrange follow-up with primary care within 1 week and specialist clinic within 4 weeks 1
• Patients at high risk of non-adherence may benefit from an IM depot corticosteroid injection at discharge 1