What is the guideline-directed algorithm for treating a severe asthma exacerbation in the Emergency Department (ED)?

From the Guidelines

The management of severe asthma exacerbation in the emergency department begins with immediate assessment of airway, breathing, and circulation while simultaneously initiating bronchodilator therapy, with the most recent and highest quality evidence recommending the use of high-flow oxygen, inhaled beta-2 agonists, and systemic corticosteroids as primary treatment 1. The treatment approach should prioritize the administration of oxygen to maintain saturation ≥94%, and the use of inhaled beta-2 agonists such as albuterol (salbutamol) 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for the first hour. Concurrently, ipratropium bromide 0.5 mg nebulized or 4-8 puffs via MDI with spacer should be administered every 20 minutes for the first hour, then as needed. Systemic corticosteroids should be administered early, with prednisone or prednisolone 40-60 mg orally, or methylprednisolone 60-80 mg IV if the patient cannot take oral medications, as there is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 1. Some key points to consider in the management of severe asthma exacerbation include:

• The use of magnesium sulfate 2 g IV over 20 minutes for patients with inadequate response to initial therapy
• Continuous cardiac monitoring, frequent vital sign checks, and serial peak flow or FEV1 measurements
• Preparation for possible intubation if the patient shows signs of respiratory failure
• Reassessment of response to treatment every 30-60 minutes
• Discharge criteria, including significant improvement in symptoms, peak flow or FEV1 >70% of predicted or personal best, oxygen saturation >94% on room air, and correct use of inhalers
• Prescription of a short course of oral corticosteroids (prednisone 40-60 mg daily for 5-7 days) and continuation or initiation of controller medications upon discharge, with follow-up within 1-2 weeks 1. The approach works because beta-agonists relax bronchial smooth muscle, anticholinergics block parasympathetic bronchoconstriction, corticosteroids reduce airway inflammation, and magnesium acts as a bronchodilator in severe cases by inhibiting calcium-mediated smooth muscle contraction. Key considerations in the treatment of severe asthma exacerbation include:
• The importance of early recognition and treatment of severe and life-threatening exacerbations
• The need for frequent monitoring and reassessment of patients
• The use of oxygen, inhaled beta-2 agonists, and systemic corticosteroids as primary treatment
• The consideration of additional therapies, such as magnesium sulfate, for patients with inadequate response to initial therapy
• The importance of proper discharge planning, including prescription of oral corticosteroids and continuation or initiation of controller medications, and follow-up within 1-2 weeks 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults and Children 2 to 12 Years of Age: The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. Patient's Instructions for Use IPRATROPIUM BROMIDEINHALATION SOLUTION, 0. 02% Ipratropium Bromide Inhalation Solution can be mixed in the nebulizer with albuterol or metaproterenol if used within one hour but not with other drugs.

Guideline Directed Algorithm for Treating a Severe Asthma Exacerbation in the Emergency Department

• Initial Treatment: Administer 2.5 mg of albuterol by nebulization, as needed, every 20 minutes for up to 3 doses 2.
• Addition of Ipratropium Bromide: If symptoms persist, ipratropium bromide can be added to the treatment regimen and mixed with albuterol in the nebulizer, as the stability and safety of this combination have been established 3.
• Assessment and Re-evaluation: Continuously assess the patient's response to treatment and re-evaluate the treatment plan as needed, considering the potential for worsening asthma that may require reassessment of therapy 2.

From the Research

Guideline for Treating Severe Asthma Exacerbation in the Emergency Department

• The primary goals of managing an asthma acute exacerbation are to maintain adequate arterial oxygen saturation with supplemental oxygen, relieve airflow obstruction with repetitive administration of short-acting beta-2 agonists (SABA), and treat airway inflammation with systemic corticosteroids (CS) to prevent future relapses 4.
• Assessment of an asthma exacerbation constitutes a process with two different dimensions: to determine the severity of attack, and to evaluate the response to treatment 4.
• SABA, oxygen, and CS form the basis of management of acute asthma exacerbation, but a role is emerging for anticholinergics 4.
• The use of heliox in treating severe asthma attacks could be regarded as a different standard treatment that can lead to significantly better control of asthma attacks in the short term 5.

Treatment Options

• Nebulized albuterol with heliox versus albuterol nebulization can be considered as a treatment option for acute asthma exacerbation, with heliox showing significantly better control of asthma attacks in the short term 5.
• Oral prednisolone can be used as a treatment of choice for the most severe asthma exacerbations, when the lung airways are extremely contracted and filled with secretions 6.
• High-dose inhaled corticosteroids can be considered an alternative treatment to oral corticosteroids in moderate to severe asthma attacks 6.
• Ipratropium bromide may be given only in addition to beta(2)-adrenoceptor agonists, while theophylline has no additional benefit, and magnesium sulfate has no clear advantage 6.

Management and Prevention

• Comprehensive asthma management should include asthma education, measures to prevent asthma triggers, and training in the use of inhalers and spacers 6.
• As-needed inhaled corticosteroids (ICSs) can empower patients to adjust their ICS intake in response to symptom fluctuation, improving asthma morbidity outcomes and reducing severe exacerbations 7.
• Combination ICS-formoterol in a single inhaler, ICS and short-acting beta2-agonists in separate inhalers, and combination ICS-albuterol in a single inhaler can be considered as treatment options for patients with asthma 7.