What are the treatment guidelines for a 60-year-old female with asthma who has failed albuterol (beta2-adrenergic agonist) rescue inhaler?

Management of Acute Asthma Exacerbation in a 60-Year-Old Female

When albuterol rescue therapy fails in this patient, immediately administer nebulized salbutamol 5 mg (or terbutaline 10 mg) plus oral prednisolone 30-60 mg, and assess severity using objective measures including peak expiratory flow, respiratory rate, heart rate, and ability to speak in complete sentences. 1, 2, 3

Immediate Assessment of Severity

First, objectively determine whether this represents acute severe or life-threatening asthma by evaluating the following criteria:

Acute Severe Asthma features (ANY of these): 1, 3

• Cannot complete sentences in one breath
• Pulse >110 beats/min
• Respirations >25 breaths/min
• Peak expiratory flow (PEF) <50% predicted or personal best

Life-threatening features (ANY of these): 1, 3

• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia, hypotension, confusion, exhaustion, or coma
• Oxygen saturation <92% despite supplemental oxygen

Initial Treatment Algorithm

If Mild Exacerbation (PEF >50% predicted, normal speech, pulse <110, respirations <25):

Treat at home with: 1

• Nebulized salbutamol 5 mg or terbutaline 10 mg
• Monitor response at 15-30 minutes after nebulizer
• If PEF improves to 50-75% predicted: Give prednisolone 30-60 mg orally 1
• If PEF improves to >75% predicted: Step up usual maintenance treatment 1
• Critical caveat: Response to treatment MUST be assessed before leaving—do not assume improvement 1

If Severe Exacerbation (PEF <50% predicted OR any severe features):

Immediate treatment: 1, 3

• Oxygen 40-60% if available
• Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen as driving gas
• Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg (or both)
• Seriously consider hospital admission if more than one severe feature is present 1, 3

If life-threatening features are present, add: 1

• Ipratropium 0.5 mg nebulized to the β-agonist
• Intravenous aminophylline 250 mg over 20 minutes OR salbutamol/terbutaline 250 µg over 10 minutes
• Do not give bolus aminophylline if patient is already taking oral theophyllines 1

If No Nebulizer Available:

Give 2 puffs of β-agonist via a large volume spacer device and repeat 10-20 times 1

Monitoring Response at 15-30 Minutes

If patient is NOT improving after initial treatment: 1

• Continue oxygen and steroids
• Give nebulized β-agonist more frequently (up to every 15-30 minutes)
• Add ipratropium 0.5 mg to nebulizer and repeat every 6 hours until improvement starts 1
• Consider intravenous aminophylline or parenteral β-agonist 1

Hospital Admission Criteria

Absolute indications for immediate hospital referral: 1, 3

• Any life-threatening features present
• Any features of acute severe asthma persist after initial treatment
• PEF 15-30 minutes after nebulization <33% of predicted or best value

Lower threshold for admission if: 1, 3

• Attack occurs in afternoon or evening (rather than earlier in day)
• Recent nocturnal symptoms or worsening symptoms
• Previous severe attacks, especially if onset was rapid
• Concern over patient's assessment of severity or social circumstances

Long-Term Management After Acute Episode

Once the acute exacerbation is controlled, this patient requires optimization of maintenance therapy to prevent future failures of rescue medication. The evidence strongly supports moving beyond albuterol-only rescue therapy:

For ongoing management, consider as-needed combination therapy: 4, 5, 6

• As-needed budesonide/formoterol (or albuterol/budesonide) reduces exacerbations requiring systemic steroids by 55% compared to SABA alone (OR 0.45,95% CI 0.34-0.60) 4
• The MANDALA trial demonstrated that albuterol-budesonide 180/160 µg as rescue therapy reduced severe exacerbations by 26% compared to albuterol alone in patients with moderate-to-severe asthma (hazard ratio 0.74,95% CI 0.62-0.89) 6
• This approach addresses both bronchoconstriction AND inflammation with each rescue use 5, 7

At discharge or follow-up, ensure: 1

• Patient has been on discharge medication for 24 hours with inhaler technique checked
• PEF >75% of predicted or best with diurnal variability <25%
• Treatment includes oral prednisolone 30-60 mg daily for 1-3 weeks 1
• Inhaled corticosteroids in addition to bronchodilators 1
• Own PEF meter with self-management plan 1
• Follow-up within 24-48 hours for severe exacerbations, within 48 hours for moderate exacerbations 1, 2

Critical Pitfalls to Avoid

Common errors that increase morbidity and mortality: 1, 2

• Underestimating severity of exacerbations—always use objective measures
• Underuse of corticosteroids—delay can be fatal 1
• Overreliance on bronchodilators without anti-inflammatory treatment
• Any sedation is absolutely contraindicated 1
• Antibiotics only if bacterial infection is present 1
• Percussive physiotherapy is unnecessary 1