What is the first line of treatment for a patient experiencing an acute exacerbation of bronchial asthma?

First-Line Treatment for Acute Asthma Exacerbation

Albuterol (short-acting beta-agonist) is the first-line treatment for all acute asthma exacerbations, administered via nebulizer (2.5-5 mg every 20 minutes for 3 doses) or metered-dose inhaler with spacer (4-8 puffs every 20 minutes for up to 3 doses), combined with early systemic corticosteroids (prednisone 40-60 mg orally for adults). 1, 2

Initial Assessment and Oxygen Therapy

• Administer supplemental oxygen immediately to maintain oxygen saturation >90% (>95% in pregnant patients or those with heart disease) via nasal cannula or mask 1, 2, 3
• Monitor oxygen saturation continuously until clear response to bronchodilator therapy occurs 1, 2
• Assess severity using symptoms, peak expiratory flow (PEF) or FEV₁, and vital signs to guide treatment intensity 1, 2

Primary Bronchodilator Therapy

Albuterol administration options (both routes are equally effective when properly administered): 1, 3

• Nebulizer route: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1, 2, 4
• MDI with spacer: 4-8 puffs every 20 minutes for up to 3 doses, then as needed 1, 2
• For severe exacerbations (FEV₁ or PEF <40%): Consider continuous nebulization of albuterol rather than intermittent dosing 1, 2

Systemic Corticosteroids - Critical Early Intervention

Administer systemic corticosteroids early in all moderate to severe exacerbations (oral route is as effective as intravenous and less invasive): 1, 2, 3

• Adults: Prednisone 40-60 mg orally in single or divided doses 1, 2, 3
• Children: 1-2 mg/kg/day (maximum 60 mg/day) 1, 2
• Alternative: Dexamethasone 0.6 mg/kg/day (maximum 16 mg/day) for 2 days may be used instead of 5-day prednisone course 2
• Duration: 5-10 days for outpatient "burst" therapy; no tapering necessary for courses <10 days 3

Adjunctive Ipratropium Bromide

Add ipratropium bromide (short-acting muscarinic antagonist) to albuterol for all moderate to severe exacerbations, as this combination reduces hospitalizations, particularly in patients with severe airflow obstruction: 1, 2, 3

• Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 1, 2, 3
• This combination provides greater bronchodilation than albuterol alone 2, 3

Reassessment and Response Monitoring

• Reassess 15-30 minutes after starting treatment by measuring PEF or FEV₁, assessing symptoms, and checking vital signs 1, 2, 3
• Response to treatment is a better predictor of hospitalization need than initial severity 1, 2
• Continue monitoring until patient demonstrates clear clinical improvement 1, 2

Escalation for Severe or Refractory Cases

For severe exacerbations not responding to initial therapy within 1 hour:

• Intravenous magnesium sulfate: 2 g IV over 20 minutes for adults (25-75 mg/kg up to 2 g maximum for children) - most effective when administered early 1, 2, 3
• Consider for patients with FEV₁ or PEF <40% after initial bronchodilator treatment 1, 2

Critical Pitfalls to Avoid

• Never delay systemic corticosteroids - early administration reduces hospitalization rates 1, 2
• Avoid sedatives of any kind in acute asthma exacerbation 1, 2
• Do not use SABA alone without corticosteroids for moderate to severe exacerbations 1, 2
• Monitor for impending respiratory failure: inability to speak, altered mental status, intercostal retractions, worsening fatigue, PaCO₂ ≥42 mmHg 1, 2
• Avoid methylxanthines (theophylline) due to increased side effects without superior efficacy 3
• Regular use of SABA four or more times daily can reduce duration of action 1

Hospital Admission Criteria

Consider hospital admission if: 2

• Life-threatening features present (PEF <33% predicted, silent chest, cyanosis, confusion, altered mental status) 2
• Features of severe attack persist after initial treatment 2
• PEF <50% predicted after 1-2 hours of treatment 3
• History of recent nocturnal symptoms, recent hospital admission, or previous severe attacks 2