What is the best course of treatment for an asthma flare-up?

Treatment of Asthma Flare-Up

For an acute asthma exacerbation, immediately administer high-flow oxygen (40-60%), nebulized short-acting beta-agonists (albuterol 5 mg or terbutaline 10 mg), and systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg IV), then reassess in 15-30 minutes to determine if hospitalization is needed. 1

Initial Assessment and Severity Classification

First, rapidly assess severity using objective measures:

Acute Severe Asthma (any of the following): 1

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

Life-Threatening Features (immediate ICU consideration): 1

• PEF <33% predicted
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia, hypotension, or arrhythmia
• Exhaustion, confusion, or altered consciousness

Immediate Treatment Protocol

Primary Therapy (All Patients)

Oxygen: 1

• Administer 40-60% oxygen via face mask
• Target oxygen saturation >90% (>95% in pregnant women or patients with heart disease)

Short-Acting Beta-Agonists: 1, 2

• Nebulized albuterol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer
• Can repeat every 20-30 minutes for first hour (up to 3 treatments)
• Alternative: MDI with spacer (4-12 puffs) if patient can cooperate
• For severe exacerbations, consider continuous nebulization

Systemic Corticosteroids (Critical - Start Early): 1, 3, 4

• Oral route preferred: Prednisolone 30-60 mg (or prednisone 40-80 mg) 1, 3
• IV route if vomiting or life-threatening: Hydrocortisone 200 mg IV stat, then 200 mg every 6 hours 1, 4
• Pediatric dosing: 1-2 mg/kg/day (maximum 40-60 mg) 1, 3
• Effects take 6-12 hours to manifest, making early administration critical 3, 5, 6

Adjunctive Therapy for Severe Exacerbations

Ipratropium Bromide: 1, 7

• Add ipratropium 0.5 mg to nebulizer with beta-agonist if severe (PEF <50%)
• Repeat every 6 hours until improvement begins
• Can be mixed with albuterol in nebulizer if used within 1 hour 7
• Reduces ED time and hospitalization rates 5

Reassessment at 15-30 Minutes

If Improving (PEF >50-75% predicted): 1

• Continue oxygen
• Continue oral corticosteroids
• Nebulized beta-agonist every 4 hours
• Consider discharge if PEF >75% with close follow-up <48 hours

If NOT Improving or Severe Features Persist: 1

• Continue oxygen and corticosteroids
• Increase beta-agonist frequency to every 30 minutes
• Continue ipratropium every 6 hours
• Arrange hospital admission
• Consider IV magnesium sulfate for severe refractory cases 3

Criteria for Hospital Admission

Admit if any of the following: 1

• Any life-threatening features present
• Features of acute severe asthma persist after initial treatment
• PEF remains <50% predicted after treatment
• Attack occurs in afternoon/evening
• Recent hospital admission or previous severe attacks
• Patient unable to manage at home

ICU Transfer Indications

Transfer to ICU with physician prepared to intubate if: 1

• Deteriorating PEF despite treatment
• Worsening exhaustion or feeble respirations
• Persistent or worsening hypoxia or hypercapnia
• Confusion, drowsiness, or altered consciousness
• Respiratory arrest

Discharge Planning (If Appropriate)

Before discharge, ensure: 1, 3

• Patient on discharge medications for 24 hours
• PEF >75% predicted with diurnal variability <25%
• Oral corticosteroids: Continue prednisolone 30-60 mg daily for 1-3 weeks (no taper needed if <1 week course) 1, 3, 8
• Increased dose of inhaled corticosteroids
• Peak flow meter provided with self-management plan
• GP follow-up arranged within 1 week
• Respiratory clinic follow-up within 4 weeks

Critical Pitfalls to Avoid

Underuse of corticosteroids is a major contributor to asthma deaths - always administer early, as benefits are delayed 6-12 hours. 1, 5, 6

Do not rely on SABA monotherapy - this addresses bronchospasm but not inflammation, leaving patients at risk for severe exacerbations. 9

Oral corticosteroids are as effective as IV and less invasive - reserve IV route for vomiting or life-threatening presentations. 3

Aminophylline is no longer recommended for acute management in children or as first-line therapy. 1

Reassessment is mandatory - never leave a patient after initial treatment without confirming response at 15-30 minutes. 1