What are the recommended medications for treating near-fatal asthma according to Cochrane trials?

Medications for Near-Fatal Asthma

For near-fatal asthma, immediately administer high-dose nebulized beta-agonists (salbutamol 5 mg or terbutaline 10 mg) with oxygen, high-dose systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg), and add nebulized ipratropium (0.5 mg) plus IV aminophylline (250 mg over 20 minutes) or IV beta-agonist (salbutamol or terbutaline 250 µg over 10 minutes). 1

Life-Threatening Features Requiring Immediate Action

Near-fatal asthma is defined by the presence of life-threatening features that demand urgent intervention 1:

• Peak expiratory flow (PEF) <33% of predicted or best 1
• Silent chest, cyanosis, or feeble respiratory effort 1
• Bradycardia or hypotension 1
• Exhaustion, confusion, or coma 1
• Normal or elevated PaCO₂ (5-6 kPa or higher) in a breathless patient 1
• Severe hypoxia: PaO₂ <8 kPa despite oxygen therapy 1

First-Line Medication Protocol

Immediate Treatment (Start ALL Simultaneously)

1. High-Dose Inhaled Beta-Agonists 1

• Nebulized salbutamol 5 mg OR terbutaline 10 mg 1
• Deliver via oxygen-driven nebulizer (40-60% oxygen) 1
• Alternative: Multiple actuations of metered-dose inhaler into large spacer device (20-40 puffs) 1
• Repeat every 15-30 minutes if no improvement 1

2. High-Dose Systemic Corticosteroids 1

• Prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg 1
• Can give both simultaneously in life-threatening cases 1
• Continue hydrocortisone 200 mg every 6 hours for seriously ill or vomiting patients 1

Additional Medications for Life-Threatening Features

3. Nebulized Ipratropium 1

• Add ipratropium 0.5 mg to the beta-agonist nebulizer 1
• Repeat every 6 hours until improvement begins 1
• Can be mixed in same nebulizer with salbutamol 1

4. IV Aminophylline OR IV Beta-Agonist 1

• IV aminophylline 250 mg over 20 minutes 1
• Critical caveat: Do NOT give bolus aminophylline to patients already taking oral theophyllines 1
• Alternative: IV salbutamol or terbutaline 250 µg over 10 minutes 1

5. Continuous Oxygen Therapy 1

• Maintain oxygen at 40-60% 1
• Continue throughout treatment 1

Monitoring and Escalation

Reassess at 15-30 minutes after initial treatment 1:

• If no improvement: Increase nebulized beta-agonist frequency to every 15 minutes 1
• If still unsatisfactory: Consider aminophylline or parenteral beta-agonist 1
• Measure arterial blood gases in all hospitalized patients 1

Intensive Care Indications

Transfer to ICU with physician prepared to intubate if 1:

• Deteriorating PEF, worsening or persistent hypoxia (PaO₂ <8 kPa) despite 60% oxygen, or hypercapnia (PaCO₂ >6 kPa) 1
• Exhaustion, feeble respiration, confusion, drowsiness, coma, or respiratory arrest 1

Critical Pitfalls to Avoid

Contraindicated treatments 1:

• Any sedation is absolutely contraindicated 1
• Antibiotics only if bacterial infection confirmed 1
• Percussive physiotherapy is unnecessary 1

Common errors leading to mortality 1:

• Failure to make objective measurements (PEF, arterial blood gases) 1
• Underestimation of severity by patients, relatives, and doctors 1
• Underuse of corticosteroids 1

Evidence Quality Note

The British Thoracic Society guidelines 1 provide the most comprehensive algorithmic approach to near-fatal asthma management. While these are from 1993, they remain the most detailed guideline-level evidence specifically addressing near-fatal asthma with explicit medication protocols. The NAEPP guidelines 1 from 2009 support similar approaches but with less specific detail for near-fatal presentations. The corticosteroid recommendations are strongly supported by research demonstrating their role in preventing asthma mortality 2, 3, 4, 5.