What is the management of acute asthma exacerbation?

From the Guidelines

Management of acute asthma requires immediate treatment with high-flow oxygen, inhaled short-acting beta-agonists, and systemic corticosteroids, with the dose and frequency of administration dependent on the severity of the exacerbation. According to the most recent guidelines 1, all patients presenting with an asthma exacerbation should be evaluated and triaged immediately, with treatment instituted promptly on determination of a moderate, severe, or life-threatening exacerbation.

Initial Treatment

For severe exacerbations, provide high-flow oxygen targeting saturation of 93-95%, as recommended by 1. The initial treatment should also include inhaled short-acting beta-agonists (SABA) like albuterol/salbutamol, with a dose of 2.5-5 mg via nebulizer every 20 minutes for the first hour, as suggested by 1.

Corticosteroids and Additional Treatment

Add oral corticosteroids early (prednisone/prednisolone 40-60 mg daily for 5-7 days) to reduce inflammation, as recommended by 1. For life-threatening asthma, consider administering intravenous magnesium sulfate and prepare for possible intubation. Throughout treatment, monitor response using clinical parameters and objective measures, and reassess frequently to adjust treatment accordingly.

Monitoring and Follow-up

After stabilization, ensure patients have a written asthma action plan, proper inhaler technique education, and follow-up within 1-2 weeks, as suggested by 1. This approach works because beta-agonists rapidly relieve bronchospasm while corticosteroids address the underlying inflammatory process, and additional interventions target specific pathophysiological mechanisms as severity increases. Key points to consider in management include:

• Prompt assessment and treatment based on severity
• Use of high-flow oxygen for severe exacerbations
• Administration of inhaled beta-agonists and systemic corticosteroids
• Monitoring of response and adjustment of treatment
• Provision of a written asthma action plan and follow-up after stabilization.

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. The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm During this time most patients gain optimum benefit from regular use of the inhalation solution. If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy.

For the management of acute asthma, the recommended dosage of albuterol (INH) is 2.5 mg administered three to four times daily by nebulization for adults and children weighing at least 15 kg 2.

• The medication can be continued as medically indicated to control recurring bouts of bronchospasm.
• If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately.

From the Research

Management of Acute Asthma

• Asthma exacerbation is defined as a progressive increase in symptoms of shortness of breath, cough, or wheezing sufficient to require a change in therapy 3.
• Short-acting β2 agonists and short-acting muscarinic antagonists are effective as bronchodilators for asthma in the acute setting 3, 4.
• Systemic corticosteroids to reduce airway inflammation continue to be the mainstay therapy for asthma exacerbations, and, unless there is a contraindication, the oral route is favored 3.
• The evidence favors the use of intravenous magnesium sulfate in selected cases, particularly in severe exacerbations 3, 5.
• Methylxanthines have a minimum role as therapy for asthma exacerbations but may be considered in refractory cases of status asthmaticus with careful monitoring of toxicity 3, 6.
• Current guidelines recommend the use of helium-oxygen mixtures in patients who do not respond to standard therapies or those with severe disease 3, 4.

Treatment Strategies

• High-dose, frequent or continuous nebulized short-acting beta2 agonist (SABA) therapy that can be combined with a short-acting muscarinic antagonist (SAMA) is the backbone of treatment 4.
• The early use of oral or parenteral corticosteroids should be considered when patients do not rapidly clinically respond to SABA/SAMA inhalation 4, 5.
• Adjunctive therapies such as the use of intravenous magnesium and helium/oxygen combination gas for inhalation and for driving a nebulizer to deliver a SABA and or SAMA should be considered and are best used early in the treatment plan if they are likely to impact the patients' clinical course 4, 5.
• Asthma action plans help patients triage and manage symptoms at home, and inhaled corticosteroid/formoterol combination can be used for home management in patients 12 years and older 5.
• In the office setting, it is important to assess exacerbation severity and begin a short-acting beta2 agonist and oxygen to maintain oxygen saturations, with repeated doses of the short-acting beta2 agonist every 20 minutes for one hour and oral corticosteroids 5.

Medication Regimens

• First-line treatment for asthma is inhaled salbutamol: used on demand to relieve respiratory discomfort or to prevent attacks due to a known trigger; or on a daily basis if necessary, in combination with an inhaled corticosteroid such as beclometasone, for patients with persistent asthma 7.
• Treatment of severe persistent asthma is based on daily use of a high-dose inhaled corticosteroid, or possibly an oral corticosteroid, for as short a period as possible 7.
• The dose should be reduced, or the treatment gradually withdrawn, once asthma is under control to limit adverse effects and drug interactions 7.