What is the best course of treatment for a patient experiencing vomiting with an asthma flare?

Treatment of Vomiting with Asthma Flare

For patients experiencing vomiting during an asthma exacerbation, administer intravenous hydrocortisone 200 mg every 6 hours instead of oral corticosteroids, while simultaneously treating the underlying asthma with high-dose nebulized β-agonists and oxygen. 1

Immediate Management Algorithm

Recognize Vomiting as a Marker of Severity

• Vomiting during an asthma flare indicates either a severe attack or that the patient cannot tolerate oral medications 1
• While vomiting can rarely be the dominant presenting symptom of acute asthma itself, it more commonly signals disease severity requiring aggressive intervention 2
• The presence of vomiting lowers the threshold for hospital admission and intensive monitoring 1

Switch Corticosteroid Route Immediately

• Give intravenous hydrocortisone 200 mg every 6 hours rather than oral prednisolone in any patient who is vomiting 1
• This is critical because corticosteroids require 6-12 hours to manifest anti-inflammatory effects, and any delay from inadequate absorption can be life-threatening 3
• Do not attempt oral prednisolone 30-60 mg in vomiting patients, as absorption is unreliable 1

Concurrent Asthma Treatment

• Administer high-flow oxygen immediately to maintain oxygen saturation 1
• Give nebulized β-agonist (salbutamol 5 mg or terbutaline 10 mg) driven by oxygen 1, 4
• Add ipratropium bromide to the nebulizer, as the combination decreases emergency department time and hospitalization rates 5
• Measure peak expiratory flow 15-30 minutes after starting treatment 1

Escalation Based on Response

If Improving After 15-30 Minutes

• Continue nebulized β-agonists every 4 hours 1
• Continue IV hydrocortisone 200 mg every 6 hours until vomiting resolves 1
• Maintain oxygen therapy 1
• Monitor peak flow regularly 1

If Not Improving After 15-30 Minutes

• Increase nebulized β-agonist frequency up to every 15 minutes 1
• Consider subcutaneous epinephrine or terbutaline (250 µg over 10 minutes) in patients not responding to continuous nebulization 1, 6
• Consider aminophylline or parenteral β-agonist if progress remains unsatisfactory 1
• Arrange immediate hospital admission 1

Critical Monitoring Requirements

Objective Assessment

• Measure peak expiratory flow before and 15-30 minutes after treatment 1
• Obtain chest radiography to exclude pneumothorax, consolidation, or pulmonary edema 1, 7
• Check plasma electrolytes, urea concentrations, and blood count, as vomiting can cause electrolyte disturbances 1, 7
• Monitor for signs of life-threatening asthma: peak flow <50% predicted, respiratory rate >25/min, heart rate >110/min, inability to complete sentences 8

Admission Criteria

• Any patient with vomiting during an asthma flare who has peak flow <33% predicted after initial nebulization requires immediate hospital referral 1
• Lower threshold for admission applies to patients seen in afternoon/evening, those with recent nocturnal symptoms, or previous severe attacks 1

Critical Pitfalls to Avoid

Contraindicated Interventions

• Never give sedatives to asthmatic patients, as they worsen respiratory depression and are absolutely contraindicated 1, 3
• Do not give antibiotics unless bacterial infection is clearly documented 1, 3
• Avoid percussive physiotherapy, as it is unnecessary and potentially harmful 1

Medication Errors

• Do not give bolus aminophylline to patients already taking oral theophyllines 1
• Do not rely on oral prednisolone in vomiting patients—this is a common error that delays effective treatment 1

Transition to Oral Therapy

• Once vomiting resolves and the patient is improving, transition from IV hydrocortisone to oral prednisolone 30-60 mg daily 1
• Continue high-dose inhaled corticosteroids at discharge 1, 3
• Provide prednisolone for 1-3 weeks after discharge with a written action plan 1, 3