What are the treatment options for an asthma flare-up?

Treatment of Asthma Flare-Ups

All patients experiencing an asthma exacerbation should receive three primary treatments immediately: supplemental oxygen to maintain saturation >90%, inhaled short-acting beta-2 agonists (albuterol or terbutaline), and systemic corticosteroids. 1, 2

Initial Assessment and Severity Classification

Before initiating treatment, rapidly assess severity using objective measures:

• Mild-Moderate Exacerbation: Speech normal, pulse <110 bpm, respiratory rate <25 breaths/min, peak expiratory flow (PEF) >50% predicted 1, 2
• Severe Exacerbation: Cannot complete sentences, pulse >110 bpm, respiratory rate >25 breaths/min, PEF <50% predicted 1, 2
• Life-Threatening: PEF <33% predicted, silent chest, cyanosis, weak respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 2

Primary Treatment Protocol

Oxygen Therapy

• Administer oxygen via nasal cannula or mask at 40-60% to maintain oxygen saturation >90% (>95% in pregnant patients or those with heart disease) 1, 2
• Continue monitoring until clear response to bronchodilator therapy occurs 1

Inhaled Short-Acting Beta-2 Agonists

• Initial dosing: Administer albuterol 5 mg or terbutaline 10 mg via nebulizer with oxygen 1, 2
• Give 3 treatments every 20-30 minutes during the first hour 1
• Delivery method: Nebulizer therapy is preferred for severe exacerbations or patients unable to cooperate with metered-dose inhalers (MDI) 1
• For milder exacerbations, 4-12 puffs via MDI with valved holding chamber is acceptable 1
• If no nebulizer available: Give 2 puffs of beta-agonist via large volume spacer and repeat 10-20 times 1

Critical point: Approximately 60-70% of patients will respond sufficiently to the initial 3 doses to be discharged 1

Systemic Corticosteroids

• Oral route (preferred): Prednisolone 30-60 mg 1, 2
• IV route: Hydrocortisone 200 mg IV for patients who are vomiting, unable to swallow, or have life-threatening features 1, 2
• Systemic corticosteroids speed resolution of airflow obstruction and should be given to most patients 1
• Anti-inflammatory effects take 6-12 hours to manifest 2

Reassessment at 15-30 Minutes

Measure and record PEF 15-30 minutes after initial treatment 1, 2

If Patient Improves (PEF >50-75% predicted):

• Continue oxygen therapy 1
• Maintain high-dose corticosteroids 1
• Administer nebulized beta-agonists every 4 hours 1

If No Improvement After 15-30 Minutes:

• Continue oxygen and steroids 1
• Increase nebulized beta-agonist frequency up to every 30 minutes 1
• Add ipratropium bromide 0.5 mg to nebulizer, repeat every 6 hours until improvement 1
• Consider aminofilina or parenteral beta-agonist 2

Important caveat: For severe exacerbations (PEF <40% predicted), continuous nebulization of beta-agonists may be more effective than intermittent administration 1

Criteria for Hospital Admission

Admit patients with:

• Any life-threatening features 1
• Any features of acute severe asthma persisting after initial treatment, especially PEF <33% 1
• Lower threshold for admission if attack occurs in afternoon/evening, recent nocturnal symptoms, recent hospital admission, or previous severe attacks 1

ICU Transfer Criteria

Transfer to intensive care unit if:

• Deteriorating PEF despite treatment 1, 2
• Worsening exhaustion or feeble respirations 1, 2
• Persistent or worsening hypoxia or development of hypercapnia 1, 2
• Confusion, drowsiness, coma, or respiratory arrest 1, 2

Discharge Planning

Patients should not be discharged until:

• On discharge medications for 24 hours with verified proper inhaler technique 1, 2
• PEF >75% of predicted or personal best with diurnal variability <25% 1, 2

Discharge medications must include:

• Oral prednisolone 30-60 mg daily for 1-3 weeks 2
• Inhaled corticosteroids at higher doses than pre-exacerbation 1, 2
• Short-acting beta-agonists for as-needed use 1, 2
• Peak flow meter with written self-management plan 1, 2

Follow-up schedule:

• Primary care physician within 1 week 1, 2
• Respiratory clinic within 4 weeks 1, 2

Common Pitfalls to Avoid

• Never delay treatment to obtain chest radiographs unless pneumothorax, pneumonia, or heart failure is suspected 1
• Do not use long-acting beta-agonists during acute exacerbations—they are not indicated for relief of acute bronchospasm 3
• Avoid underusing corticosteroids—this is a major factor in preventable asthma deaths 1
• Do not discharge patients too early—ensure 24 hours of stability on discharge regimen 1, 2