What is the treatment for an acute asthma attack in adults?

Treatment for Acute Asthma Attack in Adults

Immediately administer nebulized short-acting beta-2 agonist (salbutamol 5 mg or terbutaline 10 mg) with oxygen 40-60% and oral prednisolone 30-60 mg, then reassess at 15-30 minutes to determine disposition. 1, 2, 3

Initial Assessment and Severity Classification

Assess severity objectively using peak expiratory flow (PEF), respiratory rate, heart rate, and ability to complete sentences—never rely on clinical impression alone. 1, 2, 3

Moderate Asthma (treat at home if appropriate):

• Speech normal 1
• Pulse <110 beats/min 1
• Respiration <25 breaths/min 1
• PEF >50% predicted or personal best 1

Acute Severe Asthma (strongly consider admission):

• Cannot complete sentences in one breath 1, 2
• Pulse >110 beats/min 1, 2
• Respiration >25 breaths/min 1, 2
• PEF <50% predicted or personal best 1, 2

Life-Threatening Features (immediate ICU consideration):

• PEF <33% predicted 1, 3
• Silent chest, cyanosis, feeble respiratory effort 1, 3
• Exhaustion, confusion, drowsiness, or coma 1, 3
• Bradycardia, hypotension, or respiratory arrest 1, 3

First-Line Treatment (Within 15-30 Minutes)

Oxygen Therapy:

• Administer 40-60% oxygen immediately to maintain saturation >90% 1, 3
• Use oxygen as the driving gas for nebulizers whenever possible 3, 4

Nebulized Beta-2 Agonist:

• Salbutamol 5 mg OR terbutaline 10 mg via oxygen-driven nebulizer 1, 2, 3
• Repeat every 20 minutes for 3 doses initially 3, 5
• If no nebulizer available, use metered-dose inhaler with large-volume spacer: 4-8 puffs every 20 minutes 1, 3

Systemic Corticosteroids:

• Oral prednisolone 30-60 mg immediately (preferred route) 1, 2, 3
• Alternative: IV hydrocortisone 200 mg if unable to take oral 1
• Oral administration is as effective as IV and strongly preferred 3, 6
• Clinical benefits may not occur for 6-12 hours, so early administration is critical 7, 6

Reassessment at 15-30 Minutes

Measure PEF, vital signs, oxygen saturation, and clinical response—response to treatment predicts hospitalization need better than initial severity. 1, 3

If PEF >75% predicted/best:

• Step up usual maintenance treatment 1
• Arrange follow-up within 48 hours 1
• Provide PEF meter and self-management plan 1

If PEF 50-75% predicted/best:

• Continue prednisolone 30-60 mg 1
• Continue nebulized beta-2 agonist every 4 hours 1
• Reassess before discharge; must be stable for 60 minutes 1

If PEF <50% or any severe features persist:

• Arrange immediate hospital admission 1
• Continue oxygen and steroids 1
• Increase nebulized beta-2 agonist frequency to every 30 minutes 1
• Add ipratropium bromide 0.5 mg to nebulizer, repeat every 6 hours 1, 8

Additional Therapies for Severe/Life-Threatening Asthma

Ipratropium Bromide:

• Add 0.5 mg to nebulized beta-2 agonist for severe exacerbations 1, 7, 8
• Combination provides 16-32% greater improvement in PEF than salbutamol alone 8
• Benefits are primarily in emergency department; not sustained after hospital admission 7

IV Magnesium Sulfate:

• Consider 2 g over 20 minutes for severe exacerbations not responding to initial therapy 3
• Recommended for life-threatening presentations 3

Aminophylline:

• Reserved only for life-threatening features with inadequate response 1
• NOT recommended in first 4 hours of therapy due to increased side effects without superior efficacy 3, 6
• If used: 5 mg/kg IV over 20 minutes, then 1 mg/kg/h maintenance 1
• Omit loading dose if patient already taking oral theophyllines 1

Critical Pitfalls to Avoid

Never underestimate severity based on clinical impression alone—always use objective measurements (PEF, oxygen saturation). 1, 2, 3

Do not administer sedatives of any kind in acute asthma. 3

Do not delay systemic corticosteroids—underuse of corticosteroids is a major factor in preventable asthma deaths. 1

Do not routinely prescribe antibiotics unless strong evidence of bacterial infection exists. 3

Do not use methylxanthines (theophylline) routinely due to increased side effects without superior efficacy. 3, 4

Hospital Admission Criteria

Admit if any of the following present after initial treatment: 1

• Any life-threatening features 1
• PEF <33% predicted 1
• Any features of acute severe asthma persist after initial treatment 1

Lower threshold for admission if: 1

• Attack occurs in afternoon or evening 1
• Recent hospital admission or previous severe attacks 1
• Recent nocturnal symptoms 1
• Patient unable to assess own condition or poor social circumstances 1

ICU Transfer Indications

Transfer to ICU accompanied by physician prepared to intubate if: 1

• Deteriorating PEF or worsening exhaustion 1
• Feeble respirations, persistent hypoxia, or hypercapnia 1
• Coma, respiratory arrest, confusion, or drowsiness 1

Discharge Planning

Patients should only be discharged when: 1

• Stable on discharge medication for 24 hours 1
• PEF >75% predicted or personal best 1
• Inhaler technique checked and recorded 1
• Prescribed oral corticosteroids (30-60 mg prednisolone daily for 7-14 days, no taper needed) 3, 6
• Prescribed inhaled corticosteroids in addition to bronchodilators 1, 6
• Provided PEF meter and self-management plan 1
• GP follow-up arranged within 1 week 1