From the Guidelines
Asthma exacerbation requires prompt treatment with short-acting beta-agonists (SABAs) like albuterol, administered via metered-dose inhaler with spacer (2-4 puffs every 20 minutes for up to 1 hour) or nebulizer (2.5-5 mg every 20 minutes for up to 1 hour) as first-line therapy. Systemic corticosteroids should be given early for moderate to severe exacerbations, typically prednisone 40-60 mg daily for 5-7 days for adults (1-2 mg/kg/day for children, maximum 60 mg) 1. Oxygen supplementation is necessary if oxygen saturation falls below 92%. For severe exacerbations not responding to initial treatment, consider adding ipratropium bromide (0.5 mg by nebulizer or 4-8 puffs by MDI every 20 minutes for 1-2 hours), and in hospital settings, intravenous magnesium sulfate (2 g infused over 20 minutes) may be beneficial 1. After stabilization, patients should be discharged with a short course of oral corticosteroids, continued SABA as needed, review of inhaler technique, and a written asthma action plan.
Some key points to consider in managing asthma exacerbations include:
- Early treatment by the patient at home is the best strategy for managing asthma exacerbations 1
- Patients should be instructed how to use a written asthma action plan that notes when and how to treat signs of an exacerbation
- Removing or withdrawing from allergens or irritants in the environment that may contribute to the exacerbation is crucial
- Monitoring response to treatment and promptly communicating with the clinician about any serious deterioration in symptoms or PEF or about decreased responsiveness to SABA treatment is essential
Follow-up within 1-2 weeks is essential to adjust maintenance therapy and prevent future exacerbations. These medications work by addressing both bronchoconstriction (SABAs relax airway smooth muscle) and inflammation (corticosteroids reduce inflammatory response), the two key pathophysiological components of asthma exacerbations.
From the Research
Asthma Exacerbation Management
- Asthma exacerbations are defined as a deterioration in baseline symptoms or lung function, causing significant morbidity and mortality 2.
- Management strategies include the use of asthma action plans to help patients triage and manage symptoms at home.
- For patients 12 years and older, home management may include an inhaled corticosteroid/formoterol combination or a short-acting beta2 agonist 2.
Treatment Options
- In the office setting, treatment may involve assessing exacerbation severity, administering a short-acting beta2 agonist and oxygen, and prescribing oral corticosteroids 2.
- The addition of a short-acting muscarinic antagonist and magnesium sulfate infusion has been associated with fewer hospitalizations 2.
- Inhaled ipratropium bromide has been studied as a potential treatment for acute asthma, with some studies suggesting its use in combination with albuterol may be beneficial 3.
- Other treatment options may include inhaled steroids, ipratropium bromide, magnesium sulfate, theophylline, and heliox 4.
Severe Exacerbations
- Patients with severe exacerbations should be transferred to an acute care facility and treated with oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids 2.
- Assisted ventilation by face mask or endotracheal tube may be required in refractory patients 4.
- A ventilatory strategy that prolongs exhalation time and accepts hypercapnia may be used in intubated patients to minimize lung hyperinflation 4.
Prevention of Future Exacerbations
- The addition of inhaled corticosteroids, consideration of stepping up asthma maintenance therapy, close follow-up, and education on asthma action plans are important next steps to prevent future exacerbations 2.
- Addressing key aspects of outpatient management in the acute care setting can help prevent recurrent attacks 4.