What is the initial treatment protocol for an adult patient experiencing an asthma exacerbation?

Adult Asthma Exacerbation Protocol

Immediately administer high-dose inhaled short-acting beta-agonists, supplemental oxygen to maintain saturation >90%, and oral corticosteroids within the first 15-30 minutes of presentation for all adults with acute asthma exacerbation. 1

Immediate Assessment and Initial Treatment (0-15 Minutes)

Severity Classification

Assess severity using objective measures immediately upon presentation:

• Severe exacerbation features: inability to complete sentences in one breath, respiratory rate ≥25 breaths/min, heart rate ≥110 beats/min, peak expiratory flow (PEF) <50% predicted or personal best 2, 3
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, coma, or PaCO₂ ≥42 mmHg 2, 3
• Critical pitfall: Physicians frequently underestimate severity by relying on clinical impression alone rather than objective measurements 2, 3

First-Line Bronchodilator Therapy

Administer albuterol immediately via nebulizer or metered-dose inhaler (MDI) with spacer:

• Nebulizer dosing: 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 3, 1
• MDI with spacer dosing: 4-8 puffs every 20 minutes for up to 3 doses, then as needed 3, 1
• Both delivery methods are equally effective when properly administered 3

Oxygen Therapy

• Administer oxygen via nasal cannula or mask to maintain oxygen saturation >90% (>95% in pregnant patients or those with heart disease) 3, 1
• Use oxygen as the driving gas for nebulizers whenever possible 1
• Monitor oxygen saturation continuously until clear response to bronchodilator therapy occurs 3

Systemic Corticosteroids - Critical Early Intervention

Administer oral prednisolone or prednisone 30-60 mg immediately (or IV hydrocortisone 200 mg if patient is vomiting or severely ill) 2, 4, 1

• Oral administration is as effective as intravenous therapy and is strongly preferred 2, 4
• Clinical benefits require a minimum of 6-12 hours to become apparent, making early administration crucial 4, 5
• Critical pitfall: Never delay corticosteroid administration while "trying bronchodilators first" 3

Reassessment at 15-30 Minutes

Monitoring Parameters

• Measure PEF or FEV₁ before and after treatments 3, 1
• Assess symptoms, vital signs, and oxygen saturation 3, 1
• Response to treatment is a better predictor of hospitalization need than initial severity 3, 1

Treatment Response Categories

Good response (PEF ≥70% predicted):

• Continue albuterol every 4 hours as needed 3
• Continue oral corticosteroids for 5-10 days 4, 1
• Consider discharge if stable for 30-60 minutes after last bronchodilator dose 3

Incomplete response (PEF 40-69% predicted):

• Continue intensive treatment with albuterol every 1-2 hours 3
• Add ipratropium bromide (see below) 3
• Consider hospital admission 3

Poor response (PEF <40% predicted):

• Admit to hospital 3
• Consider ICU admission if life-threatening features present 3
• Escalate to additional therapies (see below) 3

Adjunctive Therapies for Moderate-to-Severe Exacerbations

Ipratropium Bromide

Add ipratropium bromide to albuterol for all moderate-to-severe exacerbations:

• Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for 3 doses, then as needed 2, 3, 1
• Combination therapy reduces hospitalizations, particularly in patients with severe airflow obstruction 3, 6
• Can be mixed with albuterol in the nebulizer if used within one hour 7

Intravenous Magnesium Sulfate

Consider for severe exacerbations (PEF <40% after initial treatment) or life-threatening presentations:

• Dosing: 2 g IV over 20 minutes for adults 3, 1
• Significantly increases lung function and decreases hospitalization necessity 3
• Well-tolerated with minor side effects 3

Ongoing Management and Monitoring

Continue Treatment Until Stabilization

• Prednisolone/prednisone: 30-60 mg daily (or IV hydrocortisone 200 mg every 6 hours if unable to take oral) until PEF reaches 70% of predicted or personal best 2, 4
• Duration: Typically 5-10 days for outpatient management; may extend to 21 days in severe cases until lung function returns to previous best 2, 4, 1
• No tapering necessary for courses <7-10 days, especially if patient is on inhaled corticosteroids 2, 4

Measure PEF Every 15-30 Minutes

Continue monitoring and adjust treatment frequency based on response 2, 3

If No Improvement After 15-30 Minutes

• Give nebulized beta-agonists more frequently (up to every 15 minutes) 2
• Continue ipratropium bromide 2
• Consider IV aminophylline 250 mg over 20 minutes or IV salbutamol/terbutaline 250 µg over 10 minutes (do not give bolus aminophylline to patients already taking oral theophyllines) 2

Hospital Admission Criteria

Immediate hospital referral required for:

• Life-threatening features (PEF <33%, silent chest, altered mental status, PaCO₂ ≥42 mmHg) 2, 3, 1
• Features of severe attack persisting after initial treatment 2, 1
• PEF 15-30 minutes after nebulization <33% of predicted or best value 2

Lower threshold for admission in patients:

• Presenting in afternoon/evening rather than morning 2
• With recent onset of nocturnal symptoms or worsening symptoms 2
• With previous severe attacks, especially if rapid onset 2
• With concern over assessment of severity or social circumstances 2

Critical Pitfalls to Avoid

• Never administer sedatives of any kind - this is absolutely contraindicated 2, 3, 1
• Do not use methylxanthines (theophylline) routinely due to increased side effects without superior efficacy 3, 1
• Do not routinely prescribe antibiotics unless strong evidence of bacterial infection (pneumonia, sinusitis) exists 3, 1
• Do not delay intubation once deemed necessary - it should be performed semi-electively before respiratory arrest 3, 1
• Do not underestimate severity - always use objective measurements (PEF, oxygen saturation) rather than clinical impression alone 2, 3
• Avoid aggressive hydration in adults (may be appropriate for infants/young children) 3

Discharge Planning (After Stabilization)

Discharge criteria:

• PEF ≥70% of predicted or personal best 3, 1
• Symptoms minimal or absent 3
• Oxygen saturation stable on room air 3
• Stable for 30-60 minutes after last bronchodilator dose 3

At discharge:

• Continue oral corticosteroids for 5-10 days (no taper needed) 4, 3, 1
• Initiate or continue inhaled corticosteroids 3, 1
• Provide written asthma action plan 3
• Review inhaler technique 3
• Arrange follow-up within 1 week 3