What is the management of acute asthma exacerbation?

From the Guidelines

Management of acute asthma exacerbations requires prompt assessment and stepwise treatment, with the most recent and highest quality study recommending immediate treatment with oxygen, inhaled beta-2 agonists, and systemic corticosteroids 1.

Key Components of Treatment

• Inhaled short-acting beta-agonists (SABA) like albuterol 2-4 puffs via metered-dose inhaler with spacer every 20 minutes for the first hour, then every 1-4 hours as needed
• Oral corticosteroids such as prednisone 40-60 mg daily for 5-7 days for faster resolution of symptoms
• Supplemental oxygen to maintain oxygen saturation ≥92%

Severe Exacerbations

• Administer continuous albuterol nebulization (2.5-5 mg every 20 minutes or 10-15 mg/hour continuously)
• Systemic corticosteroids (methylprednisolone 60-125 mg IV or equivalent)
• Consider ipratropium bromide 0.5 mg by nebulization every 20 minutes for the first hour

Life-Threatening Exacerbations

• Add intravenous magnesium sulfate (2 g over 20 minutes)
• Consider intubation if respiratory failure develops

Monitoring and Follow-Up

• Monitor response to treatment with serial assessments of symptoms, oxygen saturation, and peak flow measurements
• Review the patient's maintenance therapy, inhaler technique, and develop an asthma action plan to prevent future exacerbations The American Thoracic Society and European Respiratory Society statement on asthma control and exacerbations emphasizes the importance of standardizing endpoints for clinical asthma trials and clinical practice, and recommends that severe asthma exacerbations be defined as events that require urgent action to prevent a serious outcome, such as hospitalization or death from asthma 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults and Children 2 to 12 Years of Age: The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm During this time most patients gain optimum benefit from regular use of the inhalation solution. If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy.

For acute asthma exacerbation management, the drug label suggests using albuterol (INH) as needed to control recurring bouts of bronchospasm. The recommended dosage is 2.5 mg administered three to four times daily by nebulization for adults and children weighing at least 15 kg.

• Key points for management:
  • Use 2.5 mg of albuterol as needed
  • Administer by nebulization
  • Seek medical advice if symptoms worsen or if a previously effective dosage regimen fails to provide relief 2

From the Research

Acute Asthma Exacerbation Management

Overview of Management Strategies

• Asthma exacerbations are defined as a deterioration in baseline symptoms or lung function, causing significant morbidity and mortality 3.
• Management strategies include the use of asthma action plans, inhaled corticosteroids, short-acting beta2 agonists, and oral corticosteroids 3, 4.
• The goal of management is to reduce symptoms, improve lung function, and prevent hospitalization.

Pharmacological Interventions

• Short-acting beta2 agonists and short-acting muscarinic antagonists are effective as bronchodilators for asthma in the acute setting 4.
• Systemic corticosteroids are the mainstay therapy for asthma exacerbations, and the oral route is favored unless there is a contraindication 4.
• The addition of ipratropium bromide to beta2-agonist therapy has been shown to improve lung function and reduce hospitalization rates in both adults and children 5, 6.
• Intravenous magnesium sulfate may be considered in severe exacerbations, particularly in patients who do not respond to standard therapies 4, 7.

Treatment Approaches

• In patients 12 years and older, home management includes an inhaled corticosteroid/formoterol combination or a short-acting beta2 agonist 3.
• In children four to 11 years of age, an inhaled corticosteroid/formoterol inhaler can be used to reduce the risk of exacerbations and need for oral corticosteroids 3.
• In the office setting, assessment of exacerbation severity and initiation of a short-acting beta2 agonist and oxygen are crucial, with repeated doses of the short-acting beta2 agonist every 20 minutes for one hour and oral corticosteroids 3.
• 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 3.