What is the management of acute asthma exacerbation?

From the Guidelines

Management of acute asthma exacerbations should prioritize prompt assessment and stepwise treatment, starting with inhaled short-acting beta-agonists (SABA) and oral corticosteroids, as recommended by the most recent guidelines 1. The goal of treatment is to relieve hypoxemia and airflow obstruction, reduce airway inflammation, and improve symptoms.

Key Components of Treatment

• Inhaled SABA, such as albuterol, should be administered via nebulizer or metered-dose inhaler with spacer every 20 minutes for the first hour, as recommended by the guidelines 1.
• Oral corticosteroids, such as prednisone 40-60 mg daily, should be added early in the treatment, as they have been shown to reduce the risk of recurrence 1.
• Oxygen should be provided to maintain saturation ≥92%, and continuous albuterol nebulization (10-15 mg/hour) should be considered for severe exacerbations, as recommended by the guidelines 1.
• Ipratropium bromide 0.5 mg every 4-6 hours may be added for the first 24-48 hours in severe exacerbations, as it has been shown to improve symptoms and lung function 1.

Monitoring and Discharge

• Patients should be monitored closely for response to treatment, with serial assessments of symptoms, vital signs, and peak flow measurements, as recommended by the guidelines 1.
• Patients can be discharged if FEV1 or PEF results are 70% or more of predicted value or personal best and symptoms are minimal or absent, as recommended by the guidelines 1.
• Before discharge, patients should be prescribed oral systemic corticosteroids for 3 to 10 days to reduce the risk of recurrence, and should be provided with a clear action plan, continued controller medications, and follow-up within 1-2 weeks, as recommended by the guidelines 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

• Asthma exacerbation is defined as a progressive increase in symptoms of shortness of breath, cough, or wheezing sufficient to require a change in therapy 3.
• The goals of managing an asthma exacerbation are prompt recognition and rapid reversal of airflow obstruction to avert relapses and future episodes 4.

Treatment Options

• Short-acting β2 agonists and short-acting muscarinic antagonists are effective as bronchodilators for asthma in the acute setting 3.
• Systemic corticosteroids to reduce airway inflammation continue to be the mainstay therapy for asthma exacerbations, and, unless there is a contraindication, the oral route is favored 3.
• The evidence favors the use of intravenous magnesium sulfate in selected cases, particularly in severe exacerbations 3.
• High-dose, frequent or continuous nebulized short-acting beta2 agonist (SABA) therapy that can be combined with a short-acting muscarinic antagonist (SAMA) is the backbone of treatment 5.
• Adjunctive therapies such as the use of intravenous magnesium and helium/oxygen combination gas for inhalation and for driving a nebulizer to deliver a SABA and or SAMA should be considered and are best used early in the treatment plan if they are likely to impact the patients' clinical course 5.

Management Strategies

• Asthma action plans help patients triage and manage symptoms at home 6.
• In patients 12 years and older, home management includes an inhaled corticosteroid/formoterol combination for those who are not using an inhaled corticosteroid/long-acting beta2 agonist inhaler for maintenance, or a short-acting beta2 agonist for those using an inhaled corticosteroid/long-acting beta2 agonist inhaler that does not include formoterol 6.
• In the office setting, it is essential to assess exacerbation severity and begin a short-acting beta2 agonist and oxygen to maintain oxygen saturations, with repeated doses of the short-acting beta2 agonist every 20 minutes for one hour and oral corticosteroids 6.
• 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 6.