What are the normal fluids and treatments, besides hydrocortisone, for a patient with a severe asthma exacerbation?

Management of Severe Asthma Exacerbation: Essential Fluids and Treatments Beyond Hydrocortisone

For severe asthma exacerbation, immediately administer high-flow oxygen (40-60%) to maintain oxygen saturation >90% (>92% in most guidelines), continuous or frequent nebulized short-acting beta-2 agonists (salbutamol 5 mg or terbutaline 10 mg every 20 minutes for 3 doses, then every 4 hours), and add ipratropium bromide 0.5 mg to the nebulizer for severe or life-threatening features. 1

Immediate Treatment Protocol

Oxygen Therapy

• Administer 40-60% oxygen via face mask or nasal cannula immediately to maintain oxygen saturation >90% (>92% preferred, >95% in pregnant patients or those with heart disease) 1
• CO2 retention is not aggravated by oxygen therapy in asthma, so do not withhold high-flow oxygen 1
• Continue oxygen therapy throughout treatment and monitor with continuous pulse oximetry 1

Inhaled Bronchodilators (Primary Treatment)

• Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer every 20 minutes for the first hour (3 doses total) 1
• Alternative delivery: 4-12 puffs of short-acting beta-2 agonist via metered-dose inhaler (MDI) with valved holding chamber/spacer, repeated every 20 minutes 1, 2
• After initial 3 doses, continue nebulized beta-agonist every 4 hours if improving 1
• If not improving after 15-30 minutes, increase frequency to every 15-30 minutes 1
• For severe exacerbations (PEF <40% predicted), continuous nebulization may be more effective than intermittent dosing 1

Ipratropium Bromide (Anticholinergic)

• Add ipratropium 0.5 mg to the nebulizer immediately if life-threatening features are present 1
• Continue ipratropium 0.5 mg every 6 hours until patient is improving 1
• The combination of beta-agonist plus ipratropium reduces hospitalizations, particularly in severe airflow obstruction 2

Intravenous Therapies for Life-Threatening Exacerbations

When Life-Threatening Features Present

Life-threatening features include: PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, coma, or normal/high PaCO2 (5-6 kPa) 1

IV Bronchodilators

• Intravenous aminophylline 250 mg over 20 minutes (loading dose), followed by continuous infusion of 750-1500 mg/24 hours depending on patient size 1
• Do not give bolus aminophylline to patients already taking oral theophyllines unless plasma levels can be monitored 1
• Alternative: IV salbutamol or terbutaline 250 µg over 10 minutes 1
• Monitor blood concentrations if aminophylline infusion continues >24 hours 1

Magnesium Sulfate

• Consider IV magnesium sulfate for life-threatening exacerbations or those remaining severe after 1 hour of intensive conventional treatment 2
• Particularly beneficial in reducing hospitalizations when added to standard therapy 3

Supportive Care and Monitoring

Fluid and Electrolyte Management

• Arrange measurement of plasma electrolyte and urea concentrations 1
• Maintain appropriate fluid-electrolyte balance, though aggressive hydration is not recommended in older children 2
• Monitor for hypokalemia, especially with high-dose beta-agonist therapy 4

Objective Monitoring

• Measure peak expiratory flow (PEF) 15-30 minutes after starting treatment, then before and after each bronchodilator dose 1, 2
• Arterial blood gas measurement is mandatory in patients admitted to hospital with acute severe asthma 1
• Markers of very severe attack: normal or high PaCO2 (5-6 kPa), severe hypoxia (PaO2 <8 kPa despite oxygen), low pH 1
• Continuous pulse oximetry with target >90-92% 1, 2

Additional Investigations

• Chest radiograph to exclude pneumothorax, consolidation, or pulmonary edema 1
• Complete blood count rarely needed but appropriate if fever or purulent sputum present 1
• Electrocardiogram and cardiac rhythm monitoring in patients >50 years or with known heart disease 1

Common Pitfalls to Avoid

What NOT to Do

• No sedatives of any kind - sedation is absolutely contraindicated in acute severe asthma 1
• Do not give antibiotics unless bacterial infection is confirmed - they are unhelpful in viral-triggered or uncomplicated exacerbations 1, 2
• Avoid percussive physiotherapy - it is unnecessary and potentially harmful 1
• Do not delay systemic corticosteroids while giving repeated bronchodilator doses alone 2
• Underuse of corticosteroids is specifically identified as a leading cause of preventable asthma mortality 2

Escalation Criteria

Indications for Intensive Care

• Deteriorating PEF, worsening or persisting hypoxia (PaO2 <8 kPa) despite 60% oxygen, or hypercapnia (PaCO2 >6 kPa) 1
• Exhaustion, feeble respiration, confusion, drowsiness, coma, or respiratory arrest 1
• Patients with life-threatening features require intensive monitoring by experienced staff 1

Mechanical Ventilation Considerations

• Required for worsening hypoxia or hypercapnia, drowsiness, unconsciousness, or respiratory arrest 1
• Use "permissive hypercapnia" strategy with low peak airway pressures to reduce barotrauma risk 5, 4
• Intubation should ideally be performed by an anesthesiologist 1

Disposition and Follow-Up

Discharge Criteria

• PEF >75% of predicted or best value 1
• Diurnal variability <25% 1
• No nocturnal symptoms 1
• Patient stable on discharge medications for 24 hours 2

At Discharge

• Continue oral prednisolone 30-60 mg daily for 1-3 weeks 1
• Ensure patient has own PEF meter and written self-management plan 1
• GP follow-up within 1 week 1, 2
• Respiratory clinic follow-up within 4 weeks 1, 2

Nuances in Treatment Approach

The evidence strongly supports that repetitive or continuous administration of inhaled beta-2 agonists is the most effective means of reversing airflow obstruction 1. While older guidelines from the British Thoracic Society 1 and more recent NAEPP guidelines 1 are consistent on core treatments (oxygen, bronchodilators, steroids), the NAEPP guidelines 1 provide more specific oxygen saturation targets and emphasize that about 60-70% of patients respond sufficiently to initial treatment to be discharged.

The role of theophylline/aminophylline remains somewhat controversial 5, but guidelines consistently recommend it as second-line therapy for patients not responding to initial treatment 1. Research suggests it adds little to the bronchodilator effect in most patients 5, but it remains guideline-recommended for severe, refractory cases.

The key to reducing mortality is early recognition of severity, objective measurement (never rely on clinical impression alone), and aggressive early treatment with the triad of oxygen, bronchodilators, and systemic corticosteroids. 1, 4