What is the immediate management for a patient with acute exacerbation of bronchial asthma?

Immediate Management of Acute Asthma Exacerbation

Begin with high-dose inhaled albuterol (2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer) every 20 minutes for 3 doses, systemic corticosteroids (prednisone 40-60 mg orally or hydrocortisone 200 mg IV), and oxygen to maintain SaO₂ >90% (>95% in pregnant patients or those with heart disease). 1, 2

Initial Assessment and Severity Recognition

Assess severity immediately using objective measurements—never rely on clinical impression alone, as underestimation is a critical and common cause of preventable asthma deaths. 1, 2

Severe Exacerbation Features:

• Inability to complete sentences in one breath 1
• Respiratory rate >25 breaths/min 1
• Heart rate >110 beats/min 1
• Peak expiratory flow (PEF) <50% of predicted or personal best 1

Life-Threatening Features Requiring ICU Consideration:

• PEF <33% predicted 1
• Silent chest, cyanosis, or feeble respiratory effort 1
• Altered mental status, confusion, or exhaustion 1
• Bradycardia or hypotension 1
• Normal or elevated PaCO₂ (≥42 mmHg) in a breathless patient 1

First-Line Treatment Algorithm

Step 1: Oxygen Therapy (Immediate)

• Administer high-flow oxygen at 40-60% via face mask or nasal cannula to maintain SaO₂ >90% 1, 2
• Target SaO₂ >95% in pregnant patients or those with cardiac disease 1, 3
• Continue oxygen monitoring continuously until clear response to bronchodilator therapy occurs 1

Step 2: Bronchodilator Therapy (Immediate)

• Administer albuterol 2.5-5 mg via nebulizer OR 4-8 puffs via MDI with spacer every 20 minutes for 3 doses (first hour). 1, 2
• Both delivery methods are equally effective when properly administered 1
• After initial 3 doses, continue albuterol 2.5-10 mg every 1-4 hours as needed 1

Step 3: Systemic Corticosteroids (Immediate—Do Not Delay)

• Administer oral prednisone 40-60 mg in single or divided doses for adults. 1
• For children: 1-2 mg/kg/day (maximum 60 mg/day) 1
• If unable to take oral medication: IV hydrocortisone 200 mg 1
• Critical pitfall: Never delay corticosteroids to "try bronchodilators first"—clinical benefits require 6-12 hours minimum, so early administration is essential. 1

Adjunctive Therapies for Moderate-to-Severe Exacerbations

Ipratropium Bromide (Add for All Moderate-to-Severe Cases)

• Add ipratropium bromide 0.5 mg via nebulizer OR 8 puffs via MDI to albuterol every 20 minutes for 3 doses, then as needed. 1, 2
• This combination reduces hospitalizations, particularly in patients with severe airflow obstruction 1

Magnesium Sulfate (For Severe Refractory Cases)

• Administer IV magnesium sulfate 2 g over 20 minutes for patients with:
  • Life-threatening features 1, 2
  • Severe exacerbations not responding after 1 hour of intensive treatment 1, 2
  • FEV₁ or PEF <40% predicted after initial treatment 1
• Pediatric dosing: 25-75 mg/kg (maximum 2 g) IV over 20 minutes 1

Reassessment Protocol

First Reassessment (15-30 Minutes After Initial Treatment)

• Measure PEF or FEV₁ 1, 2
• Assess symptoms and vital signs 1
• Monitor oxygen saturation continuously 1

Second Reassessment (60-90 Minutes—After 3 Doses of Bronchodilator)

• Repeat PEF measurement 1, 2
• Classify response to guide disposition 1

Response Categories:

Good Response (Discharge Candidate):

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

Incomplete Response (Hospital Ward Admission):

• PEF 40-69% predicted 1
• Persistent symptoms 1
• Continue intensive treatment 1

Poor Response (Hospital/ICU Admission):

• PEF <40% predicted 1
• Consider ICU if life-threatening features present 1

Critical Pitfalls to Avoid

• Never administer sedatives of any kind to patients with acute asthma—this is absolutely contraindicated. 1
• Do not delay intubation once deemed necessary—it should be performed semi-electively before respiratory arrest occurs. 1
• Avoid methylxanthines (theophylline/aminophylline) due to increased side effects without superior efficacy 1
• Do not give bolus aminophylline to patients already taking oral theophyllines 1
• Avoid aggressive hydration in older children and adults 1
• Do not routinely prescribe antibiotics unless strong evidence of bacterial infection (pneumonia or sinusitis) exists 1

Hospital Admission Criteria

Immediate Hospital Admission Required For:

• Any life-threatening features present 1
• Features of severe attack persisting after initial treatment 1
• PEF <50% predicted after 1-2 hours of intensive treatment 1

Lower Threshold for Admission If:

• Previous intubation or ICU admission for asthma 1
• ≥2 hospitalizations or ≥3 ED visits in past year 1
• Recent hospitalization or ED visit within past month 1
• Presentation in afternoon/evening 1
• Recent onset of nocturnal symptoms 1
• Poor social circumstances or difficulty perceiving symptom severity 1

Discharge Planning (For Patients Meeting Discharge Criteria)

• Continue oral corticosteroids for 5-10 days (no taper needed for courses <10 days). 1, 2
• Initiate or continue inhaled corticosteroids at discharge 1, 2
• Provide written asthma action plan 1, 2
• Verify inhaler technique before discharge 1
• Arrange follow-up with primary care within 1 week 1, 2
• Arrange specialist clinic follow-up within 4 weeks 1
• Observe patient for 30-60 minutes after last bronchodilator dose to ensure stability 1

Monitoring Parameters Throughout Treatment

• Oxygen saturation continuously 1
• PEF or FEV₁ before and after treatments 1
• Vital signs (respiratory rate, heart rate, blood pressure) 1
• Potassium levels if administering frequent beta-agonists (albuterol can cause hypokalemia through intracellular shunting) 4