What is the first line of treatment at home for a patient with bronchial asthma in acute exacerbation?

Home Medication for Acute Asthma Exacerbation

For acute asthma exacerbation at home, immediately administer nebulized salbutamol 5 mg (or terbutaline 10 mg) OR 4-8 puffs of albuterol via metered-dose inhaler with spacer, combined with oral prednisolone 30-60 mg, and reassess response within 15-30 minutes. 1, 2

Initial Assessment Before Treatment

Assess severity objectively—do not rely on clinical impression alone, as underestimation is a critical and common pitfall 1, 2:

• Speech ability: Can the patient complete sentences? 1
• Respiratory rate: >25 breaths/min indicates severe exacerbation 1
• Heart rate: >110 beats/min suggests severity 1
• Peak expiratory flow (PEF): <50% predicted/best indicates acute severe asthma 1

First-Line Treatment Protocol

Bronchodilator Administration

Option 1 - Nebulizer (Preferred if available):

• Salbutamol 5 mg OR terbutaline 10 mg via nebulizer 1, 2
• If no nebulizer available, proceed to Option 2 1

Option 2 - Metered-Dose Inhaler with Spacer:

• Give 2 puffs of β-agonist via large volume spacer, repeat 10-20 times (total 4-8 puffs minimum) 1
• This method is equally effective when properly administered 2

Systemic Corticosteroids (Essential - Do Not Delay)

Administer immediately, not after "trying bronchodilators first" 1, 2:

• Adults: Prednisolone 30-60 mg orally as single dose 1, 2, 3
• Children: Prednisolone 1-2 mg/kg (maximum 40-60 mg) 1, 2, 3
• Clinical benefits require 6-12 hours minimum to manifest, making early administration crucial 2, 3

Reassessment at 15-30 Minutes

This step is mandatory before leaving the patient 1:

If PEF >50-75% predicted/best:

• Continue prednisolone 30-60 mg daily 1
• Step up usual maintenance treatment 1
• Arrange surgery/clinic review within 48 hours 1
• Provide self-management plan and PEF monitoring chart 1

If PEF remains <50% or severe features persist:

• Arrange immediate hospital admission 1
• Repeat nebulized salbutamol OR give additional MDI puffs 1
• Consider adding ipratropium 0.5 mg to nebulizer 1, 2
• Oxygen 40-60% if available during transport 1

Critical Pitfalls to Avoid

• Never delay corticosteroid administration—underuse of corticosteroids is a documented cause of preventable asthma deaths 1, 2
• Never administer sedatives of any kind to patients with acute asthma 1, 2
• Do not underestimate severity—always measure PEF objectively rather than relying on clinical impression 1, 2
• Do not use SABA alone without considering systemic corticosteroids for moderate-to-severe exacerbations 2

Hospital Admission Criteria

Immediate referral required if any of the following present 1:

• Any life-threatening features (confusion, silent chest, cyanosis, PEF <33%) 1
• Features of acute severe asthma persist after initial treatment 1
• Attack occurs in afternoon/evening 1
• Recent hospital admission or previous severe attacks 1
• Patient unable to assess own condition or concerning social circumstances 1

Follow-Up Requirements

• Within 48 hours: Surgery review for mild-moderate exacerbations 1
• Within 24 hours: Surgery review for severe exacerbations that improved 1
• Continue prednisolone 30-60 mg daily for 5-10 days total 2, 3
• No tapering necessary for courses <10 days, especially if on inhaled corticosteroids 2, 3
• Monitor symptoms and PEF on chart daily 1
• Modify treatment according to chronic asthma guidelines at review 1