Management of Acute Moderate Asthma Exacerbation
This patient requires immediate treatment with nebulized albuterol, systemic corticosteroids, and close monitoring with reassessment in 15-30 minutes to determine need for hospital admission. 1
Severity Classification
This patient presents with moderate-to-severe asthma exacerbation based on the following criteria 1:
- Tachycardia >110 beats/min (HR 130) - indicates severe exacerbation 1
- Tachypnea >25 breaths/min (RR 28) - indicates severe exacerbation 1
- Inability to complete sentences would indicate severe disease, but this patient can speak full sentences 1
- Mild respiratory distress with diffuse wheezing 1
The combination of tachycardia >110 and tachypnea >25 meets criteria for acute severe asthma, even though oxygen saturation is preserved at 99% 1, 2. The British Thoracic Society emphasizes that seriously consider admission if more than one severe feature is present 1.
Immediate Treatment Protocol
First-Line Bronchodilator Therapy
Administer nebulized albuterol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer immediately 1, 3. The FDA-approved dosing is 2.5 mg for routine use, but 5 mg is appropriate for acute exacerbations 4. Alternative delivery is 4-8 puffs via metered-dose inhaler with spacer every 20 minutes for 3 doses 1, 3.
Systemic Corticosteroids - Critical Early Intervention
Give prednisolone 30-60 mg orally immediately - do not delay while "trying bronchodilators first" 1, 2, 3. Oral administration is as effective as intravenous and is preferred unless the patient cannot tolerate oral intake 3, 5. Clinical benefits require a minimum of 6-12 hours to manifest, making early administration essential 2, 3, 5.
Oxygen Therapy
Administer oxygen 40-60% to maintain SaO₂ >90% 1, 3. Although this patient's oxygen saturation is currently 99%, oxygen should be used to drive the nebulizer and maintained during treatment 1.
Reassessment at 15-30 Minutes
Monitor response 15-30 minutes after the first nebulizer treatment 1, 3. Assess:
- Peak expiratory flow (PEF) or FEV₁ 1, 6
- Respiratory rate, heart rate, ability to speak 1, 3
- Oxygen saturation 3
- Symptom improvement 3
If Good Response (PEF >70% predicted, symptoms improving):
- Continue albuterol every 4-6 hours as needed 1
- Continue prednisolone 30-60 mg daily for 5-10 days (no taper needed) 6, 3
- Arrange follow-up within 48 hours 1
If Incomplete Response (PEF 50-70%, persistent symptoms):
- Add ipratropium bromide 0.5 mg to nebulized albuterol 1, 3
- Repeat nebulized treatments every 20 minutes for up to 3 doses 1, 3
- Seriously consider hospital admission 1
If Poor Response (PEF <50%, severe features persist):
- Arrange immediate hospital admission 1, 2
- Continue intensive bronchodilator therapy 2, 3
- Consider IV magnesium sulfate 2g over 20 minutes 3, 7
Hospital Admission Criteria
Absolute indications for admission 1, 2:
- Any features of acute severe asthma persist after initial treatment
- PEF <50% predicted after 1-2 hours of treatment 2, 8
- Multiple severe features present (this patient has HR >110 AND RR >25) 1
Lower threshold for admission given 1:
- Presentation in afternoon/evening (this is a 2-day history, timing unclear)
- Long history of asthma with acute worsening 1
Critical Pitfalls to Avoid
- Never delay corticosteroids while trying bronchodilators first - they must be given immediately 2, 3
- Never administer sedatives of any kind to patients with acute asthma 1, 2, 3
- Do not underestimate severity - the presence of tachycardia >110 and tachypnea >25 indicates severe disease regardless of normal oxygen saturation 1, 2
- Measure PEF objectively - subjective clinical assessment frequently underestimates severity 1, 2