What is the management approach for a patient with Acute Exacerbation of Bronchial Asthma (AEBA) according to the Clinical Practice Guidelines (CPG) of Malaysia?

Management of Acute Exacerbation of Bronchial Asthma (AEBA)

Immediate Assessment and Oxygen Therapy

Assess severity immediately using objective measures: inability to complete sentences in one breath, respiratory rate >25 breaths/min, heart rate >110 beats/min, and peak expiratory flow (PEF) <50% of predicted or personal best indicate severe exacerbation. 1, 2

• Life-threatening features requiring immediate ICU consideration include PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, altered mental status, or PaCO₂ ≥42 mmHg 1, 2
• Administer high-flow oxygen (40-60%) via face mask or nasal cannula to maintain SaO₂ >90% (>95% in pregnant patients or those with cardiac disease) 1, 2
• Continue oxygen saturation monitoring until clear response to bronchodilator therapy occurs 3, 1

Critical pitfall: Underestimating severity is the most common preventable cause of asthma deaths—always measure PEF or FEV₁ objectively, not relying on subjective clinical impression alone. 1, 2

Primary Bronchodilator Treatment (First Hour)

Administer albuterol (salbutamol) 5 mg via oxygen-driven nebulizer OR 4-8 puffs via metered-dose inhaler (MDI) with spacer every 20 minutes for 3 doses. 3, 1, 2

• For severe exacerbations (PEF <40% predicted), consider continuous nebulization of albuterol rather than intermittent dosing 1
• After initial 3 doses (60-90 minutes), adjust frequency based on patient response: most patients (60-70%) will respond sufficiently after these initial treatments 1
• Reassess patient 15-30 minutes after starting treatment, measuring PEF or FEV₁ before and after treatments 1, 2

Systemic Corticosteroids - Must Give Immediately

Administer systemic corticosteroids immediately and early—do NOT delay while "trying bronchodilators first" as clinical benefits require minimum 6-12 hours to manifest. 1, 2

• Give prednisolone 30-60 mg orally in single or divided doses for adults 3, 1, 2
• Oral administration is as effective as intravenous and is preferred unless patient cannot tolerate oral intake 1, 2
• Continue for 5-10 days total; no taper needed for courses <10 days, especially if patient is concurrently taking inhaled corticosteroids 1, 2
• If unable to take oral corticosteroids, give IV hydrocortisone 200 mg 2

Adjunctive Ipratropium Bromide

Add ipratropium bromide 0.5 mg via nebulizer OR 8 puffs via MDI to albuterol for all moderate-to-severe exacerbations. 3, 1, 2

• This combination reduces hospitalizations, particularly in patients with severe airflow obstruction 1, 2
• Administer every 20 minutes for 3 doses, then as needed 1, 2

Management of Severe/Refractory Cases (After 1 Hour)

If no improvement after initial 3 doses of bronchodilators (60-90 minutes), escalate treatment immediately:

• Continue nebulized beta-agonists every 15 minutes if needed 2
• Administer intravenous magnesium sulfate 2 g over 20 minutes for life-threatening features or severe exacerbations (PEF <40% predicted) not responding after 1 hour of intensive treatment 1, 2
• Prepare for ICU transfer if patient exhibits life-threatening features: silent chest, cyanosis, altered mental status, PaCO₂ ≥42 mmHg or rising, or PEF <33% predicted 2
• Obtain chest X-ray to exclude pneumothorax, consolidation, or pulmonary edema 2

Critical Pitfalls to Avoid

Never administer sedatives of any kind to patients with acute asthma exacerbation—this is absolutely contraindicated. 1, 2

• Avoid methylxanthines (theophylline/aminophylline) due to increased side effects without superior efficacy 2
• Do not use intravenous isoproterenol due to danger of myocardial toxicity 1
• Never delay corticosteroid administration while "trying bronchodilators first" 2
• Do not underestimate severity—always measure PEF or FEV₁ objectively 2

Hospital Admission Criteria

Admit immediately for:

• Any life-threatening features present 1, 2
• Features of severe attack persisting after initial treatment 1, 2
• PEF <50% predicted after 1-2 hours of intensive treatment 1, 2
• Previous severe attacks requiring intubation or ICU admission 2
• Lower threshold for admission if presentation occurs in afternoon/evening, recent nocturnal symptoms, or poor social circumstances 4, 2

Discharge Criteria

Discharge when ALL of the following are met:

• PEF ≥70% of predicted or personal best 1, 2
• Symptoms minimal or absent 1, 2
• Patient stable for 30-60 minutes after last bronchodilator dose 1, 2
• Oxygen saturation stable on room air 1

Discharge Planning

• Continue oral prednisolone 30-60 mg daily for 5-10 days (no taper needed) 1, 2
• Initiate or continue inhaled corticosteroids 1, 2
• Verify inhaler technique is checked and recorded 3, 2
• Provide written asthma action plan 3
• Arrange follow-up with primary care provider within 1 week 3, 2