What is the recommended acute management for a patient presenting with an asthma exacerbation?

Acute Asthma Exacerbation Management

Immediate First-Line Treatment (Within 15–30 Minutes)

Administer three therapies simultaneously without delay: high-dose inhaled albuterol, systemic corticosteroids, and supplemental oxygen. 1

Bronchodilator Therapy

• Give albuterol 2.5–5 mg via nebulizer OR 4–8 puffs via metered-dose inhaler with spacer every 20 minutes for three consecutive doses during the first hour 1, 2
• For children weighing <15 kg, use half the adult dose (2.5 mg albuterol) 1, 2
• Nebulizer and MDI-with-spacer delivery are equally effective when properly administered 1

Systemic Corticosteroids (Critical—Do Not Delay)

• Give prednisone 40–60 mg orally immediately for adults; do not wait to "try bronchodilators first" 1, 3
• For children: prednisolone 1–2 mg/kg (maximum 40–60 mg) 1, 3
• Oral administration is as effective as intravenous and is strongly preferred unless the patient is vomiting or critically ill 1, 3
• If IV route is required: hydrocortisone 200 mg every 6 hours 1, 3
• Clinical benefit requires 6–12 hours minimum, making early administration essential 1

Oxygen Therapy

• Deliver 40–60% oxygen via face mask or nasal cannula to maintain SaO₂ >90% (>95% in pregnant patients or those with cardiac disease) 1, 3

Objective Severity Assessment

• Measure peak expiratory flow (PEF) or FEV₁ before treatment and again 15–30 minutes after the first bronchodilator dose—failure to obtain objective measurements is the most common preventable cause of asthma deaths 1, 3

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Severity Classification & Risk Stratification

Severe Exacerbation Features

• Inability to speak a full sentence in one breath 1, 3
• Respiratory rate >25 breaths/min 1, 3
• Heart rate >110 beats/min 1, 3
• PEF <50% of predicted or personal best 1, 3

Life-Threatening Features (Require Immediate ICU Consideration)

• PEF <33% of predicted 1, 3
• Silent chest, cyanosis, or feeble respiratory effort 1, 3
• Altered mental status (confusion, drowsiness, exhaustion) 1, 3
• Bradycardia or hypotension 1, 3
• Normal or elevated PaCO₂ ≥42 mmHg in a breathless patient 1, 3
• Severe hypoxia (PaO₂ <8 kPa ≈60 mmHg) despite oxygen 1

High-Risk Patients (Lower Threshold for Admission)

• Previous intubation or ICU admission for asthma 1, 3
• ≥2 hospitalizations or ≥3 emergency department visits in the past year 1, 3
• Recent hospitalization or ED visit within the past month 1
• Presentation in afternoon/evening rather than morning 1, 3
• Recent nocturnal symptoms or worsening pattern 1, 3
• Poor social circumstances or inability to perceive symptom severity 1, 3

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Reassessment Protocol (15–30 Minutes After Initial Treatment)

Good Response (PEF >75% Predicted)

• Continue usual maintenance therapy with modest increase if needed 1
• Monitor with PEF chart 1
• Arrange follow-up within 48 hours 1

Incomplete Response (PEF 50–75% Predicted)

• Continue nebulized albuterol every 4–6 hours 1, 3
• Maintain oral corticosteroids 1, 3
• Consider hospital admission if severe features persist 1, 3

Poor Response (PEF <50% Predicted or Persistent Severe Features)

• Increase albuterol frequency to every 15–30 minutes 1, 3
• Add ipratropium bromide 0.5 mg to nebulizer (or 8 puffs via MDI) every 20 minutes for three doses, then every 4–6 hours 1, 3
• Arrange immediate hospital admission 1, 3

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Adjunctive Therapies for Moderate-to-Severe Exacerbations

Ipratropium Bromide (Essential Add-On)

• Add ipratropium 0.5 mg to albuterol for all moderate-to-severe exacerbations—this combination reduces hospitalizations, particularly in patients with severe airflow obstruction 1, 3
• Dosing: 0.5 mg via nebulizer or 8 puffs via MDI every 20 minutes for three doses, then every 4–6 hours as needed 1, 3

Intravenous Magnesium Sulfate

• Administer 2 g IV over 20 minutes for severe exacerbations with PEF <40% after initial treatment or life-threatening features 1, 3
• Pediatric dose: 25–75 mg/kg (maximum 2 g) IV over 20 minutes 1
• Magnesium improves pulmonary function and decreases hospitalization necessity 1

Continuous Albuterol Nebulization

• Consider for severe exacerbations not responding to intermittent dosing 1, 3

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Hospital Admission Criteria

Admit immediately if any of the following are present:

• Any life-threatening feature (PEF <33%, silent chest, altered mental status, PaCO₂ ≥42 mmHg) 1, 3
• Severe attack features persisting after initial treatment 1, 3
• PEF <50% predicted after 1–2 hours of intensive treatment 1, 3
• Previous severe attacks requiring intubation or ICU admission 1, 3

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ICU Transfer Criteria

Transfer to intensive care when:

• Deteriorating PEF despite optimal therapy 1, 3
• Worsening or persistent hypoxia/hypercapnia 1, 3
• Exhaustion, feeble respirations, or altered mental status 1, 3
• PaCO₂ ≥42 mmHg or rising 1, 3
• Impending respiratory arrest 1, 3
• Do not delay intubation once deemed necessary—it should be performed semi-electively before respiratory arrest occurs 1

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Discharge Criteria & Planning

Readiness for Discharge

• PEF ≥70–75% of predicted or personal best 1, 3, 4
• Minimal or absent symptoms 1, 3
• Oxygen saturation stable on room air 1, 3
• Clinical stability for 30–60 minutes after the last bronchodilator dose 1, 3
• Diurnal PEF variability <25% 1

Discharge Medications

• Continue oral prednisone 40–60 mg daily for 5–10 days (no taper needed for courses <10 days) 1, 3, 4
• Initiate or continue inhaled corticosteroids 1, 3, 4
• Provide albuterol rescue inhaler 4
• For high-risk patients with poor adherence, consider IM depot corticosteroid injection 1

Patient Education & Follow-Up

• Verify and document correct inhaler technique—this is mandatory before discharge 1, 3, 4
• Provide a written asthma action plan with peak-flow zones 1, 3, 4
• Supply a peak-flow meter if the patient does not already have one 1, 3, 4
• Arrange primary-care follow-up within 1 week 1, 3, 4
• Arrange respiratory-specialist follow-up within 4 weeks 1, 3, 4

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Critical Pitfalls to Avoid

• Never administer sedatives of any kind—they are absolutely contraindicated and potentially fatal 1, 3
• Do not delay corticosteroids while "trying bronchodilators first"—both must be given simultaneously 1, 3
• Never rely solely on subjective clinical impression—objective PEF/FEV₁ measurement is essential 1, 3
• Do not give bolus aminophylline to patients already taking oral theophylline 1, 3
• Avoid methylxanthines (theophylline) due to increased side effects without superior efficacy 1, 3
• Do not discharge without verifying inhaler technique and providing a written action plan—verbal instructions alone are insufficient 4
• Do not prescribe corticosteroids for <3 days—this duration is inadequate to prevent relapse 4
• Doubling inhaled corticosteroid dose during exacerbation is ineffective in adherent patients 1, 3

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Special Considerations

Pediatric Dosing

• Albuterol: 2.5 mg for children <15 kg 1, 2
• Prednisolone: 1–2 mg/kg (maximum 40–60 mg) 1, 3
• Ipratropium: 0.25–0.5 mg via nebulizer or 4–8 puffs via MDI 1
• Magnesium sulfate: 25–75 mg/kg (maximum 2 g) IV over 20 minutes 1

Pregnancy & Cardiac Disease

• Target oxygen saturation >95% (higher than the standard >90%) 1, 3

Refractory Cases

• Consider IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 µg over 10 minutes for life-threatening features 1, 3
• Obtain chest X-ray to exclude pneumothorax, consolidation, or pulmonary edema 1, 3
• Antibiotics are not recommended unless strong evidence of bacterial infection (pneumonia or sinusitis) 1, 3