What is the recommended medication regimen for an acute bronchial asthma exacerbation?

Medication Treatment for Acute Bronchial Asthma Exacerbation

Immediately administer three therapies simultaneously within the first 15–30 minutes: high-dose inhaled short-acting β₂-agonist (albuterol), systemic corticosteroids (oral prednisolone or IV methylprednisolone), and supplemental oxygen to maintain SpO₂ >90%. 1, 2

Initial Treatment Protocol (First Hour)

Bronchodilator Therapy

• Administer albuterol 2.5–5 mg via oxygen-driven nebulizer OR 4–8 puffs via metered-dose inhaler with spacer every 20 minutes for three consecutive doses. 1, 2
• For children weighing <15 kg, use half the adult dose (approximately 2.5 mg albuterol). 1, 2
• Add ipratropium bromide 0.5 mg to each nebulized treatment (or 8 puffs via MDI) for all moderate-to-severe exacerbations—this combination reduces hospitalization risk, particularly in severe airflow obstruction. 1, 2

Systemic Corticosteroids (Critical—Do Not Delay)

• Adults: prednisolone 40–60 mg orally OR IV methylprednisolone 125 mg OR IV hydrocortisone 200 mg. 1, 2, 3, 4
• Children: prednisolone 1–2 mg/kg orally (maximum 40–60 mg). 1, 2, 4
• Oral administration is as effective as IV and strongly preferred when the patient can tolerate it. 1, 2
• Never delay corticosteroids while "trying bronchodilators first"—clinical benefit requires 6–12 hours minimum, making immediate administration essential. 1, 2

Oxygen Therapy

• Deliver 40–60% oxygen via face mask or nasal cannula to maintain SpO₂ >90% (target >95% in pregnant patients or those with cardiac disease). 1, 2, 5

Severity Assessment (First 5–15 Minutes)

Obtain objective measurements (PEF or FEV₁) before treatment—failure to do so is the most common preventable cause of asthma death. 1, 2

Severe Exacerbation Features

• Inability to speak full sentences in one breath 1, 2
• Respiratory rate >25 breaths/min 1, 2
• Heart rate >110 beats/min 1, 2
• PEF <50% of predicted or personal best 1, 2

Life-Threatening Features (Require Immediate ICU Consideration)

• PEF <33% of predicted 1, 2
• Silent chest, cyanosis, or feeble respiratory effort 1, 2
• Altered mental status (confusion, drowsiness, exhaustion) 1, 2
• Bradycardia or hypotension 1, 2
• Normal or elevated PaCO₂ ≥42 mmHg in a breathless patient 1, 2

Reassessment After Initial Treatment (15–30 Minutes)

Re-measure PEF/FEV₁ and reassess symptoms, vitals, and oxygen saturation. 1, 2

Good Response (PEF >75% Predicted)

• Continue usual maintenance therapy with modest step-up 1, 2
• Monitor symptoms and PEF on a chart 1
• Arrange follow-up within 48 hours 1

Incomplete Response (PEF 50–75% Predicted)

• Continue nebulized β₂-agonist every 4–6 hours 1, 2
• Maintain oral corticosteroids 1, 2
• Consider hospital admission if severe features persist 1, 2

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

• Increase nebulized β₂-agonist frequency to every 15–30 minutes 1, 2
• Continue ipratropium bromide 0.5 mg every 20 minutes for additional doses 1, 2
• Arrange immediate hospital admission 1, 2

Escalation for Refractory Cases (After 1 Hour of Intensive Therapy)

Intravenous Magnesium Sulfate

• Administer 2 g IV over 20 minutes for severe exacerbations with PEF <40% after initial treatment or any life-threatening feature. 1, 2
• For children: 25–75 mg/kg (maximum 2 g) IV over 20 minutes 1

Continuous Nebulization

• Consider continuous albuterol nebulization (10–15 mg/hour for adults or 0.5 mg/kg/hour for children) for markedly severe cases. 1

IV Aminophylline (Use With Caution)

• 250 mg IV over 20 minutes may be used for life-threatening features 1, 2
• Never give bolus aminophylline to patients already receiving oral theophylline due to toxicity risk 1, 2

Hospital Admission Criteria

Admit immediately for: 1, 2

• Any life-threatening feature (PEF <33%, silent chest, altered mental status, PaCO₂ ≥42 mmHg)
• Severe attack features persisting after initial therapy
• PEF <50% predicted after 1–2 hours of intensive treatment

Lower threshold for admission when: 1, 2

• Presentation occurs in evening/overnight
• Recent nocturnal symptoms or worsening pattern
• Prior intubation or ICU admission for asthma
• ≥2 hospitalizations or ≥3 ED visits in past year
• Poor social circumstances limiting reliable monitoring

ICU Transfer Criteria

Transfer to intensive care when any of the following occur despite therapy: 1, 2

• Deteriorating PEF
• Worsening or persistent hypoxia/hypercapnia
• Exhaustion, feeble respirations, or altered mental status
• Impending respiratory arrest

Discharge Planning (After Stabilization)

Discharge criteria: 1, 2

• PEF ≥70–75% of predicted or personal best
• Minimal or absent symptoms
• Oxygen saturation stable on room air
• Clinical stability for 30–60 minutes after last bronchodilator dose

At discharge, ensure: 1, 2

• Continue oral corticosteroids for 5–10 days (no taper needed for courses <10 days)
• Initiate or continue inhaled corticosteroids
• Verify and document correct inhaler technique
• Provide written asthma action plan with PEF zones
• Supply peak flow meter if needed
• Arrange primary-care follow-up within 1 week
• Arrange specialist follow-up within 4 weeks

Critical Pitfalls to Avoid

• Never administer sedatives of any kind—they are absolutely contraindicated and potentially fatal. 1, 2
• Do not delay corticosteroids while attempting bronchodilator therapy alone. 1, 2
• Do not rely solely on subjective assessment—objective PEF/FEV₁ measurement is mandatory. 1, 2
• Do not underestimate severity—clinicians frequently fail to recognize dangerous exacerbations. 1, 2
• Avoid methylxanthines (theophylline) due to increased side effects without superior efficacy. 1