What is the acute management of a patient with severe bronchospasm, such as a life‑threatening asthma attack or COPD exacerbation?

Acute Management of Severe Bronchospasm

Immediately administer combined nebulized short-acting β₂-agonist (albuterol 2.5–5 mg) plus short-acting anticholinergic (ipratropium 0.25–0.5 mg) every 4–6 hours, initiate systemic corticosteroids (prednisone 40 mg orally once daily for 5 days), provide controlled oxygen targeting SpO₂ 88–92%, and prepare for non-invasive ventilation if respiratory acidosis (pH < 7.35) persists beyond 30 minutes. 1

Immediate Bronchodilator Therapy

• Deliver combined nebulized albuterol 2.5–5 mg plus ipratropium 0.25–0.5 mg every 4–6 hours during the acute phase; this combination provides superior bronchodilation lasting 4–6 hours compared with either agent alone. 1

• Nebulizers are preferred over metered-dose inhalers in severely dyspneic patients because they eliminate the need for coordinated high-frequency inhalations and are easier to use during respiratory distress. 1

• Power nebulizers with compressed air (not oxygen) when hypercapnia or respiratory acidosis is present, delivering supplemental oxygen separately via nasal cannula at 1–2 L/min. 1

• Continue scheduled nebulized treatments every 4–6 hours until clinical improvement occurs, typically within 24–48 hours, then transition to metered-dose inhalers with spacer. 1

Systemic Corticosteroid Protocol

• Administer oral prednisone 30–40 mg once daily for exactly 5 days starting immediately; this short course is as effective as 14-day regimens while reducing cumulative steroid exposure by >50%. 1

• Oral administration is equally effective to intravenous and should be the default route unless the patient cannot tolerate oral intake. 1

• This 5-day regimen improves lung function and oxygenation, shortens recovery time, reduces treatment failure by >50%, and lowers 30-day rehospitalization risk. 1

• Do not extend systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists, as longer courses increase adverse effects without additional benefit. 1

Oxygen Management

• Target SpO₂ of 88–92% using controlled-delivery devices (Venturi mask 24–28% FiO₂ or nasal cannula 1–2 L/min) to correct life-threatening hypoxemia while minimizing CO₂ retention. 1

• Obtain arterial blood gas within 60 minutes of starting oxygen to identify hypercapnia (PaCO₂ > 45 mmHg) or acidosis (pH < 7.35), which signal impending respiratory failure. 1

• If pH falls below 7.26 with rising PaCO₂, prepare immediately for non-invasive ventilation. 1

• Avoid high-flow oxygen (>28% FiO₂ or >4 L/min) without arterial blood-gas monitoring, as this can precipitate hypercapnic respiratory failure and increase mortality by approximately 78%. 1

Non-Invasive Ventilation (NIV)

• Initiate NIV immediately as first-line therapy when acute hypercapnic respiratory failure (PaCO₂ > 45 mmHg) with acidosis (pH < 7.35) persists for >30 minutes after standard medical treatment. 1

• NIV improves gas exchange, reduces work of breathing, decreases intubation rates by approximately 50%, shortens hospital stay, and improves survival; success rates in appropriately selected patients are 80–85%. 1

• Contraindications to NIV include altered mental status with inability to protect the airway, large-volume secretions, hemodynamic instability, or recent facial/upper-airway surgery; if present, prepare for invasive mechanical ventilation. 1

Antibiotic Therapy (When Indicated)

• Prescribe antibiotics for 5–7 days when sputum purulence is present together with either increased dyspnea or increased sputum volume (two of three cardinal symptoms required). 1

• First-line agents include amoxicillin-clavulanate 875/125 mg twice daily, doxycycline 100 mg twice daily, or azithromycin (500 mg day 1, then 250 mg daily for 4 days). 1

• This strategy reduces short-term mortality by approximately 77%, treatment failure by 53%, and sputum purulence by 44%. 1

Medications to Avoid

• Never use intravenous methylxanthines (theophylline/aminophylline) in acute exacerbations, as they increase adverse-effect risk without delivering clinical benefit. 1

Hospitalization Criteria

• Admit patients with any of the following: respiratory rate >30 breaths/min, marked increase in dyspnea unresponsive to initial therapy, inability to eat or sleep due to respiratory symptoms, new/worsening hypoxemia (SpO₂ <90% on room air), altered mental status or loss of alertness, persistent rhonchi after initial treatment requiring continued nebulization, or inability to care for self at home. 1

Asthma-Specific Considerations

• NIV should NOT be used in patients with acute asthma exacerbations and acute hypercapnic respiratory failure; these patients require intubation and invasive mechanical ventilation due to the risk of hyperacute bronchospasm and rapid deterioration. 2

• For acute severe asthma, target a higher SpO₂ of 96% (compared to 88–92% for COPD). 2

• In life-threatening asthma unresponsive to conventional therapy, consider intravenous magnesium sulfate as rescue therapy. 3

Common Pitfalls to Avoid

• Never power nebulizers with oxygen in hypercapnic patients; use compressed air and provide supplemental oxygen separately via nasal cannula. 1

• Never delay NIV when criteria for acute hypercapnic respiratory failure are met (pH <7.35, PaCO₂ >45 mmHg persisting >30 minutes). 1

• Never administer high-flow oxygen without concurrent arterial blood-gas monitoring, as this worsens respiratory acidosis and increases mortality. 1

• Do not continue systemic corticosteroids beyond 5–7 days for a single exacerbation unless another indication exists. 1