From the Guidelines
For an asthma exacerbation, a combination of DuoNeb (ipratropium bromide/albuterol), oral prednisone, and AirSupra (albuterol/budesonide) can be effective, as recommended by the National Asthma Education and Prevention Program expert panel report 3 guidelines for the management of asthma exacerbations 1.
Treatment Details
- DuoNeb should be administered via nebulizer every 4-6 hours as needed, typically 3 mL per dose (containing 0.5 mg ipratropium bromide and 2.5 mg albuterol) 1.
- Oral prednisone is typically given at 40-60 mg daily for 5-7 days with no taper needed for short courses, as systemic corticosteroids are the only treatment for the inflammatory component of asthma proven to be effective for acute asthma exacerbations 1.
- AirSupra (albuterol 90 mcg/budesonide 80 mcg) can be used as a rescue inhaler, 2 inhalations as needed for symptoms, providing both quick relief and anti-inflammatory effects in a portable rescue inhaler.
Rationale
This combination works well because:
- DuoNeb provides immediate bronchodilation through two mechanisms (beta-agonist and anticholinergic) 1.
- Prednisone reduces airway inflammation systemically, which is essential for managing asthma exacerbations 1.
- AirSupra offers both quick relief and anti-inflammatory effects in a portable rescue inhaler, making it convenient for patients to manage symptoms on the go.
Patient Instructions
Patients should be instructed to:
- Use a spacer with AirSupra if available.
- Stay hydrated.
- Monitor symptoms.
- Seek emergency care if breathing difficulties worsen despite treatment. This multi-modal approach addresses both the acute bronchospasm and underlying inflammation that characterize asthma exacerbations, aligning with the guidelines for the diagnosis and management of asthma 1.
From the FDA Drug Label
The usual dosage of ipratropium bromide inhalation solution is 500 mcg (1 Unit-Dose Vial) administered three to four times a day by oral nebulization, with doses 6 to 8 hours apart. Ipratropium bromide inhalation solution can be mixed in the nebulizer with albuterol or metaproterenol if used within one hour.
The combination of Duoneb (ipratropium bromide and albuterol), oral pred (prednisone), and AirSupra (metaproterenol) for asthma exacerbation is not directly addressed in the provided drug labels. However, the labels suggest that ipratropium bromide can be used with albuterol or metaproterenol.
- Key points:
- Ipratropium bromide can be mixed with albuterol or metaproterenol in a nebulizer.
- The effectiveness of ipratropium bromide inhalation solution was demonstrated in patients with bronchospasm associated with chronic obstructive pulmonary disease.
- Combined therapy with ipratropium bromide and a beta adrenergic bronchodilator produced significant additional improvement in FEV1 and FVC 2, 2. However, the specific combination and dosing for asthma exacerbation are not explicitly stated.
From the Research
Treatment Options for Asthma Exacerbation
- Duoneb, a combination of ipratropium and albuterol, is used for treating asthma exacerbations 3, 4.
- Oral prednisone, a systemic corticosteroid, is used to reduce airway inflammation in asthma exacerbations 5, 6, 4, 7.
- Airsupra, a short-acting beta2 agonist, is used for bronchodilation in asthma exacerbations 5, 6, 3, 4, 7.
Management of Asthma Exacerbations
- The goals of treatment are correction of severe hypoxemia, rapid reversal of airflow obstruction, and reduction of the risk of relapse 5.
- Administration of systemic corticosteroids within one hour of emergency department presentation decreases the need for hospitalization, with the most pronounced effect in patients with severe exacerbations 5.
- Inhaled anticholinergic medication combined with beta2 agonists improves lung function and decreases hospitalization in school-age children with severe asthma exacerbations 5.
Severity Assessment and Treatment
- Asthma exacerbations can be classified as mild, moderate, severe, or life threatening based on symptoms and physical examination parameters, as well as lung function and oxygen saturation 5, 6, 3, 4.
- Patients with severe exacerbations should be transferred to an acute care facility and treated with oxygen, frequent administration of a short-acting beta2 agonist, and corticosteroids 6, 4.