What is the treatment for a severe asthma exacerbation?

From the Guidelines

Treatment of severe asthma exacerbation requires prompt intervention with bronchodilators, corticosteroids, and supportive care, starting with high-flow oxygen to maintain oxygen saturation above 92%. Administer short-acting beta-agonists (SABA) like albuterol 2.5-5 mg via nebulizer or 4-8 puffs via metered-dose inhaler with spacer every 20 minutes for the first hour, then reassess 1. Add ipratropium bromide 0.5 mg via nebulizer or 4-8 puffs via MDI every 20 minutes for the first hour. Systemic corticosteroids should be given early: prednisone 40-60 mg orally or methylprednisolone 60-125 mg IV if the patient cannot take oral medications, as there is no known advantage for higher doses of corticosteroids in severe asthma exacerbations nor is there any advantage for intravenous administration over oral therapy provided gastrointestinal transit time or absorption is not impaired 1.

Key Considerations

• Continue steroids for 5-7 days without tapering for short courses, as the total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit or hospitalization may last from 3-10 days 1.
• For patients not responding to initial treatment, consider magnesium sulfate 2 grams IV over 20 minutes 1.
• Continuous cardiac monitoring, frequent vital sign checks, and serial peak flow measurements are essential.
• Hospitalization is indicated for patients with persistent hypoxemia, decreased level of consciousness, or poor response to initial therapy.

Additional Therapies

• Heliox-driven albuterol nebulization can also be considered in these patients, as it can quickly decrease the work of breathing 1.
• Consultation with or comanagement by a physician expert in ventilator management is essential because ventilation of patients with severe asthma is complicated and risky 1.

Ventilator Strategy

• “Permissive hypercapnia” or “controlled hypoventilation” is the recommended ventilator strategy because it provides adequate oxygenation while minimizing airway pressures and the possibility of barotrauma 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Adults and Children 2 to 12 Years of Age: The usual dosage for adults and for children weighing at least 15 kg is 2.5 mg of albuterol (one vial) administered three to four times daily by nebulization. The use of albuterol sulfate inhalation solution can be continued as medically indicated to control recurring bouts of bronchospasm During this time most patients gain optimum benefit from regular use of the inhalation solution. If a previously effective dosage regimen fails to provide the usual relief, medical advice should be sought immediately, as this is often a sign of seriously worsening asthma that would require reassessment of therapy.

For severe asthma exacerbation treatment, the drug label does not provide specific dosage recommendations.

• The label recommends seeking medical advice immediately if a previously effective dosage regimen fails to provide the usual relief, as this may indicate worsening asthma.
• The usual dosage of 2.5 mg of albuterol administered three to four times daily by nebulization may be continued as medically indicated to control recurring bouts of bronchospasm 2.

From the Research

Severe Asthma Exacerbation Treatment

• The treatment of severe asthma exacerbation often involves the use of bronchodilators, such as ipratropium bromide and albuterol, to help relax the airway muscles and improve breathing 3, 4, 5, 6, 7.
• Studies have shown that the combination of ipratropium bromide and albuterol can be more effective than albuterol alone in improving lung function and reducing hospitalization rates in patients with severe asthma exacerbation 3, 5, 7.
• A meta-analysis of randomized controlled trials found that the combination of ipratropium bromide and salbutamol significantly reduced the risk of hospital admission compared with salbutamol alone in children and adolescents with asthma, especially in those with severe and moderate to severe asthma exacerbation 7.
• However, another study found that the addition of nebulized ipratropium bromide to nebulized beta2-agonist and corticosteroid therapy in the treatment of children hospitalized because of asthma conferred no extra benefit 4.
• The use of ipratropium bromide in combination with albuterol has been shown to be safe and well-tolerated, with no significant increase in adverse events compared with albuterol alone 3, 5, 6, 7.

Key Findings

• The combination of ipratropium bromide and albuterol can be more effective than albuterol alone in improving lung function and reducing hospitalization rates in patients with severe asthma exacerbation 3, 5, 7.
• The addition of ipratropium bromide to albuterol and corticosteroid therapy may not provide extra benefit in the treatment of children hospitalized because of asthma 4.
• The use of ipratropium bromide in combination with albuterol is safe and well-tolerated, with no significant increase in adverse events compared with albuterol alone 3, 5, 6, 7.