Asthma Exacerbation Management in Inpatients

Primary Treatment Components

The American College of Allergy, Asthma, and Immunology recommends administering oxygen through nasal cannulae or mask to maintain oxygen saturation (SaO₂) >90% (>95% in pregnant patients or those with heart disease) 1
The American Thoracic Society suggests monitoring oxygen saturation continuously until a clear response to bronchodilator therapy has occurred 2
Albuterol is the first-line bronchodilator treatment for all asthma exacerbations, with administration options including nebulizer or MDI with spacer, and dosing recommendations of 2.5-5 mg every 20 minutes for 3 doses, then 2.5-10 mg every 1-4 hours as needed 1, 2, 3
For severe exacerbations (FEV1 or PEF <40% predicted), continuous administration of albuterol may be more effective than intermittent dosing 2

The American College of Allergy, Asthma, and Immunology recommends systemic corticosteroids as essential for all moderate-to-severe exacerbations and should be administered early, with dosing recommendations of prednisone 40-80 mg/day in 1-2 divided doses until PEF reaches 70% of predicted or personal best 1, 2, 3, 4
The total course of systemic corticosteroids typically lasts 3-10 days, with no tapering needed for courses less than 1 week 3, 4

The American College of Allergy, Asthma, and Immunology suggests adding inhaled ipratropium bromide to SABA therapy for severe exacerbations, with dosing options including nebulizer or MDI, and recommendations of 0.5 mg every 20 minutes for 3 doses, then as needed 1, 2, 3, 4
The combination of a beta-agonist and ipratropium has been shown to reduce hospitalizations in patients with severe airflow obstruction 1

The American Thoracic Society recommends initial assessment and treatment within the first 15-30 minutes, including administering oxygen, giving the first dose of inhaled albuterol, and administering systemic corticosteroids, and reassessing the patient 15-30 minutes after starting treatment 1
Response to treatment is a better predictor of hospitalization need than initial severity, and ongoing management should continue SABA treatments based on clinical response and lung function measurements 1, 2