Treatment of Vomiting with Asthma Flare

Immediate Management

• For patients experiencing vomiting during an asthma exacerbation, the American Thoracic Society recommends administering intravenous hydrocortisone 200 mg every 6 hours instead of oral corticosteroids, while simultaneously treating the underlying asthma with high-dose nebulized β-agonists and oxygen 1, 2
• Vomiting during an asthma flare indicates either a severe attack or that the patient cannot tolerate oral medications, and the presence of vomiting lowers the threshold for hospital admission and intensive monitoring 1, 2

Concurrent Asthma Treatment

• The British Thoracic Society recommends administering high-flow oxygen immediately to maintain oxygen saturation, and giving nebulized β-agonist (salbutamol 5 mg or terbutaline 10 mg) driven by oxygen 1, 2
• Measure peak expiratory flow 15-30 minutes after starting treatment to assess response to therapy 1, 2

Escalation Based on Response

• If the patient is not improving after 15-30 minutes, the American College of Chest Physicians recommends increasing nebulized β-agonist frequency up to every 15 minutes, and considering subcutaneous epinephrine or terbutaline (250 µg over 10 minutes) in patients not responding to continuous nebulization 1, 2
• Arrange immediate hospital admission if the patient is not improving after 15-30 minutes 1, 2

Critical Monitoring Requirements

• Measure peak expiratory flow before and 15-30 minutes after treatment, and obtain chest radiography to exclude pneumothorax, consolidation, or pulmonary edema 1, 2
• Check plasma electrolytes, urea concentrations, and blood count, as vomiting can cause electrolyte disturbances 1, 2

Admission Criteria

• Any patient with vomiting during an asthma flare who has peak flow <33% predicted after initial nebulization requires immediate hospital referral, according to the National Asthma Education and Prevention Program 1, 2
• A lower threshold for admission applies to patients seen in the afternoon/evening, those with recent nocturnal symptoms, or previous severe attacks 1, 2

Transition to Oral Therapy

• Once vomiting resolves and the patient is improving, transition from IV hydrocortisone to oral prednisolone 30-60 mg daily, as recommended by the European Respiratory Society 1, 2
• Continue high-dose inhaled corticosteroids at discharge, and provide prednisolone for 1-3 weeks after discharge with a written action plan 1, 2

Asthma Management Guidelines

Introduction to Asthma Treatment

• The American Thoracic Society recommends asthma treatment based on controlling chronic airway inflammation with inhaled corticosteroids (ICS) as first-line therapy, combined with bronchodilators for symptom relief, using a stepwise approach that escalates therapy based on disease severity and control 3, 4

Acute Exacerbation Management

• For acute severe asthma, the British Thoracic Society recommends immediately administering high-dose inhaled beta-agonists and systemic corticosteroids 5, 6, 7, 4
• The National Asthma Education and Prevention Program advises that corticosteroids require 6-12 hours to manifest anti-inflammatory effects, making early administration critical for preventing mortality 8

Critical Treatment Principles

• The American College of Chest Physicians states that sedatives are absolutely contraindicated in asthmatic patients and can worsen respiratory depression 6, 4, 9
• The European Respiratory Society recommends not prescribing antibiotics unless bacterial infection is clearly documented 6, 4, 9

Monitoring Requirements

• The British Thoracic Society suggests measuring and recording peak expiratory flow 15-30 minutes after starting treatment and according to response thereafter 5, 10, 4

Discharge and Long-Term Management

• The National Asthma Education and Prevention Program recommends that all discharged patients require prednisolone for 1-3 weeks, increased inhaled corticosteroid dose, and as-needed beta-agonists 5, 11, 8
• The American Academy of Allergy, Asthma, and Immunology advises providing a peak flow meter and written asthma action plan at discharge 8

Prednisone Dosage and Duration for Asthma

Acute Exacerbation Management

• The American Academy of Allergy, Asthma, and Immunology recommends administering prednisone 30-60 mg daily for 3-10 days, with no tapering required for short courses, for adults presenting with acute severe asthma 12
• For children, the American Academy of Allergy, Asthma, and Immunology recommends using 1-2 mg/kg/day (maximum 60 mg/day) of prednisone 12
• The British Thoracic Society suggests administering the first dose of prednisone immediately upon recognition of severe exacerbation 13, 14
• The American Academy of Allergy, Asthma, and Immunology recommends continuing prednisone for 3-10 days until control is established, then stopping abruptly without tapering 12
• The British Thoracic Society recommends continuing prednisone until 2 days after control is established, then discontinuing 14

Indications for Rescue Courses

• The British Thoracic Society indicates that prednisone should be initiated when peak expiratory flow (PEF) falls below 60% of the patient's personal best 14
• The British Thoracic Society also recommends initiating prednisone when sleep is disturbed by asthma symptoms 14
• The British Thoracic Society suggests initiating prednisone when morning symptoms persist until midday 14
• The British Thoracic Society recommends initiating prednisone when there is a diminishing response to inhaled bronchodilators 14
• The British Thoracic Society indicates that prednisone should be initiated when emergency use of nebulized or injected bronchodilators is required 14

Dosing by Severity

• The British Thoracic Society recommends prednisone 30-40 mg daily for patients discharged from emergency settings with moderate exacerbations 13
• The British Thoracic Society suggests continuing regular inhaled corticosteroids and beta-agonists as needed for moderate exacerbations 13
• The British Thoracic Society recommends prednisone 30-60 mg orally or intravenous hydrocortisone 200 mg, or both, for severe or life-threatening features 13
• The British Thoracic Society suggests adding ipratropium bromide to bronchodilator therapy for severe or life-threatening features 13
• The British Thoracic Society recommends considering aminophylline 250 mg IV over 20 minutes if not responding to initial treatment for severe or life-threatening features 13

Adverse Effects to Monitor

• The American Academy of Allergy, Asthma, and Immunology notes that short-term use (3-10 days) of prednisone may cause reversible glucose metabolism abnormalities 12
• The American Academy of Allergy, Asthma, and Immunology also notes that short-term use of prednisone may cause increased appetite and fluid retention 12
• The American Academy of Allergy, Asthma, and Immunology suggests that short-term use of prednisone may cause weight gain and facial flushing 12
• The British Thoracic Society recommends monitoring for hypertension in susceptible patients taking prednisone 13
• The American Academy of Allergy, Asthma, and Immunology notes that short-term use of prednisone may cause peptic ulcer symptoms, although this is rare 12