Asthma Management

Initial Treatment

• The American Heart Association and American College of Cardiology recommend the first-line treatment for an asthma flare is inhaled short-acting beta2-agonists (SABAs) such as albuterol, administered every 20 minutes for the first hour, followed by systemic corticosteroids within the first hour for moderate to severe exacerbations 1, 2
• Inhaled SABA can be administered as 2-4 puffs of albuterol via metered-dose inhaler with spacer, or nebulized albuterol (2.5-5 mg) every 20 minutes for up to 1 hour 1

Systemic Corticosteroids

• The American College of Cardiology recommends starting systemic corticosteroids within the first hour, with adults receiving Prednisone 40-60 mg orally or methylprednisolone 125 mg IV, and children receiving Prednisone 1-2 mg/kg/day (maximum 60 mg) 1, 2
• The British Thoracic Society recommends administering systemic corticosteroids within the first hour, such as prednisolone 30-60 mg orally or hydrocortisone 200 mg IV, for patients with acute asthma exacerbation 3

Add-on Therapies

• The American College of Cardiology suggests adding ipratropium bromide 0.5 mg via nebulizer or 4-8 puffs via MDI every 20 minutes for the first hour, then every 6 hours until improvement begins, for patients with severe exacerbations 1
• The British Thoracic Society recommends adding ipratropium bromide, 0.5 mg via nebulizer every 6 hours, until improvement begins in patients with acute asthma exacerbation 3
• For severe exacerbations not responding to initial therapy, the American College of Cardiology recommends IV magnesium sulfate 2 g infused over 20 minutes 1

Ongoing Management

• The American Academy of Family Physicians recommends continuing oral corticosteroids for 5-7 days for moderate to severe exacerbations, and considering step-up therapy according to guidelines for patients already on controller therapy 2
• The American College of Rheumatology recommends oral steroids for patients experiencing high fever and feeling unwell, with a recommended dosage of Methylprednisolone 1-2 mg per kg body weight for 3-5 days 4
• The American Academy of Allergy, Asthma, and Immunology recommends no oral steroids for mild to moderate symptoms, instead using intranasal corticosteroids and antihistamines 5
• The American Academy of Allergy, Asthma, and Immunology recommends a short course of oral glucocorticosteroids for severe symptoms not controlled with other treatments 5

Classification and Assessment

• Asthma exacerbations can be classified based on severity, using the following criteria:

6, 7, 8, 9, 3

Non-Invasive Ventilation

• The American Thoracic Society recommends initial BiPAP settings of IPAP: 8-12 cmH2O and EPAP: 3-7 cmH2O, with titration based on patient comfort, synchrony, and improvement in respiratory rate and work of breathing, targeting SpO2 >90% but no higher than 96% 10
• The American Heart Association suggests considering NIPPV for patients with acute respiratory failure to potentially delay or eliminate the need for endotracheal intubation, with a strength of evidence based on clinical trials 1
• Assess patient response to BiPAP within 1-2 hours of initiation, with favorable response indicators including decreased respiratory rate, improved SpO2, reduced accessory muscle use, and improved mental status, as recommended by the American Heart Association 10

Oxygen Therapy and Monitoring

• Administer oxygen through nasal cannulae or mask to maintain SaO2 >90% in most patients and SaO2 >95% in pregnant women and patients with heart disease, as recommended by the American Academy of Allergy, Asthma, and Immunology 7
• Consider continuous cardiac monitoring and repeat arterial blood gas measurements in severe cases, especially if clinical deterioration occurs 7

Discharge and Follow-up

• Discharge criteria for asthma exacerbations should include FEV1 or PEF ≥70% of predicted or personal best, minimal or absent symptoms, and stable response to bronchodilator therapy for 60 minutes, as recommended by the American Thoracic Society 11
• Provide a written asthma action plan, ensure proper inhaler technique, and arrange follow-up with primary care within 1 week, according to the BMJ, European Respiratory Review, and the American Academy of Allergy, Asthma, and Immunology 8, 9, 6, 3, 12

Special Considerations

• Patients with a history of rapid deterioration are at risk of sudden death and require special management plans, as recommended by the American Thoracic Society 3
• Delaying corticosteroid administration and underestimating severity based on clinical appearance alone should be avoided in acute asthma management, as recommended by the British Medical Journal 12
• Transfer to intensive care if the patient has deteriorating PEF despite treatment, persistent or worsening hypoxia, hypercapnia, exhaustion, confusion, drowsiness, or respiratory arrest, as recommended by the British Thoracic Society 3