Acute Asthma

Acute Asthma – Treatment Options

Introduction
Acute asthma (asthma exacerbation) is a sudden worsening of asthma symptoms due to increased airway inflammation, bronchoconstriction, and mucus production. It presents with dyspnea, wheezing, cough, and chest tightness, and in severe cases, hypoxemia and respiratory failure. Prompt recognition and aggressive treatment are essential to relieve bronchospasm, correct hypoxemia, and prevent progression to life-threatening status asthmaticus.

1. Immediate Stabilization

• Airway, breathing, circulation (ABC): Ensure airway patency and monitor vital signs continuously.

• Oxygen therapy: Administer supplemental oxygen to maintain SpO₂ ≥ 94%.

• Monitoring: Pulse oximetry, peak expiratory flow (PEF), and arterial blood gases in severe cases.

2. First-Line Pharmacologic Therapy

• Short-acting β₂-agonists (SABAs):

  • Salbutamol (albuterol): 2.5–5 mg via nebulizer every 20 minutes for 3 doses, then 2.5–10 mg every 1–4 hours as needed.

  • Metered-dose inhaler (MDI) with spacer: 4–8 puffs every 20 minutes for up to 4 hours, then as needed.

• Anticholinergics:

  • Ipratropium bromide: 0.5 mg nebulized every 20 minutes for 3 doses, then as needed, in combination with SABA for moderate to severe exacerbations.

• Systemic corticosteroids:

  • Prednisone: 40–60 mg orally daily for 5–7 days.

  • Methylprednisolone IV in patients unable to tolerate oral therapy.

3. Adjunctive and Advanced Therapies

• Magnesium sulfate IV: 2 g over 20 minutes for severe, life-threatening exacerbations unresponsive to initial therapy.

• Epinephrine or terbutaline (SC/IM): For severe refractory bronchospasm, especially if associated with anaphylaxis.

• Heliox therapy: Considered in selected patients with persistent severe obstruction.

• Non-invasive ventilation (BiPAP): For impending respiratory failure in selected cooperative patients.

• Endotracheal intubation and mechanical ventilation: As a last resort in severe, deteriorating cases (with caution to avoid barotrauma).

4. Supportive Measures

• IV fluids: Maintain hydration, but avoid overhydration (risk of pulmonary edema).

• Avoid sedatives: They can worsen respiratory depression.

• Electrolyte monitoring: Correct hypokalemia if present (common with high-dose β₂-agonists).

5. Discharge and Preventive Care

• Inhaled corticosteroids (ICS): Initiate or adjust long-term controller therapy.

• Asthma action plan: Provide clear instructions for medication use and recognizing early signs of exacerbation.

• Trigger avoidance: Allergen control, infection prevention, smoking cessation.

• Follow-up: Re-evaluation within 1–2 weeks after discharge.

6. Multidisciplinary Care

• Emergency physicians: For acute stabilization.

• Pulmonologists/allergists: For long-term asthma management.

• Respiratory therapists: For nebulizer treatments and patient education.

• Nursing and primary care: For monitoring adherence and reinforcing asthma education.