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acute asthma; asthma exacerbation

also see asthma &/or status asthmaticus Etiology: - allergic bronchopulmonary aspergillosis (recurrent asthma exacerbations) Clinical manifestations: - inability to speak in full sentences, diaphoresis, flaring of the nares, & use of accessory muscles during inspiration are signs of impending respiratory failure Laboratory: - arterial blood gas (hospitalized patients) - pCO2 is often low - a normal or mildly elevated pCO2 in severe asthma may be a sign of respiratory muscle fatigue & impending respiratory failure [1,3] Special laboratory: - peak flow meter (useful at home, emergency department) Complications: - pneumomediastinum Management: 1) also see status asthmaticus & specific etiology 2) admission to intensive care for: [1,3] a) pCO2 >= 42 mm Hg b) persistent FEV1 or peak flow < 40% of predicted despite 1 hour of aggressive treatment with bronchodilators c) endotracheal intubation for respiratory failure - consider vocal cord dysfunction for acute asthma that improves immediately with intubation d) noninvasive positive pressure ventilation (NPPV) benefit unclear [1] 3) pharmaceuticals a) see individual therapeutic classes b) systemic glucococorticoids - home treatment with prednisone 40 mg QD for 5 days [1] - dexamethasone 0.3 to 0.6 mg/kg, up to 15 mg/day PO QD, or as one IM injection [4] - use longer courses for kids who continue to have symptoms - single 12-mg dose of oral dexamethasone equivalent to 5 days of 60-mg prednisone daily [10] c) beta-2 adrenergic receptor agonists - MDI as effective as nebulizer [2] - continuous therapy with nebulizer more effective than intermittent therapy with MDI [7] - NNT = 10 to prevent 1 hospitalization [7] - addition of nebulized albuterol of no benefit [6]* d) albuterol-ipratropium nebulizer + intravenous methyl prednisolone - first line for hospitalized patients [1,15] - avoid beta-blocker if patient presents with concurrent NSTEMI e) epinephrine SQ 0.3-0.5 mL of a 1:1000 solution - rescue medication for life-threatening asthma r) intravenous magnesium sulfate may be beneficial in patients presenting with severe asthma [9] g) antibiotics of no benefit & may be harmful [12] - azithromycin of no benefit [11] h) vitamin D of no benefit in preventing severe asthma exacerbations [14] 4) heliox may be of benefit vs endotracheal intubation for severe asthma - of no benefit [1] 5) cardioselective beta-blockers may appropriate in patients with stable asthma & clear indications [5] - nonselective beta-blockers should be avoided - worsening of asthma symptoms & declines in pulmonary function may occur with the first few doses of a cardioselective beta-blocker - cardioselective agents can reduce FEV1 & interfere with treatment of asthma - avoid all beta-blockers in patients with unstable asthma [5,7] 6) oral glucocorticoids upon discharge from the emergency department - no added benefit or harm of inhaled glucocorticoids in combination with oral glucocorticoids [8] 7) in patients with diabetes mellitus type-2 & asthma, metformin cuts odds of asthma attacks by 30%; adding a GLP-1 receptor agonist reduces odds by another 40% [16] * The NNT lists NNT for nebulized ipratropium = 11 to prevent hospitalization due to asthma attack; however, the 2 most recent references find no benefit.

Interactions

disease interactions

Specific

status asthmaticus thunderstorm asthma

General

asthma exacerbation

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 1998, 2006, 2009, 2012, 2015, 2018. 2023. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Dhuper S et al. Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med 2011 Mar; 40:247. PMID: 19081697
  3. Lazarus SC. Clinical practice. Emergency treatment of asthma. N Engl J Med. 2010 Aug 19;363(8):755-64 PMID: 20818877
  4. Prescriber's Letter 21(4): 2014 Dexamethasone for Childhood Asthma Exacerbations Detail-Document#: 300407 (subscription needed) http://www.prescribersletter.com
  5. Morales DR et al. Adverse respiratory effect of acute beta-blocker exposure in asthma: A systematic review and meta-analysis of randomized controlled trials. Chest 2014 Apr; 145:779 PMID: 24202435 http://journal.publications.chestnet.org/article.aspx?articleid=1767055 - Morales DR, Jackson C, Lipworth BJ Adverse respiratory effect of acute beta-blocker exposure in asthma: a systematic review and meta-analysis of randomized controlled trials. Chest. 2013 Nov 7 PMID: 24202435
  6. The NNT: Nebulized Ipratropium Given During an Asthma Attack http://www.thennt.com/nnt/nebulized-ipratropium-for-asthma-attack/ - Cydulka RK, Emerman CL, Muni A. Levalbuterol versuss levalbuterol plus ipratropium in the treatment of severe acute asthma. J Asthma. 2010 Dec;47(10):1094-100 PMID: 20923385 - Salo D, Tuel M, Lavery RF, Reischel U, Lebowitz J, Moore T. A randomized, clinical trial comparing the efficacy of continuous nebulized albuterol (15 mg) versus continuous nebulized albuterol (15 mg) plus ipratropium bromide (2 mg) for the treatment of acute asthma. J Emerg Med. 2006 Nov;31(4):371-6. PMID: 17046476
  7. The NNT: Continuous versus Intermittent Beta Agonists Given During an Asthma Attack. http://www.thennt.com/nnt/continuous-vs-intermittent-beta-agonists-for-asthma-attack/ - Camargo CA Jr, Spooner CH, Rowe BH Continuous versus intermittent beta-agonists in the treatment of acute asthma. Cochrane Database Syst Rev. 2003;(4):CD001115. PMID: 4583926
  8. The NNT: Inhaled Steroids Given After Asthma Attack upon Discharge from the Emergency Department. http://www.thennt.com/nnt/inhaled-steroids-upon-discharge-for-asthma-attack/ - Edmonds ML, Milan SJ, Brenner BE, Camargo CA Jr, Rowe BH. Inhaled steroids for acute asthma following emergency department discharge. Cochrane Database Syst Rev. 2012 Dec 12;12:CD002316 PMID: 23235590
  9. The NNT: Intravenous Magnesium Sulfate Given During an Asthma Attack. http://www.thennt.com/nnt/magnesium-sulfate-for-asthma-attack/ - Rowe BH, Bretzlaff JA, Bourdon C, Bota GW, Camargo CA Jr Magnesium sulfate for treating exacerbations of acute asthma in the emergency department. Cochrane Database Syst Rev. 2000;(2):CD001490. PMID: 10796650
  10. Rehrer MW, Liu B, Rodriguez M, Lam J, Alter HJ. A randomized controlled noninferiority trial of single dose of oral dexamethasone versus 5 days of oral prednisone in acute adult asthma. Ann Emerg Med. 2016 Apr 14. PMID: 27117874
  11. Johnston SL, Szigeti M, Cross M et al. Azithromycin for acute exacerbations of asthma: The AZALEA randomized clinical trial. JAMA Intern Med 2016 Sep 19 PMID: 27653939 http://archinte.jamanetwork.com/article.aspx?articleid=2553295
  12. Stefan MS, Shieh MS, Spitzer KA et al. Association of antibiotic treatment with outcomes in patients hospitalized for an asthma exacerbation treated with systemic corticosteroids. JAMA Intern Med 2019 Jan 28 PMID: 30688986 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2721036
  13. Albertson TE, Sutter ME, Chan AL. The acute management of asthma. Clin Rev Allergy Immunol. 2015 Feb;48(1):114-25. Review.
  14. Forno E et al. Effect of vitamin D3 supplementation on severe asthma exacerbations in children with asthma and low vitamin D levels: The VDKA randomized clinical trial. JAMA. 2020 Aug 25;324(8):752-760. PMID: 32840597 https://jamanetwork.com/journals/jama/fullarticle/2769724
  15. NEJM Knowledge+ Complex Medical Care
  16. Lee B, Man KKC, Wong E, Tan T, Sheikh A, Bloom CI. Antidiabetic Medication and Asthma Attacks. JAMA Intern Med. 2024 Nov 18. PMID: 39556360 https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2826086