Asthma emergency management

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Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [1] Phone:617-632-7753; Philip Marcus, M.D., M.P.H. [2]

Overview

Inhaled β2 agonist such as albuterol, is the best drug of choice for acute severe exacerbation of asthma. In case of mild to moderate exacerbations, metered-dose inhalation (MDI) of a β2 agonist in conjunction with a spacer may be used; however, for severe exacerbations nebulized β2 agonist has shown to be effective. In case of severe exacerbation with non-reponsiveness to β2 agonist inhalation/anticholinergic therapy, parenteral β2 agonist such as terbutaline may be administered. Ipratropium may also be tried in cases of severe exacerbation. Steroid therapy remain the main-stay of therapy in the treatment of acute and sub-acute phase of exacerbation. Steroids speed in the resolution of airway obstruction and prevent a late-phase response; hence, shown to provide highly beneficial outcomes to patients with acute exacerbation presenting to the emergency department.

Emergency Management

When an asthma attack is unresponsive to a patient's usual medication, other treatments are available to the physician or hospital:

• Oxygen to alleviate the hypoxia (but not the asthma per se) that results from extreme asthma attacks;

• Nebulized salbutamol or terbutaline (short-acting beta-2-agonists), often combined with ipratropium (an anticholinergic);

• Systemic steroids, oral or intravenous (prednisone, prednisolone, methylprednisolone, dexamethasone, or hydrocortisone). Some research has looked into an alternative inhaled route.

• Other bronchodilators that are occasionally effective in cases of non-responsiveness to initial drugs include:

• Intravenous salbutamol
• Nonspecific beta-agonists, injected or inhaled (epinephrine, isoetharine, isoproterenol, metaproterenol);
• Anticholinergics, IV or nebulized, with systemic effects (glycopyrrolate, atropine, ipratropium);
• Methylxanthines (theophylline, aminophylline);
• Inhalation anesthetics that have a bronchodilatory effect (isoflurane, halothane, enflurane);
• The dissociative anaesthetic ketamine, often used in endotracheal tube induction
• Magnesium sulfate, intravenous; and

• Intubation and mechanical ventilation, for patients in or approaching respiratory arrest.

• Heliox, a mixture of helium and oxygen, may be used in a hospital setting. It has a more laminar flow than ambient air and moves more easily through constricted airways.