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Management of Acute Exacerbations


  • Progressive shortness of breath (SOB) 2/2 ↓ expiratory airflow; associated with acute airway inflammation (progressive symptom onset; slow treatment response) &/or bronchospasm (abrupt rapid symptom onset; quick treatment response)
  • Triggers: airway inflammation → respiratory infections (URI, bronchitis, sinusitis), allergens (pets, dust, pollen, etc.); bronchospasm → allergens, exercise, emotions; other → cold air, fog, tobacco, wood smoke, drugs (aspirin, NSAIDs)

Diagnosis & Evaluation

  • Identify exacerbation: acute or subacute condition; progressively worsening SOB, cough, wheezing, &/or chest tightness; PEF <80% predicted/personal best

Figure 7-1.

Management of acute asthma exacerbation. (Source: National Heart, Lung, and Blood Institute; National Institutes of Health; U.S. Department of Health and Human Services. Allergy Clin Immunolog 2007;120[5, Suppl]:S94).

Treatment & Follow-Up

  • Treatment goals: reverse airflow obstruction, correct hypoxemia, ↓ relapse/recurrent exacerbation

Pharmacological Treatment

  • SABA:albuterol, levalbuterol; DOC in exacerbation; can use MDI or nebs (Chest 2002;121:1036); onset of action ∼5min; no clinical difference between onset of action & side effect profile between albuterol or levalbuterol (Ann Emerg Med 2005;46:29); monitor: ↓ K+, especially with continuous treatment
  • Systemic corticosteroids: prednisone, methylprednisolone, prednisolone (Am J Med 2009;122:977); fast onset w/in hours; IV = PO; ↑ infection, hyperglycemia
  • Anticholinergics: ipratropium bromide; given in combination with SABA during acute exacerbation; benefit only in initial ER management (Am J Med 1999;107:363; Chest 2002;121:1977); onset w/in 15min, peak effect 1–2h; may cause urinary retention
  • Magnesium sulfate: for life-threatening exacerbations or those not responding to standard therapy (Ann Emerg Med 2000; 36:181; Chest 2002; 122:489); controversial in adults (Emerg Med J 2007;24:823); onset <20min
  • Antibiotics: only if evidence of bacterial infection (Chest 2009;136:498)
  • Criteria for discharge: PEF >70% → if rapid response to therapy, close observation for 30–60min; PEF 50–69% → evaluate on case-by-case basis
  • Consider adding inhaled corticosteroid (ICS) to therapy, or ↑ ICS dose at discharge (Cochrane Database of Syst Rev 2000;CD002316)

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Clinical Pearl 7-1

SC administration of β-agonists (epinephrine or terbutaline) is not recommended unless patient cannot tolerate inhaled therapy; no added benefit of systemic β-agonists vs inhaled with ↑ risk of adverse effects due to systemic exposure (Chest 2002;122:1200)

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Clinical Pearl 7-2

For acute asthma exacerbations, NAEEP recommends against: methylxanthines, aggressive hydration, antibiotics (unless otherwise indicated for bronchitis, pneumonia, or sinusitis), mucolytics, sedation, & chest physical therapy (J Allergy Clin Immunol 2007;120 (5 Suppl): S94)

Nonpharmacological Treatment

Oxygen to achieve SaO2 >90%, or >95% (pregnancy or concomitant heart disease); consider heliox for severe exacerbations after 1h of therapy (Anaesthesia 2007;62:34)

Chronic Asthma Management

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