Asthma emergency management

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

## Overview

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Inhaled β2 agonist, such as albuterol, is the drug of choice for acute severe exacerbation of asthma. In cases of mild to moderate exacerbations, metered-dose inhalation (MDI) of a β2 agonist in conjunction with a spacer may be used. In more severe exacerbations, nebulized β2 agonist has been demonstrated to be most 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 utilized in cases of severe exacerbation.[1] Steroid therapy remains the mainstay of therapy in the treatment of acute and sub-acute phases 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.[2][3]

## Emergency Management

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When an asthma attack is unresponsive to a patient's usual medication, other treatments are available to the physician or hospital. These include:[4]

* 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.[5]
* 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 anesthetic ketamine, often used in endotracheal tube induction.
* Magnesium sulfate, intravenous.

* 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.

## References

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1. ↑ Urbano FL (2008) Review of the NAEPP 2007 Expert Panel Report (EPR-3) on Asthma Diagnosis and Treatment Guidelines. J Manag Care Pharm 14 (1):41-9. PMID: 18240881
2. ↑ Rowe BH, Keller JL, Oxman AD (1992) Effectiveness of steroid therapy in acute exacerbations of asthma: a meta-analysis. Am J Emerg Med 10 (4):301-10. PMID: 1535500
3. ↑ Rowe BH, Edmonds ML, Spooner CH, Diner B, Camargo CA (2004) Corticosteroid therapy for acute asthma. Respir Med 98 (4):275-84. PMID: 15072167
4. ↑ Rodrigo GJ, Rodrigo C, Hall JB. Acute asthma in adults: a review. Chest. 2004;125(3):1081-102. PMID 15006973
5. ↑ Rodrigo GJ (2005) Comparison of inhaled fluticasone with intravenous hydrocortisone in the treatment of adult acute asthma. Am J Respir Crit Care Med 171 (11):1231-6. DOI:10.1164/rccm.200410-1415OC PMID: 15764724

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