Recommendations

Key Recommendations

The main goals of treatment are to relieve airflow obstruction (and hypoxemia) and address underlying inflammation, and then to prevent future relapses.[1] Early treatment is optimal.[56] Patient education and self-management (including the use of an asthma action plan), recognition of early signs of deterioration, appropriate intensification of therapy (i.e., increasing frequency of short-acting beta-2 agonist use, increasing inhaled corticosteroid [ICS] dose, or adding an oral corticosteroid), removal of any environmental factors that may be contributing to the exacerbation, and prompt communication with the physician about serious deterioration are all important strategies that can be instituted in the home setting. Starting treatment at home prevents exacerbations from becoming severe and avoids treatment delays.[57] Whether this is possible will depend on the patient's capabilities and experience.

If home treatment is not appropriate, repeated (or, if clinically indicated, continuous) administration of an inhaled short-acting beta-2 agonist should be started immediately. A short course of a systemic corticosteroid and supplemental oxygen may also be required in more severe exacerbations. Additional treatments should be considered for patients unresponsive to bronchodilators. Necessary treatments are usually given concurrently for rapid improvement.[1]

Severe and life-threatening exacerbations require urgent transfer to an acute care setting, and appropriate treatment should be started while this is arranged.[1] Monitoring and correction of fluid balance and electrolyte disturbances may be needed depending on the patient’s clinical condition (e.g., for patients requiring intravenous rehydration).[45]​ Milder exacerbations may be managed in primary care (if appropriate resources and expertise are available), though any failure to respond to treatment or further deterioration in the patient’s condition should prompt immediate transfer to an acute care setting.[1]

Acute exacerbations in pregnancy should be treated aggressively with short-acting beta-2 agonist therapy, oxygen, and prompt administration of systemic corticosteroids, to avoid fetal hypoxia.[1]

This topic covers the management of adults. For children up to ages 11 years, see  Acute asthma exacerbation in children. Children ages 12 years and older are generally treated the same as adults. However, consult your local pediatric guidance as there may be some differences in the treatment approach and weight-based dosing may be recommended in some adolescents. 

Drug administration

Short-acting bronchodilators may be given either by a metered-dose inhaler (MDI) or by a nebulizer.[1] MDIs have the advantage of being highly portable, and they provide the drug quickly. The most cost-effective and efficient mode of delivery in acute asthma that is not life-threatening is by MDI plus a spacer.[1][58] The evidence for this method is less robust for severe and near-fatal asthma.[1] Nebulizers are useful if the patient is unable to coordinate use of an MDI. Both are equally effective for mild to moderate exacerbations. Ozone-friendly hydrofluoroalkane inhalers are now mandatory.

Studies of intermittent versus continuous nebulized administration of albuterol provide conflicting results.[1] A reasonable approach in exacerbations is initial use of continuous therapy followed by intermittent on-demand therapy for hospitalized patients.

The use of nebulizers can transmit respiratory viral particles and potentially contribute to the spread of respiratory viral infections such as COVID-19.[1] Consider appropriate level of personal protective equipment (PPE). 

Oral corticosteroids are as effective as those given parenterally, and oral administration is the preferred route as it is faster and less invasive.[1] Intravenous corticosteroids can be administered to patients who are too dyspneic to swallow, are vomiting, or require noninvasive ventilation or intubation.[1] When indicated, systemic corticosteroids should ideally be administered within 1 hour of presentation.[1]

Life-threatening exacerbation or impending respiratory failure

Patients who present with signs of life-threatening asthma (e.g., drowsiness, confusion, absence of wheezing ["silent chest"]) should be considered for intubation, mechanical ventilation, and admission to the intensive care unit (ICU).[1] They are also given inhaled short-acting beta-2 agonist, inhaled anticholinergic, supplemental oxygen, and intravenous or oral corticosteroid. Some patients may also receive intravenous magnesium.[1][45]

Patients who initially present with a non-life-threatening exacerbation but do not respond adequately to treatment, or who subsequently develop signs of life-threatening asthma, may also require admission to the ICU with consideration for intubation and mechanical ventilation.[1]

Coadministration of bronchodilators with a helium-oxygen gas mixture (heliox) is controversial, and is not recommended in routine care, but may be helpful in selected patients with respiratory failure.[1][45][59][60]

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Severe exacerbation

Treatment starts with repetitive administration of an inhaled, short-acting beta-2 agonist; early introduction of systemic corticosteroids; and supplemental oxygen by nasal cannula to achieve an arterial oxygen saturation of 93% to 95%.[1][53][64] Response to therapy should be reassessed at least hourly.

The Global Initiative for Asthma (GINA) advises that use of low flow oxygen titrated to achieve an oxygen saturation of 93% to 95% is associated with better outcomes in severe exacerbations (compared with using high concentration [100%] oxygen, which has been associated with increased CO₂ retention).[1]

Inhaled ipratropium (a short-acting anticholinergic agent) should be added to a short-acting beta-2 agonist in adults with severe or life-threatening asthma exacerbations.[1][45] Combination inhaled therapy with a short-acting beta-2 agonist and a short-acting anticholinergic may reduce hospitalization and improve pulmonary function in adults presenting to the emergency department with acute asthma exacerbations, particularly in severe exacerbations.[65] However, adverse events are more likely with combination therapy.[65]

Intravenous magnesium sulfate is not recommended for routine use in asthma exacerbations.[1] However, a single infusion has been shown to reduce hospital admission rates in certain patients, including adults with a forced expiratory volume in 1 second (FEV₁) <25% to 30% of predicted and those who fail initial treatment.[66] Magnesium is thought to inhibit calcium influx into airway smooth muscle, thereby acting as a bronchodilator.[67][68] [ Cochrane Clinical Answers logo ] [Evidence A]​ GINA recommends that intravenous magnesium sulfate be considered for severe exacerbations that fail to respond to initial treatment.[1]

Systemic corticosteroids should ideally be administered within 1 hour.[1] Oral corticosteroids are as effective as those given parenterally, and oral administration is the preferred route as it is faster and less invasive.[1]

In patients with a severe or life-threatening exacerbation who are receiving systemic corticosteroids, the GINA guideline recommends consideration of add-on high-dose ICS, while also cautioning that evidence of benefit from the combination of a systemic corticosteroid plus ICS is conflicting in adults.[1][69][70]​ In practice, ICS are unlikely to be used if the patient is already on a systemic corticosteroid.[1][69]

Response to treatment should be monitored vigilantly, assessing both symptoms and objective measures (including oxygen saturation), with treatment titrated to response.[1] Repeat/serial lung function testing (using peak expiratory flow rate or FEV₁) is strongly recommended by GINA as an objective measure of response where available and practicable: it should be recorded an hour after starting treatment and then repeated at intervals until there is a clear response or measurements plateau.[1] If there is a lack of response to treatment or worsening symptoms such as drowsiness, confusion, or absence of wheezing (“silent chest”), urgent ICU admission and mechanical ventilation is indicated.[1]

Mild to moderate exacerbation

Repeated administration of an inhaled, short-acting beta-2 agonist is the first-line therapy used to rapidly reverse airflow limitation. Beta-2 agonists act on airway smooth muscle to provide a bronchodilating effect. Treatment should be initiated immediately and titrated based on the patient's response. For patients with mild to moderate exacerbations, delivery of a short-acting beta-2 agonist via a pressurized MDI and spacer or a dry powder inhaler leads to similar improvements in lung function as delivery via nebulizer.[1]

A short course of an oral corticosteroid should be given.[1] This may be done inside or outside the hospital setting. Some patients may have already started a course of oral corticosteroids if it is part of their self-management plan.[1] It can take up to 4 hours after corticosteroid administration before clinical improvements are observed.[1]

Systemic corticosteroids have been shown to speed the resolution of exacerbations and prevent relapse.[1][51] In acute care settings such as emergency departments, GINA advises that systemic corticosteroids should be given in all (other than the mildest) exacerbations; their use is especially important if short-acting beta-2 agonist treatment does not achieve lasting symptom improvement, or if the patient has a history of exacerbations requiring oral corticosteroids or was using these when the present exacerbation occurred.[1] A randomized controlled trial comparing the effects of 2 days of oral dexamethasone and 5 days of oral prednisone in patients ages 18-45 years with acute asthma exacerbations (peak expiratory flow rate <80% of ideal) showed that the former is at least as effective as the latter in returning patients to their normal level of activity and preventing relapse.[71] GINA advises that, if used, oral dexamethasone should not be continued for more than 2 days due to concerns about metabolic adverse effects: if further systemic corticosteroid treatment is needed, a switch to prednisone should be considered.[1]

Inhaled ipratropium can be added to a short-acting beta-2 agonist in adults with moderate to severe asthma exacerbations, particularly if there is a poor response to initial treatment.[1][45] This combination therapy may reduce hospitalization and lead to greater improvements in lung function in adults presenting to the emergency department with acute asthma exacerbations.[65] However, adverse events are more likely with combination therapy.[65]

Supplemental oxygen should be given, if necessary, by nasal cannula or nonrebreather mask to achieve an oxygen saturation of 93% to 95%.[1]

Closely monitor the patient (including monitoring of oxygen saturation, if available) and titrate treatment to response.[1] Repeat lung function testing an hour after starting treatment and then at regular intervals until there is a clear response or measurements plateau.[1] Inadequate response or deterioration should prompt escalation of treatment (i.e., treat as for severe exacerbation) and urgent transfer to an acute care setting (if not already there), where the patient should be reassessed for potential admission to ICU.[1]

Patients with fever and purulent sputum or radiographic evidence of pneumonia

Antibiotics should not be given routinely in asthma exacerbations unless there is strong evidence of lung infection, such as fever and purulent sputum or radiographic evidence of pneumonia.[1][53][72]​ The majority of acute asthma exacerbations are triggered by viral infection.[8][12][45]​ Antibiotic selection and dosing should be according to local resistance patterns.

A retrospective cohort study of 19,811 adults hospitalized for asthma exacerbation found that antibiotic therapy may be associated with a longer hospital length of stay and similar risk of treatment failure compared with no antibiotic therapy.[73]

Subsequent therapy

Prior to discharge, ICS-based controller therapy should be initiated, if not previously prescribed.[1] Patients already taking an ICS-containing medication should generally have their treatment stepped up for 2-4 weeks.[1] If the exacerbation occurred on a background of long-term poor asthma control (despite good adherence and inhaler technique) a longer-term step up (e.g., 2-3 months) may be indicated.[1] GINA recommends a step up or switch to maintenance-and-reliever-therapy (MART) with ICS-formoterol (“Track 1” approach) following an exacerbation, and advises that Step 4 MART is appropriate if the patient visited the emergency department or was hospitalized.[1]

Patients should resume their normal reliever inhaler before discharge if this was replaced with a short-acting beta-2 agonist reliever during acute treatment of the exacerbation.[1] They should be transitioned back to as-needed rather than regular use of reliever medication, based on symptomatic and objective improvement: regular use of a short-acting beta-2 agonist may mask worsening asthma and can increase risk of further exacerbations, and regular use for even 1-2 weeks increases airway inflammation and dampens response to bronchodilators.[1] GINA recommends considering a switch to a treatment regimen with an ICS-formoterol reliever for those who were using a short-acting beta-2 agonist reliever before the exacerbation, to reduce their risk of future exacerbations.[1]

Adherence and inhaler technique should be reassessed before discharge.[1] Patients should be followed up by a primary physician or pulmonologist within 2-7 days after an exacerbation (or within 1-2 weeks if the exacerbation was self-managed at home) to assess and optimize their asthma management, including medications, review of modifiable risk factors and comorbidities, inhaler technique, and written asthma action plan.[1]

Guidelines recommend that asthma severity and control be viewed as a ladder in which medication can be stepped up or stepped down based on the severity of the disease and adequacy of the control.[1]

The stepwise approach is meant to assist, not replace, the clinical decision-making required to meet individual patient needs. Patients may start at any step of the ladder, and medications can be added (stepped up) if needed. Increasing use of short-acting beta-agonist or use >2 days a week for symptom relief (not prevention of exercise-induced bronchospasm) generally indicates inadequate control and the need to step up treatment.

The patient's asthma control should be regularly assessed with the aim of stepping down the ladder if disease has been well controlled for at least 3 months. A step-down may increase the risk for exacerbations, especially if the patient has had an exacerbation or emergency department visit in the last year or if they have a low baseline FEV₁ or airway hyperresponsiveness.[1] To reduce the risk, avoid stepping down too far or too quickly, or at times of increased exacerbation risk (e.g., during viral sickness or pregnancy) or when the patient is unavailable for follow-up.[1] A written action plan should be in place detailing how and when to step treatment back up if asthma control worsens (ensuring the necessary medications are available to the patient to follow this plan).[1] Close monitoring during step-down (especially in patients with risk factors for exacerbations) and scheduled follow-up is advised to evaluate response.[1] ICS-containing medication should not be completely withdrawn and adherence with this during the step-down should be encouraged.[1]

There is insufficient evidence to recommend universal use of sputum eosinophils or fractional exhaled nitric oxide (FeNO) levels to tailor asthma therapy. However, some evidence suggests this approach may decrease frequency of asthma exacerbations.[1][74][75] [ Cochrane Clinical Answers logo ] ​​ GINA recommends sputum-guided treatment for adults with moderate or severe asthma who are managed in (or can be referred to) a center offering this.[1] FeNO measurement may be considered as part of an ongoing monitoring and management strategy for selected patients, if there is persisting uncertainty in choosing, monitoring, or adjusting therapies.[39] In clinical practice FeNO is mainly used to help guide treatment decisions in patients with severe asthma.[1] One large study in pregnant women demonstrated no reduction in exacerbations with FeNO-adjusted treatment versus usual care.[1] The relationship between FeNO and sputum/blood eosinophil levels is altered or lost in obesity.[1]

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