Management of acute asthma in adults

Asthma exacerbation is in acute or subacute process with increased dyspnea, cough, chest tightness, or wheezing associated with decreased forced exploratory volume lung function or peak expiratory flow rate compared with baseline levels.

Patients during a loss of asthma control focus on obtaining immediate symptom relief by relying on rescue medication, typically a short acting beta2 agonist (SABA).

As asthma symptoms worsen, patients typically rely on short acting beta two agonist rescue therapy, but such therapy does not address worsening inflammation which leaves patients at risk for greater severe asthma exacerbations.

SABA’s have a little affect on underlying airway inflammation and overreliance on SABA‘s is a metric for poor asthma control, associated with a  risk of severe asthma exacerbation.

The use of monotherapy with short acting beta agonist therapy is recommended against:retrospective studies suggested increased use of SABA‘s was associated with a higher risk of exacerbation and death.

This risk is reduced with the addition of inhale corticosteroids (ICS).

Most asthma guidelines recommend some form of ICS as part of the treatment regimen for mild asthma or whenever short acting acting beta 2 agonists are used.

ICS recommended whenever short acting beta agonist is used, with twice daily maintenance ICS and SABA in the use of ICS-formoterolol is needed.

ICS-formoterol is the preferred treatment protocol with a reduction in exacerbation and  lower overall use of ICS.

Budesonide-formoterol formulations are mostly used.

The prevention of exacerbations is imperative in the management of asthma.


The risk of severe asthma exacerbation is significantly lower with as needed use of a fixed dose combination of albuterol and budesonide than with as needed use of albuterol alone among patients with uncontrolled moderate to severe asthma who receive a wide range of inhaled glucocorticoid containing maintenance therapies (Papi A).

Asthma is usually mild or infrequent in 50 to 75% of patients, but contributes 30 to 40% of exacerbations leading to emergency care; and asthma related death may occur in persons with asthma that is usually mild.

The goals of treatment for adults with acute asthma exacerbations include: prompt recognition of the exacerbation, determination of its severity, initiation of appropriate therapy, and referred to an acute care facility if necessary.
Temporary four fold increase in dose of inhaled corticosteroids is associated with fewer severe asthma exacerbations, decreased oral corticosteroids use, and no increase in pneumonia compared to standard therapy.
Inhaled glucocorticoids are the backbone of asthma-controller therapy.

A fixed dose combination of inhaled glucocorticoid and formoterol as compared with a SABA, significantly reduces the risk of exacerbation among patients with a range of asthma severity and is generally recommended as the preferred rescue treatment strategy.

Rapid onset bronchodilators such as formotetrol  and albuterol are ideal for rescue fixed dose combination with inhaled glucocorticoid as compared with slower onset bronchodilators such as salmeterol.
In moderate to severe asthma, the use of single inhaler containing a combination of glucocorticoid and a rapid onset long acting beta2 agonist used as a regular, twice daily maintenance therapy, plus the use of an as needed reliever therapy, a single maintenance and reliever therapy, can reduce asthma exacerbation more effectively than the previously more commonly recommended strategy of twice daily use of the combination product with a short acting beta2=agonist as the reliever.
There is no benefit to adding azithromycin antibiotic during an acute asthma exacerbation.
Azithromycin may be useful for preventing acute asthma exacerbation in a randomized trial over 48 weeks compared to placebo.
With acute severe life-threatening asthma patients should be referred to an emergency department where treatment consists of supplemental oxygen to maintain pulse oximetry saturation level of 93 to 95%, short acting beta2 agonist and short acting muscarinic antagonists and systemic corticosteroids.
Chest imaging should be reserved for patients in whom pneumonia is a consideration.
Intravenous magnesium sulfate metanalysis is associated with a reduced decrease of hospitalization.
Benralizumab antibodies to critical molecules in asthma pathogenesis has promising use.

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