Asthma emergency management

Editor(s)-in-Chief: C. Michael Gibson, M.S., M.D. [mailto:mgibson@perfuse.org] Phone:617-632-7753; Philip Marcus, M.D., M.P.H. [mailto:pmarcus192@aol.com]

Overview
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. 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.

Emergency Management
When an asthma attack is unresponsive to a patient's usual medication, other treatments are available to the physician or hospital. These include:
 * 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 anesthetic 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.