Inhaled bronchodilator (anticholinergic) | |
Ipratropium bromide nebulizer solution (500 mcg/2.5 mL) |
|
Ipratropium bromide MDI with spacer (17 mcg/actuation) |
|
Systemic glucocorticoids | |
Dexamethasone |
|
Prednisone or prednisoloneΔ |
|
Methylprednisolone |
|
Systemic beta2-agonists§ | |
Epinephrine (1 mg/mL) |
|
Terbutaline (1 mg/mL)¥ |
|
Other treatment | |
Magnesium sulfate |
|
ED: emergency department; ICU: intensive care unit; IM: intramuscular; IV: intravenous; MDI: metered-dose inhaler; ODT: orally disintegrating tablet; SUBQ: subcutaneous; VHC: valved holding chamber.
* Also refer to separate UpToDate topic reviews and table on recommended doses of beta-agonist medications for treatment of acute asthma exacerbations in children <12 years of age.
¶ Continuous nebulized albuterol and ipratropium are typically administered via a large-volume nebulizer or vibrating mesh nebulizer.
Δ Useful formulations of prednisolone include concentrated oral liquids and ODTs. For additional detail, refer to the drug monographs included with UpToDate or local product information.
◊ A longer course (eg, 7 to 10 days) may be beneficial for patients who have a severe exacerbation that is slow to respond to treatment or patients who have had more than one exacerbation requiring oral glucocorticoids in the previous 2 months. In addition, patients whose control regimen includes oral glucocorticoids may benefit from a >10-day course.
§ Typically, epinephrine or terbutaline is reserved for patients who present to the ED with a severe exacerbation with markedly diminished aeration. May give IM or SUBQ epinephrine or terbutaline, but not both. IV terbutaline is reserved for severely ill patients who are poorly responsive to conventional therapy. Alternative treatment options for these patients include noninvasive positive pressure ventilation and high-flow nasal cannula. Systemic beta2-agonist treatment requires noninvasive cardiopulmonary monitoring, such as that available in a critical care setting. Orally administered systemic beta2-agonists are not recommended.
¥ Some centers reserve terbutaline for ICU care and do not use it in the ED.
‡ Maximum dose of magnesium sulfate of up to 2.5 grams IV (approximately equal to 10 mmol) may be considered.[2]Courtesy of Richard Scarfone, MD, FAAP.
Additional data from: US Department of Health and Human Services. Expert panel report 3: Guidelines for the diagnosis and management of asthma. NIH Publication No. 07-4051. August 2007 available at https://www.ncbi.nlm.nih.gov/books/NBK7232/pdf/Bookshelf_NBK7232.pdf (accessed March 12, 2020).