II. Risk Factors

  1. See Asthma-Related Death Risk Factors
  2. Acute
    1. Viral Upper Respiratory Infections (most common exacerbation trigger)
  3. Chronic
    1. Poor symptom control
    2. Asthma Exacerbation in the last year
    3. Poor Medication Compliance
    4. Incorrect use of asthma Inhaler
    5. Smoking
    6. Chronic Sinusitis
    7. Gastroesophageal Reflux

III. Definitions

  1. Asthma Exacerbation
    1. Deterioration in baseline symptoms (e.g. Dyspnea, chest tightness, cough, Wheezing) OR
    2. Deterioration in objective markers (e.g. Pulmonary Function Tests, Oxygen Saturation)

IV. Classification: Asthma Exacerbation Severity

  1. See Asthma Exacerbation Severity Evaluation
  2. See SMART Asthma Management Protocol
  3. Mild Asthma Exacerbation
    1. Dyspnea on exertion (or Tachypnea in young children)
    2. Peak Expiratory Flow (PEF) >70% of predicted
    3. Home management
      1. Prompt relief with inhaled Short-acting Beta Agonists
  4. Moderate Asthma Exacerbation
    1. Dyspnea limits usual activity and patient may speak in phrases
    2. Peak Expiratory Flow (PEF) 40-69% of predicted
    3. Tachypnea may be present, but no accessory Muscle use
    4. Oxygen Saturation 90 to 95%
    5. Mild Tachycardia (100 to 120 bpm) may be present
    6. Relief with frequent inhaled Short-acting Beta Agonists
    7. Office management
      1. Add oral Systemic Corticosteroids
      2. Anticipate 1-2 days of symptoms after treatment onset
  5. Severe Asthma Exacerbation
    1. Dyspnea at rest, limiting conversation
    2. Patient may sit forward (e.g. tripoding)
    3. Tachypnea (>30 breaths/min), Tachycardia (pulse>120 bpm) or Hypoxia (O2 Sat <90%) may be present
    4. Peak Expiratory Flow (PEF) <40% of predicted
    5. Only partial relief with inhaled Short-acting Beta Agonists
    6. Emergency department management
      1. Hospitalization is likely
      2. Add Systemic Corticosteroids and ipratroprium
      3. Anticipte >3 days of some symptoms
  6. Life Threatening Asthma Exacerbation
    1. Unable to speak, severe Dyspnea, with associated diaphoresis
    2. Patient may be confused and with quiet chest, and inappropriately decreased work of breathing (Peri-Arrest)
    3. Peak Expiratory Flow (PEF) <25% of predicted
    4. Minimal relief with inhaled Short-acting Beta Agonists
    5. Emergency department stabilization
      1. Intensive Care unit admission
      2. Frequent or continuous Albuterol Nebs
      3. Add Systemic Corticosteroids and ipratroprium
      4. ABC Management

VI. Management: Office-Based Management

  1. See Emergency Management of Asthma Exacerbation
  2. Indications
    1. Mild to moderate Asthma Exacerbation in age >= 6 years
  3. Contraindications: Need for emergency department management (arrange urgent transfer, while performing stablization below)
    1. Severe or life threatening Asthma Exacerbation
    2. Oxygen Saturation <90%
    3. Failed acute office-based management as below
  4. Protocol: Acute Office Management
    1. Albuterol MDI with spacer for 4 to 10 puffs, repeated every 20 minutes as needed for up to 1 hour
      1. Consider adding Ipratropium Bromide (e.g. duonebs) in moderate exacerbations
    2. Supplemental Oxygen if Oxygen Saturation <90% (target Oxygen Saturation >93 to 94%)
    3. Systemic Corticosteroid (e.g. Prednisolone, Prednisone) 1-2 mg/kg up to 40-50 mg orally
      1. Response will be delayed >6 hours
  5. Disposition (based on 1 hour assessment)
    1. Worsening or refractory status, or Hypoxia
      1. Transfer to emergency department
    2. Discharge to home indications
      1. Symptoms improving without the need for further Albuterol
      2. Oxygen Saturation >93 to 94%
      3. Peak Expiratory Flow >60 to 80% of predicted or personal best
      4. Adequate resources at home to continue Asthma Exacerbation management
  6. Outpatient Management
    1. Continue short-acting Bronchodilator as needed (or advance SMART Asthma Management Protocol)
    2. Assess for proper Inhaler use with spacer
    3. Review Asthma Action Plan
    4. Start or step-up controller medication
    5. Continue oral Corticosteroids for 3 to 5 days in children (5 to 7 days in adults)
  7. Follow-up at 1 to 2 days in children (2 to 7 days in adults)
    1. Assess for exacerbation improvement
    2. Consider extension of Systemic Corticosteroids if significant persistent, refractory symptoms
    3. Consider short-term (1 to 2 weeks) or long-term (3 months) advancement of controller medications
    4. Taper short-acting Bronchodilator as able (or SMART Asthma Management Protocol)
    5. Review Asthma Action Plan (consider modifications and emphasize compliance)
    6. Refer to Asthma and allergy specialist for >1 to 2 exacerbations per year

VII. Prevention

  1. See Asthma-Related Death Risk Factors
  2. Manage chronic modifiable predisposing conditions
  3. School-based Asthma intervention programs
    1. Cicutto (2013) J Sch Health 83(12): 876-84 [PubMed]

VIII. References

  1. (2022) Global Strategy for Asthma Management and Prevention (GINA)
    1. https://ginasthma.org/gina-reports/
  2. (2007) Guidelines for the diagnosis and management of Asthma, NHLBI
  3. Dabbs (2024) Am Fam Physician 109(1): 43-50 [PubMed]

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