Asthma Exacerbation Home Management

Aka: Asthma Exacerbation Home Management, Asthma Action Plan

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II. Indications

  1. Home Asthma Management
    1. Home management is critical in reducing daily symptoms and reducing morbidity and mortality
  2. Asthma Action Plan
    1. All Asthma patients should have a written plan to respond to acute worsening Asthma
    2. Asthma Action Plans are especially important in moderate to Severe Asthma

III. Contraindications: Home Management

  1. Patients who require immediate medical attention (e.g. emergency department)
  2. High risk of fatal Asthma attack
    1. See Asthma-Related Death Risk Factors
  3. Serious exacerbation signs and symptoms
    1. Significant breathlessness
    2. Unable to speak in short phrases
    3. Accessory Muscle use
    4. Lethargy
    5. Peak Expiratory Flow <50%

IV. Approach: Asthma Action Plan

  1. Individualized written instructions based on personal best reliable symptoms and Peak Expiratory Flow

V. Management: Step 1 - Inhaled Beta Agonist (e.g. Albuterol)

  1. Albuterol Trial
    1. Up to 2 treatments of Albuterol MDI 2-6 puffs each (with 20 minutes interval between each use) OR
    2. One treatment of Albuterol Nebulizer
  2. Reassessment after 1 hour

VI. Management: Step 2a - Good Response (Mild) with PEF>80%

  1. Signs
    1. No Wheezing, Dyspnea or Tachypnea
    2. Sustained response to Albuterol for 4 hours
    3. Pediatric Asthma Score (PAS): 5 to 7
  2. Home Management
    1. Albuterol 2-4 puffs every 3-4 hours for 24-48 hours
    2. Inhaled Corticosteroid increased use (if already using)
      1. Double dose for 7-10 days OR
      2. Use an additional dose of Inhaled Corticosteroid for every use of Albuterol
      3. Growing evidence for increased Inhaled Corticosteroid use in acute exacerbation
        1. Similar to SMART Asthma Management Protocol
        2. Israel (2022) N Engl J Med 386(16): 1505-18 [PubMed]
    3. Consider oral Corticosteroids
    4. Contact medical provider in 48 hours for further management

VII. Management: Step 2b - Incomplete Response (Moderate) with PEF 50-79%

  1. Signs
    1. Persistent Wheezing
    2. Shortness of Breath
    3. Tachypnea
    4. Cough
    5. Chest Tightness
    6. Pediatric Asthma Score (PAS): 8 to 11
  2. Home Management
    1. Albuterol 2-4 puffs q3-4 hours for 24-48 hours
    2. Oral Corticosteroid
      1. Adult
        1. Prednisone 40-60 mg per day divided daily to twice daily for 3-10 days OR
        2. Depo-Medrol 160 mg IM for single dose
          1. Equal to Methylprednisolone 160 mg PO x8 days
          2. Effect may be delayed 48 hours
      2. Child
        1. Prednisolone
          1. Dose: 1-2 mg/kg/day to maximum 60 mg/day for 3-10 days OR
        2. Dexamethasone
          1. Dose: 0.3 to 0.6 mg/kg/day PO/IV/IM up to 15 mg for 1-2 days
          2. Keeney (2014) Pediatrics 133(3): 493-9 [PubMed]
      3. No tapering needed if use less than 2 weeks
      4. Continue course until Peak Expiratory Flow >70%
    3. Contact medical provider urgently same day for recommendations

VIII. Management: Step 2c - Poor Response (Severe) with PEF <50%

  1. Signs
    1. Marked Wheezing
    2. Shortness of Breath, Cough or Chest Tightness
    3. Severe distress
    4. Inhaled Albuterol effect lasts less than 2 hours
    5. Pediatric Asthma Score (PAS): 12 to 15
  2. Immediate Management
    1. AlbuterolInhaler 4-6 puffs every 20 minutes prn
    2. Start oral Corticosteroids
      1. Adult: 40 to 60 mg per day divided qd to bid
      2. Child (choose one)
        1. Prednisolone 1-2 mg/kg/day to maximum 60 mg/day for 3-10 days
          1. No tapering needed if use less than 2 weeks
        2. Dexamethasone
          1. Dose: 0.3 to 0.6 mg/kg/day PO/IV/IM up to 15 mg for 1-2 days
          2. Keeney (2014) Pediatrics 133(3): 493-9 [PubMed]
    3. Pursue immediate medical care
      1. Contact doctor
      2. Proceed to Emergency Department
      3. Call 911

IX. Efficacy

  1. Asthma Action Plans reduce mortality by 70%
    1. Abramson (2001) Am J Respir Crit Care Med 163(1): 12-8 [PubMed]

X. Resources

  1. Asthma Action Plan (CDC)
    1. https://www.cdc.gov/asthma/actionplan.html
  2. Asthma Action Plan (NIH)
    1. https://www.nhlbi.nih.gov/resources/asthma-action-plan-2020

XI. References

  1. (1997) Management of Asthma, NIH 97-4053
  2. (1995) Global Strategy for Asthma, NIH 95-3659
  3. Gibson (2004) Thorax 59(2): 94-9 [PubMed]
  4. Pollart (2011) Am Fam Physician 84(1): 40-7 [PubMed]
  5. Stoloff (1997) Am Fam Physician 56(1):117-26 [PubMed]

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