Asthma Treatment

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ED Management of Asthma Attack

Acute asthma exacerbations require timely and effective treatment in the emergency department (ED). Below is an updated management guide including recommended dosages for each treatment option.

First-Line Bronchodilator Therapy: Beta-2 Agonists (Albuterol)
Dosage: For nebulized albuterol, 2.5 mg every 20 minutes for three doses during the first hour is standard. Alternatively, 5 mg doses can be used but offer no significant clinical advantage over 2.5 mg. For metered-dose inhaler (MDI) use, 2 to 4 puffs every 20 minutes up to three times is appropriate.
Onset and Duration: Onset within 5 minutes; effects last about 6 hours.
Delivery: MDI with spacer is as effective as nebulization and preferred when feasible.

Adjunct Bronchodilator Therapy: Anticholinergics (Ipratropium Bromide)
Dosage: 0.5 mg nebulized ipratropium added to albuterol every 20 minutes for three doses initially. Follow with 0.5 mg every 2 to 4 hours as needed.
Efficacy: 0.5 mg is as effective as 1.0 mg; repeated dosing is more beneficial than a single dose in severe asthma.
Combination: Typically combined with 2.5 to 5 mg albuterol during initial treatment.

Systemic Corticosteroids
Dosage: Oral prednisone or equivalent at 1 to 2 mg/kg/day, with a maximum dose of 60 to 80 mg daily. Early administration is critical.
Route: Oral steroids are as effective as intravenous steroids in acute asthma exacerbations.
Duration: Usually continued for 3 to 5 days to reduce relapse and hospital admission rates.
Onset: Effects begin within 4 to 6 hours.

Oxygen Therapy
Indication: Administer supplemental oxygen to maintain oxygen saturation ≥94%.
Notes: Oxygen should be given before and during nebulized bronchodilator therapy to prevent hypoxemia, especially in severe exacerbations.

Magnesium Sulfate (Adjunct Therapy)
Dosage: Intravenous magnesium sulfate at 40 mg/kg body weight, up to a maximum of 2 grams, infused over 20 minutes.
Indication: Consider in severe exacerbations unresponsive to initial bronchodilators and corticosteroids.
Effect: Acts by inhibiting calcium channels to promote bronchodilation and reduce neuromuscular transmission.

Conclusion
In the ED, managing acute asthma attacks involves rapid administration of inhaled beta-2 agonists with appropriate dosing, adjunctive anticholinergics, systemic corticosteroids, and oxygen therapy. Intravenous magnesium sulfate is a valuable adjunct in severe cases unresponsive to initial treatment. Accurate dosing and timely escalation of care are key to improving patient outcomes and reducing hospital admissions.