# Acute Exacerbation Management — GINA 2024

## Definition

An asthma exacerbation (also called a flare-up or attack) is an acute or subacute worsening in symptoms and lung function from the patient's usual status, or in some cases the initial presentation of asthma.

## Severity Assessment of Acute Exacerbations

| Feature | Mild-Moderate | Severe | Life-Threatening |
| :--- | :--- | :--- | :--- |
| **Talks in** | Sentences | Words | Unable to speak |
| **Posture** | Prefers sitting | Hunched forward | Drowsy or confused |
| **Respiratory rate** | Increased | >30 breaths/min | — |
| **Accessory muscle use** | Not usually | Yes | Paradoxical thoraco-abdominal movement |
| **Pulse rate (bpm)** | 100-120 | >120 | Bradycardia |
| **SpO2 (on air)** | 90-95% | <90% | <90% |
| **PEF (% predicted or personal best)** | >50% | <=50% | <25% or unable to perform |

## Management in Primary Care or Emergency Department

### Initial Assessment (0-15 minutes)

- Assess severity using the table above
- Measure SpO2 by pulse oximetry
- Measure PEF if possible (do not delay treatment)
- Identify risk factors for asthma-related death: history of near-fatal asthma (intubation/ICU), hospitalization or ED visit in the past 12 months, not currently using ICS or poor adherence, currently using or recently stopped OCS, overuse of SABA (>1 canister/month), history of psychiatric disease, food allergy in a patient with asthma

### Mild-Moderate Exacerbation Management

- **SABA:** Salbutamol (albuterol) 4-10 puffs by pMDI + spacer, repeated every 20 minutes for the first hour
  - pMDI + spacer is at least as effective as nebulizer in mild-moderate exacerbations
  - Dose: salbutamol 100 mcg/puff, 4-10 puffs per treatment cycle
- **Oxygen:** Controlled flow oxygen if available, target SpO2 93-95% (94-98% in pregnancy)
  - Do NOT routinely administer high-flow or 100% oxygen; hyperoxia is associated with worse outcomes in severe exacerbations
- **Systemic corticosteroids:** Prednisolone 40-50 mg/day PO (or equivalent), OR dexamethasone 6 mg PO or IM once daily for 2 days
  - Administer within the first hour if: patient has a severe exacerbation, patient already taking OCS, patient has a history of exacerbations requiring OCS
  - Duration: typically 5-7 days for prednisolone; no taper needed for courses <=7 days
- **Continue ICS-formoterol (for patients on MART):** Increase reliever use as needed
- **Reassess at 1 hour:** If PEF 60-80% predicted and symptoms improving, consider discharge with step-up plan

### Severe Exacerbation Management (Emergency Department)

- **SABA:** Salbutamol (albuterol) 4-10 puffs by pMDI + spacer every 20 minutes for the first hour, OR salbutamol 5 mg by nebulizer every 20 minutes for the first hour (continuous nebulization may be used)
- **Ipratropium bromide:** Add in severe exacerbations
  - Ipratropium 80 mcg by pMDI + spacer (or 500 mcg by nebulizer) every 20 minutes for 3 doses, then as needed
  - Combined SABA + ipratropium reduces hospitalization rates and improves PEF and FEV1 compared with SABA alone in moderate-severe exacerbations
- **Oxygen:** Controlled flow, target SpO2 93-95%
- **Systemic corticosteroids:** Prednisolone 40-50 mg PO, OR hydrocortisone 200 mg IV, given within the first hour
- **Consider magnesium sulfate IV:** For patients with severe exacerbations not responding to initial treatment
  - Dose: 2 g (magnesium sulfate) IV infusion over 20 minutes
  - Reduces hospitalization in severe exacerbations as adjunct therapy
  - Nebulized magnesium sulfate has NOT shown significant benefit in adults

### Life-Threatening Exacerbation

- **All of the above, PLUS:**
- Transfer to ICU or acute care setting
- Consider IV salbutamol or IV aminophylline (specialist only)
- Prepare for possible intubation and mechanical ventilation
- Contact senior/specialist clinician immediately

## Reassessment and Disposition

### Criteria for Discharge from ED

- PEF or FEV1 >60-80% of predicted or personal best
- SpO2 >=94% on room air
- Adequate resources at home
- Symptoms improved

### Discharge Plan (All Patients)

1. **Reliever:** Continue as-needed SABA (Track 2) or as-needed ICS-formoterol (Track 1) for symptom relief
2. **Controller:** Step up controller treatment for 2-4 weeks:
   - For patients on Track 1 (MART): continue at current step; the increased reliever use provides additional ICS
   - For patients on Track 2: double the ICS dose for 2-4 weeks, or add ICS if not already prescribed
3. **OCS course:** Prednisolone 40-50 mg/day PO for 5-7 days; no taper needed
4. **Review inhaler technique and adherence**
5. **Provide or update written asthma action plan**
6. **Follow-up:** Schedule review within 1-2 days after ED visit, and again within 1-4 weeks

### Criteria for Hospital Admission

- PEF or FEV1 <60% predicted after 1 hour of treatment
- Persistent severe symptoms
- Ongoing hypoxemia (SpO2 <92% on room air)
- Social circumstances that preclude safe discharge
- Patient has risk factors for asthma-related death

## Self-Management with Written Asthma Action Plan

All patients should have a written asthma action plan that includes:
- How to recognize worsening asthma (symptoms and, if available, PEF)
- How to adjust medications:
  - **Track 1 (MART):** Increase reliever (ICS-formoterol) use as needed; the plan should specify when to add OCS
  - **Track 2:** Increase ICS dose (double for 1-2 weeks); use SABA for relief; start OCS if not improving
- When to seek medical attention (persistent worsening, severe symptoms, no improvement with increased reliever, need for OCS)
- Emergency contact information

## Limitations

- PEF and SpO2 may not fully reflect severity, especially in patients with chronic airflow limitation.
- Clinical judgment should be used alongside objective measures.
- Dose recommendations for systemic corticosteroids in exacerbations are based on limited head-to-head trial data; the 5-7 day prednisolone course is the most widely studied duration.
- The effectiveness of magnesium sulfate IV is primarily demonstrated in severe exacerbations and should not be used routinely in mild-moderate cases.
