Asthma is a common chronic respiratory disease that is noncommunicable. According to the Global Initiative for Asthma, asthma is a heterogenous disease and usually characterized by chronic airway inflammation (1). Uncontrolled asthma is associated with a higher risk of exacerbations requiring escalation of therapy. The goal of asthma exacerbation treatment is to relieve symptoms and return patients to their optimal lung function. Treatment includes:
Inhaled bronchodilators (beta-2 agonists and anticholinergics)
Usually systemic glucocorticoids
Sometimes magnesium
(See also Asthma and Pharmacologic Treatment of Asthma.)
Patients having an asthma exacerbation are instructed to self-administer 2 to 4 puffs of inhaled albuterol or a similar short-acting beta agonist up to 3 times spaced 20 minutes apart for an acute exacerbation and to measure peak expiratory flow (PEF) if possible. When these short-acting rescue medications are effective (symptoms are relieved and PEF returns to Patients having an asthma exacerbation are instructed to self-administer 2 to 4 puffs of inhaled albuterol or a similar short-acting beta agonist up to 3 times spaced 20 minutes apart for an acute exacerbation and to measure peak expiratory flow (PEF) if possible. When these short-acting rescue medications are effective (symptoms are relieved and PEF returns to> 80% of baseline), the acute exacerbation may be managed in the outpatient setting. Patients who do not respond, have severe symptoms, or have a PEF persistently < 80% should follow a treatment management program outlined by the physician or should go to the emergency department (for specific dosing information, see table Pharmacologic Treatment of Asthma Exacerbations).
Pharmacologic Treatment of Asthma Exacerbations*, †
Medication | Form | Dosage in Children | Dosage in Adults | Comments |
|---|---|---|---|---|
Short-acting beta-2 agonists‡ | ||||
AlbuterolAlbuterol | HFA: 90 mcg/puff | Same as adults | 4–10 puffs every 20 minutes for 3 doses, then up to 6–10 doses every 1–2 hours | MDI is as effective as nebulized solution if patients can coordinate inhalation maneuver using spacer and holding chamber. |
Nebulized solution: 5 mg/mL and 0.63, 1.25, and 2.5 mg/3 mL | 0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses, then 0.15–0.3 mg/kg up to 10 mg every 1–4 hours as needed Alternatively, 0.5 mg/kg/hour continuous nebulization (up to 10–20 mg per hour in children < 12 years) In children > 12 years, up to 10–15 mg/hour | 2.5–5 mg every 20 minutes for 3 doses, then 2.5–10 mg every 1–4 hours as needed Alternatively, 10–15 mg/hour continuous nebulization | Continuous nebulization is similarly effective compared to episodic nebulization, but it increases frequency of adverse effects. | |
LevalbuterolLevalbuterol | HFA: 45 mg/actuation | Same as adults | 4–8 puffs every 20 minutes for 3 doses, then every 1–4 hours as needed | Levalbuterol is the R-isomer of albuterol. 0.63 mg is equivalent to 1.25 mg racemic albuterol. Levalbuterol may have fewer adverse effects than albuterol. |
Nebulized solution: 0.31, 0.63, 1.25 mg/3 mL, and 1.25 mg/0.5 mL | 0.075 mg/kg (minimum 1.25 mg) every 20 minutes for 3 doses, then 0.075–0.15 mg/kg up to 5 mg every 1–4 hours as needed | 1.25–2 mg every 20 minutes for 3 doses, then 1.25–5 mg every 1–4 hours as needed Alternatively, 5–7.5 mg/hours continuous nebulization | — | |
Anticholinergics | ||||
IpratropiumIpratropium | Nebulized solution: 500 mcg/2.5 mL (0.02%) MDI: 18 mcg per puff | 0.25–0.5 mg every 20 minutes for 3 doses, then every 2–4 hours as needed Children: 4–8 puffs every 20 minutes as needed for up to 3 hours Adolescents: 8 puffs every 20 minutes for up to 3 hours | 0.5 mg every 20 minutes for 3 doses, then every 2–4 hours as needed | Ipratropium should be added to beta-2 agonists and not used as first-line therapy. It may be mixed in same nebulizer as albuterol. Dose delivered from MDI is low and has not been studied in exacerbations. |
Combination medications | ||||
Ipratropium/albuterolIpratropium/albuterol | SMI: 20 mcg ipratroprium and 100 mcg albuterol/puff | — | 1 puff every 30 minutes for 3 doses, then every 2–4 hours as needed | Ipratropium prolongs bronchodilator effect of albuterol. |
Nebulized solution: 0.5 mg ipratropium and 2.5 mg albuterol in a 3-mL vial | 1.5 mL every 20 minutes for 3 doses, then up to 3 hours as needed | 3 mL every 30 minutes for 3 doses, then every 2–4 hours as needed | — | |
Budesonide/formoterolBudesonide/formoterol | HFA: 80 or 160 mcg budesonide and 4.5 mcg formoterol | 4 to < 12 years Budesonide 80 mcg/formoterol 4.5 mcg 1 puff as needed for symptom control administered after a few minutes as needed Maximum daily dose including maintenance and reliever therapy is 8 puffs ≥ 12 years: Budesonide 160 mcg formoterol 4.5 mcg 1 puff as needed for symptom relief after a few minutes as needed to control symptoms Maximum daily dose is 12 puffs | 2 puffs twice a day as needed Maximum total daily maintenance and rescue (reliever) of 12 puffs (54 mcg) | Additional daily maintenance therapy should be continued even if used as reliever therapy. |
Budesonide/albuterolBudesonide/albuterol | HFA: 80 mcg budesonide/90 mcg albuterol | < 18 years: not used | ≥ 18 years: 80 mcg budesonide/90 mcg albuterol 2 puffs as needed Maximum 6 doses or 12 puffs in 24-hour period | — |
Systemic glucocorticoids | ||||
MethylprednisoloneMethylprednisolone | Tablets: 2, 4, 8, 16, and 32 mg | 0–11 years of age: 1–2 mg/kg once a day or in 2 divided doses until symptoms resolve and PEF is at least 80 percent of patient's personal best | 40–80 mg day or in 2 divided doses until symptoms resolve and PEF is at least 70 % of patient's personal best | IV has no advantage over oral administration if gastrointestinal function is normal. Higher doses provide no advantage in severe exacerbations. The dose is administered once or twice a day until FEV1 or PEF = 50% of predicted or personal best and then lower the dose to twice a day, usually within 48 hours. Therapy after a hospitalization or ED visit may last 5–10 days in adults and 3–5 days in children. Tapering the dose is not needed if patients are also given inhaled glucocorticoids. |
Injectable suspension: 20 mg/mL, 40 mg/mL, and 80 mg/mL Solution for injection: 40 mg, 125 mg, 500 mg, 1000 mg, and 2000 mg | 0–11 years: 1–2 mg/kg once a day in 2 divided doses until symptoms resolve and PEF is at least 70% of patient's personal best | 60–80 mg in 3 or 4 divided doses for 48 hours, then 30–40 mg/day until PEF reaches 70% of personal best | — | |
PrednisolonePrednisolone | Tablets: 5 mg Orally disintegrating tablets: 10, 15, and 30 mg | 1–2 mg/kg in 1–2 divided doses until PEF is 70% of predicted or personal best | 40 to 80 mg once a day or in 2 divided doses until PEF reaches 70% of patient's predicted or personal best | Maximum dose: < 2 years: 20 mg/day 3–5 years: 30 mg/day 6–11 years: 40 mg/day |
Solution: 5, 10, 15, 20 and 25 mg/5 mL | Same as above | Same as above | Same as above | |
PrednisonePrednisone | Tablets: 1, 2.5, 5, 10, 20, and 50 mg | 1–2 mg/kg daily for 5 days | 40–60 mg/day in single daily dose or divided every 12 hours for 3–10 days | Maximum dose: < 2 years: 20 mg/day 3–5 years: 30 mg/day 6–11 years: 40 mg/day |
Concentrate: 5 mg/mL Solution: 5 mg/5 mL | Same as above | Same as above | Same as above | |
* All ages unless specified differently. | ||||
† Amount and timing of ongoing doses are dictated by clinical response. | ||||
‡ Short-acting-beta2-agonists must be used in combination with an inhaled corticosteroid (glucocorticoid). | ||||
ED = emergency department; FEV1= forced expiratory volume in 1 second; HFA = hydrofluoroalkane; MDI = metered-dose inhaler; PEF = peak expiratory flow; SMI = soft mist inhaler. | ||||
Adapted from National Heart, Lung, and Blood Institute: Expert Panel Report 3: Guidelines for the diagnosis and management of asthma—full report 2007. August 28, 2007. Available at www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf; and Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, et al: 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol 146(6):1217–1270, 2020. doi: 10.1016/j.jaci.2020.10.003. | ||||
For additional information, see Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated May 2025. Accessed May 20, 2025. Available from www.ginasthma.org. | ||||
Emergency department care
Inhaled bronchodilators (beta-2 agonists and anticholinergics) are the mainstay of asthma treatment in the emergency department. In adults and older children, albuterol given by a metered-dose inhaler (MDI) and spacer is as effective as that given by nebulizer. Nebulized treatment is preferred for younger children because of difficulties coordinating MDIs and spacers. It should be emphasized that, contrary to popular belief, no data favor continuous beta-2 agonist nebulization over intermittent administration; continuous nebulization is inconsistent with the pharmacokinetics of beta-agonists binding to their receptors. Evidence suggests that bronchodilator response improves when the nebulizer is powered with a mixture of helium and oxygen (heliox) rather than with oxygen. Given its lower density, helium is thought to assist with delivery of bronchodilators to distal airways. However, technical aspects of using helium for nebulization (availability, calibration of helium concentration, need for custom masks to avoid dilution with room air) have limited its widespread acceptance.(beta-2 agonists and anticholinergics) are the mainstay of asthma treatment in the emergency department. In adults and older children, albuterol given by a metered-dose inhaler (MDI) and spacer is as effective as that given by nebulizer. Nebulized treatment is preferred for younger children because of difficulties coordinating MDIs and spacers. It should be emphasized that, contrary to popular belief, no data favor continuous beta-2 agonist nebulization over intermittent administration; continuous nebulization is inconsistent with the pharmacokinetics of beta-agonists binding to their receptors. Evidence suggests that bronchodilator response improves when the nebulizer is powered with a mixture of helium and oxygen (heliox) rather than with oxygen. Given its lower density, helium is thought to assist with delivery of bronchodilators to distal airways. However, technical aspects of using helium for nebulization (availability, calibration of helium concentration, need for custom masks to avoid dilution with room air) have limited its widespread acceptance.
Nebulized ipratropiumNebulized ipratropium can be co-administered with nebulized albuterol for patients who do not respond optimally to can be co-administered with nebulized albuterol for patients who do not respond optimally toalbuterol alone; some evidence favors simultaneous high-dose beta-2 agonist and ipratropium as first-line treatment.
Systemic glucocorticoids (prednisone, prednisolone, methylprednisolone) should be given for all but the mildest acute exacerbation; they are unnecessary for patients whose PEF normalizes after 1 or 2 bronchodilator doses. IV and oral routes of administration are probably equally effective. IV (prednisone, prednisolone, methylprednisolone) should be given for all but the mildest acute exacerbation; they are unnecessary for patients whose PEF normalizes after 1 or 2 bronchodilator doses. IV and oral routes of administration are probably equally effective. IVmethylprednisolone can be given if an IV line is already in place and can be switched to oral dosing whenever necessary or convenient. In general, higher doses (prednisone 50 to 60 mg once a day) are recommended for the management of more severe exacerbations requiring in-patient care while lower doses (40 mg once a day) are reserved for outpatient treatment of milder exacerbations. Although evidence about optimal dose and duration is weak, a treatment duration of 3 to 5 days in children and 5 to 7 days in adults is recommended as adequate by most guidelines and should be tailored to the severity and duration of an exacerbation (1, 2).
Intravenous magnesium sulfate is an adjunct in the treatment of acute asthma exacerbations that are severe or life-threatening and unresponsive to initial therapy with inhaled beta-2 agonists and systemic glucocorticoids. Evidence from meta-analyses demonstrates that IV magnesium sulfate may lead to a modest decrease in hospital admissions and improvement in lung function, particularly in adults and children with more severe presentations (3, 4). Magnesium sulfate relaxes smooth muscle, but efficacy in management of asthma exacerbation in the emergency department is debated.
Antibiotics are indicated only when history, examination, or chest radiograph suggests underlying bacterial infection; most infections underlying asthma exacerbations are probably viral in origin.
Supplemental oxygen is indicated for hypoxemia and should be given by nasal cannula or face mask at a flow rate or concentration sufficient to maintain oxygen saturation > 90%.
Subcutaneous epinephrineSubcutaneous epinephrine is not recommended as a routine therapy for asthma exacerbations and should be reserved for specific indications such as concomitant anaphylaxis or refractory, life-threatening asthma when other therapies, such as inhaled short-acting beta-2-agonists, are not available or effective. In such cases, intramuscular or subcutaneous epinephrine may be administered at a dose of 0.3 to 0.5 mg (1 mg/mL solution for adults), not to exceed 0.5 mg per injection and repeated every 5 to 10 minutes as needed. In prepubertal children the dose is 0.01 mg/kg every 5-20 minutes for 3 doses (maximum dose 0.3 mg) administered intramuscularly (5).
Terbutaline is an alternative to epinephrine for children. Terbutaline is an alternative to epinephrine for children.Terbutaline may be preferable to epinephrine because of fewer cardiovascular effects and longer duration of action, but supplies are limited.
Theophylline has very little role in treatment of an acute asthma exacerbation. It is associated with an increased risk of adverse effects such as arrhythmias and seizures. As a result, Theophylline has very little role in treatment of an acute asthma exacerbation. It is associated with an increased risk of adverse effects such as arrhythmias and seizures. As a result,theophylline is not routinely recommended for acute asthma exacerbations and is reserved for selected cases, such as for patients who do not respond to standard therapies and are hospitalized with severe or life-threatening exacerbations (1).
Reassurance is the best approach when anxiety is the cause of asthma exacerbation. Anxiolytics and morphine are relatively contraindicated because they are associated with respiratory depression, and Reassurance is the best approach when anxiety is the cause of asthma exacerbation. Anxiolytics and morphine are relatively contraindicated because they are associated with respiratory depression, andmorphine may cause anaphylactoid reactions due to release of histamine by mast cells; these medications may increase mortality and the need for mechanical ventilation.
Hospitalization
Hospitalization generally is required if patients have not returned to their baseline within 4 hours of aggressive emergency department treatment. Criteria for hospitalization vary, but definite indications are:
Failure to improve
Worsening fatigue
Relapse after repeated beta-2 agonist therapy
Significant decrease in PaO2 (to < 50 mm Hg)
Significant increase in PaCO2 (to > 40 mm Hg)
A significant increase in PaCO2 indicates progression to respiratory failure.
Noninvasive positive pressure ventilation (NIPPV) may be needed in patients whose condition continues to deteriorate despite aggressive treatment to alleviate the work of breathing. NIPPV includes expiratory positive airway pressure that reduces the effect of intrinsic positive pressure that remains in the alveoli at the end of expiration during mechanical ventilation. It also includes inspiratory positive airway pressure that reduces the effects of increased airway resistance. Providing pressure support during both inspiratory and expiratory phases helps to reduce the work of breathing.
Endotracheal intubation and invasive mechanical ventilation may be needed for respiratory failure. NIPPV can be used to prevent intubation if used early in the course of a severe exacerbation and should be considered in patients with acute respiratory distress with a level of PaCO2 that is inappropriately high in relation to the degree of tachypnea. It should be reserved for exacerbations that, despite immediate therapy with bronchodilators and systemic glucocorticoids, result in respiratory distress, using criteria such as tachypnea (respiratory rate > 25 per minute), use of accessory respiratory muscles, PaCO2 > 40 but < 60 mm Hg, and hypoxemia. Mechanical ventilation should be used rather than NIPPV if patients have any of the following:
PaCO2 > 60 mm Hg
Decreased level of consciousness
Excessive respiratory secretions
Facial abnormalities (ie, surgical, traumatic) that could impede noninvasive ventilation
Mechanical ventilation should be strongly considered if there is no convincing improvement after 1 hour of NIPPV.
Intubation and mechanical ventilation allow the provision of sedation to further alleviate the work of breathing, but the routine use of neuromuscular blocking agents should be avoided because of possible interactions with glucocorticoids that can cause prolonged neuromuscular weakness. Ketamine may be used for awake intubation if the user has familiarity with its use and adverse effects (eg, laryngospasm, rigidity, bronchorrhea).and mechanical ventilation allow the provision of sedation to further alleviate the work of breathing, but the routine use of neuromuscular blocking agents should be avoided because of possible interactions with glucocorticoids that can cause prolonged neuromuscular weakness. Ketamine may be used for awake intubation if the user has familiarity with its use and adverse effects (eg, laryngospasm, rigidity, bronchorrhea).
Generally, volume-cycled ventilation in assist-control mode is used because it provides constant alveolar ventilation when airway resistance is high and changing. The ventilator should be set to a relatively low frequency with a relatively high inspiratory flow rate (> 80 L/minute) to prolong exhalation time, minimizing auto-positive end-expiratory pressure (auto-PEEP). Initial tidal volumes can be set to 6 to 8 mL/kg of ideal body weight, and extrinsic PEEP should be used to facilitate patient-initiated triggering and minimize ventilator dyssynchrony from auto-PEEP. High peak airway pressures will generally be present because they result from high airway resistance and inspiratory flow rates. In these patients, peak airway pressure does not reflect the degree of lung distention caused by alveolar pressure. However, if plateau pressures exceed 30 to 35 cm water, then tidal volume should be reduced to limit the risk of pneumothorax. When reduced tidal volumes are necessary, a moderate degree of hypercapnia is acceptable ("permissive hypercapnia"), but if arterial pH falls below 7.10, a slow sodium bicarbonate infusion can be considered to maintain pH between 7.20 and 7.25, especially if there is hemodynamic instability. Once airflow obstruction is relieved and PaCO2 and arterial pH normalize, patients can usually be quickly liberated from the ventilator. (For further details, see . When reduced tidal volumes are necessary, a moderate degree of hypercapnia is acceptable ("permissive hypercapnia"), but if arterial pH falls below 7.10, a slow sodium bicarbonate infusion can be considered to maintain pH between 7.20 and 7.25, especially if there is hemodynamic instability. Once airflow obstruction is relieved and PaCO2 and arterial pH normalize, patients can usually be quickly liberated from the ventilator. (For further details, seeRespiratory Failure and Mechanical Ventilation.)
Other therapy
Other therapies are reportedly effective for asthma exacerbation, but none have been thoroughly studied. A mixture of helium and oxygen (heliox) is used to decrease the work of breathing and improve ventilation through a decrease in turbulent flow attributable to helium, a gas less dense than oxygen. Despite the theoretical benefits of heliox, studies have reported conflicting results concerning its efficacy; lack of ready availability and inability to concurrently provide high concentrations of oxygen (due to the fact that 70 to 80% of the inhaled gas is helium) may also limit its use (6, 7).
Vocal fold dysfunction, also called inducible laryngeal obstruction, is characterized by the inappropriate adduction of the vocal folds during inspiration, can lead to airflow obstruction and mimic an asthma exacerbation. Management of vocal fold dysfunction involves a multidisciplinary approach, including speech therapy to teach breathing techniques. Heliox could also be beneficial for the management of patients with vocal fold dysfunction.
General anesthesia with agents such as sevoflurane and isoflurane in patients with status asthmaticus causes bronchodilation by an unclear mechanism, perhaps by a direct relaxant effect on airway smooth muscle or attenuation of cholinergic tone.General anesthesia with agents such as sevoflurane and isoflurane in patients with status asthmaticus causes bronchodilation by an unclear mechanism, perhaps by a direct relaxant effect on airway smooth muscle or attenuation of cholinergic tone.
References
1. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2025. Updated May 2025. Accessed May 20, 2025. Available from www.ginasthma.org
2. British Thoracic Society, National Institute for Health and Care Excellence, and Scottish Intercollegiate Guidelines Network: Asthma: diagnosis, monitoring and chronic asthma management (BTS, NICE, SIGN). London: National Institute for Health and Care Excellence (NICE). Published November 27, 2024.
3. Ambrożej D, Adamiec A, Forno E, Orzołek I, Feleszko W, Castro-Rodriguez JA. Intravenous magnesium sulfate for asthma exacerbations in children: Systematic review with meta-analysis. Paediatr Respir Rev. 2024;52:23-30. doi:10.1016/j.prrv.2024.01.003
4. Knightly R, Milan SJ, Hughes R, et al. Inhaled magnesium sulfate in the treatment of acute asthma. Cochrane Database Syst Rev. 2017;11(11):CD003898. Published 2017 Nov 28. doi:10.1002/14651858.CD003898.pub6
5. Shenoi RP, Timm N; COMMITTEE ON DRUGS; COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE. Drugs Used to Treat Pediatric Emergencies. Pediatrics. 2020 Jan;145(1):e20193450. doi: 10.1542/peds.2019-3450. PMID: 31871244.
6. Rodrigo GJ, Rodrigo C, Pollack CV, Rowe B. Use of helium-oxygen mixtures in the treatment of acute asthma: a systematic review. Chest. 2003;123(3):891-896. doi:10.1378/chest.123.3.891
7. Rodrigo GJ, Castro-Rodriguez JA. Heliox-driven β2-agonists nebulization for children and adults with acute asthma: a systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2014;112(1):29-34. doi:10.1016/j.anai.2013.09.024
Drugs Mentioned In This Article
