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In acute asthma without life threatening features, β 2 agonists can be administered by repeated
activations of a pMDI via an appropriate large volume spacer or by wet nebulisation driven by
oxygen, if available. 786 Inhaled β 2 agonists are as efficacious and preferable to intravenous β 2
agonists (meta-analysis has excluded subcutaneous trials) in adult acute asthma in the majority
of cases. 424
Metered dose inhalers with spacers can be used for patients with exacerbations of asthma other
than life threatening. 786
A use high-dose inhaled β 2 agonists as first line agents in acute asthma and administer as
early as possible. reserve intravenous β 2 agonists for those patients in whom inhaled
therapy cannot be used reliably.
; In acute asthma with life threatening features the nebulised route (oxygen-driven) is
recommended.
Parenteral β 2 agonists, in addition to inhaled β 2 agonists, may have a role in ventilated patients
or those in extremis; however there is limited evidence to support this.
Most cases of acute asthma will respond adequately to bolus nebulisation of β 2 agonists.
Continuous nebulisation of β 2 agonists with an appropriate nebuliser may be more effective
than bolus nebulisation in relieving acute asthma for patients with a poor response to initial
therapy. 425-427
A in severe asthma that is poorly responsive to an initial bolus dose of β 2 agonist, consider
continuous nebulisation with an appropriate nebuliser.
Repeat doses of β 2 agonists at 15-30 minute intervals or give continuous nebulisation of
salbutamol at 5-10 mg/hour (requires appropriate nebuliser) if there is an inadequate response
to initial treatment. Higher bolus doses, eg 10 mg of salbutamol, are unlikely to be more
effective.
6.3.3 STEROID THERAPy
Steroids reduce mortality, relapses, subsequent hospital admission and requirement for β 2 agonist
therapy. The earlier they are given in the acute attack the better the outcome. 428,429
A Give steroids in adequate doses in all cases of acute asthma.
Steroid tablets are as effective as injected steroids, provided they can be swallowed and
retained. 428 Prednisolone 40-50 mg daily or parenteral hydrocortisone 400 mg daily (100 mg
six-hourly) are as effective as higher doses. 430 For convenience, steroid tablets may be given as
2 x 25 mg tablets daily rather than 8-10 x 5 mg tablets. Where necessary soluble prednisolone
(sodium phosphate) 5 mg tablets are available. In cases where oral treatment may be a problem
consider intramuscular methylprednisolone 160 mg as an alternative to a course of oral
prednisolone. 787
; Continue prednisolone 40-50 mg daily for at least five days or until recovery.
6 MAnAGeMent of ACute AsthMA
Following recovery from the acute exacerbation steroids can be stopped abruptly. Doses do
not need tapering provided the patient receives inhaled steroids431,432 (apart from patients on
maintenance steroid treatment or rare instances where steroids are required for three or more
weeks).
It is not known if inhaled steroids provide further benefit in addition to systemic steroids. Inhaled
steroids should however be started, or continued as soon as possible to commence the chronic
asthma management plan. 788,789
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