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Management of acute exacerbations of asthma in adults

Christopher H Fanta, MD
Section Editors
Bruce S Bochner, MD
Robert S Hockberger, MD, FACEP
Deputy Editor
Helen Hollingsworth, MD


The best strategy for management of acute exacerbations of asthma is early recognition and intervention, before attacks become severe and potentially life-threatening. Detailed investigations into the circumstances surrounding fatal asthma have frequently revealed failures on the part of both patients and clinicians to recognize the severity of the disease and to intensify treatment appropriately [1].

The management of acute asthma exacerbations will be presented here. An overview of asthma management, the identification of risk factors for fatal asthma, and the use of mechanical ventilation in severe exacerbations of asthma are discussed separately. (See "An overview of asthma management" and "Identifying patients at risk for fatal asthma" and "Invasive mechanical ventilation in adults with acute exacerbations of asthma".)


The National Asthma Expert Panel has published useful algorithms on the management of acute exacerbations of asthma for both the home and acute care settings (algorithm 1 and algorithm 2) [2]. These algorithms may be used for asthma exacerbations of any severity. A table outlining the emergency management of severe asthma exacerbations in adults is also provided (table 1).

The basic principles of care are the following:

Assess the severity of the attack

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Literature review current through: Sep 2017. | This topic last updated: Jul 13, 2017.
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  1. Rodrigo GJ, Rodrigo C, Hall JB. Acute asthma in adults: a review. Chest 2004; 125:1081.
  2. National Asthma Education and Prevention Program: Expert Panel Report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD. National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051) www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on March 17, 2016).
  3. Global Initiative for Asthma (GINA). Global Burden of Asthma Report. www.ginasthma.org (Accessed on November 14, 2016).
  4. Goodacre S, Bradburn M, Cohen J, et al. Prediction of unsuccessful treatment in patients with severe acute asthma. Emerg Med J 2014; 31:e40.
  5. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Thorax 2014; 69 Suppl 1:1.
  6. Safety Concerns with Asthmanefrin and the EZ Breathe Atomizer. http://www.fda.gov/Drugs/DrugSafety/ucm370483.htm (Accessed on April 07, 2015).
  7. American Academy of Allergy Asthma & Immunology. Non-prescription racemic ephinephrine for asthma. http://www.aaaai.org/global/latest-research-summaries/New-Research-from-JACI-In-Practice/racemic-epinephrine-asthma.aspx (Accessed on April 07, 2015).
  8. Mondal P, Kandala B, Ahrens R, et al. Nonprescription racemic epinephrine for asthma. J Allergy Clin Immunol Pract 2014; 2:575.
  9. Canadian Society of Allergy and Clinical Immunology. Non-prescription availability of theophylline, epinephrine, and ephedrine for asthma. http://csaci.ca/index.php?page=359 (Accessed on April 07, 2015).
  10. Oborne J, Mortimer K, Hubbard RB, et al. Quadrupling the dose of inhaled corticosteroid to prevent asthma exacerbations: a randomized, double-blind, placebo-controlled, parallel-group clinical trial. Am J Respir Crit Care Med 2009; 180:598.
  11. FitzGerald JM, Becker A, Sears MR, et al. Doubling the dose of budesonide versus maintenance treatment in asthma exacerbations. Thorax 2004; 59:550.
  12. Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet 2004; 363:271.
  13. Brenner BE, Abraham E, Simon RR. Position and diaphoresis in acute asthma. Am J Med 1983; 74:1005.
  14. Kelsen SG, Kelsen DP, Fleeger BF, et al. Emergency room assessment and treatment of patients with acute asthma. Adequacy of the conventional approach. Am J Med 1978; 64:622.
  15. McFadden ER Jr, Lyons HA. Arterial-blood gas tension in asthma. N Engl J Med 1968; 278:1027.
  16. Martin TG, Elenbaas RM, Pingleton SH. Use of peak expiratory flow rates to eliminate unnecessary arterial blood gases in acute asthma. Ann Emerg Med 1982; 11:70.
  17. Nowak RM, Tomlanovich MC, Sarkar DD, et al. Arterial blood gases and pulmonary function testing in acute bronchial asthma. Predicting patient outcomes. JAMA 1983; 249:2043.
  18. Bloom BM, Grundlingh J, Bestwick JP, Harris T. The role of venous blood gas in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med 2014; 21:81.
  19. Tsai TW, Gallagher EJ, Lombardi G, et al. Guidelines for the selective ordering of admission chest radiography in adult obstructive airway disease. Ann Emerg Med 1993; 22:1854.
  20. Findley LJ, Sahn SA. The value of chest roentgenograms in acute asthma in adults. Chest 1981; 80:535.
  21. Zieverink SE, Harper AP, Holden RW, et al. Emergency room radiography of asthma: an efficacy study. Radiology 1982; 145:27.
  22. Aronson S, Gennis P, Kelly D, et al. The value of routine admission chest radiographs in adult asthmatics. Ann Emerg Med 1989; 18:1206.
  23. Perrin K, Wijesinghe M, Healy B, et al. Randomised controlled trial of high concentration versus titrated oxygen therapy in severe exacerbations of asthma. Thorax 2011; 66:937.
  24. Rossing TH, Fanta CH, Goldstein DH, et al. Emergency therapy of asthma: comparison of the acute effects of parenteral and inhaled sympathomimetics and infused aminophylline. Am Rev Respir Dis 1980; 122:365.
  25. Turner JR, Corkery KJ, Eckman D, et al. Equivalence of continuous flow nebulizer and metered-dose inhaler with reservoir bag for treatment of acute airflow obstruction. Chest 1988; 93:476.
  26. Salzman GA, Steele MT, Pribble JP, et al. Aerosolized metaproterenol in the treatment of asthmatics with severe airflow obstruction. Comparison of two delivery methods. Chest 1989; 95:1017.
  27. Idris AH, McDermott MF, Raucci JC, et al. Emergency department treatment of severe asthma. Metered-dose inhaler plus holding chamber is equivalent in effectiveness to nebulizer. Chest 1993; 103:665.
  28. Newman KB, Milne S, Hamilton C, Hall K. A comparison of albuterol administered by metered-dose inhaler and spacer with albuterol by nebulizer in adults presenting to an urban emergency department with acute asthma. Chest 2002; 121:1036.
  29. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev 2013; :CD000052.
  30. Dhuper S, Chandra A, Ahmed A, et al. Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med 2011; 40:247.
  31. Moriates C, Feldman L. Nebulized bronchodilators instead of metered-dose inhalers for obstructive pulmonary symptoms. J Hosp Med 2015; 10:691.
  32. Craven D, Kercsmar CM, Myers TR, et al. Ipratropium bromide plus nebulized albuterol for the treatment of hospitalized children with acute asthma. J Pediatr 2001; 138:51.
  33. Goggin N, Macarthur C, Parkin PC. Randomized trial of the addition of ipratropium bromide to albuterol and corticosteroid therapy in children hospitalized because of an acute asthma exacerbation. Arch Pediatr Adolesc Med 2001; 155:1329.
  34. Rodrigo GJ, Rodrigo C. First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med 2000; 161:1862.
  35. Stoodley RG, Aaron SD, Dales RE. The role of ipratropium bromide in the emergency management of acute asthma exacerbation: a metaanalysis of randomized clinical trials. Ann Emerg Med 1999; 34:8.
  36. Rodrigo GJ, Castro-Rodriguez JA. Anticholinergics in the treatment of children and adults with acute asthma: a systematic review with meta-analysis. Thorax 2005; 60:740.
  37. Kirkland SW, Vandenberghe C, Voaklander B, et al. Combined inhaled beta-agonist and anticholinergic agents for emergency management in adults with asthma. Cochrane Database Syst Rev 2017; 1:CD001284.
  38. Karpel JP, Schacter EN, Fanta C, et al. A comparison of ipratropium and albuterol vs albuterol alone for the treatment of acute asthma. Chest 1996; 110:611.
  39. McFadden ER Jr, elSanadi N, Strauss L, et al. The influence of parasympatholytics on the resolution of acute attacks of asthma. Am J Med 1997; 102:7.
  40. Garrett JE, Town GI, Rodwell P, Kelly AM. Nebulized salbutamol with and without ipratropium bromide in the treatment of acute asthma. J Allergy Clin Immunol 1997; 100:165.
  41. Fanta CH, Rossing TH, McFadden ER Jr. Glucocorticoids in acute asthma. A critical controlled trial. Am J Med 1983; 74:845.
  42. Stein LM, Cole RP. Early administration of corticosteroids in emergency room treatment of acute asthma. Ann Intern Med 1990; 112:822.
  43. Lougheed MD, Garvey N, Chapman KR, et al. Variations and gaps in management of acute asthma in Ontario emergency departments. Chest 2009; 135:724.
  44. Normansell R, Kew KM, Mansour G. Different oral corticosteroid regimens for acute asthma. Cochrane Database Syst Rev 2016; :CD011801.
  45. McFadden ER Jr. Acute severe asthma. Am J Respir Crit Care Med 2003; 168:740.
  46. Emerman CL, Cydulka RK. A randomized comparison of 100-mg vs 500-mg dose of methylprednisolone in the treatment of acute asthma. Chest 1995; 107:1559.
  47. Skobeloff EM, Spivey WH, McNamara RM, Greenspon L. Intravenous magnesium sulfate for the treatment of acute asthma in the emergency department. JAMA 1989; 262:1210.
  48. Green SM, Rothrock SG. Intravenous magnesium for acute asthma: failure to decrease emergency treatment duration or need for hospitalization. Ann Emerg Med 1992; 21:260.
  49. Alter HJ, Koepsell TD, Hilty WM. Intravenous magnesium as an adjuvant in acute bronchospasm: a meta-analysis. Ann Emerg Med 2000; 36:191.
  50. Rowe BH, Bretzlaff JA, Bourdon C, et al. Intravenous magnesium sulfate treatment for acute asthma in the emergency department: a systematic review of the literature. Ann Emerg Med 2000; 36:181.
  51. Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department. Cochrane Database Syst Rev 2014; :CD010909.
  52. Tobias JD. Inhalational anesthesia: basic pharmacology, end organ effects, and applications in the treatment of status asthmaticus. J Intensive Care Med 2009; 24:361.
  53. Vaschetto R, Bellotti E, Turucz E, et al. Inhalational anesthetics in acute severe asthma. Curr Drug Targets 2009; 10:826.
  54. Carroll CL. Just a lot of hot air? Volatile anesthetics in children with status asthmaticus. Pediatr Crit Care Med 2013; 14:433.
  55. Rosseel P, Lauwers LF, Baute L. Halothane treatment in life-threatening asthma. Intensive Care Med 1985; 11:241.
  56. Bierman MI, Brown M, Muren O, et al. Prolonged isoflurane anesthesia in status asthmaticus. Crit Care Med 1986; 14:832.
  57. Masuda Y, Tatsumi H, Goto K, et al. Treatment of life-threatening hypercapnia with isoflurane in an infant with status asthmaticus. J Anesth 2014; 28:610.
  58. Schutte D, Zwitserloot AM, Houmes R, et al. Sevoflurane therapy for life-threatening asthma in children. Br J Anaesth 2013; 111:967.
  59. Shankar V, Churchwell KB, Deshpande JK. Isoflurane therapy for severe refractory status asthmaticus in children. Intensive Care Med 2006; 32:927.
  60. Watanabe K, Mizutani T, Yamashita S, et al. Prolonged sevoflurane inhalation therapy for status asthmaticus in an infant. Paediatr Anaesth 2008; 18:543.
  61. Strube PJ, Hallam PL. Ketamine by continuous infusion in status asthmaticus. Anaesthesia 1986; 41:1017.
  62. Rock MJ, Reyes de la Rocha S, L'Hommedieu CS, Truemper E. Use of ketamine in asthmatic children to treat respiratory failure refractory to conventional therapy. Crit Care Med 1986; 14:514.
  63. Hemming A, MacKenzie I, Finfer S. Response to ketamine in status asthmaticus resistant to maximal medical treatment. Thorax 1994; 49:90.
  64. Denmark TK, Crane HA, Brown L. Ketamine to avoid mechanical ventilation in severe pediatric asthma. J Emerg Med 2006; 30:163.
  65. Shlamovitz GZ, Hawthorne T. Intravenous ketamine in a dissociating dose as a temporizing measure to avoid mechanical ventilation in adult patient with severe asthma exacerbation. J Emerg Med 2011; 41:492.
  66. Beute J. Emergency treatment of status asthmaticus with enoximone. Br J Anaesth 2014; 112:1105.
  67. Travers AH, Milan SJ, Jones AP, et al. Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma. Cochrane Database Syst Rev 2012; 12:CD010179.
  68. Rodrigo GJ. Comparison of inhaled fluticasone with intravenous hydrocortisone in the treatment of adult acute asthma. Am J Respir Crit Care Med 2005; 171:1231.
  69. Nuhoğlu Y, Bahçeciler NN, Barlan IB, Müjdat Başaran M. The effectiveness of high-dose inhaled budesonide therapy in the treatment of acute asthma exacerbations in children. Ann Allergy Asthma Immunol 2001; 86:318.
  70. FitzGerald JM, Shragge D, Haddon J, et al. A randomized, controlled trial of high dose, inhaled budesonide versus oral prednisone in patients discharged from the emergency department following an acute asthma exacerbation. Can Respir J 2000; 7:61.
  71. Edmonds ML, Camargo CA Jr, Brenner BE, Rowe BH. Replacement of oral corticosteroids with inhaled corticosteroids in the treatment of acute asthma following emergency department discharge: a meta-analysis. Chest 2002; 121:1798.
  72. Brenner BE, Chavda KK, Camargo CA Jr. Randomized trial of inhaled flunisolide versus placebo among asthmatic patients discharged from the emergency department. Ann Emerg Med 2000; 36:417.
  73. Schuh S, Reisman J, Alshehri M, et al. A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma. N Engl J Med 2000; 343:689.
  74. Edmonds ML, Milan SJ, Camargo CA Jr, et al. Early use of inhaled corticosteroids in the emergency department treatment of acute asthma. Cochrane Database Syst Rev 2012; 12:CD002308.
  75. Edmonds ML, Camargo CA Jr, Pollack CV Jr, Rowe BH. The effectiveness of inhaled corticosteroids in the emergency department treatment of acute asthma: a meta-analysis. Ann Emerg Med 2002; 40:145.
  76. Nakanishi AK, Klasner AK, Rubin BK. A randomized controlled trial of inhaled flunisolide in the management of acute asthma in children. Chest 2003; 124:790.
  77. Quon BS, Fitzgerald JM, Lemière C, et al. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database Syst Rev 2010; :CD007524.
  78. Kew KM, Quinn M, Quon BS, Ducharme FM. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database Syst Rev 2016; :CD007524.
  79. Camargo CA Jr, Smithline HA, Malice MP, et al. A randomized controlled trial of intravenous montelukast in acute asthma. Am J Respir Crit Care Med 2003; 167:528.
  80. Silverman RA, Nowak RM, Korenblat PE, et al. Zafirlukast treatment for acute asthma: evaluation in a randomized, double-blind, multicenter trial. Chest 2004; 126:1480.
  81. Camargo CA Jr, Gurner DM, Smithline HA, et al. A randomized placebo-controlled study of intravenous montelukast for the treatment of acute asthma. J Allergy Clin Immunol 2010; 125:374.
  82. Ramsay CF, Pearson D, Mildenhall S, Wilson AM. Oral montelukast in acute asthma exacerbations: a randomised, double-blind, placebo-controlled trial. Thorax 2011; 66:7.
  83. Watts K, Chavasse RJ. Leukotriene receptor antagonists in addition to usual care for acute asthma in adults and children. Cochrane Database Syst Rev 2012; :CD006100.
  84. Nair P, Milan SJ, Rowe BH. Addition of intravenous aminophylline to inhaled beta(2)-agonists in adults with acute asthma. Cochrane Database Syst Rev 2012; 12:CD002742.
  85. Appel D, Shim C. Comparative effect of epinephrine and aminophylline in the treatment of asthma. Lung 1981; 159:243.
  86. Siegel D, Sheppard D, Gelb A, Weinberg PF. Aminophylline increases the toxicity but not the efficacy of an inhaled beta-adrenergic agonist in the treatment of acute exacerbations of asthma. Am Rev Respir Dis 1985; 132:283.
  87. DiGiulio GA, Kercsmar CM, Krug SE, et al. Hospital treatment of asthma: lack of benefit from theophylline given in addition to nebulized albuterol and intravenously administered corticosteroid. J Pediatr 1993; 122:464.
  88. Johnston SL, Szigeti M, Cross M, et al. Azithromycin for Acute Exacerbations of Asthma : The AZALEA Randomized Clinical Trial. JAMA Intern Med 2016; 176:1630.
  89. Johnston SL, Blasi F, Black PN, et al. The effect of telithromycin in acute exacerbations of asthma. N Engl J Med 2006; 354:1589.
  90. Tang J, Long W, Yan L, et al. Procalcitonin guided antibiotic therapy of acute exacerbations of asthma: a randomized controlled trial. BMC Infect Dis 2013; 13:596.
  91. Pendino JC, Nannini LJ, Chapman KR, et al. Effect of inhaled furosemide in acute asthma. J Asthma 1998; 35:89.
  92. Hinckley JB. Inhaled furosemide in the treatment of acute exacerbations of asthma. Acad Emerg Med 2000; 7:1167.
  93. González-Sánchez R, Trujillo-Hernández B, Huerta M, et al. Furosemide plus albuterol compared with albuterol alone in children with acute asthma. Allergy Asthma Proc 2002; 23:181.
  94. Rodríguez Vázquez JC, Pino Alfonso PP, Gassiot Nuño C, Páez Prats I. Usefulness of inhaled furosemide in a bronchial asthma attack. J Investig Allergol Clin Immunol 1998; 8:290.
  95. Fiel SB, Swartz MA, Glanz K, Francis ME. Efficacy of short-term corticosteroid therapy in outpatient treatment of acute bronchial asthma. Am J Med 1983; 75:259.
  96. Chapman KR, Verbeek PR, White JG, Rebuck AS. Effect of a short course of prednisone in the prevention of early relapse after the emergency room treatment of acute asthma. N Engl J Med 1991; 324:788.
  97. Kravitz J, Dominici P, Ufberg J, et al. Two days of dexamethasone versus 5 days of prednisone in the treatment of acute asthma: a randomized controlled trial. Ann Emerg Med 2011; 58:200.
  98. Rehrer MW, Liu B, Rodriguez M, et al. A Randomized Controlled Noninferiority Trial of Single Dose of Oral Dexamethasone Versus 5 Days of Oral Prednisone in Acute Adult Asthma. Ann Emerg Med 2016; 68:608.
  99. Lahn M, Bijur P, Gallagher EJ. Randomized clinical trial of intramuscular vs oral methylprednisolone in the treatment of asthma exacerbations following discharge from an emergency department. Chest 2004; 126:362.
  100. Chan JS, Cowie RL, Lazarenko GC, et al. Comparison of intramuscular betamethasone and oral prednisone in the prevention of relapse of acute asthma. Can Respir J 2001; 8:147.
  101. Schuckman H, DeJulius DP, Blanda M, et al. Comparison of intramuscular triamcinolone and oral prednisone in the outpatient treatment of acute asthma: a randomized controlled trial. Ann Emerg Med 1998; 31:333.
  102. McNamara RM, Rubin JM. Intramuscular methylprednisolone acetate for the prevention of relapse in acute asthma. Ann Emerg Med 1993; 22:1829.
  103. Hoffman IB, Fiel SB. Oral vs repository corticosteroid therapy in acute asthma. Chest 1988; 93:11.
  104. Ljunghall S, Jakobsson S, Joborn C, et al. Longitudinal studies of mild primary hyperparathyroidism. J Bone Miner Res 1991; 6 Suppl 2:S111.
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