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 [1,2].
The National Asthma Expert Panel has published useful algorithms on the management of acute exacerbations of asthma, both in the home and acute care settings (algorithm 1 and algorithm 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 provided (table 1).
The basic principles of care are the following:
- Assess the severity of the attack
- Use inhaled short-acting beta agonists early and frequently and consider concomitant use of ipratropium for severe exacerbations
- Start systemic glucocorticoids if there is not an immediate and marked response to the inhaled short-acting beta agonists
- Make frequent (every one to two hours) objective assessments of the response to therapy until definite, sustained improvement is documented
- Admit patients who do not respond well after four to six hours to a setting of high surveillance and care
- Educate patients about the principles of self-management for early recognition and treatment of a recurrent attack and develop an "asthma action plan" for recurrent symptoms (see "What do patients need to know about their asthma?")
The management of acute asthma exacerbations will be presented here. Mechanical ventilation in severe exacerbations of asthma is discussed separately. (See "Invasive mechanical ventilation in adults with acute exacerbations of asthma".)