Acute exacerbations of asthma in adults: Home and office management

INTRODUCTION — Acute asthma exacerbations are episodes of worsening asthma symptoms and lung function; they can be the presenting manifestation of asthma or occur in patients with a known asthma diagnosis in response to a "trigger" such as viral upper respiratory infection, allergen, air pollution or other irritant exposure, lack of adherence to controller medication, or an unknown stimulus [1-3]. 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 intensify treatment appropriately [1,2].

The management of acute asthma exacerbations will be presented here. An overview of asthma management, emergency department and inpatient management of asthma exacerbations in adults, identification of risk factors for fatal asthma and asthma triggers, and the use of mechanical ventilation in severe exacerbations of asthma are discussed separately. (See "An overview of asthma management" and "Acute exacerbations of asthma in adults: Emergency department and inpatient management" and "Identifying patients at risk for fatal asthma" and "Trigger control to enhance asthma management" and "Invasive mechanical ventilation in adults with acute exacerbations of asthma".)

ALGORITHMS FOR ASSESSMENT AND TREATMENT AT HOME AND IN THE OFFICE — Our approaches to the management of acute exacerbations of asthma at home and in the office, which are consistent with international guidelines, are outlined in the algorithms (algorithm 1 and algorithm 2) [2]. The management of less acute deteriorations in asthma control are discussed separately. (See "An overview of asthma management", section on 'Adjusting controller medication'.)

The basic principles of care are the following [1,2,4]:

●Assess the severity of the attack and risk for asthma-related death

●Assess potential triggers (eg, inhaled allergens such as animal dander, pollen, and mold; respiratory infection; medications such as beta blockers or nonsteroidal anti-inflammatory drugs [NSAIDs] in susceptible individuals; inhaled irritants such as chemical fumes or cigarette smoking; and medication nonadherence)

●Use an inhaled rapid onset (fast-acting) beta-agonist (ie, albuterol, levalbuterol, albuterol-budesonide, or formoterol-inhaled glucocorticoid combination inhaler) early and frequently

●Start systemic glucocorticoids if there is not an immediate and marked response to the inhaled rapid onset beta-agonist; initiating or increasing the dose of inhaled glucocorticoids may be sufficient in mild exacerbations.

●Make frequent objective assessments of the response to therapy until definite, sustained improvement is documented

●Advise patients who are not responding to initial home or office management to go to an acute care facility or see their asthma provider immediately, especially if they have a history of near-fatal asthmatic attacks

●Educate patients about the principles of self-management for early recognition and treatment of a future attack and develop an "asthma action plan" for recurrent symptoms (see "Asthma education and self-management")

Ideally, patients will assess the severity of an attack at home by following an individualized written "asthma action plan." Asthma action plans are based upon symptoms and peak expiratory flow (PEF) measurements and provide clear instructions on how to detect and respond to changes in these parameters [1,2]. An example is available through the National Heart Lung and Blood Institute (NHLBI Asthma action plan). Asthma action plans and peak expiratory flow monitoring are discussed separately. (See "Asthma education and self-management", section on 'Asthma action plans' and "Asthma education and self-management", section on 'Attack prevention' and "Peak expiratory flow monitoring in asthma".)

DETECTING AN EXACERBATION — Some patients are very sensitive to increased asthma symptoms, while others perceive reduced airflow only when it becomes marked. For the latter group, a decrease in peak expiratory flow may be the first sign that asthma control is deteriorating.

Symptoms and severity — Symptoms that patients should recognize as suggesting an asthma exacerbation include breathlessness, wheezing, cough, and chest tightness. Some patients also report reduced exercise tolerance and fatigue as symptoms of an asthma exacerbation. Patients who have long-standing asthma are generally able to determine when they have an exacerbation.

Patients who contact their clinician should be asked about the timing of onset, likely cause (if known), severity of symptoms (eg, provoked by exertion, present at rest, causing awakening from sleep), and risk factors for asthma-related death (ie, impaired lung function, oral glucocorticoid use, prior emergency department visits, hospitalization or intubation for asthma) (table 1). Symptoms of a severe exacerbation include intractable coughing, sensation of air hunger, inability to speak in complete sentences because of labored breathing, worsening respiratory distress when attempting to lie flat, and agitation.

Current medications and response to treatment of previous exacerbations should also be explored.

The symptoms of an asthma exacerbation are nonspecific, so the initial assessment should include assessment for other processes that might present with these symptoms, such as acute bronchitis, exacerbation of chronic obstructive pulmonary disease (COPD) or bronchiectasis, pneumonia, heart failure, pulmonary embolism, and inducible laryngeal obstruction (also called vocal cord dysfunction). (See "Evaluation of wheezing illnesses other than asthma in adults".)

Peak expiratory flow — Measurement of expiratory airflow with a peak expiratory flow (PEF) meter (or spirometer) provides an assessment of the severity of airflow limitation [5]. Peak flow measurements take less than one minute to perform and are safe and inexpensive. However, careful instruction is needed to obtain reliable measurements (table 2). (See "Peak expiratory flow monitoring in asthma".)

Peak flow values can help patients and providers judge the severity of an asthma exacerbation and help guide decision-making regarding treatment and the preferred site of medical care (home, medical office, or emergency department). They provide useful adjunctive data to be combined with assessment of symptoms and physical findings. In our experience their greatest value is detection of severe airflow obstruction in a patient whose history and examination are deceptively benign. Failure to recognize severe airflow obstruction during an asthma exacerbation can result in undertreatment, with potentially life-threatening consequences.

Normal values for PEF differ with sex, height, and age (table 3A-B). Each patient should establish a baseline measure with which to compare future readings. A decrement in PEF of greater than 20 percent from normal, or from the patient's personal best value, signals the presence of an asthma exacerbation. The difference in PEF from the patient’s baseline helps one gauge the severity of the change. A PEF ≤50 percent of baseline should be considered a severe attack.

Risk factors for fatal asthma — Some patients are at greater risk for life-threatening and potentially fatal asthma attacks. It is helpful to identify such patients and to educate them about identifying early warning signs of deterioration based on PEF monitoring, following a prednisone-based action plan, and seeking emergency care promptly. (See "Identifying patients at risk for fatal asthma", section on 'Identifying high-risk patients'.)

Risk factors for a fatal asthma attack include (table 1) [2]:

●Previous life-threatening exacerbation (eg, intubation or intensive care unit admission)

●Asthma attack despite current course of oral glucocorticoids

●More than one hospitalization for asthma in the past year

●Three or more emergency department visits for asthma in the past year

●Use of more than one canister of short-acting beta-agonist (SABA) per month

●Comorbidities, such as cardiovascular or chronic lung disease

●Illicit drug use and major psychosocial problems, including depression

●IgE-mediated food allergy in a patient with asthma

●Not currently using inhaled glucocorticoids

●Difficulty perceiving asthma symptoms or severity of exacerbations

●History of poor adherence with asthma medications and/or written asthma action plan

HOME TREATMENT — Patients with an uncomplicated asthma exacerbation, good understanding of their asthma, and good inhaler technique can often be managed at home based on direction from their written asthma action plan or discussion with their asthma provider (algorithm 1). However, home management is not meant to replace supervised medical care in seriously ill patients.

Goals — The goals of home management are to relieve symptoms and improve lung function while at the same time recognizing exacerbations that require urgent medical attention. Early initiation of treatment at home can prevent deterioration to a severe and potentially life-threatening attack. To achieve these goals, the provider can:

●Advise the patient to initiate inhaled fast-acting bronchodilator and determine the need for oral glucocorticoid.

●Triage patients with symptoms suggestive of a severe asthma exacerbation (see 'Symptoms and severity' above) to seek emergency department care. While waiting for the ambulance they should take albuterol or other rapid onset bronchodilator 4 to 6 puffs (preferably with a valved holding chamber) and prednisone 40 to 60 mg orally, if available. (See "Acute exacerbations of asthma in adults: Emergency department and inpatient management".)

Interventions uniquely available in the emergency department setting are removal from potential asthma triggers in the home environment, close medical observation, rest, reassurance, and, most importantly, the ability of medical providers to respond to worsening lung function and gas exchange in the patient who is deteriorating despite standard therapy and progressing toward respiratory failure.

●Assess need for evaluation and management in the office or urgent care center (eg, unclear severity of exacerbation, patient not able to initiate proper home management, potential comorbidity). (See 'Office management' below.)

Fast-acting bronchodilator — All patients should have access to a rapid onset bronchodilator for quick relief of asthma symptoms caused by bronchoconstriction; a short-acting beta-agonist (SABA; eg, albuterol, levalbuterol) or a combination glucocorticoid with a fast-acting beta-agonist preparation (eg, albuterol-budesonide or budesonide-formoterol) can be used [1,2,4].

Short-acting beta-agonist — When the onset of an exacerbation is recognized, inhaled SABA (eg, albuterol, levalbuterol, or albuterol-budesonide) can be administered by one of the following methods (table 4) [1,2,6]:

●Metered dose inhaler – Two to four inhalations from a metered dose inhaler (depending upon the dose that is typically effective and tolerated by that individual; typically, two inhalations are used for mild to moderate symptoms and four inhalations for more severe symptoms), preferably with a valved holding chamber ("spacer") device.

●Dry powder inhaler – Albuterol can be administered by dry powder inhaler (DPI), two to four inhalations of the 90 mcg/actuation DPI; typically, two inhalations are used for mild to moderate symptoms and four inhalations for more severe symptoms. A DPI with 200 mcg/actuation is available outside the United States; one to two inhalations are used for acute exacerbations. A valved holding chamber is not used with a DPI.

●Nebulizer – A nebulizer treatment (eg, albuterol 2.5 mg in 3 mL or levalbuterol 1.25 mg in 3 mL)

The SABA treatment can be repeated every 20 minutes for one hour (three doses), if needed. Over the course of these three SABA treatments, the patient can determine (based on action plan or clinician guidance) whether to continue self-care at home or seek additional medical attention (algorithm 1). Patients should contact their clinician or proceed to the emergency department if they need high doses of inhaled beta-agonists beyond the first hour of self-treatment. (See 'Triage based on response to home treatment' below.)

Combination glucocorticoid-formoterol — A combination inhaler containing formoterol and a glucocorticoid (GC) is an alternative to an inhaled SABA for quick relief of asthma symptoms [1,2,4]. Formoterol is a long-acting beta-agonist (LABA) with a rapid onset of action comparable to albuterol. The usual dose of GC-formoterol for acute symptom relief is one to two inhalations (4.5 mcg formoterol per inhalation). The treatment can be repeated every 20 minutes up to a total of six inhalations, if needed. Over the course of the three treatments, the patient can determine (based on action plan or clinician guidance) whether to continue self-care at home or seek additional medical attention. The maximum daily dose advised by guidelines is 12 inhalations.

As a management strategy for the treatment of asthma with infrequent symptoms, "as needed" dosing of a combination GC-formoterol inhaler reduces the frequency of severe exacerbations requiring oral glucocorticoid by two-thirds compared with SABA alone (table 5) [7,8]. (See "Initiating asthma therapy and monitoring in adolescents and adults", section on 'Patients with infrequent symptoms (Step 1)' and "Initiating asthma therapy and monitoring in adolescents and adults", section on 'Patients with frequent but not daily symptoms (Step 2)'.)

Risks associated with inhaled epinephrine — Racemic epinephrine liquid for inhalation (eg, Asthmanefrin and S2) and epinephrine inhalers (eg, Primatene Mist) are available over the counter and marketed directly to consumers for temporary relief of asthma symptoms. The FDA has issued a warning about multiple adverse events associated with these products, including symptoms such as chest pain, nausea and vomiting, increased blood pressure, tachycardia, and hemoptysis, and also defective atomizer devices [9]. Epinephrine is NOT beta-2 adrenergic receptor selective, so it carries a greater risk of beta-1 and alpha adrenergic-type adverse effects, especially when used in excess doses.

It is important to ensure that patients have ready access to the more effective, inhaled rapid onset beta-2 selective agonists, such as albuterol and levalbuterol, and to advise against use of the nonselective epinephrine-based products [10-12].

Initiation of oral glucocorticoids — Oral glucocorticoids are indicated for asthma exacerbations that are moderate to severe, characterized by lack of improvement in symptoms and/or by a peak expiratory flow (PEF) <80 percent of personal best or predicted after use of an inhaled fast-acting bronchodilator (eg, albuterol or budesonide-formoterol) [1,2]. The decision to initiate oral glucocorticoids at home incorporates the severity and persistence of current symptoms (eg, nocturnal awakenings, breathlessness with minimal activity, needing repeated beta-agonist doses over one to two days), nature of the stimulus triggering the attack, if known (eg, transient irritant or allergen exposure versus worsening symptoms with a respiratory viral infection), and response to bronchodilator treatment. (See 'Triage based on response to home treatment' below.)

Patients with a history of recurrent, severe asthma exacerbations may be advised to keep oral glucocorticoids available at home and take an initial dose (eg, prednisone 40 to 60 mg) based on certain symptoms and PEF results, and then notify their clinician.

Evidence in favor of treating acute asthma exacerbations with oral glucocorticoids is presented separately. (See "Acute exacerbations of asthma in adults: Emergency department and inpatient management", section on 'Oral glucocorticoids'.)

Inhaled glucocorticoids for mild to moderate exacerbations

Short course of inhaled glucocorticoid — Patients with intermittent asthma who use only a SABA such as albuterol for symptom relief can often be managed with initiation of an inhaled glucocorticoid alone during a mild to moderate exacerbation of asthma. In this context we use a medium to high dose of inhaled glucocorticoids for 10 to 14 days (eg, budesonide DPI 180 mcg/actuation at four inhalations twice daily or fluticasone propionate MDI 220 mcg/inhalation at two inhalations twice daily) [13].

Combination quick relief and glucocorticoid inhaler — Patients with moderate to severe persistent asthma who use a combination formoterol-glucocorticoid inhaler as both maintenance and rescue therapy, a strategy referred to as Maintenance and Reliever Therapy (MART), can take up to six inhalations over the course of one hour, with a maximum recommended dose of 12 inhalations/day, as noted above (table 6). The evidence for MART is described separately. (See 'Combination glucocorticoid-formoterol' above and "Initiating asthma therapy and monitoring in adolescents and adults", section on 'Low-dose maintenance and reliever therapy (MART)' and "Ongoing monitoring and titration of asthma therapies in adolescents and adults", section on 'Patients using anti-inflammatory relievers alone (Step 1 or 2)'.)

A combination glucocorticoid-SABA inhaler has been approved by the US Food and Drug Administration [14], but is not yet widely available outside the United States. Where available, it can be used to treat an acute exacerbation like albuterol, with the advantage, as with combination glucocorticoid-formoterol, of administering anti-inflammatory therapy with each inhalation, so-called "anti-inflammatory rescue" (table 5).

Quadrupling the dose of inhaled glucocorticoid — For adolescents and adults with asthma who are already taking a daily inhaled glucocorticoid as maintenance therapy, a potential alternative to oral glucocorticoids is a substantial increase in the inhaled glucocorticoid dose (ie, four times baseline). Quadrupling the glucocorticoid dose may prevent or reduce the severity or duration of an exacerbation when given early in response to a deterioration in asthma control, such as at the first sign of a viral respiratory infection [2,15,16]. However, parameters that predict which patients would benefit from this approach have not been fully determined.

In our practice, we reserve this strategy for selected patients who have mild to moderate asthma, a mild flare in symptoms, PEF ≥60 percent of predicted, good self-management skills, and no prior history of life-threatening asthma exacerbations. This may be particularly beneficial in patients likely not adherent to their usual asthma therapy [4]. Patients should return to their baseline inhaled glucocorticoid dose after normalization of symptoms and PEF, or at a maximum of 14 days.

Evidence in favor of quadrupling the inhaled glucocorticoid dose includes the following:

●In an open-label trial, 1871 patients (≥16 years old) who were receiving inhaled glucocorticoids for asthma and had one or more exacerbations of asthma in the prior year were assigned to self-management with quadrupling the dose of inhaled glucocorticoids in response to a deterioration in asthma control or self-management without such an increase (non-quadrupling group) [15]. After 12 months of follow-up, 45 percent of the quadrupling group experienced an exacerbation compared with 52 percent of the non-quadrupling group with an adjusted hazard ratio for the time to a first severe exacerbation of 0.81 (95% confidence interval, 0.71-0.92). As participants in this study had low adherence to their regular inhaled glucocorticoid, it is possible that such patients may particularly benefit from quadrupling therapy. Further study is needed to determine whether certain patient or exacerbation characteristics predict which patients would benefit from this strategy.

●Among 403 patients with a mild increase in asthma symptoms and a small decrease in peak flow (eg, 15 percent for two days or 30 percent for one day), quadrupling the dose of inhaled glucocorticoids, rather than no change, resulted in a decrease in the likelihood of needing oral glucocorticoids (relative risk [RR] 0.43, 95% CI 0.24-0.78) [17].

In contrast, doubling the dose of inhaled glucocorticoids is not adequate to abort an asthma exacerbation once an exacerbation has developed [18-20]. Additionally, quintupling the dose of inhaled glucocorticoids in children with an incipient asthma exacerbation appears ineffective [21]. (See "Acute asthma exacerbations in children younger than 12 years: Overview of home/office management and severity assessment", section on 'Outpatient management'.)

Triage based on response to home treatment — The assessment of response to initial home therapy with a fast-acting bronchodilator (eg, albuterol or budesonide-formoterol) is based on the degree of improvement in symptoms, return of peak flow toward baseline, and course of prior exacerbations. The patient should follow their asthma action plan or contact their clinician for specific instructions.

Good response — If the patient’s symptoms (wheezing, dyspnea, cough, chest tightness) resolve and the repeat PEF measurement is ≥80 percent of the patient's predicted or personal best over the course of approximately one hour, then the patient may safely continue home management (algorithm 1). A course of prednisone (40 to 60 mg daily for five to seven days, or equivalent) is advised for patients who are on a maximal dose of controller medication, recently completed a course of prednisone, or have had recurrent symptoms after 24 to 48 hours of increased controller medication.

In contrast, if the patient’s symptoms resolve after the initial dose of a fast-acting bronchodilator (eg, two to four inhalations), PEF is ≥80 percent of baseline after the initial dose(s), and they remain improved for three to four hours, oral glucocorticoids are usually not necessary.

Other important interventions include removal of the offending stimulus (if known) and intensifying controller medication. (See "An overview of asthma management", section on 'Adjusting controller medication'.)

Incomplete response — An incomplete response to inhaled fast-acting bronchodilator is manifest by continued or recurring symptoms (eg, within two hours of reliever use) and a PEF between 50 and 80 percent of predicted or personal best [2]. The patient should take high-dose inhaled or oral glucocorticoids according to his or her action plan (algorithm 1). We would note that timely administration of oral glucocorticoids for asthma exacerbations is probably the single most effective strategy for reducing emergency department visits and hospitalizations for acute asthmatic attacks.

Other early interventions include removal of or from the offending stimulus (if known), continued administration of inhaled fast-acting bronchodilators every three to four hours, and intermittent measurements of peak flow to assess response.

Need for urgent medical attention — Patients should seek immediate medical attention if they have worsening symptoms despite three doses of their fast-acting bronchodilator, a PEF ≤50 percent of predicted or personal best, or have a concerning comorbid condition (eg, manifest by fever, chest pain, hypoxemia, tachycardia). (See 'Risk factors for fatal asthma' above.)

Under these circumstances patients should not drive themselves to an urgent care setting.

The inhaled fast-acting bronchodilator should continue to be administered while awaiting additional medical care.

OFFICE MANAGEMENT — For patients who present to the medical office with an asthma exacerbation, a focused history and physical examination should be performed promptly and nearly concurrently with administration of the first dose of short-acting beta-agonist (SABA; albuterol or levalbuterol). A quick assessment should enable the clinician to determine whether the patient’s symptoms are due to asthma and can be managed in the office or should be urgently transferred to an emergency department.

Focused assessment and triage — A brief history and physical examination should confirm the diagnosis of an asthma exacerbation, exclude worrisome comorbidities (eg, COVID-19 infection, acute bacterial sinusitis, influenza, pneumonia, pneumothorax), and determine the severity of the exacerbation and risk of impending respiratory failure (algorithm 2).

Physical examination should include assessment of posture (eg, “tripod positioning” with elbows extended and thorax tilted forward), level of consciousness, ability to speak in full sentences, temperature, heart rate, respiratory rate and duration of expiratory phase, blood pressure, use of accessory muscles, presence (or absence) of wheezing, crackles, stridor, symmetry of breath sounds, peripheral edema, and rash or angioedema.

Objective assessments, besides vital signs, include pulse oximetry and peak expiratory flow (PEF).

Indications for urgent transfer to emergency department — For patients with a severe or life-threatening exacerbation, characterized by one or more of the following features, arrangements should be made for transfer to an emergency department while initial treatment is being administered:

●Breathless at rest, sitting forward

●Drowsy, confused, or agitated

●Unable to speak in full sentences

●Respiratory rate >30 breaths/minute

●Heart rate >120 beats/minute

●PEF ≤50 percent predicted or personal best or unable to perform PEF

●Arterial oxygen saturation (SpO₂) <90%

Treatment — The main therapies in the office are prompt and repeated administration of SABAs, early addition of systemic glucocorticoids, and supplemental oxygen, titrated to a pulse oxygen saturation of 93 to 95 percent, if available. (See "Acute exacerbations of asthma in adults: Emergency department and inpatient management", section on 'Oxygen'.)

Inhaled short-acting beta-agonists — For all patients presenting with an exacerbation of asthma, we recommend administration of inhaled SABA [1,2]. In general, we start with 4 puffs by metered dose inhaler (MDI) with a valved holding chamber ("spacer") and careful coaching on proper technique. This dose is repeated every 20 minutes for 1 hour. Alternatively, for patients who have a more severe exacerbation or report lack of benefit with four inhalations at home, we administer up to six puffs by MDI (six separate inhalations), preferably with a valved holding chamber and careful attention to technique.

If the office has nebulizer equipment, the SABA can be nebulized (with appropriate precautions against transmission of COVID-19 infection). For albuterol, the usual dose is 2.5 mg in 3 mL; this may be available in a single-dose vial or in a concentrated form 2.5 mg/0.5 mL that must be diluted with 2.5 mL of sterile saline prior to administration. For levalbuterol, the usual dose is 1.25 mg in 3 mL. Nebulizer treatments can be repeated at 20-minute intervals for the first hour. (See "Acute exacerbations of asthma in adults: Emergency department and inpatient management", section on 'Inhaled beta-agonists'.)

Systemic glucocorticoids — Nearly all patients with a significant asthma exacerbation (eg, PEF <80 percent of personal best or predicted after initial inhaled beta-agonist) should receive oral glucocorticoids [1,2,4]. A short course of glucocorticoids (eg, equivalent of prednisone 40 to 60 mg/day for five to seven days) significantly reduces the likelihood of a repeat severe exacerbation within the succeeding two weeks and lessens the frequency of persistent severe symptoms evaluated at a two-week telephone follow-up [22,23]. As an alternative, oral dexamethasone (12 to 16 mg) for 1 to 2 doses has shown similar efficacy to a course of prednisone (50 to 60 mg/day for five days) [24,25]. (See "Acute exacerbations of asthma in adults: Emergency department and inpatient management", section on 'Oral glucocorticoids'.)

Patients should be advised about common adverse effects of oral glucocorticoids, such as sleep disturbance, increased appetite, gastric irritation, and mood changes. (See "Major adverse effects of systemic glucocorticoids".)

For glucocorticoid courses lasting three weeks or less, there is no need to taper the dose if patients are also taking inhaled glucocorticoids. (See "Glucocorticoid withdrawal", section on 'HPA suppression unlikely'.)

●Intramuscular glucocorticoids ─ Intramuscular injection of a long-acting glucocorticoid formulation is occasionally used for patients without access to oral medication or at high risk of medical nonadherence, although this therapy is more commonly administered in the emergency department or hospital. For instance, one might administer triamcinolone suspension 40 mg/mL at a dose of 60 to 100 mg intramuscularly. (See "Acute exacerbations of asthma in adults: Emergency department and inpatient management", section on 'Intramuscular glucocorticoids'.)

Disadvantages of intramuscular glucocorticoids are that the onset of action is slower than oral glucocorticoids (12 to 36 hours after administration) and the duration of effect varies from one individual to another (typically from 2 to 4 weeks). Cutaneous atrophy at the injection site and blanching of the overlying skin are also possible.

Disposition — Patients should be reassessed after SABA treatment to determine whether they will need further emergency department or hospital-based care, can continue therapy at home, or need evaluation of a concerning comorbid condition (eg, influenza, COVID-19 infection, pneumonia, pneumothorax, pulmonary embolism, heart failure, or cardiac arrhythmia). Signs and symptoms that may suggest a comorbid condition include fever, persistent tachycardia, myalgias, purulent sputum, chest pain, hypoxemia, and a poor response to SABA.

Worsening or lack of improvement — Patients who develop worsening symptoms and/or a declining or unimproved PEF (eg, ≤50 percent predicted) despite SABA and systemic glucocorticoid treatment in the office will need transfer to an emergency department for further management. While waiting for transfer, SABA and oxygen (aiming for 93 to 95 percent pulse oxygen saturation) should be continued. Emergency and inpatient care are discussed separately. (See "Acute exacerbations of asthma in adults: Emergency department and inpatient management".)

Improved and preparing for discharge to home — Patients who improve with office-based treatment (ie, symptoms decreased, heart and respiratory rates normal, PEF >70 percent of predicted or personal best, SpO₂ >94 percent room air) can generally manage their asthma at home, unless symptoms or signs suggest a concerning comorbid condition [26]. (See 'Need for urgent medical attention' above.)

Patients will need clear instructions about the following:

●Home monitoring with specific indications for emergency department care or contacting the office (eg, worsening symptoms, increasing need for fast-acting bronchodilator, PEF ≤60 percent of baseline)

●Dose and duration of oral glucocorticoid therapy (eg, equivalent of prednisone 40 to 60 mg daily for five to seven days)

●Potential adverse effects of systemic glucocorticoids (eg, elevated blood glucose, mood alteration, insomnia, excess energy, increased appetite, and fluid retention)

●Use of their reliever (SABA, combination SABA-inhaled glucocorticoid, or combination inhaled glucocorticoid-formoterol) every four to six hours during the first few days of an exacerbation, followed by tapering back to as-needed use as symptoms resolve

●Initiation or increase in ongoing controller medications (eg, inhaled glucocorticoids, long-acting beta-agonist)

Treatment with inhaled glucocorticoids (table 7) constitutes an important method to prevent recurrent asthma attacks after discontinuation of oral glucocorticoids and to prevent the potential decline in lung function associated with any future severe asthma exacerbation [1,27]. Virtually every patient who has an asthma attack severe enough to require office-based or urgent care should receive an inhaled glucocorticoid as part of his or her discharge medication plan (form 1). (See "An overview of asthma management".)

Patients with frequent asthma exacerbations will likely benefit from referral to an asthma specialist. A number of biologic therapies (monoclonal antibodies targeting allergic, eosinophilic, and steroid-dependent asthma phenotypes) are available that successfully reduce the frequency of exacerbations among patients with severe asthma.

Patient education — Patients should be provided with information about asthma, inhaler technique, avoidance of asthma triggers, and if they do not already have one, a personalized action plan (form 1). Follow-up care should be facilitated to ensure adequate and ongoing use of controller medications. (See "Asthma education and self-management" and "Trigger control to enhance asthma management" and 'Information for patients' below.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Asthma in adolescents and adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)" and "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Inhaler techniques in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Early recognition – Early recognition and intervention are critical for successful management of asthma exacerbations. Patients with asthma should be taught how to identify symptoms of an asthma exacerbation (eg, breathlessness, wheezing, cough, and chest tightness), and those with poor symptom perception or at increased risk for fatal asthma should be taught how to measure peak expiratory flow (PEF). (See 'Detecting an exacerbation' above.)

●Algorithms for management – Approaches to the management of acute exacerbations of asthma at home and in the medical office are outlined in the algorithms (algorithm 1 and algorithm 2). Patients should seek immediate emergency department care if they have symptoms or signs suggestive of a severe exacerbation (eg, marked breathlessness, inability to speak more than short phrases, use of accessory muscles) or a PEF ≤50 percent of baseline, or have risk factors for a fatal attack (table 1). (See 'Need for urgent medical attention' above.)

●Prompt initiation of therapy – Regardless of the treatment location (home or office), the following pharmacologic interventions are the cornerstone of therapy:

•Fast-acting beta-agonist – For all patients with symptoms of an asthma exacerbation, we recommend prompt administration of a rapid onset (fast-acting) beta-agonist (Grade 1B), either in the form of a short-acting beta-agonist (SABA) or the long-acting beta-agonist (LABA) formoterol. Formoterol has an onset of action comparable to albuterol and must be given in a combination inhaler with a glucocorticoid (GC). (See 'Fast-acting bronchodilator' above.)

SABA – The usual dose of SABA (albuterol, levalbuterol, or albuterol-budesonide) at home is two to four inhalations from a metered-dose inhaler (albuterol MDI 90 mcg/inhalation; levalbuterol MDI 45 mcg/inhalation) with a valved holding chamber ("spacer") or dry powder inhaler (albuterol DPI 90 mcg/actuation), while in the office four to six inhalations can be given. Albuterol or levalbuterol can also be given by nebulizer (2.5 mg or 1.25 mg, respectively). Dosing can be repeated every 20 minutes for one hour (three doses), as needed. (See 'Short-acting beta-agonist' above and 'Inhaled short-acting beta-agonists' above.)

Inhaled GC-formoterol – The usual dose of inhaled GC-formoterol for an acute exacerbation (eg, budesonide-formoterol 80 mcg-4.5 mcg or 160 mcg-4.5 mcg) is one to two inhalations, which can be repeated every 20 minutes for one hour (6 inhalations/treatment; maximum 12 inhalations/day), if needed. (See 'Combination glucocorticoid-formoterol' above.)

•Oral glucocorticoids – For patients whose symptoms have been recurrent over one to two days or do not improve after one to three doses of fast-acting beta-agonist and/or whose PEF remains <80 percent of personal best or predicted, we recommend initiation of oral glucocorticoids (Grade 1B). The typical initial dose is the equivalent of prednisone 40 to 60 mg orally. (See 'Initiation of oral glucocorticoids' above.)

●Trigger avoidance and monitoring response – Additional steps at home include removal from sources of potential triggers (eg, animal dander, tobacco smoke) and monitoring of medication response (algorithm 1). (See 'Home treatment' above.)

●Treatment in medical office – For patients who present to the medical office with an asthma exacerbation, a focused history and physical examination should be performed promptly and nearly concurrently with administration of the first dose of SABA (algorithm 2). (See 'Office management' above.)

•Signs of severe exacerbation – Patients with features of a severe or life-threatening asthma exacerbation (eg, breathless at rest, unable to speak in full sentences, heart rate >120/minute, respiratory rate >30/minute, PEF ≤50 percent of predicted or personal best, pulse oxygen saturation <90 percent) should be urgently transferred to an emergency department. (See 'Indications for urgent transfer to emergency department' above.)

•Supplemental oxygen – Supplemental oxygen should be titrated to a pulse oxygen saturation of 93 to 95 percent, if necessary. (See 'Office management' above.)

•Oral glucocorticoids – Most patients who require office-based treatment for an acute asthma exacerbation and have a PEF <80 percent of predicted or personal best after initial SABA treatment are candidates for oral glucocorticoids. An initial dose can be administered in the office (eg, prednisone 40 to 60 mg or equivalent), if available. (See 'Systemic glucocorticoids' above.)

●Disposition – After office-based fast-acting beta-agonist treatment, patients who have no improvement or have worsening symptoms and/or a declining PEF will need transfer to an emergency department for further management. (See 'Worsening or lack of improvement' above.)

Patients who are treated in the office and are improved enough to go home should complete a course of glucocorticoids (equivalent of prednisone 40 to 60 mg daily for five to seven days). They should be given instructions for their long-term controller medication (inhaled glucocorticoids with or without a long-acting beta-agonist), a personalized asthma action plan (NHLBI Asthma Action Plan), and follow-up care instructions (form 1). (See 'Disposition' above.)