Table 5.

Evidence-Based Management of Acute Asthma

PRACTICE	RECOMMENDATION
Systemic corticosteroids	Supports early administration of systemic corticosteroids in moderate to severe asthma exacerbations with reduction in need for hospitalization if given within 1 h of ED presentation. (100) Oral route is preferred route, and effects are considered equivalent. (43)
	Short course (1–2 d) of dexamethasone equivalent to 3- to 5-d burst of prednisolone in acute asthma exacerbation. (101) Equivocal data on single versus 2 doses of dexamethasone. (102)
Bronchodilator administration	MDI with spacer equally effective as nebulized bronchodilator therapy in the ED. (103)(104) Additional benefits include cost-savings (105) and decreased ED length of stay. (106) Equivocal studies on continuous versus intermittent bronchodilator nebulization for severe asthma, GINA guidelines recommend initial continuous therapy with spacing to intermittent in severe asthma. (60)
Inhaled ipratropium bromide	Supports use in moderate to severe exacerbations with SABA in preventing need for hospitalization, (107) no additional benefit during hospitalization. (108) Not routinely recommended in mild exacerbations. (43)(60)
Intravenous magnesium sulfate	No clear support for routine use due to paucity of data; however, administration of intravenous magnesium sulfate in moderate to severe asthma exacerbations if not improving after 1 h of bronchodilator and systemic corticosteroid treatment may reduce need for admission. (43)(109) A recent trial showed potential benefit for patients with severe asthma and pulse oximetry <92%. (95) More data needed.
Epinephrine	Insufficient evidence; however, guidelines support administration for children with very poor effort unable to adequately inhale nebulized bronchodilators or possibility of anaphylaxis and in life-threatening situations. Although no significant detrimental effects either. (43)(60)
Noninvasive respiratory support	Bilevel positive airway pressure has been studied more than HFNC in the management of severe asthma exacerbation, however still with limited evidence to support or recommend against its use. (110) Insufficient data in support of HFNC in setting of asthma to recommend use. Small pilot study using HFNC for severe asthma compared it with nasal cannula oxygen with promising results. (111) Often used in ICU settings to avoid intubation.
Heliox	Consensus-based recommendation for severe exacerbations in conjunction with standard therapy, but caution to not delay intubation if needed. (43)(60) Maximum oxygen content of heliox is 30% FiO2 and, therefore, is not recommended in patients requiring higher % FiO2.
Terbutaline	Insufficient evidence to support use. (112) Sometimes given to children with very poor effort unable to adequately inhale nebulized bronchodilators, similar to epinephrine indicated in life-threatening situations; however, has more adverse effects than epinephrine. (43)(60)
Ketamine	Insufficient evidence for ventilated or nonventilated patients. (113)
Intravenous aminophylline	Evidence recommends against use due to poor safety profile in children. (43)(60)(112)
Volatile anesthetics	Used in ICU settings in ventilated patients, not mentioned in guidelines, with insufficient evidence for routine use; no difference in outcomes in a large pediatric retrospective review. (114)
Chest radiography	Low yield in the ED and rarely changes management, consider with hypoxia and high fever if not improving on albuterol and systemic corticosteroids. (68)
ICS prescription at time of discharge from ED or admission	ICS should be initiated before ED discharge. (115) Regular use of low-dose ICS is associated with decreased risk of death from asthma. (116)

ED=emergency department, FiO₂=fraction of inspired oxygen, GINA=Global Initiative for Asthma, HFNC=high-flow nasal cannula, ICS=inhaled corticosteroid, MDI= metered-dose inhaler, SABA=short-acting inhaled β₂-agonist.