Exacerbation of Bronchial Asthma

Exacerbations of asthma are episodes of increasing dyspnoea, coughing, wheezing, or stuffiness in the chest, requiring changes in the usual mode of therapy. In asthma exacerbation, peak flow meter and FEV1 decrease. Exacerbations can develop both in patients with a known diagnosis of asthma, and be the first manifestation of asthma.

• Asthma can develop in any patient, regardless of the severity of the disease;
• The degree of exacerbation may be different (mild, moderate, severe), regardless of the degree of severity of asthma;
• The rate of asthma exacerbation can vary significantly in different patients – from several minutes or hours to 10-14 days, as well as the resolution of an exacerbation – from 5 to 14 days.

Causes of asthma exacerbation

Various triggers that induce inflammation of the respiratory tract or provoke acute bronchospasm.

Different patients have different triggers. The main triggers include respiratory tract infections (mainly viruses, most often rhinoviruses), allergens, aeroplutants, physical activity, meteorological factors, taking certain medications (beta blockers, in patients with “aspirin BA” – not steroidal anti-inflammatory drugs means), emotional reactions, etc.

Other factors that can exacerbate asthma are an exacerbation of rhinosinusitis, gastroesophageal reflux, pregnancy, and inadequate therapy.

The risk factors for exacerbations include:

• symptoms of uncontrolled asthma;
• inhaled glucocorticoids are not prescribed, poor adherence to therapy (the patient does not fulfill the prescribed doctor’s prescription);
• excessive use of short-acting b2-agonists;
• low FEV1, especially < 60% of due;
• significant psychological or socioeconomic problems;
• external influences: smoking, exposure to an allergen;
• concomitant diseases: rhinosinusitis, GERD, confirmed food allergy, obesity.⠀

Treatment of asthma exacerbations in children younger than 2 years

• Bronchodilators: β2-agonists or a combination of them with ipratropium bromide in age-related dosages;
• For a mild to moderate-severe exacerbation, the nebulizer is the optimal delivery device for the drug, but dosage aerosol inhalers + spacer is possible;
• Glucocorticosteroids are indicated for the relief of moderate and severe asthma attacks. In young children, inhaled budesonide (Pulmicort) is used through the nebulizer in medium and high doses (1-1.5 mg);
• Oral systemic steroids (prednisolone – 10 mg) are used for up to three days, only in the hospital.

Initial therapy of asthma exacerbation in children older than 2 years

• The first-line therapy: age-related doses of salbutamol through the aerosol metered dose inhaler with a spacer or nebulizer. The inhalation therapy is immediately started with 2-4 doses of the short-acting β2-agonist (salbutamol) with aerosol metered dose inhaler with a spacer or nebulizer (level of evidence A);
• In mild and moderate aggravation, the effectiveness of short-acting beta2-agonists therapy in the form of aerosol metered dose inhaler with a spacer is similar to that of a nebulizer (level of evidence A);
• If the symptoms are not amenable to treatment with salbutamol, then use Berodual;
• Double the dose of basic therapy (Pulmicort) for 5-7-10-14 days (the period depends on the degree of exacerbation). If exacerbation is severe, you can go a step higher in the treatment for at least 3 months;
• If bronchodilators are inefficient (children over 6 months), at the time of exacerbation you can add budesonide suspension (Pulmicort) through the nebulizer;
• In children with exacerbation of asthma which is not controlled by inhalation of Berodual through aerosol metered dose inhaler with a spacer to 6-8 doses/day, it is necessary to call an ambulance. Additional doses of bronchodilators are given as needed while waiting for the doctor;
• At the time of delivery of a child with a severe asthma attack in the emergency department, a bronchodilator + suspension of budesonide through a nebulizer, inhalation with oxygen are prescribed;
• Berodual is canceled if inhalation of short-acting β2-agonists is required more than 4 hours later. In this case, you’d better use salbutamol.

Inhaled steroids in very high doses through the nebulizer are effective during an exacerbation – inhalation of a suspension of budesonide (in a dose of 1-1.5 mg) through a nebulizer.

Glucocorticosteroid therapy is most often prescribed for severe exacerbation of asthma. Children under 5 years of age are recommended 3-5 days of therapy, older than 5 years – up to 7 days

• The drug is canceled immediately because a gradual decrease in dose is not justified;
• If the child was vomiting, prednisolone is administered repeatedly. Intravenous injection of glucocorticosteroids is allowed in cases where oral administration of the drug is difficult or impossible.
• Oral prednisolone for three days may be a sufficient treatment, but the duration can be prolonged to 14 days for complete relief of symptoms.

If an asthma attack is stopped, the child can be left at home and use inhalation bronchodilators. The dose of basic therapy can be doubled for 5-10 days, triggers should be excluded.

Treatment of asthma exacerbations in adults

Bronchial spasmolytic. For mild and moderate exacerbations, it’s recommended to use rapid-acting inhaled β2-agonists (2 to 4 inhalations every 20 minutes for the first hour) (level of evidence A).

After the first hour, the required dose of β2-agonists will depend on the severity of the exacerbation!

• Mild exacerbations are stopped by 2-4 doses of β2-agonists with aerosol metered dose inhaler every 3-4 hours;
• Exacerbations of moderate severity will require 6-10 doses every 1-2 hours.

Systemic glucocorticosteroids should be used in the treatment of all exacerbations, except very mild exacerbations (A level), especially if: initial therapy with inhaled β2-agonists did not provide long-term improvement; exacerbation developed in a patient who was already receiving oral glucocorticoids; previous exacerbations required the use of oral glucocorticoids.

• Oral glucocorticoids are usually not inferior in effectiveness to intravenous glucocorticoids. They are the preferred drugs;
• Adequate doses of glucocorticoids: prednisolone (or analogs) 40-50 mg/day;
• Therapy duration is 5-7 days.

There is no need for a gradual reduction in the dose of glucocorticoids for several days, except when the patient received systemic glucocorticoids on an ongoing basis before exacerbation.

If a person uses Symbicort as a basic therapy, then we can recommend him a regime of “smart therapy”. If the exacerbation is not severe and stopped in time, then there is a chance to do without systemic steroids when using the single inhaler regimen.

The therapy of pregnant women with an asthma exacerbation is the same.

Evaluation of bronchodilator therapy effectiveness after 20 minutes:

• reduction of dyspnea;
• improvement of breathing during auscultation;
• increase in peak expiratory flow rates by 15% or more.

Other therapy:

• Antibacterial therapy is indicated only if there is a radiologically confirmed pneumonia or other bacterial infection;
• Sedative drugs are strictly contraindicated!
• Other contraindicated drugs: mucolytics, phytopreparations, medical cups, mustard plasters, all kinds of physiotherapy, euphyllin, antihistamines of the first generation.