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.
- 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.
In the hospital, my child was treated with Lasolvan and saline through a nebulizer. All the doctors prescribed these drugs, even my allergist still prescribes them. When I refused Lasolvan, almost all the doctors came to persuade me to resume the therapy… They even frightened me… This is odd.
How to determine the degree of severity? For example, the pulse oximeter shows “oxygen 70 and palpitation 130” at the time of exacerbation. But we have learned to cope with these attacks at home for 1 day. Doctors always frighten that the child is dying … Every time we have to check for pneumonia. Is it really necessary? Is this the hardest stage? During the exacerbation, my child breathes through the nebulizer: Berodual + Pulmicort 4-5 times a day. When the spasm is stopped, we use Pulmicort for 7 days. My son is 5. The diagnosis is a possible virus-associated asthma.
The doctor says my son cannot be treated with Berodual until the obstruction is confirmed. Can I use it in order to prevent the development of the disease? My son is 2 months old.
You cannot use mucolytics if your child is 2 months only.
Another question. My youngest child is 1.3 years old. During the first year of life he had 4 obstructions (2 of them looked like bronchitis). The last obstruction was in October. The doctor said it’s not necessary to visit a pulmonologist since my son is small and the disease may disappear. So should I consult a pulmonologist? Or should I wait?
If the obstruction continues to recur, it is necessary to consult an allergist-immunologist and a pulmonologist.
I did not know about mucolytics. We always used Berodual, back massage and inhalation with lasolvan.
We had an obstruction when we moved to the new apartment. It turned out there was a mold in the bathroom. After removing it, the attacks decreased several times. The aggravation began in the autumn forest. It turned out, my son had a reaction to the mold. Ruzam was a great help in this regard. My son got it administered a couple of times a year. We also used it in the blooming period. It relieves symptoms very well.
It’s good that you removed a mold in time!
Well, we did it so but it seemed to me that mucolytics are not needed at all. Thank you.
Because Berodual is popular. Everyone has heard about Berodual for inhalations, but not everyone knows that salbutamol for inhalations is also available.
Our therapist does not know anything about asthma. She does not even check how we are treated. The knowledge of the allergist and the pulmonologist also does not inspire trust. I do not really understand when to cancel Berodual? We usually use it 1-2 days.
We are moving to another city soon and I hope there is a qualified doctor there.
If I have a mild exacerbation, should I use salbutamol, not Berodual? My son is 9 years old. Or did you recommend this for those who do not have a nebulizer?
In clinical recommendations, salbutamol is the first-choice drug. You can do both in general. Berodual is simply a combined bronchodilator with two active substances. You should start with a drug containing steroids only, and then – use combined drugs. I mean if salbutamol helps, then it is advisable to use it (according to the recommendations). If it does not help, you should definitely use Berodual.
Now I see! The pediatricians have never mentioned salbutamol, only Berodual.
Can we to use salbutamol through a spacer instead of Berodual? Dosed? With the onset of obstruction? Or should the child breathe 5 min through the nebulizer?
An aerosol metered dose inhaler with a spacer is equivalent to a nebulizer for mild and moderate exacerbation.
Another question. My daughter is sick now. The nose is stuffed, she is coughing. We use Singulair (only 5 days). Should we use Berodual if the peak flow meter indicators get worse? or should we continue to use Singulair? If this helps, is it possible to keep on using Singulair without using Pulmicort?
Yes, it is.
And one more question! When can I start to walk with my child? One doctor says we can go for a walk if there is no fever. Another says that we need to remain at home until the child is fully recovered…
You can walk even with a high temperature if your child is active.
My daughter has phlegm in her throat very often. Is this a sign of allergy?
Even a healthy person has mucus. Most likely your child has mucus in the throat.