In addition to some deaths, acute asthma accounts for significant morbidity and cost (emergent visits, hospitalizations, missed productivity). The mainstays of acute asthma treatment include bronchodilator therapy and systemic corticosteroids (oral or parenteral).

Bronchodilator therapy should employ albuterol or levalbuterol with a dose not more than 10 mg per hour of albuterol or 5 mg per hour of levalbuterol. Recent studies have also demonstrated that albuterol metered dose inhalers used with spacer devices are at least comparable to nebulized delivery.

In addition to bronchodilator therapy, anticholinergic therapy with ipratropium bromide used in combination has been shown to decrease hospitalization rates in children. The NHLBI Expert Panel Guidelines recommend the prompt initiation of oral corticosteroid therapy for all moderate to severe asthma exacerbations.

This recommendation is based on evidence that oral corticosteroid therapy prevents hospital admissions and hastens recovery. Additionally, oral corticosteroid treatment is preferred and is consider equally effective when compared with the parenteral route.

Although the exact dose necessary to treat an acute exacerbation has been debated, it remains largely empiric and, in the end, is left to the clinician. Generally, the dose of prednisone is 1 to 2 mg/kg/day divided once to twice daily for 4 to 10 days with a maximum daily dose of 60 to 80 mg.

A taper is not necessary for this length of treatment, but longer courses should include one. Oral dexamethasone and methylprednisolone are considered acceptable alternatives as well. Recently, the use of inhaled corticosteroids during acute exacerbations has been debated.

Inhaled corticosteroids decrease the risk of potential adverse side effects compared with systemic corticosteroids. A recent meta-analysis of four studies comparing inhaled corticosteroids to oral systemic corticosteroids in the setting of acute asthma demonstrated no difference between the two interventions in regard to relapse rate, bronchodilator use, or adverse events.

However, because of small numbers and possible limitation to mild asthma exacerbations, equivalency could not be claimed. Finally, a pediatric study showed that, although inhaled corticosteroids were beneficial, patients experienced a more rapid resolution of symptoms with systemic corticosteroids if improvement of lung function was the outcome.

While initiating or doubling the dose of inhaled corticosteroids during acute mild asthma, exacerbation has emerged to be a common practice among practitioners in an attempt to prevent the need for systemic corticosteroid therapy, or development of more severe symptoms.

There is no clear consensus of the exact role inhaled corticosteroids should have in the management of exacerbations in general. It is critical that after an acute exacerbation, patients have follow-up with their primary physician to discuss treatment and potential triggers.

Acute asthma exacerbations are also an excellent opportunity to discuss asthma action plans. There is evidence that patients with written asthma plans and peak expiratory flow monitors are less likely to visit the emergency department, be hospitalized, or have low lung function.