Asthma Management Handbook
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Table. Add-on treatment options for acute asthma

Agent

Recommended use in acute asthma

Administration and dosage

Notes

Inhaled ipratropium bromide

Second-line bronchodilator if inadequate response to salbutamol

Via pMDI 21 microg/actuation every 20 minutes for first hour

Repeat every 4–6 hours for 24 hours

 

 

Adults and children 6 years and over:
8 puffs

Children aged 1-5 years:
4 puffs

Use spacer (plus mask, if patient cannot use mouthpiece)

If a mask is used, ensure a good seal, to avoid contamination of eyes

Via nebuliser every 20 minutes for first hour

Repeat every 4–6 hours

Adults and children 6 years and over:
500 microg nebule

Children aged 1-5 years:
250 microg nebule

If salbutamol is delivered by nebuliser, add to nebuliser solution

If a mask is used, ensure a good seal, to avoid contamination of eyes

IV magnesium sulfate

Second-line bronchodilator in severe or life-threatening acute asthma, or when poor response to repeated maximal doses of other bronchodilators

IV infusion over 20 minutes

Adults: 10 mmol

Children 2 years and over: 0.1–0.2 mmol/kg (maximum 10 mmol)

Avoid magnesium sulfate in children younger than 2 years

Dilute in compatible solution

IV salbutamol

(only in ICU)

Third-line bronchodilator in life-threatening acute asthma that has not responded to continuous nebulised salbutamol after considering other add-on treatment options

Follow hospital/organisation’s protocol. If no local protocol is available, use the following as a guide:

1 mg/mL (1000 microg/mL) salbutamol concentrate for infusion diluted to 5 mg in 50 mL with normal saline

Adults and children 12 years and over:

As infusion: Loading dose 200 microg over 1  minute then 5 microg/minute (can increase to 10 microg/minute, then up to 20 microg /minute every 15–30 minutes according to response)

As bolus: 250 microg over 5 minutes.

Children 2–12 years:

Loading dose of 5 microg/kg/minute (maximum 200 microg/minute) for 1 hour then 1–2 microg/kg/minute (maximum 80 microg/minute).

Use only in critical care units (e.g. emergency department, intensive care unit/high-dependency unit)

Monitor blood electrolytes, heart rate and acid/base balance (blood lactate)

Reduce initial dose for older adults. Consider dose reduction for those with impaired renal function. Impaired liver function may result in accumulation of unmetabolised salbutamol

Aminophylline

Third-line bronchodilator in life-threatening acute asthma that has not responded to continuous nebulised salbutamol after considering other add-on treatment options

500 mg in 500 mL normal saline (1 mg/mL)

Adult not previously treated with theophylline:

Loading: 5 mg/kg IV given at a rate <25 mg/minute.

Maintenance: 0.5 mg/kg/hour IV

For obese patients, base dose on ideal weight calculated as follows:

Females: 45.5 kg + 0.9 kg/cm for each cm height >152 cm

Males: 50 kg + 0.9 kg/cm for each cm height >152 cm

Therapeutic range: plasma theophylline concentrations 10–20 mg/L (55–110 micromol/L).

Use only in critical care units (e.g. emergency department, intensive care unit/high-dependency unit)

Not routinely recommended for treatment of asthma or COPD (superseded by beta2 agonists)

 

Monitor serum theophylline concentration and titrate to maintain within therapeutic range to avoid toxicity (refer local protocols).

 

[!] theophyllines have a narrow therapeutic range; adjust dosage individually according to clinical response and plasma concentrations

Adrenaline

Limit to patients unresponsive with poor respiratory effort where inhaled bronchodilators cannot be given, or where respiratory arrest imminent

IM via needle and syringe

Adults or children, use (1:1000) and give 0.01 mg per kg up to 0.5 mg per dose (0.5 mL). Repeat every 3–5 minutes if needed.

IM via auto-injector

Adult: 0.3 mg IM

Child >20 kg: 0.3 mg IM

Child 10–20 kg, 0.15 mg IM

Repeat dose after 5 minutes if required.

IV infusion

Adult, child, initially 0.1 microgram/kg/minute IV initially, then titrate according to response.

Slow IV injection

Adult: 50 micrograms (0.5 mL adrenaline 1:10 000) IV. Repeat according to response. Give IV infusion if repeated doses required.

Child: initial dose 1 microgram/kg (0.01 mL/kg adrenaline 1:10 000) IV. Titrate dose according to response.

Do not use in place of salbutamol for initial bronchodilation

Non-invasive positive pressure ventilation 

Consider if starting to tire or signs of respiratory failure

 

Do not sedate patient

If no improvement, intubate and start mechanical ventilation

Last reviewed version 2.0

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