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Acute exacerbations of asthma in adults:

Home and office management
AUTHORS:
Christopher H Fanta, MD
Katherine N Cahill, MD, FAAAAI
SECTION EDITOR:
Anne E Dixon, BM, BCh
DEPUTY EDITOR:
Paul Dieffenbach, MD
All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: Oct 2023.
This topic last updated: Aug 03, 2023.
INTRODUCTIONAcute asthma exacerbations are episodes of
worsening asthma symptoms and lung function; they can be the
presenting manifestation of asthma or occur in patients with a
known asthma diagnosis in response to a "trigger" such as viral
upper respiratory infection, allergen, air pollution or other irritant
exposure, lack of adherence to controller medication, or an
unknown stimulus [1-3]. The best strategy for management of acute
exacerbations of asthma is early recognition and intervention,
before attacks become severe and potentially life-threatening.
Detailed investigations into the circumstances surrounding fatal
asthma have frequently revealed failures on the part of both patients
and clinicians to recognize the severity of the disease and intensify
treatment appropriately [1,2].
The management of acute asthma exacerbations will be presented
here. An overview of asthma management, emergency department
and inpatient management of asthma exacerbations in adults,
identification of risk factors for fatal asthma and asthma triggers,
and the use of mechanical ventilation in severe exacerbations of
asthma are discussed separately. (See "An overview of asthma
management" and "Acute exacerbations of asthma in adults:
Emergency department and inpatient
management" and "Identifying patients at risk for fatal
asthma" and "Trigger control to enhance asthma
management" and "Invasive mechanical ventilation in adults with
acute exacerbations of asthma".)
ALGORITHMS FOR ASSESSMENT AND TREATMENT AT
HOME AND IN THE OFFICEOur approaches to the management
of acute exacerbations of asthma at home and in the office, which
are consistent with international guidelines, are outlined in the
algorithms (algorithm 1 and algorithm 2) [2]. The management of
less acute deteriorations in asthma control are discussed
separately. (See "An overview of asthma management", section on
'Adjusting controller medication'.)
The basic principles of care are the following [1,2,4]:
●Assess the severity of the attack and risk for asthma-
related death
●Assess potential triggers (eg, inhaled allergens such as
animal dander, pollen, and mold; respiratory infection;
medications such as beta blockers or nonsteroidal anti-
inflammatory drugs [NSAIDs] in susceptible individuals;
inhaled irritants such as chemical fumes or cigarette
smoking; and medication nonadherence)
●Use an inhaled rapid onset (fast-acting) beta-agonist
(ie, albuterol, levalbuterol, or formoterol-inhaled
glucocorticoid combination inhaler) early and frequently
●Start systemic glucocorticoids if there is not an
immediate and marked response to the inhaled rapid
onset beta-agonist; initiating or increasing the dose of
inhaled glucocorticoids may be sufficient in mild
exacerbations.
●Make frequent objective assessments of the response to
therapy until definite, sustained improvement is
documented
●Advise patients who are not responding to initial home
or office management to go to an acute care facility or
see their asthma provider immediately, especially if they
have a history of near-fatal asthmatic attacks
●Educate patients about the principles of self-
management for early recognition and treatment of a
future attack and develop an "asthma action plan" for
recurrent symptoms (see "Asthma education and self-
management")
Ideally, patients will assess the severity of an attack at home by
following an individualized written "asthma action plan." Asthma
action plans are based upon symptoms and peak expiratory flow
(PEF) measurements and provide clear instructions on how to detect
and respond to changes in these parameters [1,2]. An example is
available through the National Heart Lung and Blood Institute
(NHLBI Asthma action plan). Asthma action plans and peak
expiratory flow monitoring are discussed separately. (See "Asthma
education and self-management", section on 'Asthma action
plans' and "Asthma education and self-management", section on
'Attack prevention' and "Peak expiratory flow monitoring in
asthma".)
DETECTING AN EXACERBATIONSome patients are very
sensitive to increased asthma symptoms, while others perceive
reduced airflow only when it becomes marked. For the latter group,
a decrease in peak expiratory flow may be the first sign that asthma
control is deteriorating.
Symptoms and severity — Symptoms that patients should
recognize as suggesting an asthma exacerbation include
breathlessness, wheezing, cough, and chest tightness. Some
patients also report reduced exercise tolerance and fatigue as
symptoms of an asthma exacerbation. Patients who have long-
standing asthma are generally able to determine when they have an
exacerbation.
Patients who contact their clinician should be asked about the
timing of onset, likely cause (if known), severity of symptoms (eg,
provoked by exertion, present at rest, causing awakening from
sleep), and risk factors for asthma-related death (ie, impaired lung
function, oral glucocorticoid use, prior emergency department visits,
hospitalization or intubation for asthma) (table 1). Symptoms of a
severe exacerbation include intractable coughing, sensation of air
hunger, inability to speak in complete sentences because of labored
breathing, worsening respiratory distress when attempting to lie
flat, and agitation.

Current medications and response to treatment of previous

exacerbations should also be explored.

The symptoms of an asthma exacerbation are nonspecific, so the

initial assessment should include assessment for other processes
that might present with these symptoms, such as acute bronchitis,
exacerbation of chronic obstructive pulmonary disease (COPD) or
bronchiectasis, pneumonia, heart failure, pulmonary embolism, and
inducible laryngeal obstruction (also called vocal cord dysfunction).
(See "Evaluation of wheezing illnesses other than asthma in
adults".)
Peak expiratory flow — Measurement of expiratory airflow with a
peak expiratory flow (PEF) meter (or spirometer) provides an
assessment of the severity of airflow limitation [5]. Peak flow
measurements take less than one minute to perform and are safe
and inexpensive. However, careful instruction is needed to obtain
reliable measurements (table 2). (See "Peak expiratory flow
monitoring in asthma".)

Peak flow values can help patients and providers judge the severity
of an asthma exacerbation and help guide decision-making
regarding treatment and the preferred site of medical care (home,
medical office, or emergency department). They provide useful
adjunctive data to be combined with assessment of symptoms and
physical findings. In our experience their greatest value is detection
of severe airflow obstruction in a patient whose history and
examination are deceptively benign. Failure to recognize severe
airflow obstruction during an asthma exacerbation can result in
undertreatment, with potentially life-threatening consequences.

Normal values for PEF differ with sex, height, and age (table 3A-B).
Each patient should establish a baseline measure with which to
compare future readings. A decrement in PEF of greater than 20
percent from normal, or from the patient's personal best value,
signals the presence of an asthma exacerbation. The difference in
PEF from the patient’s baseline helps one gauge the severity of the
change. A PEF ≤50 percent of baseline should be considered a
severe attack.
Risk factors for fatal asthma — Some patients are at greater risk
for life-threatening and potentially fatal asthma attacks. It is helpful
to identify such patients and to educate them about identifying early
warning signs of deterioration based on PEF monitoring, following a
prednisone-based action plan, and seeking emergency care
promptly. (See "Identifying patients at risk for fatal asthma",
section on 'Identifying high-risk patients'.)
Risk factors for a fatal asthma attack include (table 1) [2]:
●Previous life-threatening exacerbation (eg, intubation or
intensive care unit admission)
●Asthma attack despite current course of oral
glucocorticoids
●More than one hospitalization for asthma in the past year
●Three or more emergency department visits for asthma
in the past year
●Use of more than one canister of short-acting beta-
agonist per month
●Comorbidities, such as cardiovascular or chronic lung
disease
●Illicit drug use and major psychosocial problems,
including depression
 ●IgE-mediated food allergy in a patient with asthma
●Not currently using inhaled glucocorticoids
●Difficulty perceiving asthma symptoms or severity of
exacerbations
●History of poor adherence with asthma medications
and/or written asthma action plan
HOME TREATMENTPatients with an uncomplicated asthma
exacerbation, good understanding of their asthma, and good inhaler
technique can often be managed at home based on direction from
their written asthma action plan or discussion with their asthma
provider (algorithm 1). However, home management is not meant to
replace supervised medical care in seriously ill patients.
Goals — The goals of home management are to relieve symptoms
and improve lung function while at the same time recognizing
exacerbations that require urgent medical attention. Early initiation
of treatment at home can prevent deterioration to a severe and
potentially life-threatening attack. To achieve these goals, the
provider can:
●Advise the patient to initiate inhaled fast-acting
bronchodilator and determine the need for oral
glucocorticoid.
●Triage patients with symptoms suggestive of a severe
asthma exacerbation (see 'Symptoms and
severity' above) to seek emergency department care.
While waiting for the ambulance they should
take albuterol or other rapid onset bronchodilator 4 to 6
puffs (preferably with a valved holding chamber)
and prednisone 40 to 60 mg orally, if available.
(See "Acute exacerbations of asthma in adults:
Emergency department and inpatient management".)
Interventions uniquely available in the emergency
department setting are removal from potential asthma
triggers in the home environment, close medical
observation, rest, reassurance, and, most importantly,
the ability of medical providers to respond to worsening
lung function and gas exchange in the patient who is
deteriorating despite standard therapy and progressing
toward respiratory failure.
●Assess need for evaluation and management in the
office or urgent care center (eg, unclear severity of
exacerbation, patient not able to initiate proper home
management, potential comorbidity). (See 'Office
management' below.)
Fast-acting bronchodilator — All patients should have access to a
rapid onset bronchodilator for quick relief of asthma symptoms
caused by bronchoconstriction; either a short-acting beta-agonist
(eg, albuterol) or a combination glucocorticoid-formoterol
preparation can be used [1,2,4].
Short-acting beta-agonist — When the onset of an exacerbation is
recognized, inhaled SABA (eg, albuterol, levalbuterol) can be
administered by one of the following methods (table 4) [1,2,6]:
●Metered dose inhaler – Two to four inhalations from a
metered dose inhaler (depending upon the dose that is
typically effective and tolerated by that individual;
typically two inhalations are used for mild-to-moderate
symptoms and four inhalations for more severe
symptoms), preferably with a valved holding chamber
("spacer") device.
●Dry powder inhaler – Albuterol can be administered by
dry powder inhaler (DPI), two to four inhalations of the 90
mcg/actuation DPI; typically, two inhalations are used for
mild-to-moderate symptoms and four inhalations for more
severe symptoms. A DPI with 200 mcg/actuation is
available outside the United States; one to two
inhalations are used for acute exacerbations. A valved
holding chamber is not used with a DPI.
●Nebulizer – A nebulizer treatment (eg, albuterol 2.5 mg
in 3 mL or levalbuterol 1.25 mg in 3 mL)
The SABA treatment can be repeated every 20 minutes for one hour
(three doses), if needed. Over the course of these three SABA
treatments, the patient can determine (based on action plan or
clinician guidance) whether to continue self-care at home or seek
additional medical attention (algorithm 1). Patients should contact
their clinician or proceed to the emergency department if they need
high doses of inhaled beta-agonists beyond the first hour of self-
treatment. (See 'Triage based on response to home
treatment' below.)
Combination glucocorticoid-formoterol — A combination inhaler
containing formoterol and a glucocorticoid (GC) is an alternative to
an inhaled SABA for quick relief of asthma symptoms [1,2,4].
Formoterol is a long-acting beta-agonist (LABA) with a rapid onset of
action comparable to albuterol. The usual dose of GC-formoterol for
acute symptom relief is one to two inhalations (4.5 mcg formoterol
per inhalation). The treatment can be repeated every 20 minutes up
to a total of six inhalations, if needed. Over the course of the three
treatments, the patient can determine (based on action plan or
clinician guidance) whether to continue self-care at home or seek
additional medical attention. The maximum daily dose advised by
guidelines is 12 inhalations.
As a management strategy for the treatment of mild asthma, "as
needed" dosing of a combination GC-formoterol inhaler reduces the
frequency of severe exacerbations requiring oral glucocorticoid by
two-thirds compared with SABA alone [7,8].
Risks associated with inhaled
epinephrine — Racemic epinephrine liquid for inhalation (eg,
Asthmanefrin and S2) and epinephrine inhalers (eg, Primatene Mist)
are available over the counter and marketed directly to consumers
for temporary relief of asthma symptoms. The FDA has issued a
warning about multiple adverse events associated with these
products, including symptoms such as chest pain, nausea and
vomiting, increased blood pressure, tachycardia, and hemoptysis,
and also defective atomizer devices [9]. Epinephrine is NOT beta-2
adrenergic receptor selective, so it carries a greater risk of beta-1
and alpha adrenergic-type adverse effects, especially when used in
excess doses.
It is important to ensure that patients have ready access to the
more effective, inhaled rapid onset beta-2 selective agonists, such
as albuterol and levalbuterol, and to advise against use of the
nonselective epinephrine-based products [10-12].
Initiation of oral glucocorticoids — Oral glucocorticoids are
indicated for asthma exacerbations that are moderate to severe,
characterized by lack of improvement in symptoms and/or by a peak
expiratory flow (PEF) <80 percent of personal best or predicted after
use of an inhaled fast-acting bronchodilator
(eg, albuterol or budesonide-formoterol) [1,2]. The decision to
initiate oral glucocorticoids at home incorporates the severity and
persistence of current symptoms (eg, nocturnal awakenings,
breathlessness with minimal activity, needing repeated beta-agonist
doses over one to two days), nature of the stimulus triggering the
attack, if known (eg, transient irritant or allergen exposure versus
worsening symptoms with a respiratory viral infection), and
response to bronchodilator treatment. (See 'Triage based on
response to home treatment' below.)
Patients with a history of recurrent, severe asthma exacerbations
may be advised to keep oral glucocorticoids available at home and
take an initial dose (eg, prednisone 40 to 60 mg) based on certain
symptoms and PEF results, and then notify their clinician.
Evidence in favor of treating acute asthma exacerbations with oral
glucocorticoids is presented separately. (See "Acute exacerbations
of asthma in adults: Emergency department and inpatient
management", section on 'Oral glucocorticoids'.)
Inhaled glucocorticoids for mild-to-moderate exacerbations
Short course of inhaled glucocorticoid — Patients with intermittent
asthma who use only a short-acting beta-agonist such
as albuterol for symptom relief can often be managed with
initiation of an inhaled glucocorticoid alone during a mild-to-
moderate exacerbation of asthma. In this context we use a medium-
to-high dose of inhaled glucocorticoids for 10 to 14 days
(eg, budesonide DPI 180 mcg/actuation at four inhalations twice
daily or fluticasone propionate MDI 220 mcg/inhalation at two
inhalations twice daily) [13].
Combination quick relief and glucocorticoid inhaler — Patients with
moderate-to-severe persistent asthma who use a combination
formoterol-glucocorticoid inhaler as both maintenance and rescue
therapy, a strategy referred to as Single-Inhaler Maintenance and
Reliever Therapy or SMART, can take up to 6 inhalations over the
course of one hour, with a maximum recommended dose of 12
inhalations/day, as noted above. The evidence for SMART is
described separately. (See 'Combination glucocorticoid-
formoterol' above and "Treatment of moderate persistent asthma in
adolescents and adults", section on 'Single maintenance and
reliever therapy' and "Treatment of intermittent and mild persistent
asthma in adolescents and adults".)
A combination glucocorticoid-SABA inhaler has been approved by
the US Food and Drug Administration [14], but is not yet widely
available in the United States. Where available, it can be used to
treat an acute exacerbation like albuterol, with the advantage, as
with combination glucocorticoid-formoterol, of administering anti-
inflammatory therapy with each inhalation, so-called "anti-
inflammatory rescue."
Quadrupling the dose of inhaled glucocorticoid — For adolescents
and adults with asthma who are already taking a daily inhaled
glucocorticoid as maintenance therapy, a potential alternative to
oral glucocorticoids is a substantial increase in the inhaled
glucocorticoid dose (ie, four times baseline). Quadrupling the
glucocorticoid dose may prevent or reduce the severity or duration
of an exacerbation when given early in response to a deterioration in
asthma control, such as at the first sign of a viral respiratory
infection [2,15,16]. However, parameters that predict which patients
would benefit from this approach have not been fully determined.
In our practice, we reserve this strategy for selected patients who
have mild to moderate asthma, a mild flare in symptoms, PEF ≥60
percent of predicted, good self-management skills, and no prior
history of life-threatening asthma exacerbations. This may be
particularly beneficial in patients likely not adherent to their usual
asthma therapy [4]. Patients should return to their baseline inhaled
glucocorticoid dose after normalization of symptoms and PEF, or at
a maximum of 14 days.

Evidence in favor of quadrupling the inhaled glucocorticoid dose

includes the following:

●In an open-label trial, 1871 patients (≥16 years old) who

were receiving inhaled glucocorticoids for asthma and
had one or more exacerbations of asthma in the prior
year were assigned to self-management with quadrupling
the dose of inhaled glucocorticoids in response to a
deterioration in asthma control or self-management
without such an increase (non-quadrupling group) [15].
After 12 months of follow-up, 45 percent of the
quadrupling group experienced an exacerbation
compared with 52 percent of the non-quadrupling group
with an adjusted hazard ratio for the time to a first severe
exacerbation of 0.81 (95% confidence interval, 0.71-0.92).
As participants in this study had low adherence to their
regular inhaled glucocorticoid, it is possible that such
patients may particularly benefit from quadrupling
therapy. Further study is needed to determine whether
certain patient or exacerbation characteristics predict
which patients would benefit from this strategy.
●Among 403 patients with a mild increase in asthma
symptoms and a small decrease in peak flow (eg, 15
percent for two days or 30 percent for one day),
quadrupling the dose of inhaled glucocorticoids, rather
than no change, resulted in a decrease in the likelihood
of needing oral glucocorticoids (relative risk [RR] 0.43,
95% CI 0.24-0.78) [17].
In contrast, doubling the dose of inhaled glucocorticoids is not
adequate to abort an asthma exacerbation once an exacerbation
has developed [18-20]. Additionally, quintupling the dose of inhaled
glucocorticoids in children with an incipient asthma exacerbation
appears ineffective [21]. (See "Acute asthma exacerbations in
children younger than 12 years: Overview of home/office
management and severity assessment", section on 'Outpatient
management'.)
Triage based on response to home treatment — The assessment of
response to initial home therapy with a fast-acting bronchodilator
(eg, albuterol or budesonide-formoterol) is based on the degree of
improvement in symptoms, return of peak flow toward baseline, and
course of prior exacerbations. The patient should follow their
asthma action plan or contact their clinician for specific
instructions.
Good response — If the patient’s symptoms (wheezing, dyspnea,
cough, chest tightness) resolve and the repeat PEF measurement is
≥80 percent of the patient's predicted or personal best over the
course of approximately one hour, then the patient may safely
continue home management (algorithm 1). A course
of prednisone (40 to 60 mg daily for five to seven days, or
equivalent) is advised for patients who are on a maximal dose of
controller medication, recently completed a course of prednisone, or
have had recurrent symptoms after 24 to 48 hours of increased
controller medication.

In contrast, if the patient’s symptoms resolve after the initial dose of

a fast-acting bronchodilator (eg, two to four inhalations), PEF is ≥80
percent of baseline after the initial dose(s), and they remain
improved for three to four hours, oral glucocorticoids are usually not
necessary.

Other important interventions include removal of the offending

stimulus (if known) and intensifying controller medication. (See "An
overview of asthma management", section on 'Adjusting controller
medication'.)
Incomplete response — An incomplete response to inhaled fast-
acting bronchodilator is manifest by continued symptoms and a PEF
between 50 and 80 percent of predicted or personal best [2]. The
patient should take high-dose inhaled or oral glucocorticoids
according to his or her action plan (algorithm 1). We would note that
timely administration of oral glucocorticoids for asthma
exacerbations is probably the single most effective strategy for
reducing emergency department visits and hospitalizations for acute
asthmatic attacks.

Other early interventions include removal of or from the offending

stimulus (if known), continued administration of inhaled fast-acting
bronchodilators every three to four hours, and intermittent
measurements of peak flow to assess response.

Need for urgent medical attention — Patients should seek

immediate medical attention if they have worsening symptoms
despite three doses of their fast-acting bronchodilator, a PEF ≤50
percent of predicted or personal best, or have a concerning
comorbid condition (eg, manifest by fever, chest pain, hypoxemia,
tachycardia). (See 'Risk factors for fatal asthma' above.)
Under these circumstances patients should not drive themselves to
an urgent care setting.

The inhaled fast-acting bronchodilator should continue to be

administered while awaiting additional medical care.

OFFICE MANAGEMENTFor patients who present to the medical

office with an asthma exacerbation, a focused history and physical
examination should be performed promptly and nearly concurrently
with administration of the first dose of short-acting beta-agonist
(SABA; albuterol or levalbuterol). A quick assessment should
enable the clinician to determine whether the patient’s symptoms
are due to asthma and can be managed in the office or should be
urgently transferred to an emergency department.
Focused assessment and triage — A brief history and physical
examination should confirm the diagnosis of an asthma
exacerbation, exclude worrisome comorbidities (eg, COVID-19
infection, acute bacterial sinusitis, influenza, pneumonia,
pneumothorax), and determine the severity of the exacerbation and
risk of impending respiratory failure (algorithm 2).

Physical examination should include assessment of posture (eg,

“tripod positioning” with elbows extended and thorax tilted forward),
level of consciousness, ability to speak in full sentences,
temperature, heart rate, respiratory rate and duration of expiratory
phase, blood pressure, use of accessory muscles, presence (or
absence) of wheezing, crackles, stridor, symmetry of breath sounds,
peripheral edema, and rash or angioedema.

Objective assessments, besides vital signs, include pulse oximetry

and peak expiratory flow (PEF).

Indications for urgent transfer to emergency department — For

patients with a severe or life-threatening exacerbation,
characterized by one or more of the following features,
arrangements should be made for transfer to an emergency
department while initial treatment is being administered:
●Breathless at rest, sitting forward
●Drowsy, confused, or agitated
●Unable to speak in full sentences
●Respiratory rate >30 breaths/minute
●Heart rate >120 beats/minute
●PEF ≤50 percent predicted or personal best or unable to
perform PEF
●Arterial oxygen saturation (SpO2) <90%
Treatment — The main therapies in the office are prompt and
repeated administration of SABAs, early addition of systemic
glucocorticoids, and supplemental oxygen, titrated to a pulse
oxygen saturation of 93 to 95 percent, if available. (See "Acute
exacerbations of asthma in adults: Emergency department and
inpatient management", section on 'Oxygen'.)
Inhaled short-acting beta-agonists — For all patients presenting
with an exacerbation of asthma, we recommend administration of
inhaled SABA [1,2]. In general, we start with 4 puffs by metered dose
inhaler (MDI) with a valved holding chamber ("spacer") and careful
coaching on proper technique. This dose is repeated every 20
minutes for 1 hour. Alternatively, for patients who have a more
severe exacerbation or report lack of benefit with four inhalations at
home, we administer up to six puffs by MDI (six separate
inhalations), preferably with a valved holding chamber and careful
attention to technique.
If the office has nebulizer equipment, the SABA can be nebulized
(with appropriate precautions against transmission of COVID-19
infection). For albuterol, the usual dose is 2.5 mg in 3 mL; this may
be available in a single-dose vial or in a concentrated form 2.5
mg/0.5 mL that must be diluted with 2.5 mL of sterile saline prior to
administration. For levalbuterol, the usual dose is 1.25 mg in 3 mL.
Nebulizer treatments can be repeated at 20-minute intervals for the
first hour. (See "Acute exacerbations of asthma in adults:
Emergency department and inpatient management", section on
'Inhaled beta-agonists'.)
Systemic glucocorticoids — Nearly all patients with a significant
asthma exacerbation (eg, PEF <80 percent of personal best or
predicted after initial inhaled beta-agonist) should receive oral
glucocorticoids [1,2,4]. A short course of glucocorticoids (eg,
equivalent of prednisone 40 to 60 mg/day for five to seven days)
significantly reduces the likelihood of a repeat severe exacerbation
within the succeeding two weeks and lessens the frequency of
persistent severe symptoms evaluated at a two-week telephone
follow-up [22,23]. As an alternative, oral dexamethasone (12 to 16
mg) for 1 to 2 doses has shown similar efficacy to a course of
prednisone (50 to 60 mg/day for five days) [24,25]. (See "Acute
exacerbations of asthma in adults: Emergency department and
inpatient management", section on 'Oral glucocorticoids'.)
Patients should be advised about common adverse effects of oral
glucocorticoids, such as sleep disturbance, increased appetite,
gastric irritation, and mood changes. (See "Major adverse effects of
systemic glucocorticoids".)
For glucocorticoid courses lasting three weeks or less, there is no
need to taper the dose if patients are also taking inhaled
glucocorticoids. (See "Glucocorticoid withdrawal", section on 'HPA
suppression unlikely'.)
●Intramuscular glucocorticoids ─ Intramuscular injection
of a long-acting glucocorticoid formulation is
occasionally used for patients without access to oral
medication or at high risk of medical nonadherence,
although this therapy is more commonly administered in
the emergency department or hospital. For instance, one
might administer triamcinolone suspension 40 mg/mL at
a dose of 60 to 100 mg intramuscularly. (See "Acute
exacerbations of asthma in adults: Emergency
department and inpatient management", section on
'Intramuscular glucocorticoids'.)
Disadvantages of intramuscular glucocorticoids are that
the onset of action is slower than oral glucocorticoids (12
to 36 hours after administration) and the duration of
effect varies from one individual to another (typically
from 2 to 4 weeks). Cutaneous atrophy at the injection
site and blanching of the overlying skin are also possible.
Disposition — Patients should be reassessed after SABA treatment
to determine whether they will need further emergency department
or hospital-based care, can continue therapy at home, or need
evaluation of a concerning comorbid condition (eg, influenza, COVID-
19 infection, pneumonia, pneumothorax, pulmonary embolism, heart
failure, or cardiac arrhythmia). Signs and symptoms that may
suggest a comorbid condition include fever, persistent tachycardia,
myalgias, purulent sputum, chest pain, hypoxemia, and a poor
response to SABA.
Worsening or lack of improvement — Patients who develop
worsening symptoms and/or a declining or unimproved PEF (eg, ≤50
percent predicted) despite SABA and systemic glucocorticoid
treatment in the office will need transfer to an emergency
department for further management. While waiting for transfer,
SABA and oxygen (aiming for 93 to 95 percent pulse oxygen
saturation) should be continued. Emergency and inpatient care are
discussed separately. (See "Acute exacerbations of asthma in
adults: Emergency department and inpatient management".)
Improved and preparing for discharge to home — Patients who
improve with office-based treatment (ie, symptoms decreased, heart
and respiratory rates normal, PEF >70 percent of predicted or
personal best, SpO2 >94 percent room air) can generally manage
their asthma at home, unless symptoms or signs suggest a
concerning comorbid condition [26]. (See 'Need for urgent medical
attention' above.)

Patients will need clear instructions about the following:

●Home monitoring with specific indications for

emergency department care or contacting the office (eg,
worsening symptoms, increasing need for fast-acting
bronchodilator, PEF ≤60 percent of baseline)
●Dose and duration of oral glucocorticoid therapy (eg,
equivalent of prednisone 40 to 60 mg daily for five to
seven days)
●Potential adverse effects of systemic glucocorticoids
(eg, elevated blood glucose, mood alteration, insomnia,
excess energy, increased appetite, and fluid retention)
●Use of their SABA (for those using a SABA for symptom
relief) two inhalations every four to six hours OR use of
combination inhaled glucocorticoid-formoterol (for those
using SMART) one to two inhalations every four to six
hours during the first few days of an exacerbation,
followed by tapering back to as-needed use as symptoms
resolve
●Initiation or increase in ongoing controller medications
(eg, inhaled glucocorticoids, long-acting beta-agonist)
Treatment with regular inhaled glucocorticoids (table 5) constitutes
an important method to prevent recurrent asthma attacks after
discontinuation of oral glucocorticoids and to prevent the potential
decline in lung function associated with any future severe asthma
exacerbation [1,27]. Virtually every patient who has an asthma
attack severe enough to require office-based or urgent care should
receive an inhaled glucocorticoid as part of his or her discharge
medication plan (form 1). (See "An overview of asthma
management".)

Patients with frequent asthma exacerbations will likely benefit from

referral to an asthma specialist. A number of biologic therapies
(monoclonal antibodies targeting allergic, eosinophilic, and steroid-
dependent asthma phenotypes) are available that successfully
reduce the frequency of exacerbations among patients with severe
asthma.

Patient education — Patients should be provided with information

about asthma, inhaler technique, avoidance of asthma triggers, and
if they do not already have one, a personalized action plan (form 1).
Follow-up care should be facilitated to ensure adequate and ongoing
use of controller medications. (See "Asthma education and self-
management" and "Trigger control to enhance asthma
management" and 'Information for patients' below.)
SOCIETY GUIDELINE LINKSLinks to society and government-
sponsored guidelines from selected countries and regions around
the world are provided separately. (See "Society guideline links:
Asthma in adolescents and adults".)
INFORMATION FOR PATIENTSUpToDate offers two types of
patient education materials, “The Basics” and “Beyond the Basics.”
The Basics patient education pieces are written in plain language,
at the 5th to 6th grade reading level, and they answer the four or five
key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who
prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed.
These articles are written at the 10th to 12th grade reading level and
are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this
topic. We encourage you to print or e-mail these topics to your
patients. (You can also locate patient education articles on a variety
of subjects by searching on “patient info” and the keyword(s) of
interest.)

●Beyond the Basics topics (see "Patient education:

Asthma treatment in adolescents and adults (Beyond the
Basics)" and "Patient education: Trigger avoidance in
asthma (Beyond the Basics)" and "Patient education:
How to use a peak flow meter (Beyond the
Basics)" and "Patient education: Inhaler techniques in
adults (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Early recognition – Early recognition and intervention
are critical for successful management of asthma
exacerbations. Patients with asthma should be taught
how to identify symptoms of an asthma exacerbation (eg,
breathlessness, wheezing, cough, and chest tightness),
and those with poor symptom perception or at increased
risk for fatal asthma should be taught how to measure
peak expiratory flow (PEF). (See 'Detecting an
exacerbation' above.)
●Algorithms for management – Approaches to the
management of acute exacerbations of asthma at home
and in the medical office are outlined in the algorithms
(algorithm 1 and algorithm 2). Patients should seek
immediate emergency department care if they have
symptoms or signs suggestive of a severe exacerbation
(eg, marked breathlessness, inability to speak more than
short phrases, use of accessory muscles) or a PEF ≤50
percent of baseline, or have risk factors for a fatal attack
(table 1). (See 'Need for urgent medical
attention' above.)
●Prompt initiation of therapy – Regardless of the
treatment location (home or office), the following
pharmacologic interventions are the cornerstone of
therapy:
•Fast-acting beta-agonist – For all patients with
symptoms of an asthma exacerbation, we recommend
prompt administration of a rapid onset (fast-acting)
beta-agonist (Grade 1B), either in the form of a short-
acting beta-agonist (SABA) or the long-acting beta-
agonist (LABA) formoterol. Formoterol has an onset of
action comparable to albuterol and must be given in a
combination inhaler with a glucocorticoid (GC).
(See 'Fast-acting bronchodilator' above.)
SABA – The usual dose of SABA
(albuterol or levalbuterol) at home is two to four
inhalations from a metered-dose inhaler (albuterol MDI
90 mcg/inhalation; levalbuterol MDI 45 mcg/inhalation)
with a valved holding chamber ("spacer") or dry
powder inhaler (albuterol DPI 90 mcg/actuation), while
in the office four to six inhalations can be given.
Albuterol or levalbuterol can also be given by nebulizer
(2.5 mg or 1.25 mg, respectively). Dosing can be
repeated every 20 minutes for one hour (three doses),
as needed. (See 'Short-acting beta-agonist' above
and 'Inhaled short-acting beta-agonists' above.)
Inhaled GC-formoterol – The usual dose of inhaled GC-
formoterol for an acute exacerbation (eg, budesonide-
formoterol 80 mcg-4.5 mcg or 160 mcg-4.5 mcg) is one
to two inhalations, which can be repeated every 20
minutes for one hour (6 inhalations/treatment;
maximum 12 inhalations/day), if needed.
(See 'Combination glucocorticoid-formoterol' above.)
•Oral glucocorticoids – For patients whose symptoms
have been recurrent over one to two days or do not
improve after one to three doses of fast-acting beta-
 agonist and/or whose PEF remains <80 percent of
personal best or predicted, we recommend initiation of
oral glucocorticoids (Grade 1B). The typical initial dose
is the equivalent of prednisone 40 to 60 mg orally.
(See 'Initiation of oral glucocorticoids' above.)
●Trigger avoidance and monitoring response – Additional
steps at home include removal from sources of potential
triggers (eg, animal dander, tobacco smoke) and
monitoring of medication response (algorithm 1).
(See 'Home treatment' above.)
●Treatment in medical office – For patients who present
to the medical office with an asthma exacerbation, a
focused history and physical examination should be
performed promptly and nearly concurrently with
administration of the first dose of SABA (algorithm 2).
(See 'Office management' above.)
•Signs of severe exacerbation – Patients with features
of a severe or life-threatening asthma exacerbation
(eg, breathless at rest, unable to speak in full
sentences, heart rate >120/minute, respiratory rate
>30/minute, PEF ≤50 percent of predicted or personal
best, pulse oxygen saturation <90 percent) should be
urgently transferred to an emergency department.
(See 'Indications for urgent transfer to emergency
department' above.)
•Supplemental oxygen – Supplemental oxygen should
be titrated to a pulse oxygen saturation of 93 to 95
percent, if necessary. (See 'Office
management' above.)
•Oral glucocorticoids – Most patients who require
office-based treatment for an acute asthma
exacerbation and have a PEF <80 percent of predicted
or personal best after initial SABA treatment are
candidates for oral glucocorticoids. An initial dose can
be administered in the office (eg, prednisone 40 to 60
mg or equivalent), if available. (See 'Systemic
glucocorticoids' above.)
●Disposition – After office-based fast-acting beta-agonist
treatment, patients who have no improvement or have
worsening symptoms and/or a declining PEF will need
transfer to an emergency department for further
management. (See 'Worsening or lack of
improvement' above.)
 Patients who are treated in the office and are improved
enough to go home should complete a course of
glucocorticoids (equivalent of prednisone 40 to 60 mg
daily for five to seven days). They should be given
instructions for their long-term controller medication
(inhaled glucocorticoids with or without a long-acting
beta-agonist), a personalized asthma action plan (NHLBI
Asthma Action Plan), and follow-up care instructions
(form 1). (See 'Disposition' above.)
Use of UpToDate is subject to the Terms of Use.

REFERENCES

1. National Asthma Education and Prevention Program: Expert

Panel Report III: Guidelines for the diagnosis and management
of asthma. Bethesda, MD. National Heart, Lung, and Blood
Institute, 2007. (NIH publication no. 08-4051)
www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed
on September 19, 2018).
2. 2023 Global Initiative for Asthma (GINA) Report: Global
Strategy for Asthma Management and Prevention.
www.ginasthma.org/2023-gina-main-report (Accessed on May
15, 2023).
3. Bloom CI, Palmer T, Feary J, et al. Exacerbation Patterns in
Adults with Asthma in England. A Population-based Study. Am
J Respir Crit Care Med 2019; 199:446.
4. Expert Panel Working Group of the National Heart, Lung, and
Blood Institute (NHLBI) administered and coordinated
National Asthma Education and Prevention Program
Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP,
et al. 2020 Focused Updates to the Asthma Management
Guidelines: A Report from the National Asthma Education and
Prevention Program Coordinating Committee Expert Panel
Working Group. J Allergy Clin Immunol 2020; 146:1217.
5. Goodacre S, Bradburn M, Cohen J, et al. Prediction of
unsuccessful treatment in patients with severe acute asthma.
Emerg Med J 2014; 31:e40.
6. British Thoracic Society, Scottish Intercollegiate Guidelines
Network. British guideline on the management of asthma.
Thorax 2014; 69 Suppl 1:1.
7. O'Byrne PM, FitzGerald JM, Bateman ED, et al. Inhaled
Combined Budesonide-Formoterol as Needed in Mild Asthma.
N Engl J Med 2018; 378:1865.
8. Bateman ED, Reddel HK, O'Byrne PM, et al. As-Needed
Budesonide-Formoterol versus Maintenance Budesonide in
Mild Asthma. N Engl J Med 2018; 378:1877.
9. Safety Concerns with Asthmanefrin and the EZ Breathe
Atomizer.
http://www.fda.gov/Drugs/DrugSafety/ucm370483.htm
(Accessed on April 07, 2015).
10. American Academy of Allergy Asthma & Immunology.
Non-prescription racemic ephinephrine for asthma.
http://www.aaaai.org/global/latest-research-summaries/New-
Research-from-JACI-In-Practice/racemic-epinephrine-
asthma.aspx (Accessed on April 07, 2015).
11. Mondal P, Kandala B, Ahrens R, et al. Nonprescription
racemic epinephrine for asthma. J Allergy Clin Immunol Pract
2014; 2:575.
12. Canadian Society of Allergy and Clinical Immunology.
Non-prescription availability of theophylline, epinephrine, and
ephedrine for asthma. http://csaci.ca/index.php?page=359
(Accessed on April 07, 2015).
13. Boushey HA, Sorkness CA, King TS, et al. Daily versus as-
needed corticosteroids for mild persistent asthma. N Engl J
Med 2005; 352:1519.
14. FDA approval of albuterol-budesonide MDI
https://www.accessdata.fda.gov/drugsatfda_docs/appletter/20
23/214070Orig1s000ltr.pdf (Accessed on January 13, 2023).
15. McKeever T, Mortimer K, Wilson A, et al. Quadrupling
Inhaled Glucocorticoid Dose to Abort Asthma Exacerbations.
N Engl J Med 2018; 378:902.
16. Rodrigo GJ. Comparison of inhaled fluticasone with
intravenous hydrocortisone in the treatment of adult acute
asthma. Am J Respir Crit Care Med 2005; 171:1231.
17. Oborne J, Mortimer K, Hubbard RB, et al. Quadrupling the
dose of inhaled corticosteroid to prevent asthma
exacerbations: a randomized, double-blind, placebo-
controlled, parallel-group clinical trial. Am J Respir Crit Care
Med 2009; 180:598.
18. Kew KM, Flemyng E, Quon BS, Leung C. Increased versus
stable doses of inhaled corticosteroids for exacerbations of
chronic asthma in adults and children. Cochrane Database
Syst Rev 2022; 9:CD007524.
19. FitzGerald JM, Becker A, Sears MR, et al. Doubling the
dose of budesonide versus maintenance treatment in asthma
exacerbations. Thorax 2004; 59:550.
 20. Harrison TW, Oborne J, Newton S, Tattersfield AE.
Doubling the dose of inhaled corticosteroid to prevent asthma
exacerbations: randomised controlled trial. Lancet 2004;
363:271.
21. Jackson DJ, Bacharier LB, Mauger DT, et al. Quintupling
Inhaled Glucocorticoids to Prevent Childhood Asthma
Exacerbations. N Engl J Med 2018; 378:891.
22. Fiel SB, Swartz MA, Glanz K, Francis ME. Efficacy of
short-term corticosteroid therapy in outpatient treatment of
acute bronchial asthma. Am J Med 1983; 75:259.
23. Chapman KR, Verbeek PR, White JG, Rebuck AS. Effect of
a short course of prednisone in the prevention of early relapse
after the emergency room treatment of acute asthma. N Engl
J Med 1991; 324:788.
24. Kravitz J, Dominici P, Ufberg J, et al. Two days of
dexamethasone versus 5 days of prednisone in the treatment
of acute asthma: a randomized controlled trial. Ann Emerg
Med 2011; 58:200.
25. Rehrer MW, Liu B, Rodriguez M, et al. A Randomized
Controlled Noninferiority Trial of Single Dose of Oral
Dexamethasone Versus 5 Days of Oral Prednisone in
Acute Adult Asthma. Ann Emerg Med 2016; 68:608.
26. Hasegawa K, Craig SS, Teach SJ, Camargo CA Jr.
Management of Asthma Exacerbations in the Emergency
Department. J Allergy Clin Immunol Pract 2021; 9:2599.
27. Lougheed MD, Garvey N, Chapman KR, et al. Variations
and gaps in management of acute asthma in Ontario
emergency departments. Chest 2009; 135:724.
Topic 528 Version 79.0

GRAPHICS
Our approach to initial triage and home management of
asthma exacerbations in adults and adolescents

This algorithm is designed for a medical professional providing advice to a patient

who is at home and has an asthma exacerbation. More than one phone call may be
needed to complete the algorithm.
PEF: peak expiratory flow; MDI: pressurized metered dose inhaler; SpO2: pulse
oxygen saturation; DPI: dry powder inhaler; FABA: fast-acting beta agonist (eg,
albuterol, formoterol-budesonide).
* Comorbid conditions that may complicate asthma exacerbation:
 Acute bronchitis
  Acute bacterial sinusitis
 Anaphylaxis
 Heart failure, arrhythmias
 Influenza, COVID-19
 Pneumonia
 Pneumothorax

¶ Response category is generally based on the criterion with the most severe
impairment.
Reference: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention,
2021. Available from: www.ginasthma.org (Accessed on December 3, 2021).
Graphic 119823 Version 4.0
Our approach to office management of asthma
exacerbations in adults and adolescents

PEF: peak expiratory flow; SpO2: pulse oxygen saturation; SABA: short-acting beta-
agonist; MDI: metered dose inhaler; GC: glucocorticoid; LABA: long-acting beta-
agonist.
* In a minority of patients, symptoms resolve quickly and completely with one dose
of albuterol (eg, 2 to 4 inhalations or one nebulizer treatment) and PEF is ≥80% of
predicted or personal best. Oral glucocorticoid is not necessary, but a step-up in
controller medication may be needed.
¶ Refer to UpToDate content on asthma management or https://ginasthma.org/.
Δ Comorbid conditions that may complicate asthma exacerbation include the
following:
 Acute bronchitis
 Acute bacterial sinusitis
 Heart failure; arrhythmia
 Influenza, COVID-19
 Pneumonia
 Pneumothorax
Suggestive symptoms include fever, myalgias, purulent sputum, chest pain, poor
response to SABA. Refer to UpToDate content on diagnosis and management.
◊ Individuals with PEF 60-70% of predicted following initial treatment can sometimes
safely continue treatment at home if their symptoms are improving, they have an
asthma-safe home environment, have the necessary medications and understand
their proper administration, are deemed adherent to therapy, and have ready access
to emergent care if needed.
Reference: Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention.
Available from: www.ginasthma.org. (Accessed on December 15, 2021)
Graphic 119824 Version 2.0
Risk factors for a fatal asthma attack
 Indicators of severe disease

 Previous life-threatening exacerbation

 Asthma attack despite current oral glucocorticoid use

Indicators of poor asthma control

 More than 1 hospitalization for asthma in the past year

 3 or more emergency department visits for asthma in the past year

 Use of more than 1 canister of short-acting beta agonist per month

Serious comorbidities

 Cardiovascular or chronic lung disease

 Illicit drug use or major psychosocial problems

 Food allergy

Poor asthma co-management skills

 Not taking inhaled glucocorticoids

 History of poor adherence with asthma medications and/or written asthma action plan

 Difficulty perceiving asthma symptoms or severity of exacerbations

Graphic 119887 Version 1.0
Technique for peak flow measurement in asthma
Move peak flow meter indicator to zero.

Sit or stand up straight.

Take in a deep breath, as deep as you can.

Place peak flow meter in your mouth and close your lips around the mouthpiece*.

As soon as your lips are sealed around mouth piece, blow out as hard and fast as you can using your chest and belly muscle

Write down the result.

Repeat two more times (three total).

Record the highest of the three values.

 * Nose clips are not necessary.
¶ Make sure to use all of your breathing muscles, not just your mouth muscles. This
needs a lot of force, like blowing out a candle several feet away.
Graphic 53856 Version 5.0
Predicted peak expiratory flow (PEF; liters/minute) for
males age 20 to 70 years
Age Height
(years)
60 inches/152 cm 65 inches/165 cm 70 inches/178

20 477 539 606

25 484 546 613

30 488 550 616

35 487 549 616

40 483 545 611

45 474 536 603

50 462 436 591

55 446 508 575

60 426 488 554

65 402 464 530

70 374 436 503

For patients who do not know their personal best PEF, this table can help estimate an
expected "personal best." This table uses a prediction equation for White males, age
20 to 70 years. Refer to UpToDate calculator for values for additional age, height,
and race/ethnicity parameters.
Reference:

1. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the

general U.S. population. Am J Respir Crit Care Med. 1999; 159(1):179.

Graphic 57257 Version 10.0
Predicted peak expiratory flow (PEF; liters/minute) for
females age 20 to 70 years
Age Height
(years)
55 inches/140 cm 60 inches/152 cm 65 inches/165

20 333 372 418

 25 340 379 425

30 344 383 429

35 344 383 430

40 342 381 427

45 336 376 422

50 328 367 413

55 316 323 401

60 301 341 387

65 283 323 369

70 263 302 348

For patients who do not know their personal best PEF, this table can help estimate an
expected "personal best." This table uses a prediction equation for White females age
20 to 70 years. Refer to UpToDate calculator for values for additional age, height,
and race/ethnicity parameters.
Reference:

1. Hankinson JL, Odencrantz JR, Fedan KB. Spirometric reference values from a sample of the

general U.S. population. Am J Respir Crit Care Med. 1999; 159(1):179.

Graphic 62839 Version 10.0
Usual doses of short-acting bronchodilators for asthma in
adolescents and adults*
Drug name(s) Preparation(s)¶

Albuterol MDIΔ MDI: 90 mcg/inhalation (United States) Usual dose: 2 inhalations every

MDI: 100 mcg/inhalation (Canada) Acute exacerbation at home: 2 t

Acute care setting: 4 to 8 inhala

Albuterol DPI DPIΔ : 90 mcg/actuation (United States) Usual dose: 2 inhalations every
Acute exacerbation at home: 2 t
Acute care setting: 4 to 8 inhala

Albuterol DPI (Canada) DPI: 200 mcg/actuation (Canada) Usual dose: 1 inhalation every 4
Exercise-induced bronchoconst

Albuterol solution for Nebulizer solutions: Usual dose: 2.5 mg every 4 to 6

nebulization  0.083% (2.5 mg/3 mL) Acute exacerbation at home: Ad
  0.5% (2.5 mg/0.5 mL) concentrate; must be every 1 to 4 hours, as tolerated¥
diluted in 2.5 mL saline Acute care setting: Administer 2
every 1 to 4 hours, as tolerated
Acute care setting (critically ill)
monitored setting

Albuterol-budesonide MDI MDI: Albuterol 90 mcg and budesonide 80 Usual dose: 2 inhalations every
mcg/actuation (United States) Acute exacerbation at home: 2 i

Levalbuterol MDIΔ 45 mcg/inhalation (United States) Usual dose: 2 inhalations every

Acute exacerbation at home: 2 t
Acute care setting: 4 to 8 inhala

Levalbuterol solution for Nebulizer solution: Usual dose: Administer 0.63 to

nebulization  0.63 mg/3 mL per 24 hours)
 1.25 mg/3 mL Acute exacerbation at home: Ad
 1.25 mg/0.5 mL concentrate; must be diluted in frequency to every 1 to 4 hours,
2.5 mL saline Acute care setting: Administer 1
total of 3 doses, then decrease f

Terbutaline DPI DPI: 0.5 mg/actuation (Canada) Usual dose: 1 inhalation every 4
If no effect after 5 minutes, can

Ipratropium-albuterol SMI SMI: Ipratropium 20 mcg and albuterol 100 Usual dose (off-label): 2 inhalat
mcg/inhalation (United States) Acute exacerbation (off-label):

Ipratropium-albuterol solution Nebulizer solution: Ipratropium 0.5 mg and Usual dose (off-label): Adminis
for nebulization albuterol 2.5 mg per 3 mL/vial ‡
Acute exacerbation (off-label):
MDI: metered-dose inhaler; DPI: dry-powder inhaler; SMI: soft mist inhaler.

* Oral formulations of albuterol and terbutaline are less effective than inhaled
formulations and are not recommended in asthma. Inhaled epinephrine (MDI or
nebulized) is not recommended for routine use.

¶ Doses shown and strengths (ie, mcg per puff or inhalation) are based upon product
descriptions approved in the United States and Canada as noted, which may differ
from how strengths are described for products available in other countries. Consult
local product information before use.

Δ Agent can also be used to prevent exercise-induced bronchoconstriction, 2

inhalations 5 to 20 minutes prior to exercise.
◊ Typically, two puffs are used for mild-to-moderate symptoms and four puffs for
more severe symptoms; over the course of the first hour, the patient can determine
(based on action plan or clinician guidance) whether to continue self-care at home or
seek additional medical attention.

§ The number of inhalations is based on the severity of respiratory impairment,

number of inhalations the patient has already used, and availability of monitoring.
When administering an albuterol MDI for acute asthma exacerbation in an office or
acute care setting, use of a valved holding chamber and careful attention to
technique are recommended.

¥ Over the course of the first hour, the patient can determine (based on action plan
or clinician guidance) whether to continue self-care at home or seek additional
medical attention.

‡ Nebulizer solution in Canada is ipratropium 0.5 mg and albuterol 2.5 mg per 2.5
mL.
Graphic 72467 Version 27.0
Estimated comparative daily doses for inhaled
glucocorticoids in adolescents ≥12 years and adults

Drug

Beclomethasone HFA
(Qvar RediHaler product available in United States)
Administer as 2 divided doses

40 mcg per actuation

80 mcg per actuation

Beclomethasone HFAΔ
(Qvar product available in Canada, Europe, and elsewhere)
Administer as 2 divided doses

50 mcg per actuation

100 mcg per actuation

Budesonide DPI
(Pulmicort Flexhaler product available in United States)
Administer as 2 divided doses
 90 mcg per actuation

180 mcg per actuation

Budesonide DPIΔ
(Pulmicort Turbuhaler or Turbohaler product available in Canada, Europe, and elsewhere)
Administer low doses (ie, ≤400 mcg/day) once daily; administer higher doses (ie, >400 mcg/day) as 2 to 4 divided doses

100 mcg per actuation

200 mcg per actuation

400 mcg per actuation

Ciclesonide HFA
(Alvesco product available in United States, Europe, and elsewhere)
United States: Administer as 2 divided doses

Australia, Europe, and elsewhere: Administer lower doses (ie, 160 to 320 mcg/day) once daily; administer 640 mcg dose as
2 divided doses

80 mcg per actuation

160 mcg per actuation

Ciclesonide HFAΔ
(Alvesco product available in Canada)
Administer lower doses (eg, 100 to 400 mcg) once daily; administer 800 mcg dose as 2 divided doses

100 mcg per actuation

200 mcg per actuation

Fluticasone propionate HFA

(Flovent HFA product available in United States)
Administer as 2 divided doses

44 mcg per actuation

110 mcg per actuation

220 mcg per actuation

Fluticasone propionate HFAΔ

(Flovent HFA product available in Canada; Flixotide Evohaler product available in Europe and elsewhere)
Administer as 2 divided doses

50 mcg per actuation

125 mcg per actuation

250 mcg per actuation

Fluticasone propionate DPI

(Flovent Diskus product available in United States and Canada; Flixotide Accuhaler product available in Europe and
elsewhere)
Administer as 2 divided doses

50 mcg per actuation

100 mcg per actuation

250 mcg per actuation

500 mcg per actuation (strength not available in United States)

Fluticasone propionate DPI

(Armonair Digihaler product available in United States; Aermony Respiclick product available in Canada)
Administer as 2 divided doses

55 mcg per actuation

113 mcg per actuation

232 mcg per actuation

Fluticasone furoate DPI

(Arnuity Ellipta product available in United States, Canada, Australia, and elsewhere, but not available in Europe or UK)
Administer once daily

NOTE: Inhaled fluticasone furoate has a greater anti-inflammatory potency per microgram than fluticasone propionate
inhalers. Thus, fluticasone furoate is administered at a lower daily dose and used only once daily.

50 mcg per actuation

100 mcg per actuation

200 mcg per actuation

Mometasone DPI
(Asmanex Twisthaler product available in United States)
 May administer lower doses (ie, 220 to 440 mcg/day) once daily; administer 880 mcg dose as 2 divided doses

110 mcg per actuation

220 mcg per actuation

Mometasone HFA
(Asmanex HFA product available in United States)
Administer as 2 divided doses

100 mcg per actuation

200 mcg per actuation

Mometasone DPIΔ
(Asmanex Twisthaler product available in Canada, Europe, and elsewhere)
May administer lower doses (ie, 200 to 400 mcg/day) once daily; administer 800 mcg dose as 2 divided doses

200 mcg per actuation

400 mcg per actuation

 The most important determinant of appropriate dosing is the clinician's

judgment of the patient's response to therapy. The clinician must monitor the
patient's response on several clinical parameters and adjust the dose accordingly.
The stepwise approach to therapy emphasizes that once control of asthma is
achieved, the dose of medication should be carefully titrated to the minimum dose
required to maintain control, thus reducing the potential for adverse effects.
 Suggested total daily doses for low, medium, and high dose inhaled glucocorticoid
regimens are based on daily doses recommended by Global Initiative for Asthma
(GINA), National Asthma Education and Prevention Program (NAEPP), and/or
product labeling[1-5] . This is not a table of equivalence.
 Depending on the specific product, total daily doses are administered once or
divided and given twice daily. Refer to local product information or a clinical drug
reference (eg, Lexicomp).
 Some doses are outside the approved product information recommendations.
DPI: dry powder inhaler; HFA: hydrofluoroalkane propellant metered dose inhaler.

* Evidence for additional improvement with dose increases >1000 mcg/day is

limited.

¶ Select alternate preparation with higher mcg/actuation to improve convenience.

Δ Products shaded in light gray color are not available in the United States but are
available widely elsewhere.
 ◊ Select preparation with fewer mcg/actuation.
Data from:

1. Global Initiative for Asthma (GINA); Global Strategy for Asthma Management and Prevention;

2021. Available at www.ginasthma.org.

2. National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the

Diagnosis and Management of Asthma; 2007. NIH Publication 08-4051 available at

http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report and pro.

3. US Food & Drug Administration (FDA) approved product information. US National Library of

Medicine. (Available online at www.dailymed.nlm.nih.gov/dailymed/index.cfm.)

4. Health Canada-approved product monograph. Health Canada. (Available online

at https://health-products.canada.ca/dpd-bdpp/index-eng.jsp.)

5. European Medicines Agency (EMA) summary of product characteristics. European Medicines

Agency. (Available online at www.ema.europa.eu/en/medicines.)

Graphic 78011 Version 17.0
Asthma action plan

Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3):
Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.
Graphic 55900 Version 4.0