Медикаментозне лікування загострень астми*, †

Systemic beta-2 agonists

Epinephrine

Injectable solution: 1 mg/mL (1:1000)

0.01 mL/kg /dose subcutaneously (maximum 0.4–0.5 mL every 20 minutes for 3 doses or every 4 hours as needed)

0.2–0.5 mg subcutaneously every 20 minutes (for maximum of 3 doses) or every 2 hours as needed

Subcutaneous administration is no more effective than inhalation and may have more adverse effects.

Use in adults is controversial and may be contraindicated if significant cardiovascular disease is present.

Terbutaline

Injectable solution: 1 mg/mL

< 12 years: 0.005–0.01 mg/kg every 20 minutes up to 3 doses; may repeat every 2–6 hours as needed

≥ 12 years: Same as adults

0.25 mg subcutaneously once

May repeat in 15–30 minutes (maximum 0.5 mg over 4 hours)

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Short-acting beta-2 agonists

Albuterol

HFA: 90 mcg/puff

Same as adults

4–10 puffs every 20 minutes for 3 doses, then up to 6–10 doses every 1–2 hours.

MDI is as effective as nebulized solution if patients can coordinate inhalation maneuver using spacer and holding chamber.

Nebulized solution: 5 mg/mL and 0.63, 1.25, and 2.5 mg/3 mL

0.15 mg/kg (minimum 2.5 mg) every 20 minutes for 3 doses, then 0.15–0.3 mg/kg up to 10 mg every 1–4 hours as needed

Alternatively, 0.5 mg/kg/hour continuous nebulization

2.5–5 mg every 20 minutes for 3 doses, then 2.5–10 mg every 1–4 hours as needed

Alternatively, 10–15 mg/hour continuous nebulization is similarly effective but increases frequency of adverse effects.

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Levalbuterol

HFA: 90 mcg/puff

Same as adults

4–8 puffs every 20 minutes for 3 doses, then every 1–4 hours as needed

Levalbuterol is the R-isomer of albuterol.

0.63 mg is equivalent to 1.25 mg racemic albuterol.

Levalbuterol may have fewer adverse effects than albuterol.

Nebulized solution: 0.63 and 1.25 mg/3 mL

0.075 mg/kg (minimum 1.25 mg) every 20 minutes for 3 doses, then 0.075–0.15 mg/kg up to 5 mg every 1–4 hours as needed

Alternatively, 0.25 mg/kg/hour continuous nebulization

1.25–2 mg every 20 minutes for 3 doses, then 1.25–5 mg every 1–4 hours as needed

Alternatively, 5–7.5 mg/hours continuous nebulization

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Anticholinergics

Ipratroprium

Nebulized solution: 500 mcg/2.5 mL (0.02%)

0.25–0.5 mg every 20 minutes for 3 doses, then every 2–4 hours as needed

0.5 mg every 20 minutes for 3 doses, then every 2–4 hours as needed

Ipratropium should be added to beta-2 agonists and not used as first-line therapy.

It may be mixed in same nebulizer as albuterol.

Dose delivered from MDI is low and has not been studied in exacerbations.

Combination drugs

Ipratroprium and albuterol

SMI:

20 mcg ipratroprium and 100 mcg albuterol/puff

Same as adults

1 puff every 30 minutes for 3 doses, then every 2–4 hours as needed

Ipratropium prolongs bronchodilator effect of albuterol.

Nebulized solution: 0.5 mg ipratropium and 2.5 mg albuterol in a 3-mL vial

1.5 mL every 20 minutes for 3 doses, then every 2–4 hours as needed

3 mL every 30 minutes for 3 doses, then every 2–4 hours as needed

Mometasone and formoterol

HFA: 100 mcg or 200 mcg mometasone and 5 mcg formoterol; 50 mcg mometasone and 5 mcg formoterol for children < 12 years

< 6 years: Not recommended as rescue therapy

≥ 6 years: 2 puffs as needed; maximum total daily maintenance and rescue of 8 puffs (36 mcg) for children and 12 puffs for adults

2 puffs twice a day and as needed

Maximum total daily maintenance and rescue of 12 puffs (54 mcg)

Budesonide and formoterol

HFA: 80 or 160 mcg budesonide and 4.5 mcg formoterol

6– 11 years: Budesonide 80 mcg/formoterol 4.5 mcg 1–2 puffs as needed; may repeat up to a maximum total daily maintenance and rescue dose of 8 puffs/day (36 mcg of formoterol)

≥ 12 years: 2 puffs as needed; maximum total daily maintenance and rescue of 8 puffs (36 mcg)

2 puffs twice as needed

Maximum total daily maintenance and rescue of 12 puffs (54 mcg)

Systemic corticosteroids

Methylprednisolone

Tablets: 2, 4, 8, 16, and 32 mg

Inpatient:1 mg/kg every 6 hours for 48 hours, then 0.5–1.0 mg/kg twice a day (maximum, 60 mg/day) until PEF = 70% of predicted or personal best

Outpatient burst: 0.5–1.0 mg/kg twice a day (maximum 60 mg/day for 3–5 days)

Inpatient: 40–60 mg every 6– 8 hours for 48 hours, then 60–80 mg/day until PEF = 70% of predicted or personal best

Outpatient burst: 40–60 mg in single or 2 divided doses for 5–7 days

IV has no advantage over oral administration if gastrointestinal function is normal.

Higher doses provide no advantage in severe exacerbations.

Usual regimen is to continue frequent multiple daily doses until FEV1 or PEF = 50% of predicted or personal best and then lower the dose to twice a day, usually within 48 hours.

Therapy after a hospitalization or ED visit may last 5–10 days.

Tapering the dose is not needed if patients are also given inhaled corticosteroids.

Prednisolone

Tablets: 5 mg

Orally disintegrating tablets: 10, 15, and 30 mg

Solution: 5, 10, 15, 20 and 25 mg/5 mL

Prednisone

Tablets: 1, 2.5, 5, 10, 20, and 50 mg

Solution: 5 mg/mL and 5 mg/5 mL