Status Asthmaticus Medication

Updated: Mar 03, 2017
  • Author: Constantine K Saadeh, MD; Chief Editor: John J Oppenheimer, MD  more...
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Medication

Medication Summary

The following agents are used in the pharmacologic treatment of status asthmaticus:

  • Beta2-agonists - The first line of therapy in status asthmaticus
  • Anticholinergics - Are believed to work centrally by suppressing conduction in vestibular cerebellar pathways
  • Glucocorticosteroids - Among other therapeutic activities, can decrease mucus production, improve oxygenation, reduce beta-agonist or theophylline requirements, and activate properties that may prevent late bronchoconstrictive responses to allergies and provocation
  • Bronchodilators - Methylxanthines are weaker bronchodilators than beta-agonists and have many adverse effects. Intravenous magnesium sulfate can relax smooth muscle and hence cause bronchodilation by competing with calcium at calcium-mediated smooth muscle binding sites.

Enoximone is an imidazole phosphodiesterase III inhibitor that has been used in patients with heart failure. In a limited report of eight patients with status asthmaticus, and after exhausting maximal treatment in six of these patients, enoximone was noted to be effective via intravenous administration. [64] It allowed the patients to improve without the need of invasive treatment such as mechanical ventilation. Its role in the future needs to be further investigated.

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Beta2-Agonist

Class Summary

These agents relax airway smooth muscle, thus causing bronchodilation in patients with reversible airway obstruction, such as asthma.

Albuterol (Proventil HFA, Ventolin HFA, ProAir HFA)

Albuterol relaxes bronchial smooth muscle by action on beta2 receptors with little effect on cardiac muscle contractility. Administer continuous nebulization with a pump-driven aerosol or via a small-particle aerosol generator

Levalbuterol (Xopenex, Xopenex HFA)

Levalbuterol is a selective beta2-agonist. Albuterol is a racemic mixture, while levalbuterol contains only the levo isomer of albuterol. The safety and efficacy of levalbuterol have not been determined in children under 12 years; multicenter trials in children aged 12 years and younger are ongoing.

Terbutaline

Terbutaline is a selective beta2-adrenergic agent. It produces relaxation of airway smooth muscle, resulting in bronchodilation in patients with asthma.

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Anticholinergic, Respiratory

Class Summary

These agents are used for bronchodilation in patients with bronchospasm associated with asthma or chronic obstructive pulmonary disease.

Ipratropium bromide (Atrovent HFA)

Ipratropium bromide is chemically related to atropine. It has antisecretory properties and, when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa. Ipratropium bromide inhibits acetylcholine at parasympathetic sites in bronchial smooth muscle, resulting in bronchodilation.

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Corticosteroids

Class Summary

These agents decrease the inflammatory response observed in asthma. They also decrease capillary leak and augment beta-receptor response to beta-adrenergic agents.

Prednisone

Prednisone decreases inflammation by suppressing the production of leukotrienes and the migration of polymorphonuclear leukocytes and by reducing capillary permeability.

Prednisolone (Pediapred, Millipred, Orapred)

Prednisolone decreases inflammation by suppressing the production of leukotrienes and the migration of polymorphonuclear leukocytes and by reducing capillary permeability.

Methylprednisolone (Solu-Medrol, Depo-Medrol, A-Methapred, Medrol)

Prednisone and methylprednisolone interfere with arachidonic acid metabolism and the production of leukotrienes, reduce microvascular leakage, reduce cytokine production, and prevent the migration of inflammatory cells.

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Xanthine Derivatives

Class Summary

These agents are used as additional therapy for patients who remain in refractory status asthmaticus despite maximal inhalational therapy and the use of corticosteroids. These medications may be administered intravenously.

Theophylline (Theo-24, Elixophyllin Elixir)

Theophylline is a bronchodilator that is used in patients with reversible bronchospasm associated with asthma or chronic obstructive pulmonary disease. The mechanism of action of theophylline is unclear, but its beneficial effects in asthma are thought to result from bronchodilation partly caused by phosphodiesterase inhibition, improved diaphragmatic inotropicity, CNS stimulation of the respiratory drive, and possible anti-inflammatory effects.

Start oral (eg, Theo-24, Theochron, Elixophyllin Elixir) dosing when the patient is stable on continuous IV dose.

Aminophylline

Aminophylline causes bronchodilation by increasing tissue concentrations of cAMP. It can be administered intravenously. However, intravenous aminophylline is generally used for refractory status asthmaticus because of the severity of the patient's asthma, which results in the decision to add methylxanthines to the treatment regimen. The theophylline dose is 79% of the aminophylline dose. To convert a theophylline dose to aminophylline, the theophylline dose needs to be divided by 0.80.

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Pulmonary, Other

Class Summary

Asthma patients that respond poorly to beta-agonists may benefit from adjunctive use in the treatment of acute exacerbations of severe asthma.

Magnesium sulfate

Magnesium sulfate relaxes smooth muscle and may lead to adjunctive bronchodilation. Its mechanism of action is unknown, but magnesium sulfate may compete with calcium for smooth muscle binding sites, leading to relaxation.

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