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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.^[75]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.

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)

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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)

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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

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

Class Summary

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

Ipratropium bromide (Atrovent HFA)

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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.

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

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

Prednisolone (Pediapred, Millipred, Orapred)

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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)

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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.

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)

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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

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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.

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

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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.

Questions

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Media Gallery

Figure depicting antigen presentation by the dendritic cell, with the lymphocyte and cytokine response leading to airway inflammation and asthma symptoms.

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Author

Constantine K Saadeh, MD President, Allergy ARTS, LLP; Principal Investigator, Amarillo Center for Clinical Research, Ltd

Constantine K Saadeh, MD is a member of the following medical societies: American Academy of Allergy, Asthma and Immunology, American College of Rheumatology, American Medical Association, Southern Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John J Oppenheimer, MD Clinical Professor, Department of Medicine, Rutgers New Jersey Medical School; Director of Clinical Research, Pulmonary and Allergy Associates, PA

John J Oppenheimer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, New Jersey Allergy, Asthma and Immunology Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Amgen; GSK; Aquestive; Aimmune<br/>Clinical Adjudication/Data Safety Monitoring Board for AZ, GSK, Abbvie, Sanofi; Executive Editor for Annals of Allergy, Asthma & Immunology; Editor for Medscape; Reviewer for UpToDate; Honoraria from American Board of Allergy and Immunology.

Acknowledgements

Michael R Bye, MD Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society