What is the recommended treatment for severe asthma?

Treatment for Severe Asthma

For severe asthma, the recommended treatment is high-dose inhaled corticosteroids combined with long-acting beta2-agonists, with oral corticosteroids added if control cannot be achieved with this combination. 1

Assessment of Severity

Severe asthma is characterized by:

• PEF <33% of predicted normal or best
• Inability to complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• Use of accessory muscles, possible silent chest
• Exhaustion, confusion, or coma in life-threatening cases 1

Treatment Algorithm

Step 1: Immediate Management (Acute Severe Attack)

• High-dose inhaled beta2-agonists: Salbutamol 5 mg or terbutaline 10 mg via nebulizer with oxygen
• High-dose systemic steroids: Prednisolone 30-60 mg orally or hydrocortisone 200 mg IV immediately
• For life-threatening features, add:
  • Ipratropium (0.5 mg) nebulized with beta2-agonist
  • IV aminophylline (250 mg over 20 minutes) or IV salbutamol/terbutaline (250 μg over 10 minutes) 1

Step 2: Ongoing Hospital Management

1. Continuous oxygen therapy
2. High-dose systemic steroids: Prednisolone 30-60 mg daily or IV hydrocortisone 200 mg every 6 hours
3. Nebulized beta2-agonists every 4 hours if improving; more frequently (up to every 15 minutes) if not
4. Consider aminophylline or parenteral beta2-agonists if response remains unsatisfactory 1

Step 3: Long-term Management of Severe Persistent Asthma

• High-dose inhaled corticosteroids
• Long-acting inhaled beta2-agonists (e.g., salmeterol)
• If needed: Add oral corticosteroids (1-2 mg/kg/day, generally not exceeding 60 mg/day) 1

Medication Options

Inhaled Corticosteroids (ICS)

• Fluticasone propionate at high doses (500 mcg or higher)
• Budesonide nebulizer solution (for children 1-8 years)

Long-Acting Beta2-Agonists (LABA)

• Salmeterol 50 mcg twice daily
• Available in combination with ICS (e.g., fluticasone/salmeterol) 2, 3

Monitoring and Follow-up

• Measure peak expiratory flow (PEF) 15-30 minutes after starting treatment and regularly thereafter
• Monitor arterial blood gases in hospitalized patients with severe attacks
• Watch for signs of deterioration requiring intensive care:
  • Worsening PEF
  • Persistent hypoxia (PaO2 <8 kPa) despite oxygen therapy
  • Hypercapnia (PaCO2 >6 kPa)
  • Exhaustion, confusion, or drowsiness 1

Special Considerations

Combination Therapy Benefits

• Adding salmeterol to moderate doses of ICS provides greater clinical benefit than simply increasing ICS dose 4
• Combination ICS/LABA inhalers may improve adherence compared to separate inhalers 3

Cautions and Contraindications

• Do not use sedation in acute asthma (contraindicated)
• Avoid LABA monotherapy (increases risk of serious asthma-related events)
• Monitor for oral candidiasis with high-dose ICS use
• Be alert for adrenal suppression with high-dose or prolonged corticosteroid use 2

Pitfalls to Avoid

1. Underestimating severity: Physicians often subjectively underestimate airway obstruction; use objective measures like PEF
2. Delaying corticosteroids: Administer systemic corticosteroids early as benefits may take 6-12 hours to appear 5
3. Overreliance on bronchodilators alone: Severe asthma requires anti-inflammatory treatment
4. Inappropriate antibiotic use: Only give antibiotics if bacterial infection is present 1
5. Inadequate monitoring: Frequent reassessment is essential during severe attacks

For patients with severe persistent asthma not responding to high-dose ICS plus LABA, make repeated attempts to reduce systemic corticosteroids while maintaining control with high-dose inhaled corticosteroids 1.