What are the guidelines for managing asthma?

Asthma Management Guidelines

The management of asthma follows a stepwise approach focused on controlling symptoms, preventing exacerbations, and minimizing mortality and morbidity through appropriate assessment, medication, and monitoring. 1

Diagnosis and Assessment

• Confirm diagnosis through:
  • Symptoms assessment (wheezing, breathlessness, chest tightness)
  • Objective measurements (PEF, spirometry)
  • Response to therapy
• Assess severity using:
  • Ability to complete sentences in one breath
  • Respiratory rate (>25 breaths/min indicates severe asthma)
  • Heart rate (>110 beats/min indicates severe asthma)
  • PEF (<50% of predicted/best indicates severe asthma)

Stepwise Treatment Approach

Step 1: Mild Intermittent Asthma

• Short-acting β2-agonist (SABA) as needed
• Note: SABA alone without ICS is no longer recommended 2

Step 2: Mild Persistent Asthma

• Low-dose inhaled corticosteroid (ICS) as controller
• SABA as needed for symptom relief

Step 3: Moderate Persistent Asthma

• Low-dose ICS plus long-acting β2-agonist (LABA)
• OR medium-dose ICS
• Consider leukotriene receptor antagonist if exercise symptoms predominate 3

Step 4: Severe Persistent Asthma

• Medium/high-dose ICS plus LABA
• Consider adding ipratropium bromide or theophylline

Step 5: Very Severe Persistent Asthma

• High-dose ICS plus LABA
• Add-on treatments (oral corticosteroids)
• Consider biologic agents for specific phenotypes 2

Acute Severe Asthma Management

Assessment of Severity

• Life-threatening features:
  • PEF <33% of predicted/best
  • Silent chest, cyanosis, feeble respiratory effort
  • Bradycardia or hypotension
  • Exhaustion, confusion, or coma 4

Immediate Management

1. High-flow oxygen (40-60%) to maintain SaO₂ >92% 1
2. High-dose inhaled β2-agonists:
   • Salbutamol 5-10 mg or terbutaline 10 mg via oxygen-driven nebulizer
   • Or multiple actuations of MDI with spacer (2 puffs 10-20 times) 4, 1
3. Systemic corticosteroids:
   • Prednisolone 30-60 mg orally or
   • Hydrocortisone 200 mg IV 4, 1
4. For life-threatening features:
   • Add ipratropium 0.5 mg nebulized
   • Consider IV aminophylline (250 mg over 20 minutes) or IV salbutamol/terbutaline (250 μg over 10 minutes) 4
   • Caution: Do not give bolus aminophylline to patients already taking oral theophyllines 4

Monitoring Response

• Reassess PEF 15-30 minutes after initial treatment
• Monitor oxygen saturation continuously
• Measure arterial blood gases in severe cases 1

Criteria for Hospital Admission

• Any life-threatening features
• Severe symptoms persisting after initial treatment
• PEF <50% of predicted after initial treatment 4

Special Considerations

Children

• Age-appropriate dosing:
  • Salbutamol: 2.5 mg for children under 2 years, 5 mg for older children
  • Prednisolone: 1-2 mg/kg body weight daily (maximum 40 mg) 4
• Ensure proper inhaler technique with age-appropriate spacer devices
• Monitor growth in children on ICS therapy 5

Difficult-to-Control Asthma

• Confirm asthma diagnosis and exclude other airway diseases
• Check adherence to therapy
• Identify and address exacerbating factors (allergens, occupational sensitizers, GERD)
• Consider specialist referral 6

Indications for Specialist Referral

1. Diagnostic uncertainty
2. Suspected occupational asthma
3. Poor response to treatment
4. Severe or life-threatening attacks
5. Need for biological therapies 4

Discharge and Follow-up

Discharge Criteria

• On discharge medications for 24 hours
• Inhaler technique checked and recorded
• PEF >75% of predicted/best and diurnal variability <25%
• Follow-up arrangements made 4, 1

Discharge Medications

• Prednisolone tablets for 1-3 weeks
• Inhaled steroids at appropriate dose
• Inhaled β2-agonists as needed
• PEF meter for home monitoring 1

Follow-up

• GP review within 1 week
• Specialist follow-up within 4 weeks
• Self-management plan with written instructions 4

Common Pitfalls to Avoid

• Underestimating asthma severity (failure to make objective measurements)
• Inadequate corticosteroid dosing during acute attacks
• Failure to monitor response to treatment
• Discharging patients too early without adequate follow-up plans
• Not addressing adherence issues or incorrect inhaler technique
• Using sedatives in asthma patients (can worsen respiratory depression) 4, 1