What is the recommended management for bronchial asthma?

Bronchial Asthma Management

Inhaled corticosteroids (ICS) are the cornerstone of bronchial asthma management and should be initiated as first-line therapy for all patients with persistent asthma, with treatment adjusted in a stepwise approach based on symptom control and exacerbation risk. 1

Stepwise Management Approach

Step 1: Mild Intermittent Asthma

• Short-acting beta-agonist (SABA) as needed for symptom relief
• Consider low-dose ICS even in mild cases to address underlying inflammation

Step 2: Mild Persistent Asthma

• Low-dose ICS as daily controller medication
• SABA as needed for rescue

Step 3: Moderate Persistent Asthma

• Low-dose ICS/LABA (long-acting beta-agonist) combination
• Alternative: Medium-dose ICS

Step 4: Severe Persistent Asthma

• Medium to high-dose ICS/LABA combination
• Consider adding additional controllers (e.g., tiotropium, leukotriene modifiers)

Step 5: Very Severe Persistent Asthma

• High-dose ICS/LABA combination
• Add-on therapies (oral corticosteroids, biologics)

Medication Details

Controller Medications

1. Inhaled Corticosteroids (ICS)

   • First-line anti-inflammatory therapy 2, 1
   • Options include fluticasone, budesonide, beclomethasone
   • Use lowest effective dose to minimize side effects 2
   • Dosing typically twice daily

2. Long-Acting Beta-Agonists (LABA)

   • Should never be prescribed without ICS due to safety concerns 1
   • Often combined with ICS (e.g., fluticasone/salmeterol) 3
   • Provides 12-hour bronchodilation

3. Combination ICS/LABA Inhalers

   • Recommended for maintenance therapy in moderate to severe asthma 1
   • Improves adherence by combining medications
   • Example: Fluticasone propionate/salmeterol (Wixela Inhub) 3

Rescue Medications

1. Short-Acting Beta-Agonists (SABA)

   • Used for quick relief of symptoms
   • Example: Salbutamol/albuterol
   • Overreliance indicates poor control and need for controller adjustment 2

2. Short-Acting Anticholinergics

   • Ipratropium bromide may be added for severe exacerbations 1
   • Particularly useful during acute attacks

Management of Exacerbations

Mild to Moderate Exacerbations

• Increase SABA use (2-4 puffs every 20 minutes for first hour)
• Consider temporary increase in ICS dose
• Early oral corticosteroid course if not responding

Severe Exacerbations

• Nebulized salbutamol 5-10 mg every 15-30 minutes as needed 1
• Nebulized ipratropium bromide 0.5 mg every 6 hours 1
• Systemic corticosteroids: Prednisolone 30-60 mg daily for adults or 1-2 mg/kg for children 2
• Continue until 2 days after control is established 2
• Oxygen therapy to maintain saturation >92%
• Consider hospital admission if poor response

Self-Management Education

Essential Components

1. Written Asthma Action Plan 2

   • Peak flow monitoring with personalized thresholds
   • When to adjust medications
   • When to seek emergency care

2. Proper Inhaler Technique 1

   • Demonstrate and verify at each visit
   • Different devices require different techniques

3. Trigger Avoidance

   • Identify and minimize exposure to allergens and irritants
   • Address comorbidities (e.g., allergic rhinitis, GERD) 1

Key Self-Management Actions 2

• Initiate or increase inhaled steroid when symptoms worsen
• Self-administer oral steroids when peak flow falls below 60% of personal best
• Seek urgent medical attention when treatment is not working

Special Considerations

Children

• Diagnosis relies more on symptoms than lung function tests in very young children 2
• Consider alternative diagnoses in children under 2 years 2
• Monitor growth; use lowest effective ICS dose 2
• Short-term growth effects seen with ICS doses >400 μg/day 2

Pregnant Women

• Maintain controller medications; uncontrolled asthma poses greater risk than medications 1

Difficult-to-Control Asthma

• Verify diagnosis and exclude other conditions 4
• Assess adherence to therapy 4
• Identify unrecognized triggers 4
• Consider referral to specialist 2

Follow-Up and Monitoring

• Schedule follow-up within 1 week of exacerbation 1
• Regular monitoring of symptom control and lung function
• Adjust therapy to maintain control with lowest effective medication dose
• Consider specialist referral for difficult cases or diagnostic uncertainty 2

Common Pitfalls to Avoid

• Overreliance on SABAs without adequate controller therapy
• Inadequate assessment of inhaler technique
• Failure to address comorbidities that worsen asthma control
• Not providing written action plans for self-management
• Inadequate step-up of therapy during loss of control