Asthma Management Guidelines
Inhaled corticosteroids (ICS) are the cornerstone of asthma management, with short-acting beta-agonists (SABA) for symptom relief, and a stepwise approach to treatment based on symptom severity, with combination ICS/LABA therapy recommended for maintenance in patients not controlled on ICS alone. 1
Diagnosis and Assessment
- Assess symptom severity, frequency, and impact on quality of life
- Measure peak expiratory flow (PEF) and evaluate for features of severe asthma:
Stepwise Treatment Approach
Step 1: Mild Intermittent Asthma
- SABA as needed for symptom relief
- Note: SABA alone without ICS is no longer recommended 1, 3
- Low-dose ICS should be initiated as early as possible 3
Step 2: Mild Persistent Asthma
- Low-dose daily ICS (e.g., fluticasone, budesonide, beclomethasone)
- SABA as needed for breakthrough symptoms
- Monitor for ICS side effects, especially in children 1
Step 3: Moderate Persistent Asthma
- Low-dose ICS/LABA combination OR
- Medium-dose ICS
- Consider two treatment tracks:
Step 4: Severe Persistent Asthma
- Medium to high-dose ICS/LABA combination
- Consider adding anticholinergic (ipratropium bromide) if beneficial during exacerbations 1
Step 5: Very Severe Asthma
- High-dose ICS/LABA combination
- Add-on treatments before initiating phenotype-specific biologics
- Consider specialist referral for biologic therapies 1, 3
Management of Acute Exacerbations
Moderate Exacerbation:
- Oxygen 40-60% if available
- Nebulized salbutamol 5 mg or terbutaline 10 mg
- Prednisolone 30-60 mg orally
- Reassess after 15-30 minutes 2, 1
Severe Exacerbation:
- Oxygen therapy
- Nebulized salbutamol 5-10 mg every 15-30 minutes as needed
- Nebulized ipratropium bromide 0.5 mg every 6 hours
- Systemic corticosteroids (prednisolone 30-60 mg daily for adults)
- Consider IV hydrocortisone 200 mg if unable to take oral medications
- Monitor vital signs continuously 2, 1
Hospital Admission Criteria
Admit patients with:
- Life-threatening features
- Features of acute severe asthma persisting after initial treatment
- PEF <33% of predicted/best
- Lower threshold for admission if:
- Attack occurs in afternoon/evening
- Recent nocturnal symptoms
- Recent hospital admission or previous severe attacks
- Inadequate home support 2
Follow-up and Monitoring
- After acute exacerbation: Follow-up within 24-48 hours
- Regular monitoring of:
- Symptom control
- Lung function (PEF)
- Medication adherence and inhaler technique
- Growth in children (ICS doses >400 μg/day may affect growth) 1
- Provide written asthma action plan including:
- Peak flow monitoring with personalized thresholds
- When to adjust medications
- When to seek emergency care 1
Special Considerations
Children:
- Monitor growth with regular ICS use
- Use lowest effective ICS dose
- Consider alternative diagnoses in children under 2 years 1
Elderly:
- Higher risk of pneumonia with ICS/LABA in COPD
- Special caution with beta2-agonists in patients with cardiovascular disease 4
Pregnancy:
- Maintain controller medications as uncontrolled asthma poses greater risk than medications 1
Common Pitfalls and Caveats
Overreliance on SABA: Frequent SABA use (>2 canisters/month) indicates poor control and need for controller adjustment 1
Inadequate ICS dosing: Underuse of ICS is a common cause of poor asthma control 5, 6
Failure to identify comorbidities: Conditions like allergic rhinitis, GERD, or vocal cord dysfunction can mimic or worsen asthma 6
Poor inhaler technique: Regularly check and correct inhaler technique 1
Lack of written action plan: Self-management education improves outcomes 1
LABA monotherapy: LABAs should never be prescribed without ICS due to safety concerns 1
The evidence strongly supports that monitoring airway hyperresponsiveness in addition to symptoms and lung function leads to more effective asthma control and greater reduction in airway inflammation 7. This suggests that incorporating objective measures of inflammation into routine management may improve long-term outcomes.