What is the recommended protocol for managing asthma?

Asthma Management Protocol

The recommended protocol for managing asthma involves a stepwise approach with inhaled corticosteroids (ICS) as the cornerstone of therapy, with treatment adjusted based on asthma severity and control assessment. 1

Diagnosis and Assessment

• Establish diagnosis through:

  • Medical history focusing on episodic symptoms of airflow obstruction
  • Physical examination of upper respiratory tract, chest, and skin
  • Spirometry for patients ≥5 years old to confirm airflow obstruction is partially reversible
  • Additional studies to exclude alternative diagnoses 2

• Key diagnostic indicators:

  • Wheezing
  • Recurrent cough, difficulty breathing, or chest tightness
  • Symptoms that worsen with specific triggers 2

Severity and Control Assessment

• Assess both severity (intrinsic disease process) and control (fluctuating status)
• Evaluate in two domains:
  1. Current impairment: Frequency/intensity of symptoms and functional limitations
  2. Future risk: Likelihood of exacerbations, decline in lung function, or medication side effects 2

Treatment Protocol by Age Group

Adults and Children ≥12 Years

1. Step 1 (Mild Intermittent):

   • SABA as needed for symptoms

2. Step 2 (Mild Persistent):

   • Low-dose ICS daily
   • Consider allergy immunotherapy if allergic component present 2

3. Step 3 (Moderate Persistent):

   • Low-dose ICS + LABA
   • OR medium-dose ICS alone 2
   • Note: Equal consideration should be given to either increasing ICS dose to medium or adding LABA to low-dose ICS 2

4. Step 4 (Moderate-Severe Persistent):

   • Medium-dose ICS + LABA
   • Consider allergy immunotherapy if allergic component present 2

5. Step 5-6 (Severe Persistent):

   • High-dose ICS + LABA
   • Consider omalizumab for patients with allergic asthma 2, 1

Children 5-11 Years

• Similar stepwise approach with age-appropriate medication dosing
• Monitor growth velocity in children on ICS 3

Children <5 Years

• Diagnosis relies more on symptoms than lung function tests
• Consider alternative diagnoses in children <2 years 1

Acute Exacerbation Management

Assessment of Exacerbation Severity

• Severe exacerbation indicators:

  • Cannot complete sentences in one breath
  • Respiratory rate >25 breaths/min
  • Heart rate >110 beats/min
  • PEF <50% of predicted/best 2, 1

• Life-threatening features:

  • Silent chest, cyanosis, feeble respiratory effort
  • Bradycardia, hypotension
  • Confusion, exhaustion, or coma 2, 1

Treatment of Acute Exacerbations

1. Immediate management:

   • Oxygen 40-60% to maintain SpO₂ >92%
   • Nebulized salbutamol 5mg or terbutaline 10mg via oxygen-driven nebulizer
   • Systemic corticosteroids: Prednisolone 30-60mg orally or hydrocortisone 200mg IV 2, 1

2. For severe/life-threatening exacerbations:

   • Add ipratropium bromide 0.5mg nebulized
   • Consider IV aminophylline or nebulized/subcutaneous terbutaline
   • Chest radiography to exclude pneumothorax 2

3. Monitoring:

   • Reassess 15-30 minutes after treatment
   • Monitor vital signs and oxygen saturation continuously if possible 1

Long-term Management Considerations

• Medication adherence: Critical factor in poor asthma control 4

• Inhaler technique: Verify proper technique at each visit 1

• Self-management education:

  • Written asthma action plans with specific peak flow values
  • Instructions on medication use and when to seek urgent care 1

• Follow-up schedule:

  • After exacerbation: Within 24-48 hours
  • Routine: Based on control level, typically every 1-6 months 1

Special Considerations

• Pregnancy: Maintain optimal asthma control for adequate fetal oxygenation 1
• Elderly patients: Use caution with beta2-agonists in patients with cardiovascular disease 3
• Difficult-to-control asthma: Assess for:
  • Incorrect diagnosis
  • Poor adherence
  • Unidentified triggers (allergens, occupational sensitizers, GERD)
  • Psychological factors 4

Medication Considerations

• ICS efficacy: 80-90% of maximum therapeutic benefit is achieved at standard doses (200-250μg fluticasone propionate equivalent) 5
• ICS + LABA: Adding LABA to low-dose ICS often provides greater benefit than increasing ICS dose 6
• ICS side effects: Monitor for growth effects in children; most pronounced at higher doses 3

By following this protocol and adjusting treatment based on asthma control, most patients can achieve good symptom control and minimize the risk of exacerbations.