What are the guidelines for managing asthma?

Guidelines for Managing Asthma

The current standard of care for asthma management follows a stepwise approach with inhaled corticosteroids (ICS) as the cornerstone of therapy, with treatment adjusted based on symptom control and risk factors. 1

Assessment and Classification

Initial Assessment

• Evaluate symptom frequency, severity, and impact on daily activities
• Measure peak expiratory flow (PEF) or spirometry when available
• Assess risk factors for poor outcomes:
  • Previous severe exacerbations requiring hospitalization
  • Poor symptom control
  • Comorbidities (rhinitis, obesity, GERD)

Classification of Severity

• Mild Intermittent: Symptoms ≤2 days/week, nighttime awakenings ≤2 times/month, PEF ≥80% predicted
• Mild Persistent: Symptoms >2 days/week, nighttime awakenings 3-4 times/month, PEF ≥80% predicted
• Moderate Persistent: Daily symptoms, nighttime awakenings >1/week, PEF 60-80% predicted
• Severe Persistent: Symptoms throughout day, frequent nighttime awakenings, PEF <60% predicted

Treatment Approach

Step 1 (Mild Intermittent)

• No longer recommended to use short-acting beta-2 agonists (SABA) alone 2
• Low-dose ICS-formoterol as needed or low-dose ICS whenever SABA is used

Step 2 (Mild Persistent)

• Daily low-dose ICS plus as-needed SABA
• Alternative: ICS-formoterol as both maintenance and reliever therapy

Step 3 (Moderate Persistent)

• Low-dose ICS-LABA as maintenance plus as-needed SABA
• Alternative: Medium-dose ICS plus as-needed SABA

Step 4 (Moderate-to-Severe Persistent)

• Medium-to-high dose ICS-LABA plus as-needed SABA
• Consider adding long-acting muscarinic antagonist (LAMA)

Step 5 (Severe Persistent)

• High-dose ICS-LABA plus as-needed SABA
• Add-on therapies: LAMA, leukotriene modifiers
• Consider referral for phenotype-specific biologic therapy 1, 2

Acute Exacerbation Management

Assessment of Exacerbation Severity

• Mild-to-Moderate: Can complete sentences, respiratory rate <25/min, pulse <110/min, PEF >50% predicted
• Severe: Cannot complete sentences, respiratory rate >25/min, pulse >110/min, PEF <50% predicted
• Life-threatening: Silent chest, cyanosis, poor respiratory effort, altered consciousness, PEF <33% predicted

Treatment of Acute Exacerbations

1. Oxygen: Target saturation >92% 1
2. Bronchodilators:
   • Nebulized salbutamol 5mg or terbutaline 10mg every 15-30 minutes as needed
   • Add ipratropium bromide 0.5mg every 6 hours for severe exacerbations 1
3. Corticosteroids:
   • Prednisolone 30-60mg orally or hydrocortisone 200mg IV
   • Continue for 5-7 days without tapering for short courses 1
4. Additional measures for severe cases:
   • Consider IV magnesium sulfate (2g over 20 minutes)
   • Consider IV aminophylline or salbutamol infusion for refractory cases

Monitoring and Follow-up

Routine Monitoring

• Assess symptom control using validated tools (ACT, ACQ)
• Monitor PEF regularly
• Review inhaler technique at each visit
• Adjust treatment every 2-3 months until control is achieved

Criteria for Discharge After Exacerbation

• Sustained symptom improvement
• PEF >75% of predicted or personal best
• Oxygen saturation >94% on room air
• Patient has been on discharge medications for 24 hours
• Follow-up with primary care within 1 week and specialist within 4 weeks 1

Special Considerations

Pediatric Patients

• Monitor growth in children on ICS therapy
• Use lowest effective dose to minimize systemic effects 3
• Consider growth velocity: expected range for 8.5-year-old boys is 3.8-7.0 cm/year; for girls, 4.2-7.3 cm/year 3

Elderly Patients

• Higher risk of pneumonia with ICS-LABA therapy
• Use caution with beta-agonists in patients with cardiovascular disease 3

Pregnancy

• Maintain optimal asthma control to ensure adequate fetal oxygenation 1

Common Pitfalls and Caveats

1. Poor adherence: Often the main reason for treatment failure - assess and address at each visit
2. Incorrect inhaler technique: Demonstrate and check technique regularly
3. Unidentified triggers: Systematically evaluate for allergens, occupational sensitizers, and comorbidities
4. Overreliance on SABAs: Frequent SABA use (>2 times/week) indicates poor control and need for controller therapy
5. Underuse of written action plans: Provide all patients with a personalized written plan
6. Failure to step down therapy: Once good control is maintained for 3 months, consider gradual step-down to find minimum effective dose

By following these guidelines and addressing common pitfalls, clinicians can optimize asthma management and improve patient outcomes.