What are the guidelines for treating asthma?

Guidelines for Asthma Treatment

The cornerstone of asthma management is a stepwise approach with inhaled corticosteroids (ICS) as the foundation of therapy for persistent asthma, with treatment intensity adjusted based on symptom severity and control. 1

Assessment and Diagnosis

• Diagnosis should focus on two domains:

  • Impairment: Frequency and intensity of symptoms, functional limitations
  • Risk: Likelihood of exacerbations, decline in lung function, medication side effects

• Key symptoms include:

  • Wheezing
  • Coughing (particularly at night/early morning)
  • Chest tightness
  • Shortness of breath
  • Sleep disturbance due to symptoms

• Severity indicators:

  • Ability to speak in sentences
  • Respiratory rate (>25/min indicates severe asthma)
  • Heart rate (>110/min indicates severe asthma)
  • Oxygen saturation
  • Peak expiratory flow (PEF) (<50% predicted indicates severe asthma)

Treatment Algorithm

Step 1: Classify Asthma Severity

• Mild Asthma:

  • Preferred: Low-dose ICS-formoterol as needed
  • Alternative: Daily low-dose ICS plus as-needed short-acting beta-agonist (SABA)

• Moderate Asthma:

  • Preferred: Low-dose ICS-formoterol as maintenance and reliever
  • Alternative: Medium-dose ICS plus as-needed SABA

• Severe Asthma:

  • Preferred: High-dose ICS plus long-acting beta-agonist (LABA)
  • Consider adding biologics (e.g., omalizumab) for allergic asthma 1

Step 2: Acute Exacerbation Management

For acute severe asthma:

1. Administer oxygen (40-60%)
2. Nebulized salbutamol 5-10 mg or terbutaline 5-10 mg
3. Systemic corticosteroids (prednisolone 30-60 mg)
4. Consider adding ipratropium bromide 0.5 mg nebulized 2, 1

Step 3: Hospital Admission Criteria

• Any 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
  • Previous severe attacks
  • Patient unable to assess own condition
  • Concerning social circumstances 2

Step 4: Discharge Criteria

When discharging from hospital, ensure patient:

• Has been on discharge medication for 24 hours
• Has had inhaler technique checked and recorded
• Has PEF >75% of predicted/best and PEF diurnal variability <25%
• Is prescribed steroid tablets and inhaled steroids plus bronchodilators
• Has own PEF meter and self-management plan
• Has GP follow-up arranged within 1 week
• Has clinic follow-up within 4 weeks 2

Medication Selection and Delivery

• Inhaler Selection: Most children cannot use unmodified metered-dose inhalers (MDIs) correctly; large-volume spacers with MDIs are recommended, especially for inhaled steroids 1

• ICS Dosing: Use the lowest effective dose for symptom control. The dose-response curve for ICS is relatively flat, meaning higher doses provide minimal additional benefit while increasing risk of side effects 3, 4

• Combination Therapy: For moderate-to-severe asthma, adding a LABA to a low/moderate dose ICS is preferable to increasing ICS dose 4

• Fluticasone/Salmeterol (Wixela Inhub) dosing:

  • Adults and children ≥12 years: 1 inhalation twice daily (100/50,250/50, or 500/50 mcg based on severity)
  • Children 4-11 years: 1 inhalation of 100/50 mcg twice daily 5

Patient Education and Self-Management

• Provide written asthma action plan including:

  • Daily management instructions
  • How to recognize worsening symptoms
  • How to respond to worsening symptoms
  • When to seek emergency care 1

• Teach proper inhaler technique and check regularly

• Educate on difference between reliever and preventer medications

• Empower patients to adjust treatment based on symptoms rather than requiring doctor consultation for every change 1

Monitoring and Follow-up

• Use validated tools like Asthma Control Test (ACT) to assess control (score ≥20 indicates well-controlled)
• Monitor:
  • Days missed from school/work
  • Day/nighttime cough frequency
  • Frequency of reliever medication use
  • Activity limitations
  • Wheeze
  • Height and weight velocities (especially in children on ICS) 1

Common Pitfalls and Considerations

• Underuse of ICS: This is a common pitfall; ICS are the foundation of persistent asthma management 1

• Systemic Effects of ICS: Minimal at recommended doses; benefits clearly outweigh risks of uncontrolled asthma 6

• Growth Concerns: Short-term studies show decreased growth velocity with ICS, but long-term studies show no effect on final adult height 6

• Comorbidities: Failure to address GERD, rhinosinusitis, obesity, and sleep apnea can worsen asthma control 1

• Pregnancy: Most asthma medications are safe during pregnancy; uncontrolled asthma poses greater risk than medications 1

• Exercise-Induced Asthma: Pre-treatment with SABA 15 minutes before exercise, regular controller therapy, and warm-up before exercise are recommended 1