What are the guidelines for asthma treatment in adults?

Guidelines for Asthma Treatment in Adults

The stepwise approach to asthma management in adults begins with inhaled corticosteroids (ICS) as the cornerstone of controller therapy, with progressive addition of long-acting beta-agonists (LABA) and other agents based on symptom control and exacerbation risk.

Assessment of Asthma Severity

Assessment of asthma severity should include:

• Ability to complete sentences
• Respiratory rate (>25 breaths/min indicates severe asthma)
• Heart rate (>110 beats/min indicates severe asthma)
• Peak expiratory flow (PEF) measurement (<50% predicted indicates severe asthma)
• Use of accessory muscles and presence of wheezing
• Oxygen saturation via pulse oximetry 1

Stepwise Management Approach

Step 1: Mild Intermittent Asthma

• Short-acting beta-agonist (SABA) as needed
  • Salbutamol 100 mcg MDI with spacer, up to 20 puffs as needed 2
  • Alternative: Terbutaline 250 mcg MDI with spacer, up to 20 puffs as needed 2

Step 2: Mild Persistent Asthma

• Low-dose ICS as controller medication
  • Standard daily dose of fluticasone propionate 200-250 mcg or equivalent 3
• SABA as needed for symptom relief

Step 3: Moderate Persistent Asthma

• Low-dose ICS/LABA combination
  • Fluticasone propionate/salmeterol 100/50 mcg twice daily 4
• Alternative: Medium-dose ICS plus SABA as needed

Step 4: Severe Persistent Asthma

• Medium to high-dose ICS/LABA combination
  • Fluticasone propionate/salmeterol 250/50 mcg twice daily 4
• Consider adding ipratropium bromide 250 mcg nebulized six hourly if needed 2

Step 5: Very Severe Persistent Asthma

• High-dose ICS/LABA combination
  • Fluticasone propionate/salmeterol 500/50 mcg twice daily 4
• Add oral corticosteroids (prednisolone 30-60 mg daily) 1
• Consider referral to asthma specialist for biologic therapy evaluation 5

Management of Acute Exacerbations

Moderate Exacerbation:

• Oxygen to maintain saturation >92%
• Nebulized salbutamol 5 mg or terbutaline 10 mg
• Oral prednisolone 30-60 mg or IV hydrocortisone 200 mg
• Monitor response within 15-30 minutes 1

Severe Exacerbation:

• High-flow oxygen
• Nebulized salbutamol 5 mg or terbutaline 10 mg every 15-30 minutes
• Add ipratropium 0.5 mg to nebulization
• Oral prednisolone 30-60 mg or IV hydrocortisone 200 mg
• Consider IV magnesium sulfate (2 g over 20 minutes) 1

Life-threatening Features:

• PEF <33% of predicted or best
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma 1

Criteria for Hospital Admission

Hospitalization is recommended for patients with:

• Any life-threatening feature
• Persistence of severe exacerbation signs after initial treatment
• PEF <33% of predicted after initial treatment
• History of previous severe exacerbations
• Attack occurring at night or if patient lives alone
• Significant comorbidities 1

Discharge Criteria

Patients may be discharged when:

• PEF >75% of predicted or personal best
• Diurnal variability of PEF <25%
• Treatment with maintenance medication for at least 24 hours
• Verified and recorded inhalation technique
• Written action plan provided
• Follow-up with primary care physician arranged within 1 week 1

Important Considerations

• Avoid underestimating asthma severity - failure to make objective measurements is a common cause of preventable mortality 1
• Sedation is contraindicated unless proceeding to intubation 1
• Antibiotics should only be given if bacterial infection is present 1
• Regular monitoring of lung function is essential for determining treatment response 1
• The dose-response curve to ICS is relatively flat - adding another medication class may be preferable to increasing ICS dose in moderate-to-severe asthma 6

Common Pitfalls to Avoid

1. Overreliance on SABAs alone - this approach fails to address underlying inflammation and increases mortality risk
2. Excessive ICS dosing - most patients achieve 80-90% of maximum benefit at standard doses (200-250 mcg fluticasone propionate or equivalent) 3
3. Delayed escalation of care - can lead to preventable mortality
4. Failure to assess inhaler technique - poor technique significantly reduces medication effectiveness
5. Not providing written action plans - these are essential for patient self-management

By following these evidence-based guidelines, clinicians can optimize asthma control while minimizing medication side effects and reducing the risk of exacerbations in adult patients.