What is the recommended management for asthma?

Management of Asthma

The recommended management of asthma requires a stepwise approach with inhaled corticosteroids (ICS) as the cornerstone of therapy for persistent asthma, complemented by self-management education and a written action plan to reduce morbidity and mortality. 1, 2

Core Principles of Asthma Management

Aims of Management

• Recognize asthma early and accurately 1
• Abolish symptoms and restore normal or best possible airway function 1
• Reduce risk of severe attacks and minimize absence from school or work 1
• Enable normal growth in children 1
• Use lowest effective doses of medications to minimize side effects 1

Stepwise Approach to Treatment

Step 1: Mild Intermittent Asthma

• As-needed short-acting β2-agonists (SABA) for symptom relief 1
• Consider low-dose ICS even in mild asthma as inflammation may be present despite minimal symptoms 2, 3

Step 2: Persistent Asthma

• Regular low-dose ICS as first-line controller therapy 2
• Standard daily dose of 200-250 μg fluticasone propionate or equivalent provides 80-90% of maximum therapeutic benefit 4
• ICS are the most effective controllers, suppressing inflammation by switching off activated inflammatory genes 5

Step 3: If Not Controlled on Low-Dose ICS

• Add long-acting β2-agonist (LABA) rather than increasing ICS dose 2
• Combination ICS/LABA inhalers improve compliance and control at lower corticosteroid doses 5

Step 4: Moderate to Severe Asthma

• Consider higher dose ICS/LABA combination 4
• Adding another class of therapy (theophylline or antileukotrienes) may be preferable to further increasing ICS dose 2

Acute Exacerbation Management

Assessment of Severity

• Life-threatening features: Silent chest, cyanosis, poor respiratory effort, confusion, exhaustion 1
• Severe features: Cannot complete sentences, respiratory rate >25/min, pulse >110/min, PEF <50% predicted 1

Immediate Management of Acute Severe Asthma

• High-dose inhaled β2-agonists: Salbutamol 5mg or terbutaline 10mg via nebulizer or multiple actuations via spacer 1
• Systemic corticosteroids: Prednisolone 30-60mg or IV hydrocortisone 200mg 1
• Oxygen therapy to maintain saturation 1
• For life-threatening features: Add nebulized ipratropium and consider IV aminophylline or IV β2-agonists 1

Hospital Admission Criteria

• Any life-threatening features 1
• Severe features persisting after initial treatment 1
• PEF <33% of predicted after treatment 1
• Lower threshold for admission in evening presentations, recent nocturnal symptoms, or previous severe attacks 1

Self-Management Education

Essential Components

• Patient/family understanding of asthma and proper inhaler technique 1
• Knowledge of difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory) 1
• Recognition of worsening symptoms, especially nocturnal symptoms 1
• Written action plan with clear instructions for medication adjustment 1

Key Elements of Self-Management Plan

• Regular monitoring of symptoms and peak flow 1
• Pre-arranged action steps based on symptoms/peak flow 1
• Written guidance for medication adjustments 1

Action Plan Should Include

• When to increase inhaled steroids 1
• When to start oral steroids (typically when PEF <60% of personal best) 1
• When to seek urgent medical attention 1

Special Considerations

Inhaled Corticosteroids and Side Effects

• Use lowest dose providing acceptable symptom control 1
• Systemic side effects are negligible at doses most patients require 5
• Short-term growth effects may occur with doses >400 μg/day but cannot be extrapolated to long-term outcomes 1
• Monitor for potential systemic effects in sensitive patients 6

Management in Very Young Children (0-2 years)

• Diagnosis relies primarily on symptoms rather than lung function tests 1
• Bronchodilator response may be variable but should be tried 1
• Consider alternative diagnoses (reflux, cystic fibrosis) 1

Pregnancy

• Pregnant women with worsening asthma require close monitoring 1
• Maintain controller medications as uncontrolled asthma poses greater risk to mother and fetus than medication side effects 1

Monitoring and Follow-Up

• Patients should not be discharged from hospital until symptoms have stabilized with PEF >75% of predicted/personal best 1
• Follow-up within 24-48 hours after acute exacerbations 1
• Regular review of inhaler technique, adherence, and symptom control 1
• Adjust treatment based on control and consider step-down when stable for 3 months 1

Common Pitfalls to Avoid

• Overreliance on bronchodilators without anti-inflammatory treatment 1
• Underestimating severity of exacerbations 1
• Sedation is contraindicated in acute asthma 1
• Antibiotics only indicated if bacterial infection is present 1
• Delayed administration of systemic corticosteroids during severe exacerbations 1
• Using high-dose ICS when no additional clinical benefit over low/moderate doses is demonstrated 7