What are the current guidelines for asthma management?

Current Guidelines for Asthma Management

The current guidelines for asthma management recommend a stepwise approach to treatment, with the goal of achieving symptom control with the least amount of medication to minimize side effects. 1

Core Principles of Asthma Management

• The primary goals of asthma management are early and accurate diagnosis, symptom abolition, restoration of normal or best possible airway function, reduction in severe attack risk, minimizing absence from work/school, enabling normal growth in children, and using the lowest effective medication doses 1
• Asthma control should be regularly assessed using symptoms and, where appropriate, lung function measurements 1
• Treatment decisions should be based on asthma control, with step-up or step-down adjustments as needed 1

Stepwise Approach to Treatment

Step 1: Mild Intermittent Asthma

• As-needed short-acting β2-agonists (SABA) for symptom relief 1

Step 2: Regular Preventer Therapy

• Low-dose inhaled corticosteroids (ICS) as first-line controller medication for persistent asthma 2
• ICS are the most effective controllers of asthma as they suppress airway inflammation, reduce airway hyperresponsiveness, and control symptoms 3
• Standard daily dose of ICS is defined as 200-250 μg of fluticasone propionate or equivalent, which provides 80-90% of maximum therapeutic benefit 4

Step 3: Initial Add-on Therapy

• Addition of long-acting β2-agonists (LABA) to ICS is preferred over increasing ICS dose for patients with moderate-to-severe asthma 2
• Fixed-dose combinations of ICS/LABA improve compliance and control asthma at lower corticosteroid doses 3
• Available ICS/LABA combinations include fluticasone propionate/formoterol fumarate, fluticasone propionate/salmeterol xinafoate, budesonide/formoterol fumarate, and beclometasone dipropionate/formoterol fumarate 5

Step 4: Persistent Poor Control

• Higher doses of ICS/LABA combination therapy may be considered, though the dose-response curve to ICS is relatively flat 2
• Adding another class of therapy (low-dose theophylline or antileukotrienes) may be preferable to increasing ICS dose 2

Acute Exacerbation Management

Assessment of Severity

• Life-threatening features include silent chest, cyanosis, poor respiratory effort, confusion, and exhaustion 1
• Severe features include inability to complete sentences, respiratory rate >25/min, pulse >110/min, and PEF <50% predicted 1

Immediate Management

• High-dose inhaled β2-agonists (nebulized salbutamol 5 mg or terbutaline 10 mg) 6
• Systemic corticosteroids (prednisolone 30-60 mg or IV hydrocortisone 200 mg) 6
• Oxygen therapy to maintain saturation >94% 6
• Consider adding nebulized ipratropium bromide (0.5 mg) for severe exacerbations 6

Hospital Admission Criteria

• Any life-threatening features 6
• Severe features persisting after initial treatment 6
• PEF <33% of predicted after treatment 6
• Lower threshold for admission in evening presentations, recent nocturnal symptoms, or previous severe attacks 6

Self-Management Education

• Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 1
• Self-management plans should include monitoring of symptoms and peak flow, pre-arranged action steps, and written guidance 1
• Patients should be trained in proper inhaler technique and peak flow meter use 6
• Patients should be able to recognize worsening symptoms, particularly nocturnal symptoms 1

Monitoring and Follow-Up

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

Special Considerations

Pregnancy

• Pregnant women with worsening asthma should be referred to a specialist 6

Children

• Growth monitoring is important in children on ICS therapy, though short-term reductions in growth rate with doses >400 μg/day may not affect final adult height 6
• Management in very young children (0-2 years) presents particular challenges due to diagnostic difficulties and variable bronchodilator response 6

Common Pitfalls to Avoid

• Overreliance on bronchodilators without anti-inflammatory treatment 1
• Underestimating severity of exacerbations 1
• Sedation in acute asthma (contraindicated) 6
• Delayed administration of systemic corticosteroids during severe exacerbations 1
• Antibiotics should only be given if bacterial infection is present 6