What are the guidelines for managing asthma?

Asthma Management Guidelines

The British Thoracic Society recommends a stepwise approach to asthma management with the goal of achieving symptom control using the lowest effective medication doses while preventing exacerbations and minimizing side effects. 1

Assessment and Diagnosis

• Accurate early diagnosis is essential for effective management of asthma 1
• Assessment should include objective measurements such as peak expiratory flow (PEF) to avoid underestimating severity 2
• Failure to objectively assess severity is a common factor in preventable asthma deaths 2

Stepwise Management Approach

Mild Intermittent Asthma

• Use as-needed short-acting β2-agonists (SABA) for symptom relief 1
• No regular controller medication required 1

Mild Persistent Asthma

• Daily low-dose inhaled corticosteroids (ICS) as maintenance treatment 3
• Alternative options include cromolyn, oral theophylline, or leukotriene antagonists 3
• As-needed bronchodilators for symptom relief 3

Moderate Persistent Asthma

• Regular inhaled corticosteroids combined with long-acting β2-agonists (LABA) 3
• Monitor for potential growth effects in children using inhaled corticosteroids 4

Severe Persistent Asthma

• Higher-dose inhaled corticosteroids plus long-acting β2-agonists 3
• Consider adding theophylline 3
• Minimal dose of oral prednisolone (preferably alternate days) may be needed if symptoms remain uncontrolled 3

Acute Exacerbation Management

Assessment of Severity

• Life-threatening features: PEF <33% of predicted/best, silent chest, cyanosis, poor respiratory effort, bradycardia, hypotension, confusion, exhaustion, or coma 2
• Severe features: Inability to complete sentences in one breath, respiratory rate >25/min, pulse >110/min, PEF <50% of predicted/best 2

Immediate Management of Acute Severe Asthma

• High-flow oxygen (40-60%) in all cases 2
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 2
• If no nebulizer available, give 2 puffs of β-agonist via large volume spacer and repeat 10-20 times 2
• Systemic corticosteroids: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 2
• For life-threatening features, add nebulized ipratropium 0.5 mg 2
• Consider IV aminophylline (250 mg over 20 minutes) or nebulized/IV salbutamol/terbutaline (250 μg over 10 minutes) 2
• Caution: Do not give bolus aminophylline to patients already taking theophyllines 2

Hospital Admission Criteria

• Any life-threatening features 2
• Any features of acute severe asthma persisting after initial treatment 2
• PEF <33% of predicted/best after treatment 2
• Lower threshold for admission in evening presentations, recent nocturnal symptoms, previous severe attacks, or concerning social circumstances 2

Self-Management Education

• Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 1
• Provide a written action plan with clear instructions for medication adjustment 1
• Regular monitoring of symptoms and peak flow is recommended 2, 1
• Follow-up should occur within 24-48 hours after acute exacerbations 2, 1

Special Considerations

Children

• Monitor growth in children receiving inhaled corticosteroids 4
• Titrate to lowest effective dose to minimize systemic effects 4
• Children over 5 years can typically use a peak flow meter for monitoring 2
• Age-appropriate dosing: salbutamol 2.5 mg up to age 2,5 mg over age 2 2

Elderly Patients

• Special caution in geriatric patients with concomitant cardiovascular disease 4
• Higher incidence of serious adverse events and pneumonia risk in patients over 65 years 4
• No dosage adjustment based on age alone is warranted 4

Catastrophic Sudden Severe Asthma

• Some patients are at high risk of sudden death with rapid deterioration 2
• Management plan should be mutually agreed upon by patient, GP, and consultant 2
• Patients should carry duplicate medication supplies and possibly a resuscitation box 2
• Consider providing preloaded adrenaline syringe (Min-I-Jet, 0.5 mg) for subcutaneous injection 2

Common Pitfalls to Avoid

• Underestimating severity by failing to use objective measurements 2, 1
• Overreliance on bronchodilators without adequate anti-inflammatory treatment 1, 5
• Delayed administration of systemic corticosteroids during severe exacerbations 1
• Poor adherence to daily controller medications (66% of persistent asthmatics don't use medication daily) 6
• Inadequate treatment (48% of persistent asthmatics receive inadequate therapy per guidelines) 6

Monitoring and Follow-Up

• Regular review of inhaler technique, adherence, and symptom control 1
• Follow-up within 24-48 hours after acute exacerbations 2, 1
• Consider stepping down treatment when stable for 3 months 1
• Monitor for potential side effects of medications, particularly with higher doses of inhaled corticosteroids 1, 4