What are the guidelines for the treatment and management of asthma?

Asthma Management Guidelines

The stepwise approach to asthma management is the cornerstone of treatment, with inhaled corticosteroids (ICSs) being the most effective controller medications for persistent asthma, supplemented by short-acting beta-agonists for symptom relief. 1, 2

Core Components of Asthma Management

• Accurate early diagnosis and assessment of severity are essential for effective management 2
• Treatment goals include symptom control, restoration of normal lung function, reduction of exacerbation risk, and minimizing medication side effects 2
• A comprehensive approach includes medications, patient education, environmental control measures, and management of comorbidities 1
• Regular monitoring of asthma control is necessary to adjust therapy appropriately 1

Stepwise Treatment Approach

Step 1: Mild Intermittent Asthma

• As-needed short-acting β2-agonists (SABA) for symptom relief 2

Step 2: Mild Persistent Asthma

• Low-dose inhaled corticosteroid (ICS) as preferred controller medication 1
• Alternative options include leukotriene receptor antagonists (LTRAs), though ICSs are more effective 3

Step 3: Moderate Persistent Asthma

• Low-dose ICS plus long-acting β2-agonist (LABA) combination therapy 4
• Alternative: Medium-dose ICS monotherapy 1

Step 4: Severe Persistent Asthma

• Medium-dose ICS plus LABA combination therapy 1
• Consider adding ipratropium (short-acting muscarinic antagonist) for additional bronchodilation 5

Step 5-6: Very Severe Persistent Asthma

• High-dose ICS plus LABA combination therapy 1
• Consider add-on therapies such as tiotropium, leukotriene modifiers, or biologics 1

Medication Considerations

• ICSs are the cornerstone of asthma therapy, suppressing inflammation and reducing airway hyperresponsiveness 6
• The dose-response curve for ICSs is relatively flat; high-dose ICSs often provide minimal additional benefit compared to low/moderate doses 7, 8
• Adding a LABA to ICS is often more effective than increasing ICS dose for patients with moderate-to-severe asthma 8
• Fluticasone/salmeterol combination is indicated for twice-daily treatment of asthma in patients aged 4 years and older 4
• LTRAs may be considered as alternative controller medications but are generally less effective than ICSs 3, 9

Acute Exacerbation Management

• Assess severity using objective measures: ability to speak in sentences, respiratory rate, heart rate, and peak expiratory flow (PEF) 1

• For mild exacerbations (PEF >50% predicted):

  • Nebulized salbutamol 5mg or terbutaline 10mg 1
  • Prednisolone 30-60mg if PEF remains 50-75% predicted after bronchodilator 1
  • Follow-up within 48 hours 1

• For severe exacerbations (PEF <50% predicted, unable to complete sentences, respiratory rate >25/min, heart rate >110/min):

  • Oxygen 40-60% if available 1
  • Nebulized salbutamol 5mg or terbutaline 10mg with oxygen as driving gas 1
  • Prednisolone 30-60mg or IV hydrocortisone 200mg 1
  • Consider hospital admission 1

• Life-threatening features requiring immediate intensive care:

  • Silent chest, cyanosis, poor respiratory effort, confusion, exhaustion 1
  • Add ipratropium and consider IV aminophylline or high-dose nebulized beta-agonist 1

Self-Management Education

• Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 1

• Self-management plans should include:

  • Regular monitoring of symptoms and peak flow 1
  • Pre-arranged action steps based on symptoms/peak flow 1
  • Written guidance for medication adjustments 1
  • Clear instructions for when to seek urgent medical attention 1

• Education should be provided at all points of care: clinics, emergency departments, hospitals, schools, and patients' homes 1

Special Considerations

Children (0-4 years)

• Consider daily long-term controller therapy for young children with:
  • Two or more wheezing episodes in the past year lasting >1 day 1
  • Risk factors such as parental asthma history or physician-diagnosed atopic dermatitis 1
  • Monitor response closely and adjust treatment accordingly 1

Inhaled Steroids and Growth in Children

• Use the lowest effective dose of ICS to minimize potential side effects 1
• Short-term reductions in growth rate may occur with doses >400 μg/day, but these cannot be extrapolated to long-term effects 1
• Asthma itself can delay growth and puberty, but catch-up growth typically occurs 1

Common Pitfalls to Avoid

• Underestimating the severity of exacerbations 2
• Overreliance on bronchodilators without anti-inflammatory treatment 2
• Delayed administration of systemic corticosteroids during severe exacerbations 2
• Sedation in acute asthma, which can be dangerous 2
• Failure to provide patients with written action plans for self-management 1

Follow-up and Monitoring

• After acute exacerbations, follow-up should occur within 24-48 hours 2
• Regular review of inhaler technique, adherence, and symptom control is essential 2
• Consider step-down of therapy when asthma has been stable for at least 3 months 2
• Patients should not be discharged from hospital until symptoms have stabilized with PEF >75% of predicted/personal best 2