What are the guidelines for managing asthma?

Guidelines for Asthma Management

The cornerstone of asthma management is a stepwise approach using inhaled corticosteroids as the mainstay of preventive treatment, combined with patient education and self-management strategies to reduce morbidity and mortality. 1

Core Principles of Management

• The primary goals of asthma management are to abolish symptoms, restore normal or best possible airway function, reduce risk of severe attacks, minimize absence from school or work, and enable normal growth in children 1
• Treatment should use the lowest effective doses of medications to minimize short and long-term side effects 2
• Management requires a partnership between the patient/family and healthcare professionals, with education focused on shared information and acquisition of self-management skills 2

Stepwise Treatment Approach

• For mild intermittent asthma: as-needed short-acting β2-agonists (SABA) for symptom relief 1
• For persistent asthma: inhaled corticosteroids (ICS) are the most effective controller medication and the guideline-recommended first-line treatment 3
• Treatment escalation options include increasing ICS dose, adding long-acting β2-agonists (LABA), or adding leukotriene modifiers when symptoms are not adequately controlled 4
• High starting doses of ICS show no additional clinical benefit in most efficacy parameters compared to low or moderate doses for controlling moderate to severe asthma 5

Acute Exacerbation Management

• Life-threatening features include silent chest, cyanosis, poor respiratory effort, confusion, and exhaustion 2
• Severe features include inability to complete sentences, respiratory rate >25/min, pulse >110/min, and PEF <50% predicted 2
• Immediate management includes high-dose inhaled β2-agonists, systemic corticosteroids, and oxygen therapy 2
• Hospital admission criteria include any life-threatening features, severe features persisting after initial treatment, PEF <33% of predicted after treatment 1

Self-Management Education

• Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 2

• Self-management plans should include:

  • Regular monitoring of symptoms and peak flow 2
  • Pre-arranged action steps based on symptoms/peak flow 2
  • Written guidance for medication adjustments 2
  • Clear instructions for when to seek urgent medical attention 6

• Key actions in self-management include:

  • Initiation of or increase in inhaled steroid 2
  • Self-administration of steroid tablets when peak flow falls below the predetermined level or <60% of normal 2
  • Urgent seeking of medical attention when treatment is not working 2

Special Considerations for Children

• Childhood asthma is common and often underdiagnosed and undertreated, with symptoms developing in 50% of children by age 3 and 80% by age 5 2

• Diagnosis in young children (0-2 years) presents particular challenges:

  • Recurrent wheeze and cough are associated with viral infections, often without family history of asthma or atopy 2
  • Diagnosis relies almost entirely on symptoms rather than objective lung function tests 2
  • Bronchodilator response is variable in the first year but should still be tried 2
  • Other disorders may mimic asthma in young children (e.g., gastro-esophageal reflux, cystic fibrosis) 2

• Inhaled steroids are the mainstay of preventive treatment in children, but use the lowest dose that provides acceptable control 2

• Monitor growth in children on ICS therapy, as short-term reductions in growth rate have been observed with doses >400 μg/day 2

Monitoring and Follow-up

• Regular review of inhaler technique, adherence, and symptom control is essential 1
• Consider step-down of therapy when asthma has been stable for at least 3 months 6
• Patients should not be discharged from hospital until symptoms have stabilized with PEF >75% of predicted/personal best 1
• Follow-up should occur within 24-48 hours after acute exacerbations 6

Common Pitfalls to Avoid

• Overreliance on bronchodilators without anti-inflammatory treatment 1
• Underestimating the severity of exacerbations 1
• Delayed administration of systemic corticosteroids during severe exacerbations 1
• Sedation in acute asthma 1
• Failure to provide patients with written action plans for self-management 6

Specialist Referral Indications

• Patients with diagnostic uncertainty (e.g., elderly and smokers with wheeze) 2
• Patients with possible occupational asthma 2
• Patients with difficult-to-manage asthma despite appropriate treatment 2
• Pregnant women with worsening asthma 2
• Patients with catastrophic, sudden, severe (brittle) asthma 2
• Patients with continuing symptoms despite high doses of inhaled steroids 2