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 using objective measurements such as peak expiratory flow (PEF) is essential to avoid underestimating severity and ensure effective management 1
• Failure to objectively assess severity is a common factor in preventable asthma deaths 1

Stepwise Management Approach

• For mild intermittent asthma, use as-needed short-acting β2-agonists (SABA) for symptom relief with no regular controller medication required 1, 2
• The goal is to achieve control with the least amount of medication, minimizing side effects while maintaining normal or best possible airway function 2
• In children, monitor growth as inhaled corticosteroids may cause reduction in growth velocity; titrate to lowest effective dose 3

Acute Exacerbation Management

• Life-threatening features include:

  • PEF <33% of predicted/best
  • Silent chest, cyanosis, poor respiratory effort
  • Bradycardia, hypotension
  • Confusion, exhaustion, or coma 1, 2

• Severe features include:

  • Inability to complete sentences in one breath
  • Respiratory rate >25/min
  • Pulse >110/min
  • PEF <50% of predicted/best 1, 2

• Immediate management of acute severe asthma:

  • High-flow oxygen (40-60%)
  • Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer
  • Systemic corticosteroids (prednisolone 30-60 mg orally or hydrocortisone 200 mg IV) 1, 2

Hospital Admission Criteria

• Admit patients with:
  • Any life-threatening features
  • Severe features persisting after initial treatment
  • PEF <33% of predicted/best after treatment
  • Lower threshold for admission in evening presentations, recent nocturnal symptoms, or previous severe attacks 1, 2

Self-Management Education

• Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 1, 2
• Provide a written action plan with clear instructions for medication adjustment 1, 2
• Implement regular monitoring of symptoms and peak flow 1, 2

Special Considerations

• Pediatric patients:

  • Children over 5 years can typically use a peak flow meter for monitoring 1
  • Age-appropriate dosing of salbutamol is 2.5 mg up to age 2 and 5 mg over age 2 1
  • Monitor growth in children receiving inhaled corticosteroids 3

• Geriatric patients:

  • Special caution with beta2-agonists in patients with concomitant cardiovascular disease 3
  • Higher risk of pneumonia in patients over 65 years treated with fluticasone propionate and salmeterol 3

• Patients with hepatic impairment:

  • Close monitoring required as both fluticasone propionate and salmeterol are predominantly cleared by hepatic metabolism 3

Common Pitfalls to Avoid

• Underestimating severity by failing to use objective measurements 1, 2
• Overreliance on bronchodilators without adequate anti-inflammatory treatment 1, 2
• Delayed administration of systemic corticosteroids during severe exacerbations 1, 2
• Sedation in acute asthma 2

Monitoring and Follow-Up

• Regular review of inhaler technique, adherence, and symptom control 1, 2
• Follow-up within 24-48 hours after acute exacerbations 1, 2
• Consider stepping down treatment when stable for 3 months 1, 2
• Monitor for potential side effects of medications, particularly with higher doses of inhaled corticosteroids 1
• Patients should not be discharged from hospital until symptoms have stabilized with PEF >75% of predicted/personal best 2