What is the recommended initial management plan for a patient with bronchial asthma?

Initial Management Plan for Bronchial Asthma

The recommended initial management plan for bronchial asthma includes inhaled corticosteroids as the cornerstone of therapy, with short-acting beta-agonists for symptom relief, and a written self-management plan for the patient. 1

Assessment and Classification

• Assess severity of asthma based on symptoms, peak expiratory flow (PEF), and response to previous treatment 1
• Classify asthma as mild, moderate, or severe based on clinical features:
  • Severe: Cannot complete sentences in one breath, respirations >25/min, pulse >110 beats/min, PEF <50% of predicted 1
  • Life-threatening: PEF <33% of predicted, silent chest, cyanosis, bradycardia, hypotension, exhaustion, confusion, or coma 1

Initial Pharmacological Management

For Mild to Moderate Persistent Asthma:

• Start with inhaled corticosteroids (up to 800 μg/day equivalent of beclomethasone) as the primary anti-inflammatory therapy 1, 2
• Prescribe short-acting inhaled beta2-agonist (e.g., salbutamol) as needed for symptom relief 1
• Consider adding long-acting beta2-agonists if symptoms persist despite adequate doses of inhaled corticosteroids 1, 3

For Acute Severe Asthma:

• Administer oxygen 40-60% (oxygen therapy is not contraindicated in asthma) 1
• Give nebulized salbutamol 5-10 mg or terbutaline 5-10 mg via oxygen-driven nebulizer 1
• Administer oral prednisolone 30-60 mg or intravenous hydrocortisone 200 mg 1
• Consider adding ipratropium bromide 0.5 mg to nebulizer if patient is not improving after 15-30 minutes 1

Monitoring and Follow-up

• Measure PEF before and after bronchodilator administration to assess response 1
• Maintain oxygen saturation >92% using pulse oximetry 1
• Schedule follow-up within one week with primary care physician after any acute episode 1
• Arrange follow-up with respiratory specialist within 4 weeks if hospitalized 1

Patient Education and Self-Management

• Provide a written asthma action plan detailing:
  • When to increase treatment
  • When to seek medical help
  • How to adjust medications based on symptoms and PEF readings 1
• Prescribe a peak flow meter and teach proper technique 1
• Educate about proper inhaler technique and check at each visit 1
• Identify and avoid triggers (allergens, smoking, etc.) 1

Medication Delivery Devices

• Start with metered dose inhaler (MDI) for most patients 1
• Add large volume spacer if patient has difficulty using MDI alone 1
• Consider dry powder or automatic aerosol inhaler if patient finds MDI with spacer difficult to carry 1

Special Considerations

• Avoid sedatives in patients with asthma attacks 1
• Consider chest radiograph to exclude pneumothorax in severe cases 1
• For children: adjust medication doses appropriately (half doses of nebulized medications for very young children) 1
• Monitor growth in pediatric patients on long-term inhaled corticosteroids 4

Common Pitfalls to Avoid

• Underestimating severity: Any features of severe asthma should alert the clinician, even if the patient does not appear distressed 1
• Inadequate follow-up: All patients require monitoring after an acute episode 1
• Poor inhaler technique: Check and document proper technique at each visit 1
• Overreliance on bronchodilators: If using more than one canister of short-acting beta-agonist per month, increase controller therapy 1
• Failure to provide a written action plan: All patients should have a written self-management plan 1

By following this structured approach to asthma management, focusing on both anti-inflammatory therapy and bronchodilation as needed, most patients can achieve good symptom control and minimize exacerbations.