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
• Severity assessment should include evaluation of symptom frequency, PEF measurements, and rescue medication use 2

Stepwise Management Approach

• Step 1: For mild intermittent asthma, use as-needed short-acting β2-agonists (SABA) for symptom relief with no regular controller medication required 1, 3
• Step 2: For persistent symptoms, add regular low-dose inhaled corticosteroids (ICS) as first-line controller therapy 3
• Step 3: For inadequate control on low-dose ICS, add long-acting β2-agonists (LABA) 3
• Step 4: For persistent symptoms despite Step 3 therapy, increase to medium-dose ICS plus LABA 3
• Step 5: For severe persistent asthma, high-dose ICS plus LABA with consideration of add-on therapies 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, 3
• 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 includes:
  • High-flow oxygen (40-60%) 1, 2
  • Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1, 2
  • Systemic corticosteroids: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1, 2
  • Consider adding ipratropium bromide for additional bronchodilation if response is limited 2

Hospital Admission Criteria

• Patients with life-threatening features should be admitted immediately 1, 3
• Patients with severe features persisting after initial treatment require admission 1, 3
• PEF <33% of predicted/best after treatment warrants admission 1, 3
• Lower threshold for admission should be applied for evening presentations, recent nocturnal symptoms, or previous severe attacks 3

Self-Management Education

• Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 1, 3
• A written action plan should include clear instructions for medication adjustment based on symptoms or peak flow readings 1, 3
• Regular monitoring of symptoms and peak flow is recommended for ongoing assessment 1, 3

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
• Growth monitoring is essential in children receiving inhaled corticosteroids 4
• A 52-week study showed reduced growth velocity in children receiving fluticasone propionate compared to placebo 4

Elderly Patients

• Special caution is needed in geriatric patients with concomitant cardiovascular disease that could be affected by beta2-agonists 4
• Elderly patients (≥65 years) have a higher risk of pneumonia with ICS/LABA combinations 4

Comorbidities

• Patients with hepatic impairment should be monitored closely as both fluticasone propionate and salmeterol are predominantly cleared by hepatic metabolism 4
• Gastroesophageal reflux, upper airway disease, and other systemic diseases should be identified and treated as they may exacerbate asthma 5

Common Pitfalls to Avoid

• Underestimating severity by failing to use objective measurements 1, 3
• Overreliance on bronchodilators without adequate anti-inflammatory treatment 1, 3
• Delayed administration of systemic corticosteroids during severe exacerbations 1, 3
• Using sedatives in asthmatic patients, which are contraindicated and can worsen respiratory depression 2
• Administering antibiotics unless a bacterial infection is clearly present 2

Monitoring and Follow-Up

• Regular review of inhaler technique, adherence, and symptom control is recommended 1
• Follow-up within 24-48 hours after acute exacerbations 1, 3
• 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