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 is essential for effective asthma management, including objective measurements such as peak expiratory flow (PEF) to avoid underestimating severity 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
- For mild persistent asthma: add low-dose inhaled corticosteroids (ICS) as first-line controller medication 2
- For moderate persistent asthma: use inhaled steroids along with long-acting beta agonists for symptom control 2
- For severe persistent asthma: use inhaled steroids, long-acting beta agonists with or without theophylline; minimal doses of oral prednisolone may be needed in some patients 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, 4, 2
- Severe features include: inability to complete sentences in one breath, respiratory rate >25/min, pulse >110/min, PEF <50% of predicted/best 1, 4, 2
- Immediate management of acute severe asthma requires:
Hospital Admission Criteria
- Patients with life-threatening features of acute asthma exacerbation 1
- Patients with features of acute severe asthma persisting after initial treatment 1
- Patients with PEF <33% of predicted/best after treatment 1
- Lower threshold for admission in evening presentations, recent nocturnal symptoms, or previous severe attacks 2
Self-Management Education
- Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 1, 2
- A written action plan with clear instructions for medication adjustment should be provided 1, 2
- Regular monitoring of symptoms and peak flow is recommended 1, 2
Special Considerations
Pediatric Asthma
- 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 5
- Growth velocity may be reduced with higher doses of inhaled corticosteroids 5
Geriatric Patients
- Special caution should be observed in geriatric patients with concomitant cardiovascular disease that could be affected by beta2-agonists 5
- Older patients with COPD may have a higher risk of pneumonia with fluticasone propionate and salmeterol inhalation powder 5
Monitoring and Follow-Up
- Regular review of inhaler technique, adherence, and symptom control is recommended 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
Common Pitfalls to Avoid
- Underestimating severity by failing to use objective measurements 1
- Overreliance on bronchodilators without adequate anti-inflammatory treatment 1, 2
- Delayed administration of systemic corticosteroids during severe exacerbations 1, 2
- Use of sedatives in asthmatic patients (contraindicated as they can worsen respiratory depression) 4
- Antibiotics should only be administered if a bacterial infection is clearly present 4
Treatment of Difficult-to-Control Asthma
- Approximately 5% of patients are not controlled even on high doses of inhaled corticosteroids 6
- For these patients, consider: