Adult Asthma Maintenance Management and Peak Flow Meter Use
For adult asthma maintenance, a stepwise approach is recommended with inhaled corticosteroids (ICS) as the cornerstone of therapy, starting with low-dose ICS for mild persistent asthma and adding long-acting beta-agonists (LABA) for moderate persistent asthma, while peak flow meters should be used regularly to monitor lung function and guide treatment adjustments. 1
Stepwise Approach to Asthma Maintenance
- For mild intermittent asthma, use as-needed short-acting β2-agonists (SABA) for symptom relief 1
- For mild persistent asthma, low-dose inhaled corticosteroids (ICS) are recommended as first-line controller medication 1, 2
- Standard daily dose of ICS is defined as 200-250 μg of fluticasone propionate or equivalent, which achieves 80-90% of maximum therapeutic benefit 3
- For moderate persistent asthma not controlled on low-dose ICS, add a long-acting beta-agonist (LABA) rather than increasing ICS dose 1, 4
- Combination ICS/LABA in a single inhaler represents a safe, effective, and convenient treatment option for patients unstable on ICS alone 4
- Once asthma is under full control, consider reducing the dose of ICS, which is possible in many patients 4
Peak Flow Meter Use and Monitoring
- Regular monitoring of peak expiratory flow (PEF) is recommended as part of self-management 1
- Measure PEF as a percentage of predicted normal or personal best to assess asthma control 5
- PEF <50% of predicted normal or best indicates severe asthma requiring immediate treatment 5
- PEF <33% of predicted normal or best indicates life-threatening asthma 5
- Measure and record PEF 15-30 minutes after starting treatment and thereafter according to response 5
- Use PEF monitoring to guide treatment decisions, with values <75% of predicted/personal best indicating inadequate control 1
Self-Management Education
- Patients should understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 1
- A written action plan should include clear instructions for medication adjustment based on symptoms and peak flow readings 1
- Self-management plans should include pre-arranged action steps based on symptoms/peak flow and written guidance for medication adjustments 1
- Patients should be educated to recognize worsening symptoms and know when to seek medical attention 1
Common Pitfalls to Avoid
- Overreliance on bronchodilators without anti-inflammatory treatment 1
- Underestimating severity of exacerbations by failing to make objective measurements 5
- Using high-dose ICS when not necessary, as high starting doses show no additional clinical benefit in most efficacy parameters compared to low or moderate doses 2
- Failing to consider potential adverse effects with long-term use of high-dose ICS 1
- Not recognizing patients with difficult-to-control asthma who may need specialist referral 6
Special Considerations
- Some patients have instability of their asthma with unpredictable exacerbations ("brittle asthma") requiring specialized management 6
- Patients with difficult-to-control asthma should be assessed for poor adherence, unidentified triggers, or comorbidities 6
- For patients with catastrophic sudden, severe asthma, a personalized management plan should be developed with the patient, general practitioner, and specialist 5
- Once-daily administration of ICS is generally not as effective as twice-daily dosing 7
- Continuous administration of ICS does not change the natural history of asthma but is well tolerated in low to medium doses over many years 7