What are the guidelines for managing asthma?

Asthma Management Guidelines

Stepwise Treatment Approach

Asthma management follows a stepwise approach where treatment intensity is matched to disease severity, with the primary goal of achieving minimal symptoms, no nighttime awakenings, full participation in activities, and infrequent need for rescue medications. 1, 2

Chronic Asthma Management

Step 1 (Mild Intermittent):

• Use short-acting β2-agonists (SABA) as needed for symptom relief only 2
• No regular controller medication required 2

Step 2 and Beyond (Persistent Asthma):

• Initiate inhaled corticosteroids as the cornerstone of preventive treatment 3
• Use the lowest dose that provides acceptable symptom control 3
• Add long-acting β2-agonists (LABA) for inadequate control on low-dose inhaled steroids 1
• Consider additional controllers (montelukast, theophylline) if needed 4

Key Management Principles

Before escalating therapy, verify three critical factors:

• Proper inhaler technique for the patient's age 3
• Good medication adherence 4
• Full understanding of management principles by patient/family 3

Common pitfall: Overreliance on bronchodilators without adequate anti-inflammatory treatment leads to poor outcomes 2

Acute Severe Asthma Management

Severity Assessment

Severe asthma features (any of the following): 3, 1, 2

• Too breathless to complete sentences in one breath
• Respiratory rate >25 breaths/min
• Heart rate >110 beats/min
• Peak expiratory flow (PEF) <50% of predicted or personal best

Life-threatening features (any of the following): 3, 1, 2

• PEF <33% of predicted or personal best
• Silent chest, cyanosis, or feeble respiratory effort
• Bradycardia or hypotension
• Exhaustion, confusion, or coma
• Normal or elevated PaCO₂ (5-6 kPa or higher) in a breathless patient
• Severe hypoxia: PaO₂ <8 kPa despite oxygen therapy

Critical point: Severity is often underestimated due to failure to make objective measurements—this contributes to preventable asthma deaths 3, 2

Immediate Treatment (Start ALL at Once)

High-dose inhaled β-agonists: 3, 1, 2

• Salbutamol 5 mg OR terbutaline 10 mg
• Deliver via oxygen-driven nebulizer (preferred) or 10-20 puffs via metered-dose inhaler with large-volume spacer

Systemic corticosteroids (give immediately): 3, 1, 2

• Prednisolone 30-60 mg orally OR
• Hydrocortisone 200 mg intravenously OR
• Both

If life-threatening features present, add: 3, 1

• Ipratropium 0.5 mg nebulized with the β-agonist
• IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 µg over 10 minutes
• Do NOT give bolus aminophylline to patients already taking oral theophyllines 3

High-flow oxygen (40-60%): 2

• Administer to all patients with acute severe asthma

Hospital Admission Criteria

Immediate referral to hospital required for: 3, 2

• Any life-threatening features
• Features of severe attack persisting after initial treatment
• PEF <33% of predicted/best after treatment
• PEF 15-30 minutes after nebulization remains <50% 3

In hospital, always measure arterial blood gases for: 3, 1

• Normal or elevated PaCO₂ (indicates very severe, life-threatening attack)
• Severe hypoxia (PaO₂ <8 kPa)
• Low pH or high H⁺

Self-Management Education

Essential Patient Knowledge

Patients must understand: 3, 2

• "Relievers" (bronchodilators) provide immediate symptom relief
• "Preventers" (inhaled corticosteroids) reduce inflammation and prevent attacks
• Nocturnal symptoms indicate worsening asthma requiring action

Written action plan must include: 3, 2

• Monitoring of symptoms, peak flow, and medication usage
• Prearranged actions based on specific triggers (e.g., PEF falling below certain threshold)
• When to increase inhaled steroids
• When to self-administer oral steroid tablets
• When to seek emergency care

Common pitfall: Delayed administration of systemic corticosteroids during exacerbations worsens outcomes 2

Specialist Referral Indications

Refer to respiratory physician for: 3

• Diagnostic uncertainty (especially elderly smokers with wheeze)
• Possible occupational asthma
• Continuing symptoms despite high-dose inhaled steroids
• Patients requiring or likely to require systemic corticosteroids
• Catastrophic sudden severe (brittle) asthma
• Asthma interfering with lifestyle despite treatment changes
• Pregnant women with worsening asthma
• Recent hospital discharge

Pediatric Considerations

Age-Appropriate Devices and Dosing

Children 0-2 years: 3

• Diagnosis relies on symptoms rather than objective testing
• Bronchodilator response variable but should still be tried
• Consider alternative diagnoses (gastroesophageal reflux, cystic fibrosis, chronic lung disease)

Children 3-4 years: 3

• Most cannot coordinate unmodified metered-dose inhalers
• Use large-volume spacer devices
• Nebulizers are overused and often replaceable by spacer devices

Children ≥5 years: 3, 2

• Can typically use peak flow meters for monitoring
• Should carry and be responsible for their own inhalers at school

Growth Monitoring

Inhaled corticosteroids may reduce growth velocity in children: 5

• Monitor height and weight velocities regularly 3
• Use lowest effective dose 3, 5
• Weigh growth effects against clinical benefits obtained 5
• In one study, growth velocity was 5.66 cm/year with fluticasone 100 mcg twice daily vs 6.32 cm/year with placebo 5

Important Precautions

Absolute contraindications: 1, 6

• Sedatives are contraindicated in asthmatic patients—can worsen respiratory depression

Antibiotic use: 1, 6

• Only administer if bacterial infection clearly present
• Not indicated for elevated inflammatory markers alone

Monitoring requirements: 3, 1

• Regular review of inhaler technique, adherence, and symptom control 2
• Follow-up within 24-48 hours after acute exacerbations 2
• Consider stepping down treatment when stable for 3 months 2