What is the treatment for recurrent bronchial asthma attacks?

Treatment of Recurrent Bronchial Asthma Attacks

For recurrent asthma attacks, initiate or intensify daily inhaled corticosteroid (ICS) therapy as the foundation of treatment, combined with short-acting beta-agonists for acute symptom relief, and add oral corticosteroids (30-40 mg prednisolone daily for 7-21 days) for moderate to severe exacerbations. 1

Immediate Management of Acute Exacerbations

Acute Attack Treatment:

• Administer prednisolone 30-40 mg daily (or 40-60 mg in adults) until lung function returns to baseline, typically 7-21 days depending on severity 1, 2
• Oral corticosteroids are equally effective as intravenous administration and should be the preferred route 1, 2
• No tapering is required for courses under 2 weeks 1, 2
• Provide repetitive or continuous short-acting beta-agonists via nebulizer or large-volume spacer device depending on severity 1
• Maintain oxygen saturation >90% 2

Critical Pitfall: Doubling ICS doses during exacerbations is ineffective and should be avoided 2

Long-Term Controller Therapy to Prevent Recurrence

Step-Up Approach Based on Severity:

For Mild Persistent Asthma (Step 2):

• Low-dose ICS is the most effective single long-term control medication 1, 3
• Alternative: As-needed low-dose ICS-formoterol combination significantly reduces moderate-to-severe exacerbations compared with SABA monotherapy 4

For Moderate Persistent Asthma (Step 3):

• Preferred: Low-to-medium-dose ICS plus long-acting beta-agonist (LABA) 1, 3
• This combination demonstrates synergistic anti-inflammatory effects equivalent to or better than doubling the ICS dose 4
• Alternative: Increase ICS within medium-dose range, or add leukotriene receptor antagonist or theophylline 1

For Severe Persistent Asthma (Step 4-5):

• High-dose ICS plus LABA is the preferred treatment 1
• Consider adding a third controller medication (leukotriene modifier, theophylline, or triple combination inhaler) 1, 4
• Low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) may be added as a last resort 4
• Biologic therapy should be considered for severe type 2 asthma uncontrolled on Step 5 treatment 4

Key Monitoring Indicators

Triggers for Treatment Intensification:

• SABA use more than 2-3 times daily (excluding exercise-induced bronchospasm prevention) indicates inadequate control 1
• Peak expiratory flow dropping below 60% of patient's best 1
• Sleep disturbance extending to midday 1
• Diminishing response to inhaled bronchodilators 1

Essential Follow-Up:

• Schedule visits every 2-4 weeks after initial therapy, then every 1-3 months if responding 4
• Verify correct inhaler technique at every visit—this is critical for medication effectiveness 3, 4
• Check compliance before any treatment increase 1

Critical Safety Considerations

LABA Safety Warning:

• Never use LABAs as monotherapy—they must always be combined with ICS, as monotherapy increases risk of asthma exacerbations and death 1, 3

Corticosteroid Monitoring:

• Long-term high-dose ICS (>800 mcg beclomethasone equivalent) may cause systemic effects including adrenal suppression, osteoporosis, and increased pneumonia risk 4
• Use large-volume spacer devices with doses >800 mcg to reduce local and systemic adverse effects 1
• Monitor elderly patients more closely for gastrointestinal bleeding risk, especially those with prior bleeding history or on anticoagulants 1, 2

Additional Therapeutic Considerations

Adjunctive Therapies:

• For severe non-type 2 asthma unresponsive to standard therapy, consider azithromycin 250-500 mg three times weekly for 26-48 weeks to reduce exacerbations 4
• Bronchial thermoplasty may be indicated for adults with uncontrolled asthma despite optimized treatment when biologics are unavailable or inappropriate 4

Patient Education:

• Provide written asthma action plans instructing patients to recognize early warning signs and adjust medications accordingly 1
• Identify and control environmental triggers (allergens, smoking, occupational exposures) 1
• Patient education improves knowledge, behavior, and reduces hospitalizations 1

Referral Indications:

• Diagnostic uncertainty 1
• Suspected occupational asthma 1
• Persistent symptoms despite Step 4 treatment with correct technique and adherence 4
• Risk factors for asthma-related death (history of intubation, recent hospitalization, overuse of SABA, psychiatric illness, poor adherence) 4