What are the goals of care and treatment medications with doses for asthma management?

Asthma Treatment Protocol: Goals of Care and Medications with Doses

Goals of Asthma Therapy

The primary goals are to minimize chronic symptoms, maintain normal pulmonary function, prevent exacerbations, and avoid medication adverse effects while allowing patients to maintain normal activities without limitations. 1

Specific measurable goals include:

• Minimal or no chronic symptoms day or night 1
• Maintain near-normal pulmonary function 1
• No limitations on activities (work, school, exercise) 1
• Minimal or no exacerbations 1
• Minimal use of short-acting beta-agonists (SABA) - using approximately one canister per month or less 1
• No missed school or work days 1
• Minimal or no adverse effects from medications 1

Stepwise Medication Approach

Step 1: Intermittent Asthma

Quick-relief medication only:

• Short-acting beta-agonist (albuterol): 2-4 puffs as needed for symptoms 1
• No daily controller medication required 2
• If SABA use exceeds 2 times per week, escalate to Step 2 1, 3

Step 2: Mild Persistent Asthma

Preferred controller therapy:

• Low-dose inhaled corticosteroid (ICS) daily 2, 3

Specific dosing options:

• Fluticasone MDI: 88-264 mcg daily 1
• Fluticasone DPI: 100-300 mcg daily 1
• Budesonide DPI: 200-600 mcg daily (preferred in pregnancy due to more safety data) 1
• Beclomethasone HFA: 80-240 mcg daily 1

Plus:

• SABA as needed for quick relief 1

Step 3: Moderate Persistent Asthma

Preferred controller therapy:

• Low to medium-dose ICS PLUS long-acting beta-agonist (LABA) 2, 3

Alternative option:

• Medium-dose ICS alone 1, 3

Specific dosing:

• Fluticasone/salmeterol combination: 100-250 mcg/50 mcg, 1 inhalation twice daily 4
• Medium-dose ICS ranges:
  • Fluticasone MDI: 264-660 mcg daily 1
  • Budesonide DPI: 600-1,200 mcg daily 1

Critical safety warning: Never use LABA as monotherapy without concurrent ICS - this significantly increases mortality risk 3

Plus:

• SABA as needed 1

Step 4: Severe Persistent Asthma

Preferred controller therapy:

• High-dose ICS PLUS LABA 2

Specific dosing:

• Fluticasone/salmeterol: 250-500 mcg/50 mcg, 1 inhalation twice daily 4
• High-dose ICS ranges:
  • Fluticasone MDI: >660 mcg daily 1
  • Fluticasone DPI: >750 mcg daily 1
  • Budesonide DPI: >1,200 mcg daily 1

Additional controller options to consider:

• Leukotriene receptor antagonist (montelukast or zafirlukast) 1, 2
• Allergen immunotherapy for allergic asthma (ages 5+ years) 1, 2

Plus:

• SABA as needed 1

Refer to asthma specialist at this step 1

Steps 5-6: Severe Uncontrolled Asthma

Add to Step 4 regimen:

• Omalizumab (anti-IgE biologic) for allergic asthma in patients ≥12 years 1, 2
• Consider oral corticosteroids if necessary, but minimize due to systemic effects 1

Mandatory specialist referral 1

Acute Exacerbation Management

Moderate to Severe Exacerbation Features:

• Respiratory rate >25 breaths/min 1
• Heart rate >110 beats/min 1
• Peak expiratory flow <50% predicted 1
• Too breathless to complete sentences 1

Immediate treatment:

• High-dose nebulized SABA: albuterol 5 mg or terbutaline 10 mg via nebulizer with oxygen 1
• Alternative: 10-20 puffs (2 puffs × 10-20 times) of SABA via metered-dose inhaler with spacer 1
• Systemic corticosteroids: prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV immediately 1, 2
• Repeat nebulized SABA every 20 minutes up to 3 treatments 1

Life-Threatening Features:

• Peak expiratory flow <33% predicted 1
• Silent chest, cyanosis, or feeble respiratory effort 1
• Normal or elevated PaCO2 (5-6 kPa) in breathless patient 1
• Severe hypoxia: PaO2 <8 kPa 1

Add to above treatment:

• Ipratropium bromide 0.5 mg nebulized with beta-agonist 1
• IV aminophylline 250 mg over 20 minutes OR IV salbutamol/terbutaline 250 mcg over 10 minutes 1
• Do NOT give bolus aminophylline if patient already taking oral theophyllines 1

Monitoring and Adjustment Criteria

Step Up Therapy When:

• SABA use >2 times per week (excluding exercise prophylaxis) 1, 3
• Nighttime awakenings >2 nights per month 3
• Any exacerbation requiring oral corticosteroids 1
• Peak flow or FEV1 declining 1

Step Down Therapy When:

• Asthma well-controlled for at least 3 months 1, 5
• Review every 3-6 months for possible reduction 1
• Gradual stepwise reduction to minimum medication needed 1, 5

Critical pitfall: Completely stopping ICS or LABA increases exacerbation risk - always taper gradually 5

Follow-Up Schedule

• Every 1-6 weeks while gaining control 1
• Every 1-6 months once controlled (depending on step of care) 1
• Every 3 months if step-down anticipated 1

Comorbidity Management

Address conditions that worsen asthma control:

• Allergic rhinitis and sinusitis 1, 3
• Gastroesophageal reflux disease (GERD) 1
• Obesity 1
• Obstructive sleep apnea 1

Preventive care:

• Annual inactivated influenza vaccine for all patients with persistent asthma 1, 2, 3

Special Considerations

Pregnancy:

• Budesonide is preferred ICS due to more safety data 1
• Albuterol is preferred SABA due to more safety data 1
• Continue asthma medications - uncontrolled asthma poses greater risk than medications 1

Exercise-Induced Bronchoconstriction:

• SABA 15-30 minutes before exercise 2
• If symptoms persist despite overall asthma control, consider adding LABA or leukotriene modifier 2