Treatment of Reactive Airway Disease
Begin treatment with a short-acting beta agonist (SABA) as needed for all patients with reactive airway disease, and immediately initiate low-dose inhaled corticosteroids (ICS) if SABA use exceeds twice weekly, as this indicates inadequate control requiring controller therapy. 1
Initial Management
- Start all patients on a short-acting beta agonist for quick symptom relief, regardless of severity 1
- Assess symptom frequency and severity at presentation to determine the appropriate treatment step 1
- Address patient education, environmental control measures, and comorbidities at every clinical encounter 1
Stepwise Treatment Algorithm
Intermittent Symptoms
- Use inhaled SABA as needed only 1
- Monitor SABA use carefully—using it more than twice weekly signals inadequate control and mandates stepping up therapy 1
Mild Persistent Symptoms
- Low-dose inhaled corticosteroid is the preferred first-line controller medication 1
- Alternative options include leukotriene receptor antagonists, cromolyn, nedocromil, or theophylline if ICS cannot be used 1
- The standard effective ICS dose is 200-250 μg of fluticasone propionate or equivalent, which achieves 80-90% of maximum therapeutic benefit 2
Treatment Adjustments
- Before stepping up therapy, verify medication adherence, environmental control measures, and assess for comorbid conditions 1
- Step up treatment if control remains inadequate after addressing these factors 1
- Consider stepping down treatment only after asthma is well-controlled for at least three consecutive months 1
- Using SABA more than two days per week for symptom relief generally indicates inadequate control requiring escalation 1
Pediatric Considerations
- Apply the same stepwise approach in children with adjusted dosing 1
- Low-dose ICS remains the preferred treatment for mild persistent symptoms in pediatric patients 1
Critical Pitfalls to Avoid
- Do not allow patients to rely solely on short-acting beta agonists without addressing underlying inflammation with controller medications 1
- Recognize that persistent symptoms requiring frequent SABA use demand controller therapy, not just increased rescue medication 1
- Do not delay stepping up therapy when symptoms remain inadequately controlled despite proper adherence 1
- Evaluate for allergic components that may benefit from specific targeted therapies 1
- Avoid prescribing unnecessarily high ICS doses, as doses above 200-250 μg fluticasone propionate equivalent provide minimal additional benefit but significantly increase systemic adverse effects 2
Special Clinical Scenarios
For post-viral reactive airway disease (such as after RSV bronchiolitis), leukotriene receptor antagonists like montelukast may reduce lung symptoms and delay exacerbations, as cysteinyl-leukotrienes are released during viral infections and contribute to inflammation 3