What are the guidelines for using inhalers in asthma management?

Asthma Inhaler Management Guidelines

Core Inhaler Strategy

All patients with persistent asthma requiring bronchodilator use more than once daily should be on regular inhaled corticosteroids (ICS) as the foundation of treatment, combined with short-acting beta-agonists for symptom relief. 1, 2

Stepwise Approach to Inhaler Therapy

Mild-to-Moderate Asthma (Ages 12+ years)

• Start with ICS at appropriate dosing (fluticasone 100-250 mcg or equivalent twice daily) 3
• Add short-acting beta-agonist (salbutamol 5 mg or terbutaline 10 mg) for "as needed" symptom relief 1
• If control inadequate, escalate ICS dose or add long-acting beta-agonist (LABA) rather than continuing to increase ICS alone 2, 4

Moderate-to-Severe Asthma

• Use combination ICS/LABA therapy (e.g., fluticasone/salmeterol 250/50 or 500/50 twice daily) for optimal control 3, 4
• The combination addresses complementary pathophysiology: ICS suppresses inflammation while LABA provides bronchodilation and inhibits mast cell mediator release 4
• Never use LABA as monotherapy - this increases risk of serious asthma-related events 3

Pediatric Patients (Ages 4-11 years)

• Use fluticasone/salmeterol 100/50 one inhalation twice daily 3
• For acute episodes, use metered-dose inhaler (MDI) with large volume spacer: give one puff every few seconds up to maximum 20 puffs 1
• Face masks recommended for very young children 1

Critical Inhaler Technique Requirements

Proper inhaler technique is essential and must be verified before discharge from any acute care setting. 1, 5

• Check and document inhaler technique at every clinical encounter 1
• Transition from nebulizers to standard inhaler devices 24-48 hours before hospital discharge (unless home nebulizer required) 1
• Consider alternative inhaler devices if technique inadequate 1, 5
• Instruct patients to rinse mouth with water after ICS use to reduce oral candidiasis risk 3

Acute Exacerbation Management

Immediate Treatment

• High-dose inhaled beta-agonists first-line: salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer, OR 2 puffs from MDI repeated 10-20 times into large spacer 1
• Systemic corticosteroids immediately: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 1
• If life-threatening features present (PEF <33% predicted, silent chest, confusion): add ipratropium 0.5 mg nebulized 1

Hospital Discharge Requirements

All patients discharged after acute asthma must receive: 1

• Prednisolone 30+ mg daily for 1-3 weeks with written action plan
• Inhaled steroids at HIGHER dosage than pre-admission
• Inhaled beta-agonists for "as necessary" use
• Additional bronchodilators (theophylline, long-acting beta-agonists, ipratropium) if required

Self-Management and Monitoring

Every patient must have a peak flow meter and written self-management plan upon discharge. 1

• Teach patients specific PEF values to: increase treatment, call physician, or self-admit to hospital 1
• Discharge criteria: PEF >75% predicted/best, diurnal variability <25%, no nocturnal symptoms 1
• Follow-up with general practitioner within one week and respiratory physician within one month 1

Common Pitfalls to Avoid

Do not combine Wixela Inhub (or similar ICS/LABA combinations) with additional LABA-containing medications - risk of overdose 3

Never use ICS/LABA for acute symptom relief - these are controller medications only, not rescue therapy 3

Do not stop or taper prednisolone if asthma worsening - this must be emphasized to patients 1

Monitor for pneumonia in COPD patients using ICS/LABA combinations 3

Special Considerations

• Severe hypersensitivity to milk proteins is a contraindication to dry powder inhalers like Wixela Inhub 3
• Long-term ICS use requires monitoring for: adrenal suppression, decreased bone mineral density, growth suppression in children, glaucoma, and cataracts 3
• Patients transferring from systemic corticosteroids require slow taper to avoid adrenal insufficiency 3