What is the recommended approach for managing asthma?

Asthma Management Approach

Asthma management follows a stepwise approach based on disease severity and control, with inhaled corticosteroids (ICS) as the cornerstone of therapy for persistent asthma, short-acting beta-agonists (SABAs) for all patients as rescue medication, and systematic escalation or de-escalation based on symptom control and exacerbation risk. 1

Initial Assessment and Classification

Severity Assessment (Treatment-Naive Patients)

• Classify asthma severity before initiating therapy to determine the appropriate starting step, using frequency of symptoms, nighttime awakenings, SABA use, interference with normal activity, and lung function (spirometry for patients ≥5 years) 1
• Distinguish between current impairment (symptom frequency, functional limitations) and future risk (likelihood of exacerbations, progressive lung function decline) as separate domains that guide treatment decisions 1

Control Assessment (Patients Already on Therapy)

• Once treatment is initiated, shift focus from severity to control assessment, which determines whether to maintain, step up, or step down therapy 1
• Monitor SABA use as a key control indicator: use >2 days/week for symptom relief (excluding exercise-induced bronchospasm prevention) indicates inadequate control and need to step up 1

Stepwise Pharmacological Management (Patients ≥12 Years)

Step 1: Intermittent Asthma

• Prescribe SABA as needed only (no daily controller medication required) 1

Step 2: Mild Persistent Asthma

• Preferred: Low-dose ICS daily (fluticasone propionate 100-250 μg/day or equivalent) 1, 2
• Alternative options: Cromolyn, leukotriene receptor antagonist (LTRA), nedocromil, or theophylline (requires serum monitoring) 1
• Consider subcutaneous allergen immunotherapy for patients with documented allergic asthma 1

Step 3: Moderate Persistent Asthma

• Preferred: EITHER low-dose ICS + long-acting beta-agonist (LABA) OR medium-dose ICS alone (fluticasone propionate >250-500 μg/day or equivalent) 1
• Critical safety warning: LABAs must NEVER be used as monotherapy—FDA black-box warning mandates combination with ICS only 1
• Alternative options: Low-dose ICS + LTRA, theophylline, or zileuton (zileuton requires liver function monitoring and has limited evidence) 1

Step 4: Moderate-to-Severe Persistent Asthma

• Preferred: Medium-dose ICS + LABA 1
• Alternative options: Medium-dose ICS + LTRA, theophylline, or zileuton 1
• Evidence strongly favors adding LABA over increasing ICS dose: Adding salmeterol to low-dose ICS provides 41% lower odds of exacerbations compared to doubling ICS dose, with better medication adherence 3

Step 5: Severe Persistent Asthma

• Preferred: High-dose ICS + LABA (fluticasone propionate >500 μg/day or equivalent) 1
• Add omalizumab (anti-IgE therapy) for patients ≥12 years with documented IgE-mediated allergic asthma (positive skin test or RAST) and inadequate control on high-dose ICS 1
• Omalizumab reduces exacerbations with NNT of 6 for protocol-defined exacerbations 1

Step 6: Severe Refractory Asthma

• Preferred: High-dose ICS + LABA + oral corticosteroid 1
• Continue omalizumab for patients with allergic asthma 1
• Before adding oral corticosteroids, consider trial of high-dose ICS + LABA + LTRA, theophylline, or zileuton, though this approach lacks clinical trial evidence 1

Critical Dosing Principles

ICS Dose-Response Relationship

• The "low-dose" ICS range (200-250 μg fluticasone propionate equivalent) achieves 80-90% of maximum therapeutic benefit in adult asthma across severity spectrum 2
• Minimal additional benefit occurs at doses >500 μg/day, with substantially increased risk of systemic adverse effects (growth suppression in children, reduced bone mineral density in adults) 1, 2
• Prioritize adding adjunctive therapy (LABA, LTRA) over escalating ICS to high doses to optimize benefit-risk ratio 1

Stepping Down Therapy

• Step down therapy when asthma is well-controlled for ≥3 months to minimize exposure to higher medication doses and reduce adverse effect risk 1
• Before stepping up, always verify medication adherence, proper inhaler technique, environmental trigger control, and management of comorbid conditions 1

Acute Exacerbation Management

Severity Assessment

• Severe exacerbation indicators: inability to complete sentences in one breath, respiratory rate >25/min, heart rate >110/min, PEF <50% predicted 1, 4, 5
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, coma 1, 5
• Measure arterial blood gases in hospitalized patients: normal or elevated PaCO2 (>6 kPa), severe hypoxia (PaO2 <8 kPa), or low pH indicates life-threatening attack 1

Immediate Treatment

• High-dose inhaled beta-agonist: Salbutamol 5 mg or terbutaline 10 mg via nebulizer with oxygen, OR 4-12 puffs (2 puffs 10-20 times) via MDI with spacer every 20-30 minutes for three doses 1, 4
• High-dose systemic corticosteroids immediately: Prednisolone 30-60 mg PO or hydrocortisone 200 mg IV 1, 4, 5
• For life-threatening features, add ipratropium 0.5 mg nebulized (or 8 puffs via MDI) to each beta-agonist treatment 1, 4
• For life-threatening features, consider IV aminophylline 250 mg over 20 minutes (avoid if patient already taking oral theophyllines) or IV salbutamol/terbutaline 250 μg over 10 minutes 1

Hospitalization Criteria

• Immediate hospital referral required for: any life-threatening features, severe attack features persisting after initial treatment, PEF <33% predicted 15-30 minutes post-nebulization, oxygen saturation <92% on room air 1, 4, 5
• Lower threshold for admission: patients seen afternoon/evening, recent nocturnal symptom onset, previous severe attacks (especially rapid onset), concerns about symptom assessment accuracy, inadequate social support 1

Hospital Management

• Continue oxygen therapy and monitor PEF every 15-30 minutes initially 1
• Continue high-dose steroids: prednisolone 30-60 mg daily or IV hydrocortisone 200 mg every 6 hours 1
• If improving, give nebulized beta-agonist every 4 hours; if not improving after 15-30 minutes, increase frequency to every 15 minutes 1
• Obtain chest X-ray to exclude pneumothorax, consolidation, or pulmonary edema 1

Discharge Criteria and Follow-Up

• Do not discharge until: PEF >75% predicted or personal best, diurnal variability <25%, no nocturnal symptoms 1
• Discharge medications: prednisolone 30-60 mg daily for 1-3 weeks (NOT the insufficient 5-6 day Medrol dose pack), increased dose of inhaled corticosteroids, SABA as needed 1, 4
• Provide peak flow meter and written asthma action plan 4
• Schedule primary care follow-up within 1 week and respiratory specialist within 4 weeks 4

Universal Management Principles (All Steps)

Patient Education and Self-Management

• Provide education on: proper inhaler technique, difference between "reliever" (bronchodilator) and "preventer" (anti-inflammatory) medications, recognition of worsening symptoms (especially nocturnal), peak flow monitoring 1
• Develop written asthma action plan with three elements: symptom/peak flow monitoring, prearranged patient-initiated actions, written guidance for medication adjustments 1
• Empower patients to self-initiate oral corticosteroids when PEF falls below predetermined threshold or <60% normal 1

Environmental Control and Trigger Avoidance

• Identify and avoid specific triggers at every step: allergens (pollens, animal dander, molds, house dust), respiratory infections, emotional stress, exercise, irritating gases (smoke, perfumes, chlorine), temperature/humidity changes 1, 6
• For house dust sensitivity: remove feather pillows, mattresses, quilts, carpets from bedroom; use allergen-proof covers 6
• Air quality measures: air conditioning, electrostatic filters, or HEPA filters 6

Comorbidity Management

• Address comorbid conditions that worsen asthma control at every step 1
• Avoid aspirin and NSAIDs in aspirin-sensitive patients 6

Critical Pitfalls to Avoid

Medication Errors

• Never use LABAs as monotherapy—always combine with ICS due to increased mortality risk 1
• Do not prescribe antibiotics unless clear bacterial infection is documented 1, 4, 5
• Never use sedatives in asthma exacerbations—they are absolutely contraindicated and worsen respiratory depression 1, 5
• Avoid insufficient oral corticosteroid duration: 5-6 day courses are inadequate; prescribe 1-3 weeks for exacerbations 4

Clinical Management Errors

• Do not underestimate attack severity—objective measurements (PEF, vital signs) are essential as patients and physicians frequently misjudge severity 1
• Percussive chest physiotherapy is unnecessary and should not be performed 1
• Do not discharge patients who smoke or allow exposure to secondhand smoke without intensive counseling 6