What are the guidelines for managing asthma?

Asthma Management Guidelines

Stepwise Treatment Framework

Asthma management follows a stepwise approach where treatment intensity matches disease severity, with the goal of achieving symptom control using the lowest effective medication doses while preventing exacerbations. 1, 2

Mild Intermittent Asthma

• Use short-acting β2-agonists (SABA) as needed for symptom relief only 1, 2
• No regular controller medication is required 1, 2

Persistent Asthma

• Initiate inhaled corticosteroids as the cornerstone of preventive treatment 2
• Use the lowest dose that provides acceptable symptom control 2
• Add long-acting β2-agonists (LABA) if inadequate control on low-dose inhaled steroids 2
• Before escalating therapy, verify proper inhaler technique, ensure good medication adherence, and confirm full understanding of management principles 2

Acute Severe Asthma Recognition and Management

Severe Features (Immediate Treatment Required)

• Too breathless to complete sentences in one breath 2, 3
• Respiratory rate >25 breaths/min 1, 2
• Heart rate >110 beats/min 1, 2
• Peak expiratory flow (PEF) <50% of predicted or personal best 1, 2

Life-Threatening Features (Critical Emergency)

• PEF <33% of predicted or personal best 1, 2, 3
• Silent chest 1, 2
• Cyanosis 1, 2
• Feeble respiratory effort 1, 2
• Bradycardia or hypotension 1, 3
• Exhaustion, confusion, or coma 1, 3

Immediate Treatment Protocol

• Administer high-flow oxygen (40-60%) in all cases of acute severe asthma 1
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1, 3
• Systemic corticosteroids: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV immediately 1, 3
• Consider adding short-acting muscarinic antagonist (ipratropium) for additional bronchodilation if limited response 3

Hospital Admission Criteria

Admit patients with any of the following: 1, 2

• Life-threatening features present 1
• Features of acute severe asthma persisting after initial treatment 1
• PEF <33% of predicted/best after treatment 1
• Oxygen saturation <92% in ambient air 3
• Measure arterial blood gases in all patients with severe acute asthma requiring admission 3

Assessment and Monitoring

Objective Measurements Are Mandatory

• Use peak expiratory flow (PEF) measurements to avoid underestimating severity 1
• Failure to objectively assess severity is a common factor in preventable asthma deaths 1
• Regular monitoring of symptoms and peak flow is essential 1, 3

Follow-Up Schedule

• Follow-up within 24-48 hours after acute exacerbations 1, 2
• Regular review of inhaler technique, adherence, and symptom control 1, 2
• Consider stepping down treatment when stable for 3 months 1

Self-Management Education

Provide patients with clear understanding of medication roles: 1, 2

• "Relievers" are bronchodilators for immediate symptom relief 1, 2
• "Preventers" are anti-inflammatory medications (inhaled corticosteroids) for long-term control 1, 2

Written action plan must include: 1, 2

• Clear instructions for medication adjustment based on specific triggers 2
• When to increase inhaled steroids 2
• When to self-administer oral steroid tablets 2
• PEF thresholds for action 2

Specialist Referral Indications

Refer to respiratory physician for: 2, 3

• Diagnostic uncertainty 2, 3
• Possible occupational asthma 2, 3
• Continuing symptoms despite high-dose inhaled steroids 2
• Patients requiring or likely to require systemic corticosteroids 2

Pediatric-Specific Considerations

Age 0-2 Years

• Diagnose based on symptoms rather than objective testing 2
• Trial bronchodilator response 2
• Age-appropriate salbutamol dosing: 2.5 mg 1

Age 3-4 Years

• Use large-volume spacer devices 2
• Use nebulizers judiciously 2

Age ≥5 Years

• Can typically use peak flow meters for monitoring 1, 2
• Should carry and be responsible for their own inhalers at school 2
• Age-appropriate salbutamol dosing: 5 mg 1

Growth Monitoring

• Monitor growth in all pediatric patients receiving inhaled corticosteroids, as they may cause reduction in growth velocity 4
• Titrate each patient to the lowest strength that effectively controls asthma 4
• Weigh potential growth effects against clinical benefits obtained 4

Critical Pitfalls to Avoid

Common errors that worsen outcomes: 1, 2, 3

• Underestimating severity by failing to use objective measurements 1
• Overreliance on bronchodilators without adequate anti-inflammatory treatment 1
• Delayed administration of systemic corticosteroids during severe exacerbations 1
• Sedatives are absolutely contraindicated in asthmatic patients as they worsen respiratory depression 2, 3
• Antibiotics should only be administered if bacterial infection is clearly present, not for elevated inflammatory markers alone 2

Special Populations

Geriatric Patients

• Exercise special caution with concomitant cardiovascular disease when using β2-agonists 4
• Higher incidence of serious adverse events, particularly pneumonia with combination therapy 4
• No dosage adjustment warranted based on age alone 4

Hepatic Impairment

• Both fluticasone propionate and salmeterol are predominantly cleared by hepatic metabolism 4
• Monitor closely as impaired liver function may lead to drug accumulation 4

Catastrophic Sudden Severe Asthma

• Requires management plan mutually agreed upon by patient, GP, and consultant 1