Asthma Treatment Guideline
Asthma management requires a stepwise approach with inhaled corticosteroids (ICS) as the foundation of treatment, and short-acting beta-2 agonists (SABA) should never be used alone without regular ICS therapy. 1
Chronic Asthma Management: Stepwise Approach
Initial Treatment Strategy
- Start ICS-based controller therapy immediately upon diagnosis rather than waiting for symptoms to worsen, as early anti-inflammatory treatment is the cornerstone of asthma management 1, 2
- Never prescribe SABA alone as symptom relief in patients not using regular ICS—this practice is no longer recommended and contributes to poor outcomes 1
Treatment Tracks (Choose One Based on Patient Risk)
Track 1: Maintenance and Reliever Therapy (MART)
- Use ICS/formoterol both as maintenance (scheduled) and as-needed for symptom relief 1
- This approach has demonstrated improved asthma outcomes compared to traditional fixed-dose therapy 1
Track 2: Fixed-Dose Therapy
- Use scheduled ICS (with or without long-acting beta-2 agonist) plus separate SABA for rescue 1
- Both tracks are equally recommended; selection depends on patient risk factors, compliance patterns, and physician judgment 1
Step-Up Criteria
- Add long-acting beta-2 agonists (LABA) to ICS when control is inadequate on ICS alone 3, 1
- Add additional controllers (leukotriene modifiers, long-acting muscarinic antagonists) before advancing to Step 5 phenotype-specific treatments 1
- Consider biologic agents in Step 5 for severe asthma when indicated by specific phenotypes 1
Step-Down Approach
- Attempt step-down only after sustained control with ACQ score <0.75 on two consecutive assessments 4
- When stepping down from ICS/LABA combination, withdraw LABA first, then reduce ICS dose 4
- Monitor closely during step-down for loss of control 4
Acute Asthma Exacerbation Management
Severity Assessment
Acute Severe Asthma (ANY of the following):
- Cannot complete sentences in one breath 5, 6
- Pulse >110 beats/min 7, 5
- Respirations >25 breaths/min 7, 5
- Peak expiratory flow (PEF) <50% predicted or personal best 7, 5
- Diminished breath sounds 5
Life-Threatening Features (Immediate ICU consideration):
- Silent chest, cyanosis, or feeble respiratory effort 5
- Bradycardia, hypotension, confusion, exhaustion, or coma 5
- Oxygen saturation <92% despite supplemental oxygen 5
- Deteriorating PEF or persistent hypoxia/hypercapnia 7, 6
Immediate Treatment Protocol
First-Line Treatment (Initiate simultaneously):
- Oxygen 40-60% to maintain saturation >92% 7, 6
- Nebulized salbutamol 5 mg or terbutaline 10 mg 7, 5
- Systemic corticosteroids: prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg 7, 5
Monitor Response at 15-30 Minutes:
- If severe features persist: give nebulized bronchodilators every 30 minutes 7
- Add ipratropium 0.5 mg to nebulizer and repeat every 6 hours until improvement 7
- If no nebulizer available: give 2 puffs of beta-agonist via large volume spacer, repeat 10-20 times 7
Hospital Admission Criteria
Absolute Indications:
- Any life-threatening features present 5, 6
- Any features of acute severe asthma persist after initial treatment, especially PEF <33% 7, 5
Lower Threshold for Admission:
- Attack occurs in afternoon or evening 7, 6
- Recent nocturnal symptoms or recent hospital admission 7, 6
- Previous severe attacks or patient expresses concern 7, 6
ICU Transfer Criteria
Transfer accompanied by physician prepared to intubate if:
- Deteriorating PEF, worsening exhaustion, or feeble respirations 7, 6
- Coma, respiratory arrest, confusion, or drowsiness 7, 6
- Persistent hypoxia or hypercapnia despite maximal therapy 7, 6
Discharge Criteria
Patients must meet ALL criteria before discharge:
- Been on discharge medication for 24 hours with verified inhaler technique 7, 6
- PEF >75% of predicted or personal best with diurnal variability <25% 7, 6
- Prescribed oral steroid tablets (continue for 5-10 days total) and inhaled steroids plus bronchodilators 7, 5
- Own PEF meter with written self-management plan 7, 6
- GP follow-up arranged within 1 week and specialist follow-up within 4 weeks 7, 6
Monitoring and Follow-Up
Regular Assessment Parameters
- Check and record inhaler technique at every visit—improper technique is a major cause of treatment failure 8
- Assess symptom control, lung function, and exacerbation risk at each encounter 8
- Monitor PEF variability to assess treatment response 8
Post-Exacerbation Follow-Up
- Review within 24 hours for severe exacerbations 5
- Review within 48 hours for moderate exacerbations 5
- Continue prednisolone course for 3-10 days total 5
- Provide written self-management plan and verify adequate medication supply 5
Critical Pitfalls to Avoid
- Underestimation of severity by both clinicians and patients is a leading cause of preventable asthma deaths 8, 6
- Underuse of corticosteroids remains a major factor in poor outcomes and preventable deaths 7, 8
- Failure to recognize deterioration early—regard each emergency consultation as potentially severe until proven otherwise 7
- Using SABA alone without ICS in any asthma patient is no longer acceptable practice 1
- Delaying systemic steroids in acute exacerbations—delay can be fatal 7
Special Considerations for Controller Therapy
ICS/LABA Combination Products
- Do not use LABA monotherapy—LABAs increase risk of serious asthma-related events when used without ICS 3
- Do not combine with additional LABA-containing medications due to overdose risk 3
- Rinse mouth with water after inhalation to reduce risk of oral candidiasis 3
- Use with caution in patients with cardiovascular disorders, as beta-adrenergic stimulation can cause tachycardia, arrhythmias, and hypertension 3
- Avoid strong CYP3A4 inhibitors (ritonavir, ketoconazole, clarithromycin) with ICS/LABA products due to increased systemic corticosteroid effects 3