Recent Guidelines for Adult Asthma Management
The cornerstone of adult asthma management is a stepwise approach using inhaled corticosteroids (ICS) as first-line controller therapy, with treatment escalation based on symptom control and exacerbation risk, starting with low-dose ICS (100-250 μg fluticasone propionate equivalent daily) or low-dose ICS-formoterol as needed for mild asthma. 1
Initial Controller Therapy Selection
Mild Asthma (Step 1-2)
- Start with daily low-dose ICS (100-250 μg fluticasone propionate equivalent) as the preferred controller to prevent exacerbations 1
- As-needed low-dose ICS-formoterol is an alternative first-line option that empowers patients to adjust ICS intake with symptom fluctuation 1, 2
- Starting with moderate doses (400-800 μg BDP equivalent) provides minimal additional benefit over low doses for most patients, with only small improvements in morning peak flow (11.14 L/min) and nocturnal symptoms 3
- Avoid starting with high-dose ICS (>800 μg BDP equivalent) as monotherapy—it offers no clinically significant advantage over moderate doses but increases systemic side effect risk 3, 4
Moderate to Severe Asthma (Step 3-4)
- Add a long-acting β2-agonist (LABA) to low-dose ICS rather than increasing ICS dose alone 1, 5
- Combination ICS/LABA therapy (e.g., fluticasone propionate 100-500 μg + salmeterol 50 μg twice daily) provides superior symptom control and exacerbation reduction compared to high-dose ICS monotherapy 5, 6
- The trigger for treatment escalation is using short-acting β-agonist more than 2-3 times daily or inadequate symptom control 1
Acute Exacerbation Management
Severity Assessment
Assess severity objectively using peak expiratory flow (PEF), respiratory rate, heart rate, and ability to speak in complete sentences 7
Acute severe asthma features: 7
- Cannot complete sentences in one breath
- Respiratory rate >25 breaths/min
- Heart rate >110 beats/min
- PEF <50% predicted or personal best
Life-threatening features: 7
- PEF <33% predicted
- Silent chest, cyanosis, feeble respiratory effort
- Bradycardia, hypotension, exhaustion, confusion, or coma
Immediate Treatment
- High-dose short-acting β2-agonist: salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer, OR 8 puffs via MDI with spacer every 20 minutes for three doses 7, 1
- Systemic corticosteroids immediately: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 7, 1
- Oxygen therapy to maintain saturation >90% (>95% in pregnant women) 7
- Continue steroids until PEF reaches 70% of predicted or personal best; 7-21 days treatment typically sufficient 1
Monitoring and Admission Criteria
- Measure PEF 15-30 minutes after initial treatment and monitor heart rate, respiratory rate, oxygen saturation 7
- Admit to hospital if: 7
- Life-threatening features present
- Severe asthma features persist after initial treatment
- PEF remains <33% predicted after treatment
- Previous severe attacks, especially with rapid onset
Key Treatment Principles
Dose Optimization
- The "standard daily dose" of 200-250 μg fluticasone propionate equivalent achieves 80-90% of maximum ICS benefit across all severity levels 4
- Higher ICS doses (>500 μg fluticasone propionate) cause systemic side effects equivalent to oral prednisone 5 mg daily 1
- Well-controlled asthma is achievable in only ~70% of patients even with maximal ICS/LABA therapy 1
Inhaler Device Selection
- Start with metered-dose inhaler (MDI); add large-volume spacer if patient cannot use MDI properly 1
- If spacer is too bulky for daytime use, switch to the most affordable powder or automatic aerosol inhaler the patient can use correctly 1
- Always verify inhaler technique and adherence before escalating therapy 1
Additional Considerations
- Leukotriene receptor antagonists (montelukast) are indicated for prophylaxis and chronic treatment but are not first-line controller therapy 8
- Never use LABA as monotherapy—it increases risk of serious asthma-related events 5
- Do not combine with additional LABA-containing medications due to overdose risk 5
Common Pitfalls to Avoid
- Underestimating severity: Always use objective measurements (PEF, vital signs) rather than relying solely on patient perception 7
- Delaying corticosteroids: Early systemic steroid administration in acute exacerbations significantly reduces hospitalization risk 7
- Overprescribing high-dose ICS: The current "low/medium/high" dose terminology is not evidence-based and leads to excessive ICS use with unnecessary systemic side effects 4
- Inappropriate sedation: Never sedate patients with acute asthma 7
- Assuming symptom control equals exacerbation prevention: These may not be on the same causal pathway, particularly in severe asthma 1