What is the recommended management approach for asthma?

Asthma Management: A Stepwise Approach

The recommended management of asthma centers on inhaled corticosteroids (ICS) as the foundation of long-term control therapy, combined with a stepwise approach that adjusts treatment intensity based on disease severity and control status, with regular assessment of both symptom burden and exacerbation risk. 1

Initial Assessment and Severity Classification

Assess asthma severity at diagnosis using both impairment domains (current symptoms, functional limitations, SABA use frequency) and risk domains (future exacerbations, lung function decline). 1 Measure peak expiratory flow (PEF) and perform spirometry to establish baseline lung function. 1

Classify acute presentations immediately:

• Mild/Moderate: Speech normal, pulse <110 beats/min, respirations <25 breaths/min, PEF >50% predicted 2
• Acute Severe: Cannot complete sentences, pulse >110 beats/min, respirations >25 breaths/min, PEF <50% predicted 2
• Life-Threatening: PEF <33% predicted, silent chest, cyanosis, weak respiratory effort, bradycardia, hypotension, exhaustion, confusion, or coma 3

Stepwise Pharmacological Management

Step 1: Intermittent Asthma

Use as-needed short-acting beta-agonists (SABA) alone for rescue therapy—salbutamol or albuterol as needed. 4

Step 2: Mild Persistent Asthma

Initiate daily low-dose ICS plus as-needed SABA, or use as-needed concomitant ICS and SABA therapy together. 4 ICS should be started as soon as possible in patients with persistent asthma as they are the most effective long-term control therapy. 1

Step 3: Moderate Persistent Asthma

Use low-dose ICS-formoterol combination therapy as both daily maintenance and as-needed reliever therapy (single maintenance and reliever therapy, or SMART). 4 This approach is preferred for adults and adolescents because it reduces severe exacerbations more effectively than traditional fixed-dose regimens. 5

Step 4: Moderate-Severe Persistent Asthma

Escalate to medium-dose ICS-formoterol therapy for both daily and as-needed use. 4

Step 5: Severe Persistent Asthma

Add long-acting muscarinic antagonists (LAMA) to ICS-formoterol therapy when asthma remains uncontrolled. 4 Consider biologic agents for patients with severe allergic or eosinophilic asthma who remain uncontrolled despite appropriate treatment. 5

Critical Safety Warnings

Never use long-acting beta-agonists (LABAs) as monotherapy—they carry an FDA black box warning for increased risk of severe exacerbations and must always be combined with ICS. 1, 6 Do not combine Wixela Inhub or similar ICS-LABA products with additional LABA-containing medications due to overdose risk. 6

Sedatives are absolutely contraindicated in asthmatic patients as they worsen respiratory depression. 1, 3

Acute Exacerbation Management

Outpatient/Home Management (PEF >50% predicted)

• Administer nebulized salbutamol 5 mg or terbutaline 10 mg 2
• Give prednisolone 30-60 mg orally 2
• Monitor response 15-30 minutes after nebulizer treatment 2
• If PEF improves to >75% predicted, step up usual treatment and arrange follow-up within 48 hours 2

Hospital Management (PEF <50% predicted or severe features)

• Provide oxygen 40-60% immediately 2, 3
• Administer nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 2
• Give prednisolone 30-60 mg orally or hydrocortisone 200 mg IV 2, 3
• Add ipratropium 0.5 mg nebulized for severe cases 2
• Consider aminophylline 250 mg IV over 20 minutes if life-threatening features present (caution if patient already taking theophyllines) 2
• Obtain chest radiography to exclude pneumothorax in life-threatening cases 2

Hospitalize if: Any life-threatening features present, PEF remains <33% after initial treatment, attack occurs in afternoon/evening, recent nocturnal symptoms, recent hospital admission, or patient unable to assess own condition. 2

Adjunctive Therapies

Consider subcutaneous allergen immunotherapy when clear relationship exists between symptoms and specific allergen exposure in patients with persistent allergic asthma. 1, 4 Sublingual immunotherapy is not recommended specifically for asthma. 4

Fractional exhaled nitric oxide (FeNO) testing can assist in diagnosis and monitoring but should not be used alone to diagnose or monitor asthma. 4

Allergen mitigation should be allergen-specific and include multiple strategies, but only in patients with documented exposure and relevant sensitivity. 4

Common Pitfalls to Avoid

• Underestimating severity: Always assess objectively with PEF measurements—patients and relatives often fail to appreciate severity. 2
• Underuse of corticosteroids: This is a leading cause of asthma deaths. 2
• Poor inhaler technique: Verify technique at every visit. 1
• Failure to provide written action plans: All patients need clear instructions for managing worsening symptoms. 1
• Not stepping down therapy: After 3 months of good control, consider reducing treatment intensity. 1

Monitoring and Follow-Up

Assess control at every visit using validated tools like the Asthma Control Test or asthma APGAR (activities, persistent symptoms, triggers, asthma medications, response to therapy). 5 Monitor peak flow twice daily during exacerbations and provide patients with peak flow meters. 2, 7

Monitor for ICS adverse effects: Check height and weight in children, assess bone mineral density periodically, watch for oral candidiasis (advise rinsing mouth after inhalation), and refer for ophthalmology evaluation if ocular symptoms develop or with long-term use. 1, 6

Ensure annual influenza vaccination. 1

Special Considerations

Recognize and treat comorbid conditions including allergic rhinitis, sinusitis, GERD, obstructive sleep apnea, obesity, and vocal cord dysfunction, as these worsen asthma control. 1

When transferring patients from systemic corticosteroids to ICS, taper prednisone slowly (reduce by 2.5 mg weekly) while monitoring lung function, beta-agonist use, and symptoms closely for signs of adrenal insufficiency. 6

Refer to respiratory specialist for: doubtful diagnosis, possible occupational asthma, management problems, or severe uncontrolled asthma despite appropriate treatment. 3, 5