What are the guidelines for asthma management?

Asthma Management Guidelines

Core Treatment Principles

Inhaled corticosteroids are the mainstay of preventive asthma treatment, combining effectiveness with relative freedom from side effects, and should be initiated at standard doses (200-250 µg fluticasone propionate equivalent daily) for adults with persistent asthma. 1, 2

Chronic Asthma Management Algorithm

Step 1: Initial Assessment and Treatment Goals

• Treatment goals: Minimal daytime symptoms, no nocturnal awakening, full participation in activities/sports, and infrequent need for rescue medications 1
• Verify proper inhaler technique before escalating therapy 1
• Ensure patient understanding of "relievers" (bronchodilators) versus "preventers" (anti-inflammatory medications) 1

Step 2: Medication Selection by Severity

For mild-moderate persistent asthma:

• Start inhaled corticosteroids at 200-250 µg fluticasone propionate equivalent daily, which achieves 80-90% of maximum therapeutic benefit 2
• Add short-acting β-agonist (salbutamol 5 mg or terbutaline 10 mg) as needed for symptom relief 1

For patients inadequately controlled on low-dose ICS:

• Add long-acting β-agonist (LABA) to ICS rather than increasing ICS dose alone 3, 4, 5
• High-dose ICS monotherapy shows no additional clinical benefit in 3 of 4 efficacy parameters compared to low-dose ICS but carries potential safety concerns 3

For severe asthma despite ICS/LABA:

• Add leukotriene receptor antagonist or tiotropium before considering oral corticosteroids 5
• Refer to severe asthma specialist for consideration of biologics before starting oral corticosteroids 5

Step 3: Pediatric Considerations

For children (ages 2-18):

• Use lowest ICS dose providing acceptable symptom control 1
• Doses >400 µg/day show short-term reductions in tibial growth rate, though long-term implications remain unclear 1
• Asthma itself delays growth and puberty, with eventual catch-up growth 1

For very young children (0-2 years):

• Diagnosis relies primarily on symptoms rather than objective testing 1
• Bronchodilator response is variable in first year of life but should still be attempted 1
• Exclude mimics: gastro-oesophageal reflux, cystic fibrosis, chronic lung disease of prematurity 1

Acute Exacerbation Management

Severity Assessment Criteria

Acute severe asthma indicators:

• Cannot complete sentences in one breath 1, 6
• Pulse >110 beats/min 1, 6
• Respirations >25 breaths/min 1, 6
• Peak expiratory flow <50% predicted/best 1, 6

Life-threatening features:

• Silent chest, cyanosis, feeble respiratory effort 1
• Bradycardia, confusion, exhaustion, or coma 1
• Hypotension 1

Immediate Treatment Protocol

For acute severe asthma:

• Administer oxygen 40-60% immediately 1, 7
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1, 7
• Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg 1, 7
• Reassess peak expiratory flow 15-30 minutes after treatment 1, 7, 6

If vomiting is present:

• Use intravenous hydrocortisone 200 mg every 6 hours instead of oral corticosteroids 7
• Vomiting lowers threshold for hospital admission 7

If not improving after 15-30 minutes:

• Add ipratropium bromide 0.5 mg to nebulizer 1, 6
• Consider subcutaneous terbutaline 250 µg over 10 minutes 1
• Arrange immediate hospital admission 1, 7, 6

If life-threatening features present:

• Add aminophylline 250 mg IV over 20 minutes (caution if already on theophyllines) 1
• Obtain chest radiography to exclude pneumothorax 1, 7
• Patient must be accompanied by nurse or doctor at all times 1

Hospital Admission Criteria

Mandatory admission if:

• Any life-threatening features present 1
• Peak flow <33% predicted after initial treatment 1, 7, 6
• Features of acute severe asthma persist after initial treatment 1

Lower threshold for admission if:

• Attack occurs in afternoon/evening 1, 6
• Recent nocturnal symptoms 1, 6
• Recent hospital admission or previous severe attacks 1, 6
• Patient unable to assess own condition 1

Self-Management Plan Requirements

Essential Components

All patients must have written guidance including: 1

1. Monitoring of symptoms, peak flow, and drug usage 1
2. Prearranged actions based on specific thresholds 1
3. Written instructions for when to escalate treatment 1

Key self-management actions:

• Initiate or increase inhaled corticosteroids when symptoms worsen 1
• Self-administer oral corticosteroids when peak flow falls below 60% of normal or individually agreed threshold 1
• Seek urgent medical attention when treatment is not working 1

Patient Education Requirements

Patients/parents must receive training in: 1

• Proper inhaler technique and peak flow meter use 1
• Recognition of worsening asthma, especially nocturnal symptoms 1
• Difference between relievers and preventers 1
• Balanced understanding of treatment side effects 1

Discharge and Follow-Up Protocol

All discharged patients require:

• Prednisolone 30-60 mg daily for 1-3 weeks (not just 5-6 day Medrol dose pack) 7, 6
• Increased inhaled corticosteroid dose 7, 6
• Peak flow meter and written asthma action plan 7, 6
• Primary care follow-up within 1 week 6
• Respiratory specialist follow-up within 4 weeks 6

Specialist Referral Indications

Refer to respiratory physician for: 1

• Diagnostic uncertainty (especially elderly smokers with wheeze) 1
• Possible occupational asthma 1
• Catastrophic, sudden, severe (brittle) asthma 1
• Continuing symptoms despite high-dose inhaled steroids 1
• Consideration for long-term nebulized bronchodilators 1
• Pregnant women with worsening asthma 1
• Asthma interfering with lifestyle despite treatment changes 1
• Recent hospital discharge 1

Critical Pitfalls to Avoid

Absolute contraindications:

• Never use sedatives in asthmatic patients - they worsen respiratory depression and are absolutely contraindicated 7, 8

Common prescribing errors:

• Do not prescribe antibiotics unless bacterial infection is clearly documented 7, 8
• Do not discharge on insufficient steroid duration (5-6 day courses are inadequate; use 1-3 weeks) 6
• Do not escalate ICS dose before verifying proper inhaler technique and adherence 1

Monitoring failures:

• Do not skip peak flow measurement 15-30 minutes after treatment 1, 7, 6
• Do not delay corticosteroid administration - they require 6-12 hours to manifest anti-inflammatory effects 7