Medical Management of Asthma
Inhaled corticosteroids are the most potent and consistently effective long-term control medication for asthma and should be the foundation of treatment for all patients with persistent asthma, taken daily regardless of symptom frequency. 1
Chronic Asthma Management
First-Line Controller Therapy
- Inhaled corticosteroids (ICS) are the preferred controller medication because they improve asthma control more effectively than any other single long-term medication when used consistently. 1
- ICS suppress inflammation in asthmatic airways and inhibit almost every aspect of the inflammatory process, controlling symptoms, improving lung function, and preventing exacerbations. 2
- Low-dose ICS should be initiated even in patients with infrequent symptoms (≤2 days per week), as they reduce severe asthma-related events, decrease lung function decline, and improve symptom control similarly across all symptom frequency subgroups. 3
Step-Up Therapy When ICS Alone Is Insufficient
- For patients ≥12 years whose asthma is not controlled on ICS alone, adding a long-acting beta-agonist (LABA) is the preferred adjunctive therapy rather than increasing the ICS dose. 1
- Combining LABA with ICS is effective and safe, providing greater improvements in peak expiratory flow (16-21 L/min difference), reduced rescue medication use, and fewer symptoms compared to doubling the ICS dose. 4
- Never use LABAs as monotherapy because they are associated with increased asthma exacerbations and death when used alone. 1
Alternative Controller Options
- Leukotriene receptor antagonists are an alternative second-line treatment for mild persistent asthma (though not preferred over ICS), with high compliance rates and good symptom control in many patients. 1
- For patients ≥12 years, leukotriene receptor antagonists can be added to ICS, but LABA addition is preferred as adjunctive therapy. 1
Acute Exacerbation Management
Immediate Treatment
- Administer high-dose inhaled short-acting beta-agonists immediately: salbutamol 5 mg or terbutaline 10 mg via nebulizer with oxygen, or 4-12 puffs via MDI with spacer every 20-30 minutes for three doses. 1, 5
- Give systemic corticosteroids early: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV immediately, as corticosteroids require 6-12 hours to manifest anti-inflammatory effects. 1, 6
- For patients with vomiting during exacerbation, use IV hydrocortisone 200 mg every 6 hours instead of oral corticosteroids. 6
Severe Exacerbations
- Add ipratropium bromide 0.5 mg nebulized to each beta-agonist treatment for severe airflow obstruction, as this reduces hospitalization rates. 1, 5
- Consider IV aminophylline 250 mg over 20 minutes or subcutaneous terbutaline 250 µg over 10 minutes if not improving after 15-30 minutes. 1, 5
- Do not give bolus aminophylline to patients already taking oral theophyllines. 1
Monitoring Response
- Measure peak expiratory flow 15-30 minutes after starting treatment and according to response thereafter. 1, 6, 7
- Continue nebulized beta-agonists every 4 hours if improving, or up to every 15 minutes if not improving. 1
Critical Pitfalls to Avoid
- Never use sedatives in asthmatic patients as they are absolutely contraindicated and can worsen respiratory depression. 1, 6, 7
- Do not prescribe antibiotics unless bacterial infection is clearly documented, as they are unnecessary for elevated inflammatory markers alone. 1, 6, 7
- Avoid percussive physiotherapy during acute exacerbations as it is unhelpful. 1
- Do not discharge patients on inadequate steroid courses: the typical 5-6 day methylprednisolone dose pack is often insufficient; use prednisolone 30-60 mg daily for 1-3 weeks. 5
Rescue Medication Monitoring
- Using short-acting beta-agonists more than 2 days per week (excluding exercise prophylaxis) or more than 2 nights per month indicates inadequate asthma control and the need to initiate or intensify anti-inflammatory therapy. 1
- Short-acting beta-agonists are the most effective therapy for rapid reversal of airflow obstruction but should not be relied upon for chronic control. 1
Hospital Admission Criteria
- Peak expiratory flow <33% predicted after initial nebulization requires immediate hospital referral. 6, 5
- Inability to complete sentences in one breath, oxygen saturation <92% on room air, respiratory rate >25 breaths/min, or heart rate >110 bpm warrant hospitalization. 5
- Lower threshold for admission applies to patients seen in afternoon/evening, those with recent nocturnal symptoms, or previous severe attacks. 1, 6