What is the algorithm for managing asthma?

Asthma Management Algorithm

Initial Assessment and Severity Classification

Classify asthma severity before initiating therapy using both impairment (symptom frequency, nighttime awakenings, SABA use, activity limitation) and risk domains (exacerbation history, lung function decline), with spirometry required for patients ≥5 years of age. 1

• Assess impairment over the previous 2-4 weeks: daytime symptoms, nighttime awakenings, SABA use for symptom relief (not prevention), interference with normal activity, and FEV1/FVC ratios 2
• Evaluate risk by counting exacerbations requiring oral corticosteroids in the past year—patients with ≥2 exacerbations are considered to have persistent asthma regardless of symptom frequency 2, 1
• Assign severity to the most severe category in which any feature occurs 2

Stepwise Treatment Algorithm

Step 1: Intermittent Asthma

• Prescribe SABA (albuterol/salbutamol) as needed only, with no daily controller medication required 1, 3
• SABA use >2 days per week for symptom relief indicates inadequate control and need to step up 2

Step 2: Mild Persistent Asthma

• Initiate low-dose ICS daily as preferred controller therapy (fluticasone propionate 100-250 μg/day or equivalent) 1, 4
• Continue SABA as needed for symptom relief 2
• Alternative options include leukotriene receptor antagonists (LTRA), though ICS remains preferred 2

Step 3: Moderate Persistent Asthma

• Use low-to-medium dose ICS as preferred therapy 2
• Alternative: low-dose ICS plus LTRA, theophylline, or zileuton 2
• Reassess in 2-6 weeks depending on initial severity 2

Step 4: Moderate-to-Severe Persistent Asthma

• Add long-acting beta-agonist (LABA) to medium-dose ICS as preferred combination therapy 2
• Critical warning: Never use LABA as monotherapy due to increased mortality risk—always combine with ICS 1
• Alternative: medium-dose ICS plus LTRA or theophylline 2

Step 5: Severe Persistent Asthma

• Increase to high-dose ICS plus LABA 2
• Consider adding omalizumab for patients with documented allergic asthma and elevated IgE 2, 5

Step 6: Most Severe Asthma

• Add oral corticosteroids (prednisolone 7.5-60 mg daily as single morning dose) to high-dose ICS plus LABA 2
• Before introducing oral corticosteroids, trial high-dose ICS with LABA plus LTRA, theophylline, or zileuton 2
• Use oral corticosteroids for the shortest duration possible to minimize adverse effects 3

Acute Exacerbation Management

Severity Assessment

• Immediately assess for life-threatening features: inability to complete sentences, respiratory rate >25/min, heart rate >110/min, PEF <50% predicted, oxygen saturation <92% 1

Initial Treatment

• Administer SABA up to 3 treatments at 20-minute intervals 2
• Initiate oral corticosteroids early (prednisolone 40-60 mg daily for adults, 1-2 mg/kg for children with maximum 40 mg) 2, 6
• Provide supplemental oxygen to maintain saturation >92% 6

Hospital Referral Criteria

• Refer immediately if: life-threatening features present, severe attack persisting after initial treatment, PEF <33% predicted 15-30 minutes post-treatment, or oxygen saturation <92% on room air 1

Adjunctive Therapies

Allergen Immunotherapy

• Consider subcutaneous allergen immunotherapy for patients with documented allergic asthma and single allergen sensitivity 2, 1
• Clinicians must be prepared to treat anaphylaxis 2

Universal Management Principles

Patient Education (Required at Every Visit)

• Provide education on proper inhaler technique, distinction between "reliever" (SABA) and "preventer" (ICS) medications, recognition of worsening symptoms, and peak flow monitoring 1
• Develop a written asthma action plan with symptom/peak flow monitoring, prearranged patient-initiated actions, and medication adjustment guidance 1

Monitoring and Adjustment

• Reassess control every 2-6 weeks initially, then periodically 2
• Review adherence, inhaler technique, environmental exposures, and comorbid conditions if control is not achieved 2
• Step down therapy once asthma is well-controlled for at least 3 months to find the minimum effective dose 2, 3

Critical Pitfalls to Avoid

• Never prescribe LABA monotherapy—always combine with ICS due to mortality risk 1
• Avoid antibiotics unless clear bacterial infection is documented 1
• Never use sedatives during exacerbations due to respiratory depression risk 1
• Recognize that patients and physicians commonly underestimate symptom severity—39-70% of patients with moderate symptoms believe their asthma is well-controlled 2
• High starting doses of ICS provide no additional clinical benefit over low-to-moderate doses for most efficacy parameters but carry potential safety concerns 4
• Monitor growth velocity in children receiving ICS, as growth suppression can occur 7