What are the guidelines for managing asthma?

Asthma Management Guidelines

Modern asthma management follows a stepwise approach prioritizing inhaled corticosteroids (ICS) as the foundation of treatment, with the critical principle that short-acting beta-agonists (SABA) alone should never be used without concurrent anti-inflammatory therapy. 1, 2

Assessment and Severity Classification

Objective measurement is mandatory to avoid the common pitfall of underestimating severity, which remains a leading cause of preventable asthma deaths. 1, 3

Key assessment parameters include:

• Ability to complete sentences in one breath 3, 4
• Respiratory rate (>25 breaths/min indicates severe asthma) 5, 3
• Heart rate (>110 beats/min indicates severe asthma) 5, 3
• Peak expiratory flow (PEF) (<50% predicted/best indicates severe asthma) 5, 3

Stepwise Chronic Management Approach

Step 1-2: Mild Asthma

The paradigm has shifted away from SABA-only treatment. For patients with mild intermittent symptoms, use as-needed ICS-formoterol combination rather than SABA alone. 1, 2 This represents a fundamental change from historical practice, as SABA monotherapy without anti-inflammatory coverage is no longer recommended. 6

Step 3-4: Moderate Asthma

• Initiate regular low-dose ICS as the cornerstone of controller therapy 1, 2
• Add long-acting beta-agonist (LABA) when symptoms remain inadequately controlled on ICS alone 2, 6
• Consider maintenance and reliever therapy (MART) using ICS-formoterol for both daily maintenance and as-needed relief, which reduces severe exacerbations more effectively than traditional fixed-dose regimens 2, 6

Step 5: Severe Persistent Asthma

Before escalating to biologics, optimize add-on conventional therapies: 3

• Long-acting muscarinic antagonists (LAMA) 2
• Leukotriene receptor antagonists 2
• High-dose ICS-LABA combinations 6

Only after maximizing conventional therapy, consider phenotype-specific biologic agents for severe allergic or eosinophilic asthma. 2, 6

Acute Exacerbation Management

Severity Assessment

Life-threatening features requiring immediate ICU consideration: 1, 3

• PEF <33% predicted/best 1, 3
• Silent chest, cyanosis, poor respiratory effort 1
• Bradycardia, hypotension, confusion, exhaustion, or coma 1, 3

Acute severe features (but not immediately life-threatening): 5, 1

• Cannot complete sentences 5, 3
• Respiratory rate >25/min 5, 3
• Pulse >110/min 5, 3
• PEF <50% predicted/best 5, 3

Immediate Treatment Protocol

Administer simultaneously: 5, 1

1. High-flow oxygen 40-60% 5, 1, 3
2. Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 5, 1, 3
3. Systemic corticosteroids: prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 5, 1, 3

Response Assessment at 15-30 Minutes

If improving: 5

• Continue high-flow oxygen 5
• Continue prednisolone 1-2 mg/kg daily (maximum 40 mg in children) 5
• Nebulized beta-agonist every 4 hours 5

If NOT improving: 5

• Increase nebulized beta-agonist frequency to every 30 minutes 5
• Add ipratropium bromide to nebulizer, repeat every 6 hours 5, 4
• Consider IV aminophylline or subcutaneous terbutaline 5, 3

Hospital Admission Criteria

Admit immediately if: 1, 3

• Any life-threatening features present 1, 3
• Features of acute severe asthma persist after initial treatment 1, 3
• PEF remains <33% after treatment 1, 3

Lower threshold for admission when: 5, 3

• Attack occurs in afternoon/evening 5
• Recent nocturnal symptoms or previous severe attacks 5, 3
• Recent hospital admission 5, 3
• Poor social circumstances or inability to assess own condition 5

ICU Transfer Criteria

Transfer accompanied by physician prepared to intubate if: 5, 3

• Deteriorating PEF despite treatment 5, 3
• Worsening exhaustion or feeble respirations 5, 3
• Persistent hypoxia or hypercapnia 5, 3
• Coma, respiratory arrest, confusion, or drowsiness 5, 3

Discharge Planning

Patients must meet ALL criteria before discharge: 5, 1

• On discharge medications for 24 hours with verified inhaler technique 5, 1
• PEF >75% predicted/best with diurnal variability <25% 5, 1
• Prescribed oral corticosteroids AND inhaled corticosteroids plus bronchodilators 5, 1
• Own peak flow meter with written self-management action plan 5, 1
• GP follow-up scheduled within 1 week 5, 1
• Specialist follow-up within 4 weeks 5, 1

Patient Education and Self-Management

Essential components of asthma education: 1

• Clear distinction between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 1
• Written action plan with specific instructions for medication adjustment based on symptoms and PEF 1
• Regular symptom and peak flow monitoring 1

Critical Pitfalls to Avoid

The three most common preventable errors leading to asthma deaths: 5, 1, 3

1. Failure to objectively measure severity - always use PEF or spirometry 5, 1, 3
2. Underestimation of severity by patients and clinicians 5, 3
3. Underuse of corticosteroids - both in chronic management and acute exacerbations 5, 3

Additional common errors: 1

• Overreliance on bronchodilators without adequate anti-inflammatory treatment 1
• Delayed administration of systemic corticosteroids during exacerbations 1

Special Populations

Pediatric Considerations

• Children over 5 years can typically use peak flow meters 1
• Age-appropriate salbutamol dosing: 2.5 mg up to age 2, then 5 mg over age 2 1
• Monitor growth velocity closely as ICS may reduce growth in children and adolescents 7
• Titrate to lowest effective ICS dose to minimize growth suppression 7

Geriatric Considerations

• Patients ≥65 years have higher risk of serious adverse events, particularly pneumonia with ICS-LABA combinations 7
• Exercise special caution with beta-agonists in patients with cardiovascular disease 7
• No dosage adjustment required based solely on age 7

Hepatic Impairment

• Both fluticasone and salmeterol are hepatically metabolized; monitor closely for drug accumulation 7