What is the management for asthma?

Management of Asthma

Asthma management requires a stepwise, control-based approach using inhaled corticosteroids (ICS) as the foundation of treatment, with short-acting beta-2 agonists (SABA) alone no longer recommended as monotherapy for symptom relief. 1, 2

Core Treatment Goals

The primary aims of asthma management are to 1:

• Abolish symptoms completely and restore normal airway function
• Minimize risk of severe attacks and prevent mortality
• Enable normal growth in children
• Eliminate absence from school or work
• Use the lowest effective medication doses to minimize side effects

Stepwise Treatment Algorithm

Step 1: Mild Intermittent Asthma

• As-needed ICS-formoterol combination therapy is now preferred over SABA monotherapy 2, 3
• SABA alone should NOT be used in patients not on regular ICS 2

Step 2-3: Mild to Moderate Persistent Asthma

• Low-dose inhaled corticosteroids as first-line controller medication 4, 5
• For patients with moderate persistent asthma (daytime symptoms, activity limitations), add a long-acting beta-agonist (LABA) to ICS rather than doubling the ICS dose 6
• Combination ICS/LABA therapy provides superior control compared to ICS dose escalation alone 6

Specific dosing for adolescents (≥12 years): Fluticasone propionate 100 mcg/salmeterol 50 mcg (Advair 100/50) twice daily via Diskus inhaler 6, 7

Pediatric dosing (ages 4-11 years): Fluticasone propionate 100 mcg/salmeterol 50 mcg twice daily 7

Step 4-5: Severe Persistent Asthma

• Add-on treatments before phenotype-specific biologics: Consider leukotriene modifiers, theophylline, or increased ICS doses 2, 8
• Biologic agents when indicated for specific phenotypes 2
• Oral corticosteroids as last resort 1

Acute Exacerbation Management

Severity Assessment

Severe asthma features requiring immediate treatment 1, 4:

• Inability to complete sentences in one breath
• Respiratory rate >25 breaths/min
• Pulse >110 beats/min
• Peak expiratory flow (PEF) <50% of predicted or personal best

Life-threatening features 4:

• Silent chest, cyanosis, poor respiratory effort
• Confusion or exhaustion
• PEF <33% of predicted

Immediate Treatment Protocol

• High-dose inhaled beta-2 agonists via nebulizer or spacer device 1, 4
• Systemic corticosteroids immediately: 1, 4
  • Adults: Prednisolone 30-60 mg orally, continue until 2 days after control established 1
  • Children: Prednisolone 1-2 mg/kg/day (maximum 60 mg/day) for 1-5 days, no tapering needed 1, 4
• Oxygen therapy to maintain saturation 4

Hospital Admission Criteria

Admit patients with 4:

• Any life-threatening features
• Severe features persisting after initial treatment
• PEF <33% predicted after treatment
• Lower threshold for evening presentations, recent nocturnal symptoms, or previous severe attacks

Patient Self-Management Education

Every patient must have a written action plan with three essential elements 1:

1. Monitoring: Regular symptom tracking and peak flow measurements
2. Action triggers: Pre-arranged steps based on symptoms/PEF values
3. Written guidance: Clear instructions for medication adjustments

Key self-management actions 1:

• Initiate or increase inhaled steroids when symptoms worsen
• Self-administer oral prednisolone when PEF falls below 60% of personal best or agreed individual threshold
• Seek urgent medical attention when treatment fails

Patients must understand 1:

• Difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications)
• Recognition of worsening symptoms, especially nocturnal symptoms
• Proper inhaler technique verified at each visit 6

Device Selection and Technique

• Dry powder inhalers (Diskus) are appropriate for adolescents and children ≥4 years who can generate adequate inspiratory flow 6, 7
• Large volume spacers with metered-dose inhalers for children who cannot coordinate MDI use 1
• Nebulizers are overused and should be replaced by spacer devices when possible 1
• Every child on inhaled steroids from MDI should use a large volume spacer to enhance lung deposition 1

Environmental Control and Trigger Avoidance

General practitioners should actively modify environmental triggers 1:

• Maternal smoking cessation is one of the most important interventions 1
• Identify and minimize exposure to allergens (pets, pollens, dust, feathers) 1
• Address family emotional disturbances that may trigger symptoms 1

Monitoring and Follow-Up

Regular Assessment Parameters

At each visit, evaluate 1:

• Days missed from school/work since last visit
• Frequency of daytime and nighttime symptoms
• Rescue medication use
• Activity limitations and exercise tolerance
• Growth parameters in children (height and weight velocity)
• Inhaler technique and medication adherence

Treatment Goals (Steps 1-3)

Optimal control is defined as 1:

• Minimal or no chronic symptoms, including nocturnal symptoms
• Minimal exacerbations
• Minimal need for rescue bronchodilators
• No activity limitations
• PEF ≥80% of predicted or personal best
• Circadian PEF variation <20%

Follow-Up Timing

• Initial follow-up at 1 month after starting or changing therapy 6
• Step-down therapy only after 3 months of well-controlled asthma 6
• Within 24-48 hours after acute exacerbations 4

Critical Safety Considerations

Growth Monitoring in Children

• Inhaled steroids >400 mcg/day may cause short-term reductions in growth velocity 1, 6
• Asthma itself delays growth and puberty, but catch-up growth typically occurs 1, 6
• Document height and weight velocities regularly 1

Systemic Corticosteroid Transition

When transferring from oral to inhaled steroids 7:

• Taper oral prednisone by 2.5 mg weekly while monitoring lung function
• Monitor for adrenal insufficiency (fatigue, weakness, nausea, hypotension)
• Watch for unmasking of previously suppressed allergic conditions

Drug Interactions

• Avoid strong CYP3A4 inhibitors (ritonavir, ketoconazole, itraconazole) with ICS/LABA combinations due to increased systemic corticosteroid effects 7

Paradoxical Bronchospasm

• If paradoxical bronchospasm occurs, discontinue ICS/LABA immediately and treat with short-acting bronchodilator 7
• Institute alternative therapy 7

Common Pitfalls to Avoid

Do NOT use 1, 4:

• Antibiotics unless bacterial infection is documented—they have no role in uncomplicated asthma
• Antihistamines (including ketotifen)—proven disappointing in clinical practice
• Immunotherapy (hyposensitization)—not indicated for asthma management
• SABA monotherapy without ICS—increases risk of serious asthma-related events

Critical errors to avoid 4:

• Overreliance on bronchodilators without anti-inflammatory treatment
• Underestimating severity of exacerbations
• Using sedation in acute asthma
• Delaying systemic corticosteroids during severe exacerbations

Specialist Referral Indications

Refer to respiratory physician when 1:

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

Supervision and Support

Ongoing supervision should include 1:

• Attendance at asthma clinic or home visits by trained asthma nurse
• Oral and written instructions on medication use
• Clear guidance on when to seek emergency help
• Partnership approach between patient, family, and healthcare professionals