What is the recommended management for an adult patient with asthma?

Management of Adult Asthma

Start all adults with persistent asthma on daily low-dose inhaled corticosteroids (100-250 μg fluticasone propionate equivalent) as first-line controller therapy, as this achieves 80-90% of maximum ICS benefit and prevents exacerbations across all severity levels. 1, 2

Initial Controller Therapy

Mild Persistent Asthma

• Begin with low-dose ICS (100-250 μg fluticasone propionate equivalent daily) as the preferred controller medication to prevent exacerbations, even in patients with symptoms ≤2 days per week 1, 3
• Low-dose ICS reduces severe asthma-related events (hospitalizations, emergency treatment, death) by approximately 40-50% regardless of baseline symptom frequency 3
• Alternative option: as-needed low-dose ICS-formoterol allows patients to adjust ICS intake with symptom fluctuations 1
• Start with metered-dose inhaler (MDI); add large-volume spacer device only if patient cannot use MDI properly 4, 1

Critical pitfall: The traditional "more than 2 symptom days per week" threshold for starting ICS is not evidence-based—ICS reduces exacerbations and prevents lung function decline equally in patients with infrequent symptoms 3

Moderate to Severe Asthma

• Add long-acting β2-agonist (LABA) to low-dose ICS rather than increasing ICS dose alone for patients not controlled on low-dose ICS 1, 5
• ICS/LABA combination is superior to doubling or quadrupling ICS dose for achieving control and reducing exacerbations 5
• The "standard daily dose" of 200-250 μg fluticasone propionate achieves 80-90% of maximum ICS benefit; higher doses (>500 μg) cause systemic side effects equivalent to oral prednisone 5 mg daily 1, 2
• Verify inhaler technique and adherence before escalating therapy 4, 1

Important limitation: Well-controlled asthma is achievable in only ~70% of patients even with maximal ICS/LABA therapy 4, 1

Acute Exacerbation Management

Severity Assessment

• Use objective measurements: peak expiratory flow (PEF), respiratory rate, heart rate, and ability to speak in complete sentences 4, 1
• Severe features include: inability to complete sentences in one breath, respiratory rate >25/min, heart rate >110/min, PEF <50% predicted or personal best 1
• Life-threatening features: PEF <33% predicted, oxygen saturation <92%, silent chest, cyanosis, exhaustion, altered consciousness 4

Critical pitfall: Never rely solely on patient perception to assess severity—always use objective measurements 1

Immediate Treatment

• High-dose short-acting β2-agonist: salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (or 10-20 puffs via MDI with large-volume spacer) 4, 1
• Systemic corticosteroids immediately: prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 4, 1
• Oral and IV steroids are equally effective; oral route is preferred 4
• Continue oxygen therapy to maintain saturation >92% 4

Life-Threatening Features

• Add ipratropium 0.5 mg nebulized to β2-agonist 4
• Consider IV aminophylline 250 mg over 20 minutes (avoid if patient already taking oral theophyllines) 4
• Measure PEF 15-30 minutes after initial treatment 4

Hospital Admission Criteria

• Life-threatening features present 4
• PEF <33% predicted after initial treatment 4
• Features of severe attack persisting after initial treatment 4
• Lower threshold for admission: afternoon/evening presentation, recent nocturnal symptoms, previous severe attacks, concern about patient's symptom assessment or social circumstances 4

Monitoring During Recovery

• Continue high-dose steroids (prednisolone 30-60 mg daily or hydrocortisone 200 mg every 6 hours) until improvement 4
• Nebulized β2-agonist every 4 hours if improving; every 15 minutes if not improving 4
• Do not discharge until: PEF >75% predicted or personal best, diurnal variability <25%, no nocturnal symptoms 4

Important note: Short courses of oral steroids (up to 2 weeks) do not require tapering—can be stopped from full dose 4

Maintenance Therapy Principles

Dose Optimization

• Most patients achieve optimal control with low-dose ICS (200-250 μg fluticasone propionate equivalent) 1, 2
• If symptoms not controlled on standard doses, increase up to 2000 μg beclomethasone equivalent daily before adding other agents 4
• After 1-3 months of stability, reduce ICS dose by 25-50% at each step 4

Add-On Therapies

• Leukotriene receptor antagonists (montelukast) can be added to ICS, allowing 47% reduction in ICS dose versus 30% with placebo 6
• Montelukast is particularly effective in aspirin-sensitive asthma 6
• Consider tiotropium, anti-IgE, anti-IL5/5R, or anti-IL4R for severe asthma requiring phenotypic assessment 4

Medications to Avoid

• Antibiotics only if bacterial infection documented 4
• No sedation ever 4
• Percussive physiotherapy is unnecessary 4

Key Clinical Considerations

Symptom control does not equal exacerbation prevention: Patients with well-controlled symptoms may still be at risk for severe exacerbations, particularly those with severe asthma 4, 1

Inhaler technique is paramount: Always verify proper technique before escalating therapy—poor technique is a common cause of apparent treatment failure 4, 1

Cost-effectiveness: Use the cheapest inhaled steroid that the patient can use properly and that controls symptoms—no clinically important differences exist between different ICS formulations at equivalent doses 4