What is the recommended management approach for asthma?

Asthma Management

Stepwise Treatment Approach Based on Severity

For asthma management, initiate treatment with inhaled corticosteroids (ICS) as the foundation of therapy for all patients except those with the mildest intermittent symptoms, using a stepwise escalation approach that adds long-acting beta-agonists (LABAs), long-acting muscarinic antagonists (LAMAs), and systemic corticosteroids as needed to achieve control. 1, 2

Initial Classification and Treatment Selection

• Intermittent asthma (symptoms <2 days/week, nighttime awakenings <2x/month): Use as-needed short-acting beta-agonists (SABA) alone - albuterol or levalbuterol for rescue therapy 1, 3

• Mild persistent asthma (symptoms >2 days/week but not daily): Either daily low-dose ICS plus as-needed SABA, OR as-needed concomitant ICS and SABA therapy together 3

• Moderate persistent asthma (daily symptoms, nighttime awakenings >1x/week): Low-dose ICS-formoterol combination as single maintenance and reliever therapy (SMART) - this allows the same inhaler for both daily controller and rescue use 3

• Moderate-severe persistent asthma: Medium-dose ICS-formoterol combination therapy 3

• Severe persistent asthma (symptoms throughout the day, frequent nighttime awakenings): Add long-acting muscarinic antagonist (tiotropium or umeclidinium) to ICS-formoterol therapy 3

Critical Safety Warnings

• Never use LABAs as monotherapy - they must always be combined with ICS, as LABA monotherapy increases the risk of serious asthma-related events and death 4

• Daily LABA use should not exceed 100 mcg salmeterol or 24 mcg formoterol 1

• LABAs are not for acute symptom relief or exacerbations 1

Acute Exacerbation Management

Severity Assessment (Perform Within Minutes)

Moderate exacerbation indicators: 1, 5

• Can complete sentences but with difficulty
• Pulse 110-120 beats/min
• Respiratory rate 25-30 breaths/min
• Peak expiratory flow (PEF) 50-75% predicted

Severe exacerbation indicators: 1, 6

• Cannot complete sentences in one breath
• Pulse >110 beats/min
• Respiratory rate >25 breaths/min
• PEF <50% predicted

Life-threatening features: 1, 7

• Silent chest, cyanosis, feeble respiratory effort
• Bradycardia, hypotension, confusion, exhaustion, or coma
• Oxygen saturation <92% on room air 6

Immediate Treatment Protocol

For moderate exacerbations (outpatient management possible): 1, 5

• Nebulized albuterol 5 mg or terbutaline 10 mg (or 4-12 puffs via MDI with spacer) 6
• Add ipratropium bromide 0.5 mg to each albuterol treatment 6
• Prednisolone 30-60 mg orally 1, 5
• Reassess PEF and symptoms 15-30 minutes after treatment 1, 6

For severe exacerbations (hospitalization likely needed): 1, 7

• High-flow oxygen 40-60% immediately to maintain saturation 7
• Nebulized albuterol 5 mg every 15-20 minutes for first hour 5
• Add ipratropium 0.5 mg to each nebulization 1
• Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg if vomiting or unable to take oral medications 7
• If no improvement after 15-30 minutes: arrange immediate hospital admission 7

For life-threatening exacerbations: 1

• All of the above, plus:
• Consider intravenous aminophylline 250 mg over 20 minutes (caution if patient already taking theophyllines) 1
• Consider subcutaneous terbutaline 250 µg over 10 minutes 1
• Obtain chest radiography to exclude pneumothorax 1

Mandatory Hospitalization Criteria

Admit immediately if any of the following persist after initial treatment: 1, 5, 6

• PEF <33% predicted after nebulization
• Inability to complete sentences in one breath
• Oxygen saturation <92% on room air
• Any life-threatening features present
• Symptoms recurring within hours despite treatment 6

Lower threshold for admission if: 1

• Attack occurs in afternoon or evening
• Recent nocturnal symptoms or previous severe attacks
• Patient lives alone or has poor social circumstances

Discharge and Follow-Up Management

Medications at Discharge

All discharged patients require: 7, 6

• Prednisolone 30-60 mg daily for 1-3 weeks (NOT the insufficient 5-6 day Medrol dose pack) 6
• Increased dose of inhaled corticosteroid 7
• As-needed albuterol every 4 hours initially, then as needed 6
• Continue or initiate ICS-LABA combination therapy 5

Monitoring Requirements

• Provide peak flow meter and written asthma action plan 7, 6
• Instruct twice-daily peak flow monitoring 5
• Primary care follow-up within 1 week 5, 6
• Respiratory specialist review within 1 month 5

Long-Term Controller Therapy Optimization

When to Step Up Therapy

• Frequent SABA use (>2 days/week) indicates need for controller therapy escalation 1, 2
• Nighttime awakenings requiring SABA indicate inadequate control 1
• Any exacerbation requiring systemic corticosteroids warrants step-up 1

Add-On Therapies for Uncontrolled Asthma

For patients uncontrolled on ICS-LABA: 3

• Add long-acting muscarinic antagonist (tiotropium)
• Consider leukotriene receptor antagonist (montelukast) 5

For allergic asthma (ages 5+ years): 1, 3

• Subcutaneous allergen immunotherapy may be added to standard pharmacotherapy for patients with symptoms and documented sensitization 3
• Sublingual immunotherapy is NOT recommended specifically for asthma 3

For severe uncontrolled asthma despite maximal therapy: 2

• Refer to specialist for consideration of biologic agents (omalizumab for allergic asthma, mepolizumab/benralizumab for eosinophilic asthma)

Critical Pitfalls to Avoid

• Never prescribe antibiotics unless bacterial infection is clearly documented - they do not treat asthma exacerbations 7

• Never use sedatives in asthmatic patients - they are absolutely contraindicated and can cause fatal respiratory depression 7

• Never use short-term corticosteroid courses (5-6 days) for exacerbations - require 1-3 weeks to prevent relapse 6

• Never increase ICS dose alone during exacerbations without adding other therapies - this strategy is not recommended 3

• Never combine Wixela Inhub (or any ICS-LABA) with additional LABA-containing medications due to overdose risk 4

• Avoid strong CYP3A4 inhibitors (ritonavir, ketoconazole, clarithromycin) with ICS-LABA combinations due to increased systemic corticosteroid effects 4

Special Monitoring Considerations

• Adrenal suppression risk: When transferring from systemic corticosteroids to inhaled therapy, taper prednisone by 2.5 mg weekly while monitoring for adrenal insufficiency (fatigue, weakness, nausea, hypotension) 4

• Bone mineral density: Assess initially and periodically in patients on long-term ICS therapy 1

• Pediatric growth: Monitor height in children on ICS therapy 1

• Ophthalmologic effects: Consider referral for patients on long-term ICS who develop ocular symptoms, as glaucoma and cataracts may occur 1

• Cardiovascular effects: Use caution with LABA therapy in patients with coronary insufficiency, arrhythmias, or hypertension - monitor for tachycardia, palpitations, and ECG changes 4