What are the initial and subsequent treatment recommendations for asthma management?

Asthma Management

Initial Treatment Approach

For mild asthma, initiate as-needed combination ICS/fast-acting beta-agonist (budesonide-formoterol) rather than SABA alone, as this reduces exacerbations requiring systemic steroids by more than 50% while ensuring anti-inflammatory therapy accompanies symptom relief. 1

Mild Asthma (Intermittent to Mild Persistent)

Primary Strategy:

• As-needed budesonide-formoterol (200 μg/6 μg) is the preferred reliever therapy, taken only when symptomatic 1
• This approach reduces exacerbations requiring systemic steroids from 109 per 1000 to 52 per 1000 patients compared to SABA alone 1
• Hospital admissions and emergency visits are reduced by 65% (OR 0.35) versus SABA monotherapy 1

Alternative (if combination therapy unavailable):

• Regular low-dose ICS (e.g., fluticasone 100-250 μg twice daily) plus as-needed SABA 2
• However, this requires adherence to daily maintenance therapy, which is frequently poor in real-world practice 3

Key Advantage: As-needed ICS/FABA ensures patients receive anti-inflammatory treatment precisely when they use their reliever, addressing the critical problem of SABA overreliance without ICS coverage 4, 3

Moderate to Severe Persistent Asthma

Step-Up Approach:

• Regular maintenance therapy with ICS/LABA combination (e.g., fluticasone/salmeterol 100-500 μg/50 μg twice daily) 5
• Dosing based on severity: Start with 100/50 for moderate disease, 250/50 or 500/50 for more severe disease 5
• Plus as-needed SABA for breakthrough symptoms 6

Important Limitation: Never use LABA as monotherapy—it increases serious asthma-related events and must always be combined with ICS 5

Acute Exacerbation Management

Immediate Recognition and Treatment

Severe Exacerbation Criteria (requiring immediate aggressive treatment):

• Respiratory rate >25/min (adults) or >50/min (children) 2, 7
• Heart rate >110/min (adults) or >140/min (children) 2, 7
• Peak flow <50% predicted 2
• Too breathless to complete sentences 2

Life-Threatening Features:

• Peak flow <33% predicted 2
• Silent chest, cyanosis, feeble respiratory effort 2
• Exhaustion, confusion, drowsiness 2

First-Line Acute Treatment Protocol

Administer simultaneously within first 15 minutes:

1. High-flow oxygen (40-60%) via face mask to maintain SpO₂ >92% 2, 7

2. Nebulized beta-agonist:

   • Adults: Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 6, 2
   • Children: Salbutamol 2.5 mg (age ≤2 years) or 5 mg (age >2 years) 2
   • Alternative: 4-8 puffs via MDI with large-volume spacer every 20 minutes for 3 doses 2, 8

3. Systemic corticosteroids immediately (do not delay):

   • Adults: Prednisolone 30-60 mg orally OR IV hydrocortisone 200 mg 6, 2
   • Children: Prednisolone 1-2 mg/kg (max 60 mg) orally OR IV hydrocortisone 200 mg if vomiting 2, 8

4. Add ipratropium if severe or life-threatening:

   • Adults: 0.5 mg nebulized 6, 2
   • Children: 100-250 μg nebulized 2, 8
   • Repeat every 6 hours 2

Critical Pitfall: Do not delay systemic corticosteroids while giving repeated SABA doses—steroids must be given immediately upon recognition of severe asthma 2

Reassessment and Ongoing Management

Measure peak flow 15-30 minutes after initial treatment: 6, 2

• If improving and PEF >50% predicted: Continue nebulized beta-agonist every 4 hours, maintain oxygen, continue oral prednisolone 6
• If not improving or PEF remains <50%: Increase nebulizer frequency to every 15-30 minutes, consider IV aminophylline (250 mg over 20 minutes) or IV beta-agonist 6

Hospital Admission Criteria:

• PEF <50% predicted 15-30 minutes after treatment 6, 2
• Persistent severe features despite initial treatment 6, 2
• Afternoon/evening presentation (lower threshold for admission) 6
• Concern about patient's ability to assess severity or social circumstances 6

ICU Transfer Indications

Transfer immediately if:

• Deteriorating PEF despite treatment 6
• Worsening hypoxia (PaO₂ <8 kPa) despite 60% oxygen or hypercapnia (PaCO₂ >6 kPa) 6
• Exhaustion, confusion, drowsiness, or decreased consciousness 6, 7
• Respiratory arrest 6

Pediatric-Specific Considerations

Delivery Device Selection:

• MDI with large-volume spacer is preferred over nebulization in children, as it is equally effective and may result in lower admission rates with fewer cardiovascular side effects 2, 8
• Most children under age 7 cannot coordinate unassisted MDI use—always use spacer 2

Discharge Criteria for Children:

• On discharge medications for 24 hours 2
• PEF >75% predicted 2
• No nocturnal symptoms 6
• Diurnal PEF variability <25% 6

Follow-up:

• GP visit within 1 week 2
• Respiratory clinic within 4 weeks 2
• Provide written asthma action plan 8

Treatments to Avoid

Do not use:

• Antibiotics unless bacterial infection confirmed (not for viral triggers) 6, 2
• Any sedation—absolutely contraindicated 6, 7
• Chest physiotherapy—unnecessary 6
• Bolus aminophylline in patients already on oral theophyllines 6

Long-Term Management After Stabilization

Before discharge, ensure:

• Verify proper inhaler technique 8
• Assess adherence to controller therapy 8
• Provide written action plan detailing when to increase bronchodilators and when to seek emergency care 2, 8
• Continue oral corticosteroids until PEF reaches 70% predicted, typically 3-10 days 8
• Intensify maintenance therapy if asthma was not well-controlled prior to exacerbation 8