What is the approach to managing a patient with asthma?

Approach to Asthma Management

The cornerstone of asthma management is establishing the diagnosis with spirometry (in patients ≥5 years), classifying severity to initiate treatment, then continuously monitoring control to adjust therapy using a stepwise approach, with inhaled corticosteroids (ICS) as the foundation of all persistent asthma treatment. 1

Initial Diagnosis and Assessment

Establish the Diagnosis

• Perform spirometry in all patients ≥5 years old to demonstrate reversible airflow obstruction: FEV₁ improvement ≥12% AND ≥200 mL after bronchodilator administration 1
• Document recurrent episodes of wheezing, breathlessness, chest tightness, and cough (particularly nocturnal or early morning) 2, 1
• Obtain detailed history focusing on:
  • Symptom frequency: daytime symptoms per week, nighttime awakenings per month 2, 1
  • Activity limitations: interference with school/work attendance and daily activities 1
  • SABA use frequency: using rescue inhaler >2 days/week indicates inadequate control 1
  • Trigger exposures: allergens, irritants, exercise, infections, medications 2, 1
  • Family history: asthma, allergies, or atopic disorders 2

Rule Out Alternative Diagnoses

• In adults: COPD (especially smokers/elderly), congestive heart failure, vocal cord dysfunction, pulmonary embolism, ACE inhibitor-induced cough 1
• In children: foreign body aspiration, cystic fibrosis, vascular rings, recurrent aspiration 1
• Consider bronchoprovocation testing (methacholine, histamine, exercise) when spirometry is normal but asthma is suspected—a negative test helps rule out asthma 1

Classify Severity (Treatment-Naïve Patients)

Classify severity using both impairment (current symptoms/function) and risk (future exacerbations) domains before initiating therapy: 2, 1

• Intermittent: Symptoms ≤2 days/week, nighttime awakenings ≤2×/month, SABA use ≤2 days/week, no activity interference, FEV₁ >80% predicted 1
• Mild Persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4×/month 1
• Moderate Persistent: Daily symptoms, nighttime awakenings >1×/week, some activity limitation, FEV₁ 60-80% predicted 1
• Severe Persistent: Symptoms throughout the day, nighttime awakenings often 7×/week, extreme activity limitation, FEV₁ <60% predicted 1
• High-risk indicator: ≥2 exacerbations requiring oral corticosteroids in past year 1

Stepwise Pharmacotherapy

ICS are the most effective long-term control therapy and should be initiated for all patients with persistent asthma: 2, 1

Treatment Steps (Ages ≥12 Years)

• Step 1 (Intermittent): SABA as needed only 1
• Step 2 (Mild Persistent): Low-dose ICS 1
• Step 3 (Moderate Persistent): Low-dose ICS + LABA OR medium-dose ICS 2, 1
• Step 4: Medium-dose ICS + LABA 1
• Step 5 (Severe Persistent): High-dose ICS + LABA, consider omalizumab for allergic asthma 1
• Step 6: High-dose ICS + LABA + oral corticosteroids, consider omalizumab for IgE-mediated disease 1

Critical Medication Principles

• SABA (albuterol/salbutamol): Use as needed for symptom relief, up to 3 treatments at 20-minute intervals 1
• SABA use >2 days/week (excluding exercise prophylaxis) indicates inadequate control requiring step-up 1
• LABAs should NEVER be used as monotherapy—always combine with ICS 2
• For patients ≥12 years with inadequate control on low-dose ICS: give equal consideration to either increasing ICS to medium dose OR adding LABA to low-dose ICS 2

Special Populations

• Children 0-4 years: Consider daily long-term control therapy if ≥2 episodes of wheezing in past year, as young children may be at high risk for severe exacerbations despite low impairment 2
• Children 5-11 years: Use age-appropriate dosing; fluticasone propionate inhalation powder at 50-100 mcg twice daily showed growth velocities of 5.67-6.07 cm/year versus 6.32 cm/year for placebo 3

Ongoing Monitoring and Control Assessment

Once therapy is initiated, shift emphasis from severity classification to assessing control, which guides all subsequent treatment adjustments: 2

Visit Frequency

• Every 2-6 weeks when initiating therapy or stepping up 1
• Every 1-6 months once control achieved 1
• Every 3 months when considering step-down 1

Control Assessment Domains

• Impairment: frequency/intensity of current symptoms and functional limitations 2
• Risk: likelihood of future exacerbations 2
• Perform spirometry at least every 1-2 years, more frequently if poorly controlled 1
• Consider daily peak flow monitoring for moderate-severe persistent asthma, history of severe exacerbations, or poor symptom perception 2, 1

Adjusting Therapy

Before Stepping Up Treatment

Always verify these four factors first: 1

1. Medication adherence: Poor adherence is a common reason for uncontrolled asthma 2, 4
2. Correct inhaler technique: Review at every visit; physical/cognitive impairments may prevent proper technique 4
3. Environmental trigger control: Identify and eliminate persistent triggers 1
4. Treatment of comorbidities: Rhinitis, sinusitis, GERD, OSA, obesity 2, 1

Step-Up Criteria

• Step up 1-2 steps if not well-controlled or very poorly controlled 1
• Patients requiring frequent beta-agonist use need regular anti-inflammatory treatment with ICS 4

Step-Down Criteria

• Consider step-down after ≥3 months of well-controlled asthma 1
• Reduce ICS dose by 25-50% 5
• Monitor closely at 3-month intervals during step-down 1
• Do not attempt step-down until sustained control is achieved 5

Patient Education and Self-Management

Develop a written asthma action plan in partnership with the patient, addressing both daily management and managing worsening symptoms: 2, 1

Essential Education Components

• Distinguish long-term control from quick-relief medications: Controller medication (ICS) must be taken daily even when feeling well to prevent inflammation 5
• Teach proper inhaler technique and verify at every visit 2, 1
• Train self-monitoring using either symptoms or peak flow (benefits are similar for most patients) 2
• Identify and avoid triggers: allergens, tobacco smoke, irritants, infections 2, 1
• Consider adding spacer device to metered-dose inhalers to increase lung deposition and reduce systemic absorption 4

Environmental Control

• All patients must avoid tobacco smoke exposure 2, 1
• Multifaceted allergen avoidance for sensitized patients with persistent asthma (single interventions generally ineffective) 2, 1
• Consider allergen immunotherapy (by specifically trained personnel) when clear relationship exists between symptoms and specific allergen exposure 2, 1

Action Plan Instructions

• Initiate or increase ICS when symptoms worsen 2
• Self-administer oral corticosteroids when peak flow falls below previously agreed level or <60% of normal 2
• Seek urgent medical attention when treatment is not working 2

Management of Acute Exacerbations

Immediate Assessment and Treatment

• Administer albuterol 2-4 puffs via metered-dose inhaler with spacer immediately 5
• Measure peak expiratory flow before and 15-30 minutes after bronchodilator 5
• Recognize severe attack features: inability to complete sentences in one breath, respiratory rate >25 breaths/min, PEF <50% predicted 2

Systemic Corticosteroids

• Start oral prednisone 40-60 mg daily for 5-7 days when asthma frequently interrupts sleep or normal daily activities 5
• No taper necessary after short courses of 5-10 days 5
• In children: Prednisolone 1-2 mg/kg orally (maximum 40 mg) repeated for up to 5 days 2

Emergency Department Management

• If PEF ≤50% predicted: Treat as severe attack with high-flow oxygen, nebulized salbutamol 5 mg or terbutaline 10 mg, and oral prednisolone 2
• If unconscious or confused: Call intensive care anaesthetist immediately, provide uninterrupted high-flow oxygen, do not attempt intubation until most expert doctor present 2
• Schedule follow-up within 48 hours to assess response 5

Specialist Referral Indications

Refer for consultation or co-management when: 2, 1

• Difficulty achieving or maintaining control
• ≥2 oral corticosteroid bursts in past year
• Any hospitalization for asthma
• Step 4+ care required
• Immunotherapy or omalizumab considered
• Additional diagnostic testing needed (e.g., suspected occupational asthma, unexplained symptoms suggesting systemic eosinophilia or vasculitis) 2

Common Pitfalls to Avoid

• Never use LABAs as monotherapy—always combine with ICS 2
• Do not prescribe benzodiazepines for anxiety symptoms without first optimizing asthma controller therapy, as symptoms may resolve with better control and reduced beta-agonist use 4
• Never prescribe sedatives during acute exacerbations or to patients with poorly controlled asthma—this increases mortality risk 4
• Do not continue escalating beta-agonist doses without addressing underlying inflammation with ICS 4
• Aminophylline should no longer be used in children at home 2