Approach to Asthma Management

Initial Assessment: Classify Severity Before Starting Treatment

Assess asthma severity at the first encounter to determine where to initiate therapy, then shift focus to monitoring control for all subsequent visits to guide treatment adjustments. 1, 2

Severity Classification (For Treatment-Naive Patients)

Classify using both impairment (current symptoms) and risk (future exacerbations) domains: 1, 3

Impairment measures over the past 2-4 weeks: 3

Daytime symptom frequency
Nighttime awakenings per week
SABA use for symptom relief
Interference with normal activities
Lung function (FEV1/FVC ratio for patients ≥5 years) 2, 3

Risk assessment: 3

Count exacerbations requiring oral corticosteroids in the past year
≥2 exacerbations = persistent asthma regardless of symptom frequency 3

Severity categories: 2

Intermittent: Symptoms <2 days/week, no nighttime awakenings
Mild persistent: Symptoms >2 days/week but not daily
Moderate persistent: Daily symptoms
Severe persistent: Symptoms throughout the day

Stepwise Pharmacological Management

Step 1: Intermittent Asthma

SABA as needed only (no daily controller medication) 2, 3, 4
Critical update: SABA-only treatment is no longer recommended for any patient not using regular ICS 5

Step 2: Mild Persistent Asthma

Low-dose ICS daily (fluticasone propionate 100-250 mcg/day or equivalent) as preferred controller 2, 3, 4
Continue SABA as needed for symptom relief 3
Alternative options: low-dose ICS plus LTRA, theophylline, or zileuton 3

Step 3: Moderate Persistent Asthma

Low-to-medium dose ICS (fluticasone 100-250 mcg/day) as preferred therapy 2, 3
Consider adding LABA: fluticasone/salmeterol 100/50 mcg or 250/50 mcg twice daily 2

Step 4: Moderate-to-Severe Persistent Asthma

Medium-dose ICS plus LABA as preferred combination 2, 3
Never use LABA as monotherapy—this increases mortality risk 3, 4, 6

Step 5: Severe Persistent Asthma

High-dose ICS plus LABA 3
Consider adding omalizumab for documented allergic asthma with elevated IgE 3
Consider subcutaneous allergen immunotherapy for single allergen sensitivity (clinician must be prepared to treat anaphylaxis) 3, 4

Monitoring and Adjusting Therapy: Assess Control

Once treatment is initiated, stop assessing severity and start assessing control at every visit: 1

Control Assessment Measures

Symptom frequency and SABA use
Nighttime awakenings
Activity limitation
Lung function (spirometry)
Exacerbation frequency 1

Treatment Adjustment Algorithm

Reassess control every 2-6 weeks initially, then every 1-6 months once stable: 2, 3

If control is inadequate, before stepping up therapy: 2, 4

Verify proper inhaler technique
Assess medication adherence
Identify environmental triggers
Evaluate comorbid conditions (rhinitis, GERD, OSA, obesity) 1

Step up therapy if control remains inadequate after addressing above factors 2

Step down therapy once well-controlled for ≥3 months to find minimum effective dose 2, 3, 4

Acute Exacerbation Management

Severity Assessment

Life-threatening features requiring immediate intervention: 2, 3, 4

Inability to complete sentences in one breath
Respiratory rate >25/min
Heart rate >110/min
Peak expiratory flow (PEF) <50% predicted or personal best
Oxygen saturation <92% on room air 1

Immediate Treatment

For severe exacerbations: 1, 2

High-flow oxygen 40-60% via face mask to maintain saturation >92%
Nebulized albuterol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer every 20-30 minutes for three doses
Add ipratropium bromide 0.5 mg to each nebulization 2
Oral corticosteroids early: prednisolone 30-60 mg (adults) or 1-2 mg/kg (children, maximum 40 mg) 1, 3

Reassessment and Disposition

Reassess after 15-30 minutes 2
Hospital admission criteria: 4
- Life-threatening features persist after initial treatment
- PEF <33% predicted 15-30 minutes post-nebulization
- Oxygen saturation <92% on room air

Critical Pitfalls to Avoid

Do not use sedatives in asthma exacerbations—they worsen respiratory depression 4
Do not prescribe antibiotics unless clear bacterial infection is documented 4
Do not attempt intubation until the most expert available clinician (ideally an anesthesiologist) is present 1

Patient Education and Self-Management

Essential Education Components

Every patient must understand: 2, 3, 4

"Relievers" vs. "Preventers": SABA bronchodilators provide quick relief; ICS medications prevent inflammation and must be taken daily even when feeling well
Proper inhaler technique (verify at every visit)
Recognition of worsening symptoms requiring action
Peak flow monitoring technique

Written Asthma Action Plan

All patients require a written action plan with three elements: 3, 4

Symptom/peak flow monitoring instructions
Prearranged patient-initiated actions for worsening symptoms
Written guidance for medication adjustments

Special Populations

Children 0-4 Years

Start Step 2 with low-dose ICS 2
Reassess in 4-6 weeks; consider alternative diagnoses if no benefit 2

Children 5-11 Years

Maximum dose: fluticasone/salmeterol 100/50 mcg twice daily 2
Monitor growth velocity with all ICS use 2, 6
ICS may cause reduction in growth velocity; weigh benefits against risks 6

Adults ≥65 Years

Higher incidence of serious adverse events, particularly pneumonia with ICS/LABA combinations 6
Exercise special caution with beta2-agonists in patients with cardiovascular disease 6
No dosage adjustment required based on age alone 6

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