Asthma Treatment Guidelines
Chronic Asthma Management
Inhaled corticosteroids (ICS) are the preferred first-line controller medication for all patients with persistent asthma and should be taken daily on a long-term basis to achieve and maintain control of symptoms. 1
Controller Medications for Persistent Asthma
- Inhaled corticosteroids remain the foundation of asthma therapy because they improve asthma control more effectively than any other single long-term control medication when used consistently 1
- Start low-dose ICS for patients with mild persistent asthma (symptoms >2 days/week but not daily) 1, 2
- For patients aged 12 years and older with persistent asthma requiring combination therapy, use ICS/long-acting beta-agonist (LABA) combinations such as fluticasone/salmeterol 100/50 mcg, 250/50 mcg, or 500/50 mcg twice daily based on severity 3
- Never use LABA monotherapy without ICS, as this increases the risk of serious asthma-related events 3
Alternative Controller Options
- Leukotriene receptor antagonists (montelukast) are an alternative second-line treatment for mild persistent asthma, offering easy once-daily dosing with high compliance rates 1
- For patients 12 years and older, adding LABA to ICS is preferred over adding leukotriene receptor antagonists when ICS alone is insufficient 1
- Montelukast is not indicated for reversal of acute bronchospasm and should not be abruptly substituted for inhaled or oral corticosteroids 4
Rescue Medication
- Short-acting beta-agonists (albuterol/salbutamol) are the most effective therapy for rapid reversal of airflow obstruction and prompt relief of symptoms 1
- Use rescue inhalers only as needed for symptom relief 1
- Increasing use of short-acting beta-agonists (>2 days/week or >2 nights/month) indicates inadequate asthma control and the need to initiate or intensify anti-inflammatory therapy 1
Acute Asthma Exacerbation Management
Severity Assessment
Assess severity immediately using objective measurements before initiating treatment. 1, 2
Mild Exacerbation
- Speech normal, pulse <110 bpm, respiratory rate <25 breaths/min, PEF >50% predicted 1
Acute Severe Asthma
- Cannot complete sentences in one breath 1, 2
- Pulse >110 bpm 1, 2
- Respiratory rate >25 breaths/min 1, 2
- PEF <50% predicted or best 1, 2
Life-Threatening Features
- PEF <33% predicted 2
- Silent chest, cyanosis, weak respiratory effort 2
- Bradycardia, hypotension, exhaustion, confusion, or coma 2
Immediate Treatment Protocol
Administer high-dose inhaled beta-agonists and systemic corticosteroids immediately for all acute severe exacerbations. 2, 5
First-Line Therapy
- Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen (40-60%) as driving gas 1, 2
- Alternative: 4-12 puffs of albuterol via metered-dose inhaler with large-volume spacer if nebulizer unavailable 1
- Add ipratropium bromide 0.5 mg to each nebulization, as this reduces hospitalization rates 6, 7
Systemic Corticosteroids
- Prednisolone 30-60 mg orally OR hydrocortisone 200 mg intravenously immediately 1, 2, 5
- Corticosteroids require 6-12 hours to manifest anti-inflammatory effects, making early administration critical 5
- For patients with vomiting, use intravenous hydrocortisone 200 mg every 6 hours instead of oral corticosteroids 5
Response Assessment
- Reassess PEF 15-30 minutes after initial nebulization 1, 2, 6
- If PEF remains <50% predicted or severe symptoms persist, repeat nebulized treatment and arrange immediate hospital admission 1, 6
- Continue nebulized treatments every 15-30 minutes for three doses initially in severe cases 6
Hospitalization Criteria
Admit to hospital if any of the following are present: 1, 6
- Any life-threatening features 1
- PEF <33% predicted after initial treatment 6
- PEF <50% predicted with persistent symptoms after initial treatment 1
- Oxygen saturation <92% on room air 6
- Inability to complete sentences after treatment 6
Lower threshold for admission if: 1
- Attack occurs in afternoon/evening 1
- Recent nocturnal symptoms or previous severe attacks 1
- Patient unable to assess own condition or poor social circumstances 1
Critical Pitfalls to Avoid
- Never use sedatives in asthmatic patients—they are absolutely contraindicated and can worsen respiratory depression 2, 5
- Do not prescribe antibiotics unless bacterial infection is clearly documented 2, 5
- Do not discharge without ensuring adequate steroid duration (1-3 weeks, not just 5-6 day courses) 5, 6
Discharge and Follow-Up
Discharge Medications
- Prednisolone 30-60 mg daily for 1-3 weeks 5, 6
- Increased or continued inhaled corticosteroid dose 5, 6
- As-needed short-acting beta-agonist 5, 6
- Provide peak flow meter and written asthma action plan 5, 6