What is the initial management plan for a patient with bronchial asthma?

Initial Management of Bronchial Asthma

Begin with as-needed low-dose inhaled corticosteroid-formoterol (ICS-formoterol) for all patients with newly diagnosed asthma, even those with infrequent symptoms, as this approach significantly reduces moderate-to-severe exacerbations compared to short-acting beta-agonist (SABA) monotherapy. 1, 2

Immediate Assessment

Severity Classification

• Measure peak expiratory flow (PEF) at presentation to objectively determine severity—if PEF is ≤50% of predicted or patient's personal best, treat as a severe attack 2
• Assess ability to speak in complete sentences: inability to complete sentences in one breath indicates severe asthma 1
• Count respiratory rate: >25 breaths/min in adults or >50 breaths/min in children indicates severe asthma 1
• Check pulse: >110 beats/min in adults or >140 beats/min in children indicates severe asthma 1

Life-Threatening Features (Require Immediate ICU Consideration)

• PEF <33% of predicted or feeble respiratory effort 1, 3
• Silent chest, cyanosis, or bradycardia 1, 3
• Hypotension, exhaustion, confusion, or altered consciousness 1, 3
• Hypercapnia (PaCO2 >45 mmHg) or respiratory acidosis 3

Initial Pharmacological Management

For Mild Asthma (Infrequent Symptoms)

• Prescribe as-needed low-dose ICS-formoterol (e.g., budesonide-formoterol 160/4.5 μg, 1-2 inhalations as needed) as first-line therapy 1, 2
• This replaces the outdated approach of SABA-only therapy, which increases exacerbation risk 1
• Maximum daily dose should not exceed 8 inhalations 4

For Moderate Persistent Asthma

• Start regular daily low-dose ICS (beclomethasone equivalent up to 800 μg/day) plus as-needed SABA 2
• Alternative: as-needed combination ICS-SABA taken together when symptoms occur for patients ≥12 years 5
• Specific regimen: 2-4 puffs of albuterol followed by 80-250 μg beclomethasone equivalent every 4 hours as needed 5

For Severe Persistent Asthma

• Initiate medium-to-high-dose ICS-LABA combination therapy as this demonstrates synergistic anti-inflammatory effects superior to doubling ICS dose alone 4
• Consider adding long-acting muscarinic antagonist (LAMA) as triple therapy to improve symptoms, lung function, and reduce exacerbations 4, 6
• Add leukotriene modifiers as adjunct therapy if needed 5

Acute Severe Asthma Management

Immediate Treatment Protocol

• Administer high-flow oxygen 40-60% via face mask to maintain SaO2 >92%—CO2 retention is NOT aggravated by oxygen therapy in asthma 1, 3
• Give nebulized salbutamol 5-10 mg (or terbutaline 5-10 mg) via oxygen-driven nebulizer immediately 1, 2
• Administer systemic corticosteroids: oral prednisolone 30-60 mg OR intravenous hydrocortisone 200 mg 1, 2
• Add ipratropium 0.5 mg to nebulizer if patient not improving after 15-30 minutes, repeat every 6 hours 1

Monitoring During Acute Treatment

• Repeat PEF measurement 15-30 minutes after starting treatment 1, 2
• Maintain continuous pulse oximetry with target SaO2 >92% 1, 2
• Repeat arterial blood gas within 2 hours if initial PaO2 <60 mmHg or if PaCO2 was normal/elevated initially 1, 3
• Chart PEF before and after each nebulizer treatment 1

ICU Transfer Criteria

Transfer immediately with physician prepared to intubate if: 3

• Deteriorating PEF despite treatment
• Worsening or persisting hypoxia or hypercapnia
• Exhaustion, confusion, drowsiness, or coma
• Respiratory arrest

Medication Delivery and Technique

Device Selection

• Start with metered-dose inhaler (MDI) with large-volume spacer for most patients to optimize drug delivery and reduce oropharyngeal deposition 2
• For nebulized medications, use jet nebulizer connected to air compressor—ultrasonic nebulizers are NOT recommended for budesonide 7
• Check and document inhaler technique at every visit as poor technique is a major cause of treatment failure 1, 2

Patient Education and Self-Management Plan

Written Asthma Action Plan Components

Provide written instructions detailing: 1, 2

• How to recognize early warning signs (increased nocturnal symptoms, decreased PEF)
• When to increase ICS dose or add oral corticosteroids
• Specific PEF threshold for self-initiating oral prednisolone (typically <60% of personal best)
• When to seek urgent medical attention

Peak Flow Monitoring

• Prescribe peak flow meter and teach proper technique at initial visit 2
• Instruct patient to measure PEF twice daily and record in diary 1
• Establish personal best PEF during period of good control 1

Follow-Up Schedule

Initial Phase

• Schedule follow-up within 1 week after any acute episode or treatment initiation 2, 5
• Arrange visits every 2-4 weeks initially, then every 1-3 months once stable control achieved 4

Discharge Criteria After Acute Episode

Patient must have: 1

• Been on discharge medications for 24 hours
• PEF >75% of predicted or personal best
• Documented correct inhaler technique
• Written self-management plan
• Follow-up with primary care within 1 week
• Respiratory specialist appointment within 4 weeks if hospitalized

Special Considerations and Contraindications

Absolute Contraindications

• Never use sedatives in patients with acute asthma—they are absolutely contraindicated and can precipitate respiratory arrest 1, 3
• Do not use LABA monotherapy without ICS as this increases risk of serious asthma-related events 8

Pregnancy Considerations

• Budesonide is the preferred ICS during pregnancy as more safety data exists 1
• Albuterol is the preferred SABA 1
• It is safer to treat with asthma medications than to have poorly controlled asthma during pregnancy 1

Common Pitfalls to Avoid

• Do not withhold oxygen due to hypercapnia concerns—this is a dangerous misconception as CO2 retention does not worsen with oxygen therapy in asthma 1, 3
• Do not rely solely on SABA therapy even for mild asthma—this outdated approach increases exacerbation risk 1, 2
• Do not assume patient is improving based on reduced wheezing—a "silent chest" indicates life-threatening bronchospasm 1, 3
• Do not discharge patients who have not shown significant improvement after 2 hours of maximum therapy 9

Monitoring for Adverse Effects

• Assess for oral candidiasis at each visit in patients on ICS—instruct to rinse mouth after each use 7
• Monitor growth in pediatric patients on long-term ICS 1
• Consider bone mineral density screening in patients on high-dose ICS or frequent oral corticosteroids 1
• Refer for ophthalmology evaluation if using ICS long-term to screen for cataracts and glaucoma 1