What is the guideline for treating asthma and exacerbations in patients presenting to a primary care clinic?

Asthma and Exacerbation Management in Primary Care

For stable asthma, initiate treatment with inhaled corticosteroids (ICS) even for intermittent symptoms, and for acute exacerbations, immediately administer short-acting beta-agonists (SABAs) every 20 minutes for three doses plus oral corticosteroids 40-60 mg daily, then reassess within 30 minutes to determine disposition. 1, 2, 3

Initial Diagnosis and Assessment

Making the diagnosis requires three key elements:

• Episodic symptoms of airflow obstruction (wheezing, recurrent cough, difficulty breathing, chest tightness) 1
• Spirometry showing at least partially reversible airflow obstruction (for patients ≥5 years) 1
• Exclusion of alternative diagnoses through focused history and physical examination 1

Key diagnostic indicators to look for:

• Symptoms that worsen with specific triggers (allergens, exercise, viral infections, cold air, irritants) 1
• Nocturnal awakening from respiratory symptoms 1
• Family history of asthma, allergy, or atopic disorders 1
• Pattern of symptoms: perennial vs. seasonal, continual vs. episodic 1

Classification System for Treatment Decisions

Assess severity at initial presentation using two domains:

Current Impairment (symptoms and function):

• Daytime symptoms: ≤2 days/week = intermittent; >2 days/week = persistent 1
• Nighttime awakenings: ≤2x/month = well-controlled; >2x/month = not well-controlled 1
• SABA use for symptoms: ≤2 days/week = well-controlled; >2 days/week = not well-controlled 1
• Interference with normal activity: none = well-controlled; any limitation = not well-controlled 1
• Lung function: FEV1 or peak flow >80% predicted = well-controlled 1

Future Risk (exacerbations):

• 0-1 exacerbations requiring oral corticosteroids per year = low risk 1
• ≥2 exacerbations per year = high risk, indicating need for step-up therapy 1

Stepwise Treatment Algorithm for Stable Asthma

Step 1 (Intermittent Asthma):

• All patients require ICS, even with sporadic symptoms—do not rely on SABA alone 4, 5
• Low-dose ICS (budesonide 0.25-0.5 mg daily via nebulizer for children 12 months-8 years) 6
• SABA as needed for symptom relief, ≤2 days/week 1

Step 2 (Mild Persistent):

• Low-dose ICS daily (up to 400 mcg beclomethasone equivalent) 1
• SABA as needed 1
• Consider adding long-acting beta-agonist (LABA) if symptoms persist, but never use LABA as monotherapy 1

Step 3 (Moderate Persistent):

• Medium-dose ICS (400-800 mcg beclomethasone equivalent) 1
• Add LABA for patients ≥12 years with inadequate control on low-dose ICS 1
• Alternative: increase ICS dose or add leukotriene modifier 1

Step 4-6 (Severe Persistent):

• High-dose ICS plus LABA 1
• Consider omalizumab for patients ≥12 years with allergic asthma 1
• Consider allergy immunotherapy for patients ≥5 years 1
• Refer to specialist if requiring ≥2 oral corticosteroid bursts per year or recent hospitalization 1

Acute Exacerbation Management in Office

Immediate assessment priorities:

• Respiratory rate >25/min, heart rate >110/min, inability to complete sentences = severe exacerbation 7
• Peak expiratory flow (PEF) or FEV1: <40% predicted = severe; 40-69% = moderate; ≥70% = mild 7, 3
• Oxygen saturation <90% requires immediate oxygen therapy 7, 3

Initial treatment (first hour):

• Oxygen via nasal cannula or mask to maintain SpO2 >90% (>95% if pregnant or heart disease) 7, 3
• Albuterol 2.5-5 mg via nebulizer OR 4-8 puffs via MDI with spacer every 20 minutes for 3 doses 7, 3, 5
• Oral prednisolone 40-60 mg immediately (children: 1-2 mg/kg, max 60 mg) 2, 3, 5
• Add ipratropium bromide 0.5 mg to nebulizer (or 8 puffs MDI) for severe exacerbations 7, 3

Reassessment at 30-60 minutes:

• If PEF ≥70% predicted and symptoms minimal: discharge home with oral corticosteroids for 5-10 days 3, 5
• If PEF 40-69% or persistent symptoms: continue SABA every 60 minutes, observe 1-3 hours 7
• If PEF <40% or severe distress: transfer to emergency department immediately 7, 3

Discharge Planning After Exacerbation

Mandatory discharge medications:

• Oral corticosteroids: prednisolone 40-60 mg daily for 5-10 days (no taper needed for courses <2 weeks) 1, 2, 3
• Continue or initiate ICS at appropriate step level 2, 3
• SABA for as-needed relief, 2-4 puffs every 4-6 hours as needed 2

Discharge criteria (all must be met):

• PEF ≥70% of predicted or personal best 3, 5
• Oxygen saturation stable on room air 3
• Symptoms minimal or absent 3
• Stable for 30-60 minutes after last bronchodilator dose 3
• Patient has been on discharge medications for 24 hours 2, 7

Essential discharge components:

• Verify correct inhaler technique before discharge 2, 7
• Provide written asthma action plan with specific PEF thresholds for treatment escalation 2, 7, 3
• Schedule follow-up with primary care within 1 week 2, 7
• Provide peak flow meter for home monitoring 7

Monitoring Asthma Control at Follow-Up Visits

Use the Asthma Control Test (ACT) for quick assessment:

• 5 questions scored 1-5 each, total score 5-25 1, 8
• Score ≥20 = well-controlled (in conjunction with clinical assessment) 1
• Score <20 = not well-controlled, requires treatment adjustment 1, 8

Objective measures at every visit:

• Daytime symptoms frequency 1
• Nighttime awakenings frequency 1
• SABA use frequency 1
• Activity limitation 1
• Spirometry or peak flow measurement 1
• Exacerbations in past year 1

Step down therapy only after:

• 3 months of good control demonstrated 1
• No exacerbations during that period 1
• Reduce ICS dose by 25-50% every 3 months while maintaining control 1

Common Pitfalls to Avoid

Treatment errors:

• Never use LABA without concurrent ICS—increases mortality risk 1
• Do not accept ongoing symptoms as "normal" for asthma—all patients can achieve control 1
• Avoid β-blockers (even selective) in all asthma patients—can precipitate severe bronchospasm 1
• Do not prescribe antibiotics for exacerbations unless clear bacterial infection (fever with purulent sputum, pneumonia on x-ray) 3

Assessment errors:

• Physicians' subjective assessments of airway obstruction are often inaccurate—always use objective measures (PEF or FEV1) 9
• Pulse oximetry >90% can miss CO2 retention—consider arterial blood gas if severe 9
• Do not rely on wheezing alone—decreased breath sounds indicate more severe obstruction 9

Discharge errors:

• Inadequate duration of oral corticosteroids (<5 days) significantly increases relapse risk 2, 3
• Not checking inhaler technique results in medication delivery failure 2, 7
• Omitting written action plan increases relapse rates 2, 7

Special Considerations

Triggers to address:

• Smoking cessation counseling at every visit—nicotine patches can help 1
• Avoid passive smoke exposure 1
• Identify and avoid allergen triggers (house dust mite, pets, pollens) 1
• Influenza vaccination annually (though does not reduce exacerbation frequency) 1
• Screen for and treat gastroesophageal reflux disease if present 1

When to refer to specialist:

• ≥2 oral corticosteroid bursts per year 1
• Recent hospitalization for asthma 1
• Requiring Step 4 or higher therapy 1
• Considering immunotherapy or omalizumab 1
• Diagnostic uncertainty 1