Recommended Treatment Plan for Asthma
The treatment plan for asthma depends critically on disease severity and whether you are managing chronic disease or an acute exacerbation—for newly diagnosed adults with chronic asthma, initiate low-dose inhaled corticosteroid (ICS) as first-line controller therapy with as-needed short-acting beta-agonist (SABA) for symptom relief. 1
Initial Assessment and Severity Classification
Before initiating treatment, you must determine asthma severity by evaluating specific parameters 1:
- Daytime symptoms frequency (≤2 days/week suggests intermittent asthma)
- Nighttime awakenings (≤2 times/month suggests intermittent asthma)
- SABA use for symptom relief (>2 days/week indicates need for controller therapy)
- Interference with normal activities
- Objective lung function (FEV1 or PEF measurement)
SABA use more than twice weekly is a critical threshold that mandates controller therapy initiation. 1
Chronic Asthma Management by Severity
Intermittent Asthma
- Treatment: SABA (albuterol/salbutamol) as needed only 1
- No controller medication required if symptoms occur ≤2 days/week, nighttime awakenings ≤2 times/month, and no interference with normal activities 1
Mild Persistent Asthma
- Preferred treatment: Low-dose ICS (fluticasone 100-250 mcg daily or equivalent) 1
- Alternative options (less effective): Cromolyn, leukotriene receptor antagonist, nedocromil, or theophylline 1
- Plus: As-needed SABA for acute symptom relief 1
Moderate Persistent Asthma
- Preferred treatment: Low-dose ICS plus long-acting beta-agonist (LABA) 2
- Alternative: Medium-dose ICS monotherapy 1, 2
- For patients aged 12 years and older, this translates to 1 inhalation of fluticasone/salmeterol 100/50 or 250/50 twice daily 3
Moderate-to-Severe Persistent Asthma
- Preferred treatment: Medium-dose ICS plus LABA 2
- Alternative options: Medium-dose ICS plus leukotriene receptor antagonist, theophylline, or zileuton 2
Severe Persistent Asthma
- Preferred treatment: High-dose ICS plus LABA 2
- Consider: Omalizumab for patients with allergic triggers 2
- Maximum recommended dosage: Fluticasone/salmeterol 500/50 twice daily 3
- Step 6: May require addition of oral corticosteroids 2
Acute Exacerbation Management
Assess severity immediately using objective criteria—delay can be fatal. 4
Mild Exacerbation (PEF >50% predicted)
- Assessment criteria: Speech normal, pulse <110 beats/min, respiration <25 breaths/min 4
- Treatment: Nebulized salbutamol 5 mg or terbutaline 10 mg 4
- Monitor response 15-30 minutes after nebulizer 4
- If PEF 50-75% predicted: Give prednisolone 30-60 mg and step up usual treatment 4
- Follow-up: Surgery review <48 hours 4
Acute Severe Asthma (PEF <50% predicted)
- Assessment criteria: Cannot complete sentences, pulse >110 beats/min, respiration >25 breaths/min 4
- Immediate treatment:
- Monitor response 15-30 minutes after nebulizer 4
- If signs persist: Arrange hospital admission and repeat nebulized ipratropium 0.5 mg or give subcutaneous terbutaline 4
- Follow-up: Surgery review <24 hours 4
Life-Threatening Features (Immediate ICU Transfer)
- Silent chest, cyanosis, feeble respiratory effort, bradycardia, confusion, exhaustion, or coma 4
- Deteriorating PEF, persistent hypoxia or hypercapnia 4
Essential Management Components
Patient Education
Provide a written asthma action plan with specific zone-based instructions: 1, 5
- Green zone (well-controlled): Continue daily controller medication, use SABA only as needed 5
- Yellow zone (caution): Increased symptoms, use SABA every 4 hours, contact clinic if symptoms persist >24 hours 5
- Red zone (medical alert): Inability to complete sentences, respiratory rate >25/min, heart rate >110/min, PEF <50% predicted—seek immediate medical attention 5
Teach proper inhaler technique and have patients rinse mouth with water after ICS use to reduce oropharyngeal candidiasis risk. 3
Environmental Control
- Instruct on trigger avoidance and environmental control measures 1
- For adult-onset asthma, assess occupational exposures 1
Follow-Up Schedule
- Initial phase: Every 2-6 weeks to assess response 1, 5
- Once controlled: Every 1-6 months 1, 5
- Post-exacerbation: Within 24-48 hours 2
Treatment Escalation
If symptoms persist despite low-dose ICS after 4-6 weeks, add a LABA to low-dose ICS or increase to medium-dose ICS monotherapy. 1
If a previously effective regimen fails, reevaluate and consider: 3
- Replacing current strength with higher strength
- Adding additional ICS
- Initiating oral corticosteroids
Critical Pitfalls to Avoid
- Underuse of corticosteroids in acute exacerbations—this is a leading cause of preventable asthma deaths 4
- Overreliance on SABA without addressing underlying inflammation 5
- Using LABA monotherapy without ICS (increases risk of serious asthma-related events) 3
- Failing to provide written action plans 2
- Sedation in acute asthma 2
- Underestimating exacerbation severity—patients may not display all abnormalities even in severe attacks 4
Special Populations
Pediatric Patients (4-11 years)
- Treatment: 1 inhalation of fluticasone/salmeterol 100/50 twice daily for those not controlled on ICS alone 3
- Monitor growth as ICS may affect bone mineral density 3
Comorbidities
Assess and manage conditions that worsen asthma control: 1
- GERD
- Rhinosinusitis
- Obstructive sleep apnea
- Consider subcutaneous allergen immunotherapy if allergic triggers identified 1