What is the recommended management approach for a patient with asthma?

Recommended Management Approach for Asthma

Inhaled corticosteroids are the foundation of asthma therapy and should be initiated as first-line controller medication for all patients with persistent asthma, taken daily on a long-term basis to achieve and maintain symptom control. 1

Chronic Asthma Management: Stepwise Approach

Step 1: Assessment and Classification

• Evaluate asthma severity based on symptom frequency, peak expiratory flow (PEF) measurements, nighttime awakenings, and rescue medication use 2, 1
• Intermittent asthma: symptoms <2 days/week, nighttime awakenings <2x/month 2
• Mild persistent: symptoms >2 days/week but not daily, nighttime awakenings 3-4x/month 2, 1
• Moderate persistent: daily symptoms, nighttime awakenings >1x/week but not nightly 2
• Severe persistent: symptoms throughout the day, frequent nighttime awakenings (often 2x/week) 2

Step 2: Reliever Medication for All Patients

• Short-acting beta-agonists (albuterol/salbutamol) are the most effective therapy for rapid symptom relief and should be available to all asthma patients 1
• Use of short-acting beta-agonists >2 days/week or >2 nights/month indicates inadequate control and necessitates initiation or intensification of anti-inflammatory therapy 1
• Critical caveat: Using short-acting beta-agonists alone without regular inhaled corticosteroids is no longer recommended 3

Step 3: Controller Medication Selection

For Mild Persistent Asthma:

• Start low-dose inhaled corticosteroids as first-line therapy 1
• Alternative: Leukotriene receptor antagonists (montelukast) offer once-daily dosing with high compliance rates but are second-line 1

For Moderate Persistent Asthma:

• Add a long-acting beta-agonist (LABA) to inhaled corticosteroids when inhaled corticosteroids alone are insufficient in patients ≥12 years 1
• This combination is preferred over adding leukotriene receptor antagonists 1
• Never use LABAs as monotherapy—they must always be combined with inhaled corticosteroids due to increased risk of severe exacerbations and asthma-related death 2, 4
• Daily LABA use should not exceed 100 mcg salmeterol or 24 mcg formoterol 2

For Severe Persistent Asthma:

• High-dose inhaled corticosteroids plus long-acting beta-agonists 5
• Consider adding long-acting muscarinic antagonists (tiotropium) 6
• Add-on treatments should be optimized before initiating phenotype-specific biologic therapy 3
• Biologic agents (omalizumab, mepolizumab, reslizumab) for severe allergic or eosinophilic asthma uncontrolled on maximal therapy 6, 7

Step 4: Patient Education and Environmental Control

• Provide written asthma action plan for home management 8
• Ensure proper inhaler technique with training from qualified respiratory nurses 2
• Identify and avoid specific allergen sensitivities and triggers (viral infections, smoke, dust, cold air) 5, 6
• Allow children to carry and be responsible for their own inhalers 2

Step 5: Monitoring and Follow-up

• Reassess control every 8-12 weeks using validated tools (Asthma Control Test or asthma APGAR) 5, 7
• Monitor peak expiratory flow regularly 1
• Observe actual inhalation technique at each visit 5
• Step up therapy if control inadequate; step down if well-controlled for ≥3 months 2

Acute Asthma Exacerbation Management

Immediate Assessment

Assess severity using objective measurements before treatment 1, 9:

• Severe features: inability to complete sentences in one breath, respiratory rate >25/min, heart rate >110/min, PEF <50% predicted 2, 1, 9
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia/hypotension, exhaustion, confusion, or coma 2, 1, 9

Immediate Treatment Protocol

1. High-dose inhaled beta-agonists: Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen as driving gas, OR 10-20 puffs via metered-dose inhaler with large spacer device 2, 1, 9

2. Systemic corticosteroids immediately: Prednisolone 30-60 mg orally OR hydrocortisone 200 mg IV 2, 1, 9

3. If life-threatening features present: Add ipratropium 0.5 mg to nebulizer 2, 9

4. High-flow oxygen 40-60% via face mask, maintain oxygen saturation >92% 9

Reassessment and Disposition

• Measure PEF 15-30 minutes after initial treatment to evaluate response 2, 1, 9
• Hospital admission criteria: Any life-threatening features, severe features persisting after initial treatment, PEF <33% predicted after nebulization 2, 1
• Lower threshold for admission: Afternoon/evening presentation, recent nocturnal symptoms, previous severe attacks, concerns about patient's symptom assessment or social circumstances 2, 1

Hospital Management

• Arrange chest radiography to exclude pneumothorax, consolidation, or pulmonary edema 2, 10
• Measure arterial blood gases in all admitted patients with severe asthma 2, 1
• Life-threatening arterial blood gas findings: Normal or high PaCO2 (5-6 kPa) in breathless patient, severe hypoxia (PaO2 <8 kPa), low pH 2
• Check plasma electrolytes, urea, blood count 2, 10
• Continue high-dose steroids: prednisolone 30-60 mg daily or hydrocortisone 200 mg IV every 6 hours 2
• ICU transfer if: Deteriorating despite maximal therapy, persistent/worsening hypoxia or hypercapnia, exhaustion, confusion, or respiratory arrest 9

Discharge Criteria and Follow-up

• Discharge when: On discharge medications for 24 hours, PEF >75% predicted, PEF diurnal variability <25%, no nocturnal symptoms 9
• Discharge medications: Prednisolone 30-60 mg daily for 1-3 weeks, inhaled corticosteroids, albuterol inhaler, peak flow meter with written action plan 9
• Follow-up within 48 hours for severe exacerbations, within 1 week for others 1
• Respiratory specialist follow-up within 4 weeks 1

Critical Pitfalls to Avoid

• Never use sedatives in asthmatic patients—they are contraindicated and worsen respiratory depression 1, 10
• Never prescribe LABAs without concurrent inhaled corticosteroids—this increases mortality risk 2, 4
• Do not give bolus aminophylline to patients already taking oral theophyllines 2
• Do not routinely prescribe antibiotics—only use if bacterial infection is clearly present 1, 10
• Avoid strong CYP3A4 inhibitors (ritonavir, ketoconazole, clarithromycin) with inhaled corticosteroid/LABA combinations due to increased systemic corticosteroid effects 4
• Do not attempt intubation in unconscious/confused patients until the most expert available doctor (ideally an anaesthetist) is present 2