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

Management of Asthma

Asthma management requires a stepwise approach based on disease severity and control, with inhaled corticosteroids (ICS) as the foundation of therapy for all patients with persistent asthma, combined with short-acting beta-agonists for symptom relief—critically, short-acting beta-agonists should never be used alone without ICS-based controller therapy. 1, 2

Initial Assessment and Classification

Severity Classification for Treatment Initiation

Classify asthma severity before starting therapy using both impairment and risk domains 1:

Impairment Domain:

• Intermittent: Symptoms <2 days/week, nighttime awakenings <2x/month, SABA use <2 days/week, no interference with normal activity, FEV1 >80% predicted 1
• Mild Persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4x/month, SABA use >2 days/week but not daily, minor limitation of activity, FEV1 >80% predicted 1
• Moderate Persistent: Daily symptoms, nighttime awakenings >1x/week but not nightly, daily SABA use, some limitation of activity, FEV1 60-80% predicted 1
• Severe Persistent: Symptoms throughout the day, nighttime awakenings often 7x/week, SABA use several times per day, extreme limitation of activity, FEV1 <60% predicted 1

Risk Domain:

• Patients with ≥2 exacerbations requiring oral corticosteroids in the past year should be considered to have persistent asthma regardless of symptom frequency 1

Stepwise Pharmacological Management

Step 1: Intermittent Asthma

• Quick-relief only: SABA as needed for symptoms 1
• Critical update: SABA alone without ICS is no longer recommended even for intermittent asthma due to increased exacerbation risk 3, 4

Step 2: Mild Persistent Asthma

• Preferred: Low-dose ICS daily 1, 2
• Alternative: Leukotriene receptor antagonist (montelukast) for patients who cannot or will not use ICS 1, 2
• Quick-relief: SABA as needed 1

Step 3: Moderate Persistent Asthma

• Preferred: Low-dose ICS plus long-acting beta-agonist (LABA) 1
• Alternative: Medium-dose ICS alone, or low-dose ICS plus leukotriene receptor antagonist 1
• Critical warning: LABAs must never be used as monotherapy; always combine with ICS due to FDA black box warning regarding increased risk of severe exacerbations and asthma-related deaths 1
• LABA dosing limits: Do not exceed 100 mcg salmeterol or 24 mcg formoterol daily 1
• Quick-relief: SABA as needed 1

Step 4: Severe Persistent Asthma

• Preferred: Medium-dose ICS plus LABA 1
• Alternative: Medium-dose ICS plus leukotriene receptor antagonist or theophylline 1
• Important consideration: Higher ICS doses provide minimal additional benefit beyond medium doses while significantly increasing systemic side effects (reduced growth in children, decreased bone density in adults) 1
• Quick-relief: SABA as needed 1

Step 5: Severe Uncontrolled Asthma

• Preferred: High-dose ICS plus LABA 1
• Add-on therapy: Consider omalizumab (anti-IgE) for patients ≥12 years with allergic asthma (elevated IgE, positive skin test or RAST) whose symptoms remain inadequately controlled 1
• Alternative add-ons: Leukotriene receptor antagonist or theophylline 1
• Quick-relief: SABA as needed 1

Step 6: Severe Refractory Asthma

• Preferred: High-dose ICS plus LABA plus oral corticosteroids 1
• Add-on therapy: Omalizumab for eligible patients 1
• Before initiating oral corticosteroids: Trial high-dose ICS, LABA, leukotriene receptor antagonist, or theophylline combinations 1
• Quick-relief: SABA as needed 1

Monitoring and Adjusting Therapy

Assessment of Control

Evaluate control at every visit using impairment and risk domains 1:

Well-Controlled:

• Symptoms ≤2 days/week
• Nighttime awakenings ≤2x/month
• SABA use ≤2 days/week (not for exercise-induced bronchospasm prevention)
• No interference with normal activity
• FEV1 or peak flow >80% predicted
• 0-1 exacerbations requiring oral corticosteroids per year 1

Not Well-Controlled:

• Symptoms >2 days/week
• Nighttime awakenings 1-3x/week
• SABA use >2 days/week
• Some limitation of activity
• FEV1 or peak flow 60-80% predicted
• ≥2 exacerbations requiring oral corticosteroids per year 1

Very Poorly Controlled:

• Symptoms throughout the day
• Nighttime awakenings ≥4x/week
• SABA use several times per day
• Extreme limitation of activity
• FEV1 or peak flow <60% predicted
• ≥2 exacerbations requiring oral corticosteroids per year 1

Stepping Up Therapy

Before stepping up, always verify: 1

• Correct inhaler technique
• Medication adherence
• Environmental trigger control
• Treatment of comorbid conditions (rhinitis, GERD, obesity)

Step up if: 1

• Asthma is not well-controlled for ≥3 months
• Patient experiences exacerbations requiring oral corticosteroids
• SABA use exceeds 2 days/week for symptom relief (not EIB prevention) 1, 2

Stepping Down Therapy

Step down only when: 1

• Asthma has been well-controlled for at least 3 months
• Patient is at low risk for exacerbations
• Lung function is stable

Approach: 1

• Reduce ICS dose by 25-50%
• If on combination therapy, consider discontinuing LABA while maintaining ICS
• Monitor closely for 2-4 weeks after each step down

Acute Exacerbation Management

Severity Assessment

Mild Exacerbation: 2

• Speech normal
• Pulse <110 bpm
• Respiratory rate <25 breaths/min
• Peak flow >50% predicted

Severe Exacerbation: 2

• Cannot complete sentences in one breath
• Pulse >110 bpm
• Respiratory rate >25 breaths/min
• Peak flow <50% predicted

Life-Threatening: 2

• Peak flow <33% predicted
• Silent chest, cyanosis
• Weak respiratory effort
• Bradycardia, hypotension
• Exhaustion, confusion, coma

Immediate Treatment

Bronchodilator Therapy: 1, 2

• Nebulized albuterol 5 mg (or terbutaline 10 mg) with oxygen
• Repeat every 20 minutes for 3 doses initially
• Continue every 1-4 hours as needed based on response
• Measure peak flow 15-30 minutes after initial treatment 2

Systemic Corticosteroids: 1, 5, 2

• Oral (preferred): Prednisone 40-60 mg daily for adults, 1-2 mg/kg/day (max 60 mg) for children 5
• IV (if vomiting or severely ill): Hydrocortisone 200 mg immediately, then 200 mg every 6 hours 5, 2
• Duration: 5-10 days for outpatient management; no taper needed for courses <7-10 days if on ICS 5
• Critical timing: Administer within 1 hour of presentation; effects take 6-12 hours to manifest 5

Oxygen Therapy: 2

• High-flow oxygen 40-60% to maintain SpO2 >92%

Disposition Criteria

Admit to hospital if: 2

• Life-threatening features present
• Peak flow <50% predicted after initial treatment
• SpO2 <92% on room air
• Attack occurs in afternoon/evening
• Recent nocturnal symptoms or previous severe attacks
• Poor social circumstances or inability to cope at home

Discharge from ED if: 2

• Peak flow >70% predicted or personal best
• Symptoms resolved or minimal
• Patient can ambulate comfortably
• Home medications and follow-up arranged

Special Considerations

Allergen Immunotherapy

• Consider subcutaneous immunotherapy for patients with allergic asthma at Steps 2-4 1
• Role of allergy is greater in children than adults 1
• Clinicians must be prepared to treat anaphylaxis 1

Referral to Specialist

Refer when: 1

• Difficulty achieving or maintaining control
• ≥2 bursts of oral corticosteroids in 1 year
• Exacerbation requiring hospitalization
• Step 4 or higher care required (Step 3 or higher for children 0-4 years)
• Considering immunotherapy or omalizumab
• Additional testing indicated

Critical Pitfalls to Avoid

Never use SABA alone without ICS-based controller therapy in patients with persistent asthma—this increases exacerbation risk and mortality 1, 3, 4

Never use LABAs as monotherapy—always combine with ICS due to increased risk of asthma-related death 1

Never use sedatives in asthmatic patients—they are contraindicated and worsen respiratory depression 6, 2

Do not delay systemic corticosteroids during acute exacerbations—early administration is critical as effects take 6-12 hours 5

Do not rely on clinical impression alone—always measure peak flow or FEV1 objectively 2

Do not assume control is adequate if SABA use exceeds 2 days/week—this indicates need to step up therapy 1, 2

Avoid unnecessarily high ICS doses—medium doses provide most benefit with minimal additional improvement at high doses but significantly increased side effects 1