What are the guidelines for treating a patient with asthma?

Guidelines for Treating Asthma

Asthma treatment follows a structured, stepwise approach centered on three core components: objective assessment with spirometry, patient education with written action plans, and controller medications (primarily inhaled corticosteroids) adjusted based on symptom control and exacerbation risk. 1, 2

Initial Assessment and Diagnosis

Confirm Diagnosis with Objective Testing

• Perform spirometry demonstrating variable airflow obstruction through bronchodilator reversibility testing, with improvement of ≥12% and ≥200 mL in FEV1 confirming asthma 2
• Measure peak expiratory flow (PEF) to establish baseline values and evaluate daily variability, with variability >20% suggesting asthma 2
• Repeat spirometry at initial assessment, after treatment initiation when symptoms stabilize, during periods of progressive loss of control, and at least every 1-2 years 1

Document Key Clinical Parameters

• Record frequency of daytime symptoms (chest tightness, cough, shortness of breath, wheezing) 2
• Document nighttime awakenings per week 1, 2
• Assess activity limitations and days of restricted physical activity 1
• Quantify rescue medication use (short-acting beta-agonist puffs per day) 1
• Note any unscheduled visits, ED presentations, or hospitalizations 1

Identify Triggers and Comorbidities

• Perform allergy testing (skin or in vitro tests) in patients with persistent asthma requiring daily medication to identify perennial allergens 2, 3, 4
• Assess for environmental exposures: tobacco smoke, mold, house dust mite, cockroach, animal dander 1
• Screen for comorbidities that impede control: gastroesophageal reflux disease, rhinitis/rhinosinusitis, sleep apnea, obesity 1, 3, 4

Classification and Treatment Selection

Classify Asthma Severity Using Two Domains

• Current impairment: symptoms, nighttime awakenings, rescue medication use, activity limitation, lung function 1, 2
• Future risk: history of exacerbations, ED visits, hospitalizations, declining lung function 1, 2

Stepwise Pharmacological Treatment Algorithm

For Mild Persistent Asthma:

• Initiate daily low-dose inhaled corticosteroids (ICS) as first-line controller therapy 1, 2
• Provide short-acting beta-agonist (SABA) for quick relief of breakthrough symptoms 1, 2
• Leukotriene receptor antagonists are an alternative second-line option with high compliance rates 1

For Moderate Persistent Asthma:

• Use medium-dose ICS or low-dose ICS combined with long-acting beta-agonist (LABA) 1, 2
• Combining LABA with ICS is effective and safe when ICS alone is insufficient, and is preferred over increasing ICS dose 1

For Severe Persistent Asthma:

• Prescribe high-dose ICS-LABA combination as foundation therapy 2
• Consider adding long-acting muscarinic antagonist (triple therapy) to improve symptoms, lung function, and reduce exacerbations 2
• For patients with allergic asthma and elevated IgE, consider omalizumab (anti-IgE monoclonal antibody) administered subcutaneously every 2-4 weeks 3, 4
• For severe asthma with type-2 inflammation, biologics targeting specific cytokines (mepolizumab, reslizumab, benralizumab, dupilumab) improve symptoms and reduce exacerbations 4

Critical Principle: Inhaled corticosteroids are the preferred controller medication because they improve asthma control more effectively than any other single long-term control medication when used consistently 1

Patient Education and Self-Management

Provide Written Asthma Action Plan to All Patients

• Include instructions for daily management: long-term control medications and environmental control measures 1
• Specify what signs, symptoms, and PEF measurements indicate worsening asthma 1
• Detail what medications to take in response to worsening symptoms 1
• Define signs requiring immediate medical care 1
• Written action plans are particularly critical for patients with moderate-severe persistent asthma (steps 4-6), history of severe exacerbations, or poorly controlled asthma 1

Teach Proper Inhaler Technique

• Verify and correct inhaler technique at every visit, as inadequate technique is a common cause of poor control 2
• Use demonstration and return demonstration methods 1

Establish Patient Education Framework

• Educate in simple language about asthma as a chronic lung disease with sensitive, inflamed airways 1
• Distinguish between controller medications (taken daily) and quick-relief medications (used as needed) 2
• Teach patients to recognize symptoms and when to adjust medications 1
• Provide education in multiple settings: clinics, emergency departments, hospitals, schools, and homes 1
• Use varied educational strategies for different health literacy levels: individual instruction, group programs, written materials at 5th grade reading level or below, videotapes, computer programs 1

Common Pitfall: Only 60% of patients receive education on recognizing symptoms, and less than 35% have an Asthma Action Plan, contributing to poor outcomes 1

Monitoring and Adjusting Treatment

Regular Follow-Up Assessment

• Assess asthma control at each visit using validated tools like Asthma Control Test (ACT) or Asthma Control Questionnaire (ACQ) 2
• Classify control into three categories: well-controlled, not well-controlled, very poorly controlled 2
• Review patient concerns about asthma or treatment at every visit 1
• Inquire about difficulties adhering to the action plan 1

Treatment Goals (Outcomes to Achieve)

• Minimal chronic symptoms day and night 2
• Infrequent use of rescue bronchodilators (≤2 days/week for symptom relief) 1, 2
• No limitations on activities including exercise 2
• Normal or near-normal pulmonary function (PEF ≥80% predicted) 2
• Minimal exacerbations and prevention of ED visits or hospitalizations 2

Adjust Treatment Based on Control

• Use a stepwise approach to step up treatment when control is inadequate 2
• Step down treatment when asthma is well-controlled for at least 3 months to find the minimum effective dose 2
• Review medication adherence and inhaler technique before escalating therapy 2

Warning Sign: Increasing use of short-acting beta-agonists (>2 days/week or >2 nights/month) indicates inadequate control and need to initiate or intensify anti-inflammatory therapy 1

Environmental Control Measures

Reduce Exposure to Identified Triggers

• Eliminate tobacco smoke exposure; ask people to smoke outside 1
• Reduce allergen exposure based on specific sensitivities identified through testing 1, 2
• Address environmental factors that cause exacerbations: mold, house dust mite, cockroach, animal dander 1
• Substantially reducing exposure to these factors may reduce inflammation, symptoms, and medication needs 1

Acute Exacerbation Management

Immediate Treatment Protocol for Severe Exacerbations

• Administer high-flow oxygen to maintain saturation >90% 5
• Give nebulized short-acting beta-agonists: albuterol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer, repeated every 20 minutes for 3 doses initially 5, 6
• Provide systemic corticosteroids immediately: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV (benefits require 6-12 hours to manifest) 5
• Add ipratropium 0.5 mg to nebulizer if life-threatening features present 5

Recognize Life-Threatening Features Requiring ICU Consideration

• PEF <33% predicted, silent chest, cyanosis, feeble respiratory effort 5
• Bradycardia, hypotension, exhaustion, confusion, or coma 5
• Normal or elevated PaCO₂ (≥42 mmHg) in a breathless patient 5
• Severe hypoxia (PaO₂ <8 kPa) despite oxygen 5

Critical Pitfall: Never administer sedatives of any kind during status asthmaticus 5

Special Considerations for Disparities

Address Barriers to Guideline-Based Care

• African Americans and Hispanic/Latino patients are less likely to receive guideline-based treatment despite 2-3 times higher asthma-related death rates compared to whites 1
• Consider cultural and ethnic factors, language barriers, health literacy, and socioeconomic circumstances when developing treatment plans 1
• Provide communication skills training to enhance competence in caring for multicultural populations 1
• Incorporate individualized case management by trained professionals for patients with poorly controlled asthma and recurrent ED/hospital visits 1