What is the recommended treatment plan for a patient with asthma?

Asthma Treatment and Management

For newly diagnosed asthma in adults, initiate low-dose inhaled corticosteroids (fluticasone 100-250 mcg daily or equivalent) as first-line controller therapy, combined with as-needed short-acting beta-agonist (albuterol) for symptom relief. 1, 2

Initial Assessment and Classification

Before initiating treatment, classify asthma severity based on specific clinical parameters 1:

• Intermittent asthma: Symptoms <2 days/week, nighttime awakenings ≤2 times/month, no interference with activities 1, 2
• Mild persistent: Symptoms >2 days/week but not daily 1
• Moderate persistent: Daily symptoms 1
• Severe persistent: Symptoms throughout the day 1

Measure FEV1 using spirometry in all patients ≥5 years old to objectively determine severity and confirm reversible airway obstruction. 1, 3

Stepwise Pharmacological Management

Step 1: Intermittent Asthma

• Use only as-needed short-acting beta-agonist (albuterol/salbutamol 2-4 puffs via MDI with spacer, or 2.5-5 mg via nebulizer) for symptom relief. 2, 4
• No daily controller medication required 2

Step 2: Mild Persistent Asthma

• Initiate low-dose inhaled corticosteroid (fluticasone propionate 100-250 mcg/day or equivalent) as daily controller therapy. 1, 2
• Continue as-needed SABA for acute symptoms 2
• Alternative options (less effective): cromolyn, leukotriene receptor antagonist, nedocromil, or theophylline 2, 5

Critical threshold: SABA use >2 days/week indicates inadequate control and need for controller therapy. 2, 6

Step 3: Moderate Persistent Asthma

• Preferred: Low-to-medium dose ICS (fluticasone 100-250 mcg) PLUS long-acting beta-agonist (LABA), specifically fluticasone/salmeterol 100/50 mcg or 250/50 mcg twice daily. 1, 7
• Alternative: Increase to medium-dose ICS monotherapy 2

Never use LABA monotherapy—it increases risk of serious asthma-related events and death. 7, 3

Step 4: Severe Persistent Asthma

• High-dose ICS plus LABA, with consideration of adding long-acting muscarinic antagonist (tiotropium) or leukotriene receptor antagonist. 1, 3
• For severe uncontrolled asthma despite maximal therapy, consider biologic agents (omalizumab for allergic asthma, mepolizumab/reslizumab for eosinophilic asthma) after specialty referral 6, 3

Acute Exacerbation Management

Severity Assessment

Recognize severe exacerbation by these indicators 1, 8:

• Inability to complete sentences in one breath 8
• Respiratory rate >25/min 8
• Heart rate >110 bpm 8
• Peak expiratory flow <50% predicted or personal best 1, 8
• Oxygen saturation <92% on room air 8

Immediate Treatment Protocol

For severe exacerbations, administer simultaneously 9, 1, 8:

1. High-flow oxygen 40-60% to maintain SpO2 >92% 9, 1
2. Nebulized albuterol 5 mg (or 4-12 puffs via MDI with spacer) every 20-30 minutes for three doses 9, 8
3. Add ipratropium bromide 0.5 mg to each nebulization (or 8 puffs via MDI)—this reduces hospitalization rates 9, 8
4. Systemic corticosteroids: Oral prednisone 30-60 mg (or 0.6 mg/kg) OR IV hydrocortisone 200 mg immediately 9, 8

Reassess after 15-30 minutes to determine need for hospitalization. 9, 8

Hospitalization Criteria

Admit if any of the following persist after initial treatment 9, 1:

• PEF remains <50% predicted 9, 8
• Continued inability to speak in full sentences 8
• Persistent hypoxia (SpO2 <92%) despite oxygen 9
• Deteriorating mental status, exhaustion, or confusion 9

Outpatient Management Post-Exacerbation

If improved after initial treatment, discharge with 8:

• Prednisone 30-60 mg daily for 1-3 weeks (NOT the insufficient 5-6 day Medrol dose pack) 8
• Continue or increase inhaled corticosteroid dose 8
• Albuterol every 4 hours as needed 8
• Written asthma action plan and peak flow meter 9, 8
• Follow-up: Primary care within 24-48 hours, respiratory specialist within 4 weeks 1, 8

Essential Patient Education Components

Provide a written asthma action plan to all patients, particularly those with moderate-severe asthma or history of severe exacerbations. 9, 1

Key Educational Points

• Distinguish "controllers" (ICS—prevent symptoms, taken daily) from "relievers" (SABA—quick relief, not for long-term control) 9, 1
• Demonstrate proper inhaler technique and have patient return demonstration 9
• Use spacer/valved holding chamber with MDI 9
• Rinse mouth with water after ICS use to prevent oral candidiasis 7
• Identify and avoid environmental triggers (allergens, tobacco smoke, irritants) 9, 10
• Recognize early warning signs of worsening asthma 9

Written Action Plan Zones 9, 2

• Green zone: Well-controlled, continue daily medications
• Yellow zone: Worsening symptoms, increase SABA, may need to increase controller
• Red zone: Severe symptoms, take oral corticosteroids, seek immediate medical care

Monitoring and Follow-Up

Assess control every 2-6 weeks initially; once stable, extend to every 1-6 months. 1, 2

At each visit 9, 1:

• Review symptom frequency (daytime and nighttime) 9
• Assess SABA use frequency—>2 days/week indicates poor control 2, 6
• Measure peak flow or FEV1 9
• Verify inhaler technique 9, 8
• Check medication adherence 9
• Evaluate environmental trigger control 9

Step-Down Therapy

When well-controlled for ≥3 months, attempt to step down to lowest effective dose. 1

• Reduce ICS dose by 25-50% every 3 months 1
• Monitor closely for loss of control 9

Step-Up Therapy

If not well-controlled, first verify inhaler technique, adherence, environmental triggers, and comorbidities (GERD, rhinosinusitis, obstructive sleep apnea) before escalating therapy. 1, 2

Critical Pitfalls to Avoid

• Never use antibiotics unless bacterial infection is confirmed—they are not helpful for viral-triggered exacerbations 9, 8
• Never prescribe sedatives during exacerbations—they are contraindicated and worsen respiratory depression 9, 8
• Never use LABA without concurrent ICS—monotherapy increases mortality risk 7
• Do not discharge exacerbation patients until PEF >75% predicted/personal best 9, 1
• Avoid insufficient steroid courses—5-6 day Medrol dose packs often lead to relapse; use 1-3 weeks 8

Special Populations

Children (Ages 5-11 years)

• Maximum dose: fluticasone/salmeterol 100/50 mcg twice daily 1
• Monitor growth velocity with prolonged ICS use 1, 7

Children (Ages 0-4 years)

• Start Step 2 with low-dose ICS, reassess in 4-6 weeks 1
• Consider alternative diagnoses if no benefit 1

Adults ≥12 years

• Follow full stepwise approach 1
• Consider bone density monitoring with prolonged high-dose ICS 1
• Assess for occupational exposures in adult-onset asthma 2

Long-Term Considerations

• Assess for comorbidities: GERD, chronic rhinosinusitis, obstructive sleep apnea—these worsen asthma control 2, 3
• Consider subcutaneous allergen immunotherapy for allergic asthma in patients ≥5 years 2, 6
• Monitor for ICS adverse effects: oral candidiasis, dysphonia, cataracts, glaucoma, adrenal suppression 7
• Taper systemic corticosteroids slowly when transitioning to inhaled therapy—prolonged use causes hypothalamic-pituitary-adrenal axis suppression 9, 5