What are the latest guidelines for managing bronchial asthma?

Latest Guidelines for Bronchial Asthma Management

The cornerstone of modern asthma management is daily inhaled corticosteroids (ICS) as the most potent and consistently effective long-term controller medication, combined with a stepwise treatment approach that prioritizes achieving and maintaining control while minimizing future exacerbation risk. 1

Core Treatment Principles

Modern asthma management focuses on two key domains: current impairment (symptom frequency, lung function limitations, activity restrictions) and future risk (likelihood of exacerbations, progressive lung function decline, medication adverse effects). 2 The goal is minimal to no chronic symptoms, minimal exacerbations, minimal need for rescue bronchodilators, no activity limitations, peak expiratory flow (PEF) ≥80% predicted with <20% circadian variation, and minimal adverse effects from medications. 2

Stepwise Treatment Algorithm

Step 1 (Intermittent Asthma)

• As-needed low-dose ICS-formoterol is now the preferred option over SABA monotherapy, even for patients with occasional symptoms (<2 times/month). 3, 4
• This represents a major shift from older guidelines that recommended SABA alone. 1

Step 2 (Mild Persistent Asthma)

• Either daily low-dose ICS plus as-needed SABA, or as-needed concomitant ICS-SABA therapy (taken together when symptoms occur). 4
• As-needed low-dose ICS-formoterol significantly reduces moderate-to-severe exacerbations compared with SABA monotherapy. 3

Step 3 (Moderate Persistent Asthma)

• Low-dose ICS-formoterol as single maintenance and reliever therapy (SMART) is the preferred approach for both daily maintenance and as-needed rescue. 4
• This combination provides synergistic anti-inflammatory and bronchodilator effects equivalent to or better than doubling the ICS dose. 3

Step 4 (Moderate-Severe Persistent Asthma)

• Medium-dose ICS-formoterol using the SMART approach. 4
• Triple combination inhalers (ICS-LABA-LAMA) can be prescribed when asthma remains uncontrolled on medium- or high-dose ICS-LABA to improve symptoms, lung function, and reduce exacerbations. 3

Step 5 (Severe Persistent Asthma)

• Add long-acting muscarinic antagonist (LAMA) to ICS-formoterol therapy. 4
• Consider biologic therapy for severe type 2 asthma (elevated blood/sputum eosinophils ≥150/μl, FeNO ≥35 ppb, or elevated total IgE). 3
• Low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) may be added as the last choice for adults with severe asthma. 3

Acute Exacerbation Management

Administer high-dose inhaled short-acting beta-agonists immediately (salbutamol 5 mg or terbutaline 10 mg via nebulizer with oxygen) and give systemic corticosteroids early. 1

Specific Dosing for Acute Exacerbations:

• Adults: Prednisolone 30-60 mg orally immediately, continued each morning until 2 days after control is established. 2, 1
• Children: Prednisolone 1-2 mg/kg/day (maximum 60 mg/day) for 1-5 days; no tapering needed. 2, 5
• For severely ill or vomiting patients: Hydrocortisone 200 mg IV every 6 hours. 6
• Corticosteroids require 6-12 hours to manifest anti-inflammatory effects, making early administration critical. 1

Severe Exacerbations:

• Add ipratropium bromide 0.5 mg nebulized to each beta-agonist treatment for severe airflow obstruction, as this reduces hospitalization rates. 1
• Consider IV aminophylline 250 mg over 20 minutes or subcutaneous terbutaline 250 µg over 10 minutes if not improving after 15-30 minutes. 1
• Measure PEF 15-30 minutes after starting treatment and according to response thereafter. 1, 5

Hospital Admission Criteria:

• PEF <33% predicted after initial nebulization requires immediate hospital referral. 1, 5
• Inability to complete sentences in one breath, oxygen saturation <92% on room air, respiratory rate >25 breaths/min, or heart rate >110 bpm warrant hospitalization. 1, 5
• Life-threatening features include silent chest, cyanosis, poor respiratory effort, confusion, and exhaustion. 5

Monitoring and Assessment

Assess asthma control at every visit using both impairment and risk domains rather than relying solely on symptom frequency. 2 Using short-acting beta-agonists more than 2 days per week or more than 2 nights per month indicates inadequate control and the need to initiate or intensify anti-inflammatory therapy. 1

Peripheral blood eosinophil ≥150/μl identifies eosinophilic phenotype or type 2 inflammatory endotype and predicts biologic therapy response. 3 FeNO ≥35 ppb with small airway dysfunction or baseline FEV1 ≥80% predicted supports diagnostic anti-inflammatory therapy. 3

Referral Criteria to Asthma Specialist

Refer patients who have experienced more than 2 oral corticosteroid bursts per year, recent exacerbation requiring hospitalization, require therapy at step 4 or higher to achieve adequate control, or are being considered for immunotherapy or omalizumab. 2

Patients with persistent symptoms despite step 4 treatment should be referred to asthma specialists for further evaluation. 3

Critical Pitfalls to Avoid

Never use sedatives in asthmatic patients—they are absolutely contraindicated and can worsen respiratory depression. 1, 5, 6

Do not prescribe antibiotics unless bacterial infection is clearly documented; they are unnecessary for elevated inflammatory markers alone. 1

Avoid short-term increases in ICS dose alone for worsening symptoms—this approach is not recommended. 4 Instead, use the SMART approach with increased ICS-formoterol as needed.

Do not rely on bronchodilators without anti-inflammatory treatment, as this leads to undertreatment of the underlying inflammatory process. 5

Avoid underestimating severity of exacerbations—early aggressive treatment with systemic corticosteroids is essential. 5

Special Populations and Considerations

Childhood Asthma:

• Symptoms develop in 50% of children by age 3 and 80% by age 5. 2
• For children aged 4-11 years: 1 inhalation of fluticasone propionate 100 mcg/salmeterol 50 mcg twice daily. 7
• Monitor height and weight velocities, as prolonged high-dose ICS therapy may reduce linear growth rate. 5, 7

Environmental Control:

• Allergen mitigation should be allergen-specific and include multiple strategies, not single interventions. 4
• Maternal smoking is one of the most important modifiable environmental triggers. 2
• Identify allergies through specific IgE measurements and skin prick tests. 2

Immunotherapy:

• Subcutaneous immunotherapy is recommended as adjunct to standard pharmacotherapy for individuals with symptoms and sensitization to specific allergens. 4
• For house dust mite-sensitized adolescents or adults with FEV1 >70% predicted, sublingual immunotherapy may reduce symptoms and ICS dose if symptoms persist despite low-to-medium-dose ICS-containing therapy. 3
• Sublingual immunotherapy is not specifically recommended for asthma alone. 4

Alternative Therapies for Severe Asthma:

• Add-on low-dose azithromycin (250-500 mg/day, three times weekly for 26-48 weeks) may reduce exacerbations in adult patients with persistent symptoms despite step 5 treatment. 3
• Bronchial thermoplasty is indicated for adult patients whose asthma remains uncontrolled despite optimized treatment and specialist referral, or when targeted biologic therapy is unavailable or inappropriate. 3

Patient Education and Self-Management

Provide written asthma action plans with clear instructions for daily treatment and recognizing/handling worsening asthma. 2, 5 Patients must understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications). 5

Train patients in correct inhaler technique at every visit, as poor technique is a major cause of treatment failure. 3 Follow-up visits should occur every 2-4 weeks after initial therapy, then every 1-3 months if responding. 3

Educate patients not to accept symptoms or activity limitations as inevitable consequences of asthma—good control is achievable. 2

Long-Term Safety Considerations

Long-term treatment with ICS at recommended clinical doses is safe, but prolonged high-dose therapy may lead to osteoporosis, hypothalamic-pituitary-adrenal axis suppression, and increased pneumonia risk. 3 Assess bone mineral density initially and periodically in patients with major risk factors for decreased bone content. 7

Monitor for glaucoma and cataracts with long-term ICS use; consider ophthalmology referral for patients who develop ocular symptoms or use ICS long-term. 7