What is the recommended treatment plan for a patient with asthma, including medication dosages and lifestyle modifications?

Asthma Treatment: Signs, Symptoms, and Medication Dosages

Recognizing Asthma Severity

For stable asthma management, initiate inhaled corticosteroids (ICS) as first-line controller therapy at low doses for persistent asthma, with specific dosing of fluticasone 100 mcg or budesonide 200 mcg daily. 1

Chronic Asthma Classification

Intermittent Asthma:

• Symptoms ≤2 days per week 1
• Nighttime awakenings ≤2 times per month 1
• Treatment: Short-acting beta-agonist (SABA) as needed only, no daily controller required 1

Mild Persistent Asthma:

• Symptoms >2 days per week but not daily 2
• SABA use >2 times weekly indicates need for controller therapy 1
• Treatment: Low-dose ICS (fluticasone 100 mcg or budesonide 200 mcg daily) 1

Moderate-to-Severe Persistent Asthma:

• Daily symptoms with frequent nighttime awakenings 2
• Treatment: ICS-LABA combination (fluticasone 250 mcg + salmeterol 50 mcg twice daily) 1

Acute Severe Asthma Recognition

Severe Attack Features (Immediate Treatment Required):

• Unable to complete sentences in one breath 2
• Respiratory rate >25 breaths/min 2
• Peak expiratory flow (PEF) <50% of predicted or personal best 2
• Heart rate >110 beats/min 2

Life-Threatening Features (Emergency Management):

• PEF <33% of predicted 2
• Silent chest, cyanosis, or feeble respiratory effort 2
• Bradycardia, hypotension, exhaustion, confusion, or coma 2
• Normal or elevated PaCO2 (5-6 kPa) in a breathless patient 2
• Severe hypoxia: PaO2 <8 kPa despite oxygen 2

Medication Dosages for Chronic Management

Step 1: Intermittent Asthma

• Albuterol (SABA): 2 puffs as needed for symptoms 1
• No daily controller medication required 1

Step 2: Mild Persistent Asthma

• Low-dose ICS options: 1
  • Fluticasone 100 mcg daily
  • Budesonide 200 mcg daily
• Alternative: Leukotriene receptor antagonist (montelukast 10 mg daily) 1
• Plus: Albuterol as needed for symptoms 1

Step 3: Moderate Persistent Asthma (Uncontrolled on Low-Dose ICS)

• Preferred for adults ≥12 years: Add LABA to low-dose ICS 1
  • Fluticasone 100-250 mcg + salmeterol 50 mcg twice daily 3
• Alternative: Increase to medium-dose ICS alone 2
• Never use LABA as monotherapy due to increased mortality risk 1

Step 4: Moderate-to-Severe Persistent Asthma

• Medium-dose ICS-LABA combination: 1
  • Fluticasone 250 mcg + salmeterol 50 mcg twice daily 3
• Consider adding: Long-acting muscarinic antagonist (LAMA) 1

Step 5-6: Severe Persistent Asthma

• High-dose ICS-LABA combination: 1
  • Fluticasone 500 mcg + salmeterol 50 mcg twice daily 3
• Consider biologics for severe allergic or eosinophilic asthma 1

Pediatric Dosing (Ages 4-11 Years)

• Mild persistent: Budesonide 200 mcg daily 1
• Moderate persistent: Fluticasone 100 mcg + salmeterol 50 mcg twice daily 3

Acute Exacerbation Management

Immediate Treatment (At Home or Emergency Department)

High-Dose Inhaled Beta-Agonist:

• Salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen 2
• Alternative: Albuterol MDI 20-40 puffs (2 puffs × 10-20 times) via spacer 2
• Repeat every 15-30 minutes as needed 2

High-Dose Systemic Corticosteroids (Give Immediately):

• Prednisolone 30-60 mg orally 2
• Or hydrocortisone 200 mg IV 2
• Continue prednisolone 30-60 mg daily or hydrocortisone 200 mg IV every 6 hours 2

If Life-Threatening Features Present:

• Add ipratropium 0.5 mg nebulized to beta-agonist 2
• Consider IV aminophylline 250 mg over 20 minutes (avoid if patient taking oral theophyllines) 2
• Or IV salbutamol/terbutaline 250 mcg over 10 minutes 2

Hospital Admission Criteria

• Any life-threatening features 2
• PEF <33% predicted after initial treatment 2
• Severe attack features persisting after initial treatment 2
• Previous severe attacks with rapid onset 2

Discharge Medications

• Prednisolone 30 mg daily for 1-3 weeks 2
• Inhaled steroids at higher dose than pre-admission 2
• Inhaled beta-agonist as needed 2
• Peak flow meter with written self-management plan 2

Monitoring and Follow-Up

Initial Therapy:

• Follow-up every 2-4 weeks after starting treatment 1
• Reassess every 1-3 months once controlled 1
• Spirometry at initial assessment and every 1-2 years 1

Step Up Therapy If:

• Uncontrolled after 2 weeks of current regimen 1
• SABA use >2 times weekly or >2 nights monthly 1

Step Down Therapy When:

• Well-controlled and stable for ≥3 months 2
• Goal: Find minimum effective dose 1

Critical Safety Points

• Never use LABA without ICS - increases exacerbation risk and mortality 1
• Avoid sedation in acute asthma - contraindicated 2
• Antibiotics only if bacterial infection confirmed - not routine 2
• Doubling ICS dose during exacerbations is ineffective - use oral corticosteroids instead 2
• Annual influenza vaccination for all persistent asthma patients 1