What is the treatment for a patient with asthma?

Treatment of Asthma

Inhaled corticosteroids are the most effective first-line controller medication for persistent asthma and should be taken daily regardless of symptom frequency, as they improve asthma control more effectively than any other single long-term medication. 1, 2

Chronic Asthma Management

Initial Controller Therapy

• Start with low-dose inhaled corticosteroids (such as beclomethasone or fluticasone propionate) for all patients with persistent asthma, defined as symptoms more than 2 days per week or nighttime awakenings more than 2 nights per month 1
• Inhaled corticosteroids reduce airway inflammation and are superior to leukotriene receptor antagonists in improving lung function (FEV1 and PEF), reducing symptoms, and decreasing short-acting beta-agonist use 3
• Patients should rinse their mouth with water after each inhalation to reduce the risk of oral candidiasis 1, 4

Stepping Up Therapy

• For patients ≥12 years whose asthma remains uncontrolled on inhaled corticosteroids alone, add a long-acting beta-agonist (LABA) rather than increasing the inhaled corticosteroid dose 1, 2
• The combination of inhaled corticosteroids plus LABA demonstrates synergistic anti-inflammatory effects and achieves efficacy equivalent to or better than doubling the inhaled corticosteroid dose 5
• For mild persistent asthma, leukotriene receptor antagonists (such as montelukast) are an alternative second-line option with high compliance rates, though less effective than inhaled corticosteroids 1, 3

Monitoring Controller Therapy

• Using short-acting beta-agonists more than 2 days per week or more than 2 nights per month indicates inadequate asthma control and the need to initiate or intensify anti-inflammatory therapy 1, 2
• Schedule follow-up visits every 1-6 months depending on asthma severity and control 1
• Perform spirometry at initial assessment and at least every 1-2 years after treatment initiation 1

Rescue Medication

• Short-acting beta-agonists (salbutamol/albuterol) are the preferred reliever medication for rapid reversal of airflow obstruction and prompt relief of symptoms 1, 6
• Administer 2 puffs from a metered-dose inhaler as needed for symptom relief 1
• For patients using budesonide-formoterol as maintenance therapy, this same combination can be used as needed for symptom relief (single maintenance and reliever therapy) 2, 7

Acute Exacerbation Management

Immediate Treatment

• Administer high-dose inhaled short-acting beta-agonists immediately: salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1, 2
• Give systemic corticosteroids early: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV, as corticosteroids require 6-12 hours to manifest anti-inflammatory effects 2, 8
• Provide high-flow oxygen via face mask to maintain oxygen saturation 1, 2

Assessing Response

• Measure peak expiratory flow 15-30 minutes after starting treatment 1, 2
• If peak flow remains <33% predicted after initial nebulization, arrange immediate hospital admission 2, 8
• If not improving after 15-30 minutes, increase nebulized beta-agonist frequency to every 15 minutes 8

Severe Exacerbations

• Add ipratropium bromide 0.5 mg nebulized to each beta-agonist treatment for severe airflow obstruction, as this reduces hospitalization rates 2, 8
• Consider IV aminophylline 250 mg over 20 minutes or subcutaneous terbutaline 250 µg if not improving after 15-30 minutes 2, 8
• Features indicating severe attack requiring hospitalization include: peak flow <50% predicted, inability to complete sentences in one breath, oxygen saturation <92%, respiratory rate >25 breaths/min, or heart rate >110 bpm 1, 2

Critical Safety Considerations

• Never use sedatives in asthmatic patients as they are absolutely contraindicated and can worsen respiratory depression 2, 8
• Do not prescribe antibiotics unless bacterial infection is clearly documented 2, 8
• If the patient is unconscious or confused, call for intensive care support immediately and do not attempt intubation until the most expert available physician is present 1

Discharge and Follow-Up After Exacerbation

• Continue or increase inhaled corticosteroid dose at discharge 2, 8
• Provide prednisolone 30-60 mg daily for 1-3 weeks (no taper needed for short courses) 2, 8
• Supply a peak flow meter and written asthma action plan 2, 8
• Determine why the patient required emergency care, as these patients need extra follow-up attention 1

Comorbid Conditions

• Treat gastroesophageal reflux in patients with frequent heartburn or nighttime symptoms: avoid heavy meals, fried foods, caffeine, and alcohol within 3 hours of bedtime; elevate head of bed 6-8 inches; use proton pump inhibitors 1
• Evaluate and treat allergic rhinitis with intranasal corticosteroids and antihistamines, as upper airway treatment improves asthma control 1
• Consider obstructive sleep apnea in overweight/obese patients with poorly controlled asthma 1
• Advise weight loss for obese patients, as this may improve asthma control in addition to overall health 1

Additional Preventive Measures

• Administer inactivated influenza vaccination annually for patients ≥6 months old, as they are at risk for complications from influenza 1
• Consider allergen immunotherapy (administered only in a physician's office with facilities to treat anaphylaxis) for patients with allergic asthma 1
• Identify and avoid environmental triggers including tobacco smoke, house dust mites, cockroach allergens, and pet dander through patient history and allergy testing 1

Severe Asthma

• Severe asthma is defined as uncontrolled asthma despite 3+ months of medium- or high-dose inhaled corticosteroid-LABA combination, after treating comorbidities and avoiding environmental triggers 5
• Refer to an asthma specialist for: life-threatening exacerbation, lack of response to Step 4 treatment, or consideration of biologic therapy 1, 5
• Biologic agents (anti-IgE, anti-IL-5, anti-IL-4Rα monoclonal antibodies) may be considered for severe allergic or eosinophilic asthma 5, 7
• Low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) may be added as a last resort for severe asthma 5