What is the management of bronchial asthma in a patient?

Management of Bronchial Asthma

Inhaled corticosteroids (ICS) are the cornerstone of asthma management for all patients with persistent disease, combined with short-acting beta-agonists for acute symptom relief, using a stepwise approach that escalates therapy based on disease severity and control. 1

Core Treatment Goals

The primary objectives are to eliminate chronic symptoms (including nocturnal symptoms), maintain peak expiratory flow ≥80% of predicted or personal best with <20% circadian variation, minimize exacerbation risk and prevent death, enable normal activities without limitations, and minimize medication side effects while maintaining control. 2

Stepwise Pharmacological Approach

Step 1: Mild Intermittent Asthma

• As-needed low-dose ICS-formoterol is the preferred treatment for patients with occasional transient daytime symptoms (<2 times/month, lasting hours), no nocturnal symptoms, no exacerbation risk, and FEV1 >80% predicted. 3
• This approach significantly reduces moderate-to-severe exacerbations compared with SABA monotherapy. 3

Step 2: Mild Persistent Asthma

• Low-dose ICS is the preferred controller treatment (most effective anti-inflammatory medication available). 1
• Alternative options include cromolyn, leukotriene modifiers, or sustained-release theophylline to serum concentration of 5-15 mcg/mL, though these are less effective than ICS. 1
• As-needed low-dose ICS-formoterol is also recommended and significantly reduces exacerbations. 3

Step 3: Moderate Persistent Asthma

• Low-dose ICS plus long-acting beta-agonist (LABA) is the preferred treatment. 1
• ICS-LABA combinations demonstrate synergistic anti-inflammatory and anti-asthmatic effects, achieving efficacy equivalent to or better than doubling the ICS dose, and improve adherence while reducing high-dose ICS-related adverse effects. 3
• Alternative: Medium-dose ICS alone. 1

Step 4: Severe Persistent Asthma

• High-dose ICS-LABA combination is the preferred treatment. 1
• Triple combination inhalers (ICS-LABA-LAMA) can be prescribed to improve symptoms, lung function, and reduce exacerbations when asthma remains uncontrolled on medium- or high-dose ICS-LABA. 3
• For adults with severe asthma, low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) may be added as the last choice. 3

Step 5: Refractory Severe Asthma

• Patients with persistent symptomatic asthma despite Step 4 treatment should be referred to asthma specialists for evaluation. 3
• Biologic therapies targeting type 2 inflammation (anti-IgE, anti-IL-5, anti-IL-5Rα, anti-IL-4Rα monoclonal antibodies) should be considered for severe type 2 asthma. 3
• Add-on low-dose azithromycin therapy (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. 3

Quick-Relief Medications

• Short-acting inhaled beta-agonists (salbutamol 5 mg or terbutaline 10 mg nebulized, or 2 puffs 10-20 times via metered-dose inhaler into spacer) are the primary treatment for acute symptom relief. 1
• If patients use more than one canister per month, daily long-term control therapy should be increased. 1

Acute Exacerbation Management

Recognition of Severity

Severe asthma features include: respiratory rate >25 breaths/min, heart rate >110 beats/min, inability to complete sentences in one breath, and PEF <50% of predicted or best. 1

Life-threatening features include: PEF <33% of predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia, hypotension, exhaustion, confusion, coma, normal or high PaCO2 (5-6 kPa) in a breathless patient, severe hypoxia (PaO2 <8 kPa), or low pH. 1

Immediate Treatment

• Give high-dose inhaled beta-agonists immediately (salbutamol 5 mg or terbutaline 10 mg nebulized with oxygen, or multiple actuations via spacer). 1
• Give systemic corticosteroids immediately: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV. 1
• If life-threatening features present: add ipratropium 0.5 mg nebulized to the beta-agonist, and consider IV aminophylline 250 mg over 20 minutes (not if already taking oral theophyllines). 1

Monitoring and Ongoing Treatment

• Measure and record PEF 15-30 minutes after starting treatment, then according to response. 1
• Continue oxygen therapy and high-dose steroids (prednisolone 30-60 mg daily or IV hydrocortisone 200 mg every 6 hours). 1
• If improving, give nebulized beta-agonist every 4 hours; if not improving after 15-30 minutes, increase frequency to every 15 minutes. 1

Hospital Admission Criteria

Admit patients with: life-threatening features, severe attack features persisting after initial treatment, PEF <33% of predicted 15-30 minutes after nebulization, afternoon/evening presentation, recent nocturnal symptoms, previous severe attacks (especially rapid onset), concern over symptom assessment, or inadequate social support. 1

Discharge Criteria and Planning

• Do not discharge until: PEF >75% of predicted or best, diurnal variability <25%, and no nocturnal symptoms. 1
• All patients must be discharged on: prednisolone 30+ mg daily for 1-3 weeks, inhaled steroids at higher dosage than before admission, inhaled/nebulized beta-agonists as needed, and oral theophylline/long-acting beta-agonists/ipratropium if required. 1
• Every patient must receive: peak flow meter prescription, written self-management plan, and education on when to increase treatment, call doctor, or return to hospital. 1

Essential Monitoring and Follow-Up

• Schedule follow-up every 2-4 weeks after initial therapy, then every 1-3 months if responding. 3
• Regular training in correct inhaler technique is essential for optimal control. 3
• Objective monitoring with peak flow measurements is vital, similar to glucose monitoring in diabetes. 1

Patient Education Requirements

Develop a written asthma action plan covering: daily management (long-term control medication, environmental control), managing worsening asthma (medication adjustment, when to seek care), differences between long-term control and quick-relief medications, correct inhaler technique, and environmental trigger avoidance. 1

Environmental Control

• Determine exposures through history of symptoms in presence of exposures and sensitivities (use skin or in vitro testing for perennial indoor allergens in persistent asthma). 1
• Advise on reducing exposure to identified allergens and irritants using multifaceted approaches (single steps alone are generally ineffective). 1
• All patients and pregnant women must avoid tobacco smoke exposure. 1

Allergen Immunotherapy

• Subcutaneous immunotherapy may reduce required ICS dosage and improve asthma-specific quality of life and lung function in adults. 3
• For house dust mite-sensitized adolescents or adults with FEV1 >70% predicted, HDM sublingual immunotherapy may be added if symptoms persist despite low-to-medium-dose ICS-containing therapy. 3

Comorbidity Management

Recognize and treat: allergic bronchopulmonary aspergillosis, GERD, obesity, obstructive sleep apnea, rhinitis/sinusitis, stress/depression, and asthma-COPD overlap (ACO). 1

• Consider inactivated influenza vaccine for all patients older than 6 months. 1
• Patients with severe asthma and chronic rhinosinusitis with nasal polyps may benefit from biologic therapies. 3

Risk Factors for Asthma-Related Death

High-risk patients include those with: history requiring intubation/mechanical ventilation, hospitalization or emergency visit in past year, current or recent oral corticosteroid use, no current ICS use, SABA overuse (>1 canister/month), psychiatric illness or sedative use, poor adherence, confirmed food allergy, or comorbidities (pneumonia, diabetes, arrhythmias). 3

Critical Pitfalls to Avoid

• Never use sedation in acute asthma (contraindicated). 1
• Do not give antibiotics unless bacterial infection is confirmed. 1
• Do not use LABA monotherapy (increases risk of serious asthma-related events). 4
• Do not combine with additional LABA-containing medications (risk of overdose). 4
• Never stop or taper prednisolone if asthma is worsening. 1
• Do not delay systemic corticosteroids when PEF falls below 60% of best, symptoms progressively worsen, sleep is disturbed, morning symptoms persist until midday, or there is diminishing response to inhaled bronchodilators. 2
• Long-term high-dose ICS may cause systemic adverse effects including osteoporosis, hypothalamic-pituitary-adrenal axis suppression, and increased pneumonia risk. 3