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

Bronchial Asthma Treatment Plan

The recommended treatment for bronchial asthma follows a stepwise approach prioritizing inhaled corticosteroids (ICS) as the cornerstone of therapy, with treatment intensity based on disease severity and control status. 1, 2

Initial Assessment and Severity Classification

• Assess severity based on the treatment step required to achieve control, not pre-treatment symptoms alone 2, 3
• Measure peak expiratory flow (PEF) and forced expiratory volume in 1 second (FEV1) to establish baseline lung function 1
• Evaluate for type 2 inflammation through blood eosinophils (≥150/μl), fractional exhaled nitric oxide (FeNO ≥35 ppb), or atopy markers 3
• Identify risk factors for asthma-related death: history of intubation, hospitalization in past year, current or recent oral corticosteroid use, overuse of short-acting β2-agonists (>1 canister/month), psychiatric illness, poor adherence, or confirmed food allergy 3

Stepwise Maintenance Treatment Algorithm

Step 1: Mild Intermittent Asthma

• Prescribe as-needed low-dose ICS-formoterol for patients with occasional symptoms (<2 times/month), no nocturnal symptoms, and FEV1 >80% predicted 3, 2
• This approach is superior to short-acting β2-agonist (SABA) monotherapy and reduces moderate-to-severe exacerbations 3

Step 2: Mild Persistent Asthma

• Initiate low-dose ICS as first-line controller medication (e.g., fluticasone propionate 100-250 mcg/day, budesonide 200-400 mcg/day, or equivalent) 2, 4
• Add as-needed SABA (salbutamol 200-400 mcg or terbutaline 500-1000 mcg) for symptom relief 2
• ICS demonstrates superior efficacy compared to leukotriene receptor antagonists (LTRAs) in improving lung function, reducing symptoms, and achieving better quality of life 4

Step 3: Moderate Persistent Asthma

• Prescribe medium-dose ICS-LABA combination (e.g., fluticasone/salmeterol 250/50 mcg twice daily) 5, 3
• ICS-LABA combinations provide synergistic anti-inflammatory and bronchodilator effects equivalent to or better than doubling ICS dose alone 3
• Consider adding LTRA (montelukast 10 mg daily) if symptoms persist despite ICS-LABA 1

Step 4: Severe Persistent Asthma

• Increase to high-dose ICS-LABA (e.g., fluticasone/salmeterol 500/50 mcg twice daily) 1, 5
• Add triple therapy with long-acting muscarinic antagonist (LAMA) to improve symptoms, lung function, and reduce exacerbations 3
• Consider sustained-release theophylline as additional controller if needed 1
• Refer to asthma specialist if control not achieved with correct technique and adherence 3

Step 5: Refractory Severe Asthma

• Add biologic therapy for type 2 inflammation: anti-IgE (omalizumab), anti-IL-5 (mepolizumab), anti-IL-5Rα (benralizumab), or anti-IL-4Rα (dupilumab) based on phenotype 3, 1
• Consider low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) as last resort 3
• Add azithromycin 250-500 mg three times weekly for 26-48 weeks to reduce exacerbations in persistent symptomatic patients 3
• Bronchial thermoplasty may be considered for uncontrolled asthma despite optimized treatment 3

Acute Exacerbation Management

Mild Exacerbations

• Administer nebulized salbutamol 5 mg or terbutaline 10 mg 1, 2
• Monitor response at 15-30 minutes and step up usual treatment if necessary 2

Severe Exacerbations (PEF <50% predicted, respiratory rate >25/min, heart rate >110/min, inability to complete sentences)

• Immediately give high-dose inhaled β-agonist: nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen, or 20-40 puffs via metered-dose inhaler with spacer 1, 2
• Administer systemic corticosteroids immediately: prednisolone 30-60 mg orally or IV hydrocortisone 200 mg 1, 2
• Add nebulized ipratropium 0.5 mg if life-threatening features present (PEF <33% predicted, silent chest, cyanosis, exhaustion, altered consciousness) 1
• Give IV aminophylline 250 mg over 20 minutes or IV salbutamol/terbutaline 250 mcg over 10 minutes for life-threatening features (do not give bolus aminophylline if patient already taking oral theophyllines) 1
• Continue oxygen therapy to maintain SaO2 >92% 1

Monitoring During Acute Treatment

• Measure PEF 15-30 minutes after starting treatment and every 4 hours thereafter 1
• If improving: continue nebulized β-agonist every 4 hours 1
• If not improving after 15-30 minutes: increase nebulized β-agonist frequency to every 15 minutes 1
• Arrange chest radiography to exclude pneumothorax, consolidation, or pulmonary edema 1

Hospital Admission Criteria

• Any life-threatening features present 1
• PEF <33% predicted or best after initial treatment 1
• Features of severe attack persisting after initial treatment 1
• Lower threshold for admission: afternoon/evening presentation, recent nocturnal symptoms, previous severe attacks with rapid onset, concern over symptom assessment, or social circumstances 1

Intensive Care Indications

• Deteriorating PEF, worsening hypoxia (PaO2 <8 kPa) despite 60% oxygen, or hypercapnia (PaCO2 >6 kPa) 1
• Exhaustion, feeble respiration, confusion, drowsiness, coma, or respiratory arrest 1

Discharge and Follow-Up

Discharge Criteria

• PEF >75% of predicted or best value 1, 2
• Diurnal PEF variability <25% 1
• No nocturnal symptoms 1
• Stable on discharge medications for 24-48 hours 1

Discharge Medications

• Prednisolone 30-60 mg daily for 1-3 weeks (or longer in chronic asthma) according to written action plan 1
• Inhaled steroids at higher dosage than before admission 1
• Inhaled β-agonists as needed 1
• Oral theophylline, long-acting β-agonists, or inhaled ipratropium if required 1

Self-Management Education

• Provide peak flow meter and train in proper use 1, 2
• Give written asthma action plan specifying when to increase treatment, call doctor, or seek emergency care 1, 2
• Verify inhaler technique and record performance 1
• Explain difference between "relievers" and "preventers" 2

Follow-Up Schedule

• General practitioner visit within 1 week 1, 2
• Respiratory specialist appointment within 4 weeks 1, 2
• Schedule visits every 2-4 weeks after initial therapy, then every 1-3 months if responding 3

Critical Pitfalls to Avoid

• Never use antibiotics unless bacterial infection confirmed 1, 6
• Never administer sedatives - they are absolutely contraindicated and can cause respiratory depression 1, 6
• Never use percussive physiotherapy - it is unnecessary 1
• Do not discharge on insufficient steroid duration - 5-6 day courses are often inadequate; use 1-3 weeks 6
• Do not give bolus aminophylline to patients already taking oral theophyllines 1
• Do not underestimate severity - failure to recognize life-threatening features is a major cause of preventable deaths 1, 2
• Do not rely on bronchodilators without anti-inflammatory treatment for persistent asthma 2, 7

Special Considerations

Long-Term ICS Safety

• High-dose ICS (>800 mcg/day beclomethasone equivalent) is safe at recommended doses but prolonged use may cause osteoporosis, adrenal suppression, and increased pneumonia risk 3
• Assess bone mineral density initially and periodically 5
• Monitor for oral candidiasis and advise rinsing mouth after inhalation 5
• Monitor growth in pediatric patients 5

Cough Variant Asthma

• Treat with ICS-LABA as first choice for >8 weeks 3
• Add LTRA or short-term oral corticosteroids (10-20 mg/day for 3-5 days) for poor response with severe airway inflammation 3

Aspirin-Induced Asthma

• Avoid aspirin and NSAIDs - most effective prevention 3
• Consider desensitization therapy if patient requires high-dose ICS or aspirin for other conditions 3