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

Asthma Treatment Plan

Asthma management requires a stepwise approach with inhaled corticosteroids as the foundation of chronic therapy, combined with short-acting beta-agonists for symptom relief, while acute exacerbations demand immediate high-dose bronchodilators and systemic corticosteroids. 1, 2

Chronic Asthma Management

First-Line Controller Therapy

• Inhaled corticosteroids (ICS) are the preferred first-line controller medication for all patients with persistent asthma, taken daily on a long-term basis to achieve symptom control 2
• Start with low-dose ICS for mild persistent asthma (symptoms >2 days/week but not daily) 2
• For patients aged 12 years and older, add a long-acting beta-agonist (LABA) to ICS when ICS alone is insufficient, rather than adding leukotriene receptor antagonists 2
• Combination ICS/LABA dosing: 1 inhalation of fluticasone/salmeterol 100/50,250/50, or 500/50 twice daily based on asthma severity 3

Rescue Therapy

• Short-acting beta-agonists (albuterol/salbutamol) are the most effective therapy for rapid symptom relief 2
• Increasing use of short-acting beta-agonists (>2 days/week or >2 nights/month) indicates inadequate control and necessitates initiation or intensification of anti-inflammatory therapy 2

Alternative Options

• Leukotriene receptor antagonists (montelukast) are second-line for mild persistent asthma, offering once-daily dosing with high compliance 2

Critical Contraindications

• Never use LABA monotherapy without ICS, as this increases the risk of serious asthma-related events 1, 3
• Sedatives are absolutely contraindicated in asthmatic patients and can worsen respiratory depression 1

Acute Asthma Exacerbation Management

Immediate Assessment

Assess severity immediately using objective measurements before initiating treatment 4, 1, 2:

Mild Exacerbation:

• Speech normal 4
• Pulse <110 beats/min 4
• Respiratory rate <25 breaths/min 4
• Peak expiratory flow (PEF) >50% predicted or best 4

Acute Severe Asthma:

• Cannot complete sentences in one breath 4
• Pulse >110 beats/min 4
• Respiratory rate >25 breaths/min 4
• PEF <50% predicted or best 4

Life-Threatening Features:

• PEF <33% predicted 4
• Silent chest, cyanosis, feeble respiratory effort 4
• Bradycardia, hypotension, confusion, exhaustion, or coma 4

Immediate Treatment Protocol

For Mild Exacerbations (Home Treatment):

• Nebulized salbutamol 5 mg or terbutaline 10 mg 4
• Monitor response 15-30 minutes after nebulizer 4
• If PEF 50-75% predicted: give prednisolone 30-60 mg and step up usual treatment 4
• If PEF >75% predicted: step up usual treatment 4
• Response to treatment MUST be assessed before leaving the patient 4

For Acute Severe Asthma:

• Oxygen 40-60% immediately 4
• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 4, 2
• Prednisolone 30-60 mg orally OR intravenous hydrocortisone 200 mg immediately 4, 1, 2
• Corticosteroids require 6-12 hours to manifest anti-inflammatory effects, making early administration critical for preventing mortality 1
• Monitor response 15-30 minutes after nebulizer 4

If No Response After 15-30 Minutes:

• Repeat nebulized ipratropium 0.5 mg or give subcutaneous terbutaline 4
• Consider subcutaneous epinephrine or terbutaline (250 µg over 10 minutes) in patients not responding to continuous nebulization 1
• Arrange immediate hospital admission 4

Alternative if No Nebulizer Available:

• Give 2 puffs of beta-agonist via large volume spacer and repeat 10-20 times 4

Special Consideration: Vomiting with Asthma Flare

• For patients experiencing vomiting during an asthma exacerbation, administer intravenous hydrocortisone 200 mg every 6 hours instead of oral corticosteroids 1
• Vomiting indicates either severe attack or inability to tolerate oral medications, lowering the threshold for hospital admission 1

Hospital Admission Criteria

Admit if any of the following are present 4:

• Any life-threatening features 4
• Any features of acute severe asthma persist after initial treatment, especially PEF <33% 4

Lower threshold for admission if 4:

• Attack occurs in afternoon or evening 4
• Recent nocturnal symptoms 4
• Recent hospital admission or previous severe attacks 4
• Patient unable to assess own condition or poor social circumstances 4

ICU Transfer Criteria

Transfer to intensive care unit if 4:

• Deteriorating PEF or worsening exhaustion, feeble respirations 4
• Persistent hypoxia or hypercapnia 4
• Coma, respiratory arrest, confusion, or drowsiness 4

Follow-Up and Discharge Planning

Post-Acute Follow-Up

• Surgery/clinic review within 24 hours for severe exacerbations, within 48 hours for moderate exacerbations 4
• GP follow-up arranged within 1 week 4
• Respiratory specialist follow-up within 4 weeks 4, 2

Discharge Criteria

Patients should only be discharged when 4:

• Been on discharge medication for 24 hours with inhaler technique checked and recorded 4
• PEF >75% of predicted or best and PEF diurnal variability <25% 4
• Treatment includes oral steroid tablets and inhaled steroids in addition to bronchodilators 4
• Own PEF meter provided with self-management plan or written instructions 4

Discharge Medications

• Prednisolone tablets for 1-3 weeks 1
• Increased inhaled corticosteroid dose 1
• As-needed beta-agonists 1
• Written asthma action plan 1

Monitoring and Prevention

Ongoing Monitoring

• Monitor symptoms and PEF on PEF chart 4
• Ensure proper inhaler technique 4
• Assess for decrease in bone mineral density initially and periodically with long-term ICS use 3
• Monitor growth in pediatric patients 3
• Consider ophthalmology referral for patients on long-term ICS who develop ocular symptoms (glaucoma/cataracts risk) 3

Common Pitfalls to Avoid

• Underuse of corticosteroids is a major factor in preventable asthma deaths 4
• Doctors and patients often fail to appreciate severity—regard each emergency consultation as acute severe asthma until proven otherwise 4
• Delay can be fatal—assess severity by objective measurement, not subjective impression 4
• Do not prescribe antibiotics unless bacterial infection is clearly documented 1
• Approximately 5% of patients have difficult asthma not controlled on high-dose ICS, requiring specialist assessment to identify correctable factors including poor adherence, unrecognized allergens, gastroesophageal reflux, or psychological factors 5