What is the recommended approach for managing asthma in patients with variable severity?

Asthma Management: A Stepwise Approach

Manage asthma using a stepwise pharmacologic approach based on severity classification, combined with regular monitoring, patient education with written action plans, and environmental control measures to achieve the dual goals of reducing impairment (symptoms, activity limitation) and risk (exacerbations, lung function decline). 1

Initial Assessment and Diagnosis

Confirm the diagnosis with spirometry demonstrating reversible airflow obstruction (≥12% and ≥200 mL improvement in FEV1 after bronchodilator), as clinical symptoms alone are insufficient. 2 Perform spirometry at initial assessment, after treatment initiation, during loss of control, and at least every 1-2 years. 1, 2

Classify severity before initiating treatment using two domains:

• Impairment domain: frequency of daytime symptoms, nighttime awakenings, SABA use (>2 days/week indicates need for controller therapy), activity limitation, and lung function (FEV1 or FEV1/FVC ratio) 1, 2
• Risk domain: exacerbation frequency, ED visits, hospitalizations, and progressive lung function decline 1

Identify triggers and comorbidities that impede control: allergen exposures at home/work/school, rhinitis, GERD, OSA, obesity, stress, and occupational sensitizers. 1, 2 Use skin testing or specific IgE measurements for perennial indoor allergens in patients with persistent asthma requiring daily medication. 2

Stepwise Pharmacologic Treatment

Mild Intermittent Asthma (Step 1)

• No daily controller medication required; prescribe SABA (albuterol/salbutamol) as needed for symptom relief 3
• SABA use >2 days/week (excluding pre-exercise use) signals need to step up to controller therapy 1

Mild Persistent Asthma (Step 2)

• Low-dose inhaled corticosteroid (ICS) is the preferred first-line controller therapy, delivered via metered-dose inhaler with spacer device 2, 3
• Dosing: up to 800 μg/day beclomethasone equivalent or 100 μg fluticasone propionate twice daily 3, 4
• Add SABA as needed for breakthrough symptoms 2, 3

Moderate Persistent Asthma (Steps 3-4)

• Low-dose ICS plus long-acting beta-agonist (LABA) combination is preferred over increasing ICS dose alone 2, 3
• Alternative: medium-dose ICS monotherapy if combination therapy not available 3
• FDA-approved combinations include fluticasone/salmeterol (100/50 or 250/50 twice daily) 4

Severe Persistent Asthma (Steps 5-6)

• High-dose ICS/LABA combination (fluticasone 500 μg/salmeterol 50 μg twice daily, maximum dose) 3, 4
• Add long-acting muscarinic antagonist (triple therapy) for additional symptom control and exacerbation reduction 2
• Consider biologic agents for patients with evidence of type 2 inflammation who remain uncontrolled 5

Critical implementation point: Patients using ICS/LABA combinations should not use additional LABA for any reason, as higher doses increase adverse effects without additional benefit. 4

Monitoring and Adjusting Therapy

Schedule follow-up visits based on control status: 1

• Every 2-6 weeks when initiating therapy or stepping up treatment to achieve control
• Every 1-6 months once control is achieved, with frequency depending on treatment step and duration of control
• Every 3 months when considering stepping down therapy

At every visit, assess four key elements: 1

1. Asthma control using validated tools (Asthma Control Test or Asthma Control Questionnaire) 2, 6
2. Inhaler technique - verify proper use as inadequate technique is a primary cause of treatment failure 2, 3
3. Written asthma action plan adherence and understanding 1, 2
4. Patient concerns and barriers to adherence 1

Instruct patients to self-monitor using either symptom tracking or peak flow monitoring (both show similar benefits for most patients). 1, 2 Peak flow monitoring is particularly valuable for patients with moderate-to-severe asthma, history of severe exacerbations, or poor symptom perception. 1

Patient Education and Self-Management

Provide every patient with a written asthma action plan that includes: 1, 2

• Daily management instructions (controller medications, environmental controls)
• Recognition of worsening asthma (symptoms, peak flow <75% of personal best)
• Medication adjustment instructions for worsening symptoms
• Clear criteria for seeking emergency care

Teach the critical distinction between medication types: 1, 3

• Controller medications (ICS, ICS/LABA): taken daily to prevent symptoms through anti-inflammatory effects; do not provide quick relief
• Quick-relief medications (SABA): relax airway muscles for prompt symptom relief; do not provide long-term control

Verify proper inhaler technique at every visit by having patients demonstrate their technique. 2, 3 Instruct patients to rinse mouth with water after ICS use to reduce oral candidiasis risk. 3, 4

Educate patients that increasing SABA use (>2 days/week or >2 nights/month) indicates inadequate control and need to intensify anti-inflammatory therapy. 2

Environmental Control Measures

Eliminate tobacco smoke exposure completely and reduce allergen exposure based on specific sensitivities identified through testing. 2 Target perennial indoor allergens including house dust mite, cockroach, mold, and animal dander. 2

Substantially reducing exposure to identified triggers may reduce airway inflammation, symptoms, and medication requirements. 2

Management of Acute Exacerbations

For moderate-to-severe exacerbations: 1, 3

• Administer high-flow oxygen (40-60%) to maintain saturation >92%
• Nebulized salbutamol 5 mg or terbutaline 10 mg every 20-30 minutes for three doses
• Oral prednisolone 30-60 mg or IV hydrocortisone 200 mg immediately
• Add ipratropium 0.5 mg to nebulizer if no improvement after initial treatment

For life-threatening features (PEF <33% predicted, silent chest, cyanosis, altered consciousness): 1

• Continue high-dose nebulized beta-agonists with oxygen
• Add IV aminophylline 5 mg/kg over 20 minutes if no response
• Arrange immediate ICU transfer with physician prepared to intubate

Common pitfalls to avoid: 2

• Never prescribe antibiotics unless bacterial infection is confirmed (they are overused without evidence of benefit)
• Never use sedation during acute exacerbations (contraindicated and dangerous)
• Doubling ICS dose at home for exacerbations is not effective; use oral corticosteroids instead 1

Special Considerations for Difficult-to-Treat Asthma

If asthma remains uncontrolled despite adherence to optimal therapy: 5

• Reassess diagnosis to exclude COPD, vocal cord dysfunction, or other airway diseases
• Evaluate for unrecognized triggers (occupational exposures, dietary additives, GERD, upper airway disease)
• Consider trial of leukotriene receptor antagonist as add-on therapy
• Assess for phenotype with type 2 inflammation to guide biologic therapy selection

Address barriers to guideline-based care including cultural factors, language barriers, health literacy, and socioeconomic circumstances through individualized case management for patients with recurrent ED visits or hospitalizations. 2