What is the recommended management approach for a patient with asthma?

Management of Asthma

Chronic Asthma Management: Stepwise Approach

Inhaled corticosteroids (ICS) are the cornerstone of asthma management and should be initiated for all patients with persistent asthma, defined as symptoms occurring more than 2 days per week. 1

Step 1: Mild Intermittent Asthma

• As-needed low-dose ICS-formoterol is now the preferred first-line treatment for patients with occasional symptoms (<2 times/month, no nocturnal symptoms, FEV1 >80% predicted) 1
• This approach significantly reduces moderate-to-severe exacerbations compared to short-acting beta-agonist (SABA) monotherapy alone 1
• SABA monotherapy without anti-inflammatory therapy is no longer recommended, even for mild intermittent asthma 1

Step 2: Mild Persistent Asthma

• Start low-dose ICS daily (e.g., fluticasone 100-250 mcg/day or equivalent) 1
• Alternative: As-needed low-dose ICS-formoterol for patients with limited symptoms 1
• Leukotriene receptor antagonists (montelukast) are second-line alternatives with easier once-daily dosing 2

Step 3: Moderate Persistent Asthma

• Add long-acting beta-agonist (LABA) to ICS - this combination demonstrates synergistic effects equivalent to or better than doubling the ICS dose 1
• ICS-LABA combination improves adherence and reduces high-dose ICS-related adverse effects 1
• Never use LABA as monotherapy - LABAs must always be combined with ICS due to increased risk of serious asthma-related events with LABA monotherapy 1, 3
• Consider consultation with asthma specialist at this step 1

Step 4-5: Severe Persistent Asthma

• Increase to medium or high-dose ICS-LABA 1
• Add long-acting muscarinic antagonist (LAMA) as triple therapy to improve symptoms, lung function, and reduce exacerbations 1
• Consider biologic therapy for severe type 2 asthma (elevated eosinophils ≥150/μl, FeNO ≥35 ppb, or elevated IgE): omalizumab (anti-IgE), mepolizumab/reslizumab (anti-IL-5), or dupilumab (anti-IL-4Rα) 1, 4
• Low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) may be added as last resort for severe asthma 1
• Refer to asthma specialist if uncontrolled despite Step 4 treatment 1

Monitoring and Follow-Up

• Schedule visits every 2-6 weeks when initiating therapy or stepping up treatment 1
• Once controlled, schedule visits every 1-6 months depending on stability 1
• Perform spirometry at initial assessment, after treatment initiation, during loss of control, and at least every 1-2 years 1
• Assess inhaler technique, adherence, written action plan, and environmental triggers at every visit 1
• Increasing SABA use (>2 days/week or >2 nights/month) indicates inadequate control and need to step up therapy 1, 2

Stepping Down Therapy

• Consider stepping down after at least 3 months of good asthma control 1
• Reduce ICS dose by 25-50% every 3 months if control maintained 1
• Monitor closely for loss of control with peak flow monitoring and symptom assessment 1

Acute Asthma Exacerbation Management

Severity Assessment (Perform Immediately)

Measure peak expiratory flow (PEF), respiratory rate, heart rate, and oxygen saturation before initiating treatment - severity is often underestimated without objective measurements 1, 2

Moderate Exacerbation:

• Speech normal, pulse <110 bpm, respiratory rate <25/min, PEF 40-69% predicted 2

Severe Exacerbation:

• Cannot complete sentences in one breath, pulse >110 bpm, respiratory rate >25/min, PEF <50% predicted 1, 2

Life-Threatening Features:

• PEF <33% predicted, silent chest, cyanosis, confusion, exhaustion, bradycardia, hypotension 1, 2

Immediate Treatment Algorithm

Step 1: Bronchodilator Therapy

• Administer high-dose albuterol/salbutamol 5 mg via nebulizer with oxygen or 4-12 puffs via MDI with spacer 5, 2, 6
• Repeat every 20 minutes for 3 doses initially, then every 1-4 hours as needed 5
• Add ipratropium bromide 0.5 mg to each nebulizer treatment if severe or not responding adequately - this reduces hospitalization rates 5, 6

Step 2: Systemic Corticosteroids (Administer Within 1 Hour)

• Oral prednisone 40-60 mg daily for adults (or prednisolone 30-60 mg) 5, 2, 6
• Pediatric dose: 1-2 mg/kg/day (maximum 60 mg/day) in 2 divided doses 5
• Oral administration is equally effective as IV therapy and strongly preferred when patient can tolerate oral intake 5
• If vomiting or severely ill: IV hydrocortisone 200 mg immediately, then 200 mg every 6 hours 5, 6
• Corticosteroids require 6-12 hours to manifest anti-inflammatory effects, making early administration essential 5, 6

Step 3: Oxygen Therapy

• Administer high-flow oxygen 40-60% to maintain SpO2 >92% 5, 6

Step 4: Reassess at 15-30 Minutes

• Measure PEF 15-30 minutes after initial treatment to determine response 5, 2, 6
• If not improving: increase bronchodilator frequency to every 15-30 minutes and consider hospitalization 5, 6

Duration of Systemic Corticosteroids

• Continue prednisone 40-60 mg daily for 5-10 days until PEF reaches 70% of predicted or personal best 5
• No tapering necessary for courses <7-10 days, especially if patient is on inhaled corticosteroids 5
• For post-viral asthma or severe exacerbations, may require 1-3 weeks of systemic corticosteroids 6

Hospitalization Criteria

• Admit if: PEF <50% predicted after initial treatment, SpO2 <92%, inability to complete sentences, any life-threatening features present 1, 2
• Lower threshold for admission if attack occurs in afternoon/evening, recent nocturnal symptoms, or previous severe attacks 2

Discharge Planning

• Do not discharge until: PEF >75% predicted, diurnal variability <25%, no nocturnal symptoms 5, 6
• Provide: prednisolone tablets, increased dose inhaled corticosteroids (higher than pre-admission), peak flow meter, written action plan 5, 6
• Follow-up with primary care within 1 week (24-48 hours for severe exacerbations) 2, 6
• Respiratory specialist follow-up within 4 weeks 2, 6

Self-Management Education

Every patient must receive a written asthma action plan with three essential elements: symptom/peak flow monitoring, predetermined action triggers, and written guidance for treatment escalation 1, 6

Key educational points:

• Distinguish between "reliever" (SABA) and "preventer" (ICS) medications 1
• Recognize nocturnal symptoms as critical warning sign requiring immediate treatment escalation 1, 6
• Patients should self-initiate oral corticosteroids when PEF falls below predetermined threshold (typically <60% predicted) or symptoms significantly worsen 1
• Carry warning card if on systemic corticosteroids or history of severe exacerbations 1, 3

Critical Pitfalls to Avoid

• Never prescribe LABA without ICS - this increases risk of asthma-related death 1, 3
• Do not underdose systemic corticosteroids during exacerbations - underuse is a documented cause of preventable asthma deaths 5, 6
• Do not prescribe antibiotics for viral-induced exacerbations unless bacterial infection clearly documented 2, 6
• Never use sedatives in asthma exacerbations - absolutely contraindicated due to risk of respiratory depression 2, 6
• Do not rely on clinical impression alone - always measure PEF objectively to assess severity 1, 2
• Do not taper short courses (<7-10 days) of oral corticosteroids - unnecessary and may lead to underdosing during critical recovery period 5
• Do not discharge patients prematurely - ensure PEF >75% predicted and resolution of nocturnal symptoms before discharge 5, 6