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

Asthma Treatment Regimen

The recommended treatment for asthma depends critically on whether you are managing chronic persistent disease or an acute exacerbation, with inhaled corticosteroids as the cornerstone of chronic management and systemic corticosteroids plus high-dose bronchodilators for acute exacerbations. 1, 2

Chronic Persistent Asthma Management

First-Line Controller Therapy

• Inhaled corticosteroids are the preferred first-line controller medication for all patients with persistent asthma, taken daily on a long-term basis to achieve and maintain symptom control 2
• Start with low-dose inhaled corticosteroids for mild persistent asthma (symptoms >2 days/week but not daily) 2
• For patients aged 12 years and older with inadequate control on inhaled corticosteroids alone, add a long-acting beta-agonist (LABA) such as salmeterol 50 mcg twice daily combined with fluticasone propionate 3
• Leukotriene receptor antagonists (e.g., montelukast) serve as alternative second-line treatment for mild persistent asthma, offering convenient once-daily dosing 2

Rescue Medication

• Short-acting beta-agonists (albuterol/salbutamol) provide rapid reversal of airflow obstruction and prompt symptom relief 2
• Increasing use of short-acting beta-agonists (>2 days/week or >2 nights/month) signals inadequate asthma control and necessitates initiation or intensification of anti-inflammatory therapy 2

Acute Asthma Exacerbation Management

Immediate Severity Assessment

Always assess severity objectively before initiating treatment using peak expiratory flow (PEF), respiratory rate, pulse, and ability to speak in complete sentences 4, 5

Mild Exacerbation Criteria:

• Speech normal 4
• Pulse <110 beats/min 4
• Respiratory rate <25 breaths/min 4
• PEF >50% predicted or personal best 4

Severe Exacerbation Criteria:

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

Life-Threatening Features:

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

Initial Treatment Algorithm

For Mild-to-Moderate Exacerbations (Outpatient):

• Administer nebulized salbutamol 5 mg or terbutaline 10 mg immediately (if no nebulizer available, give 2 puffs of beta-agonist via large volume spacer and repeat 10-20 times) 4, 5
• Give prednisolone 30-60 mg orally immediately without delay, as clinical benefits require 6-12 hours to manifest 4, 1, 6
• Reassess PEF 15-30 minutes after initial treatment 4, 5
• If PEF improves to >50-75% predicted, continue prednisolone 40-60 mg daily for 5-10 days without tapering 1
• Step up usual inhaled corticosteroid therapy 4

For Severe Exacerbations:

• Oxygen 40-60% to maintain SpO2 >92% 4, 2
• 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
• If no improvement after 15-30 minutes, add nebulized ipratropium 0.5 mg 4
• Consider subcutaneous terbutaline or epinephrine if inadequate response to continuous nebulization 4, 7

Systemic Corticosteroid Dosing Details

Adult Dosing:

• Standard dose: prednisolone 40-60 mg daily as single morning dose or in 2 divided doses for 5-10 days 1
• For severe exacerbations requiring hospitalization: 40-80 mg/day until PEF reaches 70% of predicted or personal best 1
• Alternative: methylprednisolone 60-80 mg/day for 3-10 days 1
• No tapering necessary for courses <7-10 days, especially if patient is on inhaled corticosteroids 1

Pediatric Dosing:

• Prednisolone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) for 3-10 days 1
• Calculate dose based on ideal body weight rather than actual weight in overweight children to avoid excessive steroid exposure 1

Route of Administration:

• Oral administration is strongly preferred and equally effective as intravenous therapy when gastrointestinal absorption is intact 1
• Reserve IV hydrocortisone 200 mg every 6 hours for patients who are vomiting, severely ill, or unable to tolerate oral medications 1

Hospital Admission Criteria

Admit immediately if any of the following are present: 4, 5

• Any life-threatening features (PEF <33%, silent chest, confusion, cyanosis)
• Features of acute severe asthma persist after initial treatment
• PEF remains <50% predicted after initial treatment
• Oxygen saturation <92% on room air
• Attack occurs in afternoon/evening with recent nocturnal symptoms or previous severe attacks

Follow-Up Planning

• Primary care follow-up within 1 week (within 24-48 hours for severe exacerbations) 4, 5
• Respiratory specialist follow-up within 4 weeks 4, 5
• Provide peak flow meter and written asthma action plan for self-monitoring 4, 5
• Continue or increase inhaled corticosteroid dose for long-term control 5

Critical Pitfalls to Avoid

• Never delay systemic corticosteroid administration during acute exacerbations—underuse of corticosteroids is a documented factor in preventable asthma deaths 4, 1
• Do not underdose systemic corticosteroids; higher doses (40-60 mg range) produce better outcomes than lower doses 1
• Avoid unnecessarily high doses (>80 mg/day), as they provide no additional benefit but increase adverse effects 1
• Do not taper short courses (<7-10 days) of corticosteroids, as this is unnecessary and may lead to underdosing during the critical recovery period 1
• Never use LABA monotherapy without inhaled corticosteroids, as this increases the risk of serious asthma-related events 3
• Do not rely solely on clinical impression—always measure PEF objectively to assess severity and response 4
• Avoid sedatives in acute asthma, as they are contraindicated and can worsen respiratory depression 2