Asthma Treatment Approach
The appropriate treatment for asthma follows a stepwise approach based on severity and control, with inhaled corticosteroids (ICS) as the cornerstone of persistent asthma management, combined with short-acting beta-agonists for symptom relief. 1
Initial Assessment and Classification
Severity Assessment (For Patients Not on Long-Term Control Medications)
Classify asthma severity to determine initial treatment intensity 1:
- Intermittent: Symptoms ≤2 days/week, nighttime awakenings ≤2x/month, FEV1 >80% predicted
- Mild Persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4x/month, FEV1 >80% predicted
- Moderate Persistent: Daily symptoms, nighttime awakenings >1x/week, FEV1 60-80% predicted
- Severe Persistent: Symptoms throughout the day, nighttime awakenings ≥4x/week, FEV1 <60% predicted 1
Control Assessment (For Patients Already on Treatment)
Evaluate current control status every 2-6 weeks 1:
- Well Controlled: ≤2 symptom days/week, ≤2 nighttime awakenings/month, no activity limitation, ≤2 days/week SABA use, FEV1/PEF >80% predicted
- Not Well Controlled: >2 symptom days/week, 1-3 nighttime awakenings/week, some activity limitation, >2 days/week SABA use, FEV1/PEF 60-80% predicted
- Very Poorly Controlled: Daily symptoms, ≥4 nighttime awakenings/week, extreme activity limitation, several times daily SABA use, FEV1/PEF <60% predicted 1
Stepwise Treatment Algorithm for Chronic Management
Step 1: Intermittent Asthma
- Short-acting beta-agonist (SABA) as needed: Albuterol 2 puffs every 4-6 hours as needed for symptoms 2
- No daily controller medication required 1
Step 2: Mild Persistent Asthma
- Low-dose inhaled corticosteroid (ICS) daily as the preferred controller 1
- Alternative: Leukotriene receptor antagonist (montelukast) or theophylline 1
- Plus SABA as needed for symptom relief 1
Step 3: Moderate Persistent Asthma
- Low-dose ICS + long-acting beta-agonist (LABA) combination (preferred) 1
- Alternative: Medium-dose ICS alone 1
- Plus SABA as needed 1
- Critical warning: Never use LABA as monotherapy—always combine with ICS due to increased risk of serious asthma-related events 3
Step 4: Severe Persistent Asthma
- Medium-dose ICS + LABA combination (preferred) 1
- Consider adding: Leukotriene modifier or theophylline 1
- Plus SABA as needed 1
Step 5: Severe Persistent Asthma (Highest Intensity)
- High-dose ICS + LABA 1
- Consider adding: Omalizumab for IgE-mediated asthma 4
- Consider: Oral corticosteroids (lowest effective dose) 1
- Referral to asthma specialist is recommended at this step 1
Acute Exacerbation Management
Severity Recognition
Severe exacerbation features 5:
- Inability to complete sentences in one breath
- Respiratory rate >25 breaths/min
- Heart rate >110 beats/min
- Peak expiratory flow (PEF) <50% predicted or personal best
Life-threatening features requiring immediate ICU consideration 5:
- PEF <33% predicted
- Silent chest, cyanosis, or feeble respiratory effort
- Bradycardia or hypotension
- Altered mental status, exhaustion, confusion, or coma
Immediate Treatment Protocol
Within first 15-30 minutes 5:
High-flow oxygen: 40-60% via mask to maintain SaO₂ >90% (>95% in pregnant patients) 5, 6
High-dose inhaled beta-agonists: Albuterol 5 mg (or salbutamol 5 mg) via nebulizer with oxygen every 20 minutes for 3 doses 5, 6
- Alternative: 4-12 puffs via MDI with spacer every 20 minutes 7
Ipratropium bromide: 0.5 mg via nebulizer every 20 minutes for 3 doses, then as needed 5, 7
- Adding ipratropium reduces hospitalization rates in severe exacerbations 7
Systemic corticosteroids immediately (effects take 6-12 hours to manifest) 5, 7:
Reassessment at 15-30 Minutes
- Continue oxygen therapy
- Continue high-dose steroids (prednisolone 30-60 mg daily)
- Reduce beta-agonist frequency to every 4 hours 6
- Continue oxygen and steroids
- Increase beta-agonist frequency to every 15-30 minutes 6
- Continue ipratropium 0.5 mg every 6 hours 6
- Consider IV aminophylline 250 mg over 20 minutes (avoid if patient already on oral theophyllines) 1
- Consider IV magnesium sulfate for severe cases 5
Hospital Admission Criteria
Immediate admission required for 5:
- Life-threatening features present
- PEF <33% predicted after initial treatment
- Features of severe attack persisting after initial treatment
- PEF 15-30 minutes after treatment <50% predicted 1
- Deteriorating PEF despite treatment
- Worsening/persistent hypoxia (PaO₂ <8 kPa) or hypercapnia (PaCO₂ >6 kPa)
- Exhaustion, feeble respirations, confusion, or drowsiness
- Coma or respiratory arrest
Discharge Criteria
Patient must meet ALL of the following 5:
- PEF ≥70% of predicted or personal best (ideally >75% with variability <25%) 5, 6
- Symptoms minimal or absent
- Oxygen saturation stable on room air
- Stable for 30-60 minutes after last bronchodilator dose 5
- Been on discharge medications for 24 hours with proper inhaler technique verified 6
Discharge medications and follow-up 5, 6:
- Oral prednisolone 30-60 mg daily for 1-3 weeks (NOT just a 5-6 day course, which is often insufficient) 7
- Continue or initiate ICS at higher dose than pre-exacerbation 5, 6
- SABA for symptom relief as needed 6
- Provide peak flow meter and written asthma action plan 5, 7
- Schedule primary care follow-up within 1 week 5, 6
- Schedule respiratory specialist follow-up within 4 weeks 5, 6
Critical Pitfalls to Avoid
Never use sedatives—they are absolutely contraindicated in asthma exacerbations and can worsen respiratory depression 7, 1
Do not use antibiotics unless clear evidence of bacterial infection exists 7, 1
Do not use LABA without ICS—this increases risk of serious asthma-related events and death 3
Do not discharge with inadequate steroid duration—the common 5-6 day methylprednisolone dose pack is often insufficient; use 1-3 weeks of prednisolone 30-60 mg daily 7
Do not underestimate severity—underestimation is the most common preventable cause of asthma deaths 5
Avoid percussive physiotherapy—it is unnecessary in acute asthma management 1
Monitor for complications 1: