What are the guidelines for treating a patient with asthma?

Asthma Management Guidelines

Inhaled corticosteroids (ICS) are the most potent and consistently effective long-term controller medication for asthma and should be taken daily regardless of symptom frequency, as they improve asthma control more effectively than any other single long-term medication. 1

Chronic Asthma Management by Severity

Mild Intermittent Asthma (Step 1)

• As-needed low-dose ICS-formoterol is recommended for patients with occasional transient daytime symptoms (<2 times/month, lasting hours), no nocturnal symptoms, no exacerbation risk, and FEV1 >80% predicted 1
• This approach significantly reduces moderate-to-severe exacerbations compared with short-acting β2-agonist (SABA) monotherapy 1

Mild Persistent Asthma (Step 2)

• As-needed low-dose ICS-formoterol remains the preferred approach 1
• Alternative options include daily low-dose ICS plus as-needed SABA, or leukotriene receptor antagonists as second-line treatment with high compliance rates 1

Moderate Persistent Asthma (Steps 3-4)

• For patients ≥12 years whose asthma is not controlled on ICS alone, adding a long-acting beta-agonist (LABA) is the preferred adjunctive therapy rather than increasing the ICS dose 1
• ICS-LABA combinations demonstrate synergistic anti-inflammatory and anti-asthmatic effects, achieving efficacy equivalent to or better than doubling the ICS dose 2
• This combination improves patient adherence and reduces high-dose ICS-related adverse effects 2

Severe Persistent Asthma (Step 5)

• Triple combination inhalers (ICS-LABA-LAMA) can be prescribed to improve symptoms, lung function, and reduce exacerbations when asthma remains uncontrolled on medium- or high-dose ICS-LABA 2
• For adults with severe asthma, low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) may be added as the last choice 2
• Patients with persistent symptoms despite Step 4 treatment should be referred to asthma specialists for further evaluation 2

Acute Exacerbation Management

Initial Assessment and Treatment

Assess severity immediately using objective measurements: ability to complete sentences, pulse rate, respiratory rate, peak expiratory flow (PEF), and oxygen saturation 3, 1

Severe asthma features include: 3

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

Immediate Pharmacological Management

For all acute exacerbations: 3, 1

• Administer high-dose inhaled short-acting beta-agonists immediately: salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer
• Give systemic corticosteroids early: prednisolone 30-60 mg orally or hydrocortisone 200 mg IV immediately, as corticosteroids require 6-12 hours to manifest anti-inflammatory effects 1

For severe exacerbations with life-threatening features: 3, 1

• Add ipratropium bromide 0.5 mg nebulized to each beta-agonist treatment, as this reduces hospitalization rates 1
• Consider IV aminophylline 250 mg over 20 minutes or subcutaneous terbutaline 250 µg over 10 minutes if not improving after 15-30 minutes 3, 1
• Administer high-flow oxygen 40-60% via face mask 3

Response Assessment

• Measure peak expiratory flow 15-30 minutes after starting treatment and according to response thereafter 3, 1
• Reassess clinical features including ability to speak, vital signs, and oxygen saturation 3

Hospital Admission Criteria

Admit immediately if: 3, 1

• Any life-threatening features present
• PEF <33% predicted after initial nebulization
• Any features of acute severe asthma persist after initial treatment
• Inability to complete sentences in one breath
• Oxygen saturation <92% on room air
• Respiratory rate >25 breaths/min or heart rate >110 bpm

Lower the threshold for admission if: 3

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

Pediatric Considerations

Acute Exacerbations in Children

Immediate treatment: 3

• High-flow oxygen via face mask
• Salbutamol 5 mg (2.5 mg up to age 2,5 mg over age 2) or terbutaline 10 mg via oxygen-driven nebulizer (half doses in very young)
• Prednisolone tablets 1-2 mg/kg body weight orally (maximum 40 mg)

Alternative delivery method: Short-acting β-agonists via metered dose inhaler (MDI) with large volume spacer may be as effective as nebulized β-agonists—give one puff every few seconds until improvement occurs (maximum 20 puffs), using a face mask in very young children 3

Important: Aminophylline should no longer be used in children at home 3

Chronic Management in Children

• For children aged 4-11 years with asthma, use fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg twice daily 4
• Monitor growth of pediatric patients receiving ICS, as these medications may cause reduction in growth velocity 4

Catastrophic Sudden Severe Asthma

For patients at great risk of sudden death with rapidly deteriorating asthma: 3

1. Call for help immediately
2. Inhale salbutamol 5 mg or terbutaline 10 mg, or two puffs from MDI repeated 10-20 times
3. Consider preloaded adrenaline syringe (0.5 mg) for subcutaneous injection if previous management has failed
4. Swallow prednisolone 30-60 mg
5. Go to nearest hospital as previously agreed

These patients should: 3

• Be constantly reviewed by a respiratory physician
• Carry a Medic-Alert bracelet or equivalent
• Carry duplicate supply of emergency drugs in multiple locations
• Consider provision of resuscitation box and oxygen cylinder at home

Critical Pitfalls to Avoid

Never use sedatives in asthmatic patients—they are absolutely contraindicated and can worsen respiratory depression 1, 5

Do not prescribe antibiotics unless bacterial infection is clearly documented, as they are unnecessary for elevated inflammatory markers alone 1, 5

Do not attempt intubation in unconscious or confused patients until the most expert available doctor (ideally an anaesthetist) is present 3

Avoid beta-blockers (including ophthalmic preparations) in patients with asthma, as they can cause or exacerbate bronchospasm 6

Be cautious with NSAIDs, as they are well known to provoke wheezing in patients with intrinsic asthma 6

Monitoring and Follow-Up

Rescue Medication Use as Control Indicator

Using short-acting beta-agonists more than 2 days per week or more than 2 nights per month indicates inadequate asthma control and the need to initiate or intensify anti-inflammatory therapy 1

Follow-Up Schedule

• Schedule follow-up visits every 2-4 weeks after initial therapy, then every 1-3 months if there is a response 2
• After acute exacerbation managed at home: surgery review <48 hours 3
• After acute exacerbation requiring hospital presentation: surgery review <24 hours 3
• Regular training in correct inhaler technique is essential for optimal asthma control 2

Discharge Planning After Acute Exacerbation

Provide: 1, 5

• Continue or increase inhaled corticosteroid dose
• Prednisolone 30-60 mg daily for 1-3 weeks
• Peak flow meter and written asthma action plan
• Schedule primary care follow-up within 1 week and respiratory specialist within 4 weeks

Special Considerations

Vomiting During Asthma Exacerbation

If patient is vomiting during an asthma flare: 7

• Administer intravenous hydrocortisone 200 mg every 6 hours instead of oral corticosteroids
• Vomiting indicates either severe attack or inability to tolerate oral medications, lowering threshold for hospital admission
• Once vomiting resolves and patient improving, transition to oral prednisolone 30-60 mg daily

Severe Asthma Definition

Severe asthma is uncontrolled asthma despite: 2

• 3 or more months of continuous standardized use of medium- or high-dose ICS-LABA
• Treatment of comorbid diseases and avoidance of environmental stimuli
• Or worsening after stepping down to lower dose ICS-LABA

Biologic Therapy

Patients with severe type 2 asthma can be treated with biologic therapy 2

• Those with good response to type 2-targeted biologics can prioritize decreasing or stopping maintenance oral corticosteroids
• Should not completely stop maintenance therapy with ICS-LABA 2

Alternative Therapies for Refractory Asthma

For adult patients with persistent symptomatic asthma despite step 5 treatment: 2

• Add-on low-dose azithromycin therapy (250-500 mg/day, three times weekly for 26-48 weeks) may reduce exacerbations
• Bronchial thermoplasty is indicated for adults whose asthma remains uncontrolled despite optimized treatment and specialist referral 2

Immunotherapy

• Subcutaneous immunotherapy may reduce required ICS dosage and improve asthma-specific quality of life and lung function in adults 2
• For house dust mite-sensitized adolescents or adults with FEV1 >70% predicted, HDM sublingual immunotherapy may be added to reduce symptoms and ICS dose if symptoms persist despite low-to-medium-dose ICS-containing therapy 2