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

Management of Bronchial Asthma

The management of bronchial asthma requires a dual approach: daily inhaled corticosteroids (ICS) as the cornerstone of long-term control for all patients with persistent asthma, combined with short-acting beta-agonists (SABAs) for acute symptom relief, using a stepwise treatment algorithm that escalates or de-escalates based on asthma control. 1, 2, 3

Chronic Asthma Management: The Stepwise Approach

Step 1: Mild Intermittent Asthma

• For patients with symptoms occurring less than 2 times per month with no nocturnal symptoms and FEV1 >80% predicted, use as-needed low-dose ICS-formoterol rather than SABA alone 2, 4
• This approach significantly reduces moderate-to-severe exacerbations compared with SABA monotherapy 2, 4

Step 2: Mild Persistent Asthma

• Start low-dose ICS for patients with symptoms more than 2 days per week but not daily 3
• As-needed low-dose ICS-formoterol is the preferred option and reduces exacerbations compared to SABA alone 2, 4
• Leukotriene receptor antagonists (montelukast) are an alternative second-line treatment with high compliance rates due to once-daily dosing 3

Step 3-4: Moderate to Severe Persistent Asthma

• ICS-LABA combination therapy is the preferred treatment, demonstrating synergistic anti-inflammatory effects equivalent to or better than doubling the ICS dose 4
• For patients aged 12 years and older, adding a LABA to ICS is preferred over adding leukotriene receptor antagonists 3
• Triple combination inhalers (ICS-LABA-LAMA) can be prescribed when asthma remains uncontrolled on medium- or high-dose ICS-LABA to improve symptoms, lung function, and reduce exacerbations 4

Step 5: Severe Asthma

• Add low-dose oral corticosteroids (≤7.5 mg/day prednisone equivalent) only as a last resort after optimizing inhaled therapy 4
• Consider biologic therapy for severe type 2 asthma (elevated blood/sputum eosinophils ≥150/μl, and/or FeNO ≥35 ppb, and/or atopy) 4, 2
• Anti-IgE, anti-IL-5, anti-IL-5Rα, or anti-IL-4Rα monoclonal antibodies can reduce exacerbations and improve control 4
• Add-on azithromycin 250-500 mg three times weekly for 26-48 weeks may reduce exacerbations in patients uncontrolled on Step 5 treatment 4

Acute Asthma Exacerbation Management

Immediate Assessment (First 15-30 Minutes)

• Assess severity objectively using peak expiratory flow (PEF), respiratory rate, heart rate, and oxygen saturation—never rely on clinical impression alone 2, 1
• Severe exacerbation features include: inability to complete sentences, respiratory rate >25 breaths/min, heart rate >110 beats/min, PEF <50% predicted 1, 2
• Life-threatening features include: PEF <33% predicted, silent chest, cyanosis, altered mental status, PaCO₂ ≥42 mmHg 1, 2

Initial Treatment Protocol

• Administer high-flow oxygen via face mask to maintain SpO₂ >90% (>95% in pregnant patients or those with heart disease) 2
• Give albuterol 2.5-5 mg via nebulizer or 4-8 puffs via MDI with spacer every 20 minutes for 3 doses 2, 1
• Administer systemic corticosteroids immediately—prednisolone 40-60 mg orally or IV hydrocortisone 200 mg—do not delay while "trying bronchodilators first" 2, 5, 1
• Add ipratropium bromide 0.5 mg to nebulized beta-agonist every 20 minutes for 3 doses in moderate-to-severe exacerbations 2, 1

Reassessment After 15-30 Minutes

• Measure PEF or FEV₁ and assess symptoms and vital signs 2
• If improving (PEF >50-75% predicted): continue oxygen, prednisolone 40-60 mg daily for 5-10 days, and nebulized beta-agonist every 4-6 hours 1, 5
• If not improving (PEF <50% predicted): increase nebulized beta-agonist frequency to every 15-30 minutes and continue ipratropium every 6 hours 1, 2

Severe/Refractory Cases

• Consider IV magnesium sulfate 2 g over 20 minutes for severe exacerbations with PEF <40% predicted after initial treatment or life-threatening features 2, 5
• Transfer to ICU if: deteriorating PEF, worsening hypoxia (PaO₂ <60 mmHg), rising PaCO₂ ≥42 mmHg, altered mental status, or exhaustion 1, 2

Hospital Admission Criteria

• Immediate admission required for: life-threatening features present, PEF <50% predicted after 1-2 hours of intensive treatment, or previous severe attacks requiring intubation 2, 1
• Lower threshold for admission if: presentation in afternoon/evening, recent nocturnal symptoms, previous severe attacks, or poor social circumstances 1, 2

Critical Pitfalls to Avoid

• Never administer sedatives of any kind to patients with acute asthma—this is absolutely contraindicated 2, 1
• Never delay systemic corticosteroid administration—underuse of corticosteroids is a documented factor in preventable asthma deaths 1, 2
• Do not use LABA monotherapy without ICS, as this increases the risk of serious asthma-related events 6
• Avoid using more than one canister of SABA per month, as this indicates inadequate control and need for increased anti-inflammatory therapy 1, 3
• Do not underdose systemic corticosteroids during exacerbations—use the full 40-60 mg daily dose for adults 5, 2

Monitoring and Follow-Up

Chronic Management

• Schedule follow-up every 2-4 weeks after initial therapy, then every 1-3 months if responding 4
• Regularly train patients in correct inhaler technique at every visit 4, 1
• Monitor PEF regularly to assess response to treatment 3, 1
• Step down treatment once good control is maintained for at least 3 months 1, 3

Post-Exacerbation

• Discharge criteria: PEF >75% predicted, diurnal variability <25%, stable for 30-60 minutes after last bronchodilator dose 2, 1
• Continue oral corticosteroids for 5-10 days (no taper needed for courses <10 days) 5, 2
• Provide written asthma action plan and peak flow meter 1, 2
• Arrange GP follow-up within 1 week and respiratory specialist follow-up within 4 weeks 1, 3

Special Populations

Children (4-11 years)

• Use half doses of bronchodilators (salbutamol 2.5 mg) for children <15 kg 1, 2
• Prednisolone dosing: 1-2 mg/kg/day (maximum 40-60 mg) for exacerbations 5, 1
• For chronic management: 1 inhalation of ICS-LABA 100/50 twice daily 6

Pregnancy

• Maintain SpO₂ >95% during exacerbations 2
• Continue ICS therapy as benefits outweigh risks 6