Asthma Management Guidelines

Core Principles of Asthma Management

The British Thoracic Society recommends recognizing asthma early and accurately, abolishing symptoms and restoring normal or best possible airway function, reducing risk of severe attacks and minimizing absence from school or work, enabling normal growth in children, and using lowest effective doses of medications to minimize side effects 1
The goal of asthma management is to achieve control with the least amount of medication, as stated by the British Thoracic Society 1

For mild intermittent asthma, the British Thoracic Society recommends as-needed short-acting β2-agonists (SABA) for symptom relief 2

Life-threatening features of acute asthma exacerbation include silent chest, cyanosis, poor respiratory effort, confusion, and exhaustion, as defined by the British Thoracic Society 3
Severe features of acute asthma exacerbation include inability to complete sentences, respiratory rate >25/min, pulse >110/min, and PEF <50% predicted, as defined by the British Thoracic Society 4
The British Thoracic Society recommends high-dose inhaled β2-agonists, systemic corticosteroids, and oxygen therapy for immediate management of acute severe asthma 3
Hospital admission criteria include any life-threatening features, severe features persisting after initial treatment, PEF <33% of predicted after treatment, and a lower threshold for admission in evening presentations, recent nocturnal symptoms, or previous severe attacks, as recommended by the British Thoracic Society 4

The British Thoracic Society recommends that patients understand the difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory), recognize worsening symptoms, and have a written action plan with clear instructions for medication adjustment 5
A self-management plan should include regular monitoring of symptoms and peak flow, pre-arranged action steps based on symptoms/peak flow, and written guidance for medication adjustments, as recommended by the British Thoracic Society 6

The British Thoracic Society recommends that patients should not be discharged from hospital until symptoms have stabilized with PEF >75% of predicted/personal best, and follow-up should occur within 24-48 hours after acute exacerbations 7
Regular review of inhaler technique, adherence, and symptom control is recommended, with treatment adjustments based on control and consideration of step-down when stable for 3 months, as stated by the British Thoracic Society 2

The British Thoracic Society warns against overreliance on bronchodilators without anti-inflammatory treatment, underestimating severity of exacerbations, sedation in acute asthma, and delayed administration of systemic corticosteroids during severe exacerbations 1, 3, 4

The American Academy of Family Physicians recommends low-dose inhaled corticosteroids (ICS) as first-line controller medication for mild persistent asthma 8, 9
The American Academy of Family Physicians and the Mayo Clinic recommend starting with a low dose to minimize potential side effects, with the goal of using the lowest effective dose 9

The American Academy of Allergy, Asthma, and Immunology recommends prednisolone 40-60 mg daily in one or two divided doses until peak expiratory flow (PEF) reaches 70% of predicted or personal best for adults 10
The American Academy of Allergy, Asthma, and Immunology recommends prednisolone 1-2 mg/kg/day in 2 divided doses (maximum 60 mg/day) until PEF is 70% of predicted or personal best for children 10

Early treatment with ICS is beneficial, with greater improvement in lung function observed when treatment is initiated within the first 6 months of symptom onset, according to the Journal of Allergy and Clinical Immunology 11
Systemic corticosteroids should be administered immediately for acute exacerbations, as recommended by the Journal of Allergy and Clinical Immunology and Thorax 10, 12
The total course of systemic corticosteroids for an asthma exacerbation typically lasts 3-10 days, according to the Journal of Allergy and Clinical Immunology 10

There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, as stated by the Journal of Allergy and Clinical Immunology 10
Low-dose ICS therapy is generally considered safe, and its benefits outweigh risks for most patients with persistent asthma, according to the Mayo Clinic Proceedings 9
The American Academy of Allergy, Asthma, and Immunology notes that inhaled corticosteroids can be started at any point in the treatment of an asthma exacerbation 10

Underestimating the severity of exacerbations can lead to inadequate treatment, as warned by Thorax 12
Failing to consider potential adverse effects with long-term use of high-dose ICS can lead to reduced linear growth rate in children or lower bone mineral density in adults, according to the Mayo Clinic Proceedings 9

Measure PEF as a percentage of predicted normal or personal best to assess asthma control, with PEF <50% of predicted normal or best indicating severe asthma requiring immediate treatment, and PEF <33% of predicted normal or best indicating life-threatening asthma, according to the British Thoracic Society 13
Use PEF monitoring to guide treatment decisions, with values indicating the need for immediate treatment or adjustment of medication, as recommended by the National Asthma Guidelines 13

For patients with catastrophic sudden, severe asthma, a personalized management plan should be developed with the patient, general practitioner, and specialist, as suggested by the American Thoracic Society 14

Thorax, 1993

American family physician, 2010

Mayo Clinic Proceedings, 2009

Journal of Allergy and Clinical Immunology, 2009

Journal of Allergy and Clinical Immunology, 2002

Thorax, 1993