Asthma Management

Diagnosis and Assessment

• Asthma severity should be assessed using symptoms, short-acting beta-agonist (SABA) use, activity limitations, and pulmonary function, and classified as intermittent or persistent (mild, moderate, or severe), as recommended by the American Academy of Allergy, Asthma, and Immunology 1
• Comorbidities such as gastroesophageal reflux disease (GERD), obstructive sleep apnea (OSA), and rhinitis/sinusitis should be evaluated, as they may affect asthma control and eosinophil counts, according to the American Academy of Allergy, Asthma, and Immunology 1
• Key symptoms to consider in diagnosis include wheezing, coughing, chest tightness, shortness of breath, and sleep disturbance due to symptoms, as noted by the European Respiratory Society 2
• Risk factors for persistent asthma include parental history of asthma, atopic dermatitis, allergic rhinitis, peripheral blood eosinophilia, and wheezing apart from colds, according to the American Academy of Allergy, Asthma, and Immunology 3, 4

Treatment

• Inhaled corticosteroids (ICS) are the preferred first-line treatment for patients with asthma and eosinopenia, with a stepwise approach based on symptom severity, as recommended by the American Academy of Allergy, Asthma, and Immunology 1
• Low-dose ICS should be used as daily controller medication, with alternative options including leukotriene receptor antagonist (LTRA) if unable to use ICS, according to the American Academy of Allergy, Asthma, and Immunology 1
• Treatment approaches are recommended based on asthma severity, with the following preferred and alternative treatments:

• Infants with frequent wheezing episodes should be treated with inhaled corticosteroids as the preferred first-line treatment, with leukotriene receptor antagonists as an alternative option, as recommended by the American Academy of Allergy, Asthma, and Immunology 3

Management and Monitoring

• Asthma control should be assessed at regular intervals (typically every 2-6 weeks initially, then every 1-6 months), and therapy should be stepped up according to the stepwise approach if control is not achieved, as recommended by the American Academy of Allergy, Asthma, and Immunology 1
• The following medications and dosages are recommended for immediate treatment:

• Features of severe asthma include being too breathless to talk or feed, respiratory rate >50/min, pulse >140/min, use of accessory muscles of breathing, and PEF <50% predicted in children who can perform the test, according to the British Thoracic Society 5
• Life-threatening features requiring immediate intensive care consideration include cyanosis, silent chest, poor respiratory effort, fatigue or exhaustion, agitation, reduced consciousness, and PEF <33% predicted, as recommended by the British Thoracic Society 5
• Inhaled corticosteroids (ICS) are the cornerstone of therapy for persistent asthma, with the lowest effective dose used for symptom control, and monitor growth due to potential short-term reductions in growth rate, as recommended by the National Asthma Education and Prevention Program 2

Education and Follow-up

• Consider cultural, ethnic factors, language, and health literacy needs when educating patients about asthma management, including instructions for daily management, controller medications, environmental controls, and actions for worsening asthma, as recommended by the American Academy of Allergy, Asthma, and Immunology 1
• Teach patients to assess their level of asthma control, monitor symptoms and peak expiratory flow measurements if prescribed, and recognize early warning signs of worsening asthma, including proper inhaler technique and the difference between controller and reliever medications, as recommended by the American Academy of Allergy, Asthma, and Immunology 1
• Use validated questionnaires like the Asthma Control Test (ACT) to assess day-to-day symptoms and limitations, with an ACT score ≥20 indicating well-controlled asthma, as suggested by the American Academy of Family Physicians 6 and the Mayo Clinic Proceedings 7
• Ensure follow-up within 48 hours for patients treated at home, and arrange an outpatient appointment within one month for hospitalized patients, as recommended by the British Thoracic Society 2