Asthma Management Guidelines

Chronic Asthma Management

• The American Academy of Family Physicians recommends inhaled corticosteroids as the preferred first-line controller medication for all patients with persistent asthma, to be taken daily on a long-term basis to achieve and maintain control of symptoms 1
• Inhaled corticosteroids remain the foundation of asthma therapy because they improve asthma control more effectively than any other single long-term control medication when used consistently 1
• The American Academy of Family Physicians suggests starting low-dose inhaled corticosteroids for patients with mild persistent asthma, characterized by symptoms occurring more than 2 days a week but not daily 1
• Leukotriene receptor antagonists, such as montelukast, are an alternative second-line treatment for mild persistent asthma, offering easy once-daily dosing with high compliance rates 1
• For patients aged 12 years and older, adding a long-acting beta-agonist to inhaled corticosteroids is preferred over adding leukotriene receptor antagonists when inhaled corticosteroids alone are insufficient 1
• Short-acting beta-agonists, such as albuterol/salbutamol, are the most effective therapy for rapid reversal of airflow obstruction and prompt relief of symptoms 1
• Increasing use of short-acting beta-agonists, defined as more than 2 days a week or more than 2 nights a month, indicates inadequate asthma control and the need to initiate or intensify anti-inflammatory therapy 1

Acute Asthma Exacerbation Management

• Assess severity immediately using objective measurements before initiating treatment, according to the British Thoracic Society 2
• For mild exacerbations, speech is normal, pulse is less than 110 bpm, respiratory rate is less than 25 breaths/min, and peak expiratory flow is more than 50% predicted 2
• The British Thoracic Society recommends administering high-dose inhaled beta-agonists and systemic corticosteroids immediately for all acute severe exacerbations, although specific details are not provided in this context 2
• Nebulized salbutamol 5 mg or terbutaline 10 mg with oxygen as the driving gas is a first-line therapy option, according to the British Thoracic Society 2
• Prednisolone 30-60 mg orally or hydrocortisone 200 mg intravenously is recommended immediately for acute severe exacerbations, as per the British Thoracic Society guidelines 2
• Reassess peak expiratory flow 15-30 minutes after initial nebulization to evaluate response to treatment, as suggested by the British Thoracic Society 2
• Admit to hospital if any life-threatening features are present, such as inability to complete sentences in one breath, pulse greater than 110 bpm, respiratory rate greater than 25 breaths/min, or peak expiratory flow less than 50% predicted, according to the British Thoracic Society 2
• The British Thoracic Society recommends a lower threshold for admission if the attack occurs in the afternoon or evening, or if there are recent nocturnal symptoms or previous severe attacks 2
• Primary care follow-up within 1 week, or within 24-48 hours for severe exacerbations, is recommended, according to the British Thoracic Society 2
• Respiratory specialist follow-up within 4 weeks is suggested, as per the British Thoracic Society guidelines 2

Asthma Management

Evaluation of Asthma Severity

• Patients with asthma should be evaluated based on the frequency and severity of symptoms, measurements of peak expiratory flow (PEF), and use of rescue medication 3
• Severe asthma is considered when a patient is too wheezy or short of breath to complete sentences in one breath, respiratory rate >25 breaths/min, PEF <50% of predicted normal or best, and heart rate >110 beats/min 4
• Potentially life-threatening characteristics include PEF <33% of predicted normal, silent chest, cyanosis, weak respiratory effort, bradycardia or hypotension, and exhaustion, confusion, or coma 4

Pharmacological Treatment

Long-term Control Therapy

• Administer high doses of inhaled beta-agonists: salbutamol 5 mg or terbutalina 10 mg nebulized with oxygen or through multiple activations of a metered-dose inhaler in a large spacer device 4
• Administer systemic corticosteroids: prednisolone 30-60 mg or hydrocortisone intravenously 200 mg immediately 4, 3

Criteria for Specialized Referral and Hospitalization

• Refer to a respiratory specialist in cases of doubtful diagnosis, possible occupational asthma, or management problems 4
• Hospitalization is indicated for patients with persistent chest tightness or other symptoms of severe acute asthma, PEF <50% of predicted or best, oxygen saturation <92% in ambient air, or inability to complete sentences in one breath 3
• Arterial blood gases should always be measured in patients with severe acute asthma who are admitted to the hospital 4

Follow-up and Long-term Management

• Patients should be regularly evaluated to adjust therapy as necessary 5
• Monitor peak expiratory flow regularly to assess response to treatment 5, 3
• Consider adding a short-acting muscarinic antagonist (such as ipratropium) for additional bronchodilation in cases of limited response to standard therapy 3

Precautions and Adverse Effects

• Avoid the use of sedatives in asthmatic patients as they are contraindicated and can worsen respiratory depression 5
• Antibiotics should only be administered if a bacterial infection is clearly present 5