Asthma Management

1. Goals of Therapy

• Achieve and maintain symptom control (daytime symptoms, activity limitation, nocturnal symptoms, reliever use)
• Minimize future risk (exacerbations, fixed airflow limitation, medication side effects)
• Use the lowest effective treatment step

2. Assessment and Classification

3. Stepwise Chronic Management (GINA Framework)

Step 1 - Mild Intermittent Asthma

• Preferred reliever: As-needed low-dose ICS/formoterol (anti-inflammatory reliever - AIR) - the GINA 2025 preferred track
• Alternative: SABA (salbutamol/albuterol) as needed, though GINA now discourages SABA-only treatment
• Key message: Even at Step 1, ICS should be part of therapy given asthma's inflammatory nature

Step 2 - Mild Persistent Asthma

• Controller: Daily low-dose ICS (e.g., beclomethasone 200 mcg BDP-equivalent BID)
• Reliever: As-needed SABA or as-needed low-dose ICS/formoterol
• Alternatives: Leukotriene receptor antagonist (LTRA), though less effective than ICS

Step 3 - Moderate Persistent Asthma

• Controller: Low-to-medium dose ICS + LABA (fixed combination, single inhaler preferred)
• Evidence favors ICS/LABA combination over high-dose ICS alone
• Alternative add-ons: LTRA, or MART (Maintenance and Reliever Therapy) with ICS/formoterol

Step 4 - Severe Persistent Asthma

• Controller: Medium-to-high dose ICS/LABA
• Add-on: Long-acting muscarinic antagonist (LAMA, e.g., tiotropium) - reduces exacerbations and improves lung function
• LTRA can also be added

Step 5 - Very Severe/Refractory Asthma

• High-dose ICS/LABA + LAMA
• Biologic therapies (phenotype-guided):

• Oral corticosteroids: Last resort; titrate to lowest effective dose
• Bronchial thermoplasty: Selective use in very severe cases; reduces airway smooth muscle mass via radiofrequency energy

Step-Down

4. Non-Pharmacological Measures

• Trigger avoidance: Remove allergens (dust mite, pet dander, mold), occupational sensitizers
• Influenza vaccination (inactivated): Recommended for all adult asthmatics
• Pneumococcal vaccine (Pneumovax): Recommended for adults 19-64 with chronic illness including asthma
• Smoking cessation
• Obesity management: Weight reduction improves control
• Asthma Action Plan: Written plan for self-management of worsening symptoms

5. Management of Acute Exacerbations

High-Risk Features (Warrant ED Referral)

• Previous near-fatal asthma or intubation
• Recent hospitalization or OCS use
• Over-reliance on SABA, under-use of ICS
• Non-adherence or poor perception of airflow limitation

Acute Treatment

• Mild-moderate: Albuterol 2-6 puffs MDI with spacer (or 2.5 mg nebulized) every 20 minutes x 3 doses
• Severe: Albuterol 2.5-5 mg + ipratropium bromide 0.5 mg q20min via nebulizer; or continuous albuterol 10-15 mg/hour (with telemetry)

• Prednisone 40-60 mg/day orally (or methylprednisolone IV if unable to take PO)
• For mild-moderate: 5-7 day course (no taper needed for short courses)
• For severe/respiratory failure history: 7-14 day taper + initiate/increase ICS

• IV magnesium sulfate 2 g over 20 min - improves lung function in life-threatening exacerbations
• Heliox (70:30 He:O₂) driven nebulization - reduces airway resistance
• Theophylline - historical, last-line only due to toxicity

6. Oxygenation and Mechanical Ventilation

• Target SpO₂ >92% (>95% in pregnancy or cardiac disease)
• Ventilator settings for status asthmaticus: Large ETT (≥7.5 mm), prolonged expiratory time, high inspiratory flow, low RR to allow full exhalation (minimize air trapping/intrinsic PEEP)
• Ketamine (bronchodilatory + sedative) and propofol preferred for intubation/sedation
• Neuromuscular blockade may reduce patient-ventilator dyssynchrony

7. Special Considerations

Biomarker-Guided Therapy (2025 GINA Update)

• FeNO >50 ppb (adults): Supports eosinophilic asthma; predicts ICS response
• Blood eosinophils >300 cells/mm³: Indicates biologic candidacy (anti-IL-5, dupilumab)
• Serum IgE + skin prick testing: For omalizumab candidacy

Asthma-COPD Overlap

Pregnancy

• Undertreated asthma is more dangerous to the fetus than properly used medications
• ICS, SABAs, and LABAs are generally safe; biologics have limited data

Pediatric Asthma

• Step 1-2 in children: Low-dose ICS preferred over LABA
• Children ≥6 years follow similar step framework but with weight-adjusted dosing

8. Monitoring and Follow-Up

• Reassess control at every visit using validated tools (Asthma Control Test, ACQ)
• Review inhaler technique and adherence before stepping up therapy
• Consider comorbidities that worsen control: GERD, obesity, rhinosinusitis, OSA, anxiety/depression
• Step up if uncontrolled for >3 months; step down if controlled for 3+ months