5th January 2024

Management

Management of chronic asthma in adults (Aged 17 years or above)

Principles of Pharmacological Management

• Consider alternative diagnosis or possible reasons for uncontrolled asthma before adjusting treatment.
• Review response to treatment 4-8 weeks after starting or adjusting medicines.
• Offer regular daily inhaled corticosteroids ( ICS) instead of intermittent ICS.
• Aim for the lowest required dose of ICS for effective asthma control.
•  Offer a self-management plan consisting of a written personalised action plan and education.
• Consider the possible reasons for uncontrolled asthma before adjusting medications, such as lack of adherence, occupational exposures, psychological factors, alternative diagnosis, and smoking.
• Ensure proper technique of inhaler devices.

Pharmacological treatment pathway for adults (age 17 and above)

Pharmacological management of adults (17 years and over) with newly diagnosed asthma or uncontrolled asthma on their current treatment in a stepwise fashion:

• Short-acting Beta2 agonist (SABA) as reliever therapy alone for people with infrequent and brief periods of wheeze and normal lung function.
• Low-dose ICS as maintenance therapy for people with:
  • Uncontrolled asthma with SABA alone.
  • Symptoms at presentation indicating need for maintenance therapy such as: nocturnal symptoms or symptoms three times a week.
• Leukotriene receptor antagonist (LTRA) in addition to the above.
• Long-acting beta2 agonist ( LABA) in addition to low dose ICS and review response to LTRA.
• Change low-dose ICS and LABA to MART (Maintenance and reliever therapy combines ICS and fast-acting LABA and is used as both maintenance and reliever therapy).
• Increase ICS dose from low to moderate maintenance dose as a MART regimen or moderate dose ICS + LABA + SABA.
• Increase ICS to high dose (as part of fixed regimen);
• or trial of long-acting muscarinic antagonist or theophylline SIGN 158.

Decreasing maintenance therapy

Consider decreasing therapy when asthma symptoms are controlled with current treatments for at least 3 months.

Management of acute asthma exacerbation in adults

Determining severity

The severity of asthma is graded as follows:

Table1. Asthma severity classification

SIGN Asthma Guideline Quick Reference Guide 2019 [Internet]. British Thoracic Society; 2019. Available from: https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-asthma-guideline-quick-reference-guide-2019/

Assess the need for hospital admission

All patients with life-threatening asthma should be admitted to hospital. All patients with features of severe asthma persisting after initial bronchodilator therapy should be admitted. Patients with moderate asthma with worsening symptoms after initial treatment, or those who have had previous life-threatening attacks should be admitted.

Treatment of acute asthma

• Maintain a saturation of 94-98% with supplemental oxygen if required
• Beta 2 agonist bronchodilator (Salbutamol) via nebuliser. In patients with acute severe or life-threatening asthma, nebuliser should be oxygen-driven. Use intravenous Beta 2 agonist if inhaled therapy cannot be used reliably.
• Nebulised Ipratropium bromide (0.5 mg 4-6 hourly) for acute severe or life-threatening exacerbation or for those with inadequate response to initial Beta 2 agonist.
• Steroid to all patients with asthma exacerbation. Continue with prednisolone (40-50 mg daily) until recovery or minimum of 5 days.
• Single dose of intravenous magnesium sulphate (1.2-2 g infusion over 20 minutes) can be given in acute severe or life-threatening asthma who have had inadequate response to initial bronchodilators.
• Antibiotics should only be given in case of bacterial infection.

Any patient with one of the following features should be referred to critical care:

• Any patient who is requiring ventilatory support.
• Patients with severe or life-threatening asthma who fail to respond to therapy as:
  • Worsening PEF
  • Worsening hypoxia
  • Hypercapnia
  • Acidosis on ABG
  • Exhaustion
  • Respiratory arrest
  • Confusion or altered consciousness

References

• Recommendations | Asthma: diagnosis, monitoring and chronic asthma management | Guidance | NICE [Internet]. Nice.org.uk. NICE; 2017. Available from: https://www.nice.org.uk/guidance/ng80/chapter/Recommendations#pharmacological-treatment-pathway-for-adults-aged-17-and-over
• Asthma: Scenario: Newly-diagnosed asthma [Internet]. NICE. 2021. Available from: https://cks.nice.org.uk/topics/asthma/management/newly-diagnosed-asthma/
• Asthma: Scenario: Acute exacerbation of asthma [Internet]. NICE. Available from: https://cks.nice.org.uk/topics/asthma/management/acute-exacerbation-of-asthma/
• SIGN Asthma Guideline Quick Reference Guide 2019 [Internet]. British Thoracic Society; 2019. Available from: https://www.brit-thoracic.org.uk/document-library/guidelines/asthma/btssign-asthma-guideline-quick-reference-guide-2019/