Management of Chronic Asthma
Assess severity
"In the last week / month..."
- have you had difficulty sleeping because of asthma (inc. cough)
- have you had your usual asthma Sx during the day
- has your asthma interfered with your usual activities
Conservative Mx
1. Lifestyle
- stop smoking
- lose weight
2. Allergens
- pets - avoid exposure
- rigorous measures to remove house dust mites
British Thoracic Society guidelines: stepwise management (adults)
STEP 1
-(inhaled) short-acting beta-2 agonist (PRN, as required)
STEP 2
- (inhaled) short-acting beta-2 agonist (PRN, as required)
- (inhaled) steroid 200–800 mg OD (usually taken as an am+pm dose)
STEP 3
- add LABA (long acting beta-agonist)
- if GOOD response: continue LABA
- if MODERATE response: continue LABA & increase steroids to 800 mg OD
- if POOR response: stop LABA & trial of other drugs, such as leukotrine antagonists (e.g. Montelukast) or theophylline (e.g. aminophylline)
STEP 4
- trial of (inhaled) steroid up to 2000 mg OD
- trial of 4th drug (e.g. leukotrine antagonists (e.g. Montelukast), theophylline (e.g. aminophylline), oral beta-2 agonist)
STEP 5
- (inhaled) steroid 2000 mg OD
- (PO, oral) steroid at lowest dose providing adequate control
- other drugs as required to minimise steroid use
- specialist referral
NB: step down after 3 – 6 months of stability
Acute asthma: treatment
Mild asthma
- bronchodilator, e.g. salbutamol (inhaled)
Moderate – Severe asthma
- salbutamol 5 mg (O2 driven nebuliser) or terbutaline 10 mg
- prednisolone 40 mg (PO)
- hydrocortisone (IV steroid) usually used when patient is unconscious / unable to swallow
Life-threatening asthma
- call ITU
- nebulisers: salbutamol 5 mg (O2 driven neb, max rate = continuous) or ipratropium 500 mg (O2 driven neb, max rate = 3–4 hourly)
- IV bronchodilators: Magnesium Sulphate, aminophylline (poor evidence, side effects), salbutamol 250 mg
- these IV drugs all require senior supervision
- final consideration: aminophylline infusion
