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Asthma- General Management

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Definition

Asthma is a chronic respiratory illness with acute exacerbations
Expiratory wheeze and reversible airways obstruction.
Reversibility is key. Can be established by history, examination, PEFR records and spirometry
Asthma is increasing worldwide and each year in the UK 1000-2000 people die of Asthma.

Aetiology

Commoner in those with hay fever, urticaria and eczema and raised IgE and eosinophils - Allergic asthma.
It is this rise in 'allergy' that may account for the overall rise in asthma incidence
Excess of Th2 > Th1 in nasal and bronchial mucosa.
Th2 lymphocytes secrete cytokines, inducing the production of IgE

Pathology

Chronic inflammatory condition
Thickening of the lamina reticularis.
Eosinophilia seen in bronchial biopsies.
Curschmann's spirals containing eosinophils and Charcot-Leyden granules suggest steroid responsiveness

Precipitating factors

Cigarette smoke, Cold air and Irritant gases as well as Perfume and Deodorants
House dust mite allergen, Aspergillus spores, Viral infections, Exercise and Emotional stresses
Drugs - NSAIDs, Aspirin (associated with Nasal polyps), Beta-blockers. Tartrazine ( a colourant), Other chemicals - see occupational asthma
Types of response to precipitant: Early bronchospasm post-exposure to precipitant. Delayed bronchospasm is seen in 1/3rd even up to 10 hours after initial exposure

Clinical Classification

Intrinsic: Non atopic, Do not have evidence of raised IgE, Older patients with late onset asthma.
Extrinsic: Atopic, Allergic asthma is commoner in children and young adults, Elevated IgE

Clinical

Expiratory dyspnoea and wheeze
Chest tightness and cough (Cough often at night)
Reduced chest expansion

Diagnosis: Clinical history compatible with asthma and

Improved FEV by at least 12% (200 ml) after Salbutamol/trial of steroids.
A 15% improvement is stronger evidence.
More than 20% diurnal variation on = 3 days in a week for 2 weeks on PEF diary
FEV1 = 15% decrease after 6 mins of exercise

Investigations

Bloods: FBC, U&E. CRP/ESR normal - usually normal unless infective component.
Atopy : Elevated Eosinophils, Elevated IgE, Elevated FENO
CXR will in most cases be normal: Lobar collapse with mucus plugging, Infiltrates: aspergillus, Bronchiectasis
Spirometry: Measure FVC FEV1. FEV1/FVC ratio < 70% (or below the lower limit of normal if this value is available) is a positive test for obstructive airway disease
PEFR shows variability > 20% with time and treatment. Predicted PEFR and diary of PEFR readings can show variability.
Improved FEV1.0 by > 15% after 2 weeks of Prednisolone 30 mg od confirms the diagnosis.
Fractional exhaled nitric oxide ? 40 ppb in adults or 35 in children/young adults
Bronchodilator reversibility (BDR) test: Increase FEV1 > 12% or more and increase in volume of 200 ml is positive
Skin prick testing may be used to identify possible allergens to avoid. Aspergillus antibodies if eosinophilia or CXR shadowing

Management

Short acting beta agonist (SABA)
- Salbutamol metered dose "blue" inhaler used PRN as reliever therapy.
- Terbutaline inhaler used PRN as reliever therapy.
- Salbutamol nebuliser used in severe disease acute severe asthma.
Long-acting beta agonist (LABA) : Salmeterol.
Anticholinergics: Ipratropium blocks muscarinic receptors.
Inhaled corticosteroids (IHC):
- Low dose: Budesonide 200-400 mcg/day or equivalent
- Moderate dose: Budesonide 400-800 mcg/ay or equivalent
- High dose Budesonide 800-2000 mcg/day or equivalent
Oral or IV Corticosteroids
- Prednisolone 30 mg short course for severe acute asthma.
- Hydrocortisone is used IV for acute severe asthma
- Steroid sparing agents
  - Methotrexate
  - Ciclosporin
  - IV Immunoglobulin
  - Anti IgE monoclonal antibody Omalizumab
  - Etanercept, Infliximab, Lebrikizumab
Mast cell stabiliser: Sodium cromoglycate - inhibits. Cysteinyl Leukotriene receptor antagonist LT1 and LT2 receptors. Some are responsive. Give it a trial.
Phosphodiesterase inhibitor. Aminophylline
Biologicals: Omalizumab - monoclonal ab binds to free IgE.
Antibiotics: if evidence of infection.
Steroid sparing agents: Cyclosporin, Methotrexate
Magnesium: Used in acute severe asthma

Drugs used to treat Asthma

Drug Class	Drug Name	Indication	Comments
Short-Acting Beta-2 Agonists (SABA)	Salbutamol (Ventolin) Terbutaline (Bricanyl)	Relief of acute asthma symptoms (rescue inhalers)	First-line treatment for quick relief of bronchoconstriction. Often used as needed.
Long-Acting Beta-2 Agonists (LABA)	Formoterol (Oxis, Foradil) Salmeterol (Serevent)	Maintenance treatment in combination with inhaled corticosteroids (ICS)	Not used as monotherapy; must be combined with ICS to reduce the risk of severe asthma attacks.
Inhaled Corticosteroids (ICS)	Beclometasone (Qvar) Budesonide (Pulmicort) Fluticasone (Flixotide)	Maintenance treatment for controlling chronic asthma symptoms	Mainstay of long-term asthma control. Reduces inflammation in the airways.
Combination Inhalers (ICS + LABA)	Fluticasone/Salmeterol (Seretide) Budesonide/Formoterol (Symbicort), Beclometasone/Formoterol (Fostair)	Maintenance treatment for asthma when single-drug therapy is insufficient	Convenient for patients requiring both ICS and LABA, ensuring compliance.
Leukotriene Receptor Antagonists (LTRA)	Montelukast (Singulair) Zafirlukast (Accolate)	Add-on therapy for asthma, particularly in allergic asthma or exercise-induced symptoms	Oral medications that help reduce inflammation and bronchoconstriction.
Short-Acting Muscarinic Antagonists (SAMA)	Ipratropium Bromide (Atrovent)	Relief of bronchoconstriction, often used in combination with SABA	Primarily used in acute exacerbations, often in a nebulizer form.
Long-Acting Muscarinic Antagonists (LAMA)	Tiotropium (Spiriva) Aclidinium (Eklira Genuair)	Maintenance therapy for severe asthma, particularly in patients with overlapping COPD	Used as an add-on therapy in patients with difficult-to-control asthma.
Theophyllines	Theophylline (Uniphyllin) Aminophylline	Maintenance treatment for asthma, particularly for nocturnal symptoms	Oral or IV medications with bronchodilator effects; requires regular monitoring due to narrow therapeutic index.
Biologic Therapies	Omalizumab (Xolair) Mepolizumab (Nucala) Benralizumab (Fasenra)	Severe eosinophilic asthma or allergic asthma not controlled with standard therapy	Monoclonal antibodies targeting specific pathways in asthma; administered via injection.
Oral Corticosteroids	Prednisolone Dexamethasone	Acute exacerbations or severe asthma uncontrolled by other treatments	Used short-term due to significant side effects; long-term use is reserved for severe cases.

Standard escalation process

Step	Description	Details of management
Step 1	Mild intermittent Asthma	Short acting beta agonist as required such as a Salbutamol [Albuterol] inhaler. Teach inhaler technique.
Step 2	Regular preventer medication	Add Inhaled corticosteroid 200-800 mcg/day - start at 400 mcg/day e.g. Beclomethasone, Budesonide, Fluticasone. Advise to rinse mouth after to avoid oral candidal infection or hoarseness.
Step 3	Add on therapy	Long acting beta₂-agonist (LABA) e.g. Salmeterol and/or increase inhaled steroid to 800 mcg/day if still not controlled. No response to LABA then stop it, continue steroid and consider SR Theophylline or Leukotriene receptor antagonist (Montelukast, Zafirlukast).
Step 4	Persistent poor control	Increase inhaled steroid dose to 2000 mcg/day - Add Leukotriene receptor antagonist/ Oral beta₂ agonist tablet/SR Theophylline
Step 5	Continuous or frequent oral steroid usage	Increase inhaled steroid dose to 2000 mcg/day to minimise oral steroids. Consider other treatments - refer to a specialist. Methotrexate has been used in severe Asthma. Patient involvement and education is fundamental at all stages.

PLEASE NOTE LEGAL ADVICE: The contents are under continuing development and improvements and may contain errors of omission or fact. Feedback vital and always welcome at drokane at gmail.com. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice. It is only for educational purposes. Please adhere to your local protocols. If you are unwell please seek healthcare advice from your doctor. This does not replace senior or specialist advice. If you do not accept this then please do not use the website. If you need medical advice, please consult a doctor or other appropriate medical professional. If you are a medical professional and you need advice then speak to your senior or colleagues.

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