General principles of management
- Follow a stepped approach
- Before initiating a new drug, check that diagnosis is correct, compliance and inhaler technique are correct and eliminate trigger factors for acute exacerbations
- Start at the step most appropriate to initial severity
- Rescue course
- Give a 3-5 days “rescue course” of prednisolone at any step and at any time as required to control acute
exacerbations of asthma at a dose of:
Child < 1 year: 1-2 mg/kg daily; 1-5 years: up to 20 mg daily;
5-15 years: Up to 40 mg daily; adult: 40-60 mg daily for up to 3-5 days.
- Give a 3-5 days “rescue course” of prednisolone at any step and at any time as required to control acute
- Stepping down
- Review treatment every 3-6 months
- If control is achieved, stepwise reduction may be possible
- If treatment started recently at Step 4 (or contained corticosteroid tablets, see below), reduction may take
place after a short interval; in other patients 1-3 months or longer of stability may be needed before stepwise reduction can be done
TREATMENT
STEP 1: Intermittent asthma
- Intermittent symptoms (< once/week)
- Night time symptoms < twice/month
- Normal physical activity
Occasional relief bronchodilator
- Inhaled short-acting beta2 agonist e.g. salbutamol inhaler 1-2 puffs (100-200 micrograms)
- Use with spacer for children
- Move to Step 2 if use of salbutamol needed more than twice a week or if there are night-time
symptoms at least once a week
STEP 2: Mild persistent asthma
- Symptoms > once/week, but < once/day
- Night time symptoms > twice/month
- Symptoms may affect activity
Regular inhaled preventer therapy
- Salbutamol inhaler 1-2 puffs prn
- Plus regular standard-dose inhaled corticosteroid, e.g. beclomethasone 100-400 micrograms every 12 hours (children: 100-200 micrograms every 12 hours)
- Assess after 1 month and adjust the dose prn
- Higher dose may be needed initially to gain control
- Doubling of the regular dose may be useful to cover exacerbations
STEP 3: Moderate persistent asthma
- Daily symptoms
- Symptoms affect activity
- Night time symptoms > once/week
- Daily use of salbutamol
Children below 5 years: refer to specialist
Regular high-dose inhaled corticosteroids
- Salbutamol inhaler 1-2 puffs prn up to 2-3 hourly Usually 4-12 hourly
- PLUS beclomethasone inhaler 400-1000 micrograms every 12 hours (In child 5-12 years:
100-400 micrograms every 12 hours)
In adults, also consider 6-week trial with
- Aminophylline 200 mg every 12 hours or
- Salbutamol tablets 4 mg 8 every 8 hours
STEP 4: Severe persistent asthma
- Daily symptoms
- Frequent night time symptoms
- Daily use of salbutamol
Refer to specialist clinic especially children <12 years
Regular corticosteroid tablets
- Salbutamol (as in Step 3) plus
- Regular high-dose beclomethasone (as in Step 3)
- Plus regular prednisolone 10-20 mg daily after breakfast
Note
- If inhaler not available, consider salbutamol tablets 4 mg every 8 hours
Child < 2 years: 100 micrograms/kg per dose
Child 2-5 years: 1-2 mg per dose
Caution
- Do not give medicines such as morphine, propranolol, or other B-blockers to patients with asthma as they worsen respiratory problems
- Do not give sedatives to children with asthma, even if they are restless
Prevention
- Avoid precipitating factors e.g.
- Cigarette smoking
- Acetylsalicylic acid
- Known allergens such as dust, pollens, animal skins
- Exposure to cold air
- Exercise can precipitate asthma in children, advise them to keep an inhaler handy during sports and play
- Effectively treat respiratory infections