CHRONIC ASTHMA

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.
  • 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