Asthma Management

Diagnosis & Classification - Wheezy Kid Clues

Look for: recurrent wheeze, cough (esp. nocturnal, exercise-induced), dyspnea. Family history of atopy/asthma is crucial.

• Key Diagnostic Criteria:
  • Spirometry: FEV1/FVC ratio < 0.9 (children 6-11 yrs). Significant reversibility: ↑FEV1 >12% AND >200ml after SABA.
  • PEFR (children): Diurnal variability >13%.
• Classification (GINA): Intermittent, Mild Persistent, Moderate Persistent, Severe Persistent (based on symptoms, nighttime awakenings, SABA use, FEV1).

⭐ In children <5 years, diagnosis is often clinical; a therapeutic trial of SABA/ICS can be diagnostic if symptoms improve and recur off-treatment.

Pharmacotherapy - Meds & Moves

Relievers (Quick Relief):

• Short-Acting Beta2-Agonists (SABA): Salbutamol, Levosalbutamol.
  • Dose: 100-200 mcg (1-2 puffs) PRN.
• Low-dose ICS-Formoterol: Preferred GINA reliever (MART strategy).

Controllers (Long-term Prevention):

• Inhaled Corticosteroids (ICS): Budesonide, Fluticasone. Mainstay.
  • SE: Candidiasis (rinse mouth), dysphonia.
• Long-Acting Beta2-Agonists (LABA): Salmeterol, Formoterol.
  • ⚠️ Always use with ICS.
  • 📌 Formoterol: Fast (for MART).
• Leukotriene Receptor Antagonists (LTRA): Montelukast (10mg OD).
• Theophylline: Narrow therapeutic index.
• Biologics (Severe Asthma): Anti-IgE (Omalizumab), Anti-IL5 (Mepolizumab).

Delivery Devices:

• Metered Dose Inhaler (MDI) + Spacer (↑deposition, ↓SE).
• Dry Powder Inhaler (DPI).
• Nebulizer (acute severe exacerbations).

Stepwise Management (Simplified GINA Approach):

⭐ > Montelukast: rare neuropsychiatric events (agitation, sleep issues), esp. children.

Stepwise Management - The GINA Ladder

• Core Principle: Adjust treatment up or down for symptom control & risk reduction.
• GINA Preferred Pathway (Adults & Adolescents ≥12 years):
  • Step 1: As-needed low-dose ICS-formoterol.
  • Step 2: As-needed low-dose ICS-formoterol.
  • Step 3: Low-dose ICS-formoterol (Maintenance And Reliever Therapy - MART).
  • Step 4: Medium-dose ICS-formoterol (MART).
  • Step 5: High-dose ICS-formoterol (MART). Add LAMA. Refer; consider biologics (e.g., anti-IgE).
• Review & Adjust: Assess 2-6 weeks post-change, then 3-12 monthly. Step down if stable 3 months.

⭐ > The use of ICS-formoterol as both maintenance and reliever (MART) in Steps 3-5 simplifies treatment and improves outcomes by providing rapid relief and anti-inflammatory action with each dose.

Acute Exacerbation - SOS Protocol

• Initial Actions (First Hour):
  • Oxygen: Titrate to SpO2 > 92% (Children: 94-98%).
  • SABA (Salbutamol): Nebulized 2.5-5mg (child: 0.15mg/kg) or MDI 4-10 puffs via spacer. Repeat q20min for 1st hour.
  • Ipratropium Bromide: Add 0.5mg (child: 0.25mg) nebulized with SABA for moderate-severe cases.
  • Systemic Corticosteroids: Oral Prednisolone 1-2mg/kg (max 40-60mg) or IV Hydrocortisone. Administer within 1 hour.
• Severe/Life-Threatening (or poor response):
  • IV Magnesium Sulfate: 2g IV over 20 min (child: 25-75mg/kg, max 2g).
  • Consider continuous SABA, ICU for monitoring/ventilation.

⭐ A "silent chest" in acute asthma is an ominous sign indicating severe airflow limitation and impending respiratory failure.

High‑Yield Points - ⚡ Biggest Takeaways

• Asthma management follows a stepwise approach (GINA guidelines).
• Short-Acting Beta Agonists (SABA) like Salbutamol are for acute symptom relief.
• Inhaled Corticosteroids (ICS) are the preferred long-term controller medication.
• Leukotriene Receptor Antagonists (LTRAs) like Montelukast are add-on/alternative therapy.
• Severe exacerbations require systemic corticosteroids, oxygen, and frequent nebulized SABA/Ipratropium.
• Peak Expiratory Flow Rate (PEFR) helps monitor asthma control and severity.
• Spacer devices are crucial for effective MDI drug delivery in children.