Asthma

Grading Control

• Criteria (last 1 month):

  • Daytime symptoms >2 days/week

  • SABA use >2 days/week

  • Night waking symptoms

  • Activity limitation

• Scoring:

  • 1–2 points: Partial control

  • 3–4 points: Poor control

• Notes:

  • Check peak flow or spirometry if uncertain

  • In kids: Prioritise inhaler technique, adherence before escalating

Step Down Criteria

• When:

  • Adults: 2 months good control, no flares in past year, low flare risk

  • Children: 6 months good control

  • Spirometry: Assess 4–6 weeks post step-down

• Approach: Reduce ICS dose by 25–50% per step-down

• Action Plan: Ensure patient has an updated asthma action plan

Do Not Step Down

• If:

  • Recent or ongoing respiratory infection

  • Seasonal triggers (e.g., winter, travel)

  • Recent exacerbation or poor adherence

  • Frequent SABA use (>2 days/week) or persistent night symptoms

Risk Factors for Life-Threatening Asthma

• ICU admission or ventilation for asthma

• ≥2 hospitalisations or ≥3 ED visits in the past year

• ≥1 SABA/month

• Poor adherence or inhaler technique

• Food allergy or sudden severe exacerbations

• Comorbidities: Obesity, GORD, depression (↑ complexity)

Non-Pharmacological Management

• Triggers: Avoid allergens, smoke, occupational irritants

• Inhaler: Ensure correct technique, use spacer

• Vaccination: Annual influenza vaccine

• Exercise: 150 min/week, gradual increase if unaccustomed

• Follow-Up: Review 4 weeks post step-up therapy; annual spirometry

• Action Plan: Provide a written plan for exacerbation management

• Control Comorbidities: Treat allergic rhinitis (e.g., intranasal corticosteroids)

• Deterioration: Reliever always available, monitor peak flow if possible

• Lifestyle: Maintain healthy weight, address nutrition

• Psychosocial: Manage stress/anxiety to improve adherence

Stepwise Management

Paeds

1. SABA PRN

2. Low-dose ICS or montelukast

3. High-dose ICS + low-dose LABA ± montelukast

   NB: Avoid ICS/LABA in <5 yrs

4. Check inhaler technique/adherence before stepping up

Adults

1. SABA PRN

2. Low-dose ICS ± LABA PRN (e.g., budesonide/formoterol)

3. ICS/LABA (low-dose) maintenance ± SABA PRN

4. High-dose ICS/LABA

   NB: Symbicort (low) as MART can replace SABA if symptoms <2 days/month

5. SABA overuse (>2 canisters/year) indicates poor control

Key Drugs

• Montelukast:

  • 4 mg daily (<6 yrs), 5 mg daily (6+ yrs)

  • Ideal for allergic rhinitis or if ICS not feasible

  • Monitor for neuropsychiatric side effects (e.g., nightmares)

• ICS/LABA:

  • Budesonide/formoterol or beclometasone/formoterol (low-dose)

  • Use spacer; rinse mouth post-inhalation to avoid thrush

Exercise-Induced Asthma

• Paeds:

  • Salbutamol PRN pre-exercise

  • Add montelukast (2–14 yrs) or ICS if persistent

• Adults:

  • Salbutamol (1–4 puffs) pre-exercise

  • Add regular ICS or montelukast if uncontrolled

Dosing

• ICS Low Dose: ~200 mcg/day (budesonide equivalent)

  • Max: 500 mcg (children), 1000 mcg (adults)

• Combination: Budesonide/formoterol 100/6 or 200/6 mcg (max 2400/72 mcg/day)

Additional Notes

• Avoid step-down during high infection risk or instability

• Monitor spirometry 4–6 weeks after therapy change

• SABA >2 days/week or >2 canisters/year → Poor control

• Provide written asthma action plan for all patients

Inhaled Corticosteroids (ICS) in Kids

Indications for ICS

Ages 1–5: ICS not indicated if flares occur every ≤3 months.

Indicated if ANY:

• 1+ daytime symptom/week

• 2+ ED visits or oral steroid flares/year

• Flares > every 6 weeks

• Previous ICU/hospitalisation

Ages 6–11: ICS not indicated if flares every ≤6 weeks with no in-between symptoms.

Indicated if ANY:

• 2+ daytime symptoms/week

• 3+ ED visits or oral steroid flares/year

• 3+ night symptoms/month

• Activity/sleep limitation

• Flares > every 6 weeks

Grey Zone (11–14): Trial ICS 4–6 weeks, reassess for long-term use. Manage 14+ as adults.

Counselling for ICS

• Side Effects:

  • Oral candidiasis, dysphonia → reduced by spacer + mouth rinse

  • High doses: Minor growth suppression (<1 cm), rare adrenal insufficiency

• Benefits: Poor asthma control impacts growth more than ICS

• Review dose/need every 3–6 months

Classification of Paediatric Asthma

• Infrequent Intermittent: Flares >6 weeks apart, no symptoms between

• Frequent Intermittent: Flares <6 weeks apart, no symptoms between

• Persistent: 

  • 2+ daytime/week

  • 3+ night/month

  • Activity/sleep limitation

Management Notes

• Start low-dose ICS if criteria met, reassess in 4–8 weeks

• Consider add-ons (montelukast, LABA) if symptoms persist with adherence and good technique

• Trial reduced dose if well-controlled for 6 months

ICS Side Effects

• Kids: Minor growth suppression, rare adrenal insufficiency, no major impact on bone density

• Adults: Slightly ↑ risk of diabetes, cataracts, osteoporosis at high doses

Additional Notes

• Optimise inhaler technique + spacer to minimise side effects

• Refer to a specialist if moderate-dose ICS fails or significant comorbidities