Treatment of bronchial asthma

Cyclic algorithm and control criteria

The patient management process is structured as a continuous cycle of three regular stages. First, the physician assesses the baseline status: confirms the diagnosis, checks compliance and the correctness of the inhalation technique. Next, therapy is selected or adjusted taking into account the elimination of triggers. At the final stage, the response to treatment and parental satisfaction are evaluated.

The disease is considered controlled if the following indicators are met:

• Daytime symptoms occur no more than twice a week.
• Nighttime manifestations occur no more than once a month (up to twice in adolescents).
• Need for emergency relief occurs $\le$ 2 times a week.
• Physical activity of the child is fully preserved.
• Exacerbations occur no more than 1–2 times per year, and pulmonary function parameters remain within normal limits (in children older than 5–6 years).

Drugs and administration routes

All pharmacotherapy is functionally divided into two large groups. The first comprises controller medications (basal therapy), which suppress inflammation and are used long-term. The second comprises reliever medications (bronchodilators), necessary for the rapid relief of bronchial obstruction.

The inhalation route is recognized as the priority method of administration. The choice of delivery device strictly depends on the child's age:

• Nebulizer is universal and suitable for patients from birth.
• Children under 4 years old are prescribed a metered-dose inhaler (MDI) exclusively in combination with a small-volume spacer.
• At 4–6 years of age an MDI with a large spacer (750 ml) or dry powder inhalers are used.
• Children over 7 years old are capable of properly using an MDI without a spacer.

Step-down and step-up maintenance therapy

Treatment volume selection is based on a stepwise approach. If symptoms are uncontrolled, therapy is stepped up (step-up). If stable remission is maintained for 3–6 months, an attempt is made to reduce the drug volume (step-down).

1. Mild asthma: priority is given to monotherapy with drugs having a high safety profile—low-dose ICS. Alternatively, leukotriene receptor antagonists (LTRAs) or cromones are used.
2. Moderate asthma: the regimen is escalated. ICS doses are increased to medium levels, or low/medium-dose ICS are combined with long-acting $\beta_2$-agonists (LABAs).
3. Severe asthma: maximum-volume therapy is applied. The foundation consists of medium/high-dose ICS combined with LABAs. In case of resistance, targeted biologic therapy (monoclonal antibodies against IgE — omalizumab) or systemic steroids are prescribed.

Relief of exacerbations and risk factors

When an attack develops, short-acting $\beta_2$-agonists (SABAs: salbutamol, fenoterol) become first-line drugs, relaxing the smooth muscles of the bronchi. For moderate and severe attacks, the "first-hour rule" is applied: the patient receives three inhalations of bronchodilators during the first hour of treatment, while budesonide suspension is simultaneously administered via a nebulizer.

The risk of life-threatening conditions increases due to management errors. The main risk factors are the absence of planned maintenance therapy, a history of severe attacks (with ICU admission), and poor compliance. Maintenance therapy is often disrupted due to adolescent nihilism, delayed medical consultation, or "steroid phobia" in the patient's parents who are afraid to use hormonal drugs.

Class and exam questions

What else to study on this topic

• Pathogenetic mechanisms: how to prevent bronchial wall remodeling
• Specifics of targeted therapy with monoclonal antibodies (anti-IgE)
• Causes and consequences of "steroid phobia" in patients' parents
• Algorithms for the use of systemic glucocorticoids in severe exacerbations
• Analysis of typical diagnostic errors at the emergency care stage

Other topics in "Chapter 5. Allergic Diseases"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.