12 ‫يي‬

Mild Moderate Severe

+ asthma
Symptoms Less than 4-5 4-5 days a Daily
times a week week
Sym.
Most days
Waking up with Once a week or Once or more with
- Step 5
asthma more low lung function <
60 -Add on tiotropium (≥ 6 ys) or
LAMA (+18)
Step 3 Step 4 -Refer to phenotypic assesment
Track 1 use of + biological therapy
Low dose of Medium dose
MART Step 1-2 mart mart -consider high dose

Formeterol+ICS as needed low maintenance maintenance mart

dose MART 1 inhalation short course ocs
bid 2 inhalation
1 inhalation bid dose :more than 2 inhalation twice
daily

Reliever as needed , low dose MART ICS+ Formeterol dose 160/45

Step up if needed (first, check adherence, environment al control, and comorbid conditions assess control Step down
if possible (and asthma is well controlled for at least 3 months) same in all algorithms
 Mild asthma Moderate Severe

less than twice twice a month or 4-5 days a week Daily

Symptom more, but less than
a month Most days Sym.
s 4-5 days a week

Waking up Once or more with Step 5

- Once a week
with asthma - low lung function <
or more -Add on tiotropium (≥ 6
60 ys) or LAMA (+18)

Step 4
-Refer to phenotypic
Step 3
Track 2 use of step 2 assesment+ biological
Step 1 -Daily low Medium/high therapy
SABA+ICS Daily low dose ICS-LABA
- low dose ICS dose ICS-
LABA IF dose ICS + as- + as needed consider high dose ics+
whenever SABA LABA + as
NEEDED needed SABA SABA
is taken needed SABA LABA
dose 100/50 dose 250/50
Before using dose 100/50 dose 100/50 -short course ocs
1 Inhalation 1 Inhalation
track 2 we 1Inhalation bid 1 Inhalation dose 500/50
bid bid
should assesss bid
1 Inhalation bid
compliance

Reliever as needed , low dose SABA or SABA AND ICS

Add on tiotropium (≥ 6
ys) or LAMA (+18) •
Medium dose ICS ADD LAMA
Low dose ICS taken Add-on azithromycin (3
OTHER or add Daily LTRA and/or LTRA or
whenever SABA is days/week) (≥ 18
CONTROLLERS - or add SLIT HDM HDM SLIT
taken • Daily LTRA years) or LM/LTRA or
Low dose ICS +LABA Switch to high theophylline (+12).
Consider adding SLIT and/or LTRA or dose ICS • Add-on low dose OCS
HDM theophylline
Refer for phenotypic assessment:
Allergic asthma: Add on SC anti-IgE omalizumab (≥ 6 years).
Eosinophilic asthma: Add on SC anti-IL5 mepolizumab (≥ 6 years), benralizumab (≥ 12 years) & IV reslizumab (≥ 18 years).
Eosinophilic/Type 2 asthma: SC anti-IL4 dupilumab (≥ 6 years).
Severe asthma: SC anti-TSLP Tezepelumab ≥ 12 years

NOTE
Azithromycin is used in persistent asthma in sever cases
 6-11 Mild asthma Moderate Severe

less than twice twice a month or 4-5 days a week Daily

Symptom more, but less than
a month Most days Sym.
s daily

Waking up Once or more with

- - Once a week
with asthma low lung function <
or more Step 5
60
-Refer to phenotypic
Step 4
Step 3 assesment
Step 1 medium dose ICS-
step 2 -Medium dose ICS LABA higher dose ics+
- low dose
• Very low dose ICS- LABA or add onanti-
Preferred ICS Daily low Low dose ICS-
formoterol MART formoterol IL5 or anti-IL4R or
controller whenever dose ICS dose 80/4.5 “MART” Anti Ige All: SC
SABA is mcg/inhalation (1
1 inhalation80/4.5 omalizum. Eos/Type
taken inhalation QD)
mcg (1 inhalation 2: SC dupil. Eosin:
Low dose ICS +LABA BID) SC mepolizu.
Low dose ICS taken
Daily low whenever SABA is Low dose ICS ADD LTRA
OTHER • Add-on low dose
dose ICS taken or +LTRA
CONTROLL Ortiotropium OCS
Daily LTRA
ERS
Consider side effects

Reliever as needed , low dose SABA or Low dose Mart as in stage 3 and 4
 0-5
Step 1
step 2 Step 3 Step 4
- (Insufficient Continue
Preferred Daily low dose ICS - double low dose ICS
controller evidence for controller & refer for
daily controller) (Medium dose) specialist assessment
Daily leukotriene
Consider receptor antagonist Low dose ICS +
Add LTRA, or
intermittent (LTRA), or LTRA
Other increase
controlle short course ICS intermittent short Consider specialist
ICS frequency, or
rs at onset of viral course of ICS at referral
add intermittent
illness if Saba onset of respiratory
ICS high dose
not illness
sufficient Reliever as needed , low dose SABA

Symptom pattern not consistent with Asthma

Infrequent viral asthma but wheezing episodes requiring diagnosis, and Asthma not
Consider
Wheezing and no sABA occur frequently, e.g. a3 per well-controlled
this step Give diagnostic trial for 3 months. .year Asthma not well-
or few interval controlled on
For Symptom .Consider specialist referral controlled
symptoms double dose ICS
patter consistent with asthma, and controlled on low
asthma symptoms not well-controlled or dose ICS
.23 exacerbations per year

frequent viral-induced wheezing and Before stepping up, check for

interval asthma symptoms altemative diagnosis, check inhaler
Imp doses
Combined ICS-LABA
Fluticasone/Salmeterol DPI Diskus and Inhub 100/50 mcg, 250/50 mcg,
500/50 mcg
12 year and older Low dose medium high
Fluticasone/Salmeterol DPI 100/50 mcg 1 Inhalation 250/50 mcg 1 Inhalation 500/50 mcg
Diskus and Inhub twice daily twice daily 1 inhalation twice daily
Budesonide/Formoterol FFA 160 4.5 mcg 1 inhalation 160 4.5 mcg 2 inhalations 160/4.5 mcg > 2 inhalations
MDI twice daily twice daily twice dailv
80/4.5 mcg, 160/4.5 mcg

6-11 LOW DOSE

Budesonide/Formoterol hFA MDI 80/4.5 mcg 1 inhalation twice dailv
OUTCOME
Assess patient after 3 month
Adults, Adolescents, and Children 6-11 Years
The patient is controlled
Daytime asthma symptoms not more than twice per week
• NO Nighttime awakening due to asthma
• Reliever not needed for symptoms more than twice per week
• no Activity limitation due to asthma
 • The patient is partially uncontrolled if 2 of the above aren't met and uncontrolled if 3 to 4
are not met
Children < 5 Years
The patient is controlled if
Daytime asthma symptoms are for few minutes once a week
• NO Nighttime awakening or nighttime coughing due to asthma
• Reliever medication used once per week
• NO Activity limitation due to asthma

Step up if needed (first, check adherence, environment al control, and comorbid conditions assess control Step down
if possible (and asthma is well controlled for at least 3 months) same in all algorithms and age groups
Acute Asthma Exacerbations
Asthma exacerbation is the progressive increase in symptoms and progressive decrease in lung function.
Key Points
1. Starting therapy at home allows for rapid initiation and early assessment of response
. 2. Patients should follow their written action plan as soon as they recognize early indicators of an acute exacerbation,
including worsening signs and symptoms and worsening PEF (50-80% )
Home management
Self-management of worsening asthma in adults and adolescents with a written asthma action plan
Effective asthma self-management education requires
•Self-monitoring of symptoms and/or lung function
•Written asthma action plan
•Regular medical review

If PEF or FEV, <60% best, or not

improving after 48 hours
Continue reliever
All patients Continue controller
Increase reliever Contact doctor
Early increase in controller as Add prednisolone
below
40-50 mg/day
Review response
 Management of asthma exacerbations in primary care (adults, adolescents, children 6-11) hospital

PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation

ASSESS the PATIENT : IS it asthma

Factors for asthma-related death?
Severitv of exacerbation? consider worst feature

SEVERE LIFE-
‫س‬ MILD or MODERATE THREATENING
Talks in words, sits hunched
TAlks in phrases,Prefers sitting to lying forwards, agitated Drowsv. confused
Not agitated ,Respirator rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100-120 bpm Pulse rate >120 bpm
O. saturation (on air) 90-95% TRANSFER TO ACUTE
O, saturation (on air) <90% PEF
PEF>50% predicted or best $50% predicted or best CARE FACILITY /ICU
While waiting: give SABA, pratropium
bromide,
START TREATMENT O2. systemic corticosteroid
SABA 4-10 puffs by pMDI + spacer, repeat every
20 minutes for 1 hour Prednisolone: adults 40-
50 mg. children 1-2 mg/kg. max. 40 mg
Controlled oxygen (if available): target
saturation 93-95% (children: 94-98% ARRANGE at DISCHARGE

Reliever: continue as needed

CONTINUE TREATMENT with SABA as needed
ASSESS FOR DISCHARGE .Controller: start, or step up
ASSESS RESPONSE A 1 HOUR (or earlier)
Symptoms improved, not needing SABA PEF Check inhaler technique, adherence
improving, and >60-80% of persona
Improving ARRANGE at DISCHARGE Prednisolone: continue, usually for 5-7
Reliever: continue as needed days
Oxvgen saturation s94% room air )days for children 3-5(
Resources at home adequate(make sure there
are no triggers that can increase asthma sym.) Follow up: within 2-7 days (1-2 days for
children)
Magnesium sulfate (MgSO4 ):
IV MgSO4 recommendations:

✓ Adults with FEV1 < 25%–30% predicted at presentation.

✓ Adults and children who fail to respond to initial treatment and have persistent hypoxemia.

✓ Children whose FEV1 fails to reach 60% predicted after 1 hour of care.
 Management of asthma exacerbations in acute care facility, e.g. emergency department

ICU
INITIAL ASSESSMENT Are anv of the following present
A: airway B: breathing C:cirulation Drowsy, confused or silent chest
NO YES

Further TRIAGE BY CLINICAL STATUS according to worst feature

Consult ICU, start SABA and Oz, and prepare
patient for Endotrachial intubation
SEVERE
MILD or MODERATE Talks in words,Sits hunched forwards
TAlks in phrases,Prefers sitting to lying Not ,Agitate
agitated ,Respirator rate increased ,Accessory Respiratory rate >30/min
muscles not used
Accessory muscles being used
Pulse rate 100-120 bpm ,O.
Pulse rate > 120 bpm
saturation (on air) 90-95%
O saturation (on air) < 90%
PEF>50% predicted or best
PEF ≤50% predicted or best

TREATMENT Short-acting beta, agonists+

Short-acting beta,-agonists Ipratropium bromide
Consider ipratropium bromide
Controlled O to maintain
Controlled O to maintain saturation 93-95%
(children 94 98%) saturi an 93 95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as severe and
re assess for ICU

FEV, or PEF 60-80% of predicted or ASSESS CLINICAL PROGRESS FREQUENTLY FEV, or PEF <60% of predicted or personal
personal best and symptoms improved best, or lack of clinical response SEVERE
MEASURE LUNG FUNCTION
MODERATE Continue treatment as above and reassess
in all patients one hour after initial treatment
Consider for discharge planning in all frequently in all patients one hour after
patients one hour after initial treatment initial treatment