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Patients in the moderate asthma group who are still symptomatic with reduced activity and flow rates despite the combination of a long-acting B2-adrenergic agonist and medium doses of an inhaled corticosteroid will require additional second-line therapy. For broncho dilatation, adding an oral preparation of the B-agonist, theophylline, and/or ipratropium bromide may be helpful. Those with nocturnal symptoms may respond to evening administration of a long-acting B-agonist or theophylline. If attacks continue to be frequent a trial of an additional anti-inflammatory agent is the next step. An anti-leukotriene or cromolyn or nedocromil may be added. It should be emphasized again that the decision to start or stop medications should be based on objective findings (spirometry or peak flow readings) in addition to the patient’s symptoms and frequency of attacks.

Treatment Strategy: Moderate Asthma to Severe

Patients with moderate to severe asthma often need courses of oral corticosteroids when they continue to experience attacks and have lowered flow rates despite maximal firstand second-line therapy. It is always helpful before starting oral corticosteroids to review the correct use of MDI sprays as well as to emphasize the use and benefit of a spacer. Discussions between patient and physician must be frequent in this group to reiterate individual goals of treatment and to discuss the potential side effects of oral corticosteroids. Often it will become clear that a medication (usually inhaled corticosteroid) has not been used due to fear of dependency or side effects. When these questions are answered satisfactorily, resumption of this medication may avoid the use of oral steroids and their side effects.

Treatment Strategy: Severe Asthma

In the patient with severe persistent asthma a home nebulizer should be considered. This device may be used to deliver not only a B2-adrenergic agonist but also cromolyn sodium. This combined aerosol therapy may be extremely helpful in certain patients. A nebulizer may not prove more advantageous than medication delivered by MIDI for every patient.

Severe Asthma: The Next Step

Patients with severe persistent asthma require high doses of inhaled cordcosteroids, long-acting B2-agonist, theophylline, and frequent courses of oral corticosteroid. Maintenance oral steroid may also be necessary.


Table 4. Step-by-step strategy for treatment of asthma


Mild intermittent asthma


Inhaled B2 – Agonist as needed


Mild Persistent asthma


Add an Anti-Inflammatory Agent:
Inhaled Corticosteroid/Cromolyn/Nedocromil/Anti-Leukotrience


Moderate asthma persistent


Use Long-Acting inhaled B2 – Agonist every 12 hours
(Use short B2 – Agonist for “Rescue” from Acute Attack)

Use Medium-Dose Inhaled Corticosteroid
Add anti-leukotriene / Theophylline if still symptomatic


Severe Persistent Asthma


Use High-Dose inhaled cortocosteriod

Long-Acting inhaled B2 – Agonist every 12 hours
(Short-acting B2 – Agonist for “Rescue” )

Add Anti-Leukotriene/ Theophylline / Inhaled Anti-Cholinergic

The Next Step: Oral Corticosteroids


This should always be given in the smallest dose that is effective and only after a trial of alternate-day therapy. The addition of an anti-leukotriene may permit a reduction in the daily steroid dosage. This reduction must be done carefully with monitoring for the development of adrenal insufficiency. Those patients who need more than 10 mg of prednisone (or its equivalent) with significant side effects such as osteoporosis for maintenance should be considered candidates for trials of steroid-sparing anti-inflammatory agents such as methotrexate. Discussion of potential reactions and success rates of these agents must take place before initiating this third-line therapy.

The Peak Flow Meter and the Acute Attack of  Moderate Asthma

As outlined in Chapter 3, peak flow meter readings may be used to direct the management of an acute asthmatic attack or moderate asthma attack. The patient’s strategy for treatment should include peak flow meter readings. The patient and physician should design a plan of treatment based largely on peak flow measurements. Once the patient has obtained a “personal best” value, changes in this “normal” reading can be used to direct therapy. Changes in peak flow of 25 percent, 50 percent, and 75 percent are useful guidelines for assessing the severity of an attack and how the patient should respond. To avoid serious episodes, treatment should be initiated at the earliest indication of an attack from moderate asthma (25 percent decrease in peak flow).

Oral corticosteroids should be used for significant drops in flow (50 percent decrease). Emergency medical attention should be given for severe decreases (75 percent drop in peak flow). Table 5 is an example of a plan of action for acute asthmatic attacks and moderate asthma attack.

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