The first part of an action plan in any case of asthma is to look for the offending agent and remove it. Unfortunately, this often can’t be found, or can’t be corrected. If asthma, proven by airway obstruction reversibility in the past, is uncontrolled by short- and long-acting beta-agonist bronchodilators, it’s time to add steroids.

Advair already combines a modest dose of fluticasone combined with the long-acting beta agonist (LABA) salmeterol. At the first sign of uncontrolled asthma in a patient taking LABAs, I would add fluticasone (Flovent 250 mcg MDI or 500 mcg discus) to use 500 mcg qid for adults. They should continue the Advair as well.

When should asthma be considered “uncontrolled”?

The need to increase inhaled steroid is indicated by one of these conditions:

• Needing to use a fast-acting bronchodilator (Bricanyl, Oxese, Symbicort, Ventolin) more than 3 extra times per week
• Achieving less than 4 hours relief of symptoms from each use of the fast-acting bronchodilator
• Awakening because of asthma symptoms more than one night a week
• Coughing more than usual (most asthmatics hopefully aren’t coughing at all)
• Being unable to do usual activities because of asthma symptoms.

The earlier the intervention in uncontrolled asthma — hopefully within hours — the faster the patient should recover.

The rationale for such a sharp increase in inhaled steroid dosage comes from evidence suggesting that even doubling the inhaled steroids can be ineffective in uncontrolled asthma. Once the patient has been feeling better for 4 days in a row — i.e. no cough, no need for extra rescue doses, no awakening, etc. — the extra inhaled steroid can be cut to half. If that goes well, discontinue the extra inhaled steroid in a further 4 days, while always continuing the baseline medication such as Advair.

What about prednisone?

If the patient is worse or unimproved 48-72 hours after increasing inhaled steroids (often they will be better but still have symptoms, which is improvement) then one should add prednisone.

In a severe attack with poor vital signs, one would increase the inhaled steroids as above and start prednisone immediately.