Bronchial Asthma Management

Overview

Bronchial asthma is a chronic inflammatory airway disease characterised by reversible airflow obstruction, bronchial hyperresponsiveness, and airway remodelling. The GINA (Global Initiative for Asthma) framework guides symptom-based stepwise management with the goal of achieving good asthma control while minimising treatment burden.

GINA Stepwise Approach

• Step 1 (Intermittent): As-needed low-dose ICS-formoterol (preferred) OR SABA alone for mild symptoms.
• Step 2 (Mild Persistent): Low-dose ICS daily + as-needed SABA reliever. Alternative: LTRA.
• Step 3 (Moderate Persistent): Low-dose ICS/LABA combination. Or medium-dose ICS.
• Step 4 (Severe): Medium/high-dose ICS/LABA. Add tiotropium (LAMA) as add-on.
• Step 5 (Very Severe): Add biologics: Omalizumab (anti-IgE), Mepolizumab (anti-IL-5 for eosinophilic) or high-dose ICS/LABA + low-dose OCS.

Pharmacology

• ICS (Inhaled Corticosteroids): Reduce eosinophilic airway inflammation. First-line anti-inflammatory.
• SABA (Short-Acting Beta-2 Agonists): Salbutamol/albuterol. Rapid bronchodilation for rescue.
• LABA (Long-Acting Beta-2 Agonists): Formoterol (fast-onset), salmeterol. Never as monotherapy in asthma.
• LTRA: Montelukast. Blocks CysLT1 receptor. Useful add-on, especially in aspirin-exacerbated asthma.

Imaging Features of Asthma

• CXR: Usually normal in mild/moderate asthma. Hyperinflation (>6 anterior ribs above diaphragm on PA) in severe chronic asthma. Look for complication: pneumothorax, mucous plugging, consolidation.
• HRCT: Air trapping on expiratory CT (mosaic attenuation map). Bronchial wall thickening. Bronchiectasis in long-standing disease.

High Yield Facts