Pharmacologic Management and Device Technique
Core concepts
Controllers reduce inflammation and are taken daily: inhaled corticosteroids (ICS) are the most effective long-term controller; ICS-LABA combinations; leukotriene receptor antagonists (montelukast carries a boxed warning for neuropsychiatric events); LAMA (tiotropium, age 6 and older); biologics (omalizumab, mepolizumab, benralizumab, dupilumab, tezepelumab) for severe allergic or eosinophilic phenotypes; theophylline rarely. Relievers are SABA or, in a SMART/MART regimen, low-dose ICS-formoterol used for both maintenance and relief.
Non-negotiables
- LABA monotherapy in asthma is contraindicated; always pair with ICS.
- Do not double the ICS dose to treat worsening symptoms; use a short course of oral corticosteroids (typically 5-7 days, no taper needed if short).
- SABA overuse (2 or more canisters per year, or use more than 2 days per week) is a risk marker, not reassurance.
- Step down only after at least 3 months of good control.
Device technique
pMDI: shake, prime when new or unused, exhale, actuate at the start of a slow deep inhalation, hold about 10 seconds; use a valved holding chamber, one puff at a time with 30-60 seconds between puffs. DPI: quick forceful inhalation, no spacer, keep dry, generally not for children under 4-5 years. Recheck technique at every visit, because most apparent treatment failures are technique failures.
Worked example
A teen on high-dose ICS-LABA with daily symptoms and an albuterol refill every month: before escalating to a biologic, verify adherence and technique and review trigger exposure, then apply step 4 referral criteria.
Rule of thumb: every escalation question starts with "is the drug actually reaching the airway?"