GUIDELINES ON MANAGEMENT OF ADULT ASTHMA
A CONSENSUS STATEMENT OF THE MALAYSIAN THORACIC SOCIETY


 Outline


 Foreword
Asthma morbidity and mortality is on the increase in a number of developed countries. Our country, which is rapidly becoming industrialized, is also probably similarly saddled, especially with increased morbidity. It is therefore timely that a guideline on the management of asthma be produced for use of Malaysian doctors. These guidelines will hopefully provide well accepted and well recognized methods for the management of asthma to doctors who see and treat patients with asthma in their practice. The committee which set up to draw these guidelines consisted of chest physicians with many years of experience in managing the asthmatic patients. They have also extensively studied guidelines previously established by other groups on asthma management and modified several aspects to suit the local situation.

It is the sincerest hope of the Malaysian Thoracic Society that these guidelines will benefit both Malaysian doctors and their patients who suffer from asthma.

Thank you.

Dr. I. Kuppusamy
President,
Malaysian Thoracic Society
 

Acknowledgements
We would like to express our gratitude to the following companies who have contributed to the successful production of these guidelines:

Astra Pharmaceutical (M) Sdn Bhd
Boehringer Ingelheim Division, Diethelm Malaysia Sdn Bhd
GlaxoWellcome (Malaysia) Sdn Bhd
3M Pharmaceuticals, 3M Malaysia Sdn Bhd

We would also like to express our gratitude to Puan Norhayati Bakri for her help in the preparation of these guidelines.
 

Preface
Asthma is a common disease which affects both adults and children. It continues to cause significant mortality and potentially preventable with proper management. Clinicians managing asthma need to keep abreast with the current concept of the disease and its management so that optimal care can be provided. While this may be possible for some, many may not be able to do so because of the constrain of time due to the nature of their work or practice and the difficulty to get access to reading materials. There are guidelines published by a number of societies/countries which are available but some recommendations concerning certain aspects of the management may not be suitable for local patients. Realising these various factors the Malaysian Thoracic Society has initiated the efforts to produce the guidelines on the management of asthma in adults. I am greatly honored to be given the task to gather a group of dedicated and highly knowledgeable people who have spent their invaluable time and experience to produce these guidelines. I would like to express my gratitude and thanks to these members who have patiently worked together until the completion of the guidelines. They include Dr. Aziah Ahmad Mahayuddin, Dr. Hooi Lai Ngor, Dr. I Kuppusamy, Associate Professor C.K. Liam, Dr. George Simon, Associate Professor Dr. A. Wahab Sufarlan, Dr. Wong Wing Kin and Associate Professor Dr. Ismail Yaacob. Without their help I dont’t think we could have successfully produced theses guidelines. I am also thankful to members of the Malaysian Thoracic Society who have given their constructive views or comments on the guidelines.

We are also indebted to Astra Pharmaceutical (Malaysia) Sdn Bhd, Boehringer Ingelheim Div. Diethelm Malaysia Sdn Bhd, Glaxo Wellcome (Malaysia) Sdn Bhd and 3M Malaysia Sdn Bhd for their generosity in financially supporting this project. My special thanks also goes to Ms Norhayati Bakri for typing the manuscript.

The completion of these guidelines does not mean the end of our efforts to disseminate information on proper asthma care but rather the beginning of more efforts towards achieving an overall better informed and competent clinicians who are to manage asthma effectively. Obviously more seminars, workshop and round table discussions are needed to achieve this goal and MTS will definitely have a big role play in this respect.

With your support I am sure we can do it.
 

BMZ Zainudin, MD, MRCP, FCCP, AM 
Chairman of the Committee on Asthma Management Guidelines 
Malaysian Thoracic Society 
March 1996

 

List Of Participants Participants :   Chairman A Proffesor Dr BMZ Zainudin Department of Medicine Universiti Kebangsaan Malaysia Kuala Lumpur  

Dr A M Aziah   Institute of Respiratory Medicine  Hospital Kuala Lumpur   

Dr I Kuppusamy  Institute of Respiratory Medicine  Hospital Kuala Lumpur   

Dr L N Hooi   Chest Unit  Penang Hospital   

Dr George Simon  Chest Unit  Hospital Alor Setar   

A Professor Dr A W Sufarlan  Department of Medicine  Universiti Kebangsaan Malaysia  Kuala Lumpur   

A Professor Dr C K Liam   Department of Medicine  Hospital University  Kuala Lumpur   

A Professor Dr Ismail Yaacob   Department of Medicine  Universiti Sains Malaysia  Kubang Kerian 

Dr W K Wong  Pantai Medical Centre  Kuala Lumpur   

 


 Introduction
Asthma is a common disease with unacceptably high morbidity and mortality. Many deaths and morbidity have been associated with inadequate treatment, underuse of objective measurement of severity and inadequate supervision. Realising the need to improve the management of asthma among doctors in Malaysia, the Malaysian Thoracic Society initiated efforts to produce and publish this consensus statement on the management of asthma. Since consensus on management of asthma in children was initiated at about the same time by the Academy of medicine of Malaysia, this statement by the Malaysian Thoracic Society only covers management of asthma in adults.

We realise that several asthma management guidelines for example those by the British Thoracic Society, those from Australia and New Zealand and the International consensus are already available. However, local factors such as our health care delivery system, diverse socio-cultural background and level of education which are unique to our country need to be addressed. This prompted us to produce these local guidelines.

We regard the publication of guidelines on asthma management as one of the strategies to improve the overall management of asthma in the country. It should complement other programmes such as lectures, workshops, meetings and periodic publications. We hope these guidelines will serve as a useful reference for doctors although we also appreciate that views may differ in certain aspects of management. In certain circumstances, modification in management may have to be carried out.

Although there is no evidence to date that asthma management guidelines reduce asthma mortality, it is not unreasonable to expect that proper management will result morbidity and consequently mortality too.

To ensure a spread of opinions the working party was selected among doctors working in government hospitals, academic institutions and private hospital.
 

Concept Of Asthma
Asthma is a chronic inflammatory condition of the airways the cause of which is not completely understood. The inflammation is characterised by oedema, infiltration with inflammatory cells especially eosinophils, hypertrophy of glands and smooth muscle and damaged epithelium. The inflammation results in the state of hyperresponsiveness where airways narrow easily in response to a wide range of stimuli.7 This may result in coughing, wheezing, chest tightness and shortness of breath, which are often worse at night. These are the symptoms of an ‘attack’. The airway narrowing is usually reversible but in some patients with chronic asthma the inflammation may lead to irreversible airways obstruction.8 In general the more severe the asthma the more frequent and severe are the attacks. Sometimes an acute attack can be fatal.
 

Management Of Chronic Asthma
Aims of management
The aims of management are:

        i.     to recognise asthma
        ii.    to abolish symptoms
        iii.   to restore normal or best possible long term airway function
        iv.   to reduce morbidity and prevent mortality

Approach to management
In order to achieve those aims the approach to management should include:

        i.    Education of patient and family
        ii.   Avoidance of precipitating factors
        iii.  Use of the lowest effective dose of convenient medications minimising short and long
              term side effects.
        iv.  Assessment of severity and response to treatment.

Education of patient and family
This is an important but often neglected aspect in the management of asthma. It is essential in ensuring the patient’s cooperation and compliance with therapy. As far as possible patients and their families should be encouraged and trained to actively participate in the management of their own asthma. Patient education should include the following information:

       i.        Nature of asthma
       ii.       Preventive measures/avoidance of triggers
       iii.      Drugs used and their side-effects
       iv.      Proper use of inhaled drugs
       v.       Proper use of peak flow meter
       vi.      Knowledge of the difference between relieving and preventive medications
       vii.     Recognition of features of worsening asthma (increase in bronchodilator
                requirement, development of nocturnal symptoms, reducing peak flow rates).
       viii.    Self management plan for selected, motivated patients or parents. (Appendix 1)
       ix.      The danger of non prescribed self medication including certain traditional
                 medicines.

Avoidance of precipitating factors
The following factors may precipitate asthmatic attacks:

    i.    Beta blockers - contraindicated in all asthmatics
    ii.   Aspirin and nonsteroidal anti-inflammatory drugs - if known to precipitate asthma, these
          drugs should be avoided.
    iii.   Allergens, e.g. house dust mites, domestic pets, pollen should be avoided whenever
           possible.
    iv.   Occupation - should be considered as a possible precipitating factor.
    v.    Smoking - active or passive.
    vi.   Day to day triggers - such as exercise and cold air. It is preferable to adjust treatment
           if avoidance imposes inappropriate restrictions on lifestyle.
    vii.   Atmospheric pollution.
    viii.  Food - if known to trigger asthma, should be avoided.

Drug treatment
    There are 2 major groups of drugs to treat asthma:

    1.    Bronchodilator drugs - to relieve bronchospasm and improve symptoms.
    2.    Anti inflammatory drugs - to treat the airway inflammation and bronchial
           hyperresponsiveness, the underlying cause of asthma, i.e. to prevent attacks.

    1. Bronchodilators

          a.    Beta2 agonists
          These drugs are the most effective bronchodilators available. They are safe drugs with
          few side effects when taken by inhalation. The therapeutic effect is felt within a few
          minutes of inhalation. The main side effects are tremors and tachycardia. Oral slow
          release preparations and inhaled long acting beta2 agonists such as Salmeterol /
          bambuterol are useful for nocturnal asthma.
          Examples: Inhaled beta2 agonist:
                                  salbutamol (Ventolin, Respolin)
                                  terbutaline (Bricanyl)
                                  fenoterol (Berotec)
                                  salmeterol (Serevent) - long acting
                          Oral long acting beta2 agonist:
                                  salbutamol (Volmax)
                                  terbutaline (Bricanyl durules)
                                  bambuterol (Bambec)
                          Oral short acting beta2 agonist:
                                  salbutamol
                                  terbutaline etc.

          b.     Anticholinergic drugs
          Inhaled anticholinergics have lower onset but longer duration of action. They have very
          few side effects.
          Examples: Ipratropium bromide (Atrovent)

c.     Methylxanthines
These drugs are available in oral and parenteral forms. Their usefulness is limited by very variable metabolism and a narrow therapeutic window. Sustained release preparations may be useful in nocturnal asthma.9
Examples: Nuelin SR, Theodur, Euphylline

Note: Inhaled beta2 agonists are the bronchodilator of choice. As far as possible, avoid
          using oral beta2 agonists or xanthines as first line bronchodilator drugs.

    2. Anti-Inflammatory Drug

ii. Sodium cromoglycate (Intal)

This drug is very safe with no significant side effects. It is given by inhalation (power Spinhaler or metered dose inhaler). It is of greatest benefit in young, atopic patients.11

Other treatments
Anti-histamines including ketotifen have been proven to be of limited efficacy in many clinical trials in asthma.12-14 Hyposensitisation is of limited value in the management of asthma.15

Drug Delivery
The inhaled route is preferred for beta2 agonists and steroids as it produces the same benefit with fewer side-effects as compared to the oral route. The pressurised metered dose inhaler (MDI) is suitable for most patients as long as the inhalation technique is correct.

For patients with poor coordination, alternative methods for durg inhalation include:
spacer devices, dry powder devices and breath-actuated pressurised MDI.16-21

Although oral treatment is convenient for most patients, the dose required is higher and therefore side effects are more common.22-23
 

Approach To Drug Therapy - "Stepwise Approach"
Treatment should be carried out in a stepwise manner. Patients should be started on treatment at the step most appropriate for the initial severity of their condition. Treatment would then be changed (stepped-up or stepped-down) according to their progress.

Step 1
This treatment is for patients with MILD EPISODIC ASTHMA, characterised by normal or near normal lung function, infrequent symptoms and no nocturnal symptoms (Table 1).

A beta2 agonist by inhalation should be used on an ‘as needed’ basis. If not well controlled, i.e. requiring usage of beta2 agonist more than once a day, advance to Step 2.

Step 2
This treatment is for MODERATE ASTHMA characterised by abnormal lung function (PEF 60-80% predicted), frequent symptoms requiring beta2 agonist more than once daily or with night symptoms.

Addition of an inhaled anti-inflammatory agent is required. Low dose inhaled corticosteroids are the drugs of choice (e.g. beclomethasone or budesonide 200-800 mcg daily). Twice daily dosing is preferred to improve compliance. Sodium cromoglycate may also be effective in some patients.

Step 3
This step is for SEVERE CHRONIC ASTHMA, i.e. patients with persistent symptoms (especially nocturnal symptoms), a continuing need for inhaled bronchodilators and peak flow of less than 60% predicted or best.

High dose of inhaled steroid should be used (beclomethasone or budesonide 800-2000 mcg daily) whilst inhaled beta2 agonist should be taken on an ‘as required’ basis. It may be necessary to add one or more of the following:

        i.        Regular beta2 agonists - oral beta2 agonists (preferably long acting) or inhaled long
                  acting beta2 agonist or nebulised beta2 agonists.
        ii.        Inhaled ipratropium bromide (Atrovent) 40mcg 3-4 times a day.
        iii.       Sustained release theophylline. Whenever possible blood levels should be
                  monitored.

Alternatively, whenever there are problems with high doses of inhaled steroids, these drugs may be added to Step 2 medications.

Step 4
This step is for VERY SEVERE ASTHMA characterised by persistent symptoms not controlled by the above measures.

Oral steroids should be added and the dose kept to the lowest possible that achieves control.

Step down
Patients should be reviewed regularly. When the patient’s condition has been stable for 3-6 months, drug therapy may be stepped down gradually. The monitoring of symptoms and peak flow rate should be continued during drug reduction.
 

Management Of Chronic Asthma In Adults
See Chart 1
 

Rescue Course Of Steroid Tablets
"Rescue" courses of oral steroids may be needed to control exacerbations of asthma at any step. Indications may include:

        a.    symptoms and peak expiratory flow (PEF) get progressively worse day by day.
        b.    PEF falls below 60% of patient’s best.
        c.    sleep is disturbed by asthma.
        d.    morning symptoms persist until midday.
        e.    there is a diminishing response to inhaled bronchodilators.
        f.    emergency treatment with nebulised or injected bronchodilators is required.

Method:
Give 30-60 mg of prednisolone immediately. The dose should be tapered down and stopped within 7-14 days.
 

Assessment Of Severity And Response To Treatment
Assessment should be done as follows:

1.        Clinical assessment. This should include patient’s symptoms, sleep disturbances, effort
           tolerance, disturbance of daily activities and the frequency of bronchodilator drug
           and/or rescue courses of steroid used.

2.        Measuring peak expiratory flow (PEF). This can either be measured by Wright peak
           flow meter or mini-Wright peak flow meter. Mini-Wright peak flow meters are
           affordable for many patients.

PEF Measurements
i.         During periods of ‘well-being’

This allows measurement of patient’s best PEF value which will provide the target for the doctor and the patient to aim for. Twice daily measurements (morning and evening) before any inhaled bronchodilator treatment will determine the diurnal variability of airway calibre. This is calculated as the range divided by the highest value and expressed as a percentage.

PEF (max) - PEF (min)     x     100 = _____________%
        PEF (max)

PEF variability of less than 20% is regarded as mild, between 20-30% is moderate and more than 30% is severe. A good control of asthma means PEF variability is maintained at less than 10%.

ii.        During symptomatic episodes

Specialist Referral
Referral to a respiratory physician is appropriate when:

       a.    there is doubt about the diagnosis
       b.    occupational asthma is suspected
       c.    management is difficult, e.g. brittle asthma or very severe asthma not successfully
              controlled
       d.    long term treatment with nebulised bronchodilator is needed
       e.    asthma is worsening in a pregnant woman
       f.     asthma is interfering with patient’s lifestyle despite changes in treatment
 

Pregnancy And Asthma
During pregnancy asthma in about one-third of women becomes worse, in one-third better and in one-third remains unchanged. However this cannot be predicted. Achieving good control of asthma is more important in order to prevent adverse effects on both fetus and mother than the theoretical risks of any of the presently used anti-asthma medications. Most drugs used to treat asthma are safe with the exception of alpha adrenergic compounds and epinephrine (both are not usually used to treat asthma in Malaysia). Asthma in pregnancy therefore should be managed as in other patients. Acute exacerbations should be treated aggressively in order to avoid fatal hypoxia and maintain maternal well-being. Treatment should include nebulised beta2-agonists and oxygen, systemic corticosteroids should be instituted when necessary. Patients should also have adequate opportunity to discuss the safety of their medication.
 

 Guidelines For The Management Of Acute Asthma In Adults
The presentation of a patient with acute asthma requires rapid assessment of its severity so that the appropriate treatment can be instituted.

Although an acute severe attack of asthma may occasionally develop within a few minutes or hours, it usually occurs against a background of long term poorly controlled asthma or asthma that has been worsening for some days or weeks. The severity of acute asthma attacks is usually underestimated by patients, their relatives and their doctors, mainly because of the failure to make objective measurements.25 Inadequate assessment of such attacks or inappropriate treatment with over-reliance on bronchodilators and underuse of steroids contribute to morbidity and deaths.26-29
 

Aims Of Management
The aims of management are:

        i.        To prevent death
        ii.       To relieve respiratory distress
        iii.      To restore the patient’s lung function to the best possible level as soon as possible.
        iv.      To prevent early relapse
 

Assessment 4,30-32
The severity of the attack should be assessed by:

        i.        History taking
        ii.       Physical examination
        iii.      PEF measurement

Features of moderately severe asthma

Features of acute severe asthma
The presence of any of the following indicates a severe attack of asthma:

Life threatening features
The presence of any of the following indicates a very severe attack of asthma:

Arterial blood gas (ABG) tensions should be measured if a patient has any of the severe or life threatening features.

ABG markers of a very severe, life threatening attach include:

 
Management Of Acute Asthma In Accident And Emergency Department

Initial PEF > 75% (Mild acute asthma)
Sometimes, patients with mild acute asthma may present at the A&E. This is characterised by an initial PEF of >75% of predicted or best value. In this situation, just given the patient’s usual inhaled bronchodilator (e.g. salbutamol, terbutaline or fenoterol) from a metered dose inhaler.

Observe for 60 minutes. If the patient is stable and PEF is still >75%, discharge.

Before discharge:

P/S: Patients should be considered for admission if social situations such as staying alone,
       lack of transport for emergency visit to hospital, etc.

Initial PEF < 75%
Patients who present to the A&E with more severe degrees of acute asthma characterised by an initial PEF < 75% predicted or best value, should be managed as follows:

1. Immediate Treatment With :
        a.    High concentration oxygen (>40%) in cases with initial PEF <50% at presentation.
        b.    High doses of inhaled beta2 agonist (salbutamol 5mg or terbutaline 5mg or fenoterol
               5mg) via nebuliser driven by oxygen. If compressed air nebuliser is used,
               administration of supplemental oxygen when indicated should be continued.

               Alternatively, beta2 agonist may be given by multiple actuations of a pressurised
               aerosol inhaler into a large spacer device (2-5mg, i.e. 20-50 puffs, five puffs at a
               time).

               Consider adding anticholinergic (e.g. ipratropium bromide 0.5mg) to nebulised
               beta2 agonist for patients with acute severe asthma.

        c.    Prednisolone tablets 30-60mg. Very ill patients should be given intravenous
               hydrocortisone 200mg stat.

        NB. Sedatives should not be prescribed.
                Antibiotics are indicated only if there is evidence of a bacterial infection.
                Do a chest x-ray if pneumothorax or pneumonia is suspected or features of acute
                severe or life threatening asthma are present.

        If life threatening features are present:

        d.    Intravenous aminophylline 250mg slowly over 20 minutes or intravenous terbutaline
               or salbutamol 250mcg over 10 minutes.(Bolus aminophylline should not be given to
               patients already taking oral theophylline).

        *    Patients with features of life threatening asthma require admission preferably to the
              intensive care unit (ICU) and should be accompanied by a doctor.
 
        Effects Of Treatment
        The effects of treatment are monitored by:

        Good response to initial treatment
        Such patient should

        Incomplete response to initial treatment
        Such a patient has

        Poor response to initial treatment
        Such a patient has

        The subsequent management of patients with an initial <75% predicted or best value is
        summarised in Table 2.
 
2. Subsequent Management In The Ward Or ICU
        Continue - oxygen at 40%

        If patient is still not improving, also give

3. Monitoring The Effects Of Treatment

4. Other Investigations

5. Transfer Patient To The Intensive Care Unit Or Prepare To Intubate If There Is :

In ICU,

6. Before Discharge, the patient should be:

Management Of Acute Asthma In General Practice
Management is similar to that in the accident and emergency department. The clinic should have facility for oxygen administration and it is essential that equipment for resuscitation should be available.

These are indications for immediate referral to hospital

Threshold for referral to hospital should be lowered for patients:4

Summary Of Emergency Room Management Of Acute Asthma
See Chart 2
 

Chart And Table

CHART 1 : Management Of Chronic Asthma In Adults  

STEP 1

STEP 2

STEP 3

STEP 4

MILD EPISODIC ASTHMA MODERATE ASTHMA SEVERE CHRONIC ASTHMA VERY SEVERE ASTHMA
  • Infrequent symptoms
  • No nocturnal symptoms
  • PET 80-100% predicted

Treatment: 

  • inhaled beta2 agonist "as needed" for symptom relief. If needed more than once a day, advance to Step 2
  • Frequent symptoms
  • Nocturnal symptoms present
  • PEF 60-80% predicted

Treatment 

  • inhaled steroids, e.g. beclomethasone or budesonide 200-800 mcg/day
  • inhaled sodium cromoglycate plus 
  • inhaled beta2 agonist "as needed"
  • Persistent symptoms
  • Frequent nocturnal symptoms
  • PEF 60% predicted or less

Treatment: 

  • inhaled beclomethasone or budesonide 800-2000 mcg/day plus
  • inhaled beta2 agonist as needed plus, if necessary
  • oral beta2 agonist preferably long acting, or
  • inhaled long acting beta2 agonist, or
  • inhaled ipratropium bromide 40 mcg 3-4 times a day, or
  • oral theophylline (sustained release), or
  • nebulised beta2 agonist, 2-4 times a day
  • Persistent symptoms not controlled by step 3 medications

Treatment: 

  • as in step 3, plus oral steroids (the lowest dose possible)

NOTE:

 
 

CHART 2 :     Summary Of Emergency Room Management Of Acute Asthma    TABLE 1 - Disease Severity  

Grade

History

Bronchodilator requirement

Variability in PEF

Best PEF (percentage of predicted)

Severe Wakes at night frequently with wheeze, cough; chest tightness on waking in morning; hospital admission in the last year; previous life threatening attacks Needed more than four times a day

>30%

<60%

 Moderate Symptoms on most days 
Nocturnal symptoms  
> twice a month
 Needed on most days  20% - 30%  60% - 80%
Mild Mild occasional symptoms; e.g. only with exercise or infections Needed occasionally

10% - 20%

80% - 100%

Note : One or more features may be present for any grade of severity. An individual should be assigned to the most severe grade in which any feature occurs.
 
 

TABLE 2 : Emergency Room Management 30 Minutes After Initial Treatment Of
                        Acute Asthma With A PEF <75% Predicted Or Best On Arrival  

Good response and PEF 
> 75% predicted or best 
value 
 
Incomplete response and 
PEF 50 - 75% predicted or 
best value 
 
Poor response and PEF 
< 50% predicted or best 
value 
 
Observe for another 60 minutes 

If patient is stable or improving and PEF is still >75%, DISCHARGE. 
 
 
 
 
 
 
 
 
 
 

Repeat nebulised beta2 agonist 

Observe for 60 minutes. 

(1)      If PEF is still 75%,  
           ADMIT 

(2)      If patient improves and
          PEF >75%, 
          DISCHARGE. 

*  Patients requiring  
    admission should be 
    accompanied by a nurse 
    or doctor.

ADMIT 

*  Patients requiring  
    admission should be 
    accompanied by a nurse  
    or doctor. 
 
 
 
 
 
 
 
 
 

 

 Before discharge:

 P/S : Patients should be considered for admission if social situations such as staying alone,
          lack of transport for emergency visit to hospital etc.
 

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Appendix 1

Example of a written asthma management plan.

Name :     ……………………………………….…………………………………………

Address :  ………………………………………………………………………………

                 ………………………………………………………………………………

Tel. Numbers

General Practitioner : …………………………………………………………………….

Specialist : ……………………………………………………………………………….

Ambulance : ………………….………………………………………………………….

Hospital : …………………..……………………………………………………………

Usual Medication:

1. ……………………………………….…………………………………………

2. ………………………………………..…………………………………………

3. ……………………………………………………………………………..……

4. ……………………………….………………………………………….………

Best Peak Flow Reading : ………………………………………….L/min.

YOUR ASTHMA IS MODERATELY SEVERE IF:

You should double the dose of …………………………. for 2 weeks

  YOUR ASTHMA IS SEVERE IF:

You should double the dose of ……………. for 2 weeks and take ……………… tablets of prednisolone ( ……………..mg) on the first day and reduce that by 1 tablet each day.

YOUR ASTHMA IS VERY SEVERE IF:

You should take 5 puffs of …………………………. and immediately take ……………… tablets of prednisolone ( ……………..mg) and see your doctor.
 


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