Asthma as treated by Carlos E Mijares, MD
Former Allergy Fellow and resident at University of Kansas, USA
Currently. headquarted at www.centromedicodecaracas,com.ve
carlosmixares@gmail.com
Spirometry, which additionally measures forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), can be used to document airflow obstruction (by demonstration of a reduced FEV1/FVC ratio) and provides additional information that is useful in monitoring asthma, such as risk for exacerbations [16,25]. Spirometry has greater sensitivity for detecting airflow obstruction in the presence of a normal peak expiratory flow. As mentioned previously, the 2007 NAEPP guidelines recommend the use of spirometry in practices that are regularly caring for patients with asthma. (See "Office spirometry".)
The patient should be instructed in how to establish a baseline measure of peak flow when feeling entirely well: the "personal best" peak flow value. The personal best PEFR is then used to determine the normal PEFR range, which is between 80 and 100 percent of the patient's personal best. Readings below this normal range indicate airway narrowing, a change that may occur before symptoms are perceived by the patient. (See 'Asthma action plan' below.)
Patients must learn how to monitor their symptoms and pulmonary function; they must understand what triggers their asthma attacks and how to avoid or decrease exposure to these triggers; and they must understand what medicine to take and how to use inhalers properly (table 3 and table 4 and table 5 and table 6). If they have difficulty taking the medications regularly, they need help devising methods to improve compliance. The specific information that should be conveyed to the patient is reviewed in detail separately. (See "What do patients need to know about their asthma?".)
Some triggers are mostly unavoidable, such as upper respiratory tract illnesses, physical exertion, hormonal fluctuations, and extreme emotion, and patients should be taught to adjust their management accordingly.
Other triggers, however, should be identified and specifically addressed or treated [5,31]:
The first step in determining appropriate therapy for patients who are not already on a controller medication is classifying the severity of the patient's asthma. For patients already taking one or more controller medications, treatment options are guided by an assessment of asthma control rather than asthma severity.
The classification of severity in children aged 5 to 11 years is similar to that in adults (table 12). Severity in children under the age of four years, however, is classified somewhat differently (table 13). Initiating long-term controller medications in children under the age of 12 years is reviewed separately. (See "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
In addition, a person using a SABA to prevent exercise-induced asthmatic symptoms might fit into this category of intermittent asthma even if exercising more than twice per week. Others in whom asthmatic symptoms arise only under certain infrequently occurring circumstances (eg, upon encountering a cat or during viral respiratory tract infections) are also considered to have intermittent asthma. (See "Exercise-induced bronchoconstriction".)
Equivalent schema for classifying asthma in children 0 to 4 years and 5 to 11 years are provided (table 13 and table 12).
Equivalent figures for asthma in children 0 to 4 years and 5 to 11 years are provided (table 13 and table 12).
The pharmacologic management of mild persistent asthma is presented in greater detail elsewhere. (See "Treatment of intermittent and mild persistent asthma in adolescents and adults" and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
Step 6 therapy for the management of severe asthma involves the addition of oral glucocorticoids on a daily or alternate-day basis. Severe asthma is reviewed in more detail elsewhere. (See "Treatment of severe asthma in adolescents and adults".)
Former Allergy Fellow and resident at University of Kansas, USA
Currently. headquarted at www.centromedicodecaracas,com.ve
carlosmixares@gmail.com
An overview of asthma management
Disclosures:
Christopher H Fanta, MD
Nothing to disclose.
Robert A Wood, MD
Grant/Research/Clinical Trial Support: DBV [Food allergy].
Consultant/Advisory Boards: Sanofi [Food allergy (Epinephrine)];
Stallergenes [Allergic rhinitis (Sweet vernal/orchard/perennial
rye/timothy/kentucky blue grass mixed pollen allergen extract -
sublingual route)].
Bruce S Bochner, MD
Grant/Research/Clinical Trial Support: NIAID; NHLBI; GSK
[Siglec-8, Siglec-9, asthma, COPD, anaphylaxis, imaging; eosinophilic
granulomatosis with polyangiitis]. Consultant/Advisory Boards: TEVA;
Sanofi; Merck; GlycoMimetics; Allakos; Biogen; Svelte Medical Systems.
Patent Holder: Siglec-8 and its ligand; anti-Siglec-8 antibodies [Held
by Johns Hopkins University]. Employment: Northwestern University
Feinberg School of Medicine. Equity Ownership/Stock Options:
GlycoMimetics; Allakos. Other Financial Interest: Elsevier [Publication
royalties].
Helen Hollingsworth, MD
Nothing to disclose.
Contributor disclosures are
reviewed for conflicts of interest by the editorial group. When found,
these are addressed by vetting through a multi-level review process, and
through requirements for references to be provided to support the
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must conform to UpToDate standards of evidence.
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through:
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|
This topic last updated:
Jul 08, 2014.
INTRODUCTION — This
overview topic presents the components and goals of asthma management.
It is applicable to both children and adults. The information herein is
consistent with "The National Asthma Education and Prevention Program:
Expert Panel Report 3, Guidelines for the Diagnosis and Management of
Asthma – Full Report 2007" [1]. Similar guidelines have been published by the Global Initiative for Asthma (GINA) [2].
The diagnosis of asthma and more detailed management issues are reviewed elsewhere. (See "Diagnosis of asthma in adolescents and adults" and "Asthma in children younger than 12 years: Initial evaluation and diagnosis" and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications" and "Treatment of intermittent and mild persistent asthma in adolescents and adults" and "Treatment of moderate persistent asthma in adolescents and adults".)
COMPONENTS OF ASTHMA MANAGEMENT — The successful management of patients with asthma includes four essential components:
●Routine monitoring of symptoms and lung function
●Patient education to create a partnership between clinician and patient
●Controlling environmental factors (trigger factors) and comorbid conditions that contribute to asthma severity
●Pharmacologic therapy
GOALS OF ASTHMA TREATMENT — The goals of chronic asthma management may be divided into two domains: reduction in impairment and reduction of risk [1].
Reduce impairment — Impairment
refers to the intensity and frequency of asthma symptoms and the degree
to which the patient is limited by these symptoms. Specific goals for
reducing impairment include:
●Freedom from frequent or troublesome symptoms of asthma (cough, chest tightness, wheezing, or shortness of breath)
●Minimal need (≤2 days per week) of inhaled short acting beta agonists (SABAs) to relieve symptoms
●Few night-time awakenings (<2 nights per month) due to asthma
●Optimization of lung function
●Maintenance of normal daily activities, including work or school attendance and participation in athletics and exercise
●Satisfaction with asthma care on the part of patients and families
Reduce risk — The
2007 NAEPP guidelines introduced the concept of risk to encompass the
various adverse outcomes associated with asthma and its treatment [1].
These include asthma exacerbations, suboptimal lung development
(children), loss of lung function over time (adults), and adverse
effects from asthma medications. Proper asthma management attempts to
minimize the patient's likelihood of experiencing these outcomes.
Specific goals for reducing risk include:
●Prevention of recurrent exacerbations and need for emergency department or hospital care
●Prevention of reduced lung growth in children, and loss of lung function in adults
●Optimization of pharmacotherapy with minimal or no adverse effects
MONITORING PATIENTS WITH ASTHMA — Currently,
the majority of medical visits for asthma are for urgent care.
Effective asthma management, however, requires a proactive, preventative
approach, similar to the treatment of hypertension or diabetes. Routine
follow-up visits for patients with active asthma are recommended, at a
frequency of every one to six months, depending upon the severity of
asthma. These visits should be used to assess multiple aspects of the
patient's asthma [3].
The aspects of the patient's asthma that should be assessed at each
visit include the following: signs and symptoms, pulmonary function,
quality of life, exacerbations, adherence with treatment, medication
side effects, and patient satisfaction with care.
Well-controlled
asthma is characterized by daytime symptoms no more than twice per week
and nighttime symptoms no more than twice per month. SABAs for relief of
asthma symptoms should be needed less often than twice weekly, and
there should be no interference with normal activity (preventative use
of a SABA, such as prior to exercise, is acceptable even if used in this
way on a daily basis). Peak flow should remain normal or near-normal.
Oral glucocorticoid courses and/or urgent care visits should be needed no more than once per year [4]. Assessment of control in patients of different ages is summarized in the tables (table 1A-C).
Symptom assessment — Symptoms
over the past two to four weeks should be assessed at each visit.
Assessment should address daytime symptoms, nighttime symptoms, use of
short acting inhaled beta agonists to relieve symptoms, and difficulty
in performing normal activities and exercise. Several quick and
validated questionnaires, like the Asthma Control Test, have been
published (form 1 and figure 1) [5-15].
Assessment of impairment — The following questions are representative of those used in validated questionnaires to assess asthma control:
●Has your asthma awakened you at night or in the early morning?
●How
often have you been needing to use your quick-acting relief medication
to relieve symptoms of cough, shortness of breath, or chest tightness?
●Have you needed any unscheduled care for your asthma, including calling in, an office visit, or an emergency department visit?
●Have you been able to participate in school/work and recreational activities as desired?
●If
you are measuring your peak flow, has it been lower than your personal
best? Home monitoring of peak flow measurements is reviewed in detail
separately. (See "Peak expiratory flow rate monitoring in asthma".)
●Have you had any side effects from your asthma medications?
Assessment of risk — The following questions address the most important risk factors for future exacerbations [1]. A discussion of the risk factors for fatal and near-fatal asthma is provided separately. (See "Identifying patients at risk for fatal asthma", section on 'Identifying high-risk patients'.)
●Have you taken oral glucocorticoids ("steroids") for your asthma in the past year?
●Have you been hospitalized for your asthma? If yes, how many times have you been hospitalized in the past year?
●Have
you been admitted to the intensive care unit or been intubated because
of your asthma? If yes, did this occur within the past five years?
●Do you currently smoke cigarettes?
●Have you ever noticed an increase in asthma symptoms after taking aspirin or a nonsteroidal antiinflammatory agent (NSAID)?
Monitoring pulmonary function — Peak expiratory flow rate (PEFR) (performed in the office and/or
at home) and spirometry (performed in the office) are the two most
commonly employed modalities for monitoring pulmonary function in
children older than five years of age and in adults. The 2007 NAEPP
guidelines state a preference for use of spirometry in medical offices,
when available [1]. Children older than five years of age are usually able to perform the peak flow or spirometric maneuver.
Office monitoring — Measurement
of PEFR can be a useful indicator of airflow obstruction, the hallmark
finding of asthma. PEFR can be measured with handheld peak flow meters
in settings not equipped with a spirometer. Average normal values for
men, women, and children are listed in the tables (table 2A-C). Adolescents have values closer to children than to adults [1].
It
is important to understand the limitations of PEFR. A reduced peak flow
is not synonymous with airway obstruction; spirometry is needed to
distinguish conclusively an obstructive from restrictive abnormality [16].
Also, the accuracy of a single peak flow measurement to detect the
presence of airflow obstruction is limited, given the large variability
of PEFR among healthy individuals of the same age, height, and gender
(±20 percent) [17-19].
Nonetheless, repeated measurements of PEFR in an individual patient are
useful for determining relative changes or trends in asthma control [17,20-24].
PEFR monitoring is best used in patients in whom the diagnosis of
asthma has been previously established with a more complete evaluation.
The use of PEFR monitoring and its limitations are presented in more
detail elsewhere. (See "Peak expiratory flow rate monitoring in asthma".)Spirometry, which additionally measures forced expiratory volume in one second (FEV1) and forced vital capacity (FVC), can be used to document airflow obstruction (by demonstration of a reduced FEV1/FVC ratio) and provides additional information that is useful in monitoring asthma, such as risk for exacerbations [16,25]. Spirometry has greater sensitivity for detecting airflow obstruction in the presence of a normal peak expiratory flow. As mentioned previously, the 2007 NAEPP guidelines recommend the use of spirometry in practices that are regularly caring for patients with asthma. (See "Office spirometry".)
Home monitoring — Home
monitoring of the peak expiratory flow rate (PEFR) may be helpful in
patients with moderate to severe asthma. It is also useful in patients
who poorly perceive limitations in airflow. These individuals cannot be
easily identified at the outset of care, although over time they display
a lack of awareness of increasing impairment, and typically seek care
for exacerbations only after symptoms have become severe [26,27].
Peak
flow meters for individual use are widely available, inexpensive
(approximately $20), and easy to use. However, the resulting
measurements are highly dependent upon the patient's technique. It is
therefore important that the clinician periodically checks the patient's
use of the meter, and corrects any mistakes in technique. Instructions
for patients are provided. (See "Patient information: How to use a peak flow meter (Beyond the Basics)".)The patient should be instructed in how to establish a baseline measure of peak flow when feeling entirely well: the "personal best" peak flow value. The personal best PEFR is then used to determine the normal PEFR range, which is between 80 and 100 percent of the patient's personal best. Readings below this normal range indicate airway narrowing, a change that may occur before symptoms are perceived by the patient. (See 'Asthma action plan' below.)
Novel forms of monitoring — Measurements
of lung function such as peak flow and spirometry assess asthma control
based on airway diameter. However, it would also be desirable to
measure airway inflammation directly. Quantitative analysis of
expectorated sputum for eosinophilia and concentration of nitric oxide
in exhaled breath are two modalities currently being explored for this
purpose. Studies have reached conflicting conclusions about whether
regularly measuring these markers could help optimize asthma management.
Neither technique is currently in routine use outside of
investigational settings. The use of expectorated sputum eosinophilia
and exhaled nitric oxide analysis in the management of asthma are
discussed in more detail separately. (See "Evaluation of severe asthma in adolescents and adults", section on 'Airway inflammation' and "Exhaled nitric oxide analysis and applications".)
PATIENT EDUCATION — Clinicians
should enable patients to become active partners in managing their
asthma. Ideally, this would occur through direct education in the
office, as well as adjunctive education through other members of the
health care team, emergency department providers, pharmacists, and
organized programs [3]. The effectiveness of direct one-on-one education by the primary clinician, in particular, is well supported by evidence [1].
Patient education decreases hospitalizations due to asthma, improves daily function, and improves patient satisfaction [28-30]. A well-informed and motivated patient can assume a large measure of control over his or her asthma care.Patients must learn how to monitor their symptoms and pulmonary function; they must understand what triggers their asthma attacks and how to avoid or decrease exposure to these triggers; and they must understand what medicine to take and how to use inhalers properly (table 3 and table 4 and table 5 and table 6). If they have difficulty taking the medications regularly, they need help devising methods to improve compliance. The specific information that should be conveyed to the patient is reviewed in detail separately. (See "What do patients need to know about their asthma?".)
Asthma action plan — The patient's normal PEFR value can be used to construct a personalized "asthma action plan" (form 2).
Symptom-based plans appear to be equally effective. The asthma action
plan provides specific directions for daily management and for adjusting
medications in response to increasing symptoms or decreasing PEFR.
Instructions and forms for asthma action plans are presented elsewhere.
(See "What do patients need to know about their asthma?".)
CONTROLLING TRIGGERS AND CONTRIBUTING CONDITIONS — The
identification and avoidance of asthma "triggers" is a critical
component of successful asthma management, and successful avoidance or
remediation may reduce the patient's need for medications. Directed
questions can identify specific triggers and contributing conditions (table 7).
Adults
should be questioned about symptoms not only in the home, but also in
the workplace, as asthma can be exacerbated by both irritant and
allergen exposures in occupational settings. Patterns of symptoms that
suggest occupational triggers are presented in the table (table 8) [1]. (See "Occupational asthma: Definitions, epidemiology, causes, and risk factors".)Some triggers are mostly unavoidable, such as upper respiratory tract illnesses, physical exertion, hormonal fluctuations, and extreme emotion, and patients should be taught to adjust their management accordingly.
Other triggers, however, should be identified and specifically addressed or treated [5,31]:
●Inhaled
allergens – The patient should be questioned about symptoms triggered
by common inhaled allergens, at home, daycare, school, or work (table 7 and table 8).
Indoor allergens, such as dust mites, animal danders, molds, mice, and
cockroaches, are of particular importance. Food allergy rarely causes
isolated asthma symptoms, although wheezing and cough can be symptoms of
food-induced anaphylaxis.
If the history suggests the patient has allergic triggers, basic avoidance measures can be advised, and evaluation by an allergy specialist should be considered. The assessment and management of allergen exposure in patients with asthma are reviewed in detail separately. (See "Allergen avoidance in the treatment of asthma and allergic rhinitis".)
If the history suggests the patient has allergic triggers, basic avoidance measures can be advised, and evaluation by an allergy specialist should be considered. The assessment and management of allergen exposure in patients with asthma are reviewed in detail separately. (See "Allergen avoidance in the treatment of asthma and allergic rhinitis".)
●Respiratory
irritants – Inhaled irritants include tobacco smoke, wood smoke from
stoves or fireplaces, strong perfumes and odors, chlorine-based cleaning
products, and air pollutants. Patients should be cognizant of avoiding
irritants, and avoid exertion outdoors on days when levels of air
pollution are elevated. (See "Trigger control to enhance asthma management".)
Smoking cessation and avoidance of environmental tobacco smoke are reviewed in detail elsewhere. (See "Control of secondhand smoke exposure" and "Secondhand smoke exposure: Effects in adults" and "Secondhand smoke exposure: Effects in children" and "Overview of smoking cessation management in adults".)
Smoking cessation and avoidance of environmental tobacco smoke are reviewed in detail elsewhere. (See "Control of secondhand smoke exposure" and "Secondhand smoke exposure: Effects in adults" and "Secondhand smoke exposure: Effects in children" and "Overview of smoking cessation management in adults".)
●Comorbid
conditions – Clinicians should be vigilant for comorbid conditions in
patients with poorly-controlled asthma. In adults, these conditions
include chronic obstructive pulmonary disease/emphysema (COPD), allergic bronchopulmonary aspergillosis, gastroesophageal reflux, obesity, obstructive sleep apnea, rhinitis/sinusitis, vocal cord dysfunction, and depression/chronic stress. These conditions are reviewed separately. (See "Clinical manifestations and diagnosis of allergic bronchopulmonary aspergillosis" and "Gastroesophageal reflux and asthma" and "Clinical presentation and diagnosis of obstructive sleep apnea in adults" and "An overview of rhinitis" and "Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis".)
In young children, potential alternative or comorbid conditions include respiratory syncytial virus infection, foreign body aspiration, bronchopulmonary dysplasia, cystic fibrosis, and obesity [1].
In young children, potential alternative or comorbid conditions include respiratory syncytial virus infection, foreign body aspiration, bronchopulmonary dysplasia, cystic fibrosis, and obesity [1].
●Medications
– Non-selective beta-blockers can trigger severe asthmatic attacks,
even in the minuscule amounts that are absorbed systemically from
topical ophthalmic solutions. Selective beta-1 blockers can also
aggravate asthma in some patients, especially at higher doses. (See "Treatment of hypertension in asthma and COPD".)
Aspirin and non-steroidal anti-inflammatory drugs can trigger asthma symptoms in approximately 3 to 5 percent of adult asthmatic patients. The incidence of aspirin-exacerbated respiratory disease is higher among asthmatic patients with nasal polyposis (constituting "triad asthma" or Samter's triad). Aspirin-sensitive asthma is uncommon in children. (See "Aspirin-exacerbated respiratory disease".)
Aspirin and non-steroidal anti-inflammatory drugs can trigger asthma symptoms in approximately 3 to 5 percent of adult asthmatic patients. The incidence of aspirin-exacerbated respiratory disease is higher among asthmatic patients with nasal polyposis (constituting "triad asthma" or Samter's triad). Aspirin-sensitive asthma is uncommon in children. (See "Aspirin-exacerbated respiratory disease".)
●Complications
of influenza – Annual administration of influenza vaccine is
recommended for patients with asthma because they are particularly at
risk for complications of influenza infection. However, vaccination does
not reduce the number or severity of asthma exacerbations during the
influenza season, and providers should ensure that patients understand
this distinction. Indications for vaccination against influenza are
reviewed separately. (See "Seasonal influenza vaccination in adults" and "Seasonal influenza in children: Prevention with vaccines", section on 'Indications'.)
●Complications
of pneumococcal infection – Administration of pneumococcal vaccination
is recommended for adults whose asthma is severe enough to require
controller medication and for children with asthma who require chronic
oral glucocorticoid therapy (table 9 and table 10) [32]. (See "Pneumococcal (Streptococcus pneumoniae) conjugate vaccines in children", section on 'Indications' and "Pneumococcal (Streptococcus pneumoniae) polysaccharide vaccines in children", section on 'Indications' and "Pneumococcal vaccination in adults", section on 'Indications'.)
●Dietary
sulfites – Sulfite compounds are used in the food industry to prevent
discoloration. As many as 5 percent of patients with asthma may note
significant and reproducible exacerbations following ingestion of
sulfite-treated foods and beverages, such as beer, wine, processed
potatoes, dried fruit, sauerkraut, or shrimp.
PHARMACOLOGIC TREATMENT — Pharmacologic treatment is the mainstay of management in most patients with asthma [33].
The 2007 National Asthma Education and Prevention Program (NAEPP)
Expert Panel Report presented a stepwise approach to pharmacologic
therapy, which is reflected in this review [1]. These guidelines were intended to support, rather than dictate, care that is based upon the clinician's clinical judgment.
The
stepwise approach to pharmacotherapy is based on increasing medications
until asthma is controlled, and decreasing medications when possible to
minimize side effects. The patient's management should be adjusted, if
needed, at every visit.The first step in determining appropriate therapy for patients who are not already on a controller medication is classifying the severity of the patient's asthma. For patients already taking one or more controller medications, treatment options are guided by an assessment of asthma control rather than asthma severity.
Categories of asthma severity — Asthma severity is determined by considering the following factors [1]:
●Reported symptoms over the previous two to four weeks
●Current level of lung function (FEV1 and FEV1/FVC values)
●Number of exacerbations requiring oral glucocorticoids per year
The
use of these three elements to determine severity in adolescents over
the age of 12 years and in adults is graphically presented in the figure
(table 11).The classification of severity in children aged 5 to 11 years is similar to that in adults (table 12). Severity in children under the age of four years, however, is classified somewhat differently (table 13). Initiating long-term controller medications in children under the age of 12 years is reviewed separately. (See "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
Intermittent — Intermittent asthma is characterized by the following (table 11). The criteria for adolescents and adults are utilized in this discussion [1]:
●Daytime asthma symptoms occurring two or fewer days per week
●Two or fewer nocturnal awakenings per month
●Use of short-acting beta agonists to relieve symptoms fewer than two times a week
●No interference with normal activities between exacerbations
●FEV1 measurements between exacerbations that are consistently within the normal range (ie, ≥80 percent of predicted normal)
●FEV1/FVC ratio between exacerbations that is normal (based on age-adjusted values)
●One or no exacerbations requiring oral glucocorticoids per year
If
any of the features of a patient’s asthma is more severe than those
listed here, their asthma should be categorized as having persistent
asthma, with its severity based on the most severe element. Patients
experiencing two or more exacerbations of asthma requiring oral
glucocorticoids in the past year are considered to have persistent
asthma.In addition, a person using a SABA to prevent exercise-induced asthmatic symptoms might fit into this category of intermittent asthma even if exercising more than twice per week. Others in whom asthmatic symptoms arise only under certain infrequently occurring circumstances (eg, upon encountering a cat or during viral respiratory tract infections) are also considered to have intermittent asthma. (See "Exercise-induced bronchoconstriction".)
Equivalent schema for classifying asthma in children 0 to 4 years and 5 to 11 years are provided (table 13 and table 12).
●Symptoms more than twice weekly (although less than daily)
●Approximately three to four nocturnal awakenings per month due to asthma (but fewer than every week)
●Use of short-acting beta agonists to relieve symptoms more than two times a week (but not daily)
●Minor interference with normal activities
●FEV1 measurements within normal range (≥80 percent of predicted normal) and normal FEV1/FVC ratio (based on age-adjusted values)
●Two or more exacerbations requiring oral glucocorticoids per year
If
any of the features of a patient’s asthma is more severe than those
listed here, their asthma should be categorized according to the most
severe element.Equivalent figures for asthma in children 0 to 4 years and 5 to 11 years are provided (table 13 and table 12).
Moderate persistent — The presence of any of the following is considered an indication of moderate disease severity (table 11):
●Daily symptoms of asthma
●Nocturnal awakenings more than once per week
●Daily need for short-acting beta agonists for symptom relief
●Some limitation in normal activity
●FEV1 between 60 and 80 percent of predicted and FEV1/FVC below normal (based on age-adjusted values)
Equivalent figures for asthma in children 0 to 4 years and 5 to 11 years are provided (table 13 and table 12).
Severe persistent — Patients with severe persistent asthma experience one or more of the following (table 11):
●Symptoms of asthma throughout the day
●Nocturnal awakenings nightly
●Need for short-acting beta agonists for symptom relief several times per day
●Extreme limitation in normal activity
●FEV1 <60 percent of predicted and FEV1/FVC below normal (based on age-adjusted values)
Equivalent figures for asthma in children 0 to 4 years and 5 to 11 years are provided (table 13 and table 12).
Initiating therapy during an acute exacerbation — Patients
with acute exacerbations of asthma often require systemic
glucocorticoids. Treatment of asthma exacerbations is reviewed
separately. (See "Treatment of acute exacerbations of asthma in adults" and "Acute asthma exacerbations in children: Emergency department management".)
Initiating therapy in previously untreated patients — The
initiation of asthma therapy in a stable patient who is not already
receiving medications is based upon the severity of the individual's
asthma.
Initiating long-term controller medications in young children is reviewed separately. (See "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
Intermittent (Step 1) — Patients
with mild intermittent asthma are best treated with a quick-acting
inhaled beta-2-selective adrenergic agonist, taken as needed for relief
of symptoms (figure 2 and figure 3 and figure 4) [34-36].
Patients for whom triggering of asthmatic symptoms can be predicted
(eg, exercise-induced bronchoconstriction) are encouraged to use their
inhaled beta agonist approximately 10 minutes prior to exposure in order
to prevent the onset of symptoms. (See "Beta agonists in asthma: Acute administration and prophylactic use" and "Exercise-induced bronchoconstriction".)
The pharmacologic management of mild intermittent asthma is discussed in more detail separately. (See "Treatment of intermittent and mild persistent asthma in adolescents and adults" and "Asthma in children younger than 12 years: Rescue treatment for acute symptoms".)
Mild persistent (Step 2) — The
distinction between intermittent and mild persistent asthma is
important, because current guidelines for mild persistent asthma call
for initiation of daily long-term controller medication. For mild
persistent asthma, the preferred long-term controller is a low dose
inhaled glucocorticoid (GC) (figure 2 and figure 3 and figure 4 and table 14).
Regular use of inhaled glucocorticoids reduces the frequency of
symptoms (and the need for SABAs for symptom relief), improves the
overall quality of life, and decreases the risk of serious exacerbations
[37-39]. Regular use of inhaled glucocorticoids has not been shown to prevent progressive loss of lung function over time.
Alternative strategies for treatment of mild persistent asthma include leukotriene receptor antagonists, theophylline, and cromoglycates (figure 2).
Among these alternatives, we favor the leukotriene blockers. Patients
receiving long-term controller therapy should continue to use their
short-acting beta agonist as needed for relief of symptoms and prior to
exposure to known triggers of their symptoms.The pharmacologic management of mild persistent asthma is presented in greater detail elsewhere. (See "Treatment of intermittent and mild persistent asthma in adolescents and adults" and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
Moderate persistent (Step 3) — For
moderate persistent asthma, the preferred therapies are either
low-doses of an inhaled glucocorticoid plus a long-acting inhaled beta
agonist, or medium doses of an inhaled glucocorticoid (figure 2 and figure 3 and figure 4 and table 14).
The former combination has proven more effective in controlling
asthmatic symptoms than an increased dose of inhaled GCs, although it
entails the potential risk of adverse outcomes that have been reported
in association with long-acting inhaled beta agonists [40,41]. (See "Beta agonists in asthma: Controversy regarding chronic use", section on 'Long–acting beta-agonists'.)
Alternative strategies include adding a leukotriene modifier (leukotriene receptor antagonist or lipoxygenase inhibitor) or theophylline to low-dose inhaled GCs. The pharmacologic management of moderate asthma is presented in more detail elsewhere. (See "Treatment of moderate persistent asthma in adolescents and adults".)
Severe persistent (Step 4 or 5) — For
severe persistent asthma, the preferred treatments are medium (Step 4)
or high (Step 5) doses of an inhaled glucocorticoid, in combination with
a long-acting inhaled beta-agonist (figure 2 and figure 3 and figure 4 and table 14).
In addition, for patients who are inadequately controlled on high-dose inhaled GCs and LABAs, the anti-IgE therapy omalizumab
may be considered if there is objective evidence of sensitivity to a
perennial allergen (by allergy skin tests or in vitro measurements of
allergen-specific IgE) and if the serum IgE level is within the
established target range. (See "Anti-IgE therapy".)Step 6 therapy for the management of severe asthma involves the addition of oral glucocorticoids on a daily or alternate-day basis. Severe asthma is reviewed in more detail elsewhere. (See "Treatment of severe asthma in adolescents and adults".)
Assessing control to adjust therapy — Assessment
of asthma control rather than severity is used to adjust therapy in
returning patients, or in patients being evaluated for the first time
who are already taking a long-term controller medication. Control is
assessed based on impairment over the past two to four weeks (as
determined by history or a validated questionnaire), current FEV1 or peak flow, and estimates of risk (table 15) [1,42]. Adjusting therapy in children younger than 12 years is reviewed in more detail separately. (See 'Monitoring patients with asthma' above and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
Using
the information gathered, the clinician should determine whether the
patient's asthma is well-controlled or not. If the asthma is not
well-controlled, therapy should be "stepped-up." If the asthma is
well-controlled, therapy can be continued or possibly "stepped-down" to
minimize medication side effects. Therapy should be reassessed at each
visit, because asthma is an inherently variable condition, and the
management of asthma is a dynamic process that changes in accordance
with the patient's needs over time.
EFFICACY OF ASTHMA MANAGEMENT — A
prospective, randomized trial applied the management recommendations of
previous NAEPP guidelines to approximately 1500 patients with all
severities of asthma over the course of one year [43].
Guideline-based management resulted in significant improvement in
health-related quality of life in most patients, regardless of disease
severity. In this study, subjects who required inhaled GCs were randomly
assigned to receive either fluticasone propionate (FP) alone or the combination of fluticasone propionate and salmeterol
(FP + S). Subjects were evaluated every three months and medications
were stepped up as needed (although the protocol did not allow for
stepping down of therapy). With both treatments, the majority of
patients achieved well-controlled or totally-controlled asthma; control
was slightly better with FP + S. The greatest improvements occurred in
the first few months of therapy. This study validated a stepwise
approach to asthma management as effective in reducing symptoms and
improving health-related quality of life. The current guidelines have
expanded upon this same basic approach [1,2].
WHEN TO REFER — Both pulmonologists and allergists/immunologists
have specialty training in asthma care. Referral for consultation or
comanagement is recommended when any of the following circumstances
arise [1]:
●The patient has experienced a life-threatening asthma exacerbation
●The patient has required hospitalization or more than two bursts of oral corticosteroids in a year
●The
adult and pediatric patient older than five years requires step 4 care
or higher or a child under five requires step 3 care or higher
●Asthma is not controlled after three to six months of active therapy and appropriate monitoring
●The patient appears unresponsive to therapy
●The diagnosis of asthma is uncertain
●Other
conditions are present which complicate management (nasal polyposis,
chronic sinusitis, severe rhinitis, allergic bronchopulmonary
aspergillosis, COPD, vocal cord dysfunction, etc)
●Additional diagnostic tests are needed (skin testing for allergies, bronchoscopy, complete pulmonary function tests)
●Patient may be a candidate for allergen immunotherapy (see "Subcutaneous immunotherapy for allergic disease: Indications and efficacy")
Other possible indications for referral include [1]:
●The
adult and pediatric patient older than five years who requires step 3
care or higher or a child under five who requires step 2 care or higher
●There appear to be occupational triggers
●Patients
in whom psychosocial or psychiatric problems are interfering with
asthma management and in whom referral to other appropriate specialists
may be required
INFORMATION FOR PATIENTS — UpToDate
offers two types of patient education materials, “The Basics” and
“Beyond the Basics.” The Basics patient education pieces are written in
plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might
have about a given condition. These articles are best for patients who
want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here
are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can
also locate patient education articles on a variety of subjects by
searching on “patient info” and the keyword(s) of interest.)
●Basics topics (see "Patient information: How to use your child’s dry powder inhaler (The Basics)" and "Patient information: Asthma in children (The Basics)" and "Patient information: How to use your child’s metered dose inhaler (The Basics)" and "Patient information: Asthma and pregnancy (The Basics)" and "Patient information: How to use your dry powder inhaler (adults) (The Basics)" and "Patient information: How to use your metered dose inhaler (adults) (The Basics)" and "Patient information: Asthma in adults (The Basics)" and "Patient information: Avoiding asthma triggers (The Basics)" and "Patient information: Medicines for asthma (The Basics)" and "Patient information: Reducing the costs of medicines (The Basics)")
●Beyond the Basics topics (see "Patient information: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient information: Asthma treatment in children (Beyond the Basics)" and "Patient information: Asthma and pregnancy (Beyond the Basics)" and "Patient information: Asthma symptoms and diagnosis in children (Beyond the Basics)" and "Patient information: How to use a peak flow meter (Beyond the Basics)" and "Patient information: Asthma inhaler techniques in adults (Beyond the Basics)" and "Patient information: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient information: Exercise-induced asthma (Beyond the Basics)" and "Patient information: Trigger avoidance in asthma (Beyond the Basics)" and "Patient information: Reducing the costs of medicines (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●The
four essential components of asthma management are: routine monitoring
of symptoms and lung function, patient education, control of trigger
factors and amelioration of comorbid conditions, and pharmacologic
therapy. (See 'Components of asthma management' above.)
●The
goals of asthma treatment are to reduce impairment from symptoms,
minimize risk of the various adverse outcomes associated with asthma
(eg, hospitalizations, loss of lung function), and minimize adverse
effects from asthma medications. (See 'Goals of asthma treatment' above.)
●Effective
asthma management requires a preventative approach, with regularly
scheduled visits during which symptoms are assessed, pulmonary function
is monitored, medications are adjusted, and ongoing education is
performed. (See 'Monitoring patients with asthma' above.)
●Patients should learn to monitor asthma control at home (eg, frequency and severity of dyspnea, cough, chest tightness, and albuterol
use). Patients with moderate to severe asthma and those with poor
perception of increasing asthma symptoms may also benefit from
assessment of their peak expiratory flow rate at home. A personalized
asthma action plan should be provided with detailed instructions on how
to adjust asthma medications based upon changes in symptoms and/or lung function (form 2). (See 'Patient education' above.)
●Environmental
triggers and co-existing conditions that interfere with asthma
management should be identified and addressed for each patient. (See 'Controlling triggers and contributing conditions' above.)
●Pharmacologic
therapy varies according to asthma severity and asthma control. Asthma
control can be judged, irrespective of medication use, based on the
current level of symptoms, FEV1 or PEFR values, and number of exacerbations requiring oral glucocorticoids per year (table 11 and table 12 and table 13). (See 'Categories of asthma severity' above and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
●A stepwise approach to therapy is recommended, in which the dose of medication, the number of medications, and/or the frequency of administration are increased as necessary and decreased when possible (figure 2 and figure 3 and figure 4). (See 'Initiating therapy in previously untreated patients' above.)
●At each return visit, the patient's asthma control is evaluated (table 15).
If the asthma is not well-controlled, therapy should be "stepped-up."
If the asthma is well-controlled, therapy can be continued or possibly
"stepped-down" to minimize medication side effects. (See 'Assessing control to adjust therapy' above and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
●Guidelines for when to refer a patient to a pulmonologist or an allergist/immunologist are provided. (See 'When to refer' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
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