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Asthma Managements & treatment Guidelines

Mar 09, 20257 min read

Managements

  • Non-pharmacological:

  • Understanding asthma — The patient and family should understand the characteristics of asthma, the principles of effective treatment, the effects of various medications, and the resources available.

Avoid Your Triggers

  • Use your air conditioner.
  • Decontaminate your décor Maintain optimal humidity
  • Prevent mold spores.
  • Reduce pet dander
  • Clean regularly.
  • Cover your nose and mouth if it’s cold out

Stay Healthy

➤ Taking care of yourself and treating other conditions linked to asthma will help keep your symptoms under control. For example:

  • Get regular exercise.
  • Maintain a healthy weight.
  • Eat fruits and vegetables.
  • Control heartburn and gastroesophageal reflux disease (GERD).

The Long-term Goals of Asthma Management

  • Control asthma symptoms (cough, wheezing, or shortness of breath)
  • Infrequent and minimal use (≤2 days a week) of reliever therapy
  • Maintain (near) normal pulmonary function
  • Maintain normal exercise and physical activity levels
  • Prevent recurrent exacerbations of asthma, and minimize the need for emergency room (ER) visits or hospitalizations
  • Optimize asthma control with the minimal dose of medications
  • Reduce mortality
  • Optimize quality of life

Pharmacological Management in Adults and Adolescents

The SINA panel recommends asthma treatment to be based on the following phases:

  • Initiation of treatment

  • Adjustment of treatment

  • Maintenance of treatment.

  • At each phase, the patient is recommended to have a clinical assessment that includes symptoms assessment by ACT – Then the patient can be placed on appropriate treatment Step.

Drug Therapy

  • 2 types of drug categories are used:
    • Anti-inflammatory drugs
      • Hormone-containing (corticosteroids)
      • Non-hormone-containing (leukotriene receptor antagonists)
    • Bronchodilators
      • β₂-agonists
      • Anticholinergic drugs
      • Methylxanthines

Management - Pharmacological:

  • β2-Agonists

    • Are the most effective bronchodilators available.
    • This results in smooth muscle relaxation, mast cell membrane stabilization, and skeletal muscle stimulation.

  • Short-acting agents: Albuterol, levalbuterol or pirbuterol

  • Long-acting agents: Salmeterol, formoterol and arformoterol

Anticholinergics
  • Ipratropium bromide and tiotropium bromide are competitive inhibitors of muscarinic receptors; they produce bronchodilation only in cholinergic mediated bronchoconstriction.

Corticosteroids

  • Corticosteroids increase the number of β2-adrenergic receptors and improve receptor responsiveness to β2-adrenergic stimulation, thereby reducing mucus production and hyper-secretion, reducing BHR, and reducing airway edema and exudation.

  • Systemic toxicity of inhaled corticosteroids is minimal with low to moderate inhaled doses, but the risk of systemic effects increases with high doses.

  • Local adverse effects include oropharyngeal candidiasis and hoarseness of voice.

Leukotriene Modifiers:

Zafirlukast (Accolate) and montelukast (Singulair) are oral leukotriene receptor antagonists that reduce the pro-inflammatory (increased microvascular permeability and airway edema) and bronchoconstriction effects of leukotriene D4.

  • In adults and children with persistent asthma, they improve:
    • Pulmonary function tests,
    • Decrease nocturnal awakenings, and
    • β2-agonist use,
    • Improve asthma symptoms.

Omalizumab

  • Omalizumab (Xolair) is an anti-IgE antibody approved for the treatment of allergic asthma not well controlled by oral or inhaled corticosteroids.

  • Because of its high cost, it is only indicated as step 5 or 6 care for patients who have allergies and severe persistent asthma that is inadequately controlled with the combination of high-dose inhaled corticosteroids and long-acting β2-agonists.

  • Treatment initiation at Step 1 when ACT ≥ 20

    • Low Dose ICS/Formoterol as needed or LABA
    • SABA with ICS as needed
    • Low dose ICS in special situations (Refer to text)

  • Treatment initiation at Step 2 when ACT 16 - 19

    • Low dose ICS/LABA with a reliever

  • Treatment initiation at Step 3 when ACT ≤ 16

    • Medium dose ICS/LABA with a reliever
      • Patients with an acute attack may require a short course of oral corticosteroid

Relievers:

  • SABA (with or without ICS) as needed for non-formoterol/ICS combination
  • Formoterol/ICS combination as needed when used as maintenance

Prior to treatment initiation, ensure the following:

  • Obtain history and perform physical examination
  • Assess aggravating factors and treat comorbidities
  • Ensure patient adherence and correct inhaler technique
    • Get ACT score and PEF or Spirometry
    • Ensure optimizing patient education
    • Do not use SABA alone without ICS

Treatment at step 1

  • Symptoms are usually mild and infrequent,
  • (usually < twice a week) with an ACT score of ≥20 points and no risk factors for asthma exacerbations.
  • At this step, SABA alone on an as-needed basis is not anymore recommended.
  • Recommended option: It is recommended to use ICS/formoterol on an as-needed basis (Evidence A).

Treatment at step 2

  • Recommended options: It is recommended to use a daily fixed-dose combination of low-dose ICS/LABA with an as-needed reliever for symptom relief (Evidence A).
    • Alternative options:
  • The addition of LTRA to a low-dose ICS is another option, especially in patients with concomitant rhinitis (Evidence A).

Treatment at step 3

  • Recommended options: The fixed-dose combination of medium-dose ICS/LABA was found to improve asthma control and reduce asthma exacerbations for patients whose asthma is not controlled at step 2 (Evidence A).

  • Alternative options: Evidence has shown that when tiotropium is added to an ICS delivered by multiple inhalers; it improves symptoms, reduces the risk of exacerbation, and improves lung function in patients with inadequately controlled asthma.

Treatment at step 4

  • Recommended options:
    • Add LAMA in a single inhaler is recommended (Evidence A). This novel approach of SITT was found to be a safe and effective therapeutic approach. Moreover, when compared to multiple inhalers triple therapy (MITT), SITT usage is cost-effective and is associated with better adherence.
    • Once-a-day SITT combination of fluticasone furoate/umeclidinium/vilanterol 200/62.5/25 µg (Trelegy Ellipta®) is a recommended option.

Treatment at step 5

  • Early consideration of biological therapy may lead to clinical remission and save the patient from frequent or chronic use of OCS and reduce asthma exacerbations.

  • Consultation with an asthma specialist is strongly recommended.

  • Available biological agents like:

    • Anti-IgE therapy: Omalizumab
    • Anti-IL 5 therapy: Mepolizumab

Criteria for Admission

  • Patients whose peak flow is ≥ 60% best or predicted one hour after initial treatment can be discharged from the emergency department.

  • Criteria for admission:

    • Any feature of a life-threatening, near-fatal attack
    • Any feature of a severe attack that persists after initial treatment.
    • unless any of the following is present:
      • Still suffering from significant symptoms
      • Previous history of near-fatal or brittle asthma
      • Concerns about compliance and pregnancy

Referral to a Specialist Center

  • Status asthmatics
  • Deteriorating PEF
  • Persisting or worsening hypoxia
  • Hypercapnea, respiratory acidosis (pH <7.3)
  • Severe exhaustion
  • Increase work of breathing
  • Drowsiness
  • Confusion
  • Coma
  • Respiratory arrest

Complications

  • Airway remodeling
  • Hospitalization
  • Lifestyle disruption
    • Sleep
    • Physical activity
    • Productivity
  • Death

Management of Acute Asthma in Adults and Adolescents

  • Acute asthma exacerbation is a challenging clinical scenario that requires a systemic approach to rapidly diagnose the condition.

  • The first step is the early recognition to prevent the occurrence of exacerbations.

  • The most specific marker associated with increased asthma mortality would be a history of repeated hospital admissions.

Management of Asthma in Children

  • Asthma represents the commonest chronic illness of childhood.
  • It is also considered a leading cause for childhood morbidity as measured by school absences, ED visits, and hospitalizations.

Asthma Diagnosis in Children

  • Should be based on a careful clinical assessment that includes:

    • Recurrent or chronic symptoms related to airway obstruction, such as wheezing, coughing, night symptoms, activity limitation, and shortness of breath.
    • The diagnosis can be further supported by the presence of atopy, early sensitization, and a family history of atopy.

  • Whenever possible, spirometry is recommended to be performed to show reversibility of airway obstruction after bronchodilator therapy.

  • In general, spirometry can be performed in children aged ≥5 years.

Asthma in Preschool Children

  • Diagnosis and management differs from that of older children and adolescents.
  • In addition to the diagnosis of asthma, wheezing in preschool children can be due to unique differential diagnoses e.g.,
    • Congenital defects,
    • Infections especially viral bronchiolitis,
    • Bronchopulmonary dysplasia, and
    • Cystic fibrosis.

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