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
GOALS OF ASTHMA TREATMENT — The goals of chronic asthma management may be divided into two domains: reduction in impairment and reduction of risk.
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. 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 and to discuss steps that patients can take to intervene early in asthma exacerbations (an asthma “action plan”). 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.
By consensus from panels of asthma experts, 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 three days out of the week, 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.
Symptom assessment — Symptoms over the past two to four weeks should be assessed at each visit. Assessment should address daytime symptoms, nighttime symptoms, frequency of use of SABAs to relieve symptoms, and difficulty in performing normal activities and exercise.
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?
●Have you had any side effects from your asthma medications?
Assessment of risk — The following questions can be used to address the most important risk factors for future exacerbations.
●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. 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. Adolescents have values closer to children than to adults.
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.
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, by detecting important reductions in lung function in patients who have few symptoms or physical findings of asthma. Spirometry can detect airflow obstruction in the presence of a normal peak expiratory flow.
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.
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. 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.
●Inhaled allergens – The patient should be questioned about symptoms triggered by common inhaled allergens, at home, daycare, school, or work. 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.
●Respiratory irritants – Inhaled irritants include tobacco smoke, wood smoke from stoves or fireplaces, strong perfumes and odors, chlorine-based cleaning products, and air pollutants.
Smoking cessation and avoidance of environmental tobacco smoke are reviewed in detail elsewhere.
●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.
In young children, potential alternative or comorbid conditions include respiratory syncytial virus infection, foreign body aspiration, bronchopulmonary dysplasia, cystic fibrosis, and obesity.
●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.
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.
●Complications of influenza – Annual administration of influenza vaccine is recommended for patients with asthma because they are at increased risk for complications of influenza infection.
●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
●Dietary sulfites – Sulfite compounds are used in the food industry to prevent discoloration. Fewer than 5 percent of patients with asthma note significant and reproducible exacerbations following ingestion of sulfite-treated foods and beverages, such as beer, wine, processed potatoes, dried fruit, sauerkraut, or shrimp. Affected patients typically have severe asthma.