Lindee Abe, APRN
Asthma occurs in roughly 25 million people in the United States, making it a common diagnosis for clinicians in primary care. Asthma exacerbations are also responsible for urgent care and emergency department visits when it they not well-controlled. It is estimated that 62% of patients with asthma are not controlled. The goal of treatment is to minimize the patient’s symptoms and also reduce the risk of exacerbations of the disease.
Asthma is also a chronic condition and is the result of inflammation of the airway and variable obstruction of the airway. The leading symptoms are dyspnea, wheezing, chest tightness, and a cough. The symptoms also are usually worse at night and early morning. Wheezing with a prolonged expiratory phase can be heard on exam.
Defining the Severity
The classification of asthma severity is based on:
- Pulmonary function test (PFT) results
- Frequency of symptoms
- Night time awakenings
- Change in activity
- Frequency of rescue inhaler medication use
- Exacerbations requiring steroid use in the past year
There are five steps in the step-wise approach to identify the severity of asthma, with one being the least severe and step five being the most severe. Treatment for asthma is based on the identified step and can be increased to the next step if symptoms persist or worsen despite the use of medication.
Initial Diagnosis
The initial diagnosis of asthma is made based on PFT results and a history of respiratory symptoms consistent with asthma. Findings on pulmonary function tests indicative of asthma include baseline airflow limitation (reduced FEV1/FVC ratio) and also reversibility of airflow limitation with bronchodilator administration with normal FEV/FVC ratio. In cases of severe asthma, PFT can show restrictive pattern (decreased FVC) when with normal airflow FEV1/FVC ratio. The FEV1/FVC is used to assess the baseline airflow obstruction. The FEV1 will also characterize the degree of airflow obstruction.
Giving a bronchodilator will assess the reversibility of the identified airflow obstruction. After initial diagnosis, it is not recommended to have PFT repeated to assess response to treatment. Chest x-ray is not necessary for the diagnosis, but many providers will also use it to rule out other disease processes that can cause similar symptoms. Laboratory testing is also not needed for the diagnosis of asthma, but it can also be used to rule out other causes.
Follow-Up
Once asthma has been diagnosed and treatment has been started, the patient should follow up in 4 weeks to check their response to medication. The two most frequently used tools to determine a patients’ response to treatment are The Asthma Control Test (ACT) and the Asthma APGAR test. The Asthma APGAR test is short for
Activity
Persistence
Activity triGgers,
Adherence to asthma medications, and
Patient-perceived Response to therapy.
The Global Initiative for Asthma (GINA) also recommends the use of the Asthma Control Questionnaire-5 (ACQ-5).
Guideline Updates
In the past few years, GINA has developed some new recommendations for the treatment of asthma. One big change was in the way step 1 of asthma is treated. Patients that were identified as step 1 used to be treated with intermittent short-acting B2 agonists (SABA) when they had symptoms. Recent data has shown that there is benefit from treating mild asthma with inhaled corticosteroid therapy versus a SABA medication.
- Step 1 treatment is now an as needed low-dose combination ICS-formoterol (e.g. budesonide/formoterol).
- Step 2 should receive the same treatment with low-dose combination ICS-formoterol as needed and is now combined with step 1.
- Step 3 treatment should include a low-dose ICS-formoterol as a maintenance and reliever medication.
- Step 4 preferred treatment is a medium-dose ICS-formoterol as a maintenance and reliever medication.
- Step 5 preferred treatment is referral to expert treatment, phenotyping, and also add-on therapy.
This is a very broad overview of the treatment recommendations and additional treatment options for each step are included in detail in the GINA guidelines.
Asthma and COVID
Another new area of the GINA changes includes a section regarding asthma and COVID-19. It is noted that patients with asthma that are controlled are not at greater risk for severe disease with COVID-19, however if the patient has uncontrolled asthma (especially with need for recent steroids) the patient is at increased risk for being hospitalized and having severe disease. This represents the overall importance of the management of asthma in order to lower the risk of exacerbations that can increase the risk of hospitalizations in many respiratory conditions, not just COVID-19.
Urgent/Emergency Care
For those working in the urgent care or emergency setting, the GINA guidelines also address how to manage asthma exacerbations. Patients should have an asthma action plan with identified relief medications that could include an ICS-formoterol, ICS-SABA, or SABA. The typical treatment of oral corticosteroid course is indicated if the patient fails to respond to relief medication in 2-3 days, have worsening asthma or history of severe exacerbations, or have a decrease in PEF or FEV1 <60% of the normal value.
Personally, I have not had access to PFTs in the acute setting so I don’t know that I have used the last criteria to determine the need for oral corticosteroids. However, oral corticosteroids are recommended a 5-7 day course for adults and 3-5 days for children.
Patient Education
An additional consideration for the treatment of asthma is also patient education. Inhalers are not all the same. Likewise is is not easy to learn how to use an inhaler. Patients should have education and be able to demonstrate their ability to use the device when first given an inhaler. Education can also be done in the office. The pharmacy may not take the time to go over this with the patient.
Pediatrics
In the child population there are several things to take into account when making a treatment plan. First, most schools require an asthma action plan. The plan should include a relief medication. There should be discussion with the parents on whether they would want two relief inhalers prescribed to have one at school and one at home. Cost may be a factor in the decision and if only one inhaler is given there should be discussion on keeping it in a bag or other item that returns from school daily. Sports physicals should also take into consideration if the patient’s asthma is under control. Until the patient is stable on medication without having many exacerbations, it would not be suggested to clear the patient for sports.
Summary
There is a lot of information regarding asthma and the rules are constantly changing. GINA guidelines are also updated every year and provide a good resource for the latest recommendations. It is important to consider your patient’s lifestyle and ensure adequate education has been performed so the patient is utilizing the inhaler correctly. The key to asthma management is to reduce the risk of exacerbations and control of symptoms.
References:
Fanta CH, Lange-Vaidya N. Asthma in adolescents and adults: evaluation and diagnosis. UpToDate. UpToDate Inc. Accessed July 30, 2023. https://www.uptodate.com/contents/asthma-in-adolescents-and-adults-evaluation-anddiagnosis
Fanta CH, Barrett N. An overview of asthma management. UpToDate. UpToDate Inc. Accessed July 31, 2023.
https://www.uptodate.com/contents/an-overview-of-asthma-management
Fitzpatrick ME, Pendergast NT, Rivera-Lebron B. Approach to management asthma. In: Papadakis MA, McPhee SJ, Rabow MW, McQuaid KR, eds. Current Medical Diagnosis & Treatment 2023. 62nd ed. McGraw Hill; 2023:(Ch) 9-05.
https://accessmedicine.mhmedical.com/content.aspx?bookid=3212§ionid=2691616 41#1193145711
Global Initiative for Asthma. Global strategy for asthma management and prevention (2023 update). Published 2023. https://ginasthma.org/wp-content/uploads/2023/07/GINA-2023- Full-report-23_07_06-WMS.pdf
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