ASTHMA-MANAGEMENT

See also general section on Asthma, "Initial evaluation of an asthma patient," and "Guidelines for Referral to an Asthma Specialist"

General Issues in Asthma Management

Exercise-induced asthma
Special considerations in children
Special considerations in the elderly

Step Approach to Asthma Therapy and Routine Surveillance of Asthmatics
Maintenance Medications for Asthma
Quick-Relief Medications for Asthma and Managing Exacerbations
Non-Medication Treatments for Asthma

GENERAL ISSUES

I. Goals of tx:

  1. Prevent sx
  2. Maintain nl or near-nl pulmonary function
  3. Maintain nl activity levels
  4. Prevent exacerbations and use of ER/inpt services
  5. Minimize adverse effects of tx
  6. Meet pt/family's expectations for care

II. Classification of asthma: essential to guide tx (note that pts at any level of severity can have mild, moderate, or severe exacerbations!) See under "Step Approach" for details

  1. Mild intermittent (step 1)
  2. Mild persistent (step 2)
  3. Moderate persistent (step 3)
  4. Severe persistent (step 4)

III. Look for and treat precipitants/exacerbating factors if possible!

  1. Interventions for inhaled allergens
  1. Immunotherapy if
  1. Connection is clear
  2. Allergen is unavoidable
  3. Asthma poorly controlled w/meds
  1. Avoidance techniques
  1. Dust mites
  1. Impermeable mattress & pillow covers-Ineffective at improving PEFR or reducing need for inhaled corticosteroids in a randomized study of 1122 adults with asthma, 65% of whom were found to have sensitivity to dust-mite allergen (NEJM 349:225, 2003--abst)
  2. Wash bedding weekly in H2O > 130'F to kill mites
  3. Vacuum 2x/wk (not the patient)
  4. No carpets in bedroom or over concrete
  5. Don't lie on upholstered furniture
  6. Wash stuffed animals regularly, if have in bed
  7. Don't use humidifiers (increase dust/mold)
  1. Pets
  1. Keep out of bedroom with bedroom door closed
  2. Keep off of furniture
  3. Wash pet weekly

IV. Immunizations

  1. Influenza vaccine annually
  2. Pneumococcal vaccine

V. Mode of delivery of inhaled meds for asthma: Nebulized vs. MDI with Valved Holding Chambers (VHS, a.k.a. "spacers") vs. MDI's with newer propellants--NO DIFFERENCE

  1. Review of 10 randomized controlled trials comparing administration of meds for asthma exacerbations in kids by nebulizer or MDI w/spacer. Outcomes measured included pulmonary function and/or clinical status. 2 studies found MDI's w/spacer superior; the other 8 found the 2 methods equally effective. MDI's w/spacer probably cheaper as well (Arch. Pediat. Adolesc. Med. 151:876, 1997-JW)
  2. Efficacy of albuterol via MDI w/spacer vs. neb in 50 pts presenting to an ER w/severe asthma exacerbation (avg. age 65yo) was equivalent (measured improvement in FEV1 and sx scores--Chest 112:1501, 1997--JW)
  3. Efficacy of nebulizer vs. MDI-with-spacer for albuterol in tx of acute asthma was equivalent (sx scores & hospitalization rates) in a randomized study of 64 kids 1-5yo (Peds. 106:311, 2000--JW)
  4. In a randomized trial in 85 wheezing infants 2-24mo presenting to an ER, albuterol via nebulizer vs. MDI w/spacer & face mask was ass'd with sig. higher incidence of hospitalization (20% vs. 5%) (Arch. Ped. Adol. Med. 157:76, 2003--JW)
  5. Systematic review of 29 randomized controlled trials of children or adults w/asthma looking at chlorofluorocarbon-containing MDI's vs. other handheld devices (e.g. dry-powder inhalers, hydrofluoroalkane-pressurized inhales, etc.) for delivery of inhaled steroids; no difference found in PFT's, sx, or use of additional asthma meds (BMJ 323:896, 2001--JW)
  6. Systematic review of 84 randomized controlled trials of CFC-containing MDI's vs. other handheld devices for delivery of inhaled beta-agonists to children or adults with asthma.  No differences EXCEPT less use of rescue steroids with HFA-pressurized MDI's (BMJ 323:901--2001, JW)
  7. In a meta-analysis of 6 randomized trials involving kids > 5yo presenting to EDs for acute wheezing or asthma, administration of beta-agonists via MDI + VHC ass'd with sig. lower incidence of hospital admission than administration w/nebulizers (J. Peds. 145:172, 2004--JW) 

VI. Managing exercise-induced asthma/bronchoconstriction (Source include AFP 84:427, 2011)

  1. Exercise-induced bronchoconstriction (without other manifestations of asthma, i.e. with normal spirometry) occurs in about 10% of general population
  2. More common in cold weather and sports associated with high minute-ventilation
  3. Symptoms often peak 5-10 after exercising
  4. Short-acting inhaled beta-agonists are generally considered first-line-If not effective and spirometry is normal, consider bronchial provocation testing e.g. methacholine challenge and if normal, consider alternate diagnoses (anxiety, cardiac abnormalities, other pulmonary disease, vocal cord dysfunction, etc.)
  5. Salmeterol can prevent for longer periods (12h as opposed to 2-3h), though after a few weeks of constant use, its duration of action may shring (NEJM 339:141, 1998--JW)
  6. Also can use cromolyn or nedocromil
  7. Montelukast can be effective (NEJM 339:147, 1998--JW)
  8. Heat-exchange masks (in cold weather) and lengthy warmup may reduce needs for pharmacologic treatment

VII. Special considerations in children:

  1. Asthma probably underdiagnosed in kids
  2. Very few studies on asthma tx for infants
  3. Consultation w/ asthma specialist should be considered for kids with mild persistent asthma; recc'd for mod or severe persistent asthma
  4. For the most part, step-tx plan applies; cromolyn or nedocromil often preferred for daily anti-inflammatory therapy due to better safety profile in kids
  5. Note that good control of childhood asthma may prevent more serious asthma later in life
  6. Use of nebs for kids < 2yo; face masks or spacers attached to MDI's from 2-5yo
  7. Infants w/ allergic manifestations plus asthma have a higher likelihood of having asthma persist through childhood than those without, but tx for both should be determined by clinical aspects of the disease

VIII. Special considerations in the elderly:

  1. May have other coexistent COPD; may be worthwhile to determine degree of reversibility w/a trial of systemic steroids x 2-3wks
  2. Meds may have a greater risk of sig. adverse f/x, e.g. beta-agonists and theophylline
  3. Inhaled steroids may hasten osteoporosis; consider concurrent tx w/Ca and vit. D and/or HRT if appropriate; NHLBI recommends that if high-dose inhaled steroid tx is being used, do bone densitometry at onset and 6mos after onset of tx