II. Management: Strategy

  1. Written action plan
    1. Based on symptoms or Peak Expiratory Flow
  2. Long term use of Inhaled Corticosteroids
    1. Decrease airway inflammation
    2. Most effective medication for long-term control
  3. Intermittent and cautious use of Inhaled Beta Agonist
    1. Avoid more than 4 times per day
  4. Consider Asthma-contributers (Mnemonic: Air-Smog)
    1. Allergans (pets, Dust mites, molds, pollens)
    2. Irritants and Infections
    3. Rhinitis (allergic) or Sinusitis (acute or chronic)
    4. Smoking, Sleep Apnea or Stress
    5. Medications (Beta Blockers, Aspirin, NSAIDS)
    6. Occupational
    7. Gastroesophageal Reflux Disease
  5. Prevent Exercise-induced and cold-induced Asthma
    1. See Exercise Induced Asthma
    2. Consider Sodium cromoglycate

III. Management: Approach to Uncontrolled Symptoms

  1. Indicators of uncontrolled Asthma
    1. Frequent use and early refills of rescue Inhaler
    2. Rescue Inhaler use more than twice weekly
    3. Awakening with nighttime symptoms more than twice monthly (over age 5)
    4. Within last 12 months, two or more courses of oral Corticosteroids, or Asthma hospital admission
  2. Assessment
    1. Consider Asthma control test (see resources below)
    2. Review Asthma medication use and Asthma Action Plan
    3. Confirm compliance
    4. Patient should demonstrate use of their rescue Inhaler (and with spacer)
  3. Protocol
    1. Advance medications per stepped care and Asthma grouping (see below)
    2. For more significant symptoms start at a higher step (e.g. step 3 or 4)
    3. Re-evaluate every 2-4 weeks and step-up or step down management
    4. Advance stepped care for short-acting Bronchodilator more than twice weekly for acute symptom control
  4. Step 1
    1. Inhaled short-acting Bronchodilator (SABA)
  5. Step 2
    1. Inhaled short-acting Bronchodilator (SABA)
    2. Add low dose Inhaled Corticosteroid (ICS)
  6. Step 3
    1. Inhaled short-acting Bronchodilator (SABA)
    2. Option 1
      1. Change low dose to moderate dose Inhaled Corticosteroid (ICS)
    3. Option 2
      1. Continue low dose Inhaled Corticosteroid (ICS) AND
      2. Add long-acting Bronchodilator (LABA)
  7. Step 4
    1. Inhaled short-acting Bronchodilator (SABA)
    2. Change to Moderate dose Inhaled Corticosteroid (ICS)
    3. Long-acting Bronchodilator (LABA)
  8. Step 5
    1. Inhaled short-acting Bronchodilator (SABA)
    2. Change to High dose Inhaled Corticosteroid (ICS)
    3. Long-acting Bronchodilator (LABA)
  9. Step 6
    1. Inhaled short-acting Bronchodilator (SABA)
    2. High dose Inhaled Corticosteroid (ICS)
    3. Long-acting Bronchodilator (LABA)
    4. Add Oral Systemic Corticosteroids (or consider Omalizumab in patients with allergies)
  10. Additional measures
    1. See Asthma Education
    2. Environmental Allergen control
    3. Leukotriene Receptor Antagonist (LTRA)
      1. Montelukast is associated with increased risk of Major Depression and Suicide
        1. https://www.fda.gov/news-events/press-announcements/fda-requires-stronger-warning-about-risk-neuropsychiatric-events-associated-asthma-and-allergy
    4. Consider Allergen Immunotherapy
    5. Breathing Exercises in Asthma
    6. Asthma Monoclonal Antibody (Asthma Biologic)
      1. Indicated in severe, refractory Allergic Asthma

IV. Management: Grouping (NIH recommendations)

  1. Intermittent Asthma
    1. Occasional exacerbations (Less than twice per week)
  2. Mild Persistent Asthma
    1. Frequent exacerbations (>twice weekly, but not daily)
  3. Moderate Persistent Asthma
    1. Daily symptoms with daily Beta Agonist use
  4. Severe Persistent Asthma
    1. Continuous Symptoms and frequent exacerbations

V. Management: Available Medications

  1. All aerosolized Inhalers should be used with a spacer
    1. Without a spacer, medication delivery is inadequate
    2. See Spacer Devices for Asthma Inhalers
  2. Inhaled Corticosteroids
    1. Most important agents in reactive airway disease
    2. Should be first-line agent in all persistent Asthma
    3. Maximize steroid dose before adding other agents
    4. Ducharme (2002) BMJ 324:1545-8 [PubMed]
  3. Mast Cell Stabilizers
    1. Agents
      1. Cromolyn Sodium (Intal)
      2. Nedocromil (Tilade)
    2. Indications
      1. Alternative antiinflammatory drug for age <5 years
      2. Prophylactic agent for
        1. Exercise induced Asthma
        2. Cold-air-induced Bronchial Asthma
  4. Beta Adrenergic Agonist
    1. Short acting Rescue Inhaler (e.g. Albuterol)
    2. Long acting scheduled Inhaler (e.g. Serevent)
      1. Indicated for moderate to Severe Asthma
      2. Use as adjunct to Inhaled Corticosteroids
  5. Anticholinergics: Ipratropium Bromide (Atrovent)
  6. Leukotriene Receptor Antagonist (e.g. Montelukast)
    1. Indicated as adjunct for moderate to Severe Asthma
    2. Do not use as a first line agent in most cases
      1. Exception: Preschool children with Allergic Asthma
        1. Straub (2005) Chest 127:509-14 [PubMed]
  7. Asthma Monoclonal Antibody (Asthma Biologic)
    1. See Asthma Biologic
    2. Agents include Anti-IgE Therapy (Omalizumab) and anti-Interleukin 4-5 agents
    3. Indicated in severe refractory Allergic Asthma (Type 2 Asthma or Eosinophilic Asthma)
  8. Other measures that are generally avoided
    1. Theophyllines
      1. Rare use in modern Asthma Management
    2. Vitamin D Supplementation is not effective in Asthma
      1. Martineau (2015) Thorax 70(5): 451-7 [PubMed]
      2. Castro (2014) JAMA 311(20): 2083-91 [PubMed]
    3. Soy Supplementation is not effective in Asthma
      1. Smith (2015) JAMA 311(20): 2033-43 [PubMed]

VI. Management: Tapering down

  1. Indications
    1. Well controlled Asthma for at least 3 months
  2. Exercise caution in tapering if significant exacerbation risk
    1. Serious exacerbation has occurred in the last year
    2. Frequent and intermittent exacerbations related to triggers (e.g. allergies)
  3. Technique
    1. Step-down medications in the order that they were added
    2. Combination agent (long acting Bronchodilator and Corticosteroid) tapering (e.g. Advair)
      1. Start taper by decreasing Corticosteroid strength
      2. Next, change combination agent to Corticosteroid only (e.g. Flovent only)
      3. Next, decrease CorticosteroidInhaler strength by 25-50%
      4. Next, discontinue if no exacerbations
    3. Corticosteroid agent
      1. Start taper by decreasing Corticosteroid strength
      2. Next, decrease number of doses per day (e.g. from 2 puffs AM and 2 puffs PM, to 2 puffs AM and 1 puff PM)
      3. Next, discontinue if no exacerbations
  4. Back-up plan
    1. Asthma Action Plan
    2. Rescue medication available at home (e.g. Albuterol)
    3. Controller medication available at home to restart
      1. Restart at last effective dose if rescue medication use more than twice weekly or worsening symptoms
  5. References
    1. (2017) Presc Lett 24(4): 22

IX. Prevention

  1. See Asthma Education
  2. Weight loss in Obesity
  3. Exercise
  4. Influenza Vaccine yearly
    1. Protection lags shot by 2 weeks

X. Resources

  1. Guidelines for the diagnosis and management of Asthma, expert panel 3 (2007)
    1. https://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report

XI. References

  1. Park (2017) Asthma Updates, Mayo Clinical Reviews, Rochester, MN
  2. (2014) Presc Lett 21(12): 67-8
  3. Kalister (2001) West J Med 174:415-20 [PubMed]
  4. Narasimhan (2021) Am Fam Physician 103(5): 286-90 [PubMed]

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