Management Of Adult Asthma

Current British Guidelines on the Management of Asthma¹ provide the following recommendations for the management of asthma:

• Step up/down treatment according to disease severity to maintain good control.
• Start at the step most fitting to the initial severity of the asthma.
• Treatment plans and goals should be negotiated with the patient but usual aims would be to minimise impact of symptoms on life, reduce reliance on reliever medication and prevent severe exacerbations.
• Self-management education including individualised written asthma action plans should be offered.
• Always check concordance with medication/existing action plan, effective inhaler technique and the presence/absence of trigger factors before altering drug therapy.

Routine asthma care is largely carried out in primary care and is rewarded in the QUOF of nGMS. Practices must keep a register of patients with asthma to ensure adequate follow-up and audit. All patients with asthma should be reviewed at least annually, more often if disease is less well controlled or recently diagnosed. Reviews should be carried out by a nurse or doctor with appropriate and up-to-date training and should include:

• Current symptoms using objective measures (usually using RCP "3 Questions"):
  

  1. In the last month/week have you had difficulty sleeping due to your asthma (including cough symptoms)? 2. Have you had your usual asthma symptoms (eg. cough, wheeze, chest tightness, shortness of breath) during the day? 3. Has your asthma interfered with your usual daily activities (eg. school, work, housework)? One "yes" indicates medium morbidity and two or three "yes" answers indicate high morbidity.

• Record an up-to-date smoking status, smoking cessation advice and support where appropriate.
• Record any acute exacerbations since last seen.
• Check medication use - a prescription count can indicate over/under use of medication, inhaler and spacer use, problems and side-effects.
• Check immunisation (pneumococcal/influenza) status. (Nb. Influenza vaccine for asthmatics is no longer a quality indicator for asthma in QUOF 2006).
• Review peak flow diaries and record current PEFR.
• Address any educational needs.
• Provide a written action plan.
• Consider home monitoring of PEFR - useful particularly in those with severe or brittle asthma and those who have difficulty recognising symptom deterioration.
• Agree duration of next follow-up and ensure patient aware of how to seek help if asthma deteriorates.

Studies have shown that "telephone reviews" are effective at improving care delivery and reducing cost.² Assessing patients over the phone using the RCP '3 Questions' approach and adding 2 additional risk questions (Have you been admitted for asthma in the last year? Have you ever needed ITU care for asthma?) has been trialled. Where a positive answer occurs, a clinic review is arranged. Otherwise, action and duration till next follow-up is agreed. Telephone review appears to achieve similar rates of control, better review rates and cheaper care compared to usual clinic asthma reviews. However, QUOF does not yet accept telephone reviews for annual asthma review.

Primary prevention

Evidence suggests reducing parental smoking and encouraging breast-feeding are both likely to reduce the chance of developing asthma. Allergen avoidance, dietary manipulations and modified infant milk formulae have all shown inconsistent effects. Non-sedating antihistamines were shown in small trials to reduce asthma development but their general use is not recommended. Current research areas include immunotherapy, pollutant avoidance and microbial exposure.

Secondary prevention

• Smoking cessation Smoking exacerbates asthma symptoms. Clear personalized advice should be given to stop smoking and help provided with nicotine replacement therapy etc. where appropriate.
• Weight reduction in obese patients improves asthma symptoms and should be encouraged.
• Allergen avoidance There is little evidence that reducing allergen exposure reduces morbidity from asthma and it does not appear to be a cost-effective treatment for asthma. Avoiding house dust mite allergen (bed covers, carpet removal, high temperature washing of bedding, dehumidification and use of acaricides on soft furnishings) requires commitment beyond what is possible in most households. Similarly, cat and dog allergens are potent triggers for many people's asthma but observational evidence again is lacking that removal of the pet from the household improves asthma control. Nonetheless expert consensus usually advocates their removal.
• Other therapies (including complementary and alternative medicine or CAM):

  Therapy	Evidence
  Herbal medicine and traditional Chinese medicine Acupuncture Breathing exercises including yoga and buteyko Physical training Immunotherapy (comparative studies required and only in specialist centres)	Inconclusive but some evidence of benefit
  Massage Homeopathy High altitude and spleotherapy	Insufficient evidence to recommend
  Chiropractics Fish oil supplementation Ionisers	No benefit

Step 1: Mild intermittent asthma

Prescribe an inhaled short acting β₂ agonist as short-term reliever for all patients with symptomatic asthma.

Step 2: Introduction of regular preventer therapy

Inhaled steroids are the most effective preventer drug for achieving overall treatment goals. They should be prescribed for patients with recent exacerbations (in last 2 years), nocturnal asthma (waking with symptoms more than once a week), impaired lung function or using inhaled β₂ agonists more than three times a week. Regular use of bronchodilators alone may be linked with worsening asthma and asthma deaths. Ceiling dose for adults is 400μg beclomethasone bd or equivalent.

Step 3: Add-on therapy

First choice as add-on therapy to inhaled steroids is an inhaled long acting β₂ agonist (LABA) such as salmeterol or formoterol.

• Always commence treatment at lower doses since this is effective for most
• Discontinue if no benefit seen
• If benefit but partial control only, increase inhaled corticosteroid to high dose range (step 4)

Step 4: Poor control on moderate dose of inhaled steroid plus add-on therapy:

Recommendations at this step are based on extrapolated results as specific clinical trials are lacking and are consequently less evidence-based. Trial an additional fourth drug over six weeks (eg. Leukotriene receptor antagonist, SR Theophylline or β₂ agonist tablet) and increase inhaled steroid to high-dose ranges (up to 2000μg/day) are suggested strategies at this level.

Step 5: Continuous or frequent use of oral steroids

Where previous steps have failed to control a patient's asthma, the use of regular prednisolone is suggested. Oral steroid dose reduction is sometimes achieved by using high-dose inhaled corticosteroids. In addition these patients should be under the care of a respiratory physician.

Stepping down

Review treatment every 3 months. Step down if possible (but consider seasonal variation in symptoms, severity of asthma, risk of adverse effects, patient preference) and use the lowest possible dose of inhaled corticosteroid to control the asthma symptoms. When reducing inhaled steroids, cut dose slowly by 25-50% each time.

Increasingly, combination inhalers of LABAs and low dose inhaled steroids (eg. Symbicort® = formeterol and budesonide, Seretide®=salmeterol and fluticasone) are being marketed and used. They do not appear in the current British Guidelines and there is no clear evidence of their clinical benefit as yet. These products are convenient since many patients are on maintenance dose of both types of drugs and should be expected to improve adherence. However they should only be used if the patient requires both drugs and has previously been stabilized on a dosage regimen that is deliverable by the combination inhaler. Using combined inhalers makes it harder to assess whether a patient still requires both drugs and in what doses and so the LABA or inhaled corticosteroid may not be stepped down appropriately.

See acute severe asthma and status asthmaticus - treat as an emergency.

Asthma's course in pregnancy is very variable. The risk of deterioration is highest in those with severe asthma but equally approximately a third of asthmatic women improve symptomatically during pregnancy.
Well-controlled asthma minimises the risk of fetal and maternal complications and pregnant asthmatics should be monitored closely so that appropriate changes to their treatment can be quickly implemented in response to changed symptoms.
In general asthma medications are believed to be safe in pregnancy - women should be reassured regarding inhaled β₂ antagonists and steroids - the risk of harm to the foetus is much greater from undertreated asthma. Leukotriene Receptor antagonists should not be commenced in pregnancy as the safety data is too limited.
Smoking cessation and breast-feeding should be particularly encouraged in asthmatic women.

Occupational asthma is common and under-diagnosed. In primary care, we should consider the possibility of occupational asthma in those developing asthma for the first time as adults or in those who had asthma as children but have been long periods without symptoms. The key screening question is "Does your asthma improve when you are at home or on holiday?" Confirmation is with serial peak flows and those with suspected occupational asthma should be promptly referred to a chest or occupational physician.

Asthma management can be confusing given the array of devices, masks and spacers used to deliver inhaled drugs. When considering which inhaler device consider manual dexterity and other necessary abilities to activate a particular device, factors such as portability and convenience and the patient's willingness to use a particular device.
Whenever an inhaler is prescribed, training should be given and technique checked regularly to ensure that it is being used correctly.

Consider referral to chest physician if:

• Diagnostic uncertainty (presence of clubbing or cyanosis, PEFR/spirometry not typical)
• Suspected occupational asthma - consider occupation causes where new onset or recrudescence of childhood asthma in adult life, compare symptoms on days off with those at work and seek objective confirmation with serial peak flow readings. Any suspicion should now prompt a rapid referral.
• Persistent shortness of breath without wheeze and not intermittent
• Unilateral or fixed wheeze
• Stridor
• Chest pain
• Weight loss
• Persistent cough with or without sputum production
• Non-resolving pneumonia
• Inadequate response to maximum treatment