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 and minimise drug related side-effects.
• 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 initiating new drug therapy.

Routine asthma care is largely carried out in primary care and is rewarded in the QUOF of nGMS.² 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.
  

  The RCP "3 Questions" are widely used: In the last month/week have you had difficulty sleeping due to your asthma (including cough symptoms)? Have you had your usual asthma symptoms (eg. cough, wheeze, chest tightness, shortness of breath) during the day? 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.

  
  Alternatives include the Asthma Control Questionnaire, Asthma Control Test and Mini Asthma Quality of Life Questionnaire.
• Record an up-to-date smoking status, offer 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. The use of more than 2 canisters of short acting beta₂-agonist per month or 10-12 puffs per day - is associated with poorly controlled and higher risk asthma.
• Check immunisation (pneumococcal/influenza) status. (Note, influenza vaccine for asthmatics is no longer a quality indicator for asthma in QUOF 2008).
• Review peak flow diaries and record current PEFR/spirometry values.
• Address any educational needs.
• Provide/update 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.³ 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. Telephone reviews are endorsed by the current guidelines to reach individuals unable/unwilling to come in for regular review but are not thought suitable for those with poorly controlled asthma or where there are problems of inhaler technique.¹

Primary prevention

Effective primary prevention strategies are currently lacking. Evidence suggests reducing parental smoking and encouraging breast-feeding may both reduce the chance of developing asthma. Allergen avoidance, dietary manipulations and modified infant milk formulae have all shown inconsistent effects. Current research areas include immunotherapy, pollutant avoidance and microbial exposure.

Secondary prevention

• Smoking cessation Smoking exacerbates asthma symptoms. It increases the risk of persistent asthma in teenagers who smoke. Clear personalised 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.
• Immunotherapy This may be considered where there is a clinically significant and identified allergen that cannot be avoided. Patients need to be aware of the risk of anaphylaxis and treatment should only take place within specialist settings.

Dietary modifications (use of probiotics, antioxidants, fish oils/lipid supplements, magnesium) are not currently supported by the guidelines.

Step 1: Mild intermittent asthma

Prescribe an inhaled short acting beta₂-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 considered for any patient with:

• A recent exacerbations (in the last 2 years)
• Nocturnal asthma (waking with symptoms more than once a week)
• Day time symptoms or use of an inhaled short acting beta₂-agonist more than 3 times per week

Regular use of bronchodilators alone may be linked with worsening asthma and asthma deaths and some patients may be non-compliant with their 'preventative' medication for varied reasons. Review medication use. Start treatment at a dose appropriate to symptoms between 200-800 mcg /day beclometasone propionate or equivalent (400 mcg/day is appropriate for many).

In the past, advice has been to double inhaled steroids early in an exacerbation. Evidence for being effective at lower dose (e.g. 200 to 400 mcg/day) is lacking but there is some evidence of efficacy switching from low to high dose inhaled steroids (e.g. 200 to 1000 mcg/day) early in an exacerbation. Current guidance advises commencing oral steroids early in an exacerbation.

Step 3: Add-on therapy

First choice as add-on therapy to inhaled steroids are inhaled long acting beta₂ -agonists (LABAs) such as salmeterol or formoterol.

• Review after a trial of therapy - continue if successful in controlling symptoms. well.
• Discontinue after a trial of therapy if no benefit seen. Then, increase inhaled steroid dose to 800 mcg/day beclometasone propionate or equivalent. If control remains suboptimal consider a trial of another add on therapy such as leukotriene receptor antagonists or modified release theophylline.
• If benefit but partial control only, continue the LABA but increase inhaled corticosteroid to 800 mcg/day beclometasone propionate or equivalent.

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 (e.g. 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. These patients should be under the care of a respiratory physician. They run higher risk of steroid-related side-effects and should be monitored for the development of:

• Hypertension
• Diabetes or hyperlipidaemia
• Osteoporosis
• Cataracts
• Adrenal suppression

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.

Combination products

Increasingly, combination inhalers of LABAs and low dose inhaled steroids (e.g. Symbicort® = formoterol and budesonide, Seretide®=salmeterol and fluticasone) are being marketed and used. 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 stabilised 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.

They appear in the new British guidelines for the first time for adult patients at step 3 when the use of formoterol and budesonide combined inhalers may be stepped up from regular use as preventative treatment to rescue treatment (instead of a short-acting beta₂-agonist) when symptomatic.¹ This has been shown to be effective provided patients receive adequate education about their use.

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. Up to a fifth of pregnant women with asthma require emergency treatment, of which two thirds require hospitalisation
Well-controlled asthma minimises the risk of fetal and maternal complications. Pre-pregnancy, optimise control and emphasise the importance of continuing medication in pregnancy. Monitor pregnant asthmatics closely so that appropriate changes to their treatment can be quickly implemented in response to changed symptoms. Treat exacerbations vigorously, in particular ensuring oxygen saturation is maintained above 95%.
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 fetus 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. Asthma drugs can be used as normal in breast-feeding women.

Occupational asthma is common and under-diagnosed. It is thought responsible for between 9-15% adult onset asthma. High risk occupations include:

• Paint sprayers
• Bakers and those involved in food processing
• Welders
• Nurses
• Dental workers
• Laboratory workers
• Animal handlers
• Farm workers
• Forestry and timber workers
• Chemical workers

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.

See also our dedicated record - Which Device in Asthma

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 e.g. atypical clinical findings, unexplained restrictive spirometry
• Suspected occupational asthma
• Persistent non-variable breathlessness
• Unilateral, fixed or monophonic wheeze
• Stridor
• Prominent systemic symptoms e.g weight loss, myalgia, fever
• Chronic sputum production
• CXR shadows
• Marked blood eosinophilia
• Severe exacerbation(s)
• Inadequate response to treatment