Pulmonary

Asthma: The Stepwise Approach to Treatment

Reducing Impairment
Reducing Risk
Treatment
Managing Acute Exacerbations
Monitoring

CLINICAL ACTIONS:

Because asthma is an inherently variable condition, therapy should be reassessed at each visit. Management is a dynamic process that will change based on the patient’s needs over time.

Effective asthma management requires a proactive, preventative and stepwise approach
Control of asthma is viewed in the context of impairment and risk

Reducing Impairment

Optimize care by focusing on the following

Symptom prevention: Minimize troublesome coughing or breathlessness in the daytime, during the night, or after exertion
Infrequent use of quick-acting inhaled beta-2-selective adrenergic agonists (SABAs): ≤2days a week for quick relief of symptoms
Maintain (near) normal pulmonary function
Maintain normal activity levels including
- Exercise and other physical activity
- Attendance at work or school

Reducing Risk

Use ASTHMA ACTION PLAN (see ‘Learn More – Primary Sources’ below) or other management plan to

Prevent recurrent exacerbations
Minimize the need for ED visits or hospitalizations
Prevent progressive loss of lung function
Provide optimal pharmacotherapy with minimal or no adverse effects

SYNOPSIS:

The Expert Panel recommendations specify that treatment must be individualized in a ‘stepwise’ fashion. The guidelines note that “The stepwise approach is meant to help, not replace, the clinical decision making needed to meet individual patient needs.” If a patient remains stable for 3 months, reducing medications in a ‘step down’ approach can be used. In addition, two key factors to a successful outcome are patient education and measures to control environmental triggers and comorbidities.

KEY POINTS:

Treatment

Intermittent Asthma

Step 1

Recommendation: SABAs taken as needed for relief of symptoms
- Daily scheduled chronic use of SABA is not recommended
If SABA >2 days a week for symptom relief: Inadequate control and consider next category (mild persistent asthma) and use of anti-inflammatory therapy
SABAs
- Albuterol | Levalbuterol | Pirbuterol
  - 2 puffs q4 to 6 hours | 2 puffs 5 minutes before exercise
  - SABA in fluid form can be used for acute asthma attacks via nebulizer (breathing machine)
- Works via acute bronchodilation
- Potential side effects
  - Systemic: Tachycardia | Skeletal muscle tremor | Hypokalemia | Increased lactic acid | Headache | Hyperglycemia
  - Inhaled: Few systemic effects in otherwise healthy individuals; however, those with preexisting CVD (especially elderly) may have adverse CVD reaction  
Exercised-Induced Bronchoconstriction (EIB): Patients with triggering of asthmatic symptoms which can be predicted (e.g., EIB) advised to use their inhaled beta agonist approximately 10 minutes prior to exposure in order to prevent the onset of symptoms
- Cromolyn or nedocromil can also be used for EIB

Persistent Asthma 

Step 2

Note: Before moving on to next steps, review the following: Patient’s inhaler technique | Therapy adherence | Precipitating or aggravating factors such as allergens or comorbid conditions

Recommendation (Preferred): Daily low-dose inhaled glucocorticoid (ICS) single agent with as needed SABA or ICS and SABA used concomitantly as needed
- Reduces frequency of symptoms
- Reduces the need for SABAs for symptom relief
- Improves the overall quality of life
- Decreases the risk of serious exacerbations
- Works via anti-inflammatory effect
ICSs
- Beclomethasone dipropionate | Budesonide | Flunisolide | Fluticasone propionate | Mometasone furoate | Triamcinolone acetonide
Alternative strategies (not preferred)
- Daily leukotriene receptor antagonists (LTRAs: montelukast and zafirlukast) and as needed SABA or
- Cromolyn, or Nedocromil, or Zileuton or Theophylline, and as needed SABA
Patient with seasonal asthma (related to seasonal molds or pollens) should be considered as having
- Persistent asthma during the season
- Intermittent asthma remainder of the year

Step 3

Recommendation (Preferred): Daily and as needed combination low-dose ICS-formoterol
Alternative (not preferred)
- Daily medium-dose ICS and as needed SABA or
- Daily low-dose ICS-LABA, or daily low-dose ICS + LAMA (long-acting muscarinic antagonist), or daily low-dose ICS + LTRA, and as needed SABA or
- Daily low-dose ICS + Theophylline or Zileuton, and as needed SABA

Note: For Steps 2 to 4, the guideline conditionally recommends the use of subcutaneous immunotherapy as an adjunct treatment to standard pharmacotherapy in individuals ≥5 years of age whose asthma is controlled at the initiation, build up and maintenance phases of immunotherapy

Step 4

Recommendation (Preferred): Daily and as needed combination medium-dose ICS-formoterol
Alternative (not preferred)
- Daily medium-dose ICS-LABA or daily medium dose ICS + LAMA and as needed SABA or
- Daily medium-dose ICS + LTRA, or daily medium-dose ICS + Theophylline, or daily medium-dose ICS + Zileuton, and as needed SABA

 Step 5

Recommendation (Preferred): Daily medium-high dose ICS-LABA + LAMA and as needed SABA
Alternative (not preferred)
- Daily medium-high dose ICS-LABA or daily high-dose ICS + LTRA, and as needed SABA

Step 6

• Daily high-dose ICS-LABA + oral systemic corticosteroids + as needed SABA
- Use lowest dose to start on a daily or alternate-day regimen

Note: For Steps 5 and 6 consider adding Asthma Biologics (e.g. anti-IgE, anti-IL5, anti-IL5R, anti-IL4/IL13)

Referral To Asthma Specialist

Refer to asthma specialist for consultation or comanagement for the following indications
- Difficulty achieving or maintaining asthma control
- Immunotherapy is being considered
- Omalizumab is being considered
- Patient requires step 4 care or higher
- Exacerbation requiring hospitalization
Consider referral if patient requires step 3 care

Managing Acute Exacerbations Requiring Emergency Care

Oxygen to relieve hypoxemia in moderate or severe exacerbations
SABA to relieve airflow obstruction
- Add inhaled ipratropium bromide if severe
Add systemic corticosteroids to decrease airway inflammation
- If moderate or severe exacerbation or
- If patient doesn’t respond promptly and completely to a SABA
If severe and not responding to above, consider
- Adjunct treatments such as IV magnesium sulfate or heliox
Monitoring: Serial measurements of lung function
Prevent relapse
- Referral to follow up asthma care within 1–4 weeks
- ED asthma discharge plan that includes
  - Medication review
  - Instructions on how to increase medications or seek care if symptoms worsen
- During follow up visits
  - Review Inhaler techniques
- Consider ICSs

Monitoring

At each visit review the following
- Asthma control
- Asthma action plan
- Compliance with medications
  - Stay alert once symptoms are controlled as some patients may “skip” meds, sometimes due to lack of financial resources
  - Medication technique
  - Check peak flow

Peak flow

PEF (Peak Expiratory Flow) | PEFR (Peak Expiratory Flow Rate)
- Measures the rate of air at which patient can force air out
- “It must be stressed that peak flow meters function best as tools for ongoing monitoring, not diagnosis” (Expert Panel Report)
- Sensitive to airway changes such as narrowing even prior to manifestation of asthmatic symptoms
- Use ‘personal best’ peak flow as reference value
‘Normal’ value varies by gender, age and height
- Green zone 80-100 % of personal best: OK
- Yellow zone 50-80 % of personal best: Take quick relief medication | May need increase dose or change
- Red zone <50 %: Call physician or go to ER

Spirometry

Spirometry is recommended at the time of initial assessment for diagnostic purposes, but is also used for monitoring
- After treatment is initiated and symptoms and PEFs have stabilized
- During periods of progressive or prolonged loss of asthma control
- At least every 1–2 years

Schedule follow up visits

Every 2–6 weeks while gaining control
Every 1–6 months to monitor control
Every 3 months if step down in therapy is anticipated
- Expert Panel recommends that the dose of ICS may be reduced about 25–50 percent every 3 months to the lowest dose possible that is required to maintain control

Treat comorbid conditions and assess vaccination status

Inactivated flu vaccine yearly
CDC also recommends
- Pneumococcal vaccine PPSV23
  - 19 to 64 years: 1 dose
  - ≥65 years: One final dose at least five years following previous dose
- Zoster vaccine
- Tdap vaccine