Written by Ruth Morrow, Respiratory Nurse Specialist, Asthma Society of Ireland
Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation which is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation (GINA, 2022). This article seeks to address the management of asthma in adults both from a stable and an acute perspective.
The key to asthma management is education and empowering patients to manage their asthma as well as the use of appropriate treatment for the patient’s asthma phenotype, symptoms and lifestyle.
Management of Stable Asthma
The goals of asthma management are:
- Symptom control: to achieve good control of symptoms and maintain normal activity levels
- Risk reduction: to minimize future risk of exacerbations, fixed airflow limitation and medication side-effects
Assessment of asthma control involves assessing symptoms over the previous 4 weeks using the GINA Assessment of Asthma Control and the Asthma Control Test (ACT) and assessing risk factors for poor outcomes. Treatment issues should also be addressed at every visit and should include:
• Review of inhaler technique and adherence
• Asking about side-effects
• Reviewing the patient’s written asthma action plan?
• Exploring the patient’s attitudes and goals for their asthma?
The treatment and management of asthma should incorporate the following elements:
• Education on the disease process
• Management of trigger factors
• Medication management – actions, inhaler technique, adverse events and adherence
• Asthma Action Plan
• Management of acute flare-ups of asthma
The goal of asthma management is for the patient to be optimally controlled on the minimum amount of medication. GINA (2022) provides health care professionals with a management approach based on control using a step wise approach. This assists health professionals with the titration of medications using as step down or step up approach in attempt to achieve this goal.
The cornerstone of asthma treatment is inhaled therapy as medications are directly targeted at the airways and therefore, are more effective. This also limits the amount of systemic absorption and reduces adverse events. Patients should be commenced
on the appropriate step of the treatment guidelines which is dependent on the severity of their symptoms (GINA, 2022). Each patient is assigned to one of five treatment steps and patients may move up or down the steps depending on symptoms and the amount of reliever therapy being used. Inhaled glucocorticosteroids are the cornerstone of asthma treatment and are the most effective controller medications available. However, there are additional oral medications such as leukotriene receptor antagonists which can be added on and are very useful in patients who have an allergic component to their asthma, experience cold air bronchoconstriction and have exercise induced symptoms. These medications are also licensed for use in allergic rhinitis, a condition which 85% of people with asthma also have. Sublingual immunotherapy is also now recommended at all steps of the guideline depending on the patient’s asthma phenotype.
In 2019, GINA updated their strategy which outlined significant changes to the way asthma is managed in adults and adolescents. The changes recognise a real sea change in the use of short acting bronchodilators (SABA) and the introduction of combination therapy of inhaled corticosteroids (ICS) and long-acting bronchodilators (LABA) as “a needed therapy” at Step 1 and as a maintenance therapy at Step 2. Using a combination therapy as an “as-needed” therapy will require a significant change in the mindset of HCPs given that we haven’t been using SABAs for the last 50 years to relieve asthma symptoms.
Why this change?
Inhaled SABA (Salbutamol, Terbutaline) have been first-line treatment for asthma for 50 years. Traditionally asthma was thought to be a disease of bronchoconstriction with SABA being the drug of choice. Added to this, rapid relief of symptoms, reliance on, patient satisfaction and their low cost have meant that SABAs were widely used, overused and over-relied upon. The perception by patients that their reliever “gives me control over my asthma”, so much so that they often don’t see the need for other treatment. However, research over the past number of years has shown that regular and frequent use of SABAs decrease broncho-protection, increase rebound hyperresponsiveness, and decrease bronchodilator response (Hancox, 2000). Patients with apparently mild asthma are at risk of serious adverse events such as near fatal asthma, acute asthma and death from asthma. Regular or frequent use of SABAs are also associated with increased allergic response and increased eosinophilic airway inflammation (Aldridge, AJRCCM 2000). Patients who get 3 or more canisters of SABA per year (average 1.7 puffs/ day) are associated with higher risk of attendance to the emergency department (Stanford, AAAI 2012) and patients who receive 12 or more canisters per year are associated with higher risk of death (Suissa, AJRCCM 1994). A meta-analysis by Crossingham et al (Cochrane 2021) of four RCTs involving 9,565 patients demonstrated the benefits of LABA/ICS combination therapy showing a 55% reduction in severe exacerbations compared with SABA alone. ED visits or hospitalizations were 65% lower than with SABA alone and 37% lower than with daily ICS.
In their review of the literature, GINA found no evidence to support a Step 1 SABA-only approach. The lack of evidence for SABA-only treatment contrasted with the strong evidence for safety, efficacy and effectiveness of the treatments recommended in Steps 2-5 of the strategy i.e. ICS and ICS/LABA. For safety, GINA no longer recommends SABA-only treatment for Step 1. This decision was based on evidence that SABA-only treatment increases the risk of severe exacerbations, and that adding any ICS significantly reduces the risk. It is now recommended that all adults and adolescents with asthma should receive symptom-driven or regular low dose combination LABA/ICS-containing controller treatment, to reduce the risk of serious exacerbations (GINA, 2022). Patients who have symptoms more than twice a month should be prescribed ICS/ LABA twice daily (Step 2-5) and patients who have symptoms less than twice a month should use ICS/LABA on “an as-needed basis” (Step1). Daily ICS is no longer listed as a Step 1 option as it has a high probability of poor adherence. It is now replaced by a more feasible as-needed controller option at Step 1.Patients should be offered self-management plans with instructions on how to adjust their medications in response to worsening symptoms and/or worsening PEFR. An example of a self-management plan is available on www.asthmasociety.ie.
The non-pharmacological management of asthma include management of trigger factors, smoking cessation, management of obesity and gastroesophageal reflux disease. Influenza vaccination is recommended for those with more severe asthma. Gastro-esophageal reflux can worsen asthma symptoms and treatment of reflux may improve asthma symptoms. Hormones can also play a significant role in asthma control. Some patients will experience worsening of their asthma symptoms pre-menstrually or during menstruation. During pregnancy, asthma control may improve, deteriorate or stay the same as pre-pregnancy. Asthma may also develop in women who are menopausal and very often require high doses of inhaled corticosteroids and have more difficult to control asthma..
Adherence with medication regimes
One of the biggest challenges in asthma management is adherence to medication as many patients may be asymptomatic and therefore “don’t feel the need to use their medication daily” Exploring the patient’s beliefs and attitudes can be useful in determining a rationale for non-adherence to medication regime. Saving medication until it is needed, fear of becoming addicted or the health professional didn’t listen are amongst reasons given by patients in the INCA study (Sulaiman et al, 2014). In the Nocurrent climate, cost a significant factor even for the person who has a medical card and should not be overlooked. Two proven ways to address non-adherence are shared decision-making between the health professional and the patient and motivation interviewing. Using motivational interviewing, the health professional can assess the individual’s likelihood to adhere to their medication or to nonpharmacological interventions.
Risk factors for poor outcomes
Patients who experience uncontrolled asthma symptoms, had one or more exacerbations in the previous year, the start of the patient’s usual ‘flare-up’ season (especially if autumn), has major psychological or socio-economic problems, poor adherence with controller medication and/or incorrect inhaler technique are at risk of an exacerbation in the coming months.
Assessment and Management of Acute asthma
Accurate and timely assessment of acute asthma exacerbations should be carried out to ensure a successful outcome. Table 1 (below) differentiates between a mild and severe acute exacerbation.
The management of acute asthma includes:
1. Oxygen therapy – 24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 93-95%
2. Inhaled short-acting bronchodilator – 4-10 puffs of Salbutamol by spacer, or 5mg by nebulizer, every 20 min for first hour, then reassess severity. If symptoms persist, deteriorate or recur, give an additional 10 puffs per hour and admit to hospital
3. Oral corticosteroids – max 50mgs of oral steroids and continue for 5 -7 days
4. Additional treatments can include – For moderate/severe
exacerbations, Ipratropium bromide 80mcg (or 250mcg by nebulizer) every 20 minutes
Criteria for immediate transfer to secondary care include:
1. Features of severe exacerbation at initial or subsequent assessment
• Patient is unable to speak or drink
• Subcostal retraction
• Oxygen saturation <92% when breathing room air
• Silent chest on auscultation
2. Lack of response to initial bronchodilator treatment
3. Persisting tachypnoea despite 3 administrations of inhaled SABA,
4. Unable to be managed at home
Follow-up post exacerbationAll patients should be followed up regularly after an exacerbation, until symptoms and lung function return to normal. Patients are at increased risk during recovery from a further exacerbation. This provides an opportunity to review and update the patient’s asthma management, review inhaler technique and adherence and to ascertain if there was a cause ie new trigger factors, for this flare-up which might be helpful in preventing future flare-ups
At follow-up visit(s), the asthma review should include:
• The patient’s understanding of the cause of the flare-up
• Modifiable risk factors, e.g. smoking, weight loss if indicated, addressing new triggers
• Adherence with medications, and understanding of their purpose
• Reliever should be being used as-needed rather than routinely
• If controller medication was increased, the increased dose should be maintained for 3 weeks and possibly longer particularly, if during the winter or during Hayfever season
• Inhaler technique skills
• Written asthma action plan
This article has addressed stable and acute asthma management. The rationale for the introduction of LABA/ICS combination therapy has been explored following the changes to the GINA guidelines in 2019.
References available on request.
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