Introduction

The prevalence of asthma has increased significantly in the U.S. from a rate of 30.2/1000 in 1973 to 31.4/1000 in 1993 and reported morbidity and mortality continues to increase. Although the chronic inflammatory nature of asthma has been recognized for the past 15 years, progress towards improving clinical outcomes on a population-wide basis has been disappointing. These nationally recognized guidelines emphasize the proper diagnosis of asthma, the appropriate use of anti-inflammatory therapy and self-monitoring to proactively manage potential exacerbations.

Initial Assessment and Diagnosis of Asthma

A clinician considering the diagnosis of asthma should determine that:

• Episodic symptoms of airflow obstruction are present
• Airflow obstruction is at least partially reversible
• Alternative diagnoses are excluded

History
A detailed medical history of the new patient with known or suspected asthma should address the following:

• Identify the symptoms likely to be due to asthma
• Support the likelihood of asthma (i.e. patterns of symptoms, family history of asthma or allergy)
• Assess the severity of asthma (i.e. symptom frequency and severity, exercise tolerance, hospitalizations, medication history)
• Identify possible precipitating factors (i.e. viral respiratory infections, environmental exposure at home, work or school to allergens or irritants)

Physical Examination

The upper respiratory tract, chest and skin are the focus of the physical examination. Key findings to address:

• Hyperexpansion of the thorax (especially in children) and/or use of accessory muscles
• Sounds of wheezing during normal breathing or prolonged phase of forced exhalation (typical of airway obstruction). Wheezing during forced expiration is not a reliable indicator of airflow limitation.
• Increased nasal secretion, mucosal swelling and/or nasal polyps
• Atopic dermatitis/eczema or any other manifestation of an allergic skin condition

Pulmonary Function Testing

Spirometry measurements before and after a short-acting inhaled bronchodilator should be performed in patients in whom the diagnosis of asthma is being considered.

Goals of Asthma Therapy

The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma therapy are being achieved. The goals of therapy are as follows:

• Prevent chronic and troublesome symptoms
• Maintain [near] "normal" pulmonary function
• Maintain normal activity levels (including exercise and other physical activity)
• Prevent recurrent exacerbations of asthma and minimize the need for ER visits or hospitalizations
• Provide optimal pharmacotherapy with minimal or no adverse effects
• Meet parent's and families' expectations of and satisfaction with asthma care

Daily medications:

Anti-inflammatory: Inhaled corticosteroid (high dose) and

Long-acting bronchodilator: either long-acting inhaled beta2-agonist, sustained-release theophylline, or long-acting beta2-agonist tablets AND

Corticosteroid Tablets or syrup long term (2 mg/kd/day, generally do not exceed 60 mg per day).

Short-acting bronchodilator: inhaled beta2-agonists as needed for symptoms.

Intensity of treatment will depend on severity of exacerbation.

Use of Short-acting inhaled beta2-agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.

Steps 2 and 3 actions plus:

Refer to individual education/counseling

Daily medication:

Either

- Anti-inflammatory: inhaled corticosteroid (medium dose) OR

- Inhaled corticosteroid (low-medium dose) and add a long-acting bronchodilator, especially for nighttime symptoms: either long-acting inhaaled beta2-agonist, sustained-release theophylline, or long-acting beta2-agonist tablets.

If need

- Anti-inflammatory: inhaled corticosteroid (Medium-high dose) AND

- Long-acting bronchodilator, expecially for nighttime symptoms; either long-acting inhaled beta2-agonist, sustained-release theo-phylline, or long-acting beta2-agonist tablets.

Short-acting bronchodilator: inhaled beta2-agonists as needed for symptoms.

Intensity of treatment will depend on severity of exacerbation.

Use of short-acting inhaled beta2-agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.

Step 1 actions plus:

Teach self-monitoring

Refer to group education if available

Review and update self-management plan

Daily medication:

Anti-inflammatory: either inhaled corticosteroid (low doses) or cromolyn or nedocromil (children usually begin with a trial of cromolyn or nedocromil). Sustained-release theophylline to serum concentration of 5-15 mcg/mL is an alternative. Zafirlukast or zileuton may also be considered for patients >= 12 years of age.

Short-acting bronchodilator: inhaled beta2-agonists as needed for symptoms.

Intensity of treatment will depend of severity of exacerbation.

Use of Short-acting inhaled beta2-agonist on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.

Step 1 actions plus:

Teach self-monitoring

Refer to group education if available

Review and update self-management plan

Short-acting bronchoddilator: inhaled beta2-agonists as needed for symptoms.

Intensity of treatment will depend of severity of exacerbation.

Use of short-acting inhaled beta2-agonists more than 2 times a week may indicate the need to initiate long-term-control therapy.

Teach basic facts about asthma

Teach inhaler/spacer/holding chamber technique

Discuss roles of medications

Develop self-management plan

Develop action plan for when and how to take rescue actions

Discuss appropriate environment control measures to avoid exposure to known allergens and irritants.

Step down

Review treatment every 1 to 6 months; a dradual stepwise reduction in treatment may be possible

Step up

If control is not maintained, consider step up. First, review patient medication technique, adherence, and environmental control (avoidance of allergens or other factors that contribute to asthma severity).

Notes:

The stepwise approach presents general guidelines to assist clinical decision making; it is not intended to be a specific prescription. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients.

Gain control as quickly as possible; then decrease treatment to the least medication necessary to maintain control. Gaining control may be accomplished by either starting treatment at the step most appropriate to the initial severity of the condition or by starting at a higher level of therapy (e.g., a course of systemic corticosteroids or higher dose on inhaled corticosteroids).

A rescue course of systemic corticosteroid may be needed at any time and at any step.

Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. This may be especially common with exacerbations provoked by respiratory infections. A short course of systemic corticosteroids is recommended.

At each step, patients should control their environment to avoid or control factors that make their asthma worse (e.g. allergens, irritants); this requires specific diagnosis and education.

Daily anti-inflammatory medicine

- High-dose inhaled corticosteroid with spacer/holding chamber and face mask

- If needed, add systemic corticosteroids 2 mg/kg/day and reduce to lowest daily or alternate day dose that stabilizes symptoms

Daily anti-inflammatory medicaiton. Either:

- Medium-dose inhaled corticosteroid with spacer/holding chamber and face mask OR< once control is extablished:

- Medium-dose inhaled corticosteroid and nedocromil

OR:

- Medium-dose inhaled corticosteroid and long-acting bronchodilator (theophylline)

Daily anti-inflammatory medication. Either:

- Cromolyn (nebulizer is preferred; or MDI) or nedocromil (MDI only) tid-qid

- Infants and young children usually begin with a trial or cromolyn or nedocromil OR:

- Low-dose inhaled corticosteroid with spacer/holding chamber and face mask

Bronchodilator as needed for symptoms <2 times a week. Intensity of treatment will depend upon severity of exacerbation. Either:

- Inhaled short-acting beta2-agonist by nebulizer or face mask and spacer/holding chamber OR:

- Oral beta2-agonist for symptoms

With viral respiratory infection:

- Bronchodilator q 4-6 hours up to 24 hours (longer with physician consult) but, in general, repeat no more than once every 6 weeks

- Consider systemic corticosteroid

If current exaceration is severe OR:

If patient has history of privous severe exacerbations

Notes:

Gain control as quickly as possible; then decrease treatment to the least medication necessary to maintain control. Gaining control may be accomplished by either starting treatment at the step most appropriate to the initial severity of their condition or by starting at a higher level of therapy (e.g., a course of systemic corticosteroids or higher dose of inhaled corticosteroids).

A rescue course of ststemic corticosteroid (prednisolone) may be needed at any time and step.

In general, use fo short-acting beta2-agonist >3 or 4 times in 1 day or regular use on a daily basis indicates the need for additional therapy.

It is important to remember that there are very few studies on asthma therapy for infants.

The stepwise approach presents guidelines at assist clinical decision making. Asthma is highly variable; clinicians should tailor specific medication palns to the needs and circumstances of indiviual patients.

Consultation with an asthma specialist is recommended for patients is this age group requiring step 3 or step 4 care. Consider consultation for patients in this age group requiring step 2 care.

Step down

Review treament every 1 to 6 months. If control is sustained for at least 3 months, a gradual stepwise reduction in treatment may be possible.

Step up

If control is not achieved, consider step up. But first: review patient medication technique, adherence, and environmental control (avoidance of allergens or other precipitant factors).