Professional Documents
Culture Documents
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UPDATED 2012
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GINA BOARD OF DIRECTORS* GINA SCIENCE COMMITTEE*
Mark FitzGerald, MD, Chair Helen Reddel, MD, Chair
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University of British Columbia Woolcock Institute of Medical Research
Vancouver, BC, Canada Camperdown, NSW, Australia
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University Cape Town Lung Institute London Chest Hospital
Cape Town, South Africa London, England, UK
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Hpital Laval National Heart and Lung Institute
Sainte-Foy, Quebec, Canada London, England, UK
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Federal University of Bahia
School of Medicine Cape Town, South Africa
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Salvador, Brazil
Allan Becker, MD
Tari Haahtela, MD University of Manitoba
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Helsinki University Central Hospital Winnipeg, Manitoba, Canada
Helsinki, Finland
Elisabeth Bel, MD
Mark L. Levy, MD University of Amsterdam
University of Edinburgh T
Amsterdam, The Netherlands
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London, England, UK
Jeffrey M. Drazen, MD
Paul OByrne, MD Harvard Medical School
McMaster University Boston, Massachusetts, USA
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Pierluigi Paggiaro, MD
University of Pisa Rotterdam, The Netherlands
Pisa, Italy
Robert F. Lemanske, Jr., MD
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Kolding, Denmark
Paul OByrne, MD
Helen Reddel, MD McMaster University
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Gary W. Wong, MD
Chinese University of Hong Kong Kolding, Denmark
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Sally E. Wenzel, MD
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University of Pittsburgh
Pittsburgh, Pennsylvania, USA
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*Disclosures for members of GINA Board of Directors and Science Committees can be
found at http://www.ginasthma.org i
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PREFACE
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Asthma is a serious global health problem. People of all In spite of these dissemination efforts, international
ages in countries throughout the world are affected by surveys provide direct evidence for suboptimal asthma
this chronic airway disorder that, when uncontrolled, can control in many countries, despite the availability of
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place severe limits on daily life and is sometimes fatal. effective therapies. It is clear that if recommendations
The prevalence of asthma is increasing in most countries, contained within this report are to improve care of people
especially among children. Asthma is a significant burden, with asthma, every effort must be made to encourage
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not only in terms of health care costs but also of lost health care leaders to assure availability of and access to
productivity and reduced participation in family life. medications, and develop means to implement effective
asthma management programs including the use of
During the past two decades, we have witnessed many appropriate tools to measure success.
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scientific advances that have improved our understanding
of asthma and our ability to manage and control it In 2002, the GINA Report stated that It is reasonable
effectively. However, the diversity of national health to expect that in most patients with asthma, control
care service systems and variations in the availability of the disease can, and should be achieved and
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of asthma therapies require that recommendations for maintained. To meet this challenge, in 2005, Executive
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asthma care be adapted to local conditions throughout Committee recommended preparation of a new report
the global community. In addition, public health officials not only to incorporate updated scientific information
require information about the costs of asthma care, how but to implement an approach to asthma management
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to effectively manage this chronic disorder, and education based on asthma control, rather than asthma severity.
methods to develop asthma care services and programs Recommendations to assess, treat and maintain asthma
responsive to the particular needs and circumstances control are provided in this document. The methods used
within their countries. T
to prepare this document are described in the Introduction.
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In 1993, the National Heart, Lung, and Blood Institute It is a privilege for me to acknowledge the work of the
collaborated with the World Health Organization to many people who participated in this update project, as
convene a workshop that led to a Workshop Report: well as to acknowledge the superlative work of all who
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Global Strategy for Asthma Management and Prevention. have contributed to the success of the GINA program.
This presented a comprehensive plan to manage asthma
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with the goal of reducing chronic disability and premature The GINA program has been conducted through
deaths while allowing patients with asthma to lead unrestricted educational grants from Almirall, AstraZeneca,
productive and fulfilling lives. Boehringer-Ingelheim, Chiesi, CIPLA, GlaxoSmithKline,
Merck Sharp & Dohme, Novartis, Quintiles, Takeda. The
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At the same time, the Global Initiative for Asthma (GINA) generous contributions of these companies assured that
was implemented to develop a network of individuals, Committee members could meet together to discuss
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organizations, and public health officials to disseminate issues and reach consensus in a constructive and timely
information about the care of patients with asthma while manner. The members of the GINA Committees are,
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at the same time assuring a mechanism to incorporate however, solely responsible for the statements and
the results of scientific investigations into asthma conclusions presented in this publication.
care. Publications based on the GINA Report were
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prepared and have been translated into languages to GINA publications are available through the Internet
promote international collaboration and dissemination of (http://www.ginasthma.org).
information. To disseminate information about asthma
care, a GINA Assembly was initiated, comprised of asthma
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addition, GINA initiated an annual World Asthma Day (in Professor of Medicine
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2001) which has gained increasing attention each year Head, UBC and VGH Divisions of Respiratory Medicine
to raise awareness about the burden of asthma, and to Director, Centre for Lung Health
initiate activities at the local/national level to educate Co-Director Institute for Heart and Lung Health
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families and health care professionals about effective The Lung Centre, 7th Floor
methods to manage and control asthma. Gordon and Leslie Diamond Health Care Centre,
2775 Laurel Street
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GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION
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Table of Contents
PREFACE ii Medical History 16
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Symptoms 16
METHODOLOGY AND SUMMARY OF NEW Cough variant asthma 16
RECOMMENDATION, 2011 UPDATE vi Exercise-Induced bronchospasm 17
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Physical Examination 17
INTRODUCTION x Tests for Diagnosis and Monitoring 17
Measurements of lung function 17
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CHAPTER 1. DEFINITION AND OVERVIEW 1 Spirometry 18
Peak expiratory flow 18
KEY POINTS 2 Measurement of airway responsiveness 19
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Non-Invasive markers of airway inflammation 19
DEFINITION 2 Measurements of allergic status 19
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Prevalence, Morbidity and Mortality 3 DIFFERENTIAL DIAGNOSIS 20
Social and Economic Burden 3 Children 5 Years and Younger 20
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Older Children and Adults 20
FACTORS INFLUENCING THE DEVELOPMENT AND The Elderly 21
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EXPRESSION OF ASTHMA 4 Occupational Asthma 21
Host Factors 4 Distinguishing Asthma from COPD 21
Genetic 4
Obesity 5 T
CLASSIFICATION OF ASTHMA 21
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Sex 5 Etiology 21
Environmental Factors 5 Phenotype 22
Allergens 5 Asthma Control 22
Infections 5 Asthma Severity 23
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Occupational sensitizers 6
Tobacco smoke 6 REFERENCES 24
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Allergen-specific immunotherapy 36
INTRODUCTION 16
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CLINICAL DIAGNOSIS 16
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Reliever Medications 36 ASTHMA PREVENTION 61
Rapid-acting inhaled 2-agonists 36 PREVENTION OF ASTHMA SYMPTOMS AND
Systemic glucocorticosteroids 37 EXACERBATIONS 62
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Anticholinergics 37 Indoor Allergens 62
Theophylline 37 Domestic mites 62
Short-acting oral 2-agonists 37 Furred animals 62
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Cockroaches 63
Complementary and Alternative Medicine 37 Fungi 63
Outdoor Allergens 63
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ASTHMA TREATMENT: CHILDREN 38 Indoor Air Pollutants 63
Route of Administration 38 Outdoor Air Pollutants 63
Controller Medications 39 Occupational Exposures 63
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Inhaled glucocorticosteroids 39 Food and Drug Additives 64
Leukotriene modifiers 41 Drugs 64
Long-acting inhaled 2-agonists 41 Influenza Vaccination 64
Theophylline 42 Obesity 64
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Anti-IgE 42 Emotional Stress 64
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Cromones: sodium cromoglycate and Other Factors That May Exacerbate Asthma 64
nedocromil sodium 43
Systemic glucocorticosteroids 43 COMPONENT 3: ASSESS,TREAT AND MONITOR
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Reliever Medications 43 ASTHMA 65
Rapid-acting inhaled 2-agonists and short-acting
oral 2-agonists 43 KEY POINTS 65
Anticholinergics 43 T
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INTRODUCTION 65
REFERENCES 43
ASSESSING ASTHMA CONTROL 65
CHAPTER 4. ASTHMA MANAGEMENT AND
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ASTHMA EDUCATION 57
At the Initial Consultation 58 MONITORING TO MAINTAIN CONTROL 69
Personal Written Asthma Action Plans 58 Duration and Adjustments to Treatment 69
Follow-up and Review 58 Stepping Down Treatment When Asthma Is
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INTRODUCTION 73 GINA DISSEMINATION/IMPLEMENTATION
ASSESSMENT OF SEVERITY 74 RESOURCES 108
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MANAGEMENT-COMMUNITY SETTINGS 74 REFERENCES 108
Treatment 75
Bronchodilators 75
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Glucocorticosteroids 75
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Assessment 75
Treatment 77
Oxygen 77
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Rapid-acting inhaled 2-agonists 77
Epinephrine 77
Additional bronchodilators 77
Systemic glucocorticosteroids 77
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Inhaled glucocorticosteroids 78
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Magnesium 78
Helium oxygen therapy 78
Leukotriene modifiers 78
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Sedatives 78
Criteria for Discharge from the Emergency
Department vs. Hospitalization 78
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COMPONENT 5: SPECIAL CONSIDERATIONS 80
Pregnancy 80
Obesity 80
Surgery 80
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Rhinitis 81
Sinusitis 81
Nasal polyps 81
Occupational Asthma 81
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Respiratory Infections 81
Gastroesophageal Reflux 82
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Aspirin-Induced Asthma 82
Anaphylaxis and Asthma 83
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REFERENCES 83
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INTRODUCTION 105
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Asthma 107
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Methodology and Summary of New Recommendations
Global Strategy for Asthma Management and Prevention:
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2012 Update1
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Background: When the Global Initiative for Asthma Science Committee, providing an abstract and the full
(GINA) program was initiated in 1993, the primary goal paper are submitted in (or translated into) English.
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was to produce recommendations for the management of
asthma based on the best scientific information available. All members of the Committee receive a summary of
Its first report, NHLBI/WHO Workshop Report: Global citations and all abstracts. Each abstract is assigned to
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Strategy for Asthma Management and Prevention was at least two Committee members, although all members
issued in 1995 and revised in 2002 and 2006. In 2002 are offered the opportunity to provide an opinion on
and in 2006 revised documents were prepared based on all abstracts. Members evaluate the abstract or, up to
published research. her/his judgment, the full publication, and answer four
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specific written questions from a short questionnaire, and
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The GINA Science Committee2 was established in 2002 to indicate if the scientific data presented impacts on
to review published research on asthma management recommendations in the GINA report. If so, the member
and prevention, to evaluate the impact of this research is asked to specifically identify modifications that should
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on recommendations in the GINA documents related to be made.
management and prevention, and to post yearly updates
on the GINA website. Its members are recognized The entire GINA Science Committee meets twice yearly
leaders in asthma research and clinical practice with T
to discuss each publication that was considered by at
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the scientific credentials to contribute to the task of the least 1 member of the Committee to potentially have
Committee, and are invited to serve for a limited period an impact on the management of asthma. The full
and in a voluntary capacity. The Committee is broadly Committee then reaches a consensus on whether to
representative of adult and pediatric disciplines as well include it in the report, either as a reference supporting
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from diverse geographic regions. current recommendations, or to change the report. In the
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impact of publications from July 1 of the previous year on the best evidence available from the literature and
through June 30 of the year the update was completed. not on labeling directives from government regulators.
Posted on the website along with the updated The Committee does not make recommendations for
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documents is a list of all the publications reviewed by the therapies that have not been approved by at least one
Committee. regulatory agency.
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Process: To produce the updated documents a Pub For the 2012 update, between July 1, 2011 and June 30,
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Med search is done using search fields established by 2012, 386 articles met the search criteria. Of the 386,
the Committee: 1) asthma, All Fields, All ages, only items 19 papers were identified to have an impact on the GINA
with abstracts, Clinical Trial, Human, sorted by Authors; report. The changes prompted by these publications
and 2) asthma AND systematic, All fields, ALL ages, only were posted on the website in December 2012. These
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items with abstracts, Human, sorted by author. The first were either: A) modifying, that is, changing the text or
search includes publications for July 1-December 30 for introducing a concept requiring a new recommendation
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review by the Committee during the ATS meeting. The to the report; or B) confirming, that is, adding to or
second search includes publications for January 1 June replacing an existing reference.
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The Global Strategy for Asthma Management and Prevention (updated 2012), the updated Pocket Guides and the complete list of references examined by the Committee are available on the GINA website
www.ginasthma.org.
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Members (2011-2012): H. Reddel, Chair; P. Barnes, N. Barnes, E. Bateman, A. Becker, E. Bel, J. DeJongste, J. Drazen, M. FitzGerald, R. Lemanske, P. OByrne, K. Ohta, S. Pedersen, E. Pizzichini, S. Wenzel.
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SUMMARY OF RECOMMENDATIONS IN THE 2013 Page 38, right column, last paragraph, add statement
UPDATE and reference: although spacer devices or face masks
differ in their drug delivery, and therefore may not be
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A. Additions to the text: interchangeable237.
Reference 237. Lavorini F, Fontana GA. Targeting drugs
Page 33, right column, insert new paragraph: Tiotropium, to the airways: The role of spacer devices. Expert Opin
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a long-acting inhaled anticholinergic bronchodilator, Drug Deliv 2009;6:91-102.
has been studied in adults with uncontrolled asthma
and compared with salmeterol, doubling the dose of Page 40, left column, first paragraph replace with: The
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inhaled glucocorticosteroid and as add-on to inhaled clinical benefits of intermittent systemic or inhaled
glucocorticosteroids and salmeterol231,233. One study glucocorticosteroids for children with intermittent, viral-
showed comparable bronchodilator effects with no induced wheeze remain controversial. A one-year study
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significant changes on asthma control232. Another study of intermittent treatment with inhaled glucocorticosteroids
showed that adding tiotropium to patients not controlled was equally effective as daily treatment, and reduced
on inhaled glucocorticosteroids and long-acting 2- the total glucocorticosteroid dose threefold in preschool
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agonists improved lung function but not symptoms233. children with frequent wheezing and a high asthma
The studies have been relatively short-term and no effect predictive index238. Some studies in older children found
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on exacerbations has so far been reported. There are no small benefits while another study in young children
data about these medications in children. found no effects on wheezing symptoms139. There is no
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Reference 231: Peters SP, Kunselman SJ, Icitovic N, evidence to support the use of maintenance low-dose
Moore WC, Pascual R, Ameredes BT et al. National inhaled glucocorticosteroids for preventing early transient
Heart, Lung, and Blood Institute Asthma Clinical wheezing136, 139, 199.
Research Network. Tiotropium bromide step-up therapy T
Reference 238: Zeiger RS, Mauger D, Bacharier LB,
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for adults with uncontrolled asthma. N Engl J Med Guilbert TW, Martinez FD, Lemanske RF Jr, et al; CARE
2010;363:1715-26. Network of the National Heart, Lung, and Blood Institute.
Reference 232: Kerstjens HA, Disse B, Schroder-Babo Daily or intermittent budesonide in preschool children
W, Bantje TA, Gahlemann M, Sigmund R, Engel M, with recurrent wheezing. N Engl J Med. 2011 Nov
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P, Pivovarova A, Engel M, Fabbri LM. Tiotropium is Zeiger RS, Lemanske RF Jr, Szefler SJ, et al; Childhood
noninferior to salmeterol in maintaining improved lung Asthma Research and Education Network of the
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function in B16-Arg/Arg patients with asthma. J Allergy National Heart, Lung, and Blood Institute. Growth of
Clin Immunol. 2011 Aug;128(2):315-22. preschool children at high risk for asthma 2 years after
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Reference 235: Hanania NA, Alpan O, Hamilos DL, et Page 71, right column, replace second bullet and add
al. Omalizumab in severe allergic asthma inadequately reference: Investigate and confirm adherence with
controlled with standard therapy: a randomized trial. Ann treatment. Incorrect or inadequate use of medications
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Internal Med 2011;154:573-82. and inhalers405 remains the most common reason for
failure to achieve good control. In patients with difficult-
Page 38, left column, first paragraph, add sentence and to-treat asthma, improved adherence and improved
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reference: A systematic review of yoga interventions health outcomes can be achieved with a comprehensive
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systematic review of randomized clinical trials. J Asthma. adherence in difficult to control asthma. Respir Med.
2011 Aug;48(6):632-9. 2011 Sep;105(9):1308-15.
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Page 72, left column insert in last paragraph: Extended poorly controlled asthma: a randomized controlled trial.
follow-up on a small number of patients has provided JAMA. 2012 Jan 25;307(4):373-81.
some additional support for long-term safety of bronchial
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thermoplasty417. However, longer-term follow-up of B. References that provided confirmation or update of
larger number of control and active patients is needed previous recommendations.
to assess effectiveness and caution should be used in
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selecting patients for this procedure. Page 6, right column, first sentence in paragraph four,
Reference 417: Castro M, Rubin A, Laviolette M, add reference 136.
Hanania NA, Armstrong B, Cox G; AIR2 Trial Study Reference 136: Burke H, Leonardi-Bee J, Hashim A,
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Group. Persistence of effectiveness of bronchial Pine-Abata H, Chen Y, Cook DG, Britton JR, McKeever
thermoplasty in patients with severe asthma. Ann TM. Prenatal and passive smoke exposure and incidence
Allergy Asthma Immunol. 2011 Jul;107(1):65-70. of asthma and wheeze: systematic review and meta-
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analysis. Pediatrics. 2012 Apr;129(4):735-44.
Page 77, left column replace paragraph on oxygen:
To achieve arterial oxygen saturation of 90% (95% Page 33, right column, insert reference 234 after
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in children), oxygen should be administered by nasal reference 215.
cannulae, by mask, or rarely by head box in some Reference 234: Kemp J, Armstrong L, Wan Y,
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infants. For severe asthma exacerbations, controlled Alagappan VK, Ohlssen D, Pascoe S. Safety of
oxygen therapy using pulse oximetry to maintain formoterol in adults and children with asthma: a
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oxygen saturation at 90 93% is associated with better meta-analysis. Ann Allergy Asthma Immunol. 2011
physiological outcomes, compared to high flow 100% Jul;107(1):71-8.
oxygen therapy218, 419. Oxygen therapy should be titrated
against pulse oximetry to maintain a satisfactory oxygen T
Page 41, right column, line 10, insert reference 234 after
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saturation219. However, oxygen should not be withheld if reference 75, and in line 17, after reference 169.
oximetry is not available. Reference 234: Kemp J, Armstrong L, Wan Y,
Reference 419. Perrin K, Wijesinghe M, Healy B, Alagappan VK, Ohlssen D, Pascoe S. Safety of
Wadsworth K, Bowditch R, Bibby S, Baker T, Weatherall formoterol in adults and children with asthma: a
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M, Beasley R. Randomised controlled trial of high meta-analysis. Ann Allergy Asthma Immunol. 2011
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Page 78, left column, end of first paragraph, insert text Reference 414: Shah S, Sawyer SM, Toelle BG, Mellis
and reference: Two days of oral dexamethasone can CM, Peat JK, Lagleva M, Usherwood TP, Jenkins CR.
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also be used to treat asthma exacerbations, but there are Improving paediatric asthma outcomes in primary health
concerns about metabolic side-effects if dexamethasone care: a randomised controlled trial. Med J Aust. 2011 Oct
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several weeks, as long as the patient is on maintenance Reference 415: Gehring U, de Jongste JC, Kerkhof M,
inhaled glucocorticosteroids246 (Evidence B). Oldewening M, Postma D, van Strien RT, et al. The 8-year
Reference 420: Kravitz J, Dominici P, Ufberg J, Fisher J, follow-up of the PIAMA intervention study assessing the
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Giraldo P. Two days of dexamethasone versus 5 days of effect of mite-impermeable mattress covers. Allergy. 2012
prednisone in the treatment of acute asthma: a Feb;67(2):248-56
randomized controlled trial. Ann Emerg Med. 2011
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Reference 422. Holbrook JT, Wise RA, Gold BD, using cluster analysis. J Asthma. 2012 Mar;49(2):158-69.
Blake K, Brown ED, Castro M, Dozor AJ, et al. Writing
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Committee for the American Lung Association Asthma Page 81, right column, last sentence under section on
Clinical Research Centers. Lansoprazole for children with Occupational Asthma, insert insert (See also reference 421).
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Reference 421: Fishwick D, Barber CM, Bradshaw LM,
Ayres JG, Barraclough R, Burge S, et al. Standards of
care for occupational asthma: an update. Thorax. 2012
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Mar;67(3):278-80.
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Page 20, left column, insert new paragraph: In early life,
the presence of sensitization to common allergens, atopy,
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is a major risk factor for subsequent development of
asthma. In addition, atopy also predicts that asthma may
be more severe when it does develop.
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ug/day
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Page 64, under heading of obesity, insert: ...including by
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INTRODUCTION
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Asthma is a serious public health problem throughout the health officials in various countries to design, implement,
world, affecting people of all ages. When uncontrolled, and evaluate asthma care programs to meet local needs.
asthma can place severe limits on daily life, and is The GINA Board of Directors recognizes that this is a
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sometimes fatal. difficult task and, to aid in this work, has formed several
groups of global experts, including: a Dissemination and
In 1993, the Global Initiative for Asthma (GINA) was Implementation Committee; the GINA Assembly, a network
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formed. Its goals and objectives were described in a 1995 of individuals who care for asthma patients in many
NHLBI/WHO Workshop Report, Global Strategy for Asthma different health care settings; and two regional programs,
Management and Prevention. This Report (revised in 2002 GINA Mesoamerica and GINA Mediterranean. These efforts
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and 2006), and its companion documents, have been aim to enhance communication with asthma specialists,
widely distributed and translated into many languages. primary-care health professionals, other health care
A network of individuals and organizations interested in workers, and patient support organizations. The Board of
asthma care has been created and several country-specific Directors continues to examine barriers to implementation
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asthma management programs have been initiated. of the asthma management recommendations, especially
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Yet much work is still required to reduce morbidity and the challenges that arise in primary-care settings and in
mortality from this chronic disease. developing countries.
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In 2006, the Global Strategy for Asthma Management and While early diagnosis of asthma and implementation of
Prevention was revised to emphasize asthma management appropriate therapy significantly reduce the socioeconomic
based on clinical control, rather than classification of burdens of asthma and enhance patients quality of life,
the patient by severity. This important paradigm shift for T
medications continue to be the major component of the
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asthma care reflected the progress made in pharmacologic cost of asthma treatment. For this reason, the pricing of
care of patients. Many asthma patients are receiving, or asthma medications continues to be a topic for urgent
have received, some asthma medications. The role of need and a growing area of research interest, as this has
the health care professional is to establish each patients important implications for the overall costs of asthma
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current level of treatment and control, then adjust management. Moreover, a large segment of the worlds
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treatment to gain and maintain control. Asthma patients population lives in areas with inadequate medical facilities
should experience no or minimal symptoms (including and meager financial resources. The GINA Board of
at night), have no limitations on their activities (including Directors recognizes that fixed international guidelines
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physical exercise), have no (or minimal) requirement for and rigid scientific protocols will not work in many
rescue medications, have near normal lung function, and locations. Thus, the recommendations found in this Report
experience only very infrequent exacerbations. must be adapted to fit local practices and the availability of
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clinical control described in the 2006 report have been As the GINA Board of Directors expand their work, every
updated annually. This 2011 update reflects a number of effort will be made to interact with patient and physician
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modifications, described in Methodology and Summary of groups at national, district, and local levels, and in multiple
New Recommendations. As with all previous GINA reports, health care settings, to continuously examine new and
levels of evidence (Table A) are assigned to management innovative approaches that will ensure the delivery of the
recommendations where appropriate in Chapter 4, the Five best asthma care possible. GINA is a partner organization
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Components of Asthma Management. Evidence levels are in a program launched in March 2006 by the World
indicated in boldface type enclosed in parentheses after the Health Organization, the Global Alliance Against Chronic
relevant statemente.g., (Evidence A). Respiratory Diseases (GARD). Through the work of the
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FUTURE CHALLENGES progress toward better care for all patients with asthma
should be substantial in the next decade.
In spite of laudable efforts to improve asthma care over the
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Table A. Description of Levels of Evidence
Evidence Sources of Evidence Definition
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Category
A Randomized controlled Evidence is from endpoints of well designed RCTs that provide a consistent
trials (RCTs). Rich body pattern of findings in the population for which the recommendation is made.
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of data. Category A requires substantial numbers of studies involving substantial numbers
of participants.
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B Randomized controlled Evidence is from endpoints of intervention studies that include only a limited
trials (RCTs). Limited number of patients, posthoc or subgroup analysis of RCTs, or meta-analysis of
body of data. RCTs. In general, Category B pertains when few randomized trials exist, they are
small in size, they were under-taken in a population that differs from the target
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population of the recommendation, or the results are somewhat inconsistent.
C Nonrandomized trials. Evidence is from outcomes of uncontrolled or non-randomized trials or from
Observational studies. observational studies.
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D Panel consensus judg- This category is used only in cases where the provision of some guidance was
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ment. deemed valuable but the clinical literature addressing the subject was insufficient
to justify placement in one of the other categories. The Panel Consensus is
based on clinical experience or knowledge that does not meet the above listed
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criteria.
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CHAPTER
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OVERVIEW
DEFINITION
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Wheezing appreciated on auscultation of the chest is the
KEY POINTS: most common physical finding.
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Asthma is a chronic inflammatory disorder of the The main physiological feature of asthma is episodic airway
airways in which many cells and cellular elements obstruction characterized by expiratory airflow limitation.
play a role. The chronic inflammation is associated The dominant pathological feature is airway inflammation,
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with airway hyperresponsiveness that leads to sometimes associated with airway structural changes.
recurrent episodes of wheezing, breathlessness,
chest tightness, and coughing, particularly at night Asthma has significant genetic and environmental
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or in the early morning. These episodes are usually components, but since its pathogenesis is not clear, much
associated with widespread, but variable, airflow of its definition is descriptive. Based on the functional
obstruction within the lung that is often reversible consequences of airway inflammation, an operational
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either spontaneously or with treatment. description of asthma is:
Clinical manifestations of asthma can be controlled Asthma is a chronic inflammatory disorder of the airways
with appropriate treatment. When asthma is in which many cells and cellular elements play a role.
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controlled, there should be no more than occasional The chronic inflammation is associated with airway
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flare-ups and severe exacerbations should be rare. hyperresponsiveness that leads to recurrent episodes of
wheezing, breathlessness, chest tightness, and coughing,
Asthma is a problem worldwide, with an estimated particularly at night or in the early morning. These
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300 million affected individuals. episodes are usually associated with widespread, but
variable, airflow obstruction within the lung that is often
Although from the perspective of both the patient and reversible either spontaneously or with treatment.
society the cost to control asthma seems high, the T
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cost of not treating asthma correctly is even higher. Because there is no clear definition of the asthma
phenotype, researchers studying the development of
A number of factors that influence a persons risk of this complex disease turn to characteristics that can
developing asthma have been identified. These can be measured objectively, such as atopy (manifested as
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be divided into host factors (primarily genetic) and the presence of positive skin-prick tests or the clinical
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and different cellular patterns have been observed, no effect in normal individuals), and other measures of
but the presence of airway inflammation remains a allergic sensitization. Although the association between
consistent feature. asthma and atopy is well established, the precise links
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in the reviews and other references cited at the end of the more than occasional recurrence of symptoms and severe
chapter. exacerbations should be rare1.
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DEFINITION
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Prevalence, Morbidity, and Mortality of the individual sufferer, the health care professional,
or entities that pay for health care. Absence from school
Asthma is a problem worldwide, with an estimated 300 and days lost from work are reported as substantial social
PR
million affected individuals2,3. Despite hundreds of reports and economic consequences of asthma in studies from
on the prevalence of asthma in widely differing populations, the Asia-Pacific region, India, Latin America, the United
Kingdom, and the United States9-12.
RE
the lack of a precise and universally accepted definition of
asthma makes reliable comparison of reported prevalence
from different parts of the world problematic. Nonetheless, The monetary costs of asthma, as estimated in a variety of
based on the application of standardized methods to health care systems including those of the United States13-15
OR
measure the prevalence of asthma and wheezing illness in and the United Kingdom16 are substantial. In analyses of
children4 and adults, it appears that the global prevalence economic burden of asthma, attention needs to be paid to
of asthma ranges from 1% to 18% of the population in both direct medical costs (hospital admissions and cost of
medications) and indirect, non-medical costs (time lost from
R
different countries (Figure 1-1)2,3. There is good evidence
that international differences in asthma symptom work, premature death)17. For example, asthma is a major
TE
prevalence have been reduced, particularly in the 13-14 cause of absence from work in many countries4-6, including
year age group, with decreases in prevalence in North Australia, Sweden, the United Kingdom, and the United
America and Western Europe and increases in prevalence States2,3,18,19. Comparisons of the cost of asthma in different
AL
in regions where prevalence was previously low. Although regions lead to a clear set of conclusions:
there was little change in the overall prevalence of current
wheeze, the percentage of children reported to have had The costs of asthma depend on the individual patients
asthma increased significantly, possibly reflecting greater
T level of control and the extent to which exacerbations
NO
awareness of this condition and/or changes in diagnostic are avoided.
practice. The increases in asthma symptom prevalence
in Africa, Latin America and parts of Asia indicate that Emergency treatment is more expensive than planned
O
World Health Organization has estimated that 15 million Non-medical economic costs of asthma are substantial.
disability-adjusted life years (DALYs) are lost annually due Guideline-determined asthma care can be cost
to asthma, representing 1% of the total global disease effective.Families can suffer from the financial burden
AL
are insufficient data to determine the likely causes of the society the cost to control asthma seems high, the cost
described variations in prevalence within and between of not treating asthma correctly is even higher119. Proper
TE
Permission for use of this figure obtained from J. Bousquet. DEFINITION AND OVERVIEW 3
*(http://www.ginasthma.org/ReportItem.asp?I1=2&I2=2&intld=94
E
asthma in developed than in developing nations, in poor
FACTORS INFLUENCING THE
UC
compared totoaffluent
compared affluentpopulations
populationsin in developed
developed nations,
nations,
DEVELOPMENT AND EXPRESSION
FACTORS INFLUENCING THE and in affluent compared to poor populations in developing
and in affluent compared to poor populations in developing
OF ASTHMA
DEVELOPMENT AND EXPRESSION nationslikely reflect lifestyle differences such as
nationslikely reflect lifestyle differences such as exposure
OD
OF ASTHMA toexposure
allergens, toaccess
allergens, accesscare,
to health to health
etc. care, etc.
PR
into those that cause the development of asthma and from studies of young children. Risk factors
from studies of young children. Risk factors for thefor the
those that
Factors trigger
that asthma
influence thesymptoms;
risk of asthmasomecandobe both.
divided developmentofofasthma
development asthmaininadults,
adults,particularly de novo
particularly de novo in
in
The those
into formerthat
include
causehost
thefactors (which are
development primarily
of asthma and adults who did not have asthma in childhood, are
adults who did not have asthma in childhood, are less wellless
RE
genetic)
those and
that the latter
trigger asthmaare symptoms;
usually environmental
some do both. factors
The well defined.
defined.
(Figure 1-2) 21. host
former include However,
factors the mechanisms
(which whereby
are primarily they
genetic)
influence
and the development
the latter and expression
are usually environmental of asthma
factors (Figureare Thelack
The lackofofaaclear
cleardefinition
definitionfor
for asthma
asthma presents
presents aa
OR
complex
1-2) 21
and interactive.
. However, For example,
the mechanisms genes
whereby theylikely
influence significant problem in studying the role of
significant problem in studying the role of differentdifferent risk
risk
interact
the both with and
development otherexpression
genes andofwith environmental
asthma are complex factors in the development of this complex
factors in the development of this complex disease, disease,
factors
and to determine
interactive. asthma susceptibility
For example, genes likely22,23. In addition,
interact both with becausethe
because thecharacteristics
characteristicsthat
thatdefine
defineasthma
asthma (e.g.,
(e.g., airway
developmental
other genes andaspectssuch
with environmental as thefactors
maturation of the
to determine airway hyperresponsiveness, atopy, and allergic
hyperresponsiveness, atopy, and allergic sensitization)
R
immunesusceptibility
asthma response and the
22,23
. Intiming of infectious
addition, exposures
developmental sensiti
are ation) are
themselves themselves
products products
of complex of complex
gene-environment
gene-environment
and areinteractions andfeatures
are therefore both and
TE
during the first years
aspectssuch as theofmaturation
lifeare emerging as important
of the immune response interactions therefore both of asthma
factors
and themodifying the risk of exposures
timing of infectious asthma in the genetically
during the first years features
risk factorsoffor
asthma and risk factors
the development fordisease.
of the the development
susceptible
of person. as important factors modifying the risk
lifeare emerging of the disease.
AL
of asthma in the genetically susceptible person. Host Factors
Host Factors
Figure 1-2.
Figure 1-2. Factors
Factors Influencing
Influencing the
the Development
Development Genetic. Asthma has a heritable component, but it is not
and Expression
and Expression ofof Asthma
Asthma T
Genetic.
simple. Asthma
Current datahas showa heritable
that multiplecomponent,
genes may but itbe is not
NO
simple. in
involved Current data show that
the pathogenesis multiple24,25
of asthma gene
, ands may be
different
HOST FACTORS
HOST FACTORS involved
genes mayinbe theinvolved
pathogenesisin differentof asthma
ethnic , and different
groups.
24,25 The
Genetic, e.g.,
Genetic, e.g., search
genesfor may genes linked to
be involved in the development
different of asthma
ethnic groups. The
Genes pre-disposing
Genes pre-disposing to
to atopy
atopy has focused
search on four
for genes major
linked toareas: production of
the development of asthma
allergen- has
O
Genes pre-disposing
Genes pre-disposing to
to airway hyperresponsiveness
airway hyperresponsiveness specific
focusedIgE onantibodies
four major (atopy); expressionofofallergen-
areas: production airway
Obesity hyperresponsiveness;
specific IgE antibodiesgeneration of inflammatory
(atopy); expression of airway
-D
Obesity
Sex
Sex mediators, such as cytokines,
hyperresponsiveness; generation chemokines, and growth
of inflammatory
factors;
mediators, such as cytokines, chemokines, andTh1
and determination of the ratio between growth
ENVIRONMENTAL FACTORS
ENVIRONMENTAL FACTORS and Th2 immune
factors; responsesof(as
and determination the relevant
ratio to the hygiene
between Th1 and
AL
mice), cockroach
mice), cockroach allergen,
allergen, fungi,
fungi, molds,
molds, yeasts
yeasts
susceptibility. For example, a tendency to produce an
Outdoor: Pollens,
Pollens, fungi,
fungi, molds,
molds, yeasts Family studies
level ofand totalcase-control association analyses have
Outdoor: yeasts
elevated serum IgE is co-inherited with airway
TE
Infections (predominantly
Infections (predominantly viral)
viral) identified a number of chromosomal regions associated
hyperresponsiveness, and a gene (or genes) governing
Occupational sensiti
Occupational ers
sensitizers with asthma susceptibility. For example, a tendency to
airway hyperresponsiveness is located near a major locus
Tobacco smoke
Tobacco smoke produce an elevated level of total serum IgE is co-inherited
MA
increased risk
Additionally, for asthma,
some but are not
characteristics havethemselves
been linkedtrue
to an inconsistentFor
treatments.
24,25
.example, variations in the gene encoding
GH
causal factors.
increased The
risk for apparent
asthma, butracial and
are not ethnic differences
themselves true the beta-adrenoreceptor have been linked to differences
in the prevalence
causal factors. Theof apparent
asthma reflect
racialunderlying
and ethnicgenetic
differences inInsubjects
addition responses
to genes that to predispose
2
-agonists28to asthma
. Other thereofare
genes
variances
in with a significant
the prevalence of asthmaoverlay
reflect of socioeconomic
underlying geneticand genes that are associated with the response
interest modify the responsiveness to glucocorticosteroids to asthma 29
treatments. For example, 30 variations in the gene encoding
RI
environmental
variances with factors. In turn,
a significant the links
overlay between asthma
of socioeconomic and and leukotriene modifiers . These genetic markers will
and socioeconomic
environmental statuswith
factors. In turn, thea higher prevalence
links between of
asthma the beta-adrenoreceptor
likely become important not haveonly been linked
as risk to differences
factors in the in
PY
and socioeconomic statuswith a higher prevalence of pathogenesis of asthma but also as determinants of
asthma in developed than in developing nations, in poor responsiveness to treatment28,30-33.
4 DEFINITION AND OVERVIEW
CO
OD
lung function and more co-morbidities compared with
normal weight people with asthma131. The use of systemic For some allergens, such as those derived from house dust
glucocorticosteroids and a sedentary lifestyle may promote mites and cockroaches, the prevalence of sensitization
PR
obesity in severe asthma patients, but in most instances, appears to be directly correlated with exposure38,41.
obesity precedes the development of asthma. However, although some data suggest that exposure to
house dust mite allergens may be a causal factor in the
RE
How obesity promotes the development of asthma is development of asthma42, other studies have questioned
still uncertain but it may result from the combined effects this interpretation43,44. Cockroach infestation has been
of various factors. It has been proposed that obesity shown to be an important cause of allergic sensitization,
OR
could influence airway function due to its effect on lung particularly in inner-city homes45.
mechanics, development of a pro-inflammatory state, in
addition to genetic, developmental, hormonal or neurogenic In the case of dogs and cats, some epidemiologic
influences35,129,130. In this regard, obese patients have a studies have found that early exposure to these animals
R
reduced expiratory reserve volume, a pattern of breathing may protect a child against allergic sensitization or
TE
that may possibly alter airway smooth muscle plasticity and the development of asthma46-48, but others suggest
airway function34. Furthermore, the release by adipocytes that such exposure may increase the risk of allergic
of various pro-inflammatory cytokines and mediators such sensitization47,49-51. This issue remains unresolved.
AL
as interleukin-6, tumor necrosis factor (TNF)-, eotaxin,
and leptin, combined with a lower level of anti-inflammatory The prevalence of asthma is reduced in children raised
adipokines in obese subjects can favor a systemic in a rural setting, which may be linked to the presence of
inflammatory state although it is unknown how this could T
endotoxin in these environments52.
NO
influence airway function131,132.
Infections. During infancy, a number of viruses have been
Sex. Male sex is a risk factor for asthma in children. Prior associated with the inception of the asthmatic phenotype.
to the age of 14, the prevalence of asthma is nearly twice Respiratory syncytial virus (RSV) and parainfluenzavirus
O
as great in boys as in girls36. As children get older the produce a pattern of symptoms including bronchiolitis that
-D
difference between the sexes narrows, and by adulthood parallel many features of childhood asthma53,54. A number
the prevalence of asthma is greater in women than in men. of long-term prospective studies of children admitted
The reasons for this sex-related difference are not clear. to the hospital with documented RSV have shown that
AL
However, lung size is smaller in males than in females at approximately 40% will continue to wheeze or have asthma
birth37 but larger in adulthood. into later childhood53. On the other hand, evidence also
indicates that certain respiratory infections early in life,
RI
Environmental Factors including measles and sometimes even RSV, may protect
against the development of asthma55,56. The data do not
TE
There is some overlap between environmental factors allow specific conclusions to be drawn. Parasite infections
that influence the risk of developing asthma, and factors do not in general protect against asthma, but infection with
MA
that cause asthma symptomsfor example, occupational hookworm may reduce the risk120.
sensitizers belong in both categories. However, there are
some important causes of asthma symptomssuch as air The hygiene hypothesis of asthma suggests that
pollution and some allergenswhich have not been clearly exposure to infections early in life influences the
ED
linked to the development of asthma. Risk factors that cause development of a childs immune system along a
asthma symptoms are discussed in detail in Chapter 4.2. nonallergic pathway, leading to a reduced risk of
asthma and other allergic diseases. Although the hygiene
T
Allergens. Although indoor and outdoor allergens are well hypothesis continues to be investigated, this mechanism
GH
known to cause asthma exacerbations, their specific role in may explain observed associations between family size,
the development of asthma is still not fully resolved. Birth- birth order, day-care attendance, and the risk of asthma.
cohort studies have shown that sensitization to house dust For example, young children with older siblings and those
RI
mite allergens, cat dander, dog dander38,39, and Aspergillus who attend day care are at increased risk of infections,
mold40 are independent risk factors for asthma-like but enjoy protection against the development of allergic
PY
symptoms in children up to 3 years of age. However, the diseases, including asthma later in life57-59.
relationship between allergen exposure and sensitization in
CO
OD
infections can then influence the development of allergic Asthma is the most common occupational respiratory
sensitization, and interactions can occur when individuals disorder in industrialized countries69. Occupations
are exposed simultaneously to both allergens and viruses. associated with a high risk for occupational asthma include
PR
farming and agricultural work, painting (including spray
Occupational sensitizers. Over 300 substances have been painting), cleaning work, and plastic manufacturing62.
associated with occupational asthma61-65, which is defined
RE
as asthma caused by exposure to an agent encountered Most occupational asthma is immunologically mediated
in the work environment. These substances include highly and has a latency period of months to years after the onset
reactive small molecules such as isocyanates, irritants that of exposure70. IgE-mediated allergic reactions and cell-
OR
may cause an alteration in airway responsiveness, known mediated allergic reactions are involved71, 72.
immunogens such as platinum salts, and complex plant
and animal biological products that stimulate the production Levels above which sensitization frequently occurs
of IgE (Figure 1-3). have been proposed for many occupational sensitizers.
R
However, the factors that cause some people but not
TE
others to develop occupational asthma in response to
others to develop occupational asthma in response to the
Figure 1-3. Examples of Agents Causing Asthma in the same exposures are not well identified. Very high
Selected Occupations* same exposures are not well identified. Very high
exposures to inhaled irritants may cause irritant induced
AL
exposures to inhaled irritants may cause irritant induced
asthma (formerly called the reactive airways dysfunctional
Occupation/occupational field Agent asthma (formerly called the reactive airways dysfunctional
syndrome) even in non-atopic persons. Atopy and
Animal and Plant Proteins syndrome) even in non-atopic persons. Atopy and
tobacco smoking may increase the risk of occupational
Bakers Flour, amylase Ttobacco smoking may increase the risk of occupational
sensitization, but screening individuals for atopy is of
sensiti ation, but screening individuals for atopy is of
NO
Dairy farmers Storage mites
limited value in preventing occupational asthma73.73The
Detergent manufacturing Bacillus subtilis en
enzymes
ymes limited value in preventing occupational asthma . The
Electrical soldering Colophony (pine resin) most important method of preventing occupational asthma
most important method of preventing occupational asthma
Farmers Soybean dust is elimination or reduction of exposure to occupational
is elimination or reduction of exposure to occupational
sensitizers.
O
Laxative manufacturing Ispaghula, psyllium less responsive to treatment with inhaled and
responsive to treatment with inhaled74,124 and systemic75
Poultry farmers Poultry mites, droppings, feathers systemic glucocorticosteroids, and reduces the likelihood
74
glucocorticosteroids, and75reduces the likelihood of asthma
Research workers, veterinarians Locusts, dander, urine proteins of asthma being controlled .
RI
Sawmill workers, carpenters Wood dust (western red cedar, oak, mahogany, being controlled76.
ebrawood, redwood, Lebanon cedar, African
maple, eastern white cedar) Exposure to tobacco smoke both prenatally135,136 and
TE
Organic chemicals
studies of lung function immediately after birth have shown
Automobile painting Ethanolamine, dissocyanates immediately after birth have shown that maternal smoking
that maternal smoking during pregnancy has an influence 37
Hospital workers Disinfectants (sulfathia
(sulfathiazole,
ole, chloramines, during pregnancy has an influence on lung development .
formaldehyde, glutaraldehyde), latex on lung development37. Furthermore, infants of smoking
T
cimetidine
illnesses in the first year of life79. In contrast, there is little
Rubber processing Formaldehyde, ethylene diamine, phthalic anhydride In contrast, there is little evidence (based on meta-
evidence (based on metaanalysis) that maternal smoking
Plastics industry Toluene dissocyanate, hexamethyl dissocyanate, analysis) that maternal smoking during pregnancy has an
dephenylmethyl isocyanate, phthalic anhydride, during pregnancy has an effect 78on allergic sensitization78.
effect on allergic sensiti ation . Exposure to
RI
*See http6//www.bohrf.org.uk for a comprehensive list of known sensitizing agents illnesses 81in infancy and childhood81.
infancy and childhood82.
Occupational asthma arises predominantly in adults66, 67,
outdoor/indoor air pollution. The role of outdoor air
CO
OD
Mast cells: Activated mucosal mast cells release
infants fed formulas of intact cow's milk or soy protein
lung function 83
, but the relationship of this loss of have to
function bronchoconstrictor mediators (histamine, cysteinyl leukotrienes,
a higher incidence of whee ing illnesses in early childhood
the development of asthma is not known. prostaglandin D2)92. These cells are activated by allergens
compared with those fed breast milk 88. through high-affinity IgE receptors, as well as by osmotic stimuli
PR
Outbreaks of asthma exacerbations have been shown to (accounting for exercise-induced bronchoconstriction). Increased
Some
occurdata also suggest
in relationship that certainlevels
to increased characteristics of
of air pollution, mast cell numbers in airway smooth muscle may be linked to
airway hyperresponsiveness93.
Western
and thisdiets,
may be such as increased
related use of
to a general processed
increase in the foods
level
RE
and decreasedor
of pollutants antioxidant
to specific (in allergens
the form ofto fruits and individuals
which vegetables), Eosinophils, present in increased numbers in the airways,
increased n-6 polyunsaturated
are sensitized 84-86
. However, fatty acidof(found
the role in margarine
pollutants in release basic proteins that may damage airway epithelial cells.
and
the vegetable
development oil), of
and decreased
asthma is lessn-3 polyunsaturated
well defined. Similar They may also have a role in the release of growth factors and
OR
airway remodeling94.
fatty acid (found
associations havein oily
been fish) intakes have
observed contributed
in relation to indoor to
the recent increases
pollutants, e.g., smoke in asthma
and fumes and atopic
from gas disease
and biomass
89
. T lymphocytes, present in increased numbers in the airways,
fuels used for heating and cooling, molds, and cockroach release specific cytokines, including IL-4, IL-5, IL-9, and IL-13,
infestations. that orchestrate eosinophilic inflammation and IgE production by
R
MECHANISMS OF ASTHMA B lymphocytes95. An increase in Th2 cell activity may be due in
TE
part to a reduction in regulatory T cells that normally inhibit Th2
Diet. The role of diet, particularly breast-feeding, in relation cells. There may also be an increase in inKT cells, which release
to the development
Asthma of asthma
is an inflammatory has of
disorder been
the extensively studied
airways, which large amounts of T helper 1 (Th1) and Th2 cytokines96.
involves several inflammatory cells and multiple mediators of
and, in general, the data reveal that infants fed formulas
AL
Dendritic cells sample allergens from the airway surface and
intact
that cows
result milk or soy protein
in characteristic have a higherchanges
pathophysiological incidence
21,90 of
. migrate to regional lymph nodes, where they interact with
In ways that are87still not well understood, this pattern ofthose
wheezing illnesses in early childhood compared with regulatory T cells and ultimately stimulate production of Th2
fed breast milk .
inflammation is strongly associated with airway hyper-
responsiveness and asthma symptoms.
T
cells from na ve T cells97.
NO
Macrophages are increased in number in the airways and may
Some data also suggest that certain characteristics
be activated by allergens through low-affinity IgE receptors to
of Western
Airway diets, suchInas
Inflammation increased use of processed
Asthma release inflammatory mediators and cytokines that amplify the
foods and decreased antioxidant (in the form of fruits and inflammatory response98.
vegetables), increased n-6 polyunsaturated fatty and
acid
O
The clinical spectrum of asthma is highly variable, Neutrophil numbers are increased in the airways and sputum of
different cellular patterns have been observed, but the n-3
(found in margarine and vegetable oil), and decreased
patients with severe asthma and in smoking asthmatics, but the
-D
polyunsaturated
presence of airwayfatty acid (found
inflammation in oily fish)
remains intakes have
a consistent pathophysiological role of these cells is uncertain and their
contributed
feature. The to the recent increases in asthma and atopic
airway inflammation in asthma is persistent increase may even be due to glucocorticosteroid therapy99 .
disease 88
.
even though symptoms are episodic, and the relationship
AL
between
diet. Thethe roleseverity
of diet,ofparticularly
asthma and the intensity of
breast-feeding, in
MECHANISMS OF
relation to the development of asthma has. been
inflammation is not clearly ASTHMA
established 91,92
The Figure
Figure 1-4:
1-5: Inflammatory CellsCells
Airway Structural in Asthmatic
Involved Airways
in the
Pathogenesis of Asthma
inflammationstudied
extensively affectsand,all airways
in general, including
the data in most patients
RI
prostaglandin
express multipleD2)inflammatory
93
. These cells are activated
proteins by allergens
in asthma, and release
that result
The patternwith in characteristic
of inflammation pathophysiological
in the airways appears to be .
changes 89
compared those fed breast milk 88
. through high-affinity
cytokines, chemokines, IgE and
receptors, as well asViruses
lipid mediators. by osmotic
and stimuli
air
In ways
similar thatclinical
in all are still not well
forms understood,
of asthma, whether thisallergic,
pattern of (accounting for exercise-induced
pollutants interact bronchoconstriction). Increased
with epithelial cells.
MA
inflammation
non-allergic,
Some data also is strongly
or aspirin-induced,associated
suggest that certain and at with
all ages. hyper-
airway
characteristics of mast cell numbers in airway smooth muscle may be linked to
responsiveness and asthma symptoms. Airwayhyperresponsiveness
airway smooth muscle cells 94
. express similar inflammatory
Western diets, such as increased use of processed foods proteins to epithelial cells100.
inflammatory
and cells. The(incharacteristic
decreased antioxidant the form of fruits pattern of
and vegetables), Eosinophils, present in increased numbers in the airways,
Airway Inflammation
inflammation
increased n-6 found In Asthma
in allergic
polyunsaturated diseases is seenininmargarine
fatty acid (found asthma, Endothelial
release basiccells of the
proteins bronchial
that circulation
may damage play
airway a role incells.
epithelial
ED
89
but the
(Th2), presence
which release of mediators
airway inflammation
that contribute remains
to a involved in airway remodeling.
release specific cytokines, including IL-4, IL-5, IL-9, and IL-13,
GH
consistent(Figure
symptoms feature.1-4).The Structural
airway inflammation
cells of theinairwaysasthma that orchestrate
Airway nerves are eosinophilic inflammation
also involved. and IgE
Cholinergic production
nerves may be by
also produce inflammatory mediators, and contributeand
is persistent even though symptoms are episodic, to the B lymphocytes
activated
96
. An
by reflex increase
triggers in Th2
in the cell activity
airways and causemay be due in
the relationship
persistence between the
of inflammation in severity
various ways of asthma(Figureand1-5).
the part to a reduction inand
bronchoconstriction regulatory
mucus T cells thatSensory
secretion. normallynerves,
inhibit Th2
RI
involves
the upper several inflammatory
respiratory tract and cells
nose
now recogni ed to be involved in asthma and mediate the and butmultiple
its mediators
physiological cough andcells
Dendritic chestsample
tightness, and may
allergens fromrelease inflammatory
the airway surface and
that result inmost
characteristic pathophysiological
the airways103changes .
neuropeptides .
21,90 101
effects
complex are
inflammatory pronounced
response in
in medium-sized bronchi.
(Figure 1-6). migrate to regional lymph nodes, where they interact with
In ways that are still not well understood, this pattern of regulatory T cells and ultimately stimulate production of Th2
CO
E
in asthma (Figure 1-8).
and macrophage-derived
Cysteinyl leukotrienes chemokines (MDC) recruit Th2 cells.
are potent bronchoconstrictors and Figure 1-8: Airway Narrowing in Asthma
UC
proinflammatory mediators mainly derived from mast cells and eosinophils. Pathophysiology
Cysteinyl
Figure leukotrienes are potent bronchoconstrictors and
Figure
They are 1-6:
1-6:
the only Key
Key Mediators
Mediators
mediator whose of of Asthma
Asthma
inhibition has been associated Figure 1-8: Airway Narrowing in Asthma
proinflammatory mediators mainly derived from mast cells and eosinophils. Airway smooth muscle contraction in response to multiple
with an improvement in lung function and asthma symptoms105.
They are the only mediator whose inhibition has been associated bronchoconstrictor
Airway narrowing mediators
is the andcommon
final neurotransmitters
pathway is leading
the to
Chemokines
Chemokines are important in the recruitment
recruitment of of inflammatory Airway smooth muscle contraction in response to multiple
OD
are important in the inflammatory
with an improvement
Cytokines orchestrate in lung theare function
inflammatory and asthma
response symptoms .and predominantand
mechanism of airway narrowing and is largely
in in asthma 105
cells
cells into
into the
the airways
airways and and are mainly expressed
mainly expressed in airway
airway symptoms physiological changes in asthma.
bronchoconstrictor mediators and neurotransmitters is the Several
determine its severity 106
. Key cytokines include IL-1 [ and TNF-oc, reversed by bronchodilators.
epithelial
Cytokines cells
cells .. Eotaxin
epithelial orchestrate 104
102
Eotaxin is
is relatively
relatively selective
the inflammatory responsefor
selective forineosinophils,
asthma and
eosinophils, factors contribute
predominant mechanismto the development
of airway narrowingof airway
and narrowing
is largely
which
whereas amplify
thymus the andinflammatory
and response,
.activation-regulated and GM-CSF,
chemokines which
[ and(TARC) reversed by bronchodilators.
whereas
determine thymus
its severity 106 activation-regulated
Key cytokines include chemokines
IL-1 (TARC)
TNF-oc, inAirway edema
asthma is due1-8).
(Figure to increased microvascular leakage in
PR
prolongs
and
and eosinophil survival
macrophage-derived
macrophage-derived in the airways.
chemokines
chemokines (MDC)
(MDC) Th2-derived
recruit
recruit Th2
Th2 cytokines
cells.
cells. response to inflammatory mediators. This may be particularly
which amplify the inflammatory response, and GM-CSF, which Airway edema is due to increased microvascular leakage in
include IL-5, which is required for eosinophil differentiation and important during acute exacerbations.
prolongs
Cysteinyl eosinophil
leukotrienes survival arein the
potent airways. Th2-derived
bronchoconstrictors cytokines
and response
Cysteinyl
survival;
include
IL-4,leukotrienes
IL-5, which
which is important
is required
are potent for bronchoconstrictors
forderived
Th2 cell differentiation;
eosinophil differentiation
andand
and Figureto1-8: inflammatory mediators. This
Airway Narrowing inmay be particularly
Asthma
proinflammatory
proinflammatory
IL-13, needed for mediators
mediators
IgE formation. mainly
mainly derived from
from mastmast cells and
cells and eosinophils.
eosinophils. important during acute
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normal person. In turn, this airway narrowing leads to
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Figure 1-9: Mechanisms of
of Airway
Airway Hyperresponsiveness
Hyperresponsiveness Smoking and asthma. Tobacco smoking makes
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Excessive contraction
Excessive contraction of of airway
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113
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75. Pedersen SE, Bateman ED, Bousquet J, Busse WW, Yoxall S, asthma. J Allergy Clin Immunol 2005;115(6):1109-17.
Clark TJ. Determinants of response to fluticasone propionate
and salmeterol/fluticasone propionate combination in the 89. Tattersfield AE, Knox AJ, Britton JR, Hall IP. Asthma. Lancet
Gaining Optimal Asthma controL study. J Allergy Clin Immunol 2002;360(9342):1313-22.
O
2007;120:1036-42.
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78. Kulig M, Luck W, Lau S, Niggemann B, Bergmann R, Klettke U, immunoregulatory cells: recent advances. Annu Rev Immunol
et al. Effect of pre-and postnatal tobacco smoke exposure on 2005;23:749-86.
specific sensitization to food and inhalant allergens during the
MA
first 3 years of life. Multicenter Allergy Study Group, Germany. 93. Robinson DS. The role of the mast cell in asthma: induction
Allergy 1999;54(3):220-8. of airway hyperresponsiveness by interaction with smooth
muscle? J Allergy Clin Immunol 2004;114(1):58-65.
79. Dezateux C, Stocks J, Dundas I, Fletcher ME. Impaired airway
ED
function and wheezing in infancy: the influence of maternal 94. Kay AB, Phipps S, Robinson DS. A role for eosinophils in
smoking and a genetic predisposition to asthma. Am J Respir airway remodelling in asthma. Trends Immunol 2004;25(9):477
Crit Care Med 1999;159(2):403-10.
T
80. Nafstad P, Kongerud J, Botten G, Hagen JA, Jaakkola JJ. in the pathogenesis of asthma. J Allergy Clin Immunol
The role of passive smoking in the development of bronchial 2003;111(3):450-63.
obstruction during the first 2 years of life. Epidemiology
1997;8(3):293-7. 96. Akbari O, Faul JL, Hoyte EG, Berry GJ, Wahlstrom J,
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81. Environmental tobacco smoke: a hazard to children. American Kronenberg M, et al. CD4+ invariant T-cell-receptor+
Academy of Pediatrics Committee on Environmental Health. natural killer T cells in bronchial asthma. N Engl J Med
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62S.
98. Peters-Golden M. The alveolar macrophage: the forgotten cell
in asthma. Am J Respir Cell Mol Biol 2004;31(1):3-7. 113. Newson R, Strachan D, Archibald E, Emberlin J, Hardaker
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P, Collier C. Acute asthma epidemics, weather and pollen in
99. Wenzel S. Mechanisms of severe asthma. Clin Exp Allergy England, 1987-1994. Eur Respir J 1998;11(3):694-701.
2003;33(12):1622-8.
114. Tan WC. Viruses in asthma exacerbations. Curr Opin Pulm
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100. Chung KF. Airway smooth muscle cells: contributing to Med 2005;11(1):21-6.
and regulating airway mucosal inflammation? Eur Respir J
2000;15(5):961-8. 115. Calhoun WJ. Nocturnal asthma. Chest 2003;123(3
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Suppl):399S-405S.
101. Groneberg DA, Quarcoo D, Frossard N, Fischer A. Neurogenic
mechanisms in bronchial inflammatory diseases. Allergy 116. Bumbacea D, Campbell D, Nguyen L, Carr D, Barnes PJ,
2004;59(11):1139-52. Robinson D, et al. Parameters associated with persistent
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airflow obstruction in chronic severe asthma. Eur Respir J
102. Barnes PJ, Chung KF, Page CP. Inflammatory mediators of 2004;24(1):122-8.
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asthma: an update. Pharmacol Rev 1998;50(4):515-96. Miller
AL, Lukacs NW. Chemokine receptors: understanding their 117. Thomson NC, Chaudhuri R, Livingston E. Asthma and cigarette
role in asthmatic disease. Immunol Allergy Clin North Am smoking. Eur Respir J 2004;24(5):822-33.
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2004;24(4):667-83, vii.
118. Asher MI, Montefort S, Bjorksten B, Lai CK, Strachan DP,
103. Leff AR. Regulation of leukotrienes in the management of Weiland SK, Williams H; ISAAC Phase Three Study Group.
asthma: biology and clinical therapy. Annu Rev Med 2001;52:1-
14.
T Worldwide time trends in the prevalence of symptoms of
asthma, allergic rhinoconjunctivitis, and eczema in childhood:
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ISAAC Phases One and Three repeat multicountry cross-
104. Barnes PJ. Cytokine modulators as novel therapies for asthma. sectional surveys. Lancet 2006 Aug 26;368(9537):733-43.
Annu Rev Pharmacol Toxicol 2002;42:81-98.
119. Accordini S, Bugiani M, Arossa W, Gerzeli S, Marinoni A,
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105. Ricciardolo FL, Sterk PJ, Gaston B, Folkerts G. Nitric oxide Olivieri M, Pirina P, Carro i L, Dallari R, De Togni A, de Marco
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in health and disease of the respiratory system. Physiol Rev R. Poor control increases the economic cost of asthma. A
2004;84(3):731-65. multicentre population-based study. Int Arch Allergy Immunol
2006;141(2):189-98.
106. Barnes PJ, Dweik RA, Gelb AF, Gibson PG, George SC,
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Grasemann H, et al. Exhaled nitric oxide in pulmonary 120. Leonardi-Bee J, Pritchard D, Britton J. Asthma and
diseases: a comprehensive review. Chest. 2010 current intestinal parasite infection: systematic review
Sep;138(3):682-92. and metaanalysis. Am J Respir Crit Care Med 2006 Sep
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1;174(5):514-23
107. James A. Airway remodeling in asthma. Curr Opin Pulm Med
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2005;11(1):1-6. 121. Lazarus SC, Chinchill VM, Rollings NJ, Boushey HA, Cherniack
R, Craig TJ et al.; NationalHeart Lung and Blood Institutes
108. Vignola AM, Mirabella F, Costanzo G, Di Giorgi R, Gjomarkaj Asthma Clinical Research Network Smoking affects response
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M, Bellia V, et al. Airway remodeling in asthma. Chest to inhaled corticosteroids or leukotriene receptor antagonists in
2003;123(3 Suppl):417S-22S. asthma. Am J Respir Crit Care Med 2007 Apr 15;175(8):783
109. Hirst SJ, Martin JG, Bonacci JV, Chan V, Fixman ED, Hamid 122. Chaudhuri R, Livingston E, McMahon AD, Lafferty J, Fraser
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QA, et al. Proliferative aspects of airway smooth muscle. J I, Spears M, McSharry CP, Thomson NC. Effects of smoking
Allergy Clin Immunol 2004;114(2 Suppl):S2-17. cessation on lung function and airway inflammation in
smokers with asthma. Am J Respir Crit Care Med 2006 Jul
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110. Black JL. Asthma--more muscle cells or more muscular cells? 15;174(2):127-33.
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May 15.
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125. Ford ES. The Epidemiology of obesity and asthma. J Allergy
Clin Immunol 2005;115(5):897-909.
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126. Saint-Pierre P, Bourdin A, Chanez P, Daures JP, Godard P.
Are overweight asthmatics more difficult to control? Allergy
2006;61(1):79-84.
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127. Lavoie KL, Bacon SL, Labrecque M, Cartier A, Ditto B. Higher
BMI is associated with worse asthma control and quality of life
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but not asthma severity. Respir Med 2006;100(4):648-57.
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people with asthma: exploring an asthma-obesity interaction.
Chest. 2010 Jun;137(6):1316-23.
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129. Schaub B, von ME. Obesity and asthma, what are the links?
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130. Weiss ST, Shore S. Obesity and asthma: directions for
research. Am J Respir Crit Care Med 2004;169(8):963-8.
Metab 2005;19(4):547-66.
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133. OByrne PM, Lamm CJ, Busse WW, Tan WC, Pedersen S;
START Investigators Group. The effects of inhaled budesonide
on lung function in smokers and nonsmokers with mild
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134. Noal RB, Menezes AM, Macedo SE, Dumith SC. Childhood
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135. Cohen RT, Raby BA, Van Steen K, Fuhlbrigge AL, Celedon
JC, Rosner BA, Strunk RC, Zeiger RS, Weiss ST; Childhood
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AND
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CHAPTER
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DIAGNOSIS
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CLASSIFICATION
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E
E
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KEY POINTS: CLINICAL DIAGNOSIS
A clinical diagnosis of asthma is often prompted
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by symptoms such as episodic breathlessness, Medical History
wheezing, cough, and chest tightness.
Symptoms. A clinical diagnosis of asthma is often
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Measurements of lung function (spirometry or peak prompted by symptoms such as episodic breathlessness,
expiratory flow) provide an assessment of the wheezing, cough, and chest tightness1. Episodic symptoms
severity of airflow limitation, its reversibility, and its after an incidental allergen exposure, seasonal variability
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variability, and provide confirmation of the diagnosis of symptoms and a positive family history of asthma and
of asthma. atopic disease are also helpful diagnostic guides. Asthma
associated with rhinitis may occur intermittently, with the
Measurements of allergic status can help to identify patient being entirely asymptomatic between seasons or it
OR
risk factors that cause asthma symptoms in individual may involve seasonal worsening of asthma symptoms or
patients. a background of persistent asthma. The patterns of these
symptoms that strongly suggest an asthma diagnosis are
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Extra measures may be required to diagnose asthma variability; precipitation by non-specific irritants, such as
in children 5 years and younger and in the elderly, smoke, fumes, strong smells, or exercise; worsening at
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and occupational asthma. night; and responding to appropriate asthma therapy. In
some sensitized individuals, asthma may be exacerbated
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For patients with symptoms consistent with by seasonal increases in specific aeroallergens2. Examples
asthma,but normal lung function, measurement include Alternaria, and birch, grass, and ragweed pollens.
of airway responsiveness may help establish the
diagnosis. T
Useful questions to consider when establishing a diagnosis
of asthma are described in Figure 2-1.
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Asthma has been classified by severity in previous
reports. However, asthma severity may change over
time, and depends not only on the severity of the Figure 2-1. Questions to Consider in the Diagnosis
of Asthma
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-No nocturnal symptoms or awakening because Cough-variant asthma. Patients with cough-variant
of asthma asthma3 have chronic cough as their principal, if not only,
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-No (twice or less/week) need for reliever treatment symptom. It is particularly common in children, and is often
-Normal or near-normal lung function more problematic at night; evaluations during the day can
-No exacerbations be normal. For these patients, documentation of variability
in lung function or of airway hyperresponsiveness, and
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A correct diagnosis of asthma is essential if appropriate from so-called eosinophilic bronchitis in which patients
drug therapy is to be given. Asthma symptoms may be have cough and sputum eoinophils but normal indices of
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intermittent and their significance may be overlooked by lung function when assessed by spirometry and airway
patients and physicians, or, because they are non-specific, hyperresponsiveness5.
they may result in misdiagnosis (for example of wheezy
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bronchitis, COPD, or the breathlessness of old age). This Other diagnoses to be considered are cough-induced
is particularly true among children, where misdiagnoses by angiotensin-converting-enzyme (ACE) inhibitors,
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include various forms of bronchitis or croup, and lead to gastroesophageal reflux, postnasal drip, chronic sinusitis,
inappropriate treatment. and vocal cord dysfunction6.
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Exercise-induced bronchoconstriction typically develops asthma is usually based on the presence of characteristic
within 5-10 minutes after completing exercise (it rarely symptoms. However, measurements of lung function,
occurs during exercise). Patients experience typical asthma and particularly the demonstration of reversibility of
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symptoms, or sometimes a troublesome cough, which lung function abnormalities, greatly enhance diagnostic
resolve spontaneously within 30-45 minutes. Some forms confidence. This is because patients with asthma
of exercise, such as running, are more potent triggers7. frequently have poor recognition of their symptoms and
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Exercise-induced bronchoconstriction may occur in any poor perception of symptom severity, especially if their
climatic condition, but it is more common when the patient asthma is long-standing10 . Assessment of symptoms
is breathing dry, cold air and less common in hot, humid such as dyspnea and wheezing by physicians may also
OR
climates8. be inaccurate. Measurement of lung function provides
an assessment of the severity of airflow limitation, its
Rapid improvement of post-exertion symptoms after reversibility and its variability, and provides confirmation of
inhaled 2-agonist use, or their prevention by pretreatment the diagnosis of asthma. Although measurements of lung
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with an inhaled 2-agonist before exercise, supports a function do not correlate strongly with symptoms or other
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diagnosis of asthma. Some children with asthma present measures of disease control in either adults11 or children12,
only with exercise-induced symptoms. In this group, or these measures provide complementary information about
when there is doubt about the diagnosis, exercise testing different aspects of asthma control.
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is helpful. An 8-minute running protocol is easily performed
in clinical practice and can establish a firm diagnosis of Various methods are available to assess airflow limitation,
asthma9. but two methods have gained widespread acceptance for
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use in patients over 5 years of age. These are spirometry,
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Physical Examination particularly the measurement of forced expiratory volume in
1 second (FEV1) and forced vital capacity (FVC), and peak
Because asthma symptoms are variable, the physical expiratory flow (PEF) measurement.
examination of the respiratory system may be normal.
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The most usual abnormal physical finding is wheezing Predicted values of FEV1, FVC, and PEF based on age,
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on auscultation, a finding that confirms the presence of sex, and height have been obtained from population
airflow limitation. However, in some people with asthma, studies. These are being continually revised, and with the
wheezing may be absent or only detected when the person exception of PEF for which the range of predicted values is
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exhales forcibly, even in the presence of significant airflow too wide, they are useful for judging whether a given value
limitation. Occasionally, in severe asthma exacerbations, is abnormal or not. If precision is needed, for example,
wheezing may be absent owing to severely reduced airflow in the conduct of a clinical trial, use of a more rigorous
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and ventilation. However, patients in this state usually have definition (lower limit of normal -LLN) should be considered.
other physical signs reflecting the exacerbation and its
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severity, such as cyanosis, drowsiness, difficulty speaking, The terms reversibility and variability refer to changes in
tachycardia, hyperinflated chest, use of accessory muscles, symptoms accompanied by changes in airflow limitation
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hyperinflation result from patients breathing at a higher example after 200-400 ug salbutamol (albuterol)13or
lung volume in order to increase outward retraction of more sustained improvement over days or weeks after the
the airways and maintain the patency of smaller airways introduction of effective controller treatment such as inhaled
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(which are narrowed by a combination of airway smooth glucocorticosteroids13 . Variability refers to improvement or
GH
muscle contraction, edema, and mucus hypersecretion). deterioration in symptoms and lung function occurring over
The combination of hyperinflation and airflow limitation in time. Variability may be experienced over the course of one
an asthma exacerbation markedly increases the work of day (when it is called diurnal variability), from day to day,
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during a forced expiratory maneuver using a spirometer. variability is the minimum morning pre-bronchodilator
Recommendations for the standardization of spirometry PEF over 1 week, expressed as a percent of the recent
have been published13-15. The degree of reversibility in best (Min%Max) (Figure 2-2)19. This latter method has
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FEV1 which indicates a diagnosis of asthma is generally been suggested to be the best PEF index of airway lability
accepted as 12% and 200 ml from the pre-bronchodilator for clinical practice because it requires only a once-daily
value13. However most asthma patients will not exhibit reading, correlates better than any other index with airway
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reversibility at each assessment, particularly those on hyperresponsiveness, and involves a simple calculation.
treatment, and the test therefore lacks sensitivity. Repeated
testing at different visits is advised. Figure 2-2. Measuring PEF Variability*
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Spirometry is reproducible, but effort-dependent. Therefore, Inhaled glucocorticosteroids
commenced
proper instructions on how to perform the forced expiratory 800
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value of three recordings taken. As ethnic differences in 700
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spirometric values have been demonstrated, appropriate 600
PEF L/min
500
established for each patient. The normal range of values
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is wider and predicted values are less reliable in young 400
people (< age 20) and in the elderly (> age 70). Because 300
Peak expiratory flow measurements are made using *PEF chart of a 27-year-old man with long-standing, poorly controlled asthma, before
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and after the start of inhaled glucocorticosteroid treatment. With treatment, PEF
a peak flow meter and can be an important aid in both levels increased, and PEF variability decreased, as seen by the increase in Min%Max
diagnosis and monitoring of asthma. Modern PEF meters (lowest morning PEF/highest PEF %) over 1 week.
patients to use in home settings for day-to-day objective PEF monitoring is valuable in a subset of asthmatic
measurement of airflow limitation. However, measurements patients and can be helpful:
of PEF are not interchangeable with other measurements
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of lung function such as FEV1 in either adults16 or children17. To confirm the diagnosis of asthma. Although
PEF can underestimate the degree of airflow limitation, spirometry is the preferred method of documenting
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particularly as airflow limitation and gas trapping worsen. airflow limitation, a 60 L/min (or 20% or more of pre-
Because values for PEF obtained with different peak flow bronchodilator PEF) improvement after inhalation of
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meters vary and the range of predicted values is too wide, a bronchodilator20, or diurnal variation in PEF of more
PEF measurements should preferably be compared to the than 20% (with twice daily readings, more than 10% 21)
patients own previous best measurements18 using his/her suggests a diagnosis of asthma.
own peak flow meter. The previous best measurement is
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usually obtained when the patient is asymptomatic or on full To improve control of asthma, particularly in patients
treatment and serves as a reference value for monitoring with poor perception of symptoms10. Asthma
the effects of changes in treatment. management plans which include self-monitoring
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Careful instruction is required to reliably measure PEF have been shown to improve asthma outcomes22. It is
because PEF measurements are effort-dependent. Most easier to discern the response to therapy from a PEF
commonly, PEF is measured first thing in the morning chart than from a PEF diary, provided the same chart
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before treatment is taken, when values are often close to Inhaled glucocorticosteroids
800
700
600
commenced
format is consistently used23.
PEF L/min
500
400
300
200
310/700 500/710 620/720
100
= 44% = 70% = 86%
0
-1 0 1 2 3 4 5 6 7 8 9 10
Weeks of Inhaled Glucocorticosteroid Treatment
their lowest, and last thing at night when values are usually
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periods of suspected exposure to risk factors in or hypertonic saline-induced sputum for eosinophilic or
the home or workplace, or during exercise or other neutrophilic inflammation30. In addition, levels of exhaled
activities that may cause symptoms, and during nitric oxide (FeNO)31 and carbon monoxide (FeCO)32
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periods of non-exposure. have been suggested as non-invasive markers of airway
inflammation in asthma. Levels of FeNO are elevated
Measurement of airway responsiveness. For patients with in people with asthma (who are not taking inhaled
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symptoms consistent with asthma, but normal lung function, glucocorticosteroids) compared to people without asthma,
measurements of airway responsiveness to direct airway yet these findings are not specific for asthma. Neither
challenges such as inhaled methacholine and histamine sputum eosinophilia nor FeNO have been evaluated
OR
or indirect airway challenges such as inhaled mannitol83 prospectively as an aid in asthma diagnosis, but these
or exercise challenge may help establish a diagnosis of measurements are being evaluated for potential use in
asthma24 . Measurements of airway responsiveness reflect determining optimal treatment33,34,56, although it has been
the sensitivity of the airways to factors that can cause shown that the use of FeNO as a measure of asthma
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asthma symptoms, sometimes called triggers, and the control does not improve control or enable reduction in
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test results are usually expressed as the provocative dose of inhaled glucocorticosteroid55.
concentration (or dose) of the agonist causing a given fall
(often 20%) in FEV1 (Figure 2-3). These tests are sensitive Measurements of allergic status. Because of the strong
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for a diagnosis of asthma, but have limited specificity25. association between asthma and allergic rhinitis, the
This means that a negative test can be useful to exclude a presence of allergies, allergic diseases, and allergic rhinitis
diagnosis of persistent asthma in a patient who is not taking in particular, increases the probability of a diagnosis of
inhaled glucocorticosteroid treatment, but a positive test T
asthma in patients with respiratory symptoms. Moreover,
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does not always mean that a patient has asthma26. This is the presence of allergies in asthma patients (identified by
because airway hyperresponsiveness has been described skin testing or measurement of specific IgE in serum) can
in patients with allergic rhinitis27 and in those with airflow help to identify risk factors that cause asthma symptoms in
limitation caused by conditions other than asthma, such individual patients. Deliberate provocation of the airways
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as cystic fibrosis28, bronchiectasis, and chronic obstructive with a suspected allergen or sensitizing agent may be
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pulmonary disease (COPD)29. helpful in the occupational setting, but is not routinely
recommended, because it is rarely useful in establishing a
Figure 2-3. Measuring Airway Responsiveness* diagnosis, requires considerable expertise and can result in
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life-threatening bronchospasm35.
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the presence of one major risk factor (parental history
The differential diagnosis in patients with suspected asthma of asthma or eczema) or two of three minor risk factors
differs among different age groups: infants, children, young (eosinophilia, wheezing without colds, and allergic rhinitis)
PR
adults, and the elderly. has been shown to predict the presence of asthma in later
childhood38. However, treating children at risk with inhaled
Children 5 years and Younger glucocorticosteroids has not been shown to affect the
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development of asthma40.
In early life, the presence of sensitization to common
allergens, atopy, is a major risk factor for subsequent Alternative causes of recurrent wheezing must be
OR
development of asthma. In addition, atopy also predicts that considered and excluded. These include:
asthma may be more severe when it does develop.
Chronic rhino-sinusitis
The diagnosis of asthma in early childhood is challenging Gastroesophageal reflux
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and has to be based largely on clinical judgment and an Recurrent viral lower respiratory tract infections
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assessment of symptoms and physical findings. Since Cystic fibrosis
the use of the label asthma for wheezing in children has Bronchopulmonary dysplasia
important clinical consequences, it must be distinguished Tuberculosis
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from other causes persistent and recurrent wheeze. Congenital malformation causing narrowing of the
intrathoracic airways
Episodic wheezing and cough is very common even in Foreign body aspiration
children who do not have asthma and particularly in those T
Primary ciliary dyskinesia syndrome
NO
under age 336. Three categories of wheezing have been Immune deficiency
described in children 5 years and younger: Congenital heart disease
Transient early wheezing, which is often outgrown Neonatal onset of symptoms (associated with failure to
O
in the first 3 years. This is often associated with thrive), vomiting-associated symptoms, or focal lung or
prematurity and parental smoking.
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children in the next category of late onset wheezing/ glucocorticosteroids. Marked clinical improvement during
asthma, have no family history of atopy. The the treatment and deterioration when treatment is stopped
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symptoms normally persist through school age and supports a diagnosis of asthma. Use of spirometry and
are still present at age 12 in a large proportion of other measures recommended for older children and
children. The cause of the episode is usually the
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and into adult life38, 39. They typically have an Older Children and Adults
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COPD symptoms before beginning employment; or a definite
worsening of asthma after employment. A relationship
Non-obstructive forms of lung disease (e.g., diffuse between symptoms and the workplace (improvement in
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parenchymal lung disease) symptoms away from work and worsening of symptoms
Non-respiratory causes of symptoms (e.g., left on returning to work) can be helpful in establishing a link
ventricular failure) between suspected sensitizing agents and asthma45.
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Because asthma is a common disease, it can be found Since the management of occupational asthma frequently
in association with any of the above diagnoses, which requires the patient to change his or her job, the diagnosis
OR
complicates the diagnosis as well as the assessment of carries considerable socioeconomic implications and it is
severity and control. This is particularly true when asthma important to confirm the diagnosis objectively. This may
is associated with hyperventilation, vocal cord dysfunction, be achieved by specific bronchial provocation testing46,
or COPD. Careful assessment and treatment of both the although there are few centers with the necessary facilities
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asthma and the comorbidity is often necessary to establish for specific inhalation testing. Another method is to monitor
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the contribution of each to a patients symptoms. PEF at least 4 times a day for a period of 2 weeks when
the patient is working and for a similar period away from
The Elderly work47-50. The increasing recognition that occupational
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asthma can persist, or continue to deteriorate, even
Undiagnosed asthma is a frequent cause of treatable in the absence of continued exposure to the offending
respiratory symptoms in the elderly, and the frequent agent51, emphasizes the need for an early diagnosis so
presence of comorbid diseases complicates the diagnosis. T
that appropriate strict avoidance of further exposure and
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Wheezing, breathlessness, and cough caused by left pharmacologic intervention may be applied. Publications
ventricular failure is sometimes labeled cardiac asthma, provide an evidence-based approach to the identification
a misleading term, the use of which is discouraged. of occupational asthma and compare specific inhalation
The presence of increased symptoms with exercise and challenge testing with alternative tests for confirming the
O
and physical examination, combined with an ECG and Both asthma and COPD are major chronic obstructive
chest X-ray, usually clarifies the picture. In the elderly, airways diseases that involve underlying airway
distinguishing asthma from COPD is particularly difficult, inflammation. COPD is characterized by airflow limitation
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and may require a trial of treatment with bronchodilators that is not fully reversible, is usually progressive, and is
and/or oral/inhaled glucocorticosteroids. associated with an abnormal inflammatory response of
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control in the elderly are complicated by several factors: cigarette smoking) may develop fixed airflow limitation and
poor perception of symptoms, acceptance of dyspnea as a mixture of asthma-like inflammation and COPD-like
being normal in old age, and reduced expectations of inflammation. Thus, even though asthma can usually be
mobility and activity. distinguished from COPD, in some individuals who develop
ED
Asthma acquired in the workplace is a diagnosis that and asthma for use by primary health care professionals is
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Etiology
and the search for distinctive pathological or molecular
features that could explain these clinical patterns continues.
Many attempts have been made to classify asthma
Most work has been done on inflammatory phenotypes,
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according to etiology, particularly with regard to
identified using sputum induction. Patients with eosinophilic
environmental sensitizing agents. However, such a
and non-eosinophilic phenotypes have been shown to differ
classification is limited by the existence of patients in whom
in their clinical response to inhaled glucocorticosteroids59,60,
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no environmental cause can be identified. Despite this,
and at a group level, inflammatory markers may be
an effort to identify an environmental cause for asthma
predictive of risk of exacerbation after glucocorticosteroid
(for example, occupational asthma) should be part of
reduction61. Inflammatory phenotypes appear to be
the initial assessment to enable the use of avoidance
OR
moderately stable over time, although data are limited62,63.
strategies in asthma management. Describing patients as
At present, since few clinicians have access to qualified
having allergic asthma is usually of little benefit in guiding
sputum laboratories, identification of the inflammatory
treatment, unless a single specific trigger agent can be
phenotype is most likely to be useful for patients with
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identified.
severe asthma or in the context of research.
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Phenotype
Asthma Control
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There is increasing awareness of heterogeneity in the
Asthma control may be defined in a variety of ways. In
manifestations of asthma and in its response to treatment.
lay terms, control may indicate disease prevention, or
This is often described in terms of phenotypes57,58, the
even cure. However, in asthma, where neither of these
characteristics which result from the interaction between a T
are realistic options at present, it refers to control of the
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patients genetic makeup and their environment. Several
manifestations of disease. The aim of treatment should be
Daytime symptoms None (twice or More than twice/week Three or more features of
less/week) partly controlled
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asthma*
Limitation of activities None Any
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B. Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side-effects)
GH
Features that are associated with increased risk of adverse events in the future include:
Poor clinical control, frequent exacerbations in past year*, ever admission to critical care for asthma, low
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goal. Therefore, the assessment of asthma control should be demonstrated but will likely become evident in coming
include not only control of the clinical manifestations years. All of these tools are subject to copyright restrictions,
(symptoms, night waking, reliever use, activity limitation, and some have fees associated with their use in research.
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lung function), but also control of the expected future risk
to the patient such as exacerbations, accelerated decline There is considerable interest in controlling not only the
in lung function, and side-effects of treatment. In general, clinical manifestations of asthma, but also the inflammatory
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the achievement of good clinical control of asthma leads and patho-physiological features of the disease. There
to reduced risk of exacerbations65. However, certain is evidence that reducing inflammation with controller
patients may continue to experience exacerbations in therapy achieves good clinical control and reduces the
OR
spite of adequate interval control. Smokers are less likely risk of exacerbations. In addition, inflammatory and patho-
to achieve control and remain at risk of exacerbations66. physiological markers may be predictors of future risk of
It should be noted that inhaled glucocorticosteroids both exacerbations and decline in lung function, independent
improve clinical control and reduce future risk, but some of the patients level of clinical control66,76. Biomarker-
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pharmacological agents are more effective in improving guided treatment appears, primarily, to be of value in
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features of clinical control, while others are relatively more asthma phenotypes in which there is dissociation between
effective at reducing exacerbations. Thus, for some patient measures of clinical control and airway inflammation. For
phenotypes, treatment may be selected to address the example, treatment based on the proportion of eosinophils
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predominant problem. in sputum has resulted in a reduction of exacerbations
or minimization of doses of inhaled glucocorticosteroids
Figure 2-4 describes the clinical characteristics of in patients with uncontrolled asthma in spite of moderate
Controlled, Partly Controlled and Uncontrolled asthma. This T
levels of treatment77,78.
NO
is a working scheme based on current opinion and has not
been formally validated. However, this classification has However, in primary care, because of the cost and/or
been shown to correlate well with the Asthma Control Test67 unavailability of tests such as endobronchial biopsy and
and with assessment of asthma control according to the measurement of sputum eosinophils and exhaled nitric
O
US National Expert Panel Report 3 guidelines68,69. In clinical oxide30-34, the current recommendation is that treatment
-D
practice, this classification should be used in conjunction should be aimed at controlling the clinical features of
with an assessment of the patients clinical condition and disease, including lung function abnormalities.
the potential risks and benefits of changing treatment.
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Asthma Severity
Several standardized measures for assessing clinical
control of asthma have been developed, which score the For patients not receiving inhaled glucocorticosteroid
RI
goals of treatment as continuous variables and provide treatment, previous GINA documents subdivided asthma
numerical values to distinguish different levels of control. by severity based on the level of symptoms, airflow
TE
Examples of validated instruments are the Asthma Control limitation, and lung function variability into four categories:
Questionnaire (ACQ) (www.qoltech.co.uk/Asthma1.htm)70, Intermittent, Mild Persistent, Moderate Persistent, or
MA
the Asthma Control Test (ACT) (www.asthmacontrol. Severe Persistent, although this classification was often
com)71, the Childhood Asthma Control Test (C-ACT)72, erroneously applied to patients already on treatment79.
the Asthma Therapy Assessment Questionnaire (ATAQ) A copy of this classification system is archived at
(www.ataqinstrument.com)73, and the Asthma Control www.ginasthma.org. It is important to recognize, however,
ED
Scoring System74. Few of these instruments include a that asthma severity involves both the severity of the
measure of lung function. They are being promoted for underlying disease and its responsiveness to treatment80.
use not only in research but for patient care as well, even Thus, asthma could present with severe symptoms and
T
in the primary care setting. Some are suitable for self- airflow obstruction, but become completely controlled with
GH
assessment of asthma control by patients75, and some low-dose treatment. In addition, severity is not a static
are available in many languages, on the Internet, and in feature of an individual patients asthma, but may change
paper form and may be completed by patients prior to, or over months or years. The main limitation of this previous
RI
during, consultations with their health care provider. They method of classification of asthma severity was its poor
have the potential to improve the assessment of asthma value in predicting what treatment would be required and
PY
control, providing a reproducible objective measure that what a patients response to that treatment might be. For
may be charted over time (week by week or month by this reason, an assessment of asthma control at initial
CO
OD
In view of these limitations, asthma severity is now by Chest Physicians. Chest 1998;114(2 Suppl Managing):133S-
consensus classified on the basis of the intensity of 81S.
treatment required to achieve good asthma control79,80.
PR
Mild asthma is asthma that can be well-controlled 7. Randolph C. Exercise-induced asthma: update on
with low intensity treatment such as low-dose inhaled pathophysiology, clinical diagnosis, and treatment. Curr Probl
glucocorticosteroids, leukotriene modifiers or cromones. Pediatr 1997;27(2):53-77.
RE
Severe asthma is asthma that requires high intensity
8. Tan WC, Tan CH, Teoh PC. The role of climatic conditions and
treatment, e.g. GINA Step 4, to maintain good control,
histamine release in exercise-induced bronchoconstriction. Ann
or where good control is not achieved despite high
Acad Med Singapore 1985;14(3):465-9.
OR
intensity treatment82. It is recognized that different asthma
phenotypes may have different levels of responsiveness to 9. Anderson SD. Exercise-induced asthma in children: a marker of
conventional treatment. As phenotype-specific treatment airway inflammation. Med J Aust 2002;177 Suppl:S61-3.
becomes available, asthma previously considered to be
R
severe could become mild. 10. Killian KJ, Watson R, Otis J, St Amand TA, OByrne PM.
TE
Symptom perception during acute bronchoconstriction. Am J
Terminology around asthma severity is confusing because Respir Crit Care Med 2000;162(2 Pt 1):490-6.
severity is also used to describe the magnitude of airway
AL
obstruction or the intensity of symptoms. Patients will often 11. Kerstjens HA, Brand PL, de Jong PM, Koeter GH, Postma DS.
perceive their asthma as severe if they have intense or Influence of treatment on peak expiratory flow and its relation to
frequent symptoms, but it is important to convey that this airway hyperresponsiveness and symptoms. The Dutch CNSLD
may merely represent inadequate treatment. Because the T Study Group. Thorax 1994;49(11):1109-15.
NO
terms control and severity are used in other contexts
12. Brand PL, Duiverman EJ, Waalkens HJ, van Essen-
in lay language, it is important that health professionals
Zandvliet EE, Kerrebijn KF. Peak flow variation in childhood
communicate clearly how the words are used in the context
asthma: correlation with symptoms, airways obstruction,
of asthma.
O
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causing occupational asthma. Eur Respir J 1997;10(11):2612- subtypes in asthma: assessment and identification using
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of occupational asthma from serial measurements of lung Bel EH. Consistency of sputum eosinophilia in difficult-to-
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51. Chan-Yeung M, MacLean L, Paggiaro PL. Follow-up study of T
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232 patients with occupational asthma caused by western red 64. Bateman ED, Boushey HA, Bousquet J, Busse WW, Clark TJ,
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52. Nicholson PJ, Cullinan P, Taylor AJ, Burge PS, Boyle C. study. Am J Respir Crit Care Med 2004;170:836-44.
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55. Szefler SJ, Mitchell H, Sorkness CA, Gergen PJ, OConnor GT, predictor of GINA guideline-defined asthma control: analysis
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57. Bel EH. Clinical phenotypes of asthma. Curr Opin Pulm Med clinical asthma control assessment tools and fractional exhaled
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P, Murray JJ, Pendergraft TB. Development of the asthma 83. Anderson SD. Indirect challenge tests: Airway
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72. Liu AH, Zeiger R, Sorkness C, Mahr T, Ostrom N, Burgess
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73. Vollmer WM, Markson LE, OConnor E, Sanocki LL, Fitterman
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74. Boulet LP, Boulet V, Milot J. How should we quantify asthma
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75. Schatz M, Mosen DM, Kosinski M, Vollmer WM, Magid DJ,
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76. van Rensen EL, Sont JK, Evertse CE, Willems LN, Mauad
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2005;172:837-41.
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77. Haldar P, Pavord ID, Shaw DE, Berry MA, Thomas M, Brightling
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79. Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW,
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81. Chen H, Gould MK, Blanc PD, Miller DP, Kamath TV, Lee
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ASTHMA RE
CHAPTER
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TREATMENTS
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E
E
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KEY POINTS: ASTHMA MEDICATIONS: ADULTS
OD
Medications to treat asthma can be classified as
controllers or relievers. Controllers are medications
Route of Administration
taken daily on a long-term basis to keep asthma
PR
under clinical control chiefly through their anti-
Asthma treatment for adults can be administered in
inflammatory effects. Relievers are medications
different waysinhaled, orally or parenterally (by
used on an as-needed basis that act quickly
subcutaneous, intramuscular, or intravenous injection).
RE
to reverse bronchoconstriction and relieve its
The major advantage of inhaled therapy is that drugs are
symptoms.
delivered directly into the airways, producing higher local
Asthma treatment can be administered in different concentrations with significantly less risk of systemic side
OR
waysinhaled, orally, or by injection. The major effects.
advantage of inhaled therapy is that drugs are
delivered directly into the airways, producing higher Inhaled medications for asthma are available as
R
local concentrations with significantly less risk of pressurized metered-dose inhalers (MDIs), breath-actuated
systemic side effects. MDIs, dry powder inhalers (DPIs), soft mist inhalers, and
TE
nebulized or wet aerosols* . Inhaler devices differ in
Inhaled glucocorticosteroids are the most effective their efficiency of drug delivery to the lower respiratory
controller medications currently available. tract, depending on the form of the device, formulation of
AL
medication, particle size, velocity of the aerosol cloud or
Rapid-acting inhaled 2-agonists are the medications plume (where applicable), and ease with which the device
of choice for relief of bronchoconstriction can be used by the majority of patients. Individual patient
and for the pretreatment of exercise-induced T
preference, convenience, and ease of use may influence
NO
bronchoconstriction, in both adults and children of not only the efficiency of drug delivery but also patient
all ages. adherence to treatment and long-term control.
Increased use, especially daily use, of reliever
O
medications taken daily on a long-term basis to keep change in efficacy at the same nominal dose2. However, for
asthma under clinical control chiefly through their anti- some glucocorticosteroids, the HFA formulations provide
inflammatory effects. They include inhaled and systemic an aerosol of smaller particle size that results in less oral
glucocorticosteroids, leukotriene modifiers, long- deposition (with associated reduction in oral side effects),
ED
acting inhaled 2-agonists in combination with inhaled and correspondingly greater lung deposition3-5. Clinicians
glucocorticosteroids, sustained-release theophylline, are advised to consult the package inserts of each product
to confirm the recommended dose equivalent to currently
T
30 ASTHMA TREATMENTS
*Information on various inhaler devices available can be found on the GINA Website
(http://www.ginasthma.org).
E
UC
Pressurized MDIs may be used by patients with asthma of clinical control follows within weeks to months in a
of any severity, including during exacerbations. Breath- proportion of patients14,15.
actuated aerosols may be helpful for patients who have
OD
difficulty using the press and breathe pressurized MDI6. Inhaled glucocorticosteroids differ in potency and
Soft mist inhalers appear to require less coordination. bioavailability, but because of relatively flat dose-response
Dry powder inhalers are generally easier to use, but they relationships in asthma relatively few studies have been
PR
require a minimal inspiratory flow rate and may prove able to confirm the clinical relevance of these differences191.
difficult for some patients. DPIs differ with respect to the Figure 3-1 lists approximately equipotent doses of different
fraction of ex-actuator dose delivered to the lung. For some inhaled glucocorticosteroids based upon the available
RE
drugs, the dose may need to be adjusted when switching efficacy literature, but the categorization into dosage
from an MDI6 to a DIP7. Nebulized aerosols are rarely categories does not imply that clear dose-response
indicated for the treatment of chronic asthma in adults8. relationships have been demonstrated for each drug.
OR
The efficacy of some products varies when administered
CONTROLLER MEDICATIONS via different inhaler devices16. Most of the benefit from
inhaled glucocorticosteroids is achieved in adults at
Inhaled glucocorticosteroids* relatively low doses, equivalent to 400 ug of budesonide
R
per day17. Increasing to higher doses provides little further
TE
Role in therapy -Inhaled glucocorticosteroids are currently benefit in terms of asthma control but increases the risk
the most effective anti-inflammatory medications for the of side effects17,18. However, there is marked individual
treatment of persistent asthma. Studies have demonstrated variability of responsiveness to inhaled glucocorticosteroids
AL
their efficacy in reducing asthma symptoms9, improving and because of this and the recognized poor adherence to
quality of life9, improving lung function9, decreasing airway treatment with inhaled glucocorticosteroids, many patients
hyperresponsiveness10, controlling airway inflammation11, will require higher doses to achieve full therapeutic benefit.
reducing frequency and severity of exacerbations12, and T
As tobacco smoking reduces the responsiveness to inhaled
NO
reducing asthma mortality13. However, they do not cure glucocorticosteroids, higher doses may be required in
asthma, and when they are discontinued deterioration patients who smoke240.
O
Figure 3-1. Estimated Equipotent Daily Doses of Inhaled Glucocorticosteriods for Adults
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Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
Beclomethasone dipropionate - CFC 200-500 >500-1000 >1000-2000
Beclomethasone dipropionate - HFA 100 - 250 >250 - 500 >500 - 1000
AL
NOTES:
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The most important determinant of approprioate dosing is the clinicians judgement of the patients response therapy. The clinician must monitor the patients response in terms
of clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose of medication should carefully be titrated to the minimum dose required to
GH
As CFC preparations are taken from the market, medication inserts for HFA preparations should be carefully reviewed by the clinician for the equivalent correct dosage.
PY
*In this section recommendations for doses of inhaled glococorticosteriods are given as /day budesonide
or equivalent, because a majority of the clinical literature on these medications uses this standard
CO
ASTHMA TREATMENTS 31
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UC
To reach clinical control, add-on therapy with another One difficulty in establishing the clinical significance of
class of controller is preferred over increasing the dose such adverse effects lies in dissociating the effect of
of inhaled glucocorticosteroids211. There is, however, high-dose inhaled glucocorticosteroids from the effect
OD
a clear relationship between the dose of inhaled of courses of oral glucocorticosteroids taken by patients
glucocorticosteroids and the prevention of severe acute with severe asthma. There is no evidence that use
exacerbations of asthma12, although there appear to of inhaled glucocorticosteroids increases the risk of
PR
be differences in response according to symptom/ pulmonary infections, including tuberculosis, and inhaled
inflammation phenotype212. Therefore, some patients with glucocorticosteroids are not contraindicated in patients with
severe asthma may benefit from long-term treatment with active tuberculosis33.
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higher doses of inhaled glucocorticosteroids.
Leukotriene modifiers.
Side effects: Local adverse effects from inhaled
OR
glucocorticosteroids include oropharyngeal candidiasis, Role in therapy -Leukotriene modifiers include cysteinyl-
dysphonia, and occasionally coughing from upper airway leukotriene 1 (CysLT1) receptor antagonists (montelukast,
irritation. For pressurized MDIs the prevalence of these pranlukast, and zafirlukast) and a 5-lipoxygenase
effects may be reduced by using certain spacer devices1. inhibitor (zileuton). Clinical studies have demonstrated
R
Mouth washing (rinsing with water, gargling, and spitting that leukotriene modifiers have a small and variable
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out) after inhalation may reduce oral candidiasis. The bronchodilator effect, reduce symptoms including cough34,
use of prodrugs that are activated in the lungs but not in improve lung function, and reduce airway inflammation
the pharynx (e.g., ciclesonide19 and beclometasone), and and asthma exacerbations35-37. They may be used as an
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new formulations and devices that reduce oropharyngeal alternative treatment for adult patients with mild persistent
deposition, may minimize such effects without the need for asthma38-40, and some patients with aspirin-sensitive
a spacer or mouth washing. asthma respond well to leukotriene modifiers41. However,
T
when used alone as controller, the effect of leukotriene
NO
Inhaled glucocorticosteroids are absorbed from the lung,
modifiers are generally less than that of low doses of
accounting for some degree of systemic bioavailability.
inhaled glucocorticosteroids, and, in patients already on
The risk of systemic adverse effects from an inhaled
inhaled glucocorticosteroids, leukotriene modifiers cannot
glucocorticosteroid depends upon its dose and potency,
substitute for this treatment without risking the loss of
O
glucocorticosteroids. Several comparative studies by patients with moderate to severe asthma44, and
have demonstrated that ciclesonide, budesonide, and may improve asthma control in patients whose asthma
fluticasone propionate at equipotent doses have less is not controlled with low or high doses of inhaled
RI
systemic effect20-23. Current evidence suggests that in glucocorticosteroids43,45-47. With the exception of one
adults, systemic effects of inhaled glucocorticosteroids are study that demonstrated equivalence in preventing
TE
not a problem at doses of 400 g or less budesonide or exacerbations48, several studies have demonstrated that
equivalent daily. leukotriene modifiers are less effective than long-acting
MA
in older adults, the relative risk of non-vertebral fractures recognized. Zileuton has been associated with liver
GH
increases by about 12% for each 1000 g/day increase in toxicity204, and monitoring of liver tests is recommended
the dose BDP or equivalent but that the magnitude of this during treatment with this medication. No association was
risk was considerably less than other common risk factors found between Churg-Strauss syndrome and leukotriene
RI
for fracture in the older adult213. Inhaled glucocorticosteroids modifiers after controlling for asthma drug use, although it
have also been associated with cataracts27,29 and glaucoma is not possible to rule out modest associations given that
PY
in cross-sectional studies28, but there is no evidence of Churg-Strauss syndrome is so rare and so highly correlated
posterior-subcapsular cataracts in prospective studies30-32. with asthma severity52.
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32 ASTHMA TREATMENTS
E
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Long-acting inhaled bronchodilators Tiotropium, a long-acting inhaled anticholinergic bronchodilator,
has been studied in adults with uncontrolled asthma
Role in therapy - Long-acting inhaled 2-agonists, and compared with salmeterol, doubling the dose of
OD
including formoterol and salmeterol, should not be used inhaled glucocorticosteroid and as add-on to inhaled
as monotherapy in asthma as these medications do glucocorticosteroids and salmeterol231,233. One study showed
not appear to influence airway inflammation in asthma. comparable bronchodilator effects with no significant
PR
They are most effective when combined with inhaled changes on asthma control232. Another study showed
glucocorticosteroids55,56,193, and this combination therapy that adding tiotropium to patients not controlled on inhaled
is the preferred treatment when a medium dose of inhaled glucocorticosteroids and long-acting 2-agonists improved
RE
glucocorticosteroid alone fails to achieve control of lung function but not symptoms233. The studies have been
asthma. The addition of long-acting inhaled 2-agonists relatively short-term and no effect on exacerbations has so far
to a daily regimen of inhaled glucocorticosteroids been reported. There are no data about these medications in
OR
improves symptom scores, decreases nocturnal asthma children.
symptoms, improves lung function, decreases the use of
rapid-acting inhaled 2-agonists57-59, reduces the number Side effects - Therapy with long-acting inhaled 2-
of exacerbations12,57-62, does not increase the risk of agonists causes fewer systemic adverse effectssuch as
R
asthma-related hospitalizations214, and achieves clinical cardiovascular stimulation, skeletal muscle tremor, and
TE
control of asthma in more patients, more rapidly, and at hypokalemiathan oral therapy. The regular use of rapid-
a lower dose of inhaled glucocorticosteroids than inhaled acting 2-agonists in both short and long acting forms may
glucocorticosteroids given alone63. lead to relative refractoriness to 2-agonists74. Based on
AL
data indicating a possible increased risk of asthma-related
This greater efficacy of combination treatment has led death associated with the use of salmeterol in a small
to the development of fixed combination inhalers that group of individuals75 long-acting 2-agonists should not be
deliver both glucocorticosteroid and long-acting 2-agonist T
used as a substitute for inhaled or oral glucocorticosteroids,
NO
simultaneously (fluticasone propionate plus salmeterol, and should only be used in combination with an appropriate
budesonide plus formoterol, mometasone plus formoterol, dose of inhaled glucocorticosteroid as determined by
beclometasone plus formoterol). Controlled studies a physician215,234. Some meta-analyses of studies of
have shown that delivering this therapy in a combination long-acting 2-agonists have shown numerically very
O
inhaler is as effective as giving each drug separately64,65. small increases in the number of deaths in patients
receiving long-acting 2-agonists in combination with
-D
this purpose may provide longer protection than rapid-acting formulations that are suitable for once-or twice-daily In
inhaled 2-agonists71. Salmeterol and formoterol provide a addition, combination inhalers containing formoterol and
similar duration of bronchodilation and protection against dosing. Data on the relative efficacy of theophylline as a
RI
bronchoconstrictors, but there are pharmacological differences long-term controller is lacking. However, available evidence
between them. Formoterol has a more rapid onset of action suggests that it has little effect as a first-line controller80.
PY
than salmeterol72, 73, which may make formoterol suitable for It may used as add-on therapy in patients who do not
symptom relief as well as symptom prevention68. achieve control on inhaled glucocorticosteroids alone81-83.
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ASTHMA TREATMENTS 33
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Additionally in such patients the withdrawal of sustained- and skeletal muscle tremor. Adverse cardiovascular
release theophylline has been associated with deterioration reactions may also occur with the combination of oral 2-
of control84. As add-on therapy, theophylline is less effective agonists and theophylline. Regular use of long-acting oral
OD
than long-acting inhaled 2-agonists85,86. 2-agonists as monotherapy is likely to be harmful and
these medications must always be given in combination
Side effects -Side effects of theophylline, particularly at with inhaled glucocorticosteroids.
PR
higher doses (10 mg/kg body weight/day or more), are
significant and reduce their usefulness. Side effects can Anti-IgE*
be reduced by careful dose selection and monitoring,
RE
and generally decrease or disappear with continued use. Role in therapy -Anti-IgE (omalizumab) is a treatment
Adverse effects include gastrointestinal symptoms, loose option limited to patients with elevated serum levels
stools, cardiac arrhythmias, seizures, and even death. of IgE. Its current indication is for patients with severe
OR
Nausea and vomiting are the most common early events. allergic asthma89 who are uncontrolled on inhaled
Monitoring is advised when a high dose is started, if the glucocorticosteroids, although the dose of concurrent
patient develops an adverse effect on the usual dose, when treatment has varied in different studies. Improved
expected therapeutic aims are not achieved, and when asthma control is reflected by fewer symptoms, less need
R
conditions known to alter theophylline metabolism exist. For for reliever medications, and fewer exacerbations90,91,
TE
example, febrile illness, pregnancy, and anti-tuberculosis although this was not confirmed in all studies235. Further
medications87 reduce blood levels of theophylline, while investigations will likely provide additional clarification of the
liver disease, congestive heart failure, and certain role of anti-IgE in other clinical settings.
AL
drugs including cimetidine, some quinolones, and some
macrolides increase the risk of toxicity. Lower doses of Side effects: As indicated by several studies involving
theophylline, which have been demonstrated to provide the asthma patients ages 12 years and older207, who were
full anti-inflammatory benefit of this drug82, are associated T
already receiving treatment with glucocorticosteroids
NO
with less frequent side effects, and plasma theophylline (inhaled and/or oral) and long-acting 2-agonists89, anti-
levels in patients on low-dose therapy need not be IgE appears to be safe as add-on therapy92-94 , including
measured unless overdose is suspected. patients generally considered to be at high risk for
exacerbations229 . Withdrawal of glucocorticosteroids
O
Cromones: sodium cromoglycate and nedocromil facilitated by anti-IgE therapy has led to unmasking
-D
glucocorticosteroid88. therapy (that is, for periods longer than two weeks as a
glucocorticosteroid burst) may be required for severely
MA
Side effects -Side effects are uncommon and include uncontrolled asthma, but its use is limited by the risk
coughing upon inhalation and sore throat. Some patients of significant adverse effects. The therapeutic index
find the taste of nedocromil sodium unpleasant. (effect/side effect) of long-term inhaled glucocortico-
steroids is always more favorable than long-term
ED
slow release formulations of salbutamol, terbutaline, and e the systemic side effects. Oral preparations are preferred
GH
bambuterol, a prodrug that is converted to terbutaline in over parenteral (intramuscular or intravenous) for long-
the body. They are used only on rare occasions when term therapy because of their lower mineralocorticoid
additional bronchodilation is needed. effect, relatively short half-life, and lesser effects on
RI
*Visit GINA website, www.ginasthma.org for GRADE review of question In adults with asthma, does
34 ASTHMA TREATMENTS monoclonal anti-IgE, omalizumab, compared to placebo improve patient outcomes?
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UC
Figure 3-2. Glucocorticosteroids and Osteoporosis
Asthma patients on high-dose inhaled glucocorticosteroids or oral glucocorticosteroids at any dose are considered at risk of developing
OD
osteoporosis and fractures, but it is not certain whether this risk exists for patients on lower doses of inhaled glucocorticosteroids 1. Physicians
should consider monitoring patients who are at risk. The following summarizes monitoring and management but more detailed guidelines for
the management of steroid-induced osteoporosis are available2,3.
PR
Screening - Chest X-rays should be reviewed for the presence of vertebral fractures. Wedging, compressions, and cod-fishing of vertebral
bodies are synonymous with fractures, and indicate those who are at the highest risk for future fractures. In men, this may be a better predictor
of fracture risk than bone mineral density (BMD). BMD measurements by dual energy X-ray absorptiomety (DXA scan) should be undertaken in:
RE
Any patient with asthma who has been taking oral glucocorticosteroids for over 6 months duration at a mean daily dose of 7.5 mg
prednisone/prednisolone or above.
Post-menopausal women taking over 5 mg prednisone/prednisolone daily for more than 3 months.
OR
Any patient with asthma and a history of vertebral or other fractures that may be related to osteoporosis.
Bone density measurements should also be offered to:
Post-menopausal women taking > 2 mg inhaled BDP or equivalent daily
Any patient who is receiving frequent short courses of high-dose oral glucocorticosteroids
R
Osteoporosis is present if the bone density in lumbar spine or femoral neck shows :
T-score below -2.5 (2.5 standard deviations below the mean value of young normal subjects of the same sex in patients 19-69 years).
TE
Z-score below -1 (1 standard deviation below the predicted value for age and sex).
follow-up scanning - Repeat scanning should be done:
AL
In 2 years in those whose initial scan was not osteoporotic but in whom treatment (as above) with oral glucocorticosteroids continues.
In 1 year for those with osteoporosis on the first scan who are started on osteoporosis treatment.
Management
T
General measures include avoidance of smoking, regular exercise, use of the lowest dose of oral glucocorticosteroid possible, and a good
NO
dietary intake of calcium.
For women with osteoporosis up to 10 years post-menopausal offer bisphosphonates or hormone therapy4,5,6 (Evidence A).
For men, pre-menopausal women, and women more than 10 years since menopause consider treatment with a bisphosphonate7 (Evidence A).
O
References
1. Goldstein MF, Fallon JJ, Jr., Harning R. Chronic glucocorticoid therapy-induced osteoporosis in patients with obstructive lung disease. Chest 1999; 116:1733-1749.
-D
2. Eastell R, Reid DM, Compston J, Cooper C, Fogelman I, Francis RM et al. A UK Consensus Group on management of glucocorticoid-induced osteoporosis:
an update. J Intern Med 1998; 244:271-292.
3. Sambrook PN, Diamond T, Ferris L, Fiatarone-Singh M, Flicker L, MacLennan A et al. Corticosteroid induced osteoporosis. Guidelines for treatment. Aust Fam
Physician 2001; 30:793-796.
AL
4. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, Stefanick ML et al. Risks and benefits of estrogen plus progestin in healthy
postmenopausal women: principal results From the Women's Health Initiative randomized controlled trial. JAMA. 2002;288:321-33.
5. Cauley JA, Robbins J, Chen Z, Cummings SR, Jackson RD, LaCroix AZ, LeBoff M, Lewis CE, McGowan J, Neuner J, Pettinger M, Stefanick ML, Wactawski-
RI
Wende J, Watts NB. "Effects of Estrogen Plus Progestin on Risk of Fracture and Bone Mineral Density." JAMA 2003;290(13):1729-1738.
6. Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002;167:S1-34.
TE
7. Homik J, Cranney A, Shea B, Tugwell P, Wells G, Adachi R et al. Bisphosphonates for steroid induced osteoporosis. Cochrane Database Syst Rev 2000;CD001347.
Side effects -The systemic side effects of long-term infections have been reported among patients who
MA
oral or parenteral glucocorticosteroid treatment include are exposed to these viruses while taking systemic
osteoporosis, arterial hypertension, diabetes, hypothalamic- glucocorticosteroids, even short bursts.
pituitary-adrenal axis suppression, obesity, cataracts,
glaucoma, skin thinning leading to cutaneous striae and Oral anti-allergic compounds.
ED
(Figure 3-2)97-99. Although it is rare, withdrawal of oral mild to moderate allergic asthma. These include tranilast,
GH
glucocorticosteroids can elicit adrenal failure or unmask repirinast, tazanolast, pemirolast, ozagrel, seratrodast,
underlying disease, such as Churg-Strauss Syndrome100. amlexanox, and ibudilast. In general, their anti-asthma
Caution and close medical supervision are recommended effect appears to be limited101, but studies on the
when considering the use of systemic glucocorticosteroids
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ASTHMA TREATMENTS 35
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Side effects -Sedation is a potential side effect of some of conjunctivitis up to 7 years after treatment termination208.
these medications. However, in view of the relatively modest effect of allergen-
specific immunotherapy compared to other treatment
OD
Other controller therapies. options, these benefits must be weighed against the risk
of adverse effects and the inconvenience of the prolonged
Role in therapy -Various therapeutic regimens to reduce course of injection therapy, including the minimum half-hour
PR
the dose of oral glucocorticosteroids required by patients wait required after each injection. Specific immunotherapy
with severe asthma have been proposed. These should be considered only after strict environmental
medications should be used only in selected patients avoidance and pharmacologic intervention, including
RE
under the supervision of an asthma specialist, as their inhaled glucocorticosteroids, have failed to control a
potential steroid-sparing effects may not outweigh the risk patients asthma113. There are no studies that compare
of serious side effects. Two meta-analyses of the steroid- specific immunotherapy with pharmacologic therapy
OR
sparing effect of low-dose methotrexate showed a small for asthma. The value of immunotherapy using multiple
overall benefit, but a relatively high frequency of adverse allergens does not have support.
effects102,103. This small potential to reduce the impact of Side effects -Local and systemic side effects may occur in
glucocorticosteroid side effects is probably insufficient to conjunction with specific immunotherapy administration.
R
offset the adverse effects of methotrexate104. Cyclosporin105 Reactions localized to the injection site may range from
TE
and gold106,107 have also been shown to be effective in a minimal immediate wheal and flare to a large, painful,
some patients. The macrolide, troleandomycin, has a delayed allergic response. Systemic effects may include
small steroid-sparing effect when used with systemic anaphylactic reactions, which may be life threatening,
AL
methylprednisolone, but its effect may result from the as well as severe exacerbations of asthma. Deaths from
macrolide decreasing metabolism of the glucocorticosteroid specific immunotherapy have occurred in patients with
and therefore not improving safety. However, other effects severe asthma.
of the long-term use of macrolides in asthma remain under T
NO
study108. The use of intravenous immunoglobulin is not Reliever Medications
recommended109-111. Data on a human monoclonal antibody
against tumor necrosis factor (TNF)-alpha suggest that the Reliever medications act quickly to relieve bronchoconstriction
risk benefit equation does not favor the use of this class of
O
liver toxicity. Methotrexate also causes gastrointestinal medications of choice for relief of bronchospasm during
symptoms, and on rare occasions hepatic and diffuse acute exacerbations of asthma and for the pretreatment
pulmonary parenchymal disease, and hematological and of exercise-induced bronchoconstriction. They include
RI
Allergen-specific immunotherapy. agonist, is approved for symptom relief because of its rapid
onset of action, but it should only be used for this purpose
MA
Role in therapy -The role of specific immunotherapy in in patients on regular controller therapy with inhaled
adult asthma is limited. Appropriate immunotherapy glucocorticosteroids230.
requires the identification and use of a single well-defined
clinically relevant allergen. The later is administered in Rapid-acting inhaled 2-agonists should be used only on
ED
progressively higher doses in order to induce tolerance. an as-needed basis at the lowest dose and frequency
A Cochrane review112 that examined 75 randomized required. Increased use, especially daily use, is a warning
controlled trials of specific immunotherapy compared of deterioration of asthma control and indicates the need
T
to placebo confirmed the efficacy of this therapy in to reassess treatment. Similarly, failure to achieve a
GH
asthma in reducing symptom scores and medication quick and sustained response to 2-agonist treatment
requirements, and improving allergen-specific and non- during an exacerbation mandates medical attention, and
specific airway hyperresponsiveness. Similar modest may indicate the need for short-term treatment with oral
RI
long-term clinical effects and the potential of preventing Side effects -Use of oral 2-agonists given in standard
development of asthma in children with allergic rhino doses are associated with more adverse systemic effects
CO
36 ASTHMA TREATMENTS
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such as tremor and tachycardia than occur with inhaled Theophylline.
preparations.
Role in therapy -Short-acting theophylline may be
OD
Systemic glucocorticosteroids. considered for relief of asthma symptoms119. The role
of theophylline in treating exacerbations remains
Role in therapy -Although systemic glucocorticosteroids controversial. Short-acting theophylline may provide no
PR
are not usually thought of as reliever medications, additive bronchodilator effect over adequate doses of rapid-
they are important in the treatment of severe acute acting 2-agonists, but it may benefit respiratory drive.
exacerbations because they prevent progression of the
RE
asthma exacerbation, reduce the need for referral to Side effects -Theophylline has the potential for significant
emergency departments and hospitalization, prevent adverse effects, although these can generally be avoided
early relapse after emergency treatment, and reduce by appropriate dosing and monitoring. Short-acting
OR
the morbidity of the illness. The main effects of systemic theophylline should not be administered to patients already
glucocorticosteroids in acute asthma are only evident after on long-term treatment with sustained-release theophylline
4 to 6 hours. Oral therapy is preferred and is as effective unless the serum concentration of theophylline is known to
as intravenous hydrocortisone114. A typical short course of be low and/or can be monitored.
R
oral glucocorticosterods for an exacerbation is 40-50 mg115
TE
prednisolone given daily for 5 to 10 days depending on the Short-acting oral 2-agonists.
severity of the exacerbation. When symptoms have
subsided and lung function has approached the patients Short-acting oral 2-agonists are appropriate for use in the
AL
personal best value, the oral glucocorticosteroids can be few patients who are unable to use inhaled medication.
stopped or tapered, provided that treatment with inhaled However, their use is associated with a higher prevalence
glucocorticosteroids continues116. Intramuscular injection of of adverse effects.
glucocorticosteroids has no advantage over a short course T
NO
of oral glucocorticosteroids in preventing relapse114,116. Complementary And Alternative Medicine
Side effects -Adverse effects of short-term high-dose The roles of complementary and alternative medicine
systemic therapy are uncommon but include reversible
O
fluid retention, weight gain, rounding of the face, mood their effectiveness is largely unproven. Generally, these
alteration, hypertension, peptic ulcer, and aseptic necrosis therapies have not been validated by conventional
of the femur. standards. Although the psychotherapeutic role of the
AL
Role in therapy -Anticholinergic bronchodilators used and alternative methods, and mitigates against
in asthma include ipratropium bromide and oxitropium performance of the large, multicenter, placebo-controlled
TE
bromide. Inhaled ipratropium bromide is a less effective randomized studies required to confirm efficacy. However,
reliever medication in asthma than rapid-acting inhaled without these the relative efficacy of these alternative
MA
pulmonary function, and significantly reduces the risk of medicine, ionizers, osteopathy and chiropractic
hospital admission117. The benefits of ipratropium bromide manipulation, and speleotherapy among others. Apart from
in the long-term management of asthma have not been those mentioned below, there have been few satisfactory
T
established, although it is recognized as an alternative studies from which conclusions about their efficacy can be
GH
cause a dryness of the mouth and a bitter taste. There is no therapeutic benefit in adults with asthma. In addition, it
evidence for any adverse effects on mucus secretion118. has no effect on bronchial reactivity to methacholine217.
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ASTHMA TREATMENTS 37
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Evidence from the most rigorous studies available to the choice of inhaler device should include consideration
date indicates that spinal manipulation is not an effective of the efficacy of drug delivery, cost, safety, ease of use,
treatment for asthma121. Systematic reviews indicate that convenience, and documentation of its use in the patients
OD
homeopathic medicines have no effects beyond placebo222. age group123-125. In general, a metered-dose inhaler (MDI)
A systematic review of yoga interventions for asthma found with spacer is preferable to nebulized therapy due to
no convincing evidence of benefit; the quality of studies its greater convenience, more effective lung deposition,
PR
was generally poor236. lower risk of side effects, and lower cost. Based on these
considerations, a general strategy for choosing inhalers in
Several studies of breathing and/or relaxation techniques children is given in Figure 3-3.
RE
for asthma and/or dysfunctional breathing, including the
Buteyko method and the Papworth method210, have shown
improvements in symptoms, short-acting 2-agonist use, Figure 3-3: Choosing an Inhaler Device for
Children with Asthma*
OR
quality of life and/or psychological measures, but not in
physiological outcomes. A study of two physiologically- Age Group Preferred Device Alternate Device
contrasting breathing techniques, in which contact with Younger than 4 years Pressurized metered- Nebulizer with face
health professionals and instructions about rescue dose inhaler plus
R
mask
inhaler use were matched, showed similar improvements dedicated spacer
TE
in reliever and inhaled glucocorticosteroid use in both with face mask
groups122. This suggests that perceived improvement with 4 6 years Pressurized metered- Nebulizer with
breathing techniques may be largely due to factors such as dose inhaler plus mouthpiece
AL
dedicated spacer
relaxation, voluntary reduction in use of rescue medication, with mouthpiece
or engagement of the patient in their care. Breathing
Older than 6 years Dry powder inhaler, Nebulizer with
techniques may thus provide a useful supplement to or breath-actuated
conventional asthma management strategies, particularly T pressurized metered-
mouthpiece
NO
in anxious patients or those habitually over-using rescue dose inhaler, or
pressurized metered-
medication. The cost of some programs may be a potential
dose inhaler with
limitation. spacer and mouthpiece
O
*Based on efficacy of drug delivery, cost effectiveness, safety, ease of use, and
Side effects -Acupuncture-associated hepatitis B, bilateral
-D
convenience.
pneumothorax, and burns have been described. Side
effects of other alternative and complementary medicines Spacers retain large drug particles that would normally
are largely unknown. However, some popular herbal be deposited in the oropharynx, reducing oral and
AL
medicines could potentially be dangerous, as exemplified gastrointestinal absorption and thus systemic availability
by the occurrence of hepatic veno-occlusive disease of the inhaled drug. This is mainly important when
associated with the consumption of the commercially inhaled glucocorticosteroids with first-pass metabolism
RI
available herb comfrey. Comfrey products are sold as (beclomethasone dipropionate, flunisolide, triamcinolone,
herbal teas and herbal root powders, and their toxicity is and budesonide) are given via pressurized MDI. Use of a
TE
due to the presence of pyrroli idine alkaloids. spacer also reduces oropharyngeal side effects. During
acute asthma attacks, an MDI should always be used
with a spacer, as in this situation a child may be unable to
MA
ASTHMA TREATMENT: CHILDREN** correctly coordinate inhalation with actuation of the MDI.
**See also the Asthma Medications: Adults section at the beginning of this chapter for more
38 ASTHMA TREATMENTS information on the therapeutic role and side effects of various therapies. In this section, only information
specific to children is provided.
E
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Figure 3-4. Estimated Equipotent Daily Doses of Inhaled Glucocorticosteroids for Children Older than 5 Years
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
OD
Beclomethasone dipropionate 100 - 200 >200 - 400 >400
Budesonide* 100 - 200 >200 - 400 >400
PR
Budesonide-Neb 250 - 500 >500 - 1000 >1000
Ciclesonide* 80 - 160 >160 - 320 >320
Flunisolide 500 - 750 >750 - 1250 >1250
RE
Fluticasone propionate 100 - 200 >200 - 500 >500
Mometasone furoate* 100
100- 200 >200
200- 400 >400
400
Triamcinolone acetonide 400 - 800 >800 - 1200 >1200
OR
Comparisons based upon efficacy data.
Patients considered for high daily doses except for short periods should be referred to a specialist for assessment to consider alternative combinations of
controllers. Maximum recommended doses are arbitrary but with prolonged use are associated with increased risk of systemic side effects.
R
* Approved for once-daily dosing in mild patients.
TE
Notes
The most important determinant of appropriate dosing is the clinicians judgment of the patients response to therapy. The clinician must monitor the
patients response in terms of clinical control and adjust the dose accordingly. Once control of asthma is achieved, the dose of medication should be
AL
carefully titrated to the minimum dose required to maintain control, thus reducing the potential for adverse effects.
Designation of low, medium, and high doses is provided from manufacturers recommendations where possible. Clear demonstration of dose-
response relationships is seldom provided or available. The principle is therefore to establish the minimum effective controlling dose in each patient,
as higher doses may not be more effective and are likely to be associated with greater potential for adverse effects.
T
As CFC preparations are taken from the market, medication inserts for HFA preparations should be carefully reviewed by the clinician for the correct
NO
equivalent dosage.
Controller medications for children include inhaled and inhaled glucocorticosteroids controls asthma symptoms,
-D
systemic glucocorticosteroids, leukotriene modifiers, long- reduces the frequency of acute exacerbations and the
acting inhaled 2-agonists, theophylline, cromones, and number of hospital admissions, improves quality of life,
long-acting oral 2-agonists. lung function, and bronchial hyperresponsiveness, and
reduces exercise-induced bronchoconstriction10. Symptom
AL
Role in Therapy -Inhaled glucocorticosteroids are the course of months) and sometimes higher doses may be
most effective controller therapy, and are therefore the required to achieve maximum improvements in airway
TE
recommended treatment for asthma for children of all ages. hyperresponsiveness10. When glucocorticosteroid treatment
Figure 3-4 lists approximately equipotent doses of different is discontinued, asthma control deteriorates within weeks to
inhaled glucocorticosteroids administered via different months10.
MA
dose titration studies in children128,129 demonstrate marked asthma generally produces similar clinical effects as in
and rapid clinical improvements in symptoms and lung older children, but dose-response relationships have
function at low doses of inhaled glucocorticosteroids been less well studied. The clinical response may differ
T
(e.g., 100-200 g budesonide daily)130-134, and mild depending on the inhaler and the childs ability to use
GH
disease is well controlled by such doses in the majority the inhaler correctly. With use of a spacer device, a low-
of patients132. Early intervention with inhaled budesonide dose inhaled glucocorticosteroid results in near-maximum
is associated with improved asthma control and less benefits in the majority of patients136,137. Use of inhaled
RI
additional asthma medication use132. Some patients require glucocorticosteroids does not induce remission of asthma
higher doses (400 g/day) to achieve optimal asthma and it returns when treatment is stopped138.
PY
ASTHMA TREATMENTS 39
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The clinical benefits of intermittent systemic or inhaled the childs bone age corresponds to his or her height140,141
glucocorticosteroids for children with intermittent, viral- Ultimately, adult height is not decreased, although it is
induced wheeze remain controversial. A one year study reached at a later than normal age. The use of 400 g
OD
of intermittent treatment with inhaled glucocorticosteroids inhaled budesonide or equivalent per day to control asthma
was equally effective as daily treatment, and reduced has less impact on growth than does low socioeconomic
the total glucocorticosteroid dose threefold in preschool status141. A summary of the findings of studies on inhaled
PR
children with frequent wheezing and a high asthma glucocorticosteroids and growth is provided in Figure 3-5.
predictive index238. Some studies in older children found
small benefits while another study in young children Bones. The potential clinically relevant adverse effects
RE
found no effects on wheezing symptoms139. There is no of inhaled glucocorticosteroids on bones in children
evidence to support the use of maintenance low-dose are osteoporosis and fracture. Several cross-sectional
inhaled glucocorticosteroids for preventing early transient and longitudinal epidemiologic studies have assessed
OR
wheezing136,139,199. the effects of long-term inhaled glucocorticosteroid
treatment on these outcomes132,143-149. The conclusions are
Side effects -The majority of studies evaluating the summarized in Figure 3-6.
systemic effects of inhaled glucocorticosteroids have been
R
undertaken in children older than 5 years. Figure 3-6. Summary: Bones and
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Glucocorticosteroids in Children10,143,144
Growth. When assessing the effects of inhaled
glucocorticosteroids on growth in children with asthma, it
AL
is important to consider potential confounding factors. For No studies have reported any statistically significant
example, many children with asthma receiving inhaled increased of risk of fractures in children taking inhaled
glucocorticosteroids experience a reduction in growth glucocorticosteroids.
rate toward the end of the first decade of life140. This T
Oral or systemic glucocorticosteroid use increases the risk of
NO
reduced growth rate continues into the mid-teens and is fracture. The risk of fracture increases along with the number
of treatments, with a 32% increase at four courses ever. Use
associated with a delay in the onset of puberty. The pre-
of inhaled glucocorticosteroids reduces the need for systemic
pubertal deceleration of growth velocity resembles growth
courses.
retardation. However, the delay in pubertal growth is also
O
Important differences seem to exist between the growth- At higher doses, small changes in HPA axis function
retarding effects of various inhaled glucocorticosteroids and
can be detected with sensitive methods148. The clinical
inhalers.
relevance of these findings is not known, since there have
T
Different age groups seem to differ in their susceptibility to not been reports of adrenal crisis in clinical trials of inhaled
GH
40 ASTHMA TREATMENTS
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UC
Central nervous system effects. Although isolated case Side effects -No safety concerns have been demonstrated
reports have suggested that hyperactive behavior, from the use of leukotriene modifiers in children.
aggressiveness, insomnia, uninhibited behavior, and
OD
impaired concentration may be seen with inhaled Long-acting inhaled 2-agonists.
glucocorticosteroid treatment, no increase in such effects
has been found in a long-term controlled trial of inhaled Role in therapy -Long-acting inhaled 2-agonists are
PR
budesonide132. primarily used as add-on therapy in children older than 5
years whose asthma is insufficiently controlled by medium
Oral candidiasis, hoarseness, and bruising. Clinical thrush doses of inhaled glucocorticosteroids or as single-dose
RE
is seldom a problem in children treated with inhaled or therapy before vigorous exercise. Monotherapy with long-
systemic glucocorticosteroids. This side effect seems to acting inhaled 2-agonists should be avoided75,234.
be related to concomitant use of antibiotics, high daily
OR
doses, dose frequency, and inhaler device. Spacers Children older than 5 years. Long-acting inhaled 2-
reduce the incidence of oral candidiasis151. Mouth rinsing agonists have mainly been studied in children older
is beneficial152. The occurrence of hoarseness or other than 5 years as add-on therapy for patients whose
noticeable voice changes during budesonide treatment is asthma is not controlled on low to high doses of inhaled
R
similar to placebo30. Treatment with an average daily dose glucocorticosteroids. Significant improvements in peak
TE
of 500 g budesonide for 3 to 6 years is not associated with flow and other lung function measurements have been
an increased tendency to bruise30. found in most studies55,165-169, 234. However, the effects
on other outcomes such as symptoms and need for
AL
Dental side effects. Inhaled glucocorticosteroid treatment is reliever medication have been less consistent and
not associated with increased incidence of caries. However, have only been observed in about half of the trials
the increased level of dental erosion reported in children conducted. Add-on treatment with long-acting inhaled 2-
with asthma153 may be due to a reduction in oral pH that T
agonists has not been shown to reduce the frequency of
NO
may result from inhalation of 2-agonists154. exacerbations170. Inhalation of a single dose of long-acting
inhaled 2-agonists effectively blocks exercise-induced
Other local side effects. The long-term use of inhaled bronchoconstriction for several hours171. With daily therapy
glucocorticosteroids is not associated with an increased the duration of the protection is somewhat reduced171, but is
O
incidence of lower respiratory tract infections, including still longer than that provided by short-acting 2-agonists.
-D
provide partial protection against exercise-induced Children 5 years and younger. The effect of long-acting
bronchoconstriction within hours after administration with
inhaled 2-agonists has not yet been adequately studied.
no loss of bronchoprotective effect200. As add-on treatment
MA
in children whose asthma is insufficiently controlled by Combination therapy with budesonide and formoterol
low doses of inhaled glucocorticosteroids, leukotriene used both as maintenance and rescue has been shown to
modifiers provide moderate clinical improvements, reduce asthma exacerbations in children ages 4 years and
including a significant reduction in exacerbations162. older with moderate to severe asthma202.
ED
Montelukast has not been demonstrated to be an effective because of inconsistency of reports on their effects on
GH
inhaled glucocorticosteroid sparing alternative in children exacerbations of asthma, they are not the recommended
with moderate-to-severe persistent asthma219. option when more than one controller is required170. If used,
long-acting 2-agonists should only be used in combination
Children 5 years and younger. In addition to the efficacy as
RI
combination inhaler.
history of intermittent asthma164.
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ASTHMA TREATMENTS 41
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Theophylline. 28 week, randomized, double-blind, placebo-controlled
study223, 224 included 334 children with moderate to severe
Role in therapy -Theophylline has been shown to be allergic asthma who were well controlled on inhaled
OD
effective as monotherapy and as add-on treatment to glucocorticosteroid doses equivalent to 200-500 g/day
inhaled or oral glucocorticosteroids in children older than of beclomethasone. There was no difference in clinical
5 years. It is significantly more effective than placebo at effects between placebo and anti-IgE during a 16-week
PR
controlling day and night symptoms and improving lung stable inhaled glucocorticosteroid dose period. During a
function172-174. Maintenance treatment offers a marginal 12-week tapering period urgent, unscheduled physician
protective effect against exercise-induced broncho- visits were significantly reduced from by 30.3% in the
RE
constriction175. Add-on treatment with theophylline has anti-IgE compared with placebo (12.9%) group223, and
been found to improve asthma control and reduce the there were significant improvements in quality of life in
maintenance glucocorticosteroid dose necessary in the patients receiving anti-IgE, both during stable inhaled
OR
children with severe asthma treated with inhaled or oral glucocorticosteroid dosing and during tapering224. The
glucocorticosteroids176,177. A few studies in children 5 years remaining outcomes were very similar in the two treatment
and younger also suggest some clinical benefit. However, groups.
the efficacy of theophylline is less than that of low-dose
R
inhaled glucocorticosteroids. A one-year study evaluated the efficacy and safety of anti-
TE
IgE in 627 children with IgE-mediated asthma inadequately
Most clinical evidence regarding the use of theophylline in controlled on doses of inhaled glucocorticosteroid
children has been obtained from studies in which plasma equivalent to 200 g/day fluticasone propionate or higher
AL
theophylline levels were maintained within the therapeutic (mean dose 500 g/day)225. Anti-IgE treatment was
range of 55-110 mol/L (5-10 g/ml). Further studies associated with a significantly lower exacerbation rate
suggest that its controller functions may occur at lower and the overall incidence of serious adverse events was
plasma levels (corresponding to doses of around 10 mg/ T
significantly lower in the children receiving anti-IgE than
NO
kg/day). Sustained-release products are preferable for placebo.
maintenance therapy, since they enable twice-daily dosing.
Sustained-release products with reliable absorption profiles A substantial number of children with difficult asthma
and complete bioavailability with and without concomitant will have higher IgE levels than the upper limit of IgE
O
food intake are preferred. recommended for therapy (1,300 IU)226. It is unknown if
-D
Theophylline elimination may vary up to tenfold between these patients will still benefit from omalizumab therapy.
individuals. Measurement of plasma theophylline levels There are no tests that can currently be recommended in
is not necessary in otherwise healthy children when order to predict who will respond227.
AL
theophylline levels should be measured two hours before benefit analysis suggested that there would be a fiscal
administration of the next dose once steady state has been saving if this treatment is given to children with five or more
TE
reached (after 3 days). hospital admissions and cumulatively twenty days or more
in hospital228.
MA
bleeding may also occur. These side effects are mainly seen term (beyond one year) safety and efficacy has not yet
at doses higher than 10 mg/kg/day. The risk of adverse been studied.
effects is reduced if treatment is initiated with daily doses
T
around 5 mg/kg/day and then gradually increased to 10 mg/ Cromones: sodium cromoglycate and nedocromil sodium.
GH
in children age 6 to 12 years with moderate-to-severe significantly better than placebo for management of asthma
and severe persistent allergic (IgE-mediated) asthma. A in children179. Another has confirmed superiority of low dose
CO
42 ASTHMA TREATMENTS
E
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inhaled glucocorticosteroids over sodium cromoglycate in Side effects -Skeletal muscle tremor, headache,
persistent asthma, but as there were no placebo arms in palpitations, and some agitation are the most common
these studies, the efficacy of sodium cromoglycate cannot complaints associated with high doses of 2-agonists
OD
be confirmed from the studies reviewed; no between in children. These complaints are more common after
treatment difference in safety was observed180. systemic administration and disappear with continued
treatment189.
PR
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exacerbations, but its effect on other asthma outcomes Anticholinergics.
is not superior to placebo. A single dose of sodium
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cromoglycate or nedocromil sodium attenuates broncho- Role in therapy -Inhaled anticholinergics are not recommended
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219. Strunk RC, Bacharier LB, Phillips BR, Szefler SJ, Zeiger Ameredes BT et al. National Heart, Lung, and Blood Institute
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221. Wechsler ME, Wong DA, Miller MK, Lawrence-Miyasaki L. Allergy Clin Immunol. 2011 Aug;128(2):315-22.
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238. Zeiger RS, Mauger D, Bacharier LB, Guilbert TW, Martinez FD,
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ASTHMA
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PREVENTION
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MANAGEMENT
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CHAPTER 4: ASTHMA MANAGEMENT AND PREVENTION
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COMPONENT 1: DEFINITION
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INTRODUCTION COMPONENT 1: DEVELOP
PATIENT/DOCTOR PARTNERSHIP
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Asthma has a significant impact on individuals, their
families, and society. Although there is no cure for asthma,
appropriate management that includes a partnership KEY POINTS:
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between the physician and the patient/family most often
results in the achievement of control. The effective management of asthma requires
the development of a partnership between the
The goals for successful management of asthma are to: person with asthma and his or her health care
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Achieve and maintain control of symptoms professional(s) (and parents/caregivers, in the case
Maintain normal activity levels, including exercise of children with asthma).
Maintain pulmonary function as close to normal as The aim of this partnership is guided self-
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possible managementthat is, to give people with asthma the
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Prevent asthma exacerbations ability to control their own condition with guidance
Avoid adverse effects from asthma medications from health care professionals.
Prevent asthma mortality. The partnership is formed and strengthened as
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patients and their health care professionals discuss
These goals for therapy reflect an understanding of and agree on the goals of treatment, develop a
asthma as a chronic inflammatory disorder of the airways personalized, written asthma action plan including
characterized by recurrent episodes of wheezing,
breathlessness, chest tightness, and coughing. Clinical
T self-monitoring, and periodically review the patients
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treatment and level of asthma control.
studies have shown that asthma can be effectively
controlled by intervening to suppress and reverse the Education should be an integral part of all
inflammation as well as treating the bronchoconstriction interactions between health care professionals and
patients, and is relevant to asthma patients of all
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airway may help improve the control of asthma and reduce Personal written asthma action plans help individuals
medication needs. Experience in occupational asthma with asthma make changes to their treatment in
indicates that long-standing exposure to sensitizing agents response to changes in their level of asthma control,
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may lead to irreversible airflow limitation. as indicated by symptoms and/or peak expiratory
flow, in accordance with written predetermined
The management of asthma can be approached in guidelines.
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far as possible on controlled clinical studies, and the text development of a partnership between the person with
references many of these studies. For those aspects of asthma and his or her health care professional(s) (and
the clinical management of asthma that have not been the parents/caregivers in the case of children with asthma). The
ED
subject of specific clinical studies, recommendations are aim of this partnership is to enable patients with asthma
based on literature review, clinical experience, and expert to gain the knowledge, confidence, and skills to assume
opinion of project members. a major role in the management of their asthma. The
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in five interrelated components of therapy: goals of treatment, develop a personalized, written asthma
action plan including self-monitoring, and periodically
1. Develop Patient/Doctor Partnership review the patients treatment and level of asthma control
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specific systems of guided self-management have been stage of the children may affect the outcomes of such
developed1-10 for use in a wide range of settings: primary programs373.
care1,4,6, hospitals2,3,7,10, and emergency departments8.
PR
Internet-based home monitoring340,372, and mobile phones395 Figure 4.1-2 outlines the key features and components of
have been shown to be successful modes to improve an asthma education program. The information and skills
asthma control. Self-management programs have been training required by each person may vary, and their ability
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tested in diverse groups, including community health
workers371, pregnant women with asthma11, children and Figure 4.1-2. Education and the Patient Doctor
adolescents12,13, and in multi-racial populations14. Partnership
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Guided self-management may involve varying degrees Goal: To provide the person with asthma, their family, and other
of independence, ranging broadly from patient-directed caregivers with suitable information and training so that they can
self-management in which patients make changes without keep well and adjust treatment according to a medication plan
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reference to their caregiver, but in accordance with a prior developed with the health care professional.
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written action plan, to doctor-directed self-management in
which patients rely follow a written action plan, but refer Key Components:
most major treatment changes to their physician at the o Focus on the development of the partnership
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o Acceptance that this is a continuing process
o A sharing of information
Figure 4.1-1. Essential Features of the o Full discussion of expectations
Doctor-Patient Partnership to Achieve Guided T
o Expression of fears and concerns
Self-Management in Asthma
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Education Key Components:
Joint setting of goals o Diagnosis
Self-monitoring. The person with asthma is taught to combine
o Difference between relievers and controllers
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assessment of asthma control with educated interpretation of o Potential side effects of medications
o Use of inhaler devices
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key symptoms
Regular review of asthma control, treatment, and skills by a o Prevention of symptoms and attacks
health care professional o Signs that suggest asthma is worsening and actions to take
o Monitoring control of asthma
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Self-monitoring is integrated with written guidelines for both the The person then requires:
long-term treatment of asthma and the treatment of asthma o A written asthma action plan
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time of planned or unplanned consultations. Cochrane or willingness to take responsibility similarly differs. Thus
systematic reviews13,15-18 have examined the role of all individuals require certain core information and skills,
education and self-management strategies in the care of but most education must be personalized and given to
asthma patients. the person in a number of steps. Social and psychological
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Education should be an integral part of all interactions good compliance/adherence19-22,414 (Evidence B). Key
between health care professionals and patients, and is factors that facilitate good communication are23:
relevant to asthma patients of all ages. Although the focus
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of education for small children will be on the parents and A congenial demeanor (friendliness, humor, and
caregivers, children as young as 3 years of age can be attentiveness)
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Eliciting shared goals asthma make changes to their treatment in response to
Feedback and review changes in their level of asthma control, as indicated by
symptoms and/or peak expiratory flow, in accordance with
PR
Teaching health care professionals to improve their written predetermined guidelines23,31,32 .
communication skills can result in measurably better
outcomesincluding increased patient satisfaction, better The effects were greatest where the intervention involved
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health, and reduced use of health careand these benefits each of the following elements: education, self-monitoring,
may be achieved without any increase in consultation regular review, and patient-directed management using
times24. Studies have also shown that patients can a written asthma action plan (Evidence A). Within
OR
be trained to benefit more from consultations. Patients these studies, the effects were also greater when
taught how to give information to doctors in a clearer the action plans themselves both stepped up inhaled
manner, and how to seek information and check their glucocorticosteroids and added oral glucocorticosteroids,
understanding of what the doctor had told them gained and for peak flow-based plans, when they were based on
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significant improvements in compliance with treatment personal best rather than percent predicted peak flow32.
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recommendations25. Lay educators can be recruited Patients experience a one-third to two-thirds reduction
and trained to deliver a discrete area of respiratory care in hospitalizations, emergency room visits, unscheduled
(for example, asthma self-management education) with visits to the doctor for asthma, missed days of work,
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comparable outcomes to those achieved by primary care and nocturnal wakening. It has been estimated that the
based practice nurses362 (Evidence B). implementation of a self-management program in 20
patients prevents one hospitalization, and successful
At the Initial Consultation T
completion of such a program by eight patients prevents
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one emergency department visit16-18,23 . Less intensive
Early in the consultation the person with asthma interventions that involve self-management education but
needs information about the diagnosis and simple not a written plan are less effective15. The efficacy is similar
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information about the types of treatment available, the regardless of whether patients self-adjust their medications
rationale for the specific therapeutic interventions being according to an individual written plan or adjustments
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recommended, and strategies for avoiding factors that of medication are made by a doctor15 (Evidence B).
cause asthma symptoms374. Different inhaler devices can Thus, patients who are unable to undertake guided self-
be demonstrated, and the person with asthma encouraged management can still achieve benefit from a structured
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to participate in the decision as to which is most suitable for program of regular medical review. Although interactive
them. Some of these devices and techniques for their use computerized asthma education programs may improve
are illustrated on the GINA Website (http://www.ginasthma. patient asthma knowledge and symptoms, their effect on
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org). Criteria for initial selection of inhaler device include objective clinical outcomes is less consistent353 .
device availability and cost, patient skills, and preferences
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of the health professional and patient26-28 . Patients Examples of written asthma action plans that have been
should be given adequate opportunity to express their recommended can be found on several Websites (UK
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expectations of both their asthma and its treatment. A frank National Asthma Campaign Plan, www.asthma.org.uk;
appraisal should be made of how far their expectations may International Asthma Management Plan Zone System,
or may not be met, and agreement should be made about www.nhlbisupport.com/asthma/index.html; New Zealand
specific goals for therapy. Credit Card System, www.asthmanz.co.nz. An example
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encouraged to make a note of any questions that arise from discussed, and any problems with asthma and its initial
reading this information or as a result of the consultation, treatment are reviewed. Patients should be asked to
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and should be given time to address these during the next demonstrate their inhaler device technique at every visit,
consultation. with correction and re-checking if it is inadequate33,375.
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the patient has been asked to keep a diary of symptoms persons asthma. Routine follow-up visits may be an
(and where appropriate, home peak flow recordings) this effective time to review the written asthma action plan and
its understanding354 . Educational messages should be
PR
Figure 4.1-3 Example of Contents of Written Asthma reviewed and repeated or added to if necessary. A single
Action Plan to Maintain Asthma Control page prompt to clinicians has been shown to improve the
provision of preventive care to children with asthma during
RE
Your Regular Treatment: office visits341. Telehealthcare follow-up is unlikely to benefit
1. Each day take ___________________________
2. Before exercise, take _____________________
in mild asthma but may be of benefit in those with severe
disease at risk of hospital admission397.
OR
WHEN TO INCREASE TREATMENT
Assess your level of Asthma Control
In the past week have you had: Improving Adherence
Daytime asthma symptoms more than 2 times ? No Yes
Activity or exercise limited by asthma? No Yes
Although interventions for enhancing medication adherence
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Waking at night because of asthma? No Yes
The need to use your [rescue medication] more than 2 times? No Yes have been developed363, studies of adults and children
TE
If you are monitoring peak flow, peak flow less than______? No Yes with asthma34 have shown that around 50% of those on
if you answered YeS to three or more of these questions, your asthma is Long-term therapy fail to take medications as directed at
uncontrolled and you may need to step up your treatment.
least part of the time. Patient concern about side-effects of
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HOW TO INCREASE TREATMENT inhaled glucocorticosteroids whether real or perceived may
STEP-UP your treatment as follows and assess improvement every day: influence adherence342. Non-adherence may be defined in a
_________________________________ [Write in next treatment step here]
nonjudgmental way as the failure of treatment to be taken as
Maintain this treatment for _____________ days [specify number] T
agreed upon by the patient and the health care professional.
NO
WHEN TO CALL THE DOCTOR/CLINIC. Non-adherence may be identified by prescription monitoring,
Call your doctor/clinic: _______________ [provide phone numbers]
If you dont respond in _________ days [specify number]
pill counting, or drug assay, but at a clinical level it is
____________________________ [optional lines for additional instruction] best detected by asking about therapy in a way that
O
3If you have severe shortness of breath, and can only speak in short sentences,
3 If you are having a severe attack of asthma and are frightened, often you actually take the medicine?). Short questionnaires
3If you need your reliever medication more than every 4 hours and are not can assist with identification of poor adherence376. Providing
improving.
adherence information to clinicians does not improve use
1. Take 2 to 4 puffs ___________ [reliever medication]
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2. Take ____mg of ____________ [oral glucocorticosteroid] of inhaled glucocorticosteroid among patients with asthma
3. Seek medical help: Go to ________________; Address______________ unless clinicians are sufficiently interested in adherence to
Phone: _______________________
view the details of this medication use398. Specific drug and
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Self-Management in Children
MA
devices Fears about side effects teach self-management skills) among children admitted to
Awkward regimes (e.g., Dissatisfaction with health care professionals the hospital with asthma have been shown to significantly
four times daily or Unexpressed/undiscussed fears or concerns reduce the readmission rate and reduce morbidity13 . A
T
OD
significantly improved asthma outcomes including reduced
hospitalizations399.
PR
THE EDUCATION OF OTHERS
RE
The education of the general public about asthma is helpful
in that it enables members of the public to recognize
asthma symptoms and their consequences and encourages
those with asthma to seek medical attention and follow
OR
their asthma management program. Greater awareness
of asthma is also likely to help dispel misconceptions
that may exist about the condition and reduce feelings of
R
stigmatization on the part of patients.
TE
Specific advice about asthma and its management should
be offered to school teachers and physical education
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instructors, and several organizations produce materials for
this purpose. Schools may need advice on improving the
environment and air quality for children with asthma35 . It is
also helpful for employers to have access to clear advice
about asthma. Most occupations are as suitable for those
T
NO
with asthma as for those without, but there may be some
circumstances where caution is needed.
O
-D
AL
RI
TE
MA
T ED
GH
RI
PY
CO
OD
EXPOSURE TO RISK FACTORS
PR
atopy, likely to be most relevant prenatally and perinatally),
KEY POINTS: or the prevention of asthma development in sensitized
people. Other than preventing tobacco exposure both
RE
Pharmacologic intervention to treat established in utero and after birth, there are no proven and widely
asthma is highly effective in controlling symptoms accepted interventions that can prevent the development of
and improving quality of life. However, measures asthma.
OR
to prevent the development of asthma, asthma
symptoms, and asthma exacerbations by avoiding Allergic sensitzation can occur prenatally37,38. There is
or reducing exposure to risk factors should be currently insufficient information on the critical doses
implemented wherever possible. and timing of allergen exposure to permit intervention in
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At this time, few measures can be recommended this process, and no strategies can be recommended to
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for prevention of asthma because the development prevent allergic sensitization prenatally415. Prescription of
of the disease is complex and incompletely an antigen-avoidance diet to a high-risk woman during
pregnancy is unlikely to reduce substantially her risk of
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understood.
giving birth to an atopic child39. Moreover, such a diet may
Asthma exacerbations may be caused by a variety have an adverse effect on maternal and/or fetal nutrition.
of risk factors, sometimes referred to as "triggers",
including allergens, viral infections, pollutants, and T
The role of diet, particularly breast-feeding, in relation to the
NO
drugs. development of asthma has been extensively studied and,
Reducing a patients exposure to some categories in general, infants fed formulas of intact cows milk or soy
of risk factors improves the control of asthma and protein compared with breast milk have a higher incidence
O
OD
have other atopic diseases remains an area of investigation, Measure Evidence Evidence
and these interventions cannot be recommended for wide of effect of clinical
on allergen benefit
adoption in clinical practice at this time.
PR
levels
House dust mites
Encase bedding in impermeable covers Some None
RE
PREVENTION OF ASTHMA (adults)
Some
SYMPTOMS AND EXACERBATIONS (children)
Wash bedding in the hot cycle (55-60oC) Some None
OR
Replace carpets with hard flooring Some None
Acaricides and/or tannic acid Weak None
Asthma exacerbations may be caused by a variety of Minimize objects that accumulate dust None None
factors, sometimes referred to as triggers, including
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Vacuum cleaners with integral HEPA filter Weak None
allergens, viral infections400, pollutants, and drugs. and double-thickness bags
TE
Reducing a patients exposure to some of these categories Remove, hot wash, or freeze soft toys None None
of risk factors (e.g., smoking cessation, reducing exposure
to secondhand smoke, reducing or eliminating exposure
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Pets
to occupational agents known to cause symptoms, and Remove cat/dog from the home Weak None
avoiding foods/additives/drugs known to cause symptoms) Keep pet from main living areas/bedrooms Weak None
improves the control of asthma and reduces medication
needs. In the case of other factors (e.g., allergens, viral T
HEPA-filter air cleaners Some None
NO
Wash pet Weak None
infections and pollutants), measures where possible
Replace carpets with hard flooring None None
should be taken to avoid these. Because many asthma
Vacuum cleaners with integral HEPA filter None None
patients react to multiple factors that are ubiquitous in and double-thickness bags
the environment, avoiding these factors completely is
O
usually impractical and very limiting to the patient. Thus, *Adapted from Custovic A, Wijk RG. The effectiveness of measures to change the
-D
indoor environment in the treatment of allergic rhinitis and asthma: ARIA update
medications to maintain asthma control have an important (in collaboration with GA(2)LEN). Allergy 2005;60(9):1112-1115.
role because patients are often less sensitive to these risk
factors when their asthma is under good control. Patients Domestic mites. Domestic mite allergy is a universal
health problem59. Since mites live and thrive in many
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to indoor allergens are effective at reducing asthma has been suggested, although its efficacy at reducing
symptoms54,55 . The majority of single interventions symptoms has only been confirmed in deprived populations
have failed to achieve a sufficient reduction in allergen with a specific environmental exposure58 (Evidence B) and
T
load to lead to clinical improvement55-57. It is likely that a recommendation for its widespread use cannot be made.
GH
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Installation of non-polluting, more effective heating (heat
Cockroaches. Avoidance measures for cockroaches pump, wood pellet burner, flued gas) in the homes of
include eliminating suitable environments (restricting children with asthma does not significantly improve lung
PR
havens by caulking and sealing cracks in the plasterwork function but does significantly reduce symptoms of asthma,
and flooring, controlling dampness, and reducing the days off school, healthcare utilization, and visits to a
availability of food), restricting access (sealing entry pharmacist365.
RE
sources such as around paperwork and doors), chemical
control, and traps. However, these measures are only Outdoor Air Pollutants
partially effective in removing residual allergens68
OR
(Evidence C). Several studies have suggested that outdoor pollutants
aggravate asthma symptoms74, 356, possibly having an
Fungi. Fungal exposure has been associated with additive effect with allergen exposure75 . Outbreaks of
exacerbations from asthma and the number of fungal asthma exacerbations have been shown to occur in
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spores can best be reduced by removing or cleaning mold- relationship to increased levels of air pollution, and this
TE
laden objects69. In tropical and subtropical climates, fungi may be related to a general increase in pollutant levels
may grow on the walls of the house due to water seepage or to an increase in specific allergens to which individuals
and humidity. To avoid this, the walls could be tiled or are sensitized76-78. Most epidemiological studies show a
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cleaned as necessary. Air conditioners and dehumidifiers significant association between air pollutantssuch as
may be used to reduce humidity to levels less than 50% ozone, nitrogen oxides, acidic aerosols, and particulate
and to filter large fungal spores. However, air conditioning matterand symptoms or exacerbations of asthma. On
and sealing of windows have also been associated with T
occasion, certain weather and atmospheric conditions,
NO
increases in fungal and house dust mite allergens70. e.g., thunderstorms78 favor the development of asthma
exacerbations by a variety of mechanisms, including
Outdoor Allergens dust and pollution, increases in respirable allergens, and
O
changes in temperature/humidity.
Outdoor allergens such as pollens and molds are
-D
air conditioning if possible. Some countries use radio, to control, practical steps to take during unfavorable
television, and the Internet to provide information on environmental conditions include avoiding strenuous
outdoor allergen levels. The impact of these measures is physical activity in cold weather, low humidity, or high air
RI
caregivers of children with asthma should be advised not sensitized patients from any further exposure are important
to smoke and not to allow smoking in rooms their children aspects of the management of occupational asthma
use. In addition to increasing asthma symptoms and (Evidence B). Once a patient has become sensitized to
T
causing long-term impairments in lung function, active an occupational allergen, the level of exposure necessary
GH
cigarette smoking reduces the efficacy of inhaled and to induce symptoms may be extremely low, and resulting
systemic glucocorticosteroids71,72 (Evidence B). Asthma exacerbations become increasingly severe. Attempts
patients who smoke, and are not treated with inhaled to reduce occupational exposure have been successful
RI
glucocorticosteroids, have a greater decline in lung function especially in industrial settings, and some potent
than asthmatic patients who do not smoke378. Smoking sensitizers, such as soy castor bean, have been replaced
PY
cessation needs to be vigorously encouraged for all by less allergenic substances80 (Evidence B). Prevention
patients with asthma who smoke. of latex sensitization has been made possible by the
CO
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cost effective. to asthmatic adults and children over the age of 3 years,
including those with difficult-to-treat asthma91. There are
Food and Food Additives data to suggest that intranasal vaccination in children under
PR
age 3 may be associated with an increased incidence of
Food allergy as an exacerbating factor for asthma is asthma exacerbations92.
uncommon and occurs primarily in young children. Food
RE
avoidance should not be recommended until an allergy has Obesity
been clearly demonstrated (usually by oral challenges)83.
When food allergy is demonstrated, food allergen Increases in body mass index (BMI) have been associated
OR
avoidance can reduce asthma exacerbations84 (Evidence with increased prevalence of asthma93. Weight reduction in
D). Sulfites (common food and drug preservatives found obese patients with asthma, including by bariatric surgery,
in such foods as processed potatoes, shrimp, dried fruits, has been has been demonstrated to improve lung function,
beer, and wine) have often been implicated in causing symptoms, morbidity, and health status94 (Evidence B).
R
severe asthma exacerbations but the likelihood of a
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reaction is dependent on the nature of the food, the level Emotional Stress
of residual sulfite, the sensitivity of the patient, the form of
residual sulfite and the mechanism of the sulfite-induced
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Emotional stress may lead to asthma exacerbations
reaction85 . The role of other dietary substancesincluding in children402 and adults. Extreme emotional
the yellow dye tartrazine, benzoate, and monosodium expressions (laughing, crying, anger, or fear) can lead
glutamatein exacerbating asthma is probably minimal; to hyperventilation and hypocapnia that can cause
confirmation of their relevance requires double-blind
T
airway narrowing95,96. Panic attacks, that are rare but not
NO
challenge before making specific dietary restrictions. exceptional in some patients with asthma, have a similar
effect97,98. However, it is important to note that asthma is not
Drugs primarily a psychosomatic disorder.
O
Some medications can exacerbate asthma. Aspirin and Other Factors That May Exacerbate Asthma
-D
evidence that exposure to acetaminophen increases the treatment of bacterial sinusitis has been shown to
risk of asthma and wheezing in children401 and adults but reduce the severity of asthma99. However, sinusitis and
further studies are needed379. asthma may simply coexist. Apart from sinusitis, there
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exacerbate bronchospasm (Evidence A) and close medical asthma, especially in children, and asthma sometimes
supervision is essential when these are used by patients improves when the reflux is corrected100,101. Many women
MA
with asthma87. Beta blockers have a proven benefit in the complain that their asthma is worse at the time of
management of patients with acute coronary syndromes menstruation, and premenstrual exacerbations have been
and for secondary prevention of coronary events. Data documented102. Similarly, asthma may improve, worsen,
suggest that patients with asthma who receive newer more or remain unchanged during pregnancy103. A randomized
ED
cardio-selective beta blockers within 24 hours of hospital clinical trial of a self-regulation, telephone counseling
admission for an acute coronary event have lower in- intervention emphasizing sex and gender role factors in
hospital mortality rates366, 367. the management of asthma indicated that a program with
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MONITOR ASTHMA
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KEY POINTS: ASSESSING ASTHMA CONTROL
RE
The goal of asthma treatment, to achieve and Each patient should be assessed to establish his or her
maintain clinical control, can be reached in current treatment regimen, adherence to the current
a majority of patients with a pharmacologic regimen, and level of asthma control. A simplified
OR
intervention strategy developed in partnership scheme for recognizing controlled, partly controlled,
between the patient/family and the doctor. and uncontrolled asthma in a given week is provided in
Treatment should be adjusted in a continuous cycle Figure 4.3-1. This is a working scheme based on current
opinion and has not been validated. Several composite
R
driven by the patients asthma control status. If
asthma is not controlled on the current treatment control measures (e.g., Asthma Control Test105, Asthma
TE
regimen, treatment should be stepped up until Control Questionnaire106-108, Asthma Therapy Assessment
control is achieved. When control is maintained for Questionnaire109, Asthma Control Scoring System110)
have been developed and are being validated for various
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at least three months, treatment can be stepped
down. applications, including use by health care providers to
assess the state of control of their patients' asthma and by
In treatment-nave patients with persistent asthma, patients for self-assessments as part of a written personal
treatment should be started at Step 2, or, if very T
asthma action plan. Uncontrolled asthma may progress
NO
symptomatic (uncontrolled), at Step 3. For Steps 2 to the point of an exacerbation, and immediate steps,
through 5, a variety of controller medications are described in Component 4, should be taken to regain
available. control.
At each treatment step, reliever medication should
O
Ongoing monitoring is essential to maintain control The patients current level of asthma control and current
and to establish the lowest step and dose of
treatment determine the selection of pharmacologic
treatment to minimize cost and maximize safety.
AL
UC
A. Assessment of current clinical control (preferably over 4 weeks)
OD
(All of the following) (Any measure present)
PR
Daytime symptoms None (twice or More than twice/week Three or more features of
less/week) partly controlled
asthma*
Limitation of activities None Any
RE
Nocturnal None Any
OR
symptoms/awakening
R
Lung function (PEF or Normal <80% predicted or
TE
FEV1) personal best (if known)
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B. Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side-effects)
Features that are associated with increased risk of adverse events in the future include:
T
Poor clinical control, frequent exacerbations in past year*, ever admission to critical care for asthma, low
FEV1, exposure to cigarette smoke, high dose medications
NO
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate
By definition, an exacerbation in any week makes that an uncontrolled asthma week
Without administration of bronchodilator.
O
Lung function is not a reliable test for children 5 years and younger.
-D
Most of the medications available for asthma patients, Step 1: as-needed reliever medication. Step 1 treatment
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when compared with medications used for other chronic with an as-needed reliever medication is reserved for
diseases, have extremely favorable therapeutic ratios. untreated patients with occasional daytime symptoms
RI
Each step represents treatment options that, although not (cough, wheeze, dyspnea occurring twice or less per
of identical efficacy, are alternatives for controlling asthma. week, or less frequently if nocturnal) of short duration
TE
Steps 1 to 5 provide options of increasing efficacy, except (lasting only a few hours) comparable with controlled
for Step 5 where issues of availability and safety influence asthma (Figure 4.3-1). Between episodes, the patient is
the selection of treatment. Step 2 is the initial treatment asymptomatic with normal lung function and there is no
MA
for most treatment-nave patients with persistent asthma nocturnal awakening. When symptoms are more frequent,
symptoms. If symptoms at the initial consultation suggest and/or worsen periodically, patients require regular
that asthma is severely uncontrolled (Figure 4.3-1), controller treatment (see Steps 2 or higher) in addition to
ED
At each treatment step, a reliever medication (rapid- For the majority of patients in Step 1, a rapid-acting
T
onset bronchodilator, either short-acting or long- inhaled 2-agonist is the recommended reliever
GH
acting) should be provided for quick relief of symptoms. treatment114 (Evidence A). An inhaled anticholinergic,
However, regular use of reliever medication is one of the short-acting oral 2-agonist, or short-acting theophylline
elements defining uncontrolled asthma, and indicates that may be considered as alternatives, although they have
RI
controller treatment should be increased. Thus, reducing a slower onset of action and higher risk of side effects
or eliminating the need for reliever treatment is both an (Evidence A).
PY
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Management Approach Based On Control
***
**=
* ICS=Receptor
Preferred
= inhaled controller
antagonist glucocorticosteroids options
or are shown
synthesis in shaded boxes
inhibitors
theophylline
sustained
Low-dose release
ICS plus
leukotriene
Low-dose theophylline
Sustained ICS modifier
modifier**
high-dose
Leukotriene
options***
Controller Medium-or modifier
Leukotriene ICS plus
treatment
Anti-IgE
release
* long-acting
ICS
Low-dose 2-agonist
Low-dose ICS 2-inhaled
Medium-or agonist (lowest
plus
Oral ICS dose)
long-acting
glucocorticosteroid
, high-dose
Select Select one so
ele plus
2-agonistAs
acting T-Stcp
o3
ne oa
trertmo
ern
e
t,one
T
oS ed
tap4e
tire
h
e
trm
a entrapid-acting
As neededEnvironmental needed
rapid- 2 agonist control
Step
1 Step2 Asthma
Step
3 Step 4 education Step5
Reduce Treatm
entS teps Increase
E
xacerbation Treatasexacerbation
Uncontrolled Step up until controlled
Partly controlled
rI
e esaecn
Management Y
ears,A dolescentsandA dults Approach
Older ThanBased 5
ecud
On Control
PR
Reduce
Level of Control Treatment Action
RE
Controlled Maintain and find lowest controlling step
OR
Uncontrolled Step up until controlled
Increase
R
Exacerbation Treat as exacerbation
TE
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Reduce Treatment Steps Increase
T
NO
Step 1 Step 2 Step 3 Step 4 Step 5
Asthma education. Environmental control.
(If step-up treatment is being considered for poor symptom control, first check inhaler technique, check adherence, and confirm symptoms are due to asthma.)
O
As needed rapid-
As needed rapid-acting 2-agonist
-D
acting 2-agonist
Medium-or high-dose
Low-dose inhaled Low-dose ICS plus Oral glucocorticosteroid
ICS plus long-acting
ICS* long-acting 2-agonist
2-agonist (lowest dose)
RI
Controller
options*** Leukotriene Medium-or Leukotriene Anti-IgE
high-dose ICS
TE
Alternative reliever treatments include inhaled anticholinergics, short-acting oral 2-agonists, some long-acting 2-agonists, and short-acting theophylline.
GH
Regular dosing with short and long-acting 2-agonists is not advised unless accompanied by regular use of an inhaled glucocorticorsteriod.
RI
For management of asthma in children 5 years and younger, refer to the Global Strategy for the Diagnosis and Management
of Asthma in Children 5 Years and Younger, available at http://www.ginasthma.org.
PY
CO
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exercise-induced bronchoconstriction often indicates that of glucocorticosteroid is usually sufficient, and need
the patients asthma is not well controlled, and stepping only be increased if control is not achieved within 3 or 4
up controller therapy generally results in the reduction months with this regimen (Evidence A). The long-acting
PR
of exercise-related symptoms. For those patients who 2-agonist formoterol, which has a rapid onset of action
still experience exercise-induced bronchoconstriction whether given alone145,146,148 or in combination inhaler with
despite otherwise well-controlled asthma, and for those budesonide149, has been shown to be as effective as short-
RE
in whom exercise-induced bronchoconstriction is the only acting 2-agonist in acute asthma exacerbation. However
manifestation of asthma, a rapid-acting inhaled 2-agonist its use as monotherapy as a reliever medication is strongly
(short-or long-acting), taken prior to exercise or to relieve discouraged since it must always be used in association
OR
symptoms that develop after exercise, is recommended115. with an inhaled glucocorticosteroid.
A leukotriene modifier116,345 or cromone117 are alternatives
(Evidence A). Training and sufficient warm-up also For all children but particularly those 5 years and younger,
reduce the incidence and severity of exercise-induced combination therapy has been less well studied and the
R
bronchoconstriction118,119 (Evidence B). Information on addition of a long-acting 2-agonist may not be as effective
TE
treatment of exercise-induced asthma in athletes can as increasing the dose of inhaled glucocorticosteroids in
be found in a Joint Task Force Report prepared by the reducing exacerbations151-153 . However, the interpretation
European Respiratory Society, the European Academy of of some studies is problematic as not all children received
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Allergy and Clinical Immunology, and GA(2)LEN359 and the concurrent inhaled glucocorticosteroids152,153 .
World Anti-Doping Agency website (www.wada-ama.org).
If a combination inhaler containing formoterol and
Step 2: Reliever medication plus a single controller. T
budesonide is selected, it may be used for both rescue
NO
Treatment Steps 2 through 5, combine an as-needed and maintenance. This approach has been shown to
reliever treatment with regular controller treatment. result in reductions in exacerbations and improvements
At Step 2,a low-dose inhaled glucocorticosteroid is in asthma control in adults and adolescents at relatively
recommended as the initial controller treatment for asthma low doses of treatment154-157 (Evidence A). Whether this
O
patients of all ages111,120 (Evidence A). Equivalent doses approach can be employed with other combinations of
-D
of inhaled glucocorticosteroids, some of which may be controller and reliever requires further study.
given as a single daily dose, are provided in Figure 3-1 for
adults and in Figure 3-4 for children older than 5 years. Another option for both adults and children, but the
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for patients who are unable or unwilling to use inhaled high-dose of inhaled glucocorticosteroid delivered by a
glucocorticosteroids, or who experience intolerable side pressurized metered-dose inhaler, use of a spacer device
TE
effects such as persistent hoarseness from inhaled is recommended to improve delivery to the airways,
glucocorticosteroid treatment and those with concomitant reduce oropharyngeal side effects, and reduce systemic
MA
Other options are available but not recommended for routine Another option at Step 3 is to combine a low-dose inhaled
use as initial or first-line controllers in Step 2. Sustained- glucocorticosteroid with leukotriene modifiers165-173
ED
release theophylline has only weak anti-inflammatory (Evidence A). Alternatively, the use of sustained-release
and controller efficacy126-130 (Evidence B) and is commonly theophylline given at low-dose may be considered129
associated with side effects that range from trivial to (Evidence B). These options have not been fully studied
T
Step 3: Reliever medication plus one or two controllers. on prior selections at Steps 2 and 3. However, the order in
At Step 3, the recommended option for children403 and which additional medications should be added is based,
PY
adolescents and adults is to combine a low-dose of as far as possible, upon evidence of their relative efficacy
inhaled glucocorticosteroid with an inhaled long- in clinical trials. Where possible, patients who are not
CO
OD
causes of difficult-to-treat asthma.
When asthma control has been achieved, ongoing
The preferred treatment at Step 4 is to combine a monitoring is essential to maintain control and to establish
PR
medium-or high-dose of inhaled glucocorticosteroid the lowest step and dose of treatment necessary, which
with a long-acting inhaled 2-agonist. However, in minimizes the cost and maximizes the safety of treatment.
most patients, the increase from a medium-to a high- On the other hand, asthma is a variable disease, and
RE
dose of inhaled glucocorticosteroid provides relatively treatment has to be adjusted periodically in response to
little additional benefit104,159-161,174 (Evidence A), and the loss of control as indicated by worsening symptoms or the
high-dose is recommended only on a trial basis for 3 to 6 development of an exacerbation.
OR
months when control cannot be achieved with medium-
dose inhaled glucocorticosteroid combined with a long- Asthma control should be monitored by the health care
acting 2-agonist and/or a third controller (e.g. leukotriene professional and preferably also by the patient at regular
modifiers or sustained-release theophylline)130,175,346 intervals, using either a simplified scheme as presented in
R
(Evidence B). Prolonged use of high-dose inhaled Figure 4.3-1 or a validated composite measure of control.
TE
glucocorticosteroids is also associated with increased The frequency of health care visits and assessments
potential for adverse effects. At medium-and high-doses, depends upon the patients initial clinical severity, and the
twice-daily dosing is necessary for most but not all inhaled patients training and confidence in playing a role in the
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glucocorticosteroids176 (Evidence A). With budesonide, on-going control of his or her asthma. Typically, patients
efficacy may be improved with more frequent dosing are seen one to three months after the initial visit, and
(four times daily)177 (Evidence B). (Refer to Figure 3-1 for every three months thereafter. After an exacerbation,
adults and Figure 3-4 for children older than 5 years for T
follow-up should be offered within two weeks to one month
NO
recommendations on dosing and frequency for different (Evidence D). General practitioners should be encouraged
inhaled glucocorticosteroids.) to assess asthma control at every visit, not just when the
patient presents because of their asthma380.
Leukotriene modifiers as add-on treatment to medium-
O
Step 5: Reliever medication plus additional controller The reduced need for medication once control is achieved
TE
options. Addition of oral glucocorticosteroids to other is not fully understood, but may reflect the reversal of
controller medications may be effective179 (Evidence D) some of the consequences of long-term inflammation of
the airways. Higher doses of anti-inflammatory medication
MA
Patients should be counseled about potential side effects cyclical natural history of asthma. Rarely, asthma may go
and all other alternative treatments must be considered. into remission particularly in children aged 5 years and
younger and during puberty. Whatever the explanation,
T
Addition of anti-IgE treatment to other controller in all patients the minimum controlling dose of treatment
GH
medications has been shown to improve control of must be sought through a process of regular follow-up and
allergic asthma when control has not been achieved on staged dose reductions.
combinations of other controllers including high-doses of
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inhaled or oral glucocorticosteroids181-186 (Evidence B). At other times treatment may need to be increased either
in response to loss of control or threat of loss of control
PY
OD
Stepping Down Treatment When Asthma Is
Controlled
Stepping Up Treatment In Response To Loss Of Control
PR
There is little experimental data on the optimal timing,
sequence, and magnitude of treatment reductions in Treatment has to be adjusted periodically in response
to worsening control, which may be recognized by the
RE
asthma, and the approach will differ from patient to
patient depending on the combination of medications and minor recurrence or worsening of symptoms195. Treatment
the doses that were needed to achieve control. These options are as follows:
changes should ideally be made by agreement between
OR
patient and health care professional, with full discussion Rapid-onset, short-acting or long-acting 2-
of potential consequences including reappearance of agonist bronchodilators. Repeated dosing with
symptoms and increased risk of exacerbations. bronchodilators in this class provides temporary relief
until the cause of the worsening symptoms passes.
R
Although further research on stepping down asthma
treatment is needed, some recommendations can be The need for repeated doses over more than one or
TE
made based on the current evidence: two days signals the need for review and possible
increase of controller therapy.
When inhaled glucocorticosteroids alone in
AL
In the context of asthma self-management
medium-to high-doses are being used, a 50% studies, action plans in which the dose of inhaled
reduction in dose should be attempted at 3 month glucocorticosteroids was at least doubled were
intervals189-191 (Evidence B).
Where control is achieved at a low-dose of inhaled
T associated with improved asthma outcomes and
NO
reduced health care utilisation32. In placebo-
glucocorticosteroids alone, in most patients treatment controlled trials, temporarily doubling the dose of
may be switched to once-daily dosing192,193 (Evidence inhaled glucocorticosteroids was not effective404
A). (Evidence A), but an average interval of 5-7 days
O
OD
threatened exacerbation since studies involving doses of inhaled glucocorticosteroids beyond 6 months
doubling or quadrupling doses of combination in the hope of achieving better control. Instead, dose
treatment once deterioration is established (for 2 optimization should be pursued by stepping down to a dose
PR
or more days) show some benefit but results are that maintains the maximal level of control achieved on the
inconsistent195. Because there are no studies using higher dose.
this approach with other combinations of controller
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and relievers, other than budesonide/formoterol, Because very few patients are completely resistant to
the alternative approaches described in this section glucocorticosteroids, these medications remain a mainstay
should be used for patients on other controller of therapy for difficult-to-treat asthma, while additional
OR
therapies. diagnostic and generalized therapeutic options can and
should also be considered:
For children (6 to 17 years) who have uncontrolled asthma
despite the use of low-dose inhaled glucocorticosteroids, Confirm the diagnosis of asthma. In particular, the
R
step-up therapy with long-acting 2-agonist bronchodilator presence of COPD must be excluded. Vocal cord
TE
was significantly more likely to provide the best dysfunction must be considered.
response than either step-up therapy with inhaled Investigate and confirm adherence with treatment.
glucocorticosteroids or leukotriene receptor antagonist. Incorrect or inadequate use of medications and
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However, many children had a best response to inhaled inhalers405 remains the most common reason for
glucocorticosteroids or leukotriene receptor antagonist failure to achieve good control. In patients with
step-up therapy, highlighting the need to regularly monitor difficult-to-treat asthma, improved adherence and
and appropriately adjust each childs asthma therapy382. T improved health outcomes can be achieved with a
NO
comprehensive concordance intervention416.
Combination therapy with budesonide and formoterol
Consider smoking, current or past, and
used both as maintenance and rescue has been shown to
encourage complete cessation. A history of past
reduce asthma exacerbations in children ages 4 years and
O
maintenance treatment can generally be resumed at that may aggravate asthma. Chronic sinusitis,
previous levels unless the exacerbation was associated gastroesophageal reflux, and obesity/obstructive
sleep apnea have been reported in higher
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targeted level of control (Figure 4.3-1), some patients When these reasons for lack of treatment response have
will not do so even with the best therapy104. Patients who been considered and addressed, a compromise level of
do not reach an acceptable level of control at Step 4 control may need to be accepted and discussed with the
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(reliever medication plus two or more controllers) can patient to avoid futile over-treatment (with its attendant
be considered to have difficult-to-treat asthma198. These cost and potential for adverse effects). The objective is
then to minimize exacerbations and need for emergency
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OD
as is a degree of chronic lung function impairment.
Although lower levels of control are generally associated
with an increased risk of exacerbations, not all patients
PR
with chronically impaired lung function, reduced activity
levels, and daily symptoms have frequent exacerbations.
In such patients, the lowest level of treatment that retains
RE
the benefits achieved at the higher doses of treatment
should be employed. Reductions should be made
cautiously and slowly at intervals not more frequent than
OR
3 to 6 months, as carryover of the effects of the higher
dose may last for several months and make it difficult
to assess the impact of the dose reduction (Evidence
D). Referral to a physician with an interest in and/or
R
special focus on asthma may be helpful and patients
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may benefit from phenotyping into categories such as
allergic, aspirin-sensitive, and/or eosinophilic asthma201.
Patients categorized as allergic might benefit from anti-IgE
AL
therapy183, and leukotriene modifiers can be helpful for
patients determined to be aspirin sensitive (who are often
eosinophilic as well)172 .
T
NO
Thermoplasty
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appears to be more likely in males. A clinically useful tool
KEY POINTS: to assess the likelihood of asthma-related hospitalizations
or emergency department visits in adults with severe or
PR
Exacerbations of asthma (asthma attacks or acute difficult to treat asthma have been described349,418.
asthma) are episodes of progressive increase in
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shortness of breath, cough, wheezing, or chest Strategies for treating exacerbations, though generalizable,
tightness, or some combination of these symptoms. are best adapted and implemented at a local level204,205.
Exacerbations are characterized by decreases in Severe exacerbations are potentially life threatening, and
their treatment requires close supervision. Patients with
OR
expiratory airflow that can be quantified and monitored
by measurement of lung function (PEF or FEV1). severe exacerbations should be encouraged to see their
physician promptly or, depending on the organization of
The primary therapies for exacerbations include local health services, to proceed to the nearest clinic or
the repetitive administration of rapid-acting inhaled
R
hospital that provides emergency access for patients with
bronchodilators, the early introduction of systemic acute asthma. Close objective monitoring (PEF) of the
TE
glucocorticosteroids, and oxygen supplementation. response to therapy is essential.
The aims of treatment are to relieve airflow obstruction
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and hypoxemia as quickly as possible, and to plan the The primary therapies for exacerbations includein
prevention of future relapses. the order in which they are introduced, depending
on severity repetitive administration of rapid-acting
Severe exacerbations are potentially life threatening,
and their treatment requires close supervision. Most T
inhaled bronchodilators, early introduction of systemic
glucocorticosteroids, and oxygen supplementation202.
NO
patients with severe asthma exacerbations should be
The aims of treatment are to relieve airflow obstruction
treated in an acute care facility. Patients at high risk of
and hypoxemia as quickly as possible, and to plan the
asthma-related death also require closer attention.
prevention of future relapses.
Milder exacerbations, defined by a reduction in peak
O
flow of less than 20%, nocturnal awakening, and Patients at high risk of asthma-related death require closer
-D
increased use of short acting 2-agonists can usually attention and should be encouraged to seek urgent care
be treated in a community setting. early in the course of their exacerbations. These patients
include those:
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expiratory airflow that can be quantified by measurement of Who are overdependent on rapid-acting inhaled 2-
lung function (PEF or FEV1)202 . These measurements are agonists, especially those who use more than one
more reliable indicators of the severity of airflow limitation canister of salbutamol (or equivalent) monthly208
T
than is the degree of symptoms. The degree of symptoms With a history of psychiatric disease or psychosocial350
GH
may, however, be a more sensitive measure of the onset problems, including the use of sedatives209
of an exacerbation because the increase in symptoms With a history of poor adherence with asthma
usually precedes the deterioration in peak flow rate203 . medications and/or a written asthma action plan.
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significant change in symptoms. This situation especially be closely monitored using clinical as well as objective
affects patients with a history of near-fatal asthma and also measurements. The increased treatment should continue
CO
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these values. Patients who can be safely discharged will
have responded within the first two hours, at which time MANAGEMENTCOMMUNITY
decisions regarding patient disposition can be made.
SETTINGS
PR
ASSESSMENT OF SEVERITY
Most patients with severe asthma exacerbations should
RE
The severity of the exacerbation (Figure 4.4-1) determines be treated in an acute care facility (such as a hospital
the treatment administered. Indices of severity, particularly emergency department) where monitoring, including
OR
Figure 4.4-1. Severity of Asthma Exacerbations*
Mild Moderate Severe Respiratory arrest
imminent
R
Breathless Walking Talking At rest
TE
Infantsofter Infant stops feeding
shorter cry;
difficulty feeding
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Can lie down Prefers sitting Hunched forward
Talks in Sentences Phrases Words
Alertness May be agitated Usually agitated Usually agitated Drowsy or confused
Respiratory rate Increased Increased T Often > 30/min
NO
Normal rates of breathing in awake children:
Age Normal rate
< 2 months < 60/min
2-12 months < 50/min
1-5 years < 40/min
O
and/or
PaCO2 < 45 mm Hg < 45 mm Hg > 45 mm Hg;
GH
Possible respiratory
failure (see text)
SaO2% (on air) > 95% 91-95% < 90%
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*Note: The presence of several parameters, but not necessarily all, indicates the general classification of the exacerbation.
Note:Kilopascals are also used internationally; conversion would be appropriate in this regard.
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less than 20%, nocturnal awakening, and increased
use of short acting 2-agonists can usually be treated Severe exacerbations of asthma are life-threatening
in a community setting. If the patient responds to the medical emergencies, treatment of which is often most
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increase in inhaled bronchodilator treatment after the safely undertaken in an emergency department. Figure 4.4-
first few doses, referral to an acute care facility is not 2 illustrates the approach to acute care-based management
required, but further management under the direction of of exacerbations.
RE
a primary care physician may include the use of systemic
glucocorticosteroids. Patient education and review of Assessment
maintenance therapy should also be undertaken.
OR
A brief history and physical examination pertinent to the
exacerbation should be conducted concurrently with the
Treatment
prompt initiation of therapy. The history should include:
severity and duration of symptoms, including exercise
Bronchodilators. For mild to moderate exacerbations,
R
limitation and sleep disturbance; all current medications,
repeated administration of rapid-acting inhaled -agonists
including dose (and device) prescribed, dose usually
TE
(2 to 4 puffs every 20 minutes for the first hour) is usually
taken, dose taken in response to the deterioration, and the
the best and most cost-effective method of achieving rapid
patients response (or lack thereof) to this therapy; time
reversal of airflow limitation. After the first hour, the dose
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of onset and cause of the present exacerbation; and risk
of -agonist required will depend on the severity of the
factors for asthma-related death.
exacerbation. Mild exacerbations respond to 2 to 4 puffs
every 3 to 4 hours; moderate exacerbations will require 6
to 10 puffs every 1 or 2 hours. Treatment should also be
T
The physical examination should assess exacerbation
NO
severity by evaluating the patients ability to complete a
titrated depending upon the individual patients response, sentence, pulse rate, respiratory rate, use of accessory
and if there is a lack of response or other concern about muscles, and other signs detailed in Figure 4.4-2. Any
how the patient is responding, the patient should be complicating factors should be identified (e.g., pneumonia,
O
Many patients will be able to monitor their PEF after arterial oxygen saturation measurements are strongly
the initiation of increased bronchodilator therapy. recommended as physical examination alone may not
Bronchodilator therapy delivered via a metered-dose fully indicate the severity of the exacerbation, particularly
AL
inhaler (MDI), ideally with a spacer, produces at least an the degree of hypoxemia213,214 . Without unduly delaying
equivalent improvement in lung function as the same dose treatment, a baseline PEF or FEV1 measurement should be
164,211
delivered via nebulizer. At the clinic level, this route of
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personal best) and the response lasts for 3 to 4 hours. Oxygen saturation should be closely monitored, preferably
by pulse oximetry. This is especially useful in children
Glucocorticosteroids. Oral glucocorticosteroids (0.5 to because objective measurements of lung function may
1 mg of prednisolone/kg or equivalent during a 24-hour be difficult. Oxygen saturation in children should normally
ED
period) should be used to treat exacerbations, especially if be greater than 95%, and oxygen saturation less than
they develop after instituting the other short-term treatment 92% is a good predictor of the need for hospitalization210
options recommended for loss of control (see Stepping
T
(Evidence C).
up treatment in response to loss of control in Component
GH
3). If patients fail to respond to bronchodilator therapy, as In adults a chest X-ray is not routinely required, but should
indicated by persistent airflow obstruction, prompt transfer be carried out if a complicating cardiopulmonary process is
to an acute care setting is recommended, especially if they suspected, in patients requiring hospitalization, and in those
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are in a high risk group. not responding to treatment where a pneumothorax may be
difficult to diagnose clinically215 . Similarly, in children routine
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Initial Assessment (see Figure 4.4-1)
History, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate, PEF or FEV1, oxygen
saturation, arterial blood gas if patient in extremis)
PR
Initial Treatment
Oxygen to achieve O2 saturation 90% (95% in children)
Inhaled rapid-acting 2-agonist continuously for one hour.
RE
Systemic glucocorticosteroids if no immediate response, or if patient recently took oral glucocorticosteroid, or if episode is severe.
Sedation is contraindicated in the treatment of an exacerbation.
t
OR
Reassess after 1 Hour
Physical Examination, PEF, O2 saturation and other tests as needed
t t
R
Criteria for Severe Episode:
Criteria for Moderate Episode: History of risk factors for near fatal asthma
TE
PEF 60-80% predicted/personal best PEF < 60% predicted/personal best
Physical exam: moderate symptoms, accessory muscle use Physical exam: severe symptoms at rest, chest retraction
Treatment: No improvement after initial treatment
AL
Oxygen
Treatment:
Inhaled 2-agonist and inhaled anticholinergic every 60 min Oxygen
Oral glucocorticosteroids Inhaled 2-agonist and inhaled anticholinergic
Continue treatment for 1-3 hours, provided there is improvement Systemic glucocorticosteroids
T
Intravenous magnesium
NO
t t
Reassess after 1-2 Hours
O
t t t
Incomplete Response within 1-2 Poor Response within 1-2 Hours:
-D
Good Response within 1-2 Hours: Risk factors for near fatal asthma
Response sustained 60 min after last Hours:
Risk factors for near fatal asthma Physical exam: symptoms severe,
treatment Physical exam: mild to moderate signs
Physical exam normal: No distress drowsiness, confusion
PEF < 60% PEF < 30%
AL
Reassess at intervals
t t
Improved: Criteria for Discharge Home Poor Response (see above):
T
OD
to initial treatment, or when there is concern regarding on-demand therapy led to a significantly shorter hospital
deterioration. The patient should continue on supplemental stay, fewer nebulizations, and fewer palpitations when
oxygen while the measurement is made. A PaO2 < 60 mm compared with intermittent therapy given every 4 hours. A
PR
Hg (8 kPa) and a normal or increased PaCO2 (especially reasonable approach to inhaled therapy in exacerbations,
> 45 mm Hg, 6 kPa) indicates the presence of respiratory therefore, would be the initial use of continuous therapy,
failure. followed by intermittent on-demand therapy for hospitalized
RE
patients. There is no evidence to support the routine use
Treatment of intravenous 2-agonists in patients with severe asthma
exacerbations230 .
OR
The following treatments are usually administered
concurrently to achieve the most rapid resolution of the Epinephrine. A subcutaneous or intramuscular injection
exacerbation217: of epinephrine (adrenaline) may be indicated for acute
treatment of anaphylaxis and angioedema, but is not
R
Oxygen. To achieve arterial oxygen saturation of 90% ( routinely indicated during asthma exacerbations.
TE
95% in children), oxygen should be administered by nasal
cannulae, by mask, or rarely by head box in some infants. Additional bronchodilators.
For severe asthma exacerbations, controlled oxygen
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therapy using pulse oximetry to maintain oxygen saturation Ipratropium bromide. A combination of nebulized 2-agonist
at 90 93% is associated with better physiological with an anticholinergic (ipratropium bromide) may produce
outcomes, compared to high flow 100% oxygen therapy218, better bronchodilation than either drug alone231 (Evidence
419
. Oxygen therapy should be titrated against pulse
T
B) and should be administered before methylxanthines
NO
oximetry to maintain a satisfactory oxygen saturation219. are considered. Combination 2-agonist/anticholinergic
However, oxygen should not be withheld if oximetry is not therapy is associated with lower hospitalization rates212,232,233
available. (Evidence A) and greater improvement in PEF and
FEV1233 (Evidence B). Similar data have been reported
O
Rapid-acting inhaled 2agonists. Rapid-acting inhaled in the pediatric literature212 (Evidence A). However, once
-D
use of a combination of formoterol and budesonide early in than that of 2-agonists. The benefit as add-on treatment
asthma exacerbations. in adults with severe asthma exacerbations has not been
demonstrated. However, in one study of children with near-
A modestly greater bronchodilator effect has been shown fatal asthma, intravenous theophylline provided additional
ED
with levabuterol compared to racemic albuterol in both benefit to patients also receiving an aggressive regimen
adults and children with an asthma exacerbation223-226. In a of inhaled and intravenous 2-agonists, inhaled ipatropium
large study of acute asthma in children227, and in adults not bromide, and intravenous systemic glucocorticosteroids236.
T
acting 2-agonists in acute asthma provide conflicting The initial rapid-acting inhaled 2-agonist therapy fails
results. In a systematic review of six studies228, there were to achieve lasting improvement
CO
OD
glucocorticosteroids.
Magnesium*. Intravenous magnesium sulphate (usually
given as a single 2 g infusion over 20 minutes) is not
PR
Oral glucocorticosteroids are usually as effective as those
administered intravenously and are preferred because this recommended for routine use in asthma exacerbations,
route of delivery is less invasive and less expensive239,240 . but can help reduce hospital admission rates in certain
patients, including adults with FEV1 25-30% predicted at
RE
If vomiting has occurred shortly after administration of oral
glucocorticosteroids, then an equivalent dose should be presentation, adults and children who fail to respond to
re-administered intravenously. In patients discharged from initial treatment, and children whose FEV1 fails to improve
the emergency department, intramuscular administration above 60% predicted after 1 hour of care253,254,409 (Evidence
OR
may be helpful241, especially if there are concerns about A). Nebulized salbutamol administered in isotonic
compliance with oral therapy. Oral glucocorticosteroids magnesium sulfate provides greater benefit than if it is
require at least 4 hours to produce clinical improvement. delivered in normal saline255,256 (Evidence A). Intravenous
magnesium sulphate has not been studied in young
R
Daily doses of systemic glucocorticosteroids equivalent to
60-80 mg methylprednisolone as a single dose, or 300- children.
TE
400 mg hydrocortisone in divided doses, are adequate
for hospitalized patients, and 40 mg methylprednisolone Helium oxygen therapy. A systematic survey of studies
that have evaluated the effect of a combination of helium
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or 200 mg hydrocortisone is probably adequate in most
cases238,242 (Evidence B). An oral glucocorticosteroid dose and oxygen, compared to helium alone, suggests there is
of 1 mg/kg daily is adequate for treatment of exacerbations no routine role for this intervention. It might be considered
for patients who do not respond to standard therapy257.
in children with mild persistent asthma243. A 7-day course
in adults has been found to be as effective as a 14-day
T
NO
course244, and a 3-to 5-day course in children is usually Leukotriene modifiers. There are little data to suggest
considered appropriate (Evidence B). Two days of a role for leukotriene modifiers in acute asthma258. Small
oral dexamethasone can also be used to treat asthma investigations have demonstrated improvement in PEF410,
but clinical relevance requires more study.
O
days420. Evidence suggests that there is no benefit to Sedatives. Sedation should be strictly avoided during
tapering the dose of oral glucocorticosteroids, either in exacerbations of asthma because of the respiratory
the short-term245 or over several weeks, as long as the depressant effect of anxiolytic and hypnotic drugs. An
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patient is on maintenance inhaled glucocorticosteroids246 association between the use of these drugs and avoidable
(Evidence B). asthma deaths209,259 has been demonstrated.
RI
in acute asthma provided greater bronchodilation than discharged from the emergency department or admitted to
salbutamol alone247 (Evidence B), and conferred greater the hospital have been succinctly reviewed and stratified
benefit than the addition of systemic glucocorticosteroids based on consensus260 . Patients with a pre-treatment FEV1
across all parameters, including hospitalizations, especially or PEF < 25% percent predicted or personal best, or those
ED
for patients with more severe attacks248 . with a post-treatment FEV1 or PEF < 40% percent predicted
or personal best, usually require hospitalization. Patients
with post-treatment lung function of 40-60% predicted
T
discharged from the emergency department on prednisone available in the community and compliance is assured.
and inhaled budesonide have a lower rate of relapse than Patients with post-treatment lung function
those on prednisone alone237 (Evidence B). A high-dose 60% predicted can be discharged.
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40 mg oral prednisone daily251 (Evidence A). Cost is a is beyond the scope of this document and readers are
significant factor in the use of such high-doses of inhaled referred to recent comprehensive reviews261 .
CO
*Visit GINA website, www.ginasthma.org for GRADE review of question In adults with acute
78 ASTHMA MANAGEMENT AND PREVENTION exacerbations of asthma, does intravenous magnesium sulphate compared to placebo improve patient
important outcomes?
E
UC
For patients discharged from the emergency department: opportunity to review patient understanding of the causes
of asthma exacerbations, avoidance of factors that may
At a minimum, a 7-day course of oral cause exacerbations (including, where relevant smoking
OD
glucocorticosteroids for adults and a shorter course cessation), the purposes and correct uses of treatment, and
(3-5 days) for children should be prescribed, along the actions to be taken to respond to worsening symptoms
with continuation of bronchodilator therapy. or peak flow values263 (Evidence A).
PR
The bronchodilator can be used on an as-needed Referral to an asthma specialist should be considered for
basis, based on both symptomatic and objective hospitalized patients. Following discharge from continuous
improvement, until the patient returns to his or her pre- supervision, the patient should be reviewed by the family
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exacerbation use of rapid-acting inhaled 2-agonists. health care professional or asthma specialist regularly over
the subsequent weeks until personal best lung function is
Ipratropium bromide is unlikely to provide additional reached. Use of incentives improves primary care follow up
benefit beyond the acute phase and may be quickly
OR
but has shown no effect on long term outcomes264. Patients
discontinued. who come to the emergency department with an acute
Patients should initiate or continue inhaled exacerbation should be especially targeted for an asthma
glucocorticosteroids. education program, if one is available.
R
The patients inhaler technique and use of peak flow
TE
meter to monitor therapy at home should be reviewed.
Patients discharged from the emergency department
with a peak flow meter and action plan have a better
AL
response than patients discharged without these
resources8.
The factors that precipitated the exacerbation should T
NO
be identified and strategies for their future avoidance
implemented.
The patients response to the exacerbation should be
evaluated. The action plan should be reviewed and
O
exacerbations.
TE
OD
Special considerations are required in managing asthma Obesity
in relation to pregnancy; obesity; surgery; rhinitis, sinusitis,
and nasal polyps; occupational asthma; respiratory Asthma is more difficult to control in the obese patient 383-386.
PR
infections; gastroesophageal reflux; aspirin-induced This may be due to a different type of airway inflammation
asthma; and anaphylaxis. (less eosinophilic), obesity-related co-morbidities such
RE
as obstructive sleep apnea and gastroesophageal reflux,
Pregnancy mechanical factors or other as yet undefined factors. There
is not sufficient evidence to suggest that the management
During pregnancy the severity of asthma often changes, of asthma in the obese should be different than in patients
OR
and patients may require close follow-up and adjustment of with normal weight. However, there seems to be a reduced
medications. In approximately one-third of women asthma response to inhaled glucocorticosteroids in the obese
becomes worse; in one-third asthma becomes less severe; patient, and although this seems to be less evident with
R
and in the remaining one-third it remains unchanged during leukotriene antagonists, inhaled glucocorticosteroids
pregnancy265-267. are considered the mainstay of asthma treatment in this
TE
population385, 386.
Although there is a general concern about the use of any
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medication in pregnancy, poorly controlled asthma can Although asthma is not more often over-diagnosed in
have an adverse effect on the fetus, resulting in increased obese compared to non-obese patients, it is particularly
perinatal mortality, increased prematurity, and low birth important to confirm the diagnosis by objective measures
weight266,267. The overall perinatal prognosis for children
born to women with asthma that is well-managed during
T
of variable airway obstruction or bronchial hyper-
responsiveness, as respiratory symptoms associated to
NO
pregnancy is comparable to that for children born to women obesity may mimic asthma388. Weight loss in the obese
without asthma268. For this reason, using medications to patient improves asthma control, lung function and reduces
obtain optimal control of asthma is justified even when medication needs and should be included in the treatment
O
modifiers (specifically montelukast) is not associated mucus hypersecretion predispose patients with asthma to
with an increased incidence of fetal abnormalities369 . intraoperative and postoperative respiratory complications.
RI
Inhaled glucocorticosteroids have been shown to prevent The likelihood of these complications depends on the
exacerbations of asthma during pregnancy269,270 (Evidence severity of asthma at the time of surgery, the type of
TE
B). As in other situations, the focus of asthma treatment surgery (thoracic and upper abdominal surgeries pose the
must remain on control of symptoms and maintenance greatest risks), and type of anesthesia (general anesthesia
of normal lung function271. Acute exacerbations should with endotracheal intubation carries the greatest risk).
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be treated aggressively in order to avoid fetal hypoxia. These variables need to be assessed prior to surgery
Treatment should include nebulized rapid-acting 2- and pulmonary function should be measured. If possible,
agonists and oxygen and systemic glucocorticosteroids this evaluation should be undertaken several days before
should be instituted when necessary. surgery to allow time for additional treatment. In particular,
ED
discuss the safety of their medications, pregnant patients considered to reduce airflow limitation274,275 (Evidence
with asthma should be advised that the greater risk to their C). Furthermore, patients who have received systemic
GH
baby lies with poorly controlled asthma, and the safety of glucocorticosteroids within the past 6 months should
most modern asthma treatments should be stressed. Even have systemic coverage during the surgical period (100
with a good patient/health care professional relationship, mg hydrocortisone every 8 hours intravenously). This
RI
independent printed material, such as a statement from the should be rapidly reduced 24 hours following surgery, as
US National Asthma Education and Prevention Program on prolonged systemic glucocorticosteroid therapy may inhibit
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the treatment of asthma during pregnancy272, will provide wound healing276 (Evidence C).
important additional reassurance265,273.
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in some patients with asthma. Although the mechanisms when available. In children with suspected rhinosinusitis,
behind this relationship have not been established, antibiotic therapy for 10 days is recommended (Evidence
inflammation likely plays a similarly critical role in the B). Treatment should also include medications to reduce
PR
pathogenesis of rhinitis, sinusitis, and nasal polyps as in nasal congestion, such as topical nasal decongestants or
asthma. topical nasal or even systemic glucocorticosteroids. These
agents remain secondary to primary asthma therapies279,288.
RE
Rhinitis. The majority of patients with asthma have a
history or evidence of rhinitis and up to 30% of patients with Nasal polyps. Nasal polyps associated with asthma and
persistent rhinitis have or develop asthma277,278. Rhinitis rhinitis, and sometimes with aspirin hypersensitivity298, are
OR
frequently precedes asthma, and is both a risk factor for the seen primarily in patients over 40 years old. Between 36%
development of asthma279 and is associated with increased and 96% of aspirin-intolerant patients have polyps, and
severity and health resource use in asthma280. Rhinitis and 29% to 70% of patients with nasal polyps may have
asthma share several risk factors: common indoor and asthma298,299. Children with nasal polyps should be
R
outdoor allergens such as house dust mites, animal dander, assessed for cystic fibrosis and immotile cilia syndrome.
TE
and, less commonly, pollen affecting both the nose and Nasal polyps are quite responsive to topical
bronchi281,282, occupational sensitizers283, and non-specific glucocorticosteroids288. A limited number of patients with
factors like aspirin. For these reasons, the Allergic Rhinitis glucocorticosteroid-refractory polyps may benefit from
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and its Impact on Asthma (ARIA) initiative recommends that surgery.
the presence of asthma must be considered in all patients
with rhinitis, and that in planning treatment, both should be Occupational Asthma
considered together284. T
NO
Once a diagnosis of occupational asthma is established,
Both asthma and rhinitis are considered to be complete avoidance of the relevant exposure is ideally an
inflammatory disorders of the airway, but there are some important component of management300-302,412. Occupational
O
differences between the two conditions in mechanisms, asthma may persist even several years after removal
clinical features, and treatment approach. Although the from exposure to the causative agent, especially when
-D
inflammation of the nasal and bronchial mucosa may be the patient has had symptoms for a long time before
similar, nasal obstruction is largely due to hyperemia in cessation of exposure303,304. Continued exposure may
rhinitis, while airway smooth muscle contraction plays a lead to increasingly severe and potentially fatal asthma
AL
(Evidence A). Anti-inflammatory agents including therapy for occupational asthma is identical to therapy for
glucocorticosteroids and cromones as well as leukotriene other forms of asthma, but it is not a substitute for adequate
TE
modifiers and anticholinergics can be effective in both avoidance. Consultation with a specialist in asthma
conditions. However, some medications are selectively management or occupational medicine is advisable.
MA
asthma and reducing asthma morbidity in some but not all www.bohrf.org.uk/downloads/asthevre.pdf. (See also
studies289-291. Leukotriene modifiers125,292, allergen-specific reference 421.)
immunotherapy284,293, and anti-IgE therapy294,295 are effective
T
Additional information on this topic from the Allergic Rhinitis Respiratory infections have an important relationship
and its Impact on Asthma (ARIA) initiative can be found at to asthma as they provoke wheezing and increased
RI
Sinusitis. Sinusitis is a complication of upper respiratory studies have found that infectious microorganisms
infections, allergic rhinitis, nasal polyps, and other forms associated with increased asthma symptoms are often
CO
OD
cold), are the principal triggers of wheezing and worsening benefit. A study on adult patients with symptomatic asthma
of asthma in older children and adults310. Other respiratory without symptoms of gastroesophageal reflux found that
viruses, such as parainfluenza, influenza, adenovirus, and treatment with high dose proton pump inhibitors did not
PR
coronavirus, are also associated with increased wheezing improve symptoms or exacerbations of asthma393. In
and asthma symptoms311. Adults with asthma may be at patients with moderate to severe asthma treated with
increased risk of serious pneumococcal disease370. anti-inflammatory asthma medications and symptomatic
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gastroesophageal reflux, treatment with proton pump
A number of mechanisms have been identified that inhibitors demonstrated a small and probably clinically
explain why respiratory infections trigger wheezing and non-significant improvement in lung function and quality
OR
increased airway responsiveness, including damage to of life392. Few data are available on studies of treatment
airway epithelium, stimulation of virus-specific IgE antibody, for children with asthma symptoms and symptoms of
enhanced mediator release, and the appearance of a gastroesophageal reflux394.
late asthmatic response to inhaled antigen312. Thus, there
R
is evidence that viral infections are an adjuvant to the In summary, despite a high prevalence of asymptomatic
TE
inflammatory response and promote the development of gastroesophageal reflux among patients with poorly
airway injury by enhancing airway inflammation313. controlled asthma, treatment with proton-pump inhibitors
does not improve asthma control in adults392-394 or
AL
Treatment of an infectious exacerbation follows the same children422. Asymptomatic gastroesophageal reflux is
principles as treatment of other asthma exacerbations not a likely cause of poorly controlled asthma. Surgery
that is, rapid-acting inhaled 2-agonists and early for gastroesophageal reflux is reserved for the severely
introduction of oral glucocorticosteroids or increases T
symptomatic patient with well-documented esophagitis and
NO
in inhaled glucocorticosteroids by at least four-fold are failure of medical management. In patients with asthma,
recommended. Because increased asthma symptoms can it should be demonstrated that the reflux causes asthma
often persist for weeks after the infection is cleared, anti- symptoms before surgery is advised321,322.
inflammatory treatment should be continued for this full
O
The role of chronic infection with Chlamydia pneumoniae Up to 28% of adults with asthma, but rarely children with
and Mycoplasma pneumoniae in the pathogenesis or asthma, suffer from asthma exacerbations in response
AL
worsening of asthma is currently uncertain314. The benefit to aspirin and other nonsteroidal anti-inflammatory drugs
from macrolide antibiotics remains unclear315-317. A relatively (NSAIDs). This syndrome is more common in severe
small but well conducted study showed no evidence of asthma323 .
RI
glucocorticosteroids413. However, further research in this (AIA) are characteristic324. The majority of patients first
area is required. experience symptoms, which may include vasomotor
MA
reflux is more common in patients with asthma than The hypersensitivity to aspirin presents a unique picture:
in the general population392. This has led to research within minutes to one or two hours following ingestion of
to determine whether treatment of gastroesophageal aspirin, an acute, often severe, asthma attack develops,
T
reflux can improve asthma symptoms or control. and is usually accompanied by rhinorrhea, nasal
GH
Gastroesophageal reflux is undoubtedly a cause of dry obstruction, conjunctival irritation, and scarlet flush of the
cough and some of the confusion in the literature is head and neck. This may be provoked by a single aspirin
probably due to patients with dry cough symptoms being or other cyclooxygnease-1 (COX-1) inhibitor and include
RI
attributed to asthma. This relationship may in part relate violent bronchospasm, shock, loss of consciousness, and
to the use of medications to manage asthma, such as 2- even respiratory arrest325,326.
PY
OD
with AIA327,328. Airway expression of interleukin-5 (IL-5), can both mimic and complicate severe asthma. Effective
which is involved in recruitment and survival of eosinophils, treatment of anaphylaxis demands early recognition of the
is also increased328. AIA is further characterized by event. The possibility of anaphylaxis should be considered
PR
increased activation of cysteinyl leukotriene pathways, in any setting where medication or biological substances
which may be partly explained by a genetic polymorphism are given, especially by injection. Examples of documented
of the LTC4 synthase gene found in about 70% percent of causes of anaphylaxis include the administration of
RE
patients329. However, the exact mechanism by which aspirin allergenic extracts in immunotherapy, food intolerance
triggers bronchoconstriction remains unknown330. (nuts, fish, shellfish, eggs, milk), avian-based vaccines,
insect stings and bites, latex hypersensitivity, drugs
OR
The ability of a cyclooxygenase inhibitor to trigger reactions (-lactam antibiotics, aspirin and NSAIDs, and angiotensin
depends on the drugs cyclooxygenase inhibitory potency, converting enzyme (ACE) inhibitors), and exercise.
as well as on the individual sensitivity of the patient329.
Symptoms of anaphylaxis include flushing, pruritis,
R
A characteristic history of reaction is considered adequate urticaria, and angioedema; upper and lower airway
TE
for initiating avoidance strategies. However, the diagnosis involvement such as stridor, dyspnea, wheezing, or apnea;
can only be confirmed by aspirin challenge, as there dizziness or syncope with or without hypotension; and
are no suitable in vitro tests for diagnosis. The aspirin gastrointestinal symptoms such as nausea, vomiting,
AL
challenge test is not recommended for routine practice cramping, and diarrhea. Exercise-induced anaphylaxis,
as it is associated with a high risk of potentially fatal often associated with medication or food allergy, is a unique
consequences and must only be conducted in a facility physical allergy and should be differentiated from exercise-
with cardiopulmonary resuscitation capabilities331. Further T
induced bronchoconstriction338.
NO
safeguards are that patients should only be challenged
when their asthma is in remission and their FEV1 is Airway anaphylaxis could account for the sudden onset
greater than 70% of predicted or personal best. Bronchial of asthma attacks in severe asthma and the relative
(inhalational) and nasal challenges with lysine aspirin
O
in specialized centers332,333. Once aspirin or NSAID involved in an asthma attack, epinephrine should be the
hypersensitivity develops, it is present for life. Patients bronchodilator of choice. Prompt treatment for anaphylaxis
with AIA should avoid aspirin, products containing it, is crucial and includes oxygen, intramuscular epinephrine,
other analgesics that inhibit COX-1, and often also
AL
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349. Miller MK, Lee JH, Blanc PD, Pasta DJ, Gujrathi S, Johnson TR. A randomized trial of a self-regulation
Barron H, Wenzel SE, Weiss ST; TENOR Study Group. intervention for women with asthma. Chest 2007
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Bardagi S, Lamela J, Sanchis J; Spanish High Risk Immunology; GA(2)LEN. Treatment of exercise-induced
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16;(2):CD000011 RR, Little RJ. An evaluation of asthma interventions for
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NO
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parallel-group clinical trial. Am J Respir Crit Care Med
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HS, Ekelund J, Illueca M, Beckman O, Sostek MB.
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Effects of esomeprazole 40 mg twice daily on asthma:
DJ, Boehmer SJ, Martinez FD, et al.; Childhood
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15;183(2):171-8. 410. Ramsay CF, Pearson D, Mildenhall S, Wilson AM. Oral
montelukast in acute asthma exacerbations: a randomised,
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characteristics associated with the onset and course Jan;66(1):7-11.
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Jan;82(1):11-9. Noya FJ, Resendes S, Khomenko L, Rouleau R, Zhang
X. Written action plan in pediatric emergency room
403. Vaessen-Verberne AA, van den Berg NJ, van Nierop improves asthma prescribing, adherence, and control.
JC, Brackel HJ, Gerrits GP, Hop WC, Duiverman EJ; Am J Respir Crit Care Med. 2011 Jan 15;183(2):195-
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Nov 15;182(10):1221-7. D, Frings-Dresen MH, Mattioli S, Verbeek JH.
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corticosteroids for exacerbations of chronic asthma in T
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adults and children. Cochrane Database Syst Rev. 2010 413. Sutherland ER, King TS, Icitovic N, Ameredes BT,
Oct 6;(10):CD007524. Bleecker E, Boushey HA, et al; National Heart, Lung and
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405. Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, trial of clarithromycin for the treatment of suboptimally
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Martucci P, Serra M,Scichilone N, Sestini P, Aliani M, controlled asthma. J Allergy Clin Immunol. 2010
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term (5 year) safety of bronchial thermoplasty: Asthma control asthma. Respir Med. 2011 Sep;105(9):1308-15.
Intervention Research (AIR) trial. BMC Pulm Med. 2011
Feb 11;11:8. 417. Castro M, Rubin A, Laviolette M, Hanania NA, Armstrong
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408. Cox G, Thomson NC, Rubin AS, et al. Asthma control B, Cox G; AIR2 Trial Study Group. Persistence of
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Med. 2007;356:1327-37. severe asthma. Ann Allergy Asthma Immunol. 2011
Jul;107(1):65-70.
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versus titrated oxygen therapy in severe exacerbations
of asthma. Thorax. 2011 Nov;66(11):937-41.
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420. Kravitz J, Dominici P, Ufberg J, Fisher J, Giraldo P. Two
days of dexamethasone versus 5 days of prednisone in
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the treatment of acute asthma: a randomized controlled
trial. Ann Emerg Med. 2011 Aug;58(2):200-4.
OR
Barraclough R, Burge S, et al. Standards of care
for occupational asthma: an update. Thorax. 2012
Mar;67(3):278-80.
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422. Holbrook JT, Wise RA, Gold BD, Blake K, Brown ED,
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Castro M, et al. Writing Committee for the American
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Lansoprazole for children with poorly controlled
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asthma: a randomized controlled trial. JAMA. 2012 Jan
25;307(4):373-81.
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IMPLEMENTATION
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GUIDELINES IN
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CHAPTER 5: IMPLEMENTATION OF ASTHMA
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GUIDELINES IN HEALTH SYSTEMS
problem worldwide. Barriers to implementation range from
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KEY POINTS: poor infrastructure that hampers delivery of medicines to
remote parts of a country, to cultural factors that make
In order to effect changes in medical practice and patients reluctant to use recommended medications (e.g.,
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consequent improvements in patient outcomes, inhaled preparations), suboptimal use of medications21, and
evidence-based guidelines must be implemented and lack of physician use of guidelines.
disseminated at the national and local levels.
OR
An important barrier to the successful translation of asthma
Implementation of asthma guidelines should involve guidelines into clinical practice is access to available
a wide variety of professional groups and other and affordable medication especially for patients in less
stakeholders, and take into account local cultural and developed economies where the cost of treatment is high in
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economic conditions. comparison to income and assets.
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An important part of the implementation process is to
establish a system to evaluate the effectiveness and GUIDELINE IMPLEMENTATION
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quality of care.
STRATEGIES
Those involved in the adaptation and implementation
of asthma guidelines require an understanding of the
cost and cost effectiveness of various management
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Implementation of asthma guidelines should begin with the
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recommendations in asthma care. setting of goals and development of strategies for asthma
care through collaboration among diverse professional
GINA has developed a number of resources and groups including both primary and secondary health care
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programs to aid in guideline implementation and professionals, public health officials, patients, asthma
dissemination. advocacy groups, and the general public. Goals and
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Figure 5-1.
It has been demonstrated in a variety of settings that The next step is adaptation of guidelines on asthma
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patient care consistent with recommendations in evidence- management for local use by teams of local primary and
based asthma guidelines leads to improved outcomes. secondary care health professionals. Many low-and middle
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Guidelines are designed to ensure that all members of income countries do not consider asthma a high-priority
a patients health care team are aware of the goals of health concern because other, more common respiratory
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treatment and of the different ways of achieving these diseases such as tuberculosis and pneumonia are of
goals. They help set standards of clinical care, may serve greater public health importance1. Therefore, practical
as a basis for audit and payment, and act as a starting asthma guidelines for implementation in low-income
point for the education of health professionals and patients. countries should have a simple algorithm for separating
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evidence-based guidelines must be implemented and low-risk medications recommended for asthma control; a
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disseminated at national and local levels. Dissemination simple regime for recognizing severe asthma; and simple
involves educating clinicians to improve their diagnosis and management approaches relevant to the
awareness, knowledge, and understanding of guideline facilities and limited resources available.
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guidelines into real-life practice with improvement of health multiple venues and using multiple formats. This can be
outcomes for the patient. Implementation remains a difficult accomplished, for example, by publication in professional
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groups, government, and the private sector, have been
What is the size of the problem and burden of asthma in this implemented in Australia (Australian National Asthma
country or district?
Council, http://www.nationalasthma.org.au), and the
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What arrangements will be made for shared care among United States (National Asthma Education and Prevention
different health care providers (doctors and nurses, hospital
Program, http://www.nhlbi.nih.gov).
and primary care)?
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How will medical care be linked with community health facilities
An important part of the implementation process is to
and educational initiatives?
establish a system to evaluate the effectiveness and quality
What are the major preventable factors in this country or district of care. Evaluation involves surveillance of traditional
that could help prevent asthma from developing or could
OR
prevent asthma exacerbations from occurring in those who epidemiological parameters, such as morbidity and
already have asthma? mortality, as well as the specific audit of both process
What preconceived assumptions about asthma and its treatment and outcome within different sectors of the health care
system. Each country should determine its own minimum
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and what cultural factors will need special attention?
What treatments are currently used?
sets of data to audit health outcomes. There are a variety
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of assessment tools which provide a consistent and
How affordable and accessible are medications and services to
the patient?
objective assessment of asthma morbidity or control (e.g.,
Asthma Control Test9, Asthma Control Questionnaire10-12 ,
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What other treatments are available, cheap enough for
purchase, and stable in local climatic conditions?
Asthma Therapy Assessment Questionnaire13). Results
of these assessments should be recorded at each visit,
Can inhaler devices and medicines be standardized to reduce
providing a record of the long-term clinical response of
cost/storage/availability problems? T
the patient to treatment. Direct feedback provides several
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Who will provide emergency care?
benefits-a means for the patient/caregiver to become
Which groups of the population are at special risk (e.g., inner- familiar with, and sensitized to, satisfactory versus poor
city, poor, teenage, minority)?
control of asthma; a reference point from which to evaluate
Whom can we enlist to help in education (community health deteriorating asthma; and an indicator of changes in
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program that has improved patient outcomes is provided populations of asthma patients by considering the balance
by the national asthma program in Finland, a long-term, and tradeoffs between costs and clinical outcomes
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comprehensive, multifaceted public health initiative with (benefits and harms), often in relation to competing public
well-defined targets for asthma guideline implementation7,8. health and medical needs. Treatment costs must also be
CO
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involved in the adaptation and implementation of asthma Once data on use of health care resources are collected,
guidelines require an understanding of the cost and cost costs can be determined by assigning local currency
effectiveness of various management recommendations price weights to health care resources consumed. Unit
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in asthma care. To this end, a short discussion of cost- price weights are normally collected from government
effectiveness evaluation for asthma care follows. reports, price audits of local payers, billing records, claims
databases, and patient surveys.
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Utilization and Cost of Health Care Resources
Assessment of patient and caregiver travel and waiting
Between 35 and 50% of medical expenditures for time for medical visits, as well as absences from and
OR
asthma are consequences of exacerbations14, an asthma productivity while at school or work, comprise additional
outcome most view as representing treatment failure. and important outcome measures in asthma. These indirect
Hospitalization, emergency department and unscheduled costs of asthma are substantial, estimated to be roughly
clinic visits, and use of rescue medication comprise the 50% of the overall disease burden14 . However, there are no
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majority of exacerbation-related treatment costs. In clinical standardized, validated, and culturally adapted instruments
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trials of asthma treatments, exacerbations are customarily for assessing these measures in a variety of populations.
characterized by use of health care resources, alone or
in combination with symptom and lung function data, Determining the Economic Value of Interventions
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especially when the primary study outcome is reduction in Asthma
in the exacerbation frequency or time to an exacerbation
event. Routine collection of health care resource Economic evaluations require the selection of three main
consumption data can be undertaken in the field through
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outcome parameters-estimates of treatment-related health
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patient or caregiver self-report. In some circumstances, benefits, treatment-related risks, and treatment-related
automated data from clinical or billing records can costs. These parameters can be determined directly from
substitute for self-report and are more reliable and valid13,15. clinical studies or through the application of modeling
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one or more health care utilization items. These items measures. When the decision to be considered is at the
typically describe the presence of an exacerbation or macro-level, for example the inclusion of a new treatment
an exacerbation-related treatment in precise and valid in a government-sponsored health care program or the
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terms. Many of the published composite measures benefits package of a health insurer, economic evaluations
of asthma control have included hospitalization and require the use of a common metric such as life years
emergency treatment data, such as unscheduled or urgent gained, improvement in generic quality of life, or quality-
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care visits or use of nebulized 2-agonists and/or oral adjusted life years (QALY) gained18 . These outcomes
glucocorticosteroids17 . Although health care utilization support comparison of cost-effectiveness ratios across
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elements are essential to any pragmatic definition of different disease states and patient populations. However,
asthma control, as yet unanswered in the literature is which in asthma, QALYs are difficult to measure, particularly
MA
of the number of possible health care options (single items in children where validated preference measures are
or combinations of items) can contribute to an acceptable not available. Some have advocated the use of clinical
definition of control, and the values of each that might be measures such as symptom-free days or asthma control
viewed as acceptable control. as the denominator in economic evaluations19 . A unified
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health care professionals and patients in each region.
Educational materials based on this Global Strategy for
Asthma Management and Prevention are available in
GINA Assembly. To maximize interaction with global
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several forms, including a pocket guide for health care
asthma-care practitioners, a GINA Assembly was initiated
professionals and one for patients and families. These are
in January 2005. The Assembly provides a forum for
available on the GINA Website (http://www.ginasthma.org).
dialogue among these health care professionals and
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Each year, the GINA Science Committee examines peer-
facilitates sharing of information about scientific advances
reviewed literature on asthma management and updates
and implementation of health education, management, and
various GINA documents. A report of a GINA Working
prevention programs for asthma.
Group20 provides a blueprint for implementation strategies.
OR
Global Alliance Against Chronic Respiratory Diseases
Other activities to assist with implementation of asthma
(GARD). GINA is a partner organization of the Global
management recommendations through the GINA program
Alliance Against Chronic Respiratory Diseases (GARD),
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include:
a World Health Organization initiative (http://www.
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who.int/respiratory/gard/en/). The goal of GARD is to
Gina Website -www.ginasthma.org. The Internet is
facilitate collaboration among existing governmental
creating a conduit for the access, sharing, and exchange
and nongovernmental programs interested in chronic
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of information and permits the global distribution of
respiratory diseases to assure more efficient utilization
medical information. Although it is still not widely available,
of resources and avoid duplication of efforts. The
especially in low-income countries, the global trend is for
participating organizations will develop a comprehensive
increasing use of the Internet for medical education by T
global approach to the prevention and control of
NO
asthma patients and their health care providers. Thus, to
chronic respiratory diseases, with a special emphasis
facilitate communication with health professionals, health
on developing countries. Strategies for affordable drug
policy experts, patients, and their families internationally,
procurement through an Asthma Drug Facility (www.
GINA has maintained a Website since 1995 to provide
GlobalADF.org) are among the goals of GARD and are
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Almirall
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AstraZeneca
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Boehringer Ingelheim
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CIPLA
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Chiesi
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GlaxoSmithKline
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Novartis
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Quintiles
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Takeda
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