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Management

 Treatment Guidelines        Drug Therapy  


Management

Treatment Guidelines

Asthma is a chronic disease caused by inflammation of the airways. It is characterized by variable and recurring symptoms of breathlessness, coughing, and wheezing. Severe onset of such symptoms results in an asthma attack or acute asthma exacerbation. If a patient fails to receive appropriate treatment then it can further worsen the condition.

According to the Centers for Diseases Control and Prevention (CDC), asthma is the third leading cause of hospitalization among children under the age of 15 years. Goals of Therapy

Diagnosis of Asthma

Goals of Therapy

Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma –2007 provide a new approach to help the patients suffering from asthma symptoms. These guidelines focus on two major components:

Reducing Impairment
  • To prevent chronic and bothersome symptoms experienced by patients, such as, coughing, breathlessness in the day time, night, or after exertion
  • In maintaining normal activity levels (including exercise and other physical activity and attendance at school or work)
  • To maintain nearly or normal lung (pulmonary) function
Reducing Risk
  • To prevent the recurrent exacerbations of asthma and to minimize the need for emergency visits or hospitalizations
  • To prevent loss of lung function and side effects of drug therapy

According to EPR-3, there are four components, which should be considered for effective asthma control.

Diagnosis of Asthma

Step 1: Asthma Diagnosis

Based on the physical examination and medical history, your physician will determine if any of the following indicators are present or not:

  • Dyspnea (shortness of breath) and coughing (worse at night or early in the morning, making it hard to sleep)
  • Breathing problem or chest tightness or pain
  • Nasal irritation
  • Wheezing (wheezing is a whistling or shrill sound that occurs when you breathe, especially at night)
  • Your doctor will check whether these symptoms occur or get worse with exercise, viral infection, exposure to allergens and irritants, changes in weather, stress, or any other factor

(Hyperlink to test and diagnosis section)

Step 2: Assessment and Monitoring

  • Initial visit: Before the initial treatment, your physician will assess the severity of asthma and determine whether you are suffering from intermittent, mild persistent, moderate persistent, or severe persistent asthma

Stage 1

Intermittent (Irregular)

Symptoms occur not more than two times per week and night-time awakening occurs not more than twice per month

Stage 2

Mild Persistent

Symptoms occur more than two days per week but not daily, and three to four night-time awakenings each month

Stage 3

Moderate Persistent

Asthma symptoms appear once every day and night-time awakenings occurs more than once per week

Stage 4

Severe Persistent Asthma

Symptoms occur throughout the day, every day and night-time awakening may occur every night

 

Step 3: Initiate the Drug Therapy: Based on the severity of the asthma attack, your physician will select an appropriate therapy to control your asthma symptoms.

  • A short acting beta agonist (SABA) is used as a preferred therapy for people suffering from intermittent asthma as they provide quick relief from asthma symptoms. Albuterol (SABA), a bronchodilator when inhaled produces bronchodilation within five minutes and the action lasts for two to four hours. However, frequent use of SABA may indicate that a patient has poorly controlled asthma and there is a need to step up the treatment. Short course of oral systemic corticosteroids is considered if asthma exacerbations/attack is severe or if a patient has history of severe exacerbations/attacks
  • Inhaled Corticosteroids (ICSs) are the preferred first line treatment for patients suffering from persistent asthma (long-term control). ICSs are the most effective anti-inflammatory therapy for all age groups. They are given in combination with Long-Acting Beta Agonists (LABAs)
Caution:

 LABAs should not be used as monotherapy for long-term control. Even though symptoms may improve significantly, it is better to use ICSs while taking LABA.The dose of ICSs and LABA depends on whether the patient is suffering from mild persistent, moderate persistent or severe persistent asthma

  • While selecting the medication, the patient’s history of response to the medication, willingness, and ability to use a particular therapy is also considered

Diagnosis of Asthma

Step 4: Patient Education for Self-Management: Education plays a key role in the management of asthma and with adequate knowledge you can control your asthma symptoms.

  • You should monitor your symptoms regularly to check whether the asthma symptoms are under control and to recognize the signs of worsening asthma. This may reduce the need for emergency visits or hospital admission
  • Develop an asthma action plan: Developing a written asthma action plan based on peak flow (hyperlink to peak flow) and/or symptom-monitoring may assists you to manage your asthma symptoms. Make sure you update your asthma action plan at every visit (at least after every six months)

Step 5: Control of Environmental factors and Co-morbid Conditions

  • Your physician may recommend multifaceted approaches to control the exposures to allergens and irritants (hyperlink) to which you are sensitive
  • If you are suffering from other co-morbid conditions like gastro esophageal reflux disease (GERD), obesity, obstructive sleep apnea, rhinitis and sinusitis, stress, or depression, treating these conditions may help improve the symptoms of asthma

Step 6: Follow-up visits: If you need a dose adjustment, then your physician may schedule follow-up visits. During each visit:

  • Asthma control, proper medication technique, and written asthma action plan is assessed
  • Lung function is measured with the help of spirometry (hyperlink to test and diagnosis section) at least once every one to two years (more frequently for asthma that is not well controlled)
  • The need to adjust the therapy is determined
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