Introduction
Patients with asthma should be re-assesed at regular intervals to ensure compliance, understanding and overall control of their asthma. It is good practice for such patients to be seen at least yearly or twice yearly, for example at the end of summer or prior to spring if cold weather or seasonal allergies are a trigger. Poorly controlled asthmatics should be seen more often until they reach a level of improved symptoms.
At these visits, medications should be reviewed, in addition to their proper use. Refills should be given if needed, and use of a spacer reinforced. If the child is on steroids for maintenance, reminders to wash their mouth out after use should be provided.
CLICK ON THE LINKS BELOW FOR VIDEO EXAMPLES OF
HOW TO USE A SPACER AND FACEMASKS
Trigger avoidance should be discussed and reviewed, and consideration should be given to allergy testing if appropriate.
If there are changes in medication, a new asthma action plan should be given to and review to the family, and a new copy should be provided to the child's school or daycare.
Click on the link below to access an
asthma action plan.
Goals of pharmacologic management include:
- Reducing the amount of impairment caused by symptoms.
- Preventing future severe attacks, ER or urgent care visits and hospitalizations.
Asthma Classification
Classification of asthma severity can help guide pharmacological treatment. The table below can serve as a rudimentary guide, but does not include all possible evidence-based treatment options.
Additionally, treatment must be personalized to each patient and should take into consideration the severity of previous exacerbations as well as triggers and comorbid conditions.
|
|
Daytime symptoms (albuterol use) |
Nighttime symptoms* |
FEV1, FEV1/FVC* |
Risk of exacerbations requiring oral steroids |
Initial treatment (not all-inclusive) |
|---|---|---|---|---|---|
|
Mild intermittent |
<2/week |
<2/month *0 times |
>80% >85% |
0-1/year |
Step 1: Albuterol prn only |
|
Mild persistent |
>2/week, but not daily |
<1/week *1-2/month |
>80% >80% |
2 or more/year |
Step 2: Low dose ICS |
|
Moderate persistent |
Daily |
>1/week *3-4/month |
60-80% 75-80% |
2 or more/year |
Step 3: <11 yo: med dose ICS >12 yo: above or LABA + low dose ICS |
|
Severe persistent |
Several times per day |
Often daily *>1/week |
<60% <75% |
2 or more/year |
Step 3: <11 yo: med dose ICS
Step 4: LABA + med dose ICS
Step 5: LABA + high dose ICS
Step 6: above + systemic steroids |
*Difference in classification for 0-4 year olds for nighttime symptoms. Spirometry not conducted this age group. ICS: Inhaled corticosteroids (flovent, pulmicort). LABA: Long-acting beta agonists, always combined with an ICS (symbicort, advair). Leukotriene receptor antagonist (LTRA) may be used for the maintenance treatment of asthma, particularly when there is also a diagnosis of seasonal allergies.
If symptoms continue to persist at a level greater than “mild intermittent,” then asthma is not adequately controlled. In poorly controlled asthma, discuss adherence, inhaler technique, and control of environmental triggers prior to stepping up the level of therapy.
Patients and providers can also consider stepping down therapy if symptoms are well controlled for 3 months.
References
- National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.
- Thomas A, Lemanske RF Jr, Jackson DJ.Approaches to stepping up and stepping down care in asthmatic patients. J Allergy ClinImmunol 2011; 128:915
- Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). www.ginasthma.org