Management of Asthma

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National and international guidelines for the management of asthma concur on the goals of therapy (Table 1)  and on the components of the care necessary to achieve them (Table 2). The components of care involve eliminating or avoiding disease exacerbating factors, monitoring, education and pharmacotherapy. The guidelines agree that pharmacotherapy should consist of the treatment that can most effectively reduce symptoms, prevent exacerbations and maintain lung function as near to normal as possible while producing the least amount of adverse effects.

Table 1. Goals of asthma management

Goals

• Prevent chronic and troublesome symptoms
• Maintain “normal” pulmonary function
• Maintain normal activity levels
• Prevent recurrent exacerbations of asthma
• Provide optimal pharmacotherapy with minimal or no adverse effects
• Meet patients’ and families’ expectations

Table 2. Major components of asthma management

1) Avoidance off Contributing Factors я

• Skin testing to identify allergens
• Control of household and workplace allergens and irritants
• Prevention and treatment of viral infections
• Prevention and treatment of gastroesophageal reflux

2) Patient Education

• Provide basic asthma education
• Teach and reinforce inhaler and peak flow technique
• Develop action plans
• Encourage self-management

3) Periodic Assessment and Monitoring

• Monitor signs and symptoms of asthma
• Monitor pulmonary function (spirometry, peak flow monitoring)
• Monitor quality of life and functional status
• Monitor history of asthma exacerbations
• Monitor pharmacotherapy (adverse effects, inhaler technique and frequency of quick reliever use)
• Monitor patient-provider communication and patient satisfaction

4) Pharmacotherapy

• Explain and reinforce role of medications (quick relief, long-term agents)
• Stepwise therapy recommended with provision for step-up and step-down in therapy

Table 3. Stepwise approach to asthma management (preferred therapies in bold)

Step 1 Mild Intermittent	Step 2 Mild Persistent	Step3 Moderate Persistent	Step 4 Severe Persistent
Quick Relief • Short-acting inhaled beta-2 agonist as needed for symptoms	Quick Relief • Short-acting inhaled beta-2 agonist as needed for symptoms	Quick Relief • Short-acting inhaled beta-2 agonist as needed for symptoms	Quick Relief • Short-acting inhaled beta-2 agonist as needed for symptoms
Long-Term Control Daily medications: • Not necessary	Long-Term Control Daily medications: • Low-dose inhaled corticosteroid OR •    Cromolyn, nedocromil OR •    Theophylline OR •    Leukotriene inhibitors	Long-Term Control Daily medications: • Low-to-medium dose inhaled corticosteroid plus LABA OR • Medium dose inhaled corticosteroid OR • Low-to-medium dose inhaled corticosteroid plus sustained-release theophylline OR • Low-medium dose inhaled corticosteroid plus leukotriene modifier	Long-Term Control Daily medications: • High-dose inhaled corticosteroid plus LABA AND if needed • Systemic corticosteroids • The addition of a third controller medication to inhaled corticosteroid and LABA has not been adequately studied

The current national and international guidelines for the management of asthma again resemble each other in recommending a stepwise approach to matching the intensity of therapy to the severity of asthma as outlined in Table 3. The classification is based upon the frequency and severity of symptoms, the frequency of nocturnal awakenings and the severity of airflow obstruction as revealed by an objective test of pulmonary function, such as the FEVj or peak expiratory flow (PEF). This classification is outlined in Table 4. It is important to note that the severity classification is determined by the worst rating in any single category and that patients may change classifications at various time points depending on clinical status. Asthma characterized by daytime symptoms occurring more often than twice weekly, by nocturnal symptoms occurring more often than twice monthly and by pulmonary function in the normal range is classified as “mild persistent asthma.” Daily use of a long-term controller therapy (step 2) is indicated for this level of severity. The preferred long-term controller therapy is a low dose of an inhaled corticosteroid, with the chromones (cromolyn sodium), leukotriene modifiers and theophylline as nonpre-ferred alternatives. More intensive therapy (step 3) is indicated for moderate persistent asthma, if the patient has daily symptoms, experiences exacerbations that affect activity twice weekly or is awakened by asthmatic symptoms more often than once weekly. Patients are also classified as having moderate persistent asthma if their baseline lung function is reduced to 60-80% of the values predicted, even if their symptoms are infrequent and mild. The preferred therapy for step 3 is the addition of a LABA toa low-to-medium dose of an inhaled corticosteroid. The alternatives include increasing the dose of inhaled corticosteroids and the addition of either a sustained-release theophylline or a leukotriene modifier to low-to-medium-dose inhaled corticosteroids, but these options are not preferred. Step-4 therapy is then reserved for patients who respond inadequately to step-3 therapy and includes high-dose inhaled corticosteroids plus LABA and the possible addition of oral corticosteroids. Minimal evidence is available to appropriately evaluate the efficacy of adding a third long-term controller drug. Thus, it is recommended that these patients be referred to a specialist.

Table 4. Classification of asthma severity by symptoms

Step 4 Severe persistent	Days with Symptoms Continual Limits activity	Nights with Symptoms Frequent	PEF or FEVt PEF Variability <60% >30%
Step 3 Moderate persistent	Daily Affects activity	>5/month	>60%-<80 >30%
Step 2 Mild persistent	3-6/week	3-4/month	>80% 20-30%
Step 1 Mild	<2/week	<2/month	>80% <20%

In reality, patients may move up or down along a continuum of severity, rather than remain in a clearly defined step and, thus, provisions are made for stepping therapy up or down as needed to control the disease. Adequate control of asthma is defined as the maintenance of symptoms and pulmonary function meeting the criteria for “mild intermittent” asthma. This means that as-needed, inhaled short-acting beta-2-agonist rescue medications are taken no more often than twice weekly, nocturnal awakenings occur no more often than twice monthly, and infrequent, and exacerbations are brief, causing little interference with function. If a patient experiences an exacerbation requiring significant intervention (i.e., a course of prednisone, emergency department visit or hospitalization) they are considered appropriate for step-3 or -4 therapy for at least 2-3 months following the exacerbation.

The combination of a LABA and an inhaled corticosteroid was initially listed as an optional therapy for severity steps 3 (“moderate persistent”) and 4 (“severe persistent”), based upon two seminal studies demonstrating that lung function and asthma control improved more when salmeterol was added to a low or medium dose of an inhaled corticosteroid than when the dose of the inhaled corticosteroid was doubled. Since the publication of the 1997 NAEPP Expert Panel Report 2, numerous well-controlled clinical trials provided a persuasive argument for making the addition of a LABA to low-to-medi¬um dose inhaled corticosteroids as the only preferred therapy for step-3 and step-4 therapy in the new recommendations. Some of these studies will be reviewed in more detail below. Beat the drug companies and buy cheap levitra