++
++
► Global Initiative for Asthma (GINA) 2021
++
–Advise pregnant persons and parents of young children not to smoke.
–Treat vitamin D deficiency in pregnant persons.
–Encourage vaginal delivery.
–Minimize use of broad-spectrum antibiotics during the first year of life.
++
Practice Pearls
Environmental exposures such as automobile exhaust and dust mites are associated with higher rates of asthma, while others (household pets and farm animals) may be protective. Avoiding tobacco smoke and air pollution is protective, but allergen avoidance measures have not been shown to be effective in primary prevention.
Public health interventions to reduce childhood obesity, increase fruit and vegetable intake, improve maternal-fetal health, and reduce socioeconomic inequality would address major risk factors. (Lancet. 2015;386:1075–1085)
Maternal intake of allergenic food likely decreases the risk of allergy and asthma in offspring.
Breastfeeding is generally advisable, but not for the specific purpose of preventing allergies and asthma.
Obesity in pregnancy is associated with asthma development in children, but data is lacking on the safety and efficacy of weight loss efforts during pregnancy.
++
++
Children > 5 y and Adults, Acute Exacerbation
++
++
–Consider alternative causes for the patient’s respiratory symptoms, including anaphylaxis, foreign body, bronchiectasis, congenital heart disease/cardiac failure, pulmonary embolism, and chronic obstructive pulmonary disease (COPD).
–If in the clinic, assess the severity of asthma exacerbation while starting short-acting beta agonist (SABA) and supplemental oxygen as needed. Transfer to acute care facility if altered mentation, silent chest, or signs of severe exacerbation (agitated, accessory muscle use, HR > 120, 90% O2 saturation on room air) are observed. Give inhaled SABA, inhaled ipratropium bromide, oxygen, and systemic corticosteroids as soon as possible.
–If in the ED, start treatment with repeated doses of inhaled SABA, early oral corticosteroids, and supplemental oxygen. Titrate oxygen to maintain O2 saturation 93%–95% in adults, and 94%–98% in children aged 6–12 y.
–Consider IV magnesium if patient is not responding to initial SABA, ipratropium bromide, oxygen, and systemic steroids.
–No role for routine antibiotics, chest X-ray (CXR), or blood gases in asthma exacerbation. Use antibiotics only for suspected bacterial infections.
–After stabilization:
Initiate inhaled corticosteroid (ICS) before hospital discharge or step-up ICS treatment for 2–4 wk. Stress daily use.
Prescribe 5–7 d course oral corticosteroid for adults and 3–5 d course for children. Follow-up within 2–7 d to ensure symptoms are well controlled and that the treatment is continued.
Use the exacerbation as an opportunity to review the patient’s chronic medication regimen, identify misunderstandings, and review the asthma action plan.
++