NAEP outlines four components of care: assessment and monitoring, provision of education, control of environmental factors and comorbid conditions, and use of medications.3 The goals of asthma therapy are two-fold:3
To determine appropriate medication management, assess severity based on symptoms, medication usage, and lung function (Figure 55-1). In addition, assess risk based on number of exacerbations requiring systemic steroids (Figure 55-1). For children, severity is assessed through symptoms, night time awakenings, interference with normal activity, and lung function; the latter if the child is older than 4 years of age. Risk is assessed by exacerbations requiring systemic steroids and treatment-related adverse effects.3 A chart for children is available in the NAEP reference to facilitate these assessments and includes treatment protocols.3
For youths age 12 years and up and adults, persistent asthma can then be divided into mild, moderate, or severe; these categories are matched to steps of medications described below and shown in Figure 55-1. Children are categorized as controlled, not-well controlled, or very poorly controlled with steps of care suggested as well.
The NAEP six steps of care with respect to asthma medications are:3
- Step 1: For all patients of all ages with intermittent asthma, an inhaled short-acting β2-agonist (SABA) is recommended. SOR A Metered-dose inhalers with spacers are at least as effective (with fewer side effects) as nebulized treatment for most patients.
- Step 2: Low-dose inhaled corticosteroids (ICSs) are the preferred long-term control therapy for all ages with persistent asthma. SOR A Alternatives include cromolyn inhaler, leukotriene receptor antagonist (LTRA), nedocromil, or theophylline.
- LTRAs are less effective than ICSs but better than placebo.3 SOR A
- In a RCT of preschool-age children with recurrent wheezing (N = 278), intermittent budesonide inhalation suspension (1 mg twice daily for 7 days, starting early during a predefined respiratory tract illness) was as effective as a daily low-dose regimen (0.5 mg nightly) in preventing acute exacerbations (about 1 fewer per patient-year) while reducing mean exposure to budesonide.19
- Step 3: Combination low-dose ICSs and long-acting β2-agonist (LABA) or medium-dose ICSs are equally preferred options in patients older than 4 years of age.3 SOR A Alternatives include low-dose ICS plus LTRA (less effective than ICS and LABA), theophylline, or zileuton. Theophylline requires monitoring serum concentration levels. Zileuton is less desirable because of limited supporting data and the need to monitor liver function. Authors of a Cochrane review found the combination ICS-LABA modestly more effective in reducing the risk of exacerbations requiring oral corticosteroids than higher-dose ICSs for adolescents and adults, but a trend toward increased risks of exacerbation and hospitalization among children.20
- For patients age 4 years and younger, low-dose ICSs and LABA are suggested initially by NAEP, followed by increasing the ICS dose if persistent low lung function and more than 2 days per week of impairment3; the ICS-LABA combination may not reduce exacerbations but appears to improve PEF and growth.21 Although serious asthma-related events (asthma-related deaths, intubations, and hospitalizations) attributable to LABAs appear to be greatest among children, in a metaanalysis, there was no statistically significant difference in serious events by age group for the subgroup on both ICS and LABA.22
- One trial of step-up therapy for children with not-well-controlled persistent asthma on ICSs found that although combination ICS-LABA was most likely to result in a best response, some children had a best response to doubling ICSs or combination ICSs-LTRA.23
- Step 4: Combination medium-dose ICS and LABA. Alternatives are combination medium-dose ICS plus LTRA, theophylline, or zileuton (see above).
- Step 5: Combination high-dose ICS and LABA.
- Step 6: Combination high-dose ICS and LABA plus oral corticosteroid.
- In a RCT, the addition of tiotropium bromide (a long-acting anticholinergic agent approved for the treatment of COPD but not asthma) to inhaled ICSs was superior to doubling the ICS dose in improving lung function and symptoms and noninferior to the addition of a LABA to ICSs (step 3 above).24
- Omalizumab should be considered for patients older than 11 years of age who have allergies or for adults who require step 5 or 6 care (severe asthma).3 In a RCT with inner-city children, adolescents, and young adults (N = 419) with persistent asthma, omalizumab reduced symptom days and the proportion of subjects who had 1 or more exacerbations (30.3% vs. 48.8% on placebo).25
- To assist with smoking cessation, consider nicotine-replacement therapy (bupropion [150 mg, twice daily], varenicline [1 mg twice daily], nortriptyline [75 to 100 mg daily], or nicotine replacement [gum, inhaler, spray, patch]) and supportive counseling and follow-up; using these interventions improves rates of smoking cessation by up to two-fold (Chapter 236, Tobacco Addiction).26-28 SOR A
- In patients with persistent asthma attributed to allergies, consider allergy immunotherapy.3 SOR B One metaanalysis concluded that specific immunotherapy for patients with positive skin tests resulted in a reduction in need for increased medications (number needed to treat = 5) and another study in patients with high IgE found immunotherapy reduced exacervations.4
- Using proton pump inhibitor therapy in adults with asthma is unlikely to add significant benefit.29 Among children with uncontrolled asthma on ICSs but without GI reflux symptoms, the addition of a lansoprazole (versus placebo) resulted in no improvement in symptoms or lung function, but increased adverse events.30
For patients with a mild exacerbation of asthma (dyspnea with activity, PEF ≥70% predicted or personal best), SABAs, and sometimes oral corticosteroids, are used for home management of patients following their action plan. NAEP does not recommend doubling the dose of ICSs for home management versus oral steroids for exacerbations.3 A Cochrane review concluded that a short course of oral steroids was effective in reducing the number of relapses to additional care, hospitalizations, and use of SABA without an apparent increase in side effects.31
- Moderate exacerbation (dyspnea interferes with usual activity, PEF 40% to 69% predicted or personal best) usually requires an office or ED visit; SABA and oral corticosteroids (typically 40 to 60 mg prednisone for adults and 1 to 2 mg/kg per day of prednisolone liquid in two divided doses) are recommended for 3 to 10 days. SOR A SABA can be administered every 20 minutes as needed and the addition of inhaled ipratropium bromide may reduce the need for hospitalization (0.68 to 0.75).4 SOR A Symptoms usually abate in 1 to 2 days.
- Severe exacerbation (dyspnea at rest, PEF <40% predicted or personal best) usually requires an ED visit and hospitalization is likely; combination SABA-anticholinergic nebulized treatment hourly or continuously as needed, oral corticosteroids, adjunctive treatment as needed (see below). Symptoms last for longer than 3 days after treatment begins.
- Life-threatening exacerbation (too dyspneic to speak, diaphoresis, PEF <25% predicted or personal best) requires an ED visit and/or hospitalization; consider intensive care unit, SABA-anticholinergic, intravenous corticosteroids, and adjunctive therapies.
- Oxygen therapy—Use to correct hypoxia in patients with moderate to life-threatening exacerbations; maintain O2 saturation above 90%.3,4 SOR C
- Consider intravenous magnesium sulfate or heliox-driven albuterol nebulization if severe exacerbation and unresponsive to treatment after initial assessments.
- Monitor response to treatment with serial assessments of FEV1 or PEF. Pulse oximetry may be useful in children for assessing initial severity—a result of less than 92% to 94% after 1 hour is an indication for hospitalization.3 For adults, pulse oximetry may be useful for severe episodes or when unable to perform lung function testing; repeat assessments for hypoxia are useful for predicting need for hospitalization, as are signs and symptoms at 1 hour posttreatment.
- Patients with severe or life-threatening exacerbation unresponsive to initial treatments may require intubation and mechanical ventilation. Drowsiness may be a symptom of impending respiratory failure.
- The following should not be used as they have no supporting evidence and may delay effective treatment: drinking large volumes of liquids; breathing warm, moist air; using nonprescription products, such as antihistamines or cold remedies; and pursed-lip and other forms of breathing.3 In addition, the NAEP does not recommend use of methylxanthines, antibiotics (except as needed for comorbid conditions), aggressive hydration, chest physical therapy, mucolytics, or sedation in the ED or hospital setting.3