Management of worsening asthma
SELF-MANAGEMENT OF EXACERBATIONS WITH A WRITTEN ASTHMA ACTION PLAN
All patients with asthma should be provided with guided self-management education as described in Chapter 3 (p.55), including monitoring of symptoms and/or lung function, a written asthma action plan, and regular review by a health professional.123 (For children 5 years and younger, see Chapter 6, p.112.)
Treatment options for written asthma action plans
A written asthma action plan helps patients to recognize and respond appropriately to worsening asthma. It should include specific instructions for the patient about changes to reliever and controller medications, how to use oral corticosteroids (OCS) if needed (Box 4-2) and when and how to access medical care.
The criteria for initiating an increase in controller medication will vary from patient to patient. For patients taking conventional maintenance ICS-containing treatment, this should generally be increased when there is a clinically important change from the patient’s usual level of asthma control, for example, if asthma symptoms are interfering with normal activities, or PEF has fallen by >20% for more than 2 days.246
Inhaled short-acting beta2-agonists
Repeated dosing with inhaled short-acting beta2-agonist (SABA) bronchodilators provides temporary relief until the cause of the worsening symptoms passes or increased controller treatment has had time to take effect. The need for repeated doses over more than 1–2 days signals the need to review, and possibly increase, controller treatment if this has not already been done. This is particularly important if there has been a lack of response to increased use of beta2 -agonist therapy. Although the rapid-acting long-acting beta2-agonist formoterol has been studied in the emergency department management of acute asthma,336 its use in a separate inhaler is no longer recommended in asthma, in order to avoid the possibility of it being used without concomitant inhaled corticosteroids (ICS).
Inhaled corticosteroids
In a systematic review of self-management studies, action plans in which the ICS dose was at least doubled were associated with improved asthma outcomes and reduced health care utilization.246 In placebo-controlled trials, temporarily doubling the dose of ICS was not effective337 (Evidence A); however, the delay before increasing the ICS dose (mean 5–7 days338,339) may have contributed. Only one small study of doubling ICS has been carried out in children.340 There is emerging evidence in adults341 and young children342 that higher ICS doses might help prevent worsening asthma progressing to a severe exacerbation. Patients who quadrupled their ICS dose (to average of 2000mcg/day BDP equivalent) after their PEF fell were significantly less likely to require OCS.343 In adult patients with an acute deterioration, high-dose ICS for 7–14 days (500–1600mcg BDP-HFA equivalent) had an equivalent effect to a short course of OCS341 (Evidence A).
Combination low dose ICS (budesonide or beclometasone) with rapid-onset LABA (formoterol)
The combination of rapid-onset LABA (formoterol) and low dose ICS (budesonide or beclometasone) in a single inhaler as both the controller and the reliever medication is effective in improving asthma control,140 and in at-risk patients, reduces exacerbations requiring OCS, and hospitalizations167-170 (Evidence A). The combination ICS/formoterol inhaler may be taken up to a maximum total formoterol dose of 72 mcg in a day (Evidence A). The benefit of this regimen in preventing exacerbations appears to be due to intervention at a very early stage of worsening asthma.170 This regimen is also effective in reducing exacerbations in children aged 4–11 years,344 (Evidence B), but it is not approved for this age group in many countries. This approach should not be attempted with other combination controller therapies with a slower-onset LABA, or if evidence of efficacy and safety with this regimen is lacking.
Box 4-2. Self-management of worsening asthma in adults and adolescents with a written asthma action plan
BDP: beclometasone dipropionate; FEV1: forced expiratory volume in 1 second; ICS: inhaled corticosteroid;
PEF: peak expiratory flow; SABA: short-acting beta2-agonist. Options are listed in order of evidence.
*ICS/formoterol maintenance and reliever regimen: low dose budesonide or beclometasone with formoterol.
This regimen is not approved for children <12 years in many countries.
Comment [A21]: In Box 4-2, “ICS/salmeterol”
has been changed to “ICS/other LABA”, so that it covers both FP/SX and FF/VI
Deleted: ...
Other combination ICS/LABA controllers
For adults taking combination ICS/LABA as a fixed dose maintenance controller medication, the ICS dose may be increased by adding a separate ICS inhaler341 (Evidence D). More research is needed to standardize this strategy.
Leukotriene receptor antagonists
For patients using a leukotriene receptor antagonist (LTRA) as their controller, there are no specific studies about how to manage worsening asthma. Clinician judgment should be used (Evidence D).
Oral corticosteroids
For most patients, the written asthma action plan should provide instructions for when and how to commence OCS.
Typically, a short course of OCS is used (e.g. 40–50 mg/day usually for 5–7 days,341 Evidence B) for patients who:
• Fail to respond to an increase in reliever and controller medication for 2–3 days
• Deteriorate rapidly or who have a PEF or FEV1 <60% of their personal best or predicted value
• Have a history of sudden severe exacerbations.
For children 6–11 years, the recommended dose of OCS is 1–2 mg/kg/day to a maximum of 40 mg/day (Evidence B), usually for 3–5 days. Patients should contact their doctor if they start taking OCS (Evidence D).
Reviewing response
Patients should see their doctor immediately or present to an acute care unit if their asthma continues to deteriorate despite following their written asthma action plan, or if their asthma suddenly worsens.
Follow up after a self-managed exacerbation
After a self-managed exacerbation, patients should see their primary care health care provider for a semi-urgent review (e.g. within 1–2 weeks), for assessment of symptom control and additional risk factors for exacerbations (Box 2-2, p.29), and to identify the potential cause of the exacerbation. The written asthma action plan should be reviewed to see if it met the patient’s needs. Maintenance controller treatment can generally be resumed at previous levels 2–4 weeks after the exacerbation (Evidence D), unless the history suggests that the exacerbation occurred on a background of long-term poorly controlled asthma. In this situation, provided inhaler technique and adherence have been checked, a step up in treatment is indicated (Box 3-5, p.43).
MANAGEMENT OF ASTHMA EXACERBATIONS IN PRIMARY CARE