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Diagnosis
Assessment
Principles of
management
Management
Asthma
in adults
the author
Professor Amanda
Barnard
chair, Australian Asthma
Handbook Guidelines Committee,
and associate dean, rural clinical
school and Indigenous health,
Australian National University
Medical School, Canberra, ACT.
Background
ABOUT one in 10 Australian
children and adults has asthma.1
Asthma rates have declined in children and young adults since 2001,
but have remained stable in adults.
Asthma represents a spectrum
of conditions with different pathophysiological mechanisms, but the
clinical and treatment implications
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Details
The indication for regular inhaled corticosteroids in adults and adolescents includes
any patient with asthma symptoms twice or more during the past month, waking due
to asthma symptoms once or more during the past month, or an asthma flare-up
requiring treatment with oral corticosteroids in the previous 12 months
Dizziness,
lightheadedness,
peripheral tingling
Isolated cough with
no other respiratory
symptoms
Chronic sputum
production
No abnormalities on
physical examination of
chest when symptomatic
(over several visits)
Change in voice
Symptoms only present
during URTIs
Current or past heavy
smoker
Cardiovascular disease
Normal spirometry or
PEF when symptomatic
(despite repeated tests)
Allergen avoidance strategies are only recommended if clinically relevant for the
individual (supported by evidence that they are likely to improve asthma control) and
patient or carers are motivated to implement them
Healthy eating is recommended, with an emphasis on fruit and vegetables and limiting
processed and takeaway foods
Assessment
THE possibility of asthma should
be considered in adults with episodic breathlessness, wheezing,
chest tightness and/or cough. The
history should include a review of
symptoms, risk factors and impact
on the patient (see box, Questions
to include when taking a history
in adults with suspected asthma).
Physical
examination
should
include chest auscultation and
inspection of the upper respiratory
tract for signs of allergic rhinitis.
The absence of abnormalities on
physical examination does not
exclude a diagnosis of asthma.
The differential diagnosis for
asthma-like respiratory symptoms
in adults includes poor cardiopulmonary fitness, bronchiectasis,
COPD, hyperventilation or other
dysfunctional breathing, inhaled
foreign body, large airway stenosis, pleural effusion, pulmonary
fibrosis,
rhinitis/rhinosinusitis,
upper airway dysfunction (also
known as vocal cord dysfunction),
cardiovascular disease (eg, chronic
heart failure, pulmonary hypertension), obesity, gastro-oesophageal
reflux and lung cancer. Chronic
29
Principles of management
THE overall aims of asthma management are to establish and maintain good asthma control, while
minimising the potential side effects
of treatment. The box (Steps in
asthma management) outlines the
steps in managing asthma.
Asthma management involves
the prompt use of self-administered (or carer-administered)
rapid-acting beta2 bronchodilators
(relievers) to control flare-ups
(times when asthma symptoms are
getting worse over hours or days
or recur within a few hours of taking reliever) and acute symptoms.
Most adults also need regular
treatment with preventers such
as inhaled corticosteroids. Regardless of the type of inhaler device
prescribed, patients need clear
instruction on correct inhalation
technique, including a physical
demonstration. Inhaler technique
must be checked regularly.
Current national guidelines for
asthma management emphasise
stepwise adjustment of treatment
(see figure 2), based on periodic
reassessment of recent symptom
control and regular assessment of
risk factors for asthma flare-ups or
treatment side effects. Whenever
recent symptom control is suboptimal, reconsider the diagnosis
of asthma, confirm that the current symptoms are due to asthma,
assess the persons adherence to
preventer treatment, and check
inhaler technique before adjusting
treatment.
Diagnosis
Management
Adherence
30
Lifestyle factors
Lifestyle modification is relevant to
asthma self-management, just as for
other chronic diseases.
Patients who smoke should be
advised and supported to quit.
Smoking increases the risk of flareups, hastens decline in lung function, and reduces the effectiveness
of inhaled corticosteroids and the
chance of achieving good asthma
control.8-12
Physical training should be recommended for adults with asthma.
Regular, moderately intense physical activity improves cardiopulmonary fitness and quality of life
in people with asthma, and is well
tolerated, although it has no effect
on lung function or asthma symptoms.13
Emerging evidence suggests that
antioxidant-rich fruit and vegetables may help reduce the risk of
asthma flare-ups and improve lung
function.14 High-fat and low-fibre
Identify and manage comorbid conditions that may affect asthma or respiratory
symptoms
Emerging evidence
suggests that
antioxidant-rich fruit
and vegetables may
help reduce the risk
of asthma flare-ups
and improve lung
function.
Inhaled corticosteroids
In addition to a reliever taken as
needed (or before exercise, if indicated), most adults with asthma
also need regular treatment with
an inhaled corticosteroid preventer (beclomethasone, budesonide,
ciclesonide, fluticasone propionate).
An inhaled corticosteroid should be
prescribed for all adults and adolescents who report any of the following: asthma symptoms twice or more
during the past month, waking as a
result of asthma symptoms once or
more during the past month, or an
asthma flare-up requiring treatment
with oral corticosteroids in the past
12 months.
Inhaled corticosteroids reduce
asthma symptoms, improve quality of life, improve lung function,
reduce airway hyper-responsiveness, control airway inflammation, reduce the frequency and
severity of asthma flare-ups, and
reduce the risk of death due to
asthma.22-31 For most adults, the
starting dose should be low (see
table 5). Most of the benefit is
achieved with doses at the upper
limit of the low-dose range.32,33
On average, higher doses provide
relatively little extra benefit but
are associated with a higher risk
of adverse effects. The response to
treatment should be reviewed 6-8
Good
All of:
Daytime symptoms two days per week
Need for reliever two days per week*
No limitation of activities
No symptoms during night or on waking
Partial
Poor
SABA as needed
Montelukast*
Cromones
Adjusting treatment
SABA = Short-acting beta2 agonist; LABA = Long-acting beta2 agonist; ICS = inhaled corticosteroid
*Montelukast treatment is not subsidised by the PBS for people aged 15 years or over. Special authority is available for DVA gold
card holders or white card holders with approval for asthma treatments.
Requires multiple daily doses and daily maintenance of inhaler
#
Inhaled corticosteroids/LABA combination therapy as first-line preventer treatment is not subsidised by the PBS, except for
patients with frequent symptoms while taking oral corticosteroids.
Medium
High
Beclomethasone dipropionate
100200
250400
> 400
Budesonide
200400
500800
> 800
Ciclesonide
80160
240320
> 320
Fluticasone propionate
100200
250500
> 500
43
Self-management
To self-manage asthma well, patients
need information, skills and tools.
These include training in correct
inhaler technique, information and
support to maximise adherence, and
information about avoiding triggers,
where appropriate.
A written asthma action plan
should be prepared for every
patient. It should list the persons
usual asthma and allergy medicines. Clear instructions on how
to change medication including
when and how to start a course of
oral corticosteroids and when and
how to get medical care, including
during an emergency should be
provided. The date and the name
of the person preparing the plan
should be recorded each time the
plan is updated.
Managing flare-ups
Flare-ups of asthma can occur
from time to time, even in people with asthma that is generally
well controlled. Flare-ups range
in severity from slight worsening
of asthma control compared with
the persons normal range when
well, or distressing symptoms that
require a change in treatment, to
severe acute asthma that requires
treatment by emergency services.
Each patients written asthma
action plan should include instruc-
44
Online resources
Australian Asthma Handbook
www.asthmahandbook.org.au
National Asthma Council
Australia
Spirometry: training, published
guides, video
www.nationalasthma.org.au/
health-professionals/spirometryresources
First aid for asthma: wall charts
and instructions for patients of
all ages
www.nationalasthma.org.au/
first-aid
Asthma action plan library:
templates to print or download
www.nationalasthma.org.au/
health-professionals/asthmaaction-plans/asthma-action-planlibrary
Using your inhaler: how-to video
www.nationalasthma.org.au/howto-videos/using-your-inhaler
Further reading
National Asthma Council Australia.
Inhaler Technique in Adults with
Asthma or COPD. An Information
Paper for Health Professionals.
NAC, Melbourne, 2008.
National Asthma Council Australia.
Intranasal Corticosteroid Spray
Technique for People with Allergic
Rhinitis. Information Paper for
Health Professionals. NAC,
Melbourne, 2010.
National Asthma Council Australia.
Managing Allergic Rhinitis in People
with Asthma. An Information Paper
for Health Professionals. NAC,
Melbourne, 2012.
National Asthma Council Australia.
Asthma and Healthy Living. An
Information Paper for Health
Professionals. NAC, Melbourne,
2013.
Johns DP, Pierce R. Pocket Guide
to Spirometry. 3rd edn. McGraw
Hill, Sydney, 2011.
References
Recent asthma
symptom control was
assessed by asking
about frequency of
daytime symptoms,
frequency of reliever
use, limitation of
activities and night
or waking symptoms
during the past four
weeks.
contd page 46