Asthma diagnosis and management.

Background

Asthma is one of the most common chronic diseases of children and young adults, affecting more than 22 million Americans. The National Heart, Lung, and Blood Institute recently released updated guidelines for the diagnosis and management of asthma that incorporate significant changes from their last (2002) guidelines. This review highlights the current recommendations for the treatment of adolescents and adults.

Conclusions

Recommendations for asthma care are divided into those for children aged 4 years and younger, children aged 5-11 years, and persons aged 12 years and older. Because the course of asthma may change over time and its effects may not be the same in all age groups, scientific evidence differs for these various groups.

The norms used for the interpretation of pulmonary function testing in adolescents are generally closer to those used for children than to those used for adults.

Asthma treatment should be stratified into a series of six steps. (See box.) The goal of this approach is to simplify the actions recommended for achieving control in each patient. Asthma severity should be used to determine the initial treatment step.

The long-term goal of asthma treatment is to optimize the balance between minimizing the impairment of lifestyle as a result of asthma, and minimizing the risk of exacerbations, declines in lung function, and potential adverse effects of medications.

Implementation

History, physical examination, and spirometry with bronchodilator challenge (to assess for reversible airway obstruction) should be used to establish the diagnosis of asthma.

All patients treated for asthma should have individualized, written, daily management plans, which can be symptom or peak-flow based. (See the full text of the guidelines for examples.) This is particularly important for patients with a history of persistent disease or severe exacerbations.

When treatment for asthma is initiated, follow-up at 2- to 6-week intervals is important to ensure that control is achieved.

Once control is reached, regular assessment of compliance, disease control, and comorbidity is necessary. Reevaluation at least every 3 months is recommended in patients in whom step-down treatment is attempted.

Patients with exercise-induced bronchospasm should be treated with a short-acting bronchodilator, cromolyn, or nedocromil prior to exercise.

Step 1 care is appropriate for patients who have intermittent asthma. In this step, short-acting bronchodilators are used on an as-needed basis for control of symptoms. If these medications are needed more than 2 days a week, or if exacerbations are more frequent than every 6 weeks, step-up care is recommended.

Patients who have had two or more exacerbations requiring oral corticosteroids in the past year should be treated as patients with persistent asthma, even in the absence of more frequent symptoms.

Daily anti-inflammatory "controller" medications are recommended for all patients with persistent asthma (treatment steps 2-6). Inhaled corticosteroids are the most effective controller agents and are preferred for all patients with persistent asthma.

Short-acting bronchodilators should also be available at all times for the treatment of symptoms in patients with persistent asthma.

Leukotriene-modifying agents and sustained-release theophylline are alternative treatments that may be used in asthma care at steps 2-4. The data supporting their use are not as strong as data supporting the use of inhaled corticosteroids. Zileuton is not recommended for step 2 treatment because of the paucity of data and the need for liver enzyme monitoring. Theophylline should not be used in the absence of periodic monitoring of drug levels to minimize the risk of toxicity.

Long-acting [[beta].sub.2]-agonists, in combination with inhaled corticosteroids, are the preferred treatment for steps 2-6. Studies have shown improved lung function, decreased symptoms, and reduced exacerbations with this combination, but these benefits must be weighed against the risk of uncommon but potentially serious side effects resulting from the use of long-acting bronchodilators.

Consultation with an asthma expert is suggested for patients requiring treatment at steps 4-6, and for those treated with omalizumab or immunotherapy.

Oral corticosteroids are useful for the acute treatment of exacerbations, and their addition to inhaled treatments (above) is recommended for step 6 treatment.

Older patients with asthma may be more sensitive to the [[beta].sub.2]-adrenergic side effects of short-acting bronchodilators. The use of anticholinergics may be useful in this setting.

Pregnant women with asthma should be monitored for asthma control at all prenatal visits. Inhaled budesonide is the preferred long-term controller--there are more data in pregnancy for this than for other agents--and albuterol is the preferred short-acting bronchodilator.

Inhaled anticholinergic medications, heliox, and magnesium infusions all have roles in emergency department treatment of severe exacerbations that are not responsive to short-acting [[beta].sub.2]-agonists and corticosteroids.

Reference

National Heart, Blood, and Lung Institute. Expert panel report 3: Guidelines for the diagnosis and management of asthma--Full report 2007 (www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm).

DR. GOLDEN (right) is professor of medicine and public health, and DR. HOPKINS is program director for the internal medicine/pediatrics combined residency program, at the University of Arkansas, Little Rock. Write to Dr. Golden and Dr. Hopkins at our editorial offices or imnews@elsevier.com.

BY WILLIAM E. GOLDEN, M.D., AND ROBERT H. HOPKINS, M.D.

Preferred Stepwise Treatment for The Management of Asthma

Step 1: Short-acting [[beta].sub.2]-agonist as required.

Step 2: Low-dose inhaled corticosteroid.

Alternative: Cromolyn, leukotriene-receptor agonist, nedocromil, or theophylline.

Step 3: Low-dose inhaled corticosteroid plus long-acting [[beta].sub.2]-agonist, or medium-dose inhaled corticosteroid.

Alternative: Low-dose inhaled corticosteroid plus leukotriene-receptor agonist, theophylline, or zileuton.

Step 4: Medium-dose inhaled corticosteroid plus long-acting [[beta].sub.2]-agonist.

Alternative: Medium-dose inhaled corticosteroid plus leukotriene-receptor agonist, theophylline, or zileuton.

Step 5: High-dose inhaled corticosteroid plus long-acting [[beta].sub.2]-agonist.

Note: Consider omalizumab for patients with allergies.

Step 6: High-dose inhaled corticosteroid plus long-acting [[beta].sub.2]-agonist, and an oral corticosteroid.

Note: Consider omalizumab for patients with allergies.

Source: National Heart, Lung, and Blood Institute