Managing Outpatient Asthma Exacerbations

Asthma is a chronic inflammatory disease that renders individuals vulnerable to acute exacerbations. A wide variety of allergic and nonallergic triggers can incite an asthma exacerbation. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, avoidance of relapses, and prevention of future episodes. A written asthma home management plan is essential to minimize the severity of exacerbations. Short-acting β-agonists, oxygen, and corticosteroids remain fundamental to early intervention in acute asthma exacerbations. Anticholinergics and magnesium sulfate can help nonresponders. Combination inhalers of the long-acting β-agonist formoterol and inhaled steroid budesonide have been effective in flexible dosing in treating early acute exacerbations and as a daily controller medication outside the United States. Initiation or intensification of long-term controller therapy, treatment of comorbid conditions, trigger avoidance, and prompt follow-up can help prevent relapses. Listening to patient preferences and concerns enhances adherence, and regular follow-up care can help prevent future episodes.     

Asthma: Versatile Treatment for a Variable Disease

Objective. This review describes factors contributing to the variable nature of asthma and the versatile treatment strategies required for the clinical management of the disease. Data Sources. A comprehensive review of the literature using MEDLINE was conducted. Study Selection. Included articles were selected for their relevance to variability or severity of asthma. Bibliographies of selected articles served as additional sources of considered publications. Results. Asthma severity can vary substantially among patients and within individual patients because of physiologic, environmental, or behavioral factors. Inhaled corticosteroids are an effective and versatile treatment option for special populations with asthma and for patients with varying degrees of asthma severity. Inhaled corticosteroids are now the preferred treatment for all three severity levels of persistent asthma, especially in young children and pregnant women. Treatment regimens may be adjusted up or adjusted down when appropriate to maintain optimal symptom control and limit potential adverse systemic effects. Conclusions. The clinical management of asthma is challenging given the day-to-day variability of the disease. Variability in pulmonary function and asthma symptoms may be minimized through increased awareness of the factors contributing to asthma variability as well as the effective use of inhaled corticosteroid therapy. Flexible treatment strategies that consider the different severities of asthma and account for variability within individual patients may be particularly useful in improving adherence and patient outcomes.     

Japanese guidelines for adult asthma 2020

Bronchial asthma is characterized by chronic airway inflammation, which manifests clinically as variable airway narrowing (wheezes and dyspnea) and cough. Long-standing asthma may induce airway remodeling and become intractable. The prevalence of asthma has increased; however, the number of patients who die from it has decreased (1.3 per 100,000 patients in 2018). The goal of asthma treatment is to control symptoms and prevent future risks. A good partnership between physicians and patients is indispensable for effective treatment. Long-term management with therapeutic agents and the elimination of the triggers and risk factors of asthma are fundamental to its treatment. Asthma is managed by four steps of pharmacotherapy, ranging from mild to intensive treatments, depending on the severity of disease; each step includes an appropriate daily dose of an inhaled corticosteroid, which may vary from low to high. Long-acting β₂-agonists, leukotriene receptor antagonists, sustained-release theophylline, and long-acting muscarinic antagonists are recommended as add-on drugs, while anti-immunoglobulin E antibodies and other biologics, and oral steroids are reserved for very severe and persistent asthma related to allergic reactions. Bronchial thermoplasty has recently been developed for severe, persistent asthma, but its long-term efficacy is not known. Inhaled β₂-agonists, aminophylline, corticosteroids, adrenaline, oxygen therapy, and other approaches are used as needed during acute exacerbations, by selecting treatment steps for asthma based on the severity of the exacerbations. Allergic rhinitis, eosinophilic chronic rhinosinusitis, eosinophilic otitis, chronic obstructive pulmonary disease, aspirin-exacerbated respiratory disease, and pregnancy are also important conditions to be considered in asthma therapy.     

Effect of corticosteroids on exacerbations of asthma and chronic obstructive pulmonary disease

Periodic exacerbations of disease severity, which may lead to hospitalization, are a characteristic feature of asthma and chronic obstructive pulmonary disease (COPD), becoming more prevalent as disease severity increases. Oral corticosteroids increase the rate of resolution of these episodes in both diseases. Inhaled corticosteroids are much less effective at conventional doses and are not recommended as a primary treatment for exacerbations of either disease. Maintenance therapy with inhaled corticosteroids significantly reduces the chance that a further exacerbation will occur in asthma. In general, increasing doses of inhaled corticosteroids are more effective than placebo therapy in preventing exacerbations, at least until patients become persistently symptomatic and regular users of inhaled corticosteroid therapy. Thereafter, the gains from doubling the dose of inhaled corticosteroid maintenance therapy are modest and generally inferior to those that result from adding other antiinflammatory or bronchodilator agents to the treatment regime. The reduction in the incidence of exacerbations with inhaled corticosteroids, compared with placebo, ranges from 15 to 20% in COPD versus almost 50% in severe asthma. However, given the impact of exacerbations on overall quality of life in COPD, even this modest reduction is likely to be clinically important.     

Similarities and differences in asthma and chronic obstructive pulmonary disease exacerbations

There is no generally accepted definition of an exacerbation either for asthma or for chronic obstructive pulmonary disease. There is little consistency among the symptomatic or functional criteria used in different studies. The most consistent criterion is the introduction of systemic corticosteroids for the acute worsening of the disease. The time course of an exacerbation does not seem to differ very much between asthma and chronic obstructive pulmonary disease (COPD). The decrease in peak flow rate is more pronounced in asthma than in COPD. The frequency of exacerbations is linked to disease severity both in asthma and COPD. Common causes are viral infections and increased environmental air pollution, whereas allergen exposure and bacterial infections are more specific for asthma and COPD exacerbations, respectively. Few data are available about the airway pathology of asthma or COPD exacerbations. Eosinophilia and/or neutrophilia have been associated with exacerbations in both diseases. Avoidance of the causal factors decreases exacerbation rate in both diseases. Pharmacologic prevention of exacerbations in asthma has been shown for inhaled corticosteroids, combination therapy with long-acting inhaled beta(2)-agonists and inhaled corticosteroids, and monoclonal anti-IgE. Inhaled corticosteroids, long-acting inhaled beta(2)-agonists, combination therapy with both, and the long-acting inhaled anticholinergic tiotropium decrease the exacerbation rate in COPD.     

« Asthme : prévention et traitement des exacerbations »

Existing asthma treatment guidelines emphasize the importance of management of exacerbations. Different profiles of exacerbations can be classified according to the severity and to their slow or rapid onset. Recognition on an individual basis of the patient’s signs and symptoms will help further management. Evidence based medicine data underline the role of tailored written action plans based on symptoms and/or on peak expiratory flow measurements for better overall therapeutic management. There are still questions concerning the details of the planning, especially with respect to the dose of inhaled steroids; this needs further evaluation. Finally, written action plans for treatment of exacerbations must evolve, taking into account new long-term treatment options.     

Managing Asthma in Expectant Mothers

Pregnancy does not appear to have a consistent effect on the frequency or severity of asthma. The most common cause of worsening asthma in pregnancy is likely to be noncompliance with medication. Emphasizing to the patient in advance that fetal well-being is dependent on maternal well-being may help prevent this.In general, well controlled asthma is not associated with a higher risk of adverse pregnancy outcomes. Essential to successful asthma management is patient education that helps to ensure effective medication use, avoidance of triggers, and prompt treatment. This education should include measurement of peak expiratory flow rate and a written asthma action plan. Most of the medications that are used to control asthma in the general population can be safely used in pregnant women. Inhaled beta-adrenoceptor agonists (beta-agonists), cromolyn sodium (sodium cromoglycate), and inhaled and systemic corticosteroids all appear to be very well tolerated by the fetus. Budesonide and beclomethasone should be considered as the preferred inhaled corticosteroids for the treatment of asthma in pregnancy. Use of the leukotriene receptor antagonists zafirlukast and montelukast in pregnancy is probably safe but should be limited to special circumstances, where they are viewed essential for asthma control. Zileuton should not be used in pregnancy.Acute asthma exacerbations in pregnant women should be treated in a similar manner to that in non-pregnant patients. Maternal blood glucose levels should be monitored periodically in pregnant women receiving systemic corticosteroids because of the deleterious effects of hyperglycemia upon embryos and fetuses. During pregnancy, maternal arterial oxygen saturations should be kept above 95% if possible for fetal well-being. Ambulatory oxygenation should be checked prior to discharge to ensure that women do not desaturate with their daily activities.Acute exacerbations of asthma during labor and delivery are rare. Dinoprost, ergometrine, and other ergot derivatives can cause severe bronchospasm, especially when used in combination with general anesthesia, and should be avoided in asthmatic patients. Pregnant women who have been treated with corticosteroids in the past year may require stress-dose corticosteroids during labor and delivery. Most asthma medications, including oral prednisone, are considered compatible with breast-feeding.     

Inhaled corticosteroids and leukotriene modifiers in the acute treatment of asthma exacerbations

Asthma exacerbation has a considerable impact on patients' quality of life and constitutes a challenging condition for primary health-care providers. Severe exacerbations are also an important cause of hospital admissions and require high costs. Despite this, a widely accepted definition is still lacking; etiologic and pathogenetic mechanisms are still incompletely defined. Although the efficacy of inhaled corticosteroids (ICS) and leukotriene modifiers in preventing mild to moderate asthma exacerbation is well recognized, their role within the context of an asthma action plan in general practice and in home-based early intervention for acute exacerbations is still controversial. Although systemic corticosteroids (CS) are standard care for severe exacerbation in the emergency department's (ED) management of asthma, published evidence suggests that high doses of ICS may be beneficial in the ED. The additive benefit of ICS when used with systemic CS is still debated. Data on leukotriene modifiers in the management of asthma exacerbation are limited. However, therapeutic strategies of this emergency including ICS and leukotriene modifiers seem logical and may be suitable, at least in certain patient groups. The availability of different drugs, active on different targets, can potentially contribute to a better management of asthma exacerbations.     

Management of severe asthma: targeting the airways,comorbidities and risk factors

Severe asthma is a complex heterogeneous disease that is refractory to standard treatment and is complicated by multiple comorbidities and risk factors. In mild to moderate asthma, the burden of disease can be minimised by inhaled corticosteroids, bronchodilators and self‐management education. In severe asthma, however, management is more complex. When patients with asthma continue to experience symptoms and exacerbations despite optimal management, severe refractory asthma (SRA) should be suspected and confirmed, and other aetiologies ruled out. Once a diagnosis of SRA is established, patients should undergo a systematic and multidimensional assessment to identify inflammatory endotypes, risk factors and comorbidities, with targeted and individualised management initiated. We describe a practical approach to assessment and management of patients with SRA.     

The burden of systemic corticosteroid use in asthma management in Asia

For most patients, asthma can be effectively managed using inhaled medications. However, patients who have severe and/or uncontrolled asthma, or who experience exacerbations, may require systemic corticosteroids (SCSs) to maintain asthma control. Although SCS are highly effective in this regard, even modest exposure to these medications can increase the risk for long-term, adverse health outcomes, such as type 2 diabetes, renal impairment, cardiovascular disease and overall mortality. Clinical and real-world data from studies investigating asthma severity, control and treatment practices around the globe have suggested that SCS are overused in asthma management, adding to the already substantial healthcare burden experienced by patients. Throughout Asia, although data on asthma severity, control and SCS usage are limited and vary widely among countries, available data strongly suggest a pattern of overuse consistent with the broader global trend. Coordinated changes at the patient, provider, institutional and policy levels, such as increasing disease awareness, promoting better adherence to treatment guidelines and increasing availability of safe and effective alternatives to SCS, are likely necessary to reduce the SCS burden for patients with asthma in Asia.     

Uncontrolled asthma: a review of the prevalence, disease burden and options for treatment

An estimated 300 million people are affected by asthma worldwide and the burden is likely to rise substantially in the next few decades. Estimates of the prevalence of asthma range from 7% in France and Germany to 11% in the USA and 15-18% in the United Kingdom. Approximately 20% of these patients have severe asthma, of which 20% is inadequately controlled. Patients with inadequately controlled severe persistent asthma are at a particularly high risk of exacerbations, hospitalization and death, and often have severely impaired quality of life. Current management of asthma focuses on a stepwise approach tailored to disease severity. In addition to needing high-dose inhaled corticosteroids (ICS) and long-acting beta(2)-agonists (LABAs), patients with severe persistent asthma often require additional controller medications, such as anti-leukotrienes, oral LABAs, oral corticosteroids and/or anti-IgE therapy. There is currently little evidence on which to base treatment decisions in patients with inadequately controlled severe persistent asthma already treated with ICS and LABAs. The anti-IgE monoclonal antibody omalizumab is the most recent addition to the list of treatment options for these patients and has been shown to reduce exacerbations and emergency visits and improve lung function, symptom scores and quality of life in patients with difficult-to-treat asthma whose symptoms remain inadequately controlled despite receiving ICS and LABAs. Comparative trials are needed to determine the merits of different treatments and strategies for patients with inadequately controlled severe persistent asthma and to identify patients likely to benefit from new treatment options.     

Asthma control in adults in Asia-Pacific

OBJECTIVE: The Asthma Insights and Reality in Asia-Pacific (AIRIAP) survey collected detailed information on asthma severity and management in the urban centres of eight areas of the Asia-Pacific region. This study compared asthma morbidity and management practices in these areas. METHODOLOGY: Following recruitment, face-to-face interviews were completed with 2323 adults with diagnosed asthma, who had current symptoms or were using asthma medication. Comparisons between areas were made for asthma severity, asthma burden and management practices. RESULTS Asthma severity varied significantly between areas (P < 0.01), with Vietnam and mainland China reporting the most cases with severe, persistent symptoms. Severity of asthma was significantly associated with advancing age and a lower level of education in a multivariate analysis (P < 0.001). The total use of acute healthcare for asthma was significantly associated with increased asthma severity. Work absence due to asthma was highest in the Philippines (46.6%) and lowest in South Korea (7.5%). The use of inhaled corticosteroids was associated with age in a non-linear manner. There was significant variation among countries in usage of inhaled corticosteroids, from 1.3% in South Korea to 29.0% in Taiwan (P < 0.00001). A peak flow meter was owned by a total of 7.7% of respondents, and overall, 17.9% of adults had a written action plan for asthma management. CONCLUSIONS: Within the Asia-Pacific region, asthma in adults differs significantly in disease severity, management and treatment according to area of residence. International recommendations on the management of asthma are generally not being followed.     

Japanese guidelines for adult asthma 2017

Adult bronchial asthma is characterized by chronic airway inflammation, and presents clinically with variable airway narrowing (wheezes and dyspnea) and cough. Long-standing asthma induces airway remodeling, leading to intractable asthma. The number of patients with asthma has increased; however, the number of patients who die of asthma has decreased (1.2 per 100,000 patients in 2015). The goal of asthma treatment is to enable patients with asthma to attain normal pulmonary function and lead a normal life, without any symptoms. A good relationship between physicians and patients is indispensable for appropriate treatment. Long-term management by therapeutic agents and elimination of the causes and risk factors of asthma are fundamental to its treatment. Four steps in pharmacotherapy differentiate between mild and intensive treatments; each step includes an appropriate daily dose of an inhaled corticosteroid, varying from low to high levels. Long-acting β₂-agonists, leukotriene receptor antagonists, sustained-release theophylline, and long-acting muscarinic antagonist are recommended as add-on drugs, while anti-immunoglobulin E antibody and oral steroids are considered for the most severe and persistent asthma related to allergic reactions. Bronchial thermoplasty has recently been developed for severe, persistent asthma, but its long-term efficacy is not known. Inhaled β₂-agonists, aminophylline, corticosteroids, adrenaline, oxygen therapy, and other approaches are used as needed during acute exacerbations, by choosing treatment steps for asthma in accordance with the severity of exacerbations. Allergic rhinitis, eosinophilic chronic rhinosinusitis, eosinophilic otitis, chronic obstructive pulmonary disease, aspirin-induced asthma, and pregnancy are also important issues that need to be considered in asthma therapy.     

Managing outpatient asthma exacerbations

Asthma is a chronic inflammatory disease that renders individuals prone to acute exacerbations. Several allergic and nonallergic triggers can incite an asthma exacerbation. The goals of managing an asthma exacerbation are prompt recognition, rapid reversal of airflow obstruction, prevention of relapses, and forestalling future episodes. A written asthma home-management plan is essential to minimize the severity of exacerbations. Short-acting β-agonists, oxygen, and corticosteroids are fundamental to early intervention in acute asthma exacerbation. Anticholinergics and magnesium sulfate can help nonresponders. Newer agents such as levalbuterol and long-acting β-agonists might be future additions to our armamentarium of drugs to treat acute exacerbations. Initiation or intensification of long-term controller therapy, treatment of co-morbid conditions, and avoidance of possible triggers along with prompt follow-up can help prevent relapses. Listening to patient preferences and concerns to enhance adherence and regular follow-up care can help prevent future episodes.     

Effectiveness of Asthma Education with and Without a Self-Management Plan in Hospitalized Children

Background. Formal education in primary care can reduce asthma exacerbations. However, there are few studies in hospitalized children, with none originating in Latin America. Methods. A prospective randomized study was designed to evaluate whether a full education with self-management plan (ESM) was more effective than an education without self-management plan (E) in reducing asthma hospitalization. Children (5 to 15 years of age) who were hospitalized for an asthma attack were divided in two groups. Children in the E group received general instructions based on a booklet. Those in the ESM group received the same booklet plus a self-management guide and a puzzle game that reinforces the lessons learned in the booklet. Patients were interviewed every 3 months, by telephone, for one year. Interviewers recording the number of hospitalizations, exacerbations, and emergency visits for asthma and oral steroid burst uses. Results. From 88 children who met the inclusion criteria, 77 (86%) completed one year of follow-up (41 from E and 36 from ESM group). Overall, after one year, the hospitalization decreased by 66% and the inhaled corticosteroids therapy increased from 36% to 79%. At the end of the study, there was no difference in exacerbations, emergency visits, oral steroid burst uses, or hospitalizations between the two groups. Conclusions. Asthma education with or without a self-management plan during asthma hospitalization were effective in reducing exacerbations, emergency visits, oral steroid burst uses, and future rehospitalizations. This evidence supports the importance of providing a complete asthma education plan in any patient who is admitted for asthma exacerbation.     

Fatal asthma in Finnish children and adolescents 1976-1998: validity of death certificates and a clinical description

Several studies show that asthma mortality in children and adolescents increased until the mid-1990s, after which it has slightly decreased worldwide. The objective of this study was to describe the mortality rates of childhood asthma in Finland, and to analyze patient characteristics to identify predisposing factors for fatal asthma exacerbation among children and adolescents during 1976-1998 (2004). All death certificates where asthma or related respiratory tract disease was coded as the underlying cause of death were reviewed for those under 20 years of age. Health care records and autopsy reports were evaluated to validate the cause of death and to identify any predisposing factors. In all, there had been 28 asthma deaths. The validity of the death certificates proved to be good as only 7% were misclassified. Death occurred either in the very young children or adolescents: the median age in the group of <12 years (n = 15) was 3.3 years while the median age in the group of >12 years (n = 13) was 18.1 years. The fatal exacerbations occurred mostly during summer and early autumn. Clinical triggers, recorded for 14/22 patients with available patient records, included respiratory infection, (12) use of ibuprofen despite known allergy (1), and exercise after visiting a horse stable (1). The severity of the disease was discernible in 21 patients: severe in 15, moderate in 5, and mild in 1 patient. Inhaled corticosteroids were not used as maintenance or periodic therapy in 12/22 patients, of whom 4 had died during the 1990s. In conclusion, asthma mortality in Finnish children and adolescents was rare and its incidence remained stable. The validity of the death certificate diagnoses proved to be good. Poor asthma management and non or undertreatment with inhaled corticosteroids were risk factors for fatal asthma.     

Japanese guidelines for childhood asthma 2017

The Japanese Guideline for the Diagnosis and Treatment of Allergic Diseases 2017 (JAGL 2017) includes a minor revision of the Japanese Pediatric Guideline for the Treatment and Management of Asthma 2012 (JPGL 2012) by the Japanese Society of Pediatric Allergy and Clinical Immunology. The section on child asthma in JAGL 2017 provides information on how to diagnose asthma between infancy and adolescence (0–15 years of age). It makes recommendations for best practices in the management of childhood asthma, including management of acute exacerbations and non-pharmacological and pharmacological management. This guideline will be of interest to non-specialist physicians involved in the care of children with asthma. JAGL differs from the Global Initiative for Asthma Guideline in that JAGL emphasizes diagnosis and early intervention of children with asthma at <2 years or 2–5 years of age. The first choice of treatment depends on the severity and frequency of symptoms. Pharmacological management, including step-up or step-down of drugs used for long-term management based on the status of asthma control levels, is easy to understand; thus, this guideline is suitable for the routine medical care of children with asthma. JAGL also recommends using a control test in children, so that the physician aims for complete control by avoiding exacerbating factors and appropriately using anti-inflammatory drugs (for example, inhaled corticosteroids and leukotriene receptor antagonists).     

An overview of chronic severe asthma

Most asthmatic patients with moderate to severe disease can be satisfactorily managed with a combination of inhaled corticosteroids and beta(2)-agonists. However, there are a few with persistent symptoms, impaired quality of life and excessive health-care utilization, despite this management regimen. These patients often require frequent and even occasionally regular oral corticosteroid use. Chronic, severe asthma is a heterogeneous disease and a systematic diagnostic work-up may help to guide treatment and may even provide information about prognosis. Optimal treatment of chronic severe asthma (CSA) should achieve the best possible asthma control and quality of life with the least dose of systemic corticosteroids. The choice and formulation of therapeutic agent is dictated by the severity of disease and includes conventional, immunosuppressive/immunomodulating and biologic therapies. Unfortunately, current asthma management guidelines offer little contribution to the care of the challenging patient with CSA. In this review, a diagnostic and therapeutic overview of CSA is provided for the benefit of those who have a specific interest in this problematic condition.     

Management of the Acute Exacerbation of Asthma

All patients with asthma are at risk of having asthma exacerbations characterized by worsening symptoms, airflow obstruction, and an increased requirement for rescue bronchodilators. The goals of managing an asthma exacerbation are prompt recognition and rapid reversal of airflow obstruction to avert relapses and future episodes. Short-acting beta-agonists, oxygen, and corticosteroids form the basis of management of acute asthma exacerbation, but a role is emerging for anticholinergics and newer agents such as levalbuterol and formoterol. Initiation or intensification of long-term controller therapy, treatment of comorbid conditions, avoidance of likely triggers, and timely follow-up care prevent setbacks. Acceptance of current treatment guidelines by physicians and adherence to the recommended clinical regimens by patients are essential for effective management of asthma. The physician should strive to establish a constructive relationship with the patient by addressing the patient's concerns, reaching agreement on the goals of therapy, and developing a written action plan for patient self-management.     

Effects of corticosteroids on lung function in asthma and chronic obstructive pulmonary disease

Both oral and inhaled corticosteroids have clinically significant effects on symptoms, exacerbations, health status, and lung function in asthma, and to a lesser extent in chronic obstructive pulmonary disease (COPD). Change in FEV(1) does not correlate well with functional tests in COPD and may not be the best measure of response to treatment. Inhaled corticosteroids may be beneficial when added to a beta-agonist for treatment of acute asthma, and the efficacy of oral corticosteroids in this setting is well established. Oral corticosteroids inconsistently improve lung function in stable outpatients with COPD. Individual inhaled corticosteroids do not have a marked effect, but the combination of fluticasone propionate and salmeterol and the combination of budesonide plus formoterol seem to improve FEV(1) over treatment with the individual components. In addition, there is convincing evidence for the use of systemic corticosteroids during acute exacerbations of COPD. Some evidence suggests that patients with COPD who respond to corticosteroids have eosinophilic inflammation and other attributes of an asthma phenotype.