5 курс / Пульмонология и фтизиатрия / Clinical_Manifestations_and_Assessment_of_Respiratory

FIGURE 14.5 Chest x-ray film of a 2-year-old patient during an acute asthma attack.

General Management of Asthma

GINA provides an excellent clinical guideline program for the management and prevention of asthma. The complete GINA guidelines are readily available at http://www.ginasthma.org. An overview of GINA's global strategy for asthma management and prevention are discussed in the following text.

GINA's long-term goals for asthma management are symptom control (i.e., obtain control of the respiratory symptoms and maintain normal daily activities) and risk reduction of future exacerbations (e.g., removal of potential risk factors, such as smoking, beta-blockers, or allergen exposure, and checking for correct inhaler technique, adherence, and comorbidities, such as rhinitis, rhinosinusitis, obesity, obstructive sleep apnea, or depression or anxiety). The basic foundation to achieve these two goals is securing a strong partnership between the patient and the health care providers (e.g., good verbal and written communications and, importantly, presented at the patient's basic health literacy level). A good partnership enhances the asthma patient's ability to gain the knowledge, confidence, and skills necessary to self-manage his or her asthma. Along with a strong patient and health care provider partnership, GINA recommends a control-based asthma management program.

Control-Based Asthma Management Program

In a control-based asthma management program, the pharmacologic and nonpharmacologic treatment is a continuous cycle that entails the assessment of the patient's condition, treatment selection and/or adjustment (i.e., up-regulate or down-regulate the therapy), and the review of the patient's response (Fig. 14.6). In a control-based management program, both the symptom control and future risk for exacerbations need to be considered when selecting asthma treatment and assessing the patient's response to the therapy. The pharmacologic options for long-term treatment of asthma fall into the following three categories:

FIGURE 14.6 The control-based asthma management cycle. (Modified from Global Strategy for Asthma Management and Prevention, 2017, GINA. http://www.ginasthma.org.)

• Controller medications: These agents are used for regular maintenance treatment. They decrease airway inflammation, control symptoms, and reduce the future risks for exacerbations and decreased lung function. Table 14.2 shows medications commonly used to control the symptoms of asthma.

The Stepwise Management Approach to Control Asthma Symptoms and Reduce Future Risk

Based on the patient's current level of asthma control and current treatment regimen, GINA recommends one of five possible treatment steps that can be assigned to the patient. The preferred treatment at each step is based on (1) efficacy,

(2) effectiveness, (3) safety, and (4) the availability and cost of the treatment. In addition, the patient's asthma characteristics (phenotype), patient preference (i.e., goals and concerns), and practical issues (e.g., inhaler technique, adherence, and costs) need to be considered at each step.

Fig. 14.7 summarizes GINA's stepwise asthma management approach for adults, adolescents, and children 6 to 11 years.8 As can be seen, Step 1 through Step 5 progressively increase treatment medication options and intensity. In short, if the patient's asthma symptoms are not controlled on the current treatment program (e.g., Step 2), the treatment should be up-regulated to Step 3, Step 4, or Step 5 until control is achieved. Before considering a step-up, check for common problems such as poor inhaler technique, poor adherence, and environmental exposure to allergic allergens. When the control of the asthma symptoms has been maintained for at least 3 months, the ICS dose should be slowly titrated to the minimum dose that will maintain good symptom control and minimize exacerbation risk and potential side effects.

Stepwise asthma management for adults, adolescents, and children 6 to 11 years. ICS: inhaled corticosteroids; LABA: long-acting beta2-agonists; med: medium dose; OCS: oral cortisosteroids; SLIT: sublingual immunotherapy.

Global Strategy for Asthma Management and Prevention, 2017, GINA. http://www.ginasthma.org.)

STEP 1: As-Needed Reliever Inhaler

The preferred option is to start the patient on an as-needed short-acting beta2-agonist (SABA). SABAs are highly

effective in controlling asthma symptoms quickly (see Fig. 14.7). A second controller option is a regular low-dose ICS, in addition to as-needed SABA, in patients at risk for exacerbation. Table 14.2 provides common ICS agents used to control asthma symptoms.

STEP 2: Low-Dose Controller Medication Plus Needed Reliever Medication

The preferred option is to place the patient on a regular low-dose ICS, plus an as-needed SABA. ICSs at low doses have been shown to decrease asthma symptoms, improve lung function and quality of life, and reduce the risk for exacerbations and asthma-related hospitalizations and death. A second controller option is leukotriene receptor antagonists (LTRA), although they are considered less effective than ICSs. However, they may be appropriate for some patients who are unable or unwilling to use an ICS, the patient who experiences uncomfortable side effects from ICS, or the patient with concurrent allergic rhinitis. For the adult or adolescent patients, not previously on any controller treatment, a low-dose combination of ICS and long-acting beta2-agonists (LABAs) as the initial treatment has shown to reduce symptoms and improve lung

function when compared with a low-dose ICS alone. A low-dose sustained-released theophylline may be considered, although it has only a weak efficacy in asthma (see Fig. 14.7).

STEP 3: One or Two Controllers, Plus As-Needed Reliever Medication

The two preferred options for adults and adolescents are a combination of low-dose ICS/LABA as maintenance treatment, plus an as-needed SABA, or a combination low-dose ICS/formoterol (budesonide or beclomethasone) as both maintenance and reliever treatment. For adult patients with allergic rhinitis and sensitized to house dust mites, with exacerbations despite lowto high-dose ICS, consider adding sublingual allergen immunotherapy (SLIT) when the FEV1 is greater than 70% predicted. A second option for adults and adolescents is to increase the ICS to a medium dose or administer a

FIGURE 14.8 Bronchial thermoplasty. Arrow points to thermal energy element.

Nonpharmacologic Interventions in the Treatment of Asthma

In addition to the pharmacologic interventions used to manage asthma, a number of other therapies may be helpful in the control of asthma and/or reducing future exacerbation risks. Box 14.4 provides an overview of common nonpharmacologic interventions.

Box 14.4

Nonpharmacologic Interventions Commonly Used to Manage Asthma

•Smoking cessation

•Physical activity

•Avoidance of occupational exposures

•Avoidance of medications that make asthma worse (e.g., aspirin and NSAIDs)

•Healthy diet

•Avoidance of indoor allergens (e.g., mold, dust mites, and/or pets)

•Allergen immunotherapy

•Weight reduction in obese patients

•Breathing exercises

•Avoidance of indoor air pollution

•Avoidance of outdoor pollution

•Encourage influenza vaccinations

•Bronchial thermoplasty

•Encourage strategies to deal with emotional stress

•Avoidance of certain foods and chemicals

Indications for Referral for Expert Evaluation

Although most patients with asthma usually can be controlled in primary care, some clinical circumstances justify the referral for expert advice regarding the diagnosis and/or management of asthma. Box 14.5 shows common indications for considering referral for expert advice when possible.

Box 14.5

Indications for Considering Referral for Expert Advice

•Difficulty confirming the diagnosis of asthma

•Suspected occupational asthma

•Persistent uncontrolled asthma or frequent exacerbations

•Any risk factors for asthma-related death

•Evidence of, or risk for, significant treatment side effects

•Symptoms suggesting complications or subtypes of asthma (e.g., aspirin-exacerbated asthma)

•See recommendations presented in Step 5, page 232.

Protocol When Asthma Is Controlled

When asthma control has been achieved, regular and ongoing monitoring of the patient's symptom control, risk factors, occurrence of exacerbations, and documentation of responses to any treatment changes is essential to maintain control and determine the lowest step and dose of treatment, which minimizes cost and maximizes the safety of treatment. It is also important to establish the patient's adherence with medications and other advice and any factors that contribute to poor adherence. It is also essential to ensure the patient has a full understanding of all asthma information associated with the patient's condition.

In addition, it should be confirmed that the patient is adequately trained in guided asthma self-management. Guided self-

decreased PEFR or FEV1). Exacerbations may occur in patients with a preexisting diagnosis of asthma or, in some cases, as

the first presentation of asthma. Exacerbations most often occur after the patient has been exposed to an external agent (e.g., viral upper respiratory tract infection, pollen, or pollution) and/or poor adherence with controller medications. Severe exacerbations may occur in patients with mild to well-controlled asthma. Table 14.4 provides a clinical scale to classify the severity of asthma exacerbations. Severe asthma exacerbations are potentially life threatening, and their monitoring and treatment require close supervision. Fig. 14.10 provides an overview of GINA's recommended management of asthma exacerbations in primary care in adults, adolescents, and children 6 to 11 years. Fig. 14.11 shows an overview of GINA's management of asthma exacerbations in an acute care facility (e.g., emergency department).

TABLE 14.4

Classification of Severity of Acute Asthma Exacerbations*

*The presence of several findings, but not necessarily all, suggests the general classification of the exacerbation. Many of these parameters have not been systematically studied, so they serve only as general guides. From Expert Panel Response 3 (EPR 3): Guidelines for the diagnosis and management of asthma, 2007 (http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm).

PEFR, Peak expiratory flow rate.

FIGURE 14.11 Management of asthma exacerbations in acute care facility (e.g., emergency department). (Modified from Global Strategy for Asthma Management and Prevention, 2017, GINA. http://www.ginasthma.org.)

Management of Asthma With Comorbidities and Special Populations

Several comorbidities are often associated with asthma, especially those with difficult-to-treat asthma or severe asthma. When possible, the treating of comorbidities is strongly recommended because they often contribute to the patient's symptoms. Common comorbidities associated with asthma include the following:

•Obesity: Asthma is more difficult to control in obese patients. Weight loss in the obese patient improves asthma control and lung function and reduces medication needs.

•Gastroesophageal reflux disease (GERD): Significant evidence indicates that gastroesophageal reflux is more common in patients with asthma and obstructive sleep apnea than the general population.

•Anxiety and depression: Psychiatric disorders, especially depressive and anxiety disorders, are common among people with asthma.

•Food allergy and anaphylaxis: Although food allergy as a trigger for asthma symptoms is rare (less than 2% of people with asthma), in patients with confirmed food-induced allergic reaction (anaphylaxis), coexisting asthma is a strong risk factor for more severe and even fatal reactions. Food-induced anaphylaxis often presents as life-threatening asthma.

•Rhinitis, sinusitis, and nasal polyps: Most patients with asthma, either allergic or nonallergic, have rhinitis. Upper airway disease often adversely influences airway function in some patients with asthma.