Management of stable and acute asthma

The key to asthma management is educating and empowering patients to manage their condition, as well as provision of the appropriate treatment for the patient’s asthma phenotype, symptoms, and lifestyle

Asthma is a heterogeneous disease, usually characterised by chronic airway inflammation, which is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that can vary over time and in intensity, together with variable expiratory airflow limitation.¹ 

The key to asthma management is educating and empowering patients to manage their asthma, as well as provision of the appropriate treatment for the patient’s asthma phenotype, symptoms, and lifestyle. The disorder is commonly managed in primary care settings, and the general practice nurse (GPN) is ideally placed to provide many vital components of optimal management and prevention.

Management of stable asthma

The goals of asthma management are:¹

1. Symptom control: To achieve good control of symptoms and maintain normal activity levels.

2. Risk reduction: To minimise the risk of future exacerbations, fixed airflow limitation, and medication side-effects. 

Assessment of asthma control involves assessing symptoms over the previous four weeks using the Global Initiative for Asthma (GINA) Assessment of Asthma Control¹ and the Asthma Control Test (ACT), as well as assessing risk factors for poor outcomes. Treatment issues must also be addressed at every visit and should include:

• Review of inhaler technique and adherence;

• Asking about side-effects;

• Reviewing the patient’s written asthma action plan;

• Exploring the patient’s attitudes and goals for their asthma management.

The treatment and management of asthma should incorporate the following elements:

• Education on the disease process;

• Management of triggers;

• Medication management: Actions, inhaler technique, adverse events, and adherence;

• Asthma action plan;

• Management of acute flare-ups of asthma.

The goal of asthma management is for the patient to be optimally controlled on the minimum amount of medication. GINA¹ provides healthcare professionals with a management approach based on control, using the step-wise method outlined in Figure 1. This assists healthcare professionals with the titration of medications as step-down or step-up approaches, while attempting to achieve this goal.

The cornerstone of asthma treatment is inhaled therapy, as medications are directly targeted at the airways and, therefore, are more effective. This also limits the amount of systemic absorption of drugs and reduces adverse events. Patients should be commenced on the appropriate step of the treatment guidelines, which is dependent on the severity of their symptoms.¹ Each patient is assigned to one-of-five treatment steps, and patients may move up or down the steps depending on individual symptoms and the amount of reliever therapy being used. Inhaled glucocorticosteroids are the cornerstone of asthma treatment and are the most effective controller medications available. However, there are additional oral medications such as leukotriene receptor antagonists, which can be added to drug regimens, and are useful in patients who have an allergic component to their asthma, experience cold air bronchoconstriction, and have exercise-induced symptoms. These medications are also licensed for use in allergic rhinitis, a condition that 85 per cent of people with asthma also have. Sublingual immunotherapy is also now recommended at all steps of the guideline, depending on the patient’s asthma phenotype. 

In 2019, GINA updated their strategy and outlined significant changes in best practice recommendations for asthma management in adults and adolescents. One of the most significant adaptations was in relation to short-acting bronchodilators (SABA), which are no longer recommended as only-treatments at step one. They now recommend the introduction of combination therapy of inhaled corticosteroids (ICS) and long-acting bronchodilators (LABAs) as an as-needed therapy at step one, and as a maintenance therapy at step two. Using a combination therapy as an as-needed therapy will require a significant change in the mindset and routine practices of healthcare providers and long-term sufferers, considering the long-standing use of short-acting bronchodilators (SABAs) in the alleviation of asthma symptoms. 

Why this change?

Inhaled SABAs (salbutamol, terbutaline) have been first-line treatment for asthma for 50 years. Traditionally, asthma was believed to be a disease of bronchoconstriction, with a SABA being the primary drug of choice. Added to this, rapid relief of symptoms, reliance on, patient satisfaction, and their low cost have meant that SABAs were widely used, overused, and over-relied upon. The perception by patients that their reliever provides more control over their asthma can mean that they often do not recognise the need for other treatments. Research over the past number of years has shown that regular and frequent use of SABAs actually decreases broncho-protection, increases rebound hyperresponsiveness, and decreases bronchodilator response.² Patients with apparently mild asthma are at risk of serious adverse events such as near fatal asthma, acute asthma, and death from asthma. Regular or frequent use of SABAs is also associated with increased allergic response and increased eosinophilic airway inflammation.³ Patients who get three or more canisters of SABA per year (average 1.7 puffs/day) are associated with higher risk of attendance to the emergency department⁴ and patients who receive 12 or more canisters per year are associated with higher risk of death.⁵ A 2021 meta-analysis of four randomised-control trials involving 9,565 patients demonstrated the benefits of LABA/ICS combination therapy, showing a 55 per cent reduction in severe exacerbations compared with SABA alone. Emergency department visits or hospitalisations were 65 per cent lower than with SABA alone, and 37 per cent lower than with daily ICS.⁶

In their review of the literature, GINA found no evidence to support a step one SABA-only approach. The lack of evidence for SABA-only treatment contrasted with the strong evidence for the safety, efficacy, and effectiveness of the treatments recommended in steps two-to-five of the strategy such as ICS and ICS/LABA. Therefore, GINA no longer recommends SABA-only treatment for step one. It is now recommended that all adults and adolescents with asthma should receive symptom-driven or regular low-dose combination LABA/ICS-containing controller treatment to reduce the risk of serious exacerbations.¹ Patients who have symptoms more than twice a month should be prescribed ICS/LABA twice-daily (steps two-to-five), and patients who have symptoms less than twice a month should use ICS/LABA on an as-needed basis (step one). Daily ICS is no longer listed as a step one option as it has a high probability of poor adherence. It is now replaced by a more feasible as-needed controller option at step one. Patients should be offered self-management plans with instructions on how to adjust their medications in response to worsening symptoms and/or worsening peak expiratory flow rate (PEFR). An example of an asthma self-management plan is available at www.asthmasociety.ie.

Non-pharmacological management

The non-pharmacological management of asthma includes management of trigger factors, smoking cessation, management of obesity, and managing gastro-oesophageal reflux disease (GORD) if present. GORD can worsen asthma symptoms and treatment of reflux may improve them. Hormones can also play a significant role in asthma control. Some patients will experience worsening of their asthma symptoms pre-menstrually or during menstruation. During pregnancy, asthma control may improve, deteriorate, or stay the same as pre-pregnancy. Asthma may also develop in women who are menopausal, and very often requires high doses of ICS as it can be more difficult to control. Influenza vaccination is also recommended for those with more severe asthma.

Adherence with medication regimes

One of the biggest challenges in asthma management is adherence to medication, as many patients may be asymptomatic, and therefore do not feel the need to use their medication daily. Exploring the patient’s beliefs and attitudes can be useful in determining a rationale for non-adherence to medication regimes. Saving medication until it is needed, fear of becoming addicted, or “the health professional did not listen” are among reasons given by patients in the INCA study.⁷ In the current climate, cost is a significant factor, even for the person who has a medical card, and should not be overlooked. Two proven ways to address non-adherence are shared decision-making between the health professional and the patient, and motivation interviewing. Using motivational interviewing, the GPN can assess the individual’s likelihood to adhere to their medication or to non-pharmacological interventions. 

Assessment and management of acute asthma

Accurate and timely assessment of acute asthma exacerbations should be carried out to ensure a successful outcome. Table 1 differentiates between a mild and severe acute exacerbation.

The management of acute asthma includes:

1. Oxygen therapy: 24 per cent delivered by face mask (usually one litre/min) to maintain oxygen saturation 93-to-95 per cent;

2. Inhaled SABA: Four-to-10 puffs of salbutamol by spacer, or five milligrams by nebuliser, every 20 minutes for the first hour, then reassess severity. If symptoms persist, deteriorate, or recur, give an additional 10 puffs per hour and admit to hospital;

3. Oral corticosteroids should be given at a maximum of 50mg orally and continue for five-to-seven days;

4. Additional treatments for moderate or severe exacerbations can include ipratropium bromide 80mcg (or 250mcg by nebuliser) every 20 minutes.

Criteria for immediate transfer to secondary care include:

1. Features of severe exacerbation at initial or subsequent assessment:

• Patient is unable to speak or drink;

• Cyanosis;

• Subcostal retraction;

• Oxygen saturation less than 92 per cent when breathing room air;

• Silent chest on auscultation.

2. Lack of response to initial bronchodilator treatment.

3. Persisting tachypnoea after three administrations of inhaled SABA.

4. Unable to be managed at home.

Follow-up post exacerbation

All patients should be followed up regularly after an exacerbation until symptoms and lung function return to normal. Patients are at increased risk during recovery from a further exacerbation. This period also provides an opportunity to review and update the patient’s asthma management, review inhaler technique and adherence, and to ascertain if there was a cause or new trigger factors for this flare-up, which might be helpful in preventing future exacerbations.

At follow-up visit(s), the asthma review should include:

• The patient’s understanding of the cause of the flare-up;

• Modifiable risk factors, including smoking, weight loss if indicated, and addressing new triggers;

• Adherence with medications and an understanding of their purpose;

• Reliever should be administered as-needed rather than routinely;

• If controller medication was increased, the increased dose should be maintained for three weeks and possibly longer, particularly during the winter or during hayfever season;

• Inhaler technique skills;

• Written asthma action plan.

References

GINA. Global Strategy for Asthma Management and Prevention, updated November 2022. Available at: https://ginasthma.org/gina-reports/

Hancox RJ, Cowan JO, Flannery EM, Herbison GP, McLachlan CR, et al. (2000). Bronchodilator tolerance and rebound bronchoconstriction during regular inhaled B2-agonist treatment. Respiratory Medicine. 94(8), 767-771

Aldridge RE, Hancox RJ, Robin Taylor D, Cowan JO, Winn MC, et al. (2000). Effects of terbutaline and budesonide on sputum cells and bronchial hyperresponsiveness in asthma. Am J Respir Crit Care Med. 161(5), 1459-64 

Stanford RH, Shah MB, D’Souza AO, Dhamane AD, Schatz M. (2012). Short-acting beta-agonist use and its ability to predict future asthma-related outcomes. Ann Allergy Asthma Immunol. 109(6), 403-7

Suissa S, Ernst P, Boivin JF, Horwitz RI, Habbick B, et al. (1994). A cohort analysis of excess mortality in asthma and the use of inhaled beta-agonists. Am J Respir Crit Care Med. 149(3 Pt 1), 604-10

Crossingham I, Turner S, Ramakrishnan S, Fries A, Gowell M, Yasmin F, et al. Combination fixed-dose beta agonist and steroid inhaler as required for adults or children with mild asthma. Cochrane Database of Systematic Reviews. 2021, Issue 5 

Sulaiman I, Mac Hale E, Holmes M, et al. A protocol for a randomised clinical trial of the effect of providing feedback on inhaler technique and adherence from an electronic device in patients with poorly controlled severe asthma. BMJ Open. 2016;6:e009350