Putting guidelines into practice begins with the history
A detailed medical history and a physical examination focusing on the upper respiratory tract, chest, and skin are needed to arrive at an asthma diagnosis. JJ’s physician asked his mother to describe recent symptoms and inquired about comorbid conditions that can aggravate asthma. He also identified viral respiratory infections, environmental causes, and activity as precipitating factors.
In considering an asthma diagnosis, try to determine the presence of episodic symptoms of airflow obstruction or bronchial hyperresponsiveness, as well as airflow obstruction that is at least partly reversible (an increase in forced expiratory volume in 1 second [FEV1] of >200 mL and ≥12% from baseline or an increase of ≥10% of predicted FEV1), and to exclude alternative diagnoses.
EPR-3 emphasizes spirometry
Recognizing that patients’ perception of airflow obstruction is highly variable and that pulmonary function measures do not always correlate directly with symptoms,3,4 the EPR-3 recommends spirometry for patients ≥5 years of age, both before and after bronchodilation. In addition to helping to confirm an asthma diagnosis, spirometry is the preferred measure of pulmonary function in classifying severity, because peak expiratory flow (PEF) testing has not proven reliable.5,6
Objective measurement of pulmonary function is difficult to obtain in children <5 years of age. If diagnosis remains uncertain for patients in this age group, a therapeutic trial of medication is recommended. In JJ’s case, however, 3 courses of oral corticosteroids (OCS) in less than 6 months were indicative of persistent asthma.
Spirometry is often underutilized. For patients ≥5 years of age, spirometry is a vital tool, but often underutilized in family practice. A recent study by Yawn and colleagues found that family physicians made changes in the management of approximately half of the asthma patients who underwent spirometry.7 (Information about spirometry training is available through the National Institute for Occupational Safety and Health at http://www.cdc.gov/niosh.) Referral to a specialist is recommended if the physician has difficulty making a differential diagnosis or is unable to perform spirometry on a patient who presents with atypical signs and symptoms of asthma.
What is the patient’s level of severity?
In patients who are not yet receiving long-term controller therapy, severity level is based on an assessment of impairment and risk (FIGURE 1). For patients who are already receiving treatment, severity is determined by the minimum pharmacologic therapy needed to maintain asthma control.
The severity classification—intermittent asthma or persistent asthma that is mild, moderate, or severe—is determined by the most severe category in which any feature occurs. (In children, FEV1/FVC [forced vital capacity] ratio has been shown to be a more sensitive determinant of severity than FEV1,4 which may be more useful in predicting exacerbations.8)
Asthma management: Preferred and alternative Tx
The recommended stepwise interventions include both preferred therapies (evidence-based) and alternative treatments (listed alphabetically in FIGURE 3 because there is insufficient evidence to rank them). The additional steps and age categories support the goal of using the least possible medication needed to maintain good control and minimize the potential for adverse events.
In initiating treatment, select the step that corresponds to the level of severity in the bottom row of FIGURE 1; to adjust medications, determine the patient’s level of asthma control and follow the corresponding guidance in the bottom row of FIGURE 2.
Inhaled corticosteroids remain the bedrock of therapy
ICS, the most potent and consistently effective long-term controller therapy, remain the foundation of therapy for patients of all ages who have persistent asthma. (Evidence: A).
Several of the age-based recommendations follow, with a focus on preferred treatments:
Children 0 to 4 years of age
- The guidelines recommend low-dose ICS at Step 2 (Evidence: A) and medium-dose ICS at Step 3 (Evidence: D), as inhaled corticosteroids have been shown to reduce impairment and risk in this age group.9-16 The potential risk is generally limited to a small reduction in growth velocity during the first year of treatment, and offset by the benefits of therapy.15,16
- Add a long-acting β2-adrenergic agonist (LABA) or montelukast to medium-dose ICS therapy at Step 4 rather than increasing the ICS dose (Evidence: D) to avoid the risk of side effects associated with high-dose ICS. Montelukast has demonstrated efficacy in children 2 to 5 years of age with persistent asthma.17
- Recommendations for preferred therapy at Steps 5 (high-dose ICS + LABA or montelukast) and 6 (Step 5 therapy + OCS) are based on expert panel judgment (Evidence: D). When severe persistent asthma warrants Step 6 therapy, start with a 2-week course of the lowest possible dose of OCS to confirm reversibility.
- In this age group, a therapeutic trial with close monitoring is recommended for patients whose asthma is not well controlled. If there is no response in 4 to 6 weeks, consider alternative therapies or diagnoses (Evidence: D).