Asthma management handbook 2006.

Introduction .....................................................................................................................................................1 Levels of evidence and key messages ............................................................................................2 Asthma: basic facts.....................................................................................................................................3 Asthma in Australia ..........................................................................................................................3 Definition of asthma ........................................................................................................................4 Diagnosis and classifications in adults ........................................................................................5 Detection and diagnosis ........................................................................................................................5 History.............................................................................................................................................5 Examination ...................................................................................................................................6 Diagnostic testing ............................................................................................................................7 Diagnosis of asthma ........................................................................................................................7 Other tests .....................................................................................................................................8 Classification of asthma in adults ........................................................................................................8 Diagnosis and classification of asthma in children ..............................................................11 Diagnosis .................................................................................................................................................11 Tests to confirm the diagnosis........................................................................................................11 Alternative diagnoses that are commonly confused with asthma ..................................................12 Patterns of asthma in children ............................................................................................................12 Intermittent asthma ........................................................................................................................12 Persistent asthma ..........................................................................................................................13 Asthma classification in children ......................................................................................................13 Principles of drug therapy ....................................................................................................................15 Principles of drug treatment in adults ..............................................................................................17 Management of intermittent asthma ..............................................................................................17 Management of persistent asthma ................................................................................................17 When to initiate ICS therapy ..........................................................................................................18 Review regularly ............................................................................................................................18 Adjusting maintenance therapy ....................................................................................................18 Add-on therapy: the role of LABAs ................................................................................................19 Fixed-dose ICS–LABA combination therapy regimens..................................................................22 Other add-on therapy options ........................................................................................................23 Principles of drug treatment in children and adolescents ..........................................................23 Stepwise approach to drug therapy in children..............................................................................23 Wheezing .....................................................................................................................................23 Drugs and devices .....................................................................................................................................25 Relievers...................................................................................................................................................25 Short-acting beta2 agonists............................................................................................................25 Long-acting beta2 agonist with rapid onset ....................................................................................26 Ipratropium bromide ......................................................................................................................26 Theophylline .................................................................................................................................26 Preventers ...............................................................................................................................................27 Inhaled corticosteroids ..................................................................................................................27 Leukotriene receptor antagonists ..................................................................................................29 Cromones .....................................................................................................................................30 Anti-immunoglobulin therapy ........................................................................................................31 Oral or parenteral corticosteroids ..................................................................................................32 Copyright National Asthma Council Australia 2006. Non-profit reproduction for patient counselling or educational purposes only is permitted. Contents vii Symptom controllers.............................................................................................................................32 Combination medications ....................................................................................................................33 Other medications and asthma ..........................................................................................................34 Antibiotics .....................................................................................................................................34 Antihistamines ..............................................................................................................................34 Sedatives .....................................................................................................................................34 Medications that can exacerbate asthma ......................................................................................34 Delivery devices .....................................................................................................................................35 Deposition.....................................................................................................................................35 Prescribing devices........................................................................................................................35 Device training ..............................................................................................................................36 Use and care of spacers................................................................................................................36 Acute asthma ...............................................................................................................................................38 Managing acute asthma in adults ......................................................................................................38 Initial assessment ..........................................................................................................................38 History...........................................................................................................................................40 Management.................................................................................................................................40 Other investigations ......................................................................................................................41 Follow-up care after an acute asthma episode..............................................................................41 Managing acute asthma in children ..................................................................................................43 Initial assessment ........................................................................................................................43 Management.................................................................................................................................43 Community-based first aid ............................................................................................................45 Follow-up care after an acute asthma episode..............................................................................45 Managing exacerbations ........................................................................................................................47 Distinguish exacerbations from poor asthma control ....................................................................48 The role of PEF monitoring in detecting exacerbations ................................................................48 Managing exacerbations in adults ....................................................................................................48 Oral corticosteroids.......................................................................................................................48 Short-acting beta2 agonists............................................................................................................48 Inhaled corticosteroids ..................................................................................................................49 Managing exacerbations in children..................................................................................................49 Oral corticosteroids.......................................................................................................................50 Short-acting beta2 agonists............................................................................................................50 Inhaled corticosteroids ..................................................................................................................50 Leukotriene receptor antagonists ..................................................................................................50 Complementary and alternative medicine in asthma............................................................51 Clinical evaluation and regulation of CAM ....................................................................................52 Breathing techniques ....................................................................................................................52 Dietary modification ......................................................................................................................53 Manual therapies ..........................................................................................................................53 Acupuncture .................................................................................................................................53 Exercise therapies ........................................................................................................................53 Medicinal therapies.......................................................................................................................53 Psychological therapies ................................................................................................................54 Other therapies ..............................................................................................................................54 Alternative diagnostic tests ................................................................................................................54 Information resources ....................................................................................................................54 Diet and asthma...........................................................................................................................................55 Food allergy .................................................................................................................................55 Food as a trigger for asthma..........................................................................................................55 Copyright National Asthma Council Australia 2006. Non-profit reproduction for patient counselling or educational purposes only is permitted. AppenPdriecveesnOttihoenr AcosmthomrPabr ieidngi tntiheaOesnc cecylud paeEanrxltdyieo arncsaiCtslh heamdrsoa-tinhnSimdcmu aocobeksdiOtn ragnus gcatothniivmdAne glaa lp escurtaghlrmyDme ioaaent adar nCayds od tmahissmpetlhDaemsrmueaeg ansnEt adaxnr aydcs aetdhnPrebmdrvia inactlcietoiespnrlsne asat niovdfe de mrmueegdr igtcheienrecaipeys Diagnosis and classification of asthma in children Diagnosis and classification of asthma in adults AsthmCao: nthteen btsasic facts viii Weight loss in the obese patient....................................................................................................56 Infant feeding ...............................................................................................................................56 Asthma and allergy ...................................................................................................................................57 The concept of one airway ............................................................................................................57 Inhalant allergens as triggers for asthma ......................................................................................58 Food allergy and asthma ..............................................................................................................59 Allergy tests .................................................................................................................................59 Allergic rhinitis and asthma ................................................................................................................60 Diagnosis .....................................................................................................................................60 Allergen avoidance ........................................................................................................................60 Drug therapy .................................................................................................................................60 Immunotherapy (desensitisation) ..................................................................................................61 Specialist referral for patients with allergic rhinitis ........................................................................61 Immunomodulatory therapy ................................................................................................................61 Conventional (subcutaneous) specific immunotherapy in asthma ................................................62 Sublingual immunotherapy in asthma............................................................................................63 Anti-IgE monoclonal antibody therapy ..........................................................................................63 Other immunomodulatory strategies currently under investigation................................................63 Ongoing care.................................................................................................................................................64 Assess asthma control regularly........................................................................................................65 Asthma history checklist for new patients......................................................................................66 Assessment of control ..................................................................................................................66 Assessment of severity..................................................................................................................67 Severity versus control ..................................................................................................................68 Assessment of asthma in adults and adolescents ........................................................................68 Assessment of asthma in children ................................................................................................68 Ongoing review.............................................................................................................................70 Identify patients with high-risk asthma ..........................................................................................70 Identify and avoid trigger factors ......................................................................................................70 Allergens.......................................................................................................................................71 Drugs ...........................................................................................................................................71 Foods ...........................................................................................................................................72 Gastro-oesophageal reflux ............................................................................................................72 Air pollutants .................................................................................................................................72 Air environment.............................................................................................................................72 Prevent exacerbations ..........................................................................................................................72 Infections .....................................................................................................................................72 Provide asthma self-management education..................................................................................73 Structured self-management programs ........................................................................................74 Training in correct use of inhaler devices ......................................................................................74 Asthma action plans ......................................................................................................................74 Self-management for adolescents ................................................................................................75 Opportunistic asthma education ....................................................................................................75 Self-management should be part of a comprehensive care program............................................75 Information resources for patients ................................................................................................76 Troubleshooting .....................................................................................................................................76 Reassess triggers ..........................................................................................................................76 Review the history ........................................................................................................................77 Review self-management proficiency ............................................................................................77 When to refer to a specialist ..........................................................................................................78 Organising your practice for effective asthma management......................................................78 Considerations for organisation of asthma review ........................................................................79 Copyright National Asthma Council Australia 2006. Non-profit reproduction for patient counselling or educational purposes only is permitted. Contents ix The role of the practice nurse ........................................................................................................79 The role of the community pharmacist ..........................................................................................80 Demographic considerations: organising your practice to suit your patients ................................81 Smoking and asthma ...............................................................................................................................82 Smoking rates in Australia ............................................................................................................82 Effects of smoking on asthma........................................................................................................83 Make the car and home a smoke-free zone ..................................................................................83 Mechanisms for effects of smoking on asthma..............................................................................83 Clinical interventions to help patients quit smoking ......................................................................84 Public policy .................................................................................................................................86 Chronic obstructive pulmonary disease (COPD) and asthma ........................................88 COPD and asthma ........................................................................................................................89 Prevalence ...................................................................................................................................89 Risk factors ...................................................................................................................................89 Diagnosis .....................................................................................................................................90 Management of COPD ..................................................................................................................91 Exercise-induced asthma ......................................................................................................................93 Exercise-induced asthma and exercise-induced bronchospasm ..................................................93 Pathogenesis ...............................................................................................................................93 Impact on quality of life, asthma and sporting performance ..........................................................94 Detection.......................................................................................................................................94 Assessment of lung function..........................................................................................................94 Under- and over-diagnosis ............................................................................................................95 Effect of training ............................................................................................................................95 Treatment strategies to manage exercise-induced asthma ..........................................................95 Drug-free strategies ......................................................................................................................96 Use of asthma medications in competitive sport ..........................................................................97 Occupational asthma ...............................................................................................................................98 Definition and mechanism ............................................................................................................98 Incidence, risk factors and prevention ..........................................................................................99 Diagnosis .....................................................................................................................................99 Prognosis ...................................................................................................................................100 Management of occupational asthma..........................................................................................100 Further information ......................................................................................................................100 Pregnancy and asthma ..........................................................................................................................101 Before pregnancy ........................................................................................................................101 Antenatal care.............................................................................................................................102 Asthma exacerbations during pregnancy ....................................................................................102 Delivery.......................................................................................................................................102 Post-partum phase ......................................................................................................................102 Medications during pregnancy and lactation ..............................................................................103 Smoking .....................................................................................................................................103 Asthma in the elderly ..............................................................................................................................104 Asthma in the elderly is under-diagnosed....................................................................................104 Diagnosis of asthma in older patients..........................................................................................105 Suggested diagnostic steps in the elderly ..................................................................................105 Identifying patients with airflow limitation ....................................................................................105 Copyright National Asthma Council Australia 2006. Non-profit reproduction for patient counselling or educational purposes only is permitted. Contents x Excluding diagnoses other than asthma and COPD ..................................................................106 Distinguishing asthma from COPD ..............................................................................................107 Spirometry in the elderly ..............................................................................................................107 The role of a diagnostic treatment trial in the elderly ..................................................................108 Managing asthma in elderly patients ..............................................................................................108 Drug treatment ............................................................................................................................108 Patient education ........................................................................................................................109 Review of asthma in the elderly patient ......................................................................................109 Acute exacerbations and action plans in elderly patients ............................................................111 Other comorbidities.................................................................................................................................112 Obstructive sleep apnoea ..................................................................................................................112 OSA in adults ..............................................................................................................................112 OSA in children ............................................................................................................................112 Aetiology of OSA..........................................................................................................................112 Treatment ...................................................................................................................................113 Clinical implications of OSA in asthma management ..................................................................113 Gastro-oesophageal reflux and obesity..........................................................................................113 Gastro-oesophageal reflux ..........................................................................................................113 Obesity .......................................................................................................................................114 Asthma and mental illness ................................................................................................................114 Asthma is not a psychosomatic illness ........................................................................................114 Asthma and depression ..............................................................................................................114 Asthma and anxiety disorders......................................................................................................115 Mental illness and adherence to treatment ..................................................................................115 Mental illness and smoking..........................................................................................................115 Mental illness and children with asthma ......................................................................................115 Prevention of asthma ..............................................................................................................................116 Primary prevention: can the onset of asthma be prevented? ..................................................117 Does exposure to environmental tobacco smoke increase asthma risk? ....................................117 Does infant feeding affect asthma risk? ......................................................................................117 Does allergen avoidance reduce asthma risk? ............................................................................117 Other environmental factors ........................................................................................................119 Secondary prevention: can asthma be prevented in patients with other atopic disease?....120 Children ....................................