Patient discussions
All patients with asthma should be provided with self-management education, including how to monitor symptoms and/or lung function, a personalized written asthma action plan, and regular review by a healthcare professional.[1] Information on correct inhaler use, importance of medication adherence (in particular, correctly taking their inhaled corticosteroid [ICS]-containing medications), and avoiding asthma triggers is also emphasized.[1] The written asthma action plan helps patients to recognize when their asthma is deteriorating and how to respond appropriately. This may include instructions on how and when to:[1]
Change usual reliever medication
Change usual controller medication
Use oral corticosteroids
Contact a healthcare professional.
The advice and criteria will vary from patient to patient and should be tailored to health literacy and sociocultural factors.[1] The patient may be given a peak flow meter with proper instruction on technique, and their action plan may be based on changes in the measured peak flow: this approach can be useful for patients with a history of sudden severe exacerbations, or for earlier detection of exacerbations in patients with poor perception of airflow limitation.[1] Depending on patient ability and clinical appropriateness, medication changes may be patient-initiated (by following instructions in the written action plan) or initiated by a healthcare provider.[1] Patients with a history of rapid deterioration may be advised to seek medical attention immediately if their asthma starts to worsen.[1]
For patients taking maintenance-only ICS-containing treatment, the maintenance treatment should generally be increased if there is a clinically important change from the patient's usual level of asthma control: for example, if asthma symptoms are interfering with normal activities, or peak expiratory flow rate has reduced by more than 20% for more than 2 days.[1]
An unblinded, randomized trial involving 1871 adults and adolescents with asthma looked at the effect of a personalized asthma action plan that included a temporary quadrupling of the dose of ICS when asthma control started to deteriorate. This resulted in fewer severe asthma exacerbations than a plan in which the ICS dose was not increased.[99] This approach is now recommended by some guidelines, including the Global Initiative for Asthma (GINA), the British Thoracic Society (BTS), and the Scottish Intercollegiate Guidelines Network (SIGN), in the self-management of asthma exacerbations in adults.[1][45]
In adults, increased asthma morbidity benefits are seen when the written action plan includes both increasing ICS and adding oral corticosteroids.[1] If oral corticosteroids are part of the written action plan, the patient should be advised against inappropriate use of these.[1] While oral corticosteroids can be necessary and life-saving (especially for severe exacerbations), there are long-term risks associated with repeat courses: even 4-5 courses in an adult is linked to an increased dose-dependent risk of diabetes, osteoporosis, and heart failure, among other conditions.[1] There are also important short-term adverse effects, including mood changes and increased thromboembolism and infection risk.[1] Steps should be taken to reduce risk of future exacerbations and thus minimize future use of oral corticosteroids.[1]
If home treatment is not appropriate, then treatment in primary care, an acute care facility, the emergency department, or in the hospital will be required. Patients should contact their doctor if they start oral corticosteroids at home and should be advised to urgently seek medical attention if their symptoms worsen despite (or do not respond to) appropriate self-management.[1]
After a self-managed exacerbation, the patient should have a semi-urgent review in primary care within 1 to 2 weeks, ideally before stopping any oral corticosteroids.[1] If the patient needed treatment in primary care, an acute care facility, the emergency department, or in the hospital, then a follow-up visit should be scheduled for the patient within 2 to 7 days. The follow-up review should assess:[1]
Whether or not the exacerbation has resolved
Whether or not oral corticosteroids can be stopped
The patient's level of symptom control
The patient's risk factors
The potential cause of the exacerbation
The patient's written asthma action plan (e.g., was it understood and followed appropriately; does it need to be amended or updated)
The patient's inhaler technique and adherence to treatment.
The follow-up review also provides opportunity for additional education.[1] GINA recommends that patients discharged from the emergency department or after hospitalization should in particular be targeted for an asthma education programme if available.[1] Patients who have been hospitalized may be especially receptive to education, and there is evidence that comprehensive intervention (with optimization of treatment and inhaler technique, and self-management education) after emergency department presentation significantly improves asthma outcomes.[1] Educational interventions in the emergency department that target either patients or primary care providers may reinforce the need for office follow-up visits after asthma exacerbations.[100]
Patients with a high risk of life-threatening asthma exacerbations (e.g., one or more risk factors present for asthma-related death) should be flagged for more frequent review, and are encouraged to seek urgent medical care early in the course of an exacerbation.[1] Risk factors for asthma-related death (which should be clearly identified in the patient’s medical notes) include:[1]
A history of near-fatal asthma requiring intubation and mechanical ventilation
Hospitalization or emergency care visit for asthma in the past year
Currently using or having recently stopped oral corticosteroids
Not currently using ICS
Overuse of short-acting beta-2 agonists, especially use of one or more inhalers of albuterol (or equivalent) monthly on average, or use of nebulized short-acting beta-2 agonist
Poor adherence to ICS-containing medications and/or poor adherence to (or lack of) a written asthma action plan
A history of psychiatric disease or psychosocial problems
Food allergy (or anaphylaxis) in a patient with asthma
Comorbidities including pneumonia, diabetes, and arrhythmias.
Women with asthma who are pregnant or planning a pregnancy should be advised not to stop ICS-containing therapy, as doing so will increase their risk of exacerbations.[1] Exacerbations in pregnancy are associated with increased risk of poor pregnancy outcomes (e.g., low birthweight) but well-controlled asthma during pregnancy poses little or no increased risk of maternal or fetal complications.[1] Counsel the patient that the benefits of treating asthma during pregnancy (and the risks of not controlling asthma during pregnancy) heavily outweigh any potential risks of using standard asthma treatments in pregnancy.[1]
How to use a peak flow meter to obtain a peak expiratory flow rate measurement.
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