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In patients of all ages with respiratory symptoms (acute, chronic, recurrent):
Include asthma in the differential diagnosis.
Confirm the diagnosis of asthma by appropriate use of:
history.
physical examination.
spirometry.
In a child with acute respiratory distress, distinguish asthma or bronchiolitis from croup and foreign body aspiration by taking an appropriate history and doing a physical examination.
In a known asthmatic, presenting either because of an acute exacerbation or for ongoing care, objectively determine the severity of the condition (e.g., with history, including the pattern of medication use), physical examination, spirometry). Do not underestimate severity.
In a known asthmatic with an acute exacerbation:
Treat the acute episode (e.g., use beta-agonists repeatedly and early steroids, and avoid under-treatment).
Rule out co-morbid disease (e.g., complications, congestive heart failure, chronic obstructive pulmonary disease).
Determine the need for hospitalization or discharge (basing the decision on the risk of recurrence or complications, and on the patient’s expectations and resources).
For the ongoing (chronic) treatment of an asthmatic, propose a stepwise management plan including:
self-monitoring.
self-adjustment of medication.
when to consult back.
For a known asthmatic patient, who has ongoing or recurrent symptoms:
Assess severity and compliance with medication regimens.
Recommend lifestyle adjustments (e.g., avoiding irritants, triggers) that may result in less recurrence and better control.
Diagnosis
Diagnosis
History of variable respiratory symptoms
Generally more than one respiratory symptom (wheeze, dyspnea, cough, chest tightness)
Isolated cough in adults is seldom due to asthma
Worse at night or early morning (on waking)
Symptoms vary over time and in intensity
Triggered by endogenous/exogenous stimuli (exercise, laughter, allergens, changes in weather, irritants - eg. car fumes, viral infections)
Documented airflow limitation: Reduced FEV1/FVC (<0.75-0.8 in adults and <0.9 for children) AND variable expiratory airflow limitation:
Post-bronchodilator reversiblity increase in FEV1 >12% (minimum of 200mL in adults)
Excessive variability in twice-daily (diurnal) PEF over 2 weeks (adults >10%, children >13% daily diurnal variability)
Significant increase in lung function after 4 weeks of anti-inflammatory treatment (adults FEV1 >12% and >200mL increase from baseline)
Positive exercise challenge test (adults decrease FEV1 >10% and >200mL or in children decrease FEV1>12% predicted or PEF >15%)
Positive bronchial challenge test/methacholine (Fall FEV1≥20% or ≥15% with standard hyperventilation, hypertonic saline or mannitol challenge)
Excessive variation in lung function between visits *less reliable (FEV1>12% and 200mL in adults)
Diagnosis in Preschoolers (one to five years of age)
Diagnosis in Preschoolers (one to five years of age)
Documentation of airflow obstruction (eg. wheezing or other symptom)
Documentation of reversibility of airflow obstruction (eg. improved with SABA ± oral corticosteroids)
No clinical evidence of an alternative diagnosis
Some experts differentiate into "viral-induced wheezing" if only occurs in context of viral URIs
Wheezing in Infants/Children DDx
Wheezing in Infants/Children DDx
Asthma
GERD
Infectious
Bronchiolitis (<2yo, wheezing/crackles, increased respiratory effort)
Pneumonia
Viral-induced wheezer (recurrent viral-triggered wheezing, history of asthma, eczema, atopy)
Foreign body aspiration
Cystic fibrosis
Tracheobronchial anomalies (vascular rings)
Mediastinal mass
Congenital heart disease / Heart failure (hepatomegaly, poor weight gain)
Asthma Management
Asthma Management
Asthma control
Symptom Control
Daytime > 2/week
Night-time waking due to asthma
Reliever use >2/week
Activity limitation due to asthma
Future risk of adverse outcomes (independent of symptom control)
History of ≥ 1 exacerbation in previous year
Poor adherence
Incorrect inhaler technique
Low lung function
Measure lung function at 0, 3-6 months, then periodically
Smoking
Blood eosinophilia
Treatment issues
Technique, adherence, side-effects
Patient education
Encourage adherence with controller medication (even if symptoms infrequent)
Comorbidities (rhinitis, sinusitis, GERD, obesity, OSA, mood)
Smoking cessation
Controlling environmental factors (triggers)
Asthma action plan
Pharmacological therapy
Pharmacological therapy
GINA recommends adding an ICS-formeterol (eg. Symbicort) even in mild intermittent asthma in 12+ year old, as adding any ICS significantly reduces the risk of severe exacerbations (NNT 8 to prevent one severe exacerbation per year) and decline in lung function at a population level
No studies of "as needed" ICS-formoterol in children
An alternative first-step is ICS + SABA, but there are concerns of poor adherence to the ICS
ICS + LABA PRN (reliever) in 12+ years old
Symbicort Turbuhaler (budesonide/formoterol) 200/6 mcg 1 inh PRN (max 6 inh/time, max 8 inh/day)
ICS maintenance + SABA PRN (reliever)
Flovent HFA (fluticasone) 50, 125, 250mcg 1 inh BID
Pulmicort Turbuhaler (budesonide) 100, 200, 400mcg 1 inh BID
Ciclesonide (Alvesco) 400 mcg once daily
Starting doses: Flovent 100-250mcg, Pulmicort 200-400mcg
ICS + LABA maintenance and PRN in 12+ years old
Symbicort Turbuhaler (budesonide/formoterol)100/6, 200/6 mcg 1-2 inh BID (max total including maintenance and reliever 72 mcg formoterol/24h)
Reliever 200/6 mcg 1 inh PRN (max 6 inh/time)
Advair Diskus (fluticasone/salmeterol) 100/50, 250/50, 500/50mcg 1inh BID
Refer for add-on treatment (LAMA Tiotropium, anti-IgE, anti-IL5, oral steroids, Bronchial thermoplasty, SC/SLIT)
LTRA are less effective than ICS
Consider if unable/unwilling to use ICS or in concomitant allergic rhinitis
Singulair (Montelukast) 5, 10mg 1 tab PO PRN
In <5yo, use MDI with spacer and face mask or nebulizer, and dose-adjust
Recommendations for initial controller therapy
Recommendations for initial controller therapy
If symptoms <2/month and no risk factors
Consider no controller
If symptoms >2/month or risk factors
Consider Low-dose ICS
If symptoms >2/week
Low-dose ICS
Asthma most days or waking due to asthma ≥1/week
Medium/high-dose ICS or Low dose ICS/LABA
Severely uncontrolled asthma or acute exacerbation
Short course oral corticosteroids AND High-dose ICS or Moderate-dose ICS/LABA
Follow-up
Follow-up
Ideally 1-3 months after starting treatment, and q3-12 months after
Step-up vs. Step-down
Patient Education
Smoking cessation
Healthy diet
Weight reduction
Breathing exercises
Dealing with emotional stress
Swimming in young people with asthma
Vaccinations (influenza)
Avoid indoor/outdoor allergens
Avoid occupational exposures/allergens
Caution with medications that could worsen asthma (NSAIDs, BB)
Consider vaccinations (no good evidence)
Consider referral if
Difficult confirming diagnosis
Occupational asthma
Uncontrolled asthma
Risk factors for asthma-related death (ICU admission, anaphylaxis or confirmed food allergy)
Treatment side effects
Exacerbation
Exacerbation
Self-Management (Action Plan)
Self-Management (Action Plan)
Early intervention in worsening asthma is key
Increase reliever frequency
Increase usual controller
Quadruple ICS or Quadruple maintenance ICS/formoterol (max formoterol 72mcg/day)
Severe exacerbation (PEF <60%) or not improving after 48h
Oral corticosteroids and contact doctor
Prednisolone 1mg/kg/day (40-50mg)
Hospital Management
Hospital Management
Initial assessment
ABC
Life-threatening signs: Drowsiness, Confusion, Silent chest
Consult ICU, SABA, O2, prepare for intubation
Assess severity based on dyspnea, RR, HR, O2 sat, Lung function (or PRAM score)
Mild-moderate
Talks in phrases, not agitated, Pulse 100-120, O2>90%
Severe
Talks in words, agitated, RR>30/min, Accessory muscle use, Pulse >120bpm, O2 <90%
Oxygen (Target 93-95%)
SABA MDI with spacer 4-8 puffs or 5mg nebulizer q20 mins x 3 (for one hour)
Then depending on severity, SABA 4-8 puffs q1-4 hours
No additional SABA if PEF >60-80% of predicted or personal best x4 hours
New spacer should be washed or primed with 20 puffs of salbutamol (because of static charge)
Early oral corticosteroids
Methylprednisolone 40mg IV q12h (1-2mg/kg/day divided BID) until improved
Prednisone 40-60mg daily (1-2mg/kg/day divided BID) x 3-5d for children, 5-7d for adults
Dexamethasone 12-16mg daily (0.6mg/kg/day) for 1-2 doses
Consider longer 5-10 days depending on severity, taper glucocorticoids if >10d course
If severe
Ipratropium bromide (Atrovent) MDI/spacer 4-8 inh or 0.5mg neb q20 mins then PRN q1-4h
Consider MgSO4 2g (25-75mg/kg/dose) IV over 20 minutes
Transfer to acute care facility
Measure lung function after one hour of treatment
PEF<60% of predicted or best, or clinically not improved -> SEVERE
Continue treatment and reassess
PEF 60-80% of predicted or best -> MODERATE
Consider Discharge
Discharge if no SABA x4h, PEF >60-80% of best or predicted, O2 >94% on RA
Reduce reliever to as needed
Start controller or step-up controller for 2-4 weeks
Continue steroids if started, eg. Prednisone 30-50mg (or 1-2mg/kg/day) PO x 5 days
Review action plan (and modify if needed)
Early follow-up within 1 week
References:
Global Initiative for Asthma (GINA) 2019. http://ginasthma.org/gina-reports/
CTS/CPS 2015. Diagnosis and management of asthma in preschoolers. http://www.cps.ca/en/documents/position/asthma-in-preschoolers
CPS 2012. Acute asthma exacerbation. http://www.cps.ca/en/documents/position/management-acute-asthma-exacerbation
CTS 2012. https://cts.lung.ca/sites/default/files/documents/cts/FINAL%20ASTHMA%20GUIDELINE%20APRIL%202012.pdf
NIH 2007. https://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines
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