Asthma Management: Guidelines for the Primary Care Physician

Peer Review Status: Internally Peer Reviewed
First Published: May 1995
Last Revised: June 2006

Table of Contents

• The Problem
• Guideline Goals
• Diagnosis of Asthma
• Classification by Clinical Pattern
• Therapeutic Strategies
• Follow-up Guidelines
• Guidelines for Urgent Physician Care of Acute Symptoms
• Formulary of Commonly Used Anti-asthmatic Medication
• Tables
• Recommendations for Further Reading
• Other Educational Resources

The Problem
Asthma is the most common medical diagnosis among hospitalized children. In the United States, asthma has accounted for about 15 percent of non-surgical admissions to the hospital in the pediatric age group. Asthma is also one of the leading causes for emergency care requirements, one of the leading causes for missed school and a cause for considerable morbidity, disability, and occasional mortality at all ages. Despite these discouraging statistics, there is convincing data indicating that this failure of asthma management is not the result of inadequate therapeutic potential, but instead represents a failure of effective medical care delivery. Conflicting and/or complex regimens from multiple sources result in confusion and lack of clear guidelines realistically applicable in the primary care setting.

Guideline Goals
Guidelines realistically applicable in the primary care setting can be termed low intensity, and it is the goal of this guide to emphasize those low-intensity measures likely to have the greatest influence on outcome. These strategies can therefore be called low-intensity high-yield measures for managing asthma.

Low-intensity measures for assessment and therapy are necessary in the primary care setting because of the prevalence of asthma, the likelihood that most patients with asthma will continue to receive most of their care from primary care physicians, and the limited time available per patient in the primary care setting. Choosing those measures that provide high-yield are necessary to gain the greatest clinical benefit with the least clinician time and cost. These guidelines therefore are not an attempt to identify all possible measures that might be useful for asthma. Measures that are high intensity and/or low yield may be very important for selected patients but are probably most appropriate in a subspecialty setting. These guidelines are therefore designed to cut through the morass of potential diagnostic and therapeutic options in order to isolate the most efficient initial means of effectively managing asthma.

Diagnosis of Asthma
Establishing the diagnosis is critical, although historically asthma has often been misdiagnosed. Particularly in the young child, the symptoms resulting from airway inflammation associated with asthma have been misdiagnosed as pneumonia and bronchitis, leading to ineffective and unnecessary use of antibiotics (Figure 1). If there is not a firmly established alternative diagnosis, asthma should be considered when patients present with the following symptoms:

• recurrent or chronic lower respiratory wheezing most prominent on expiration
• recurrent or chronic coughing
• repeated diagnoses of bronchitis
• repeated diagnoses of pneumonia not clinically consistent with pyogenic infection

The diagnosis of asthma is most efficiently confirmed by demonstrating the complete response of symptoms, or spirometric measurement of airway obstruction, to an inhaled b₂ agonist and/or a 5 to 10 day course of high dose oral corticosteroids. Patients not clearly made asymptomatic with these measures should be referred to an appropriate subspecialist for further investigation of other inflammatory or occasionally functional disorders that can cause similar symptoms. These can include such varied disorders as cystic fibrosis, cigarette smoking induced chronic obstructive pulmonary disease, primary ciliary dyskinesia, tracheal or bronchial malacia, foreign body aspiration, vocal cord dysfunction, or habit cough syndrome.

Classification by Clinical Pattern
Planning effective and efficient strategies for managing asthma requires identification of the clinical pattern of disease in the patient to be treated. These clinical patterns include:

Intermittent. Patients with episodic illness interspersed with extended symptom-free periods. Episodes are most commonly triggered by viral respiratory infections or transient exposure to an environmental allergen or irritant.

Chronic. Patients experience virtually daily symptoms and, in the absence of continuous therapy, do not have extended symptom-free periods.

Seasonal allergic. Patients experience virtually daily symptoms during an inhalant allergy season. In the North Central United States, this is most commonly from outdoor molds that grow on decaying vegetation from early spring through late fall, with peaks particularly in the spring and fall. Allergens and seasonal patterns will vary with the geographic region. In other parts of the world, seasonal symptoms may be in reaction to molds, pollens, or a combination of both.

There is potential overlap among these clinical patterns. For example, patients with chronic disease often have intermittent exacerbations from viral respiratory illness and may have seasonal allergic exacerbations. Nonetheless, identification of the clinical pattern contributes to the determination of a therapeutic strategy.

Severity, as assessed by degree of morbidity, is independent of the clinical pattern. Both intermittent and chronic disease may range from relatively benign to life-threatening. Severity should be judged by the frequency and intensity of urgent care requirements, missed school or work, and interference with activity or sleep.

Therapeutic Strategies
Therapeutic strategies fall into two categories: intervention, defined as measures to stop acute symptoms, and maintenance, defined as measures to prevent symptoms from occurring.

All patients require availability of efficient and effective intervention measures. Effective intervention requires anticipating symptom progression so that anti-inflammatory corticosteroids, which act slowly, may be started before urgent care is needed. Therefore, b₂ agonists and corticosteroids should be available at home, and patients and their families should be taught when and how to apply them, as outlined below.

Intervention alone is sufficient for treatment of those with intermittent asthma. However, patients with chronic disease need maintenance medication in addition, to prevent their daily symptoms. Patients with seasonal allergic disease may require maintenance medication, but only seasonally, and patients with chronic disease may require seasonal increases in their maintenance medication during seasonal allergic exacerbations. Adding or increasing maintenance medication at the times when increased symptoms are anticipated avoids morbidity and decreases the likelihood that urgent care will be needed.

Pharmacologic therapy must meet several criteria to be considered successful in controlling asthma (Table 1). First, the treatment plan should eliminate the need for hospitalization and unscheduled medical care due to asthma, and should prevent asthma from interfering with sleep or any activities, including competitive athletics. Maintenance therapy, when needed, should minimize the need for intervention with inhaled b₂ agonist to a maximum of twice daily, not counting pre-exercise prophylaxis, and reduce the need for intervention with short courses of high dose daily oral corticosteroids ideally to no more than four times yearly. Long-term use of daily oral corticosteroids is not safe in any dose and is not indicated for acceptable control of asthma. Patients on maintenance therapy should be capable of normal post-bronchodilator pulmonary function by office spirometry. Finally, patients should suffer no adverse medication effects or adverse effects of treatment on their quality of life.

Low-intensity High-yield Early Intervention Measures
The first intervention should be a b₂ agonist delivered promptly by age-appropriate inhalational device (Figure 2). This should be applied repeatedly when needed. An inhaled b₂ agonist is also the most effective means of prophylaxis for exercise-induced bronchospasm. Careful instruction regarding appropriate use of the prescribed device is essential.

In the case of subresponsiveness to b₂ agonists, identified by incomplete clearing of symptoms or need for repeated use, high dose oral corticosteroids should be initiated immediately and continued until the patient is symptom-free for 24 hours. This usually requires 5 to 10 days of therapy (Figure 3). Patients must be educated on the criteria for subresponsiveness to b₂ agonists, which include failure to experience complete relief of symptoms, failure of the b₂ agonist effect to last 4 hours, and repeated use (for example, symptoms requiring a third use within any eight-hour period). This algorithm should be clearly communicated to the patient. Patients who have had previous urgent care requirements or hospitalizations require a low threshold for progression to corticosteroid therapy (Table II).

Early and vigorous intervention with these measures efficiently and effectively prevents at least 90% of acute exacerbations of asthma from requiring emergency medical care or hospitalization. There are no absolute contraindications to either of these measures. It should be noted, however, that corticosteroids will increase hyperglycemia in diabetics. Also, the onset of chickenpox in children receiving corticosteroids during the incubation period justifies institution of acyclovir in full recommended doses.

Low-intensity High-yield Maintenance Measures
Low dose inhaled corticosteroids should be administered as the first-line of treatment in preventing asthma exacerbations.

Inhaled corticosteroids.   If the inhaled corticosteroid at low to usual doses does not result in criteria for control (table 1), a long acting b₂ agonist is generally the most effective additive agent.  The combination of an inhaled steroid and a long acting b₂ agonist is available as Advair (fluticasone and salmeterol) and as Symbicort (budesonide and formoterol), both of which are dry powder inhalers.  However, there is an occasional patient who has worsening of their asthma control with the addition of a long acting b₂ agonist.  This is observed particularly when the response to a rescue bronchodilator such as albuterol becomes lessened after beginning a long acting b₂ agonist.  Theophylline also has substantial additive effect with an inhaled steroid but requires careful dosing and monitoring of serum theophylline concentrations.  Both a long acting b₂ agonist and theophylline added to a usual dose of inhaled corticosteroid results in greater effectiveness than a higher does of inhaled corticosteroid.  Montelukast (Singulair) also has additive effect with an inhaled steroid but that effect appears to be less than that for a long acting b₂ agonist or theophylline.

A maximum of two maintenance medications at a twice-daily schedule with judicious use of a pre-exercise b₂ agonist and appropriate measures of intervention, is generally sufficient for control of asthma. Patients requiring maintenance medication should, in general be evaluated to determine the role of environmental factors involved in their symptoms. This evaluation involves careful history and skin testing for specific IgE. This would be particularly relevant for patients requiring more than low-dose inhaled steroids for maintenance.

If asthma is resistant to control by the regimens listed above, the patient should be referred to subspecialty clinical care for more intensive evaluation and treatment.

Follow-up Guidelines
Patients whose disease meets criteria for control should receive routine follow-up at scheduled intervals to assess control and assure safety of treatment (Table IV). Measurement of pre- and post-bronchodilator pulmonary function with office spirometry should be performed at each visit. Growth and weight gain should be monitored, because both asthma and treatment with maintenance inhaled have the potential to slow growth. Blood pressure measurement and eye exam for cataracts should be performed on all patients receiving maintenance corticosteroids. In susceptible patients, increased blood pressure may be a systemic effect of corticosteroids. Also, a small increased risk of cataracts has been demonstrated even from inhaled corticosteroids.

Frequency of follow-up. Patients with an intermittent pattern of asthma can be followed with annual checkups if they meet criteria for control. However, more frequent visits may be required to reinforce instructions. Patients with a chronic pattern of asthma should be followed closely until criteria for control are met. Once disease control on stable doses of medication has been achieved, appropriate follow-up depends on the maintenance regimen. Patients requiring more than low doses of inhaled corticosteroids, alternate morning prednisone, or more than one maintenance medication should be seen every three months. Patients on low doses of inhaled corticosteroid or other single-maintenance medication may be followed once every 6 months.

Guidelines For Urgent Physician Care of Acute Symptoms
Patients should be treated immediately with oxygen if they are in respiratory distress (Figure 4). They should also be given a b₂ agonist immediately, by inhalation if they are capable of effective inhalation, and by injection if they are severely dyspneic. High dose systemic corticosteroids should be administered promptly by mouth if there is no concern regarding retention, and parenterally if the patient is obtunded or vomiting. The patient should be monitored with pulse oximetry. Blood gases should be drawn (venous or capillary gases are adequate when pulse oximeter is used) if O₂ saturation is less than 94 percent on room air and patient is dyspneic or retracting, or if O₂ saturation is less than 90 percent regardless of signs or symptoms (Table V).

Patients may be discharged if they are comfortable at rest without retractions or use of accessory muscles of respiration, and if O₂ saturation is greater than 90% on room air. Early follow-up is important. Patients should be admitted to the hospital if respirations continue to be labored or their O₂ saturation is less than or equal to 90%. They should also be admitted if they are sufficiently dehydrated to require IV hydration, or if they have a history of rapid deterioration and distant access to an appropriately staffed ICU (Table VI). Dehydration is particularly likely to occur in small children because of decreased intake during an extended period of respiratory distress, combined with increased insensible losses.

Once admitted, patients may be discharged when they are comfortable at rest without retractions or use of accessory muscles of respiration, and their O₂ saturation greater than 90%. Discharge should be delayed if labored respirations continue or O₂ saturation remains below 90%, the patient is sufficiently dehydrated to require IV hydration, there is a history of rapid deterioration and distant access to an appropriately staffed ICU, or social concerns regarding home care.

The considerations for decision-making regarding admission or discharge for asthma are based on three related principles. First, there are no medications for asthma that are inherently more effective parenterally than orally or by inhalation. Second, there is therefore nothing that can routinely be done in the hospital that can not be done at home, except providing oxygen, close monitoring, and assisted ventilation, if needed. And third, admission and discharge decisions are based on the level of concern for the possibility of respiratory failure.

Formulary of Commonly Used Anti-asthmatic Medication
Inhaled b₂ agonists. Albuterol, pirbuterol (Maxair Autohaler) or levalbuterol. Two to six inhalations of the metered dose inhaler can be used when needed for acute symptoms or pre-exercise to block exercise induced bronchospasm. Use an assist device such as the Maxair Autohaler (3M) or a valved holding chamber (AeroChamber Max or Pari Vortex) for patients with difficulty coordinating inspiration with activation. Albuterol nebulizer solution, 2.5 mg can be used via a compressed air driven nebulizer, but generally provides no more benefit than 6 inhalations, one at a time, from the MDI through a valved holding chamber (with face mask if needed). Levalbuterol (Xopenex) is the active component of racemic albuterol and has no therapeutic advantage over racemic albuterol when used in equivalent doses; bronchodilation and side effects do not differ significantly.

Systemic corticosteroids. For interventional therapy, a sufficiently high dose of prednisone or equivalent should be used such that more is unlikely to be beneficial. For prednisone, we use the following doses: less than 1 year old, 15 mg bid; 1 to 3 years old, 20 mg bid; 3 to 13 years old, 30 mg b.i.d.; >13 years old, 40 mg bid. Higher doses may be justified for impending or actual respiratory failure. For ambulatory use, patients should be instructed to discontinue the evening dose if any side effects develop during the course of therapy. These may include insomnia, mood or behavior changes, musculoskeletal pains, or bloating. Methylprednisolone may be used as a substitute for prednisone at 80% of the prednisone dose if side effects from short courses of prednisone remain troublesome. Dosage should be continued until the patient is free from symptoms and signs of asthma. The mean duration of therapy is 7 days, with a usual range of 5 to 10 days. Dosage should be discontinued without tapering. Oral corticosteroids are as effective as parenteral unless they are not retained.

Inhaled corticosteroids. Beclomethasone dipropionate is available at 40 and 80 micrograms per metered inhalation (QVAR 40 or 80) with 100 metered inhalations per canister. This HFA microaerosal formulation provides considerably improved delivery over older formulations of this drug. Fluticasone is available at 3 concentrations, each with 120 metered inhalations per canister - 44, 110, and 220 mcg per metered inhalation (Flovent 44, Flovent 110, Flovent 220); budesonide (Pulmicort Flexhaler ) is available as a 120 dose dry powder inhaler at 180 and 90 mcg per inhalation and as Pulmicort respules for delivery by compressed air driven nebulizer with face mask (250 mcg or 500 mcg/dose). Mometasone is available as a dry powder inhaled (Asmanex Twisthaler) with 30, 60, or 120 inhalations for the 220 (that delivers 200 mcg/inhalation) and with 30 inhalations of the 110 (that delivers 100 mcg per inhalation). However, metered dose inhalers, propellent driven or dry powder, are much more convenient and cost effective than the nebulizer preparation. Even for infants and toddlers, an assist device, such as the AeroChamber or Pari Vortex with soft flexible face mask permits effective delivery from an MDI.(Figure 2) For all inhaled corticosteroids, the lower end of the dose recommendations is generally adequate since inhaled corticosteroids have a shallow dose-response relationship. Adding salmeterol, formaoterol, or theophylline is usually more effective than increasing the dose of inhaled corticosteroid. None of the inhaled corticosteroids are of value for the prevention of urgent medical care or hospitalization resulting from viral respiratory infection induced asthmatic exacerbations, even when given in high doses.

Salmeterol and formoterol.  Long acting b₂ agonists (LABAs) include both salmeterol and formoterol and are available as the dry powder inhalers, Serevent and Foradil. However, they are more typically and preferable used in combination products with an inhaled corticosteroid, Advair (fluticasone and salmeterol) and Symbicort (budesonide and formoterol). These are maintenance medications and not meant to be for acute symptoms. The "black box" warnings that the FDA now requires to be associated with these products are the consequence of a small number of acute life-threatening events and fatalities associated with their use in an uncontrolled manner. Since there appears to be occasional patients who experience less good control with these medications, they are best added to an inhaled corticosteroid as one of the combination products (Advair or Symbicort) with the patient then observed to see if they experience the usual increased benefit from the combination or if they are the very occasional exception who experience less good control of asthma, especially manifested by increasing requirement for acute bronchodilator use with less benefit from that standard initial intervention measure for acute asthma

Theophylline. Theophylline is less frequently used currently than it was in the past.  Although an effective maintenance medication, whether used alone or when added to an inhaled steroid, it requires careful dosing and monitoring of serum theophylline concentration to be used with maximal safety and effectiveness.

Montelukast (Singulair). Montelukast is marketed as a once daily evening dosage preparation, 10 mg plain tablets with 5 and 4 mg chewable tablets for younger children, and 4 mg packets of a granular preparation for infants and toddlers. Its efficacy is modest but often adequate for those with mild chronic disease. There is at least some additive effect with inhaled corticosteroids. No toxicity or drug interactions has been described.

• Absence of hospitalization
• Absence of unscheduled medical care
• Absence of interference with sleep or activities (including competitive athletics)
• Infrequent intervention with inhaled Theophylline is less frequently used currently than it was in the past. Although an effective maintenance medication, whether used alone or when added to an inhaled steroid, it requires careful dosing and monitoring of serum theophylline concentration to be used with maximal safety and effectiveness. agonist (not counting pre-exercise prophylaxis) < twice-daily
• Infrequent intervention with short courses of high dose daily oral corticosteroids (< 4 times yearly ideally, but some young children may have viral respiratory induced exacerbations more frequently for an occasional year for which, there is no good alternative to an oral corticosteroid)
• Normal or best attainable post-bronchodilator pulmonary function by office spirometry
• Absence of adverse medication effects
• Absence of effects of asthma or its treatment on quality of life

• Intermittent - Reassess at 6- to 12-month intervals once controlled, however:
  • Reinforce intervention measures with telephone contact during acute exacerbations
  • Monitor frequency of intervention
  • Reassess if b₂ used multiple times weekly
• Chronic
  • Reassess at least monthly until controlled
  • Once controlled, reassess at 6- to 12-month intervals for patients on stable low-dose inhaled corticosteroids or theophylline
  • Reassess others at no greater than three month intervals

• Immediate oxygen for patients in respiratory distress
• Immediate b₂ agonist by inhalation if patient can inhale effectively
• Initial bronchodilator dose by injection of epinephrine or tertbutaline if patient is severely dyspneic
• Prompt administration of high dose systemic corticosteroid
• Monitor with pulse oximeter
• Blood gases if O₂ saturation <94 percent at room air and patient is dyspneic or retracting, or if O₂ saturation <90 percent regardless of signs or symptoms

• Admission not generally needed if:
  • Comfortable at rest without retractions or use of accessory muscles of respiration
  • O₂ saturation >90 percent at room air^*
• Admit to hospital if:
  • Labored respirations continue
  • O₂ saturation less than or equal to 90 percent
  • Dehydrated sufficient to require IV hydration
  • History of rapid deterioration and distant access to appropriately staffed ICU

^*Early follow-up is important.

Recommendations for Further Reading
Weinberger M: Proceedings of consensus conference on treatment of viral respiratory infection induced asthma in young children. J Pediatr, 142; Suppl, Feb 2003:S1 and S45-46

Weinberger M: Epidemiology and natural history of asthma.  J Pediatr 142; Suppl, Feb 2003:S15-20

Weinberger M: Treatment strategies for viral respiratory infection induced asthma.  J Pediatr 142; Suppl, Feb 2003:S34-39

Weinberger M, Abu-Hasan M.  Chapter 55:  Asthma in the pre-school child.  In Kendig’s Disordres of the Respiratory Tract in Children, 7th edition, Edited by V. Chernick, TF Boat, RW Wilmott, A Bush.  2006, Saunders Elsevier, Philadephia, pp 795-809.

Other Educational Resources
http://www.uihealthcare.com/allerpulm

Asthma Management: Guidelines for the Primary Care Physician
Copyright 1995
Revised 2006