Asthma, chronic persistent

J45.0/1/8/9

• Description
• General Measures
• Medicine Treatment
• Patient and Caregiver Education on Inhaler and Spacer Techniques

DESCRIPTION

Asthma must be distinguished from chronic obstructive pulmonary disease, which is often mistaken for asthma. The history is a reliable diagnostic guideline and may be of value in assessing treatment response.

LoEII [11]

GENERAL MEASURES

Patient education: including advice on smoking cessation.
Decrease exposure to triggers, e.g. house dust mite, pollens, grasses, pets, smoke, fumes, etc.

MEDICINE TREATMENT

Concomitant use of preparations of the same therapeutic class is hazardous and must be avoided.
Nocturnal symptoms of cough and wheeze, or the need for bronchodilators > twice a week, or PEF <80% of the patient’s best value, indicates poor asthma control.
Patients with poorly controlled asthma need to step up their maintenance therapy as described below.
The Asthma Control Test®, a validated measure of clinical asthma control, can be completed by the patient (after initial instruction) at each visit to the clinic prior to consultation. A value of ≥19 suggests adequate asthma control.(see Appendix V)

A patient with poorly controlled asthma should be assessed for the following and identified problems addressed prior to stepping up therapy:

1. Correct inhaler technique should be demonstrated and checked regularly, as many asthmatic patients do not use their inhalers correctly.
2. Adherence to medication, especially the inhaled corticosteroid.
3. Exposure to triggers of bronchospasm.
4. Use of medications that may aggravate asthma e.g. NSAIDS.
5. Other medical conditions such as cardiac disease.
6. Treat allergic rhinitis (see Rhinitis, allergic, persistent ) and GORD (see Gastro-Oesophageal Reflux Disease (GORD) if present.

Asthma therapy

Inhaled corticosteroids (ICS) are the mainstay of treatment in asthma.

For patients with infrequent asthma symptoms < twice a month:

As reliever/rescue therapy:

• Short acting ß2-agonists, e.g.:
  • Salbutamol, MDI, 200 mcg, as needed.

LoEIII [12]

AND

• ICS, e.g.:
  • Budesonide, inhalation, 200 mcg whenever salbutamol is taken.

In patients on protease inhibitors, replace ICS with beclomethasone:

• Beclomethasone, inhalation, 200 mcg whenever salbutamol taken.

LoEIII [13]

For patients with asthma symptoms ≥ twice a month

As controller therapy:

• ICS, low dose, e.g.:
  • Budesonide, inhalation, 200 mcg 12 hourly.
    • Well and stable after 6 months: can attempt to reduce budesonide dose to 200 mcg daily.
    • Dose adjustments may be required at change of seasons

LoEI [14]

In patients on protease inhibitors, replace ICS with beclomethasone:

• Beclomethasone, inhalation, 200 mcg 12 hourly for 6 months; reduced to 200 mcg daily once well and stable.

LoEIII [15]

AND

As reliever/rescue therapy:

• Short acting ß2-agonists, e.g.:
• Salbutamol, MDI, 200 mcg, 6 hourly as necessary.

For patients with asthma symptoms almost daily or waking due to asthma at least once a week:

• Long-acting β2-agonist/corticosteroid combination inhaler, e.g.:
  • Salmeterol/fluticasone, inhalation, 50/250 mcg 12 hourly.
    • Maximum dose: 50/500 mcg 12 hourly.
    • Well and stable for 6 months: step down to budesonide, inhaled, 200 mcg 12 hourly.

LoEI [16]

In patients on protease inhibitors:

• Beclomethasone, inhalation, 400 mcg 12 hourly.

LoEIII [17]

AND

• Formoterol, inhalation, 12 mcg 12 hourly.

Failure of above therapy:

While awaiting appointment with specialist.

ADD

• Corticosteroids (intermediate-acting) e.g.:
  • Prednisone, oral, 10 mg daily.

Note: Prednisone should not be used as maintenance therapy but only as a bridging step while awaiting review by specialist.

For short-term exacerbations in patients not responding to the above, while awaiting review with specialist:

• Corticosteroids (intermediate-acting) e.g.:
  • Prednisone, oral, 40 mg daily for 10 days.

PATIENT AND CAREGIVER EDUCATION ON INHALER AND SPACER TECHNIQUES:

Spacer devices

Patients who are unable to use inhalers correctly after adequate counselling may benefit from the use of a spacer.

Inhalation therapy without a spacer in adults:

1. Remove the cap from the mouthpiece.
2. Shake the inhaler well.
3. While standing or sitting upright, breathe out as much air as possible.
4. Place the mouth piece of the inhaler between the lips and gently close the lips around it.
5. While beginning to inhale, press down the canister of the metered dose inhaler once to release one puff while breathing in as deeply/slowly as possible.
6. Hold the breath for 5–10 seconds, if possible.
7. Breathe out slowly and rest for a few breaths (30–60 seconds).
8. Repeat steps 2–6 for each puff prescribed.
9. Rinse mouth with water after inhalation of corticosteroids.

Inhalation therapy with a spacer in adults:

1. Remove the caps from the inhaler and the spacer.
2. Shake the inhaler well.
3. Insert the mouthpiece of the metered dose inhaler into the back of the spacer.
4. Insert the mouthpiece of the spacer into the mouth and close the lips around the mouthpiece. Avoid covering any small exhalation holes.
5. Press down the canister of the metered dose inhaler once to release one puff into the spacer.
6. Immediately take 3–4 slow deep breaths.
7. Repeat steps 4–6 for each puff prescribed, waiting at least 30 seconds between puffs.
8. Rinse mouth with water after inhalation of corticosteroids.