Asthma

Introduction

Asthma is a respiratory disease that is chronic and the leading cause of morbidity globally (Global Initiative for Asthma, 2019). It is caused by the inflammation of the airways. This inflammation triggers recurrent episodes of chest tightness, wheezing, and coughing in susceptible persons (Global Initiative for Asthma, 2019).  The goal of treatment therapy is to minimize airflow obstruction for all asthma severity levels. Treatment is also aimed at achieving good control of symptoms and minimizing the risk of asthma-related exercitations, and death. Asthma is incurable but can be controlled and managed by medication. Treatment involves pharmacologic and non-pharmacologic strategies. The objective of pharmacological and non-pharmacological treatment in asthma management is to improve symptom control, reduce exacerbation and future risks.

Pharmacological Options

Categories

• Controller medications are employed to control symptoms, reduce airway inflammation and future risks. ICS the commonly used controller medication. ICS are the first-line therapy. Long-acting bronchodilators (LABA) clear airway obstruction by relaxing the smooth muscles (Sobieraj, & Barker, 2018).
• Reliever medications are used for as-needed relief to break symptoms during worsening asthma exacerbations. They work by relaxing the muscles which tighten around the airway. Relievers are recommended for temporary prevention of exercise induced bronchoconstriction. Examples of relief medications include short-acting bronchodilators (Albuterol) and systematic corticosteroids.
• Add-on therapies are used for patients with severe asthma accompanied with persistent symptoms in spite of optimized treatment with high dose controller medications.
  asthma inhalers are used to deliver drugs to the lungs. Dry power inhaler and metered dose inhaler are the most common.

Biologic therapies– Injectable medications used alongside other controller medications

Leukotriene receptor modifiers: Oral medications used for reducing chemicals produced in the body in response to allergens (Sobieraj, & Barker, 2018).

Patient with mild asthma: After the diagnosis is confirmed, inhaled corticosteroid (ICS) containing control is initiated immediately. ICS are anti-inflammatory and disease modifying leading to improved function and reduction of exacerbations. Common inhaled corticosteroids are ciclesonide, budesonide, fluticasone and beclomethasone. Inhaled long-acting beta-agonists help in opening the airways

Low doses of ICS are effective in decreasing asthma symptoms and exercitations in patient with mild asthma. Once treatment has been initiated, continued treatment decisions will be informed by a personalized cycle of assessment, adjusted treatment and review of patient’s response.

Patient with persistent symptoms:  For patient with persistent exacerbations and uncontrolled symptoms, combination of low dose ICS-long-acting beta2-agonist (LABA) combination is recommended in adult patients. But the provider needs to check for common issues like incorrect inhaler technique, exposure to persistent allergen, incorrect diagnosis, and poor adherence before stepping up. For children under 11 years, medium ICS dose plus combination low dose ICS-LABA are recommended.

The clinician should review the response of the patient and step down treatment once symptom control is achieved. Step down treatment must be maintained for 3 months in order to find the lowest treatment which controls exacerbations and symptoms.

Patients with at least one risk Factor for exacerbation: Prescription of daily ICS-containing medication is necessary accompanied with asthma action plan. Modifiable risk factors are identified and treated to improve symptom control. Modifiable risk factors are also addressed such as smoking.

Difficult-to-treat and severe asthma:  difficult-to-treat patients have poor symptom control. The clinician may consider assessing the contributing factors and optimize treatment. If the symptoms persist, the clinician may consider referring the patient for phenotypic assessment as well as consider add-on therapy.

Non-Pharmacological Strategies and Interventions

Non-pharmacological treatments are considered where necessary to compliments phrenological therapy in reducing future exacerbations and improving symptom control. Non-pharmacological approaches include physical activity, education, counseling, avoidance of environmental exposures, avoidance of medications that cause exacerbations, and cessation of smoking.

Smoking cessation: Asthmatic people who smoke are advised to quit through counseling or smoking cessation program. Smoking has deleterious impact in patients with established asthma. Exposure to smoke is known to lead to poor symptom control and hospitalization.

Physical Exercise: Patients with asthma are encouraged to engage in moderate physical activity. While regular physical activity does not improve lung function or symptom control, it does enhance cardiopulmonary fitness. swimming training is associated with increased cardiopulmonary fit ness and lung function among young patients (Beggs et al. 2013).

Avoidance to occupational exposure: Patients with asthma are advised to avoid exposures to sensitizers or allergens. These exposures contribute to increased incidences of asthma in adults. During assessment and review of response, the clinician should ask the patient about their occupational exposure. The patient can also be asked to identify and remove all occupational exposures or sensitizer.

Pulmonary rehabilitation programs help increase cardiopulmonary fitness and reduce dyspnea. Education intervention ensures pharmacological interventions are adhered to and used appropriately. Breathing technique offer no health benefits despite being used commonly in patients who are unresponsive to optimized (Hall, Nici, Sood, ZuWallack, & Castro, 2017).

Avoidance of Indoor Triggers: animals, insects and substances that can set off asthma attack. This include dust mites, pet danger, cold air, mold, cockroaches, and pollen grains (Pichardo, G. (2020).

Pharmaceutical Care

Pharmaceutical care is a critical factor for asthma management. Pharmaceutical care covers asthma education, lifestyle modification, medication counseling, and asthma care diary. It is offered by a clinical pharmacist.  Patient-provider partnership is essential for asthma management and to enable the patient to gain skills, knowledge, and confidence necessary to take control of her or his condition (Gibson et al. 2003). This shared approach is linked to improved outcomes (Wilson et al. 2010). Treatment decisions factor in any patient phenotype or characteristics that predict the likely response by the patient.

Control-based asthma management of asthma involves pharmacologic and non-pharmacologic treatment that is adjusted in continuous cycle, which encompasses assessment and treatment. Introduction of control-based guidelines has been found to improve asthma outcomes.

References

Global Initiative for Asthma. (2019). Global Strategy for Asthma Management and Prevention. Retrieved on March 8, 2021 from https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf

Hall, C., Nici, L., Sood, S. ZuWallack, R., & Castro, M. (2017). Previous Article Asthma Exacerbations: Pathogenesis, Prevention, a … Non-pharmacologic Therapy for Severe Persistent Asthma. Clinical Commentary Review, 5(4),928-935.

Janson, C. et al (2019). Pharmacological treatment of asthma in a cohort of adults during a 20-year period: results from the European Community Respiratory Health Survey I, II and III. ERJ Open Res. 2019 Feb; 5(1): 00073-2018.

Pichardo, G. (2020). Asthma treatments. https://www.webmd.com/asthma/asthma-treatments

Sobieraj, D. M., Barker, W.L. (2018). Medications for asthma. JAMA, 319(14):1520. doi:10.1001/jama.2018.3808