Bronchial Asthma - Standard Treatment Guidelines

Asthma is a common clinical problem encountered at all levels of health care. Asthma can be defined as a chronic inflammatory disorder of the airways. Different terms such as allergic or asthmatic bronchitis, wheezy bronchitis, intrinsic and extrinsic asthma are frequently employed in clinical practice. Asthma commonly begins in childhood and early youth, but may also start later in life at any age. Contrary to common belief, children do not necessarily ‘grow out of asthma’. Almost two third of the asthmatic children continue to have symptoms in puberty/adulthood. About 5-10% children with ‘mild’ asthma may go on to develop severe asthma later in life.

Ministry of Health and Family Welfare, Government of India has issued the Standard Treatment Guidelines for Bronchial Asthma. Following are the major recommendations :

Case definition (for both situations of care):

Asthma is characterized by recurrent episodes of cough, wheezing, breathlessness, and chest tightness that are often reversible, either spontaneously or with treatment.

Incidence of The Condition In Our Country

The prevalence rates are variable depending upon the definition and methodology employed. As per the results of the Indian Study on Epidemiology of Asthma, Respiratory symptoms and Chronic bronchitis (INSEARCH), the population prevalence in adults is about 2 percent or more. In children, the prevalence is likely to be higher, exceeding 5 percent. Both men and women are about equally affected.

Differential Diagnosis

Diagnosis of asthma is a two-step approach. The first important step is to suspect the diagnosis while the second step involves exclusion of other diagnoses and laboratory assessment to confirm the diagnosis and assess the severity stage of asthma. Documentation of reversibility and/or variability of forced expiratory flow, 1st second (FEV1) or peak expiratory flow (PEF) is important to diagnose asthma and differentiate it from chronic obstructive pulmonary disease.

Prevention And Counseling

Exact cause of asthma is not known. Both environmental and genetic factors are important. A family history of asthma or atopy (allergy), presence of other atopic manifestations (e.g. allergic rhinitis, skin allergies) and airway hyperresponsiveness predispose an individual to develop asthma. However, asthma can develop in the absence of a family history. Asthma attacks are generally triggered by one or more of exposures/ risk-factors. Most patients may have more than one trigger.

Besides complying with the therapy for treatment and control of asthma, the common triggers (as below) should be identified and avoided:

Respiratory infections – usually viral

Allergens (Indoor/Outdoor)

Air pollution (Indoor/Outdoor) including smoke and fumes (biomass fuel)

Tobacco smoke (both active and passive)

Drugs – beta-blockers and non-steroidal anti-inflammatory drugs (NSAIDs)

Food additives and preservatives- food is normally not a trigger unless it is specifically proved to be so in an individual.

Since asthma is a lifelong problem, it is crucial that the patient and the family are educated about the disease and its management for a normal and healthy life.

Optimal Diagnostic Criteria, Investigations, Treatment & Referral Criteria

Situation 1: At Secondary Hospital: Optimal Standards of Treatment in Situations where technology and resources are limited

Diagnosis

The diagnosis is essentially based on history and physical findings of wheezing. FEV1/FVC ratio less than 70% and reversibility more than 12% and 200 ml establishes the diagnosis.This should also be categorized in to mild, moderate and severe depending upon the symptoms and treatment requirement.

	Mild	Moderate	Severe
Symptoms disturbing sleep	< once per week	> once per week	Daily
Daytime symptoms	< Daily	Daily	Daily
Limitation of accustomed activities	Nil	Some limitation	Severe limitation
Use of rescue medication *	<1 unit per day	1-2 units per day	>2 units per day
FEV1 or peak expiratory flow	Normal	60-80%	<60%

Treatment:

Basically in asthma four components are important in management; i) diagnosis, assessment and monitoring of severity ii) education for partnership of patient and doctor iii) identification and control of trigger factors and iv) pharmacologic management.

All these components of care are possible even at a place where resources are limited. Therefore primarily management of asthma does not vary due to resource constraint or lack of technology.

It is important to effectively manage asthma to help an individual to live a normal life, and avoid acute exacerbations as well as long-term complications. Currently available important anti-asthma drugs can be classified as controllers (required for maintenance treatment) and relievers (required for quick relief, rescue drugs). Inhaled corticosteroids constitute the cornerstone of maintenance therapy.

• Controllers (Prophylactic, Preventive, Maintenance)

1. Taken daily to keep asthma under control


2. Steroids, long-acting beta-2 agonists, sustained-release theophyllines, leukotriene receptor antagonists, and cromones

• Relievers (Quick relief, Rescue)

1. Rapid acting drugs that relieve bronchoconstriction


2. Short acting beta-2 agonists, anticholinergics, theophyllines, short-course oral steroids

The recommendations for use of drugs vary depending upon the stage of asthma. Mild asthma can be further divided into intermittent (symptoms for less than two days per week) and persistent (symptoms for more than two days per week) categories, and treatment given accordingly. Low dose inhaled steroids are recommended. Alternatively, oral theophyllines can be used. Moderate asthma is treated with medium dose ICS + long acting beta-agonists (LABA) and/or leukotriene antagonists (LTRA). Alternate choices are: - medium dose ICS + LTRA / theophylline. Severe asthma is managed with high-dose ICS and/or oral steroids at the lowest dose + LABA + theophylline + LTRA.

Systemic corticosteroids on long-term basis must be avoided. A short-course of up to two weeks (0.5 mg/kg/day) is, however, often valuable for managing acute severe asthma.

In addition to daily controller therapy, reliever medications on as-needed basis may be taken in all stages.

Asthma control requires frequent stepping up or down of therapy.

Patients with intermittent or seasonal symptoms can be managed with only reliever medications taken on an as-needed basis.

Management of acute severe asthma

Hour 1: 4 doses of inhaled salbutamol ± ipratropium, 100 mg hydrocortisone (IV) or oral prednisolone 60 mg, oxygen, adequate hydration

Hour 2: 4 more doses of inhaled salbutamol with ipratropium, IV aminophylline, subcutaneous terbutaline/adrenaline 0.3-0.5 mg (0.01 mg/kg for children) for 3 doses

Acute severe asthma not responding within 2 hours of treatment, or deteriorating:

Refer Immediately

Expectorants and mucokinetic drugs do not have any significant role.

General principles of pharmacotherapy in patients with bronchial asthma

• Inhaled drugs should preferably be given using metered dose inhaler with spacer


• Education about proper inhalation technique is most essential for optimal results


• Long-acting beta-agonists (LABA) should always be combined with ICS


• Short-acting beta-agonists (SABA) should be used only as reliever medication


• Methylxanthines can be used as an alternative to inhaled steroids only in mild disease, or in acute severe asthma when standard treatment is not effective


• Anticholinergic drugs provide additive effect to SABA aerosol during exacerbations

Systemic glucocorticoids are important only in the treatment of mild to moderate exacerbations of asthma.

Referral criteria:

• Diagnosis unclear or in doubt


• Atypical signs or symptoms


• Failure to respond to treatment over one month


• Other conditions complicating asthma or its diagnosis, necessitating additional work-up


• Severe persistent asthma


• Life-threatening asthma (cyanosis, mental obtundation)


• Patients requiring additional tests such allergy testing, induced sputum eosinophil, FeNO etc


• Patients requiring special treatment such as immunotherapy.

Situation 2: At Super Specialty Facility in Metro location where higher-end technology is available

Clinical Diagnosis : Same as in Situation 1 (a)

Investigations : exhaled nitric oxide (FeNO), induced sputum eosinophils

Treatment : not applicable

Standard Operating procedure

In Patient: ventilator care

Out Patient: same

Day Care: same

WHO DOES WHAT? and TIMELINES

Doctor:

diagnosis, assessment of severity and prescription of medicines for the patient. Explaining action plan to deal with exacerbation.

Nurse:

Educating patients about inhaler techniques and controlling trigger factors.

Technician:

Proper spirometry and measurement of peak flow

Resources Required For One Patient

Situation	Human Resources	Investigations	Drugs & Consumables	Equipment
1.	1.Physician 2. Nurse 3. Pulmonary function test technician 4. Radiographer	1. Chest radiograph 2. Pulmonary function test 3. Arterial blood gases	1. Inhaled bronchodilators (salbutamol, ipratropium) 2. Inhaled steroids (budesonide, beclamethasone) 3. ICS (fluticasone/budeson -ide)+ LABA (formoterol/salmeterol) 4. Parenteral and oral bronchodilators (theophylline, terbutaline) 5. Parenteral and oral steroids (hydrocortisone, prednisolone) 6. Parenteral and oral antibiotics preferably macrolides	1. Oxygen cylinder 2. Nebulizers 3. Spirometer 4. Handheld spirometer (PEFR meter) 5. X-ray machine 6. ABG analyzer
2.	Above plus 1. ICU staff with pulmonary training	Above plus 1. FeNO	Above plus 1. Higher generation antibiotics	Above plus 1. ICU set-up 2. Noninvasive and invasive ventilators 3. FeNO analyzer

Guidelines by The Ministry of Health and Family Welfare :

Dr S.K. SHARMA AIIMS