Last updated December 18, 2021

Global Strategy for Asthma Management and Prevention

Recommendations

Step 1

Effective asthma management requires the development of a partnership between the person with asthma (or the parent/carer) and health care providers. This should enable the person with asthma to gain the knowledge, confidence and skills to assume a major role in the management of their asthma. Self-management education reduces asthma morbidity in both:

  • adults and

(A)
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  • children.

(A)
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Good communication by health care providers is essential as the basis for good outcomes.

(B)
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Treatment guided by fractional concentration of exhaled nitric oxide (FeNO)

In several studies of FeNO-guided treatment, problems with the design of the intervention and/or control algorithms make comparisons and conclusions difficult. Results of FeNO measurement at a single point in time should be interpreted with caution. In children and young adults with asthma, FeNO-guided treatment was associated with a significant reduction in the number of patients with ≥1 exacerbation (OR 0.67 [95% CI 0.51–0.90]) and in exacerbation rate (mean difference -0.27 [-0.49 to -0.06] per year) compared with guidelines-based treatment.

(A)

Similar differences were seen in comparisons between FeNO-guided treatment and non-guidelines-based algorithms.

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Sputum-guided treatment is recommended for adult patients with moderate or severe asthma who are managed in (or can be referred to) centers experienced in this technique.

(A)
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In children, FeNO-guided treatment significantly reduces exacerbation rates compared with guidelines-based treatment.

(A)
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Box 3-4A. Initial asthma treatment - recommended options for adults and adolescents

Presenting symptoms

Preferred INITIAL treatment

(Track 1)

Alternative INITIAL treatment

(Track 2)

Infrequent asthma symptoms,

e.g. less than twice a month and no risk factors for exacerbations

As-needed low dose ICS-formoterol

(Evidence B)

Low dose ICS taken whenever SABA is taken, in combination or separate inhalers (Evidence B)

Asthma symptoms or need for reliever twice a month or more

As-needed low dose ICS-formoterol

(Evidence A)

Low dose ICS with as-needed SABA (Evidence A). Consider likely adherence with daily ICS.

Troublesome asthma symptoms most days; or waking due to asthma once a week or more, especially if any risk factors exist

Low dose ICS-formoterol maintenance and reliever therapy (Evidence A)

Low dose ICS-LABA with as-needed SABA (Evidence A), OR

Medium dose ICS with as-needed SABA (Evidence A). Consider likely adherence with daily controller.

Initial asthma presentation is with severely uncontrolled asthma, or with an acute exacerbation

Medium dose ICS-formoterol maintenance and reliever therapy (Evidence D). A short course of oral corticosteroids may also be needed.

High dose ICS (Evidence A) or medium dose ICS-LABA (Evidence D) with as- needed SABA. Consider likely adherence with daily controller. A short course of oral corticosteroids may also be needed.

Box 3-4C. Initial asthma treatment - recommended options for children aged 6–11 years

Presenting symptoms

Preferred INITIAL treatment

Infrequent asthma symptoms,

e.g. less than twice a month and no risk factors for exacerbations

As needed SABA

Other options include taking ICS whenever SABA is taken, in combination or separate inhalers.

Asthma symptoms or need for reliever twice a month or more

Low dose ICS with as-needed SABA (Evidence A), or

Other options include daily LTRA (less effective than ICS, Evidence A), or taking ICS whenever SABA is taken in combination or separate inhalers (Evidence B). Consider likely adherence with controller if reliever is SABA.

Troublesome asthma symptoms most days; or waking due to asthma once a week or more, especially if any risk factors exist

Low dose ICS-LABA with as needed SABA (Evidence A), OR

Medium dose ICS with as-needed SABA (Evidence A), OR

Very low dose ICS-formoterol maintenance and reliever (Evidence B)

Other options include low dose ICS with daily LTRA, with as needed SABA.

Initial asthma presentation is with severely uncontrolled asthma, or with an acute exacerbation

Start regular controller treatment with medium dose ICS-LABA with as-needed SABA or low dose ICS-formoterol maintenance and reliever (MART). A short course of OCS may also be needed.

Use of low dose ICS-formoterol as needed for symptom relief in Step 1 for adults and adolescents  is supported by indirect evidence for a reduction in risk of severe exacerbations compared with as-needed SABA alone.

(B)
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For pre-exercise use in patients with mild asthma, one 6-week study showed that use of low dose budesonideformoterol for symptom relief and before exercise reduced exercise-induced bronchoconstriction to a similar extent as regular daily low dose ICS with SABA for symptom relief and before exercise. More studies are needed, but this study suggests that patients with mild asthma who are prescribed as-needed ICS-formoterol to prevent exacerbations and control symptoms can use the same medication prior to exercise, if needed, and do not need to be prescribed a SABA for pre-exercise use.

(B)
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Low dose ICS taken whenever SABA is taken.

(B)
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Regular daily low dose ICS has been suggested by GINA since 2014 for consideration in Step 1, for patients with symptoms less than twice a month, to reduce the risk of exacerbations. This was based on indirect evidence from studies in patients eligible for Step 2 treatment.

(B)
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Possible controller options for this age-group include taking ICS whenever SABA is taken, based on indirect evidence from Step 2 studies with separate inhalers in children and adolescents. One of these showed substantially fewer exacerbations compared with SABA-only treatment, and another showed similar outcomes as physician-adjusted treatment but with lower average ICS dose. 

(B)
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Regular ICS with as-needed SABA is also a possible option for this age-group), but the likelihood of poor adherence in children with infrequent symptoms should be taken into account.

(B)
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GINA no longer recommends SABA-only treatment of asthma in adults or adolescents. Although inhaled SABAs are highly effective for the quick relief of asthma symptoms, patients whose asthma is treated with SABA alone (compared with ICS) are at increased risk of asthma-related death and urgent asthma-related healthcare.

.

(A)
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The rapid-onset LABA, formoterol, is as effective as SABA as a reliever medication in adults and children, and reduces the risk of severe exacerbations by 15–45% compared with as-needed SABA, but use of regular or frequent LABA without ICS is strongly discouraged because of the risk of exacerbations.

(A)
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Step 2

The current evidence for this combination controller + reliever treatment is with low dose budesonide-formoterol:

  • A large double-blind study in mild asthma found a 64% reduction in severe exacerbations compared with SABA-only treatment, with a similar finding in an open-label study in patients with mild asthma previously taking SABA alone. 

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  • Two large double-blind studies in mild asthma showed as-needed budesonide-formoterol was non-inferior for severe exacerbations compared with regular ICS.

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  • In two open-label randomized controlled trials, representing the way that patients with mild asthma would use as-needed ICS-formoterol in real life, as-needed budesonide-formoterol was superior to maintenance ICS in reducing the risk of severe exacerbations.
(A)
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  • In all four studies, the as-needed ICS-formoterol strategy was associated with a substantially lower average ICS dose than with maintenance low dose ICS.

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A post hoc analysis of one study found that a day with >2 doses of as-needed budesonide-formoterol reduced the short-term (21-day) risk of severe exacerbations compared to as needed terbutaline alone, suggesting that timing of use of ICS-formoterol is important.

For pre-exercise use in patients with mild asthma, one study showed that budesonide-formoterol taken as-needed and before exercise had similar benefit in reducing exercise-induced bronchoconstriction as daily ICS with SABA as-needed and pre-exercise. More studies are needed, but this suggests that patients with mild asthma who are prescribed asneeded ICS-formoterol to prevent exacerbations and control symptoms can use the same medication prior to exercise, if needed, and do not need to be prescribed a SABA for pre-exercise use.

(B)
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For regular daily low dose ICS plus as-needed SABA, the most important consideration was to reduce the risk of severe exacerbations. There is a large body of evidence from RCTs and observational studies showing that the risks of severe exacerbations, hospitalizations and mortality are substantially reduced with regular low dose ICS. Symptoms and exercise-induced bronchoconstriction are also reduced.

(A)
Severe exacerbations are halved with low dose ICS even in patients with symptoms 0–1 days a week.
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Leukotriene receptor antagonists (LTRA) are less effective than ICS, particularly for exacerbations.

(A)
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For adult or adolescent patients not previously using controller treatment, regular daily combination low dose ICS-LABA as the initial maintenance controller treatment reduces symptoms and improves lung function compared with low dose ICS alone. However, it is more expensive and does not further reduce the risk of exacerbations compared with ICS alone.

(A)
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For patients with purely seasonal allergic asthma, e.g. with birch pollen, with no interval asthma symptoms, regular daily ICS or as-needed ICS-formoterol should be started immediately symptoms commence, and be continued for four weeks after the relevant pollen season ends.

(D)
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Sustained-release theophylline has only weak efficacy in asthma, and side-effects are common and may be life-threatening at higher doses.  Chromones (nedocromil sodium and sodium cromoglycate) have a favorable safety profile but low efficacy, and their inhalers require burdensome daily washing to avoid blockage.

(A)
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Step 3

In adult and adolescent patients with ≥1 exacerbation in the previous year, ICS-formoterol maintenance and reliever therapy reduced exacerbations and provided similar levels of asthma control at relatively low doses of ICS, compared with a fixed dose of ICS-LABA as maintenance treatment or a higher dose of ICS, both with as-needed SABA.

(A)
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Maintenance ICS-LABA with as-needed SABA

For patients receiving maintenance ICS with as-needed SABA, adding LABA in a combination inhaler provides additional improvements in symptoms and lung function with a reduced risk of exacerbations compared with the same dose of ICS,  but there is only a small reduction in reliever use.

(A)
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Another option for adults and adolescents is to increase ICS to medium dose, but at a group level this is less effective than adding a LABA.

(A)
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Other less efficacious options are low dose ICS plus either:

  • LTRA or
(A)
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  • low dose, sustained-release theophylline.

(B)
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In children, after checking inhaler technique and adherence, and treating modifiable risk factors, there are three preferred options at a population level:
  • to increase ICS to medium dose, or
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  • change to combination low dose ICS-LABA,
(A)
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  • both with as-needed SABA reliever, or to switch to maintenance and reliever therapy with a very low dose of ICS-formoterol.

(B)
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Step 4

For adult and adolescent patients, combination ICS-formoterol as maintenance and reliever treatment is more effective in reducing exacerbations than the same dose of maintenance ICS-LABA or higher doses of ICS.

(A)
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As above, individual ICS responsiveness varies, and some patients whose asthma is uncontrolled or who have frequent exacerbations on low dose ICS-LABA despite good adherence and correct inhaler technique may benefit from medium dose ICS-LABA.

(B)

with as-needed SABA, if maintenance and reliever therapy is not available. Occasionally, high dose ICS-LABA may be needed.

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Long-acting muscarinic antagonists (LAMA) may be considered as add-on therapy in a separate inhaler for patients aged ≥6 years (tiotropium), or in a combination (‘triple’) inhaler for patients aged ≥18 years (beclometasone-formoterol-glycopyrronium; fluticasone furoate-vilanterol-umeclidinium; mometasone-indacaterol-glycopyrronium) if asthma is persistently uncontrolled despite medium or high dose ICS-LABA. Adding LAMA to medium or high dose ICS-LABA modestly improved lung function but with no difference in symptoms.

(A)
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For medium or high dose budesonide, efficacy may be improved with dosing four times daily, 

(B)

but adherence may be an issue.

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For other ICS, twice-daily dosing is appropriate.

(D)
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Other options for adults or adolescents that can be added to a medium or high dose ICS, but that are less efficacious than adding LABA, include:

  • LTRA or
(A)
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  • low dose sustained-release theophylline.
(B)
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For children whose asthma is not adequately controlled by low dose maintenance ICS-LABA with as-needed SABA, treatment may be increased to medium dose ICS-LABA. (B)
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For maintenance and reliever therapy with budesonide-formoterol, the maintenance dose may be increased to 100/6 mcg twice daily (metered dose; 80/4.5 mcg delivered dose).

(D)

This is still a low dose regimen.

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Other controller options include increasing to high pediatric dose ICS-LABA, but adverse effects must be considered. Tiotropium (long-acting muscarinic antagonist) by mist inhaler may be used as add-on therapy in children aged 6 years and older. It modestly improves lung function and reduces exacerbations

(A)
[largely independent of baseline IgE or blood eosinophils].
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Step 5

Patients of any age with persistent symptoms or exacerbations despite correct inhaler technique and good adherence with Step 4 treatment and in whom other controller options have been considered, should be referred to a specialist with expertise in investigation and management of severe asthma.

(D)
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Combination high dose ICS-LABA

this may be considered in adults and adolescents, but for most patients, the increase in ICS dose generally provides little additional benefit,

(A)
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and there is an increased risk of side-effects, including adrenal suppression. A high dose is recommended only on a trial basis for 3–6 months when good asthma control cannot be achieved with medium dose ICS plus LABA and/or a third controller (e.g. LTRA or sustained-release theophylline.

(B)
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Add-on long-acting muscarinic antagonists (LAMA) can be prescribed in a separate inhaler for patients aged ≥6 years (tiotropium), or in a combination (‘triple’) inhaler for patients aged ≥18 years (beclometasone-formoterol-glycopyrronium; fluticasone furoate-vilanterol-umeclidinium; mometasone-indacaterol-glycopyrronium) if asthma is not well controlled with medium or high dose ICS-LABA. Adding LAMA to ICS-LABA modestly improves lung function, but not symptoms.

(A)
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In some studies, add-on LAMA modestly increased the time to severe exacerbation requiring oral corticosteroids.

(B)

For patients with exacerbations despite ICS-LABA, it is essential that sufficient ICS is given, i.e. at least medium dose ICS-LABA, before considering adding a LAMA.

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Add-on azithromycin (three times a week) can be considered after specialist referral for adult patients with persistent symptomatic asthma despite high dose ICS-LABA. Before considering add-on azithromycin, sputum should be checked for atypical mycobacteria, ECG should be checked for long QTc (and re-checked after a month on treatment), and the risk of increasing antimicrobial resistance should be considered. Diarrhea is more common with azithromycin 500mg 3 times a week. Treatment for at least 6 months is suggested, as a clear benefit was not seen by 3 months in the clinical trials.266,505 The evidence for this recommendation includes a meta-analysis of two clinical trials in adults with persistent asthma symptoms that found reduced asthma exacerbations among those taking medium or high dose ICS-LABA who had either an eosinophilic or noneosinophilic profile and in those taking high dose ICS-LABA.

(B)

The option of add-on azithromycin for adults is recommended only after specialist consultation because of the potential for development of resistance at the patient or population level.

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Add-on anti-immunoglobulin E (anti-IgE) (omalizumab) treatment

for patients aged ≥6 years with moderate or severe allergic asthma that is uncontrolled on Step 4–5 treatment

(A)
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Add-on anti-interleukin-5/5R treatment (subcutaneous mepolizumab for patients aged ≥6 years; intravenous reslizumab for ages ≥18 years or subcutaneous benralizumab for ages ≥12 years), with severe eosinophilic asthma that is uncontrolled on Step 4–5 treatment.

(A)

Efficacy data for mepolizumab in children 6–11 years are limited to one very small open label uncontrolled study.

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Add-on anti-interleukin-4R α treatment (subcutaneous dupilumab) for patients aged ≥12 years with severe Type 2 asthma, or requiring treatment with maintenance OCS.

(A)
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Sputum-guided treatment

For adults with persisting symptoms and/or exacerbations despite high dose ICS or ICS-LABA, treatment may be adjusted based on eosinophilia (>3%) in induced sputum. In severe asthma, this strategy leads to reduced exacerbations and/or lower doses of ICS, 

(A)

but few clinicians currently have access to routine sputum testing.

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Add-on treatment with bronchial thermoplasty

May be considered for some adult patients with severe asthma.

(B)

Evidence is limited and in selected patients. The long-term effects compared with control patients, including for lung function, are not known.

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Add-on low dose oral corticosteroids (≤7.5 mg/day prednisone equivalent)

May be effective for some adults with severe asthma,

(D)
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but are often associated with substantial side effects.

(A)
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REVIEWING RESPONSE AND ADJUSTING TREATMENT

All health care providers should be encouraged to assess asthma control, adherence and inhaler technique at every visit, not just when the patient presents because of their asthma. The frequency of visits depends upon the patient’s initial level of control, their response to treatment, and their level of engagement in self-management. Ideally, patients should be seen 1–3 months after starting treatment and every 3–12 months thereafter. After an exacerbation, a review visit within 1 week should be scheduled.

(D)
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How to step asthma treatment down

If treatment is stepped down too far or too quickly, exacerbation risk may increase even if symptoms remain reasonably controlled.

(B)

To date, higher baseline FeNO has not been found to be predictive of exacerbation following step-down of ICS dose.

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Complete cessation of ICS is associated with a significantly increased risk of exacerbations.

(A)
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Box 3-7. Options for stepping down treatment once asthma is well controlled

General principles of stepping down asthma treatment

  • Consider stepping down when asthma symptoms have been well controlled and lung function has been stable for 3 or more months (Evidence D). If the patient has risk factors for exacerbations, for example a history of exacerbations in the past year, or persistent airflow limitation, step down only with close supervision.
  • Choose an appropriate time (no respiratory infection, patient not travelling, not pregnant).
  • Approach each step as a therapeutic trial. Engage the patient in the process; document their asthma status (symptom control, lung function and risk factors); provide clear instructions; provide a written asthma action plan and ensure the patient has sufficient medication to resume their previous dose if necessary; monitor symptoms and/or PEF; and schedule a follow-up visit (Evidence D).
  • Stepping down ICS doses by 25–50% at 3 month intervals is feasible and safe for most patients300 (Evidence A).

Current   Current medication step and dose

Options for stepping down

Evidence

Step 5

High dose ICS-LABA plus oral corticosteroids (OCS)

  • Continue high dose ICS-LABA and reduce OCS dose
  • Use sputum-guided approach to reducing OCS
  • Alternate-day OCS treatment
  • Replace OCS with high dose ICS

D

B

D D

High dose ICS-LABA plus other add-on agents

  • Refer for expert advice

D

Step 4

Moderate to high dose ICS- LABA maintenance treatment

  • Continue combination ICS-LABA with 50% reduction in ICS component, by using available formulations
  • Discontinuing LABA may lead to deterioration

B




A

Medium dose ICS-formoterol* as maintenance and reliever

  • Reduce maintenance ICS-formoterol* to low dose, and continue as-needed low dose ICS-formoterol* reliever

D

High dose ICS plus second controller

  • Reduce ICS dose by 50% and continue second controller

B

Step 3

Low dose ICS-LABA maintenance

  • Reduce ICS-LABA to once daily
  • Discontinuing LABA may lead to deterioration

D A

Low dose ICS-formoterol* as maintenance and reliever

  • Reduce maintenance ICS-formoterol* dose to once daily and continue as needed low dose ICS-formoterol* reliever

C

Medium or high dose ICS

  • Reduce ICS dose by 50%
  • Adding LTRA may allow ICS dose to be stepped down

A B

Step 2

Low dose ICS

  • Once-daily dosing (budesonide, ciclesonide, mometasone)
  • Switch to as-needed low dose ICS-formoterol
  • Switch to taking ICS whenever SABA is taken

A

A

B

Low dose ICS or LTRA

  • Switch to as-needed low dose ICS formoterol
  • Complete cessation of ICS in adults and adolescents is not advised as the risk of exacerbations is increased with SABA-only treatment

A

*ICS-formoterol maintenance and reliever treatment can be prescribed with low dose budesonide-formoterol or BDP-formoterol.
†Note FDA warning on neuropsychiatric effects with montelukast.

Box 3-8. Treating potentially modifiable risk factors to reduce exacerbations

Risk factor

Treatment strategy

Evidence

Any patient with ≥1 risk factor for exacerbations (including poor symptom control)

  • Ensure patient is prescribed an ICS-containing controller.
  • Maintenance and reliever therapy (MART) with ICS-formoterol reduces risk of severe exacerbations compared with if the reliever is SABA.
  • Ensure patient has a written action plan appropriate for their health literacy.
  • Review patient more frequently than low-risk patients.
  • Check inhaler technique and adherence frequently.
  • Identify any modifiable risk factors.

A
A

A
A
A
D

≥1 severe exacerbation

in last year

  • ICS-formoterol maintenance and reliever regimen reduces risk of severe exacerbations compared with if the reliever is SABA.
  • Consider stepping up treatment if no modifiable risk factors.
  • Identify any avoidable triggers for exacerbations.

A

A
C

Exposure to tobacco smoke

  • Encourage smoking cessation by patient/family; provide advice and resources.
  • Consider higher dose of ICS if asthma poorly controlled.

A
B

Low FEV1, especially if <60% predicted

  • Consider trial of 3 months’ treatment with high dose ICS.
  • Consider 2 weeks’ OCS, but take short- and long-term risks into account
  • Exclude other lung disease, e.g. COPD.
  • Refer for expert advice if no improvement.

B
B
D
D

Obesity

  • Strategies for weight reduction
  • Distinguish asthma symptoms from symptoms due to deconditioning, mechanical restriction, and/or sleep apnea.

B
D

Major psychological problems

  • Arrange mental health assessment.
  • Help patient to distinguish between symptoms of anxiety and asthma; provide advice about management of panic attacks.

D
D

Major socioeconomic problems

  • Identify most cost-effective ICS-based regimen.

D

Confirmed food allergy

  • Appropriate food avoidance; injectable epinephrine.

A

Allergen exposure if sensitized

  • Consider trial of simple avoidance strategies; consider cost.
  • Consider step up of controller treatment.
  • Consider adding SLIT in symptomatic adult HDM-sensitive patients with allergic rhinitis despite ICS, provided FEV1 is >70% predicted.

C
D
B

Sputum eosinophilia (limited centers)

  • Increase ICS dose independent of level of symptom control.

A*

* Based on evidence from relatively small studies in selected populations.


OTHER THERAPIES

Allergen immunotherapy

Compared to pharmacological and avoidance options, potential benefits of SCIT must be weighed against the risk of adverse effects and the inconvenience and cost of the prolonged course of therapy, including the minimum half-hour wait required after each injection.

(D)
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Sublingual immunotherapy (SLIT)

For adult patients with allergic rhinitis and sensitized to house dust mite, with persisting asthma symptoms despite low-medium dose ICS-containing therapy, consider adding SLIT, provided FEV1 is >70% predicted.

(B)
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As for any treatment, potential benefits of SLIT for individual patients should be weighed against the risk of adverse effects, and the cost to the patient and health system.

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Vaccinations

Advise patients with moderate to severe asthma to receive an influenza vaccination every year, or at least when vaccination of the general population is advised.

(C)
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There is insufficient evidence to recommend routine pneumococcal vaccination in people with asthma.

(D)
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The current recommendation is for a gap of 14 days between COVID-19 vaccination and influenza vaccination.

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Bronchial thermoplasty

Bronchial thermoplasty is a potential treatment option at Step 5 in some countries for adult patients whose asthma remains uncontrolled despite optimized therapeutic regimens and referral to an asthma specialty center.

(B)
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For adult patients whose asthma remains uncontrolled despite optimization of asthma therapy and referral to a severe asthma specialty center, bronchial thermoplasty is a potential treatment option at Step 5 in some countries.

(B)
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Caution should be used in selecting patients for this procedure. The number of studies is small, people with chronic sinus disease, frequent chest infections or FEV1 <60% predicted were excluded from the pivotal sham-controlled study, and patients did not have their asthma treatment optimized before bronchial thermoplasty was performed.

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Bronchial thermoplasty should be performed in adults with severe asthma only in the context of an independent Institutional Review Board-approved systematic registry or a clinical study, so that further evidence about effectiveness and safety of the procedure can be accumulated.

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Box 3-9. Non-pharmacological interventions - summary

 
Intervention Advice/recommendation Evidence
Cessation of smoking and ETS exposure
  • At every visit, strongly encourage people with asthma who smoke to quit. Provide access to counseling and smoking cessation programs (if available).
A
  • Advise parents/carers of children with asthma not to smoke and not to allow smoking in rooms or cars that their children use.
A
  • Strongly encourage people with asthma to avoid environmental smoke exposure.
B
  • Assess smokers/ex-smokers for COPD or overlapping features of asthma and COPD (asthma– COPD overlap), as additional treatment strategies may be required.
D
Physical activity
  • Encourage people with asthma to engage in regular physical activity for its general health benefits.
A
  • Provide advice about prevention of exercise-induced bronchoconstriction with regular ICS.
A
  • Provide advice about prevention of breakthrough exercise-induced bronchoconstriction with
    • warm-up before exercise
    • SABA before exercise
    • low dose ICS-formoterol before exercise.



A
A
B
  • Regular physical activity improves cardiopulmonary fitness, and can have a small benefit for asthma control and lung function, including with swimming in young people with asthma.
B
  • There is little evidence to recommend one form of physical activity over another.
D
Avoidance of occupational exposures
  • Ask all patients with adult-onset asthma about their work history and other exposures.
D
  • In management of occupational asthma, identify and eliminate occupational sensitizers as soon as possible, and remove sensitized patients from any further exposure to these agents.
A
  • Patients with suspected or confirmed occupational asthma should be referred for expert assessment and advice, if available.
A
Avoidance of medications that may make asthma worse
  • Always ask about asthma before prescribing NSAIDs, and advise patients to stop using them if asthma worsens.
D
  • Always ask people with asthma about concomitant medications.
D
  • Aspirin and NSAIDs (non-steroidal anti-inflammatory drugs) are not generally contraindicated unless there is a history of previous reactions to these agents (see p.99).
A
  • Decide about prescription of oral or ophthalmic beta-blockers on a case-by-case basis. Initiate treatment under close medical supervision by a specialist.
D
  • If cardioselective beta-blockers are indicated for acute coronary events, asthma is not an absolute contra-indication, but the relative risks/benefits should be considered.
D
Healthy diet
  • Encourage patients with asthma to consume a diet high in fruit and vegetables for its general health benefits.
A
  Avoidance of indoor allergens
  • Allergen avoidance is not recommended as a general strategy in asthma.
A  
 
  • For sensitized patients, there is limited evidence of clinical benefit for asthma in most circumstances with single-strategy indoor allergen avoidance.
A  
 
  • Remediation of dampness or mold in homes reduces asthma symptoms and medication use in adults.
A  
 
  • For patients sensitized to house dust mite and/or pets, there is limited evidence of clinical benefit for asthma with avoidance strategies (only in children) .
B  
 
  • Allergen avoidance strategies are often complicated and expensive, and there are no validated methods for identifying those who are likely to benefit.
D  
  Weight reduction
  • Include weight reduction in the treatment plan for obese patients with asthma.
  • For obese adults with asthma a weight reduction program plus twice-weekly aerobic and strength exercises is more effective for symptom control than weight reduction alone.
B
 B
 
  Breathing exercises
  • Breathing exercises may be a useful supplement to asthma pharmacotherapy for symptoms and quality of life, but they do not reduce exacerbation risk or have consistent effects on lung function.
A  
  Avoidance of indoor air pollution
  • Encourage people with asthma to use non-polluting heating and cooking sources, and for sources of pollutants to be vented outdoors where possible.
B  
  Avoidance of outdoor allergens
  • For sensitized patients, when pollen and mold counts are highest, closing windows and doors, remaining indoors, and using air conditioning may reduce exposure to outdoor allergens.
D  
  Dealing with emotional stress
  • Encourage patients to identify goals and strategies to deal with emotional stress if it makes their asthma worse.
D  
 
  • There is insufficient evidence to support one stress-reduction strategy over another, but relaxation strategies and breathing exercises may be helpful.
B  
 
  • Arrange a mental health assessment for patients with symptoms of anxiety or depression.
D  
  Avoidance of outdoor air pollutants/weather conditions
  • During unfavorable environmental conditions (very cold weather or high air pollution) it may be helpful to stay indoors in a climate-controlled environment, and to avoid strenuous outdoor physical  activity; and to avoid polluted environments during viral infections, if feasible.
D  
  Avoidance of foods and food chemicals
  • Food avoidance should not be recommended unless an allergy or food chemical sensitivity has been clearly demonstrated, usually by carefully supervised oral challenges.
D  
 
  • For confirmed food allergy, food allergen avoidance may reduce asthma exacerbations.
D  
 
  • If food chemical sensitivity is confirmed, complete avoidance is not usually necessary, and sensitivity often decreases when asthma control improves.
D  

Interventions with highest level evidence are shown first.

Smoking cessation and avoidance of environmental tobacco smoke

At every visit, strongly encourage people with asthma who smoke to quit. They should be provided with access to counseling and, if available, to smoking cessation programs.

(A)
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Strongly encourage people with asthma to avoid environmental smoke exposure.

(B)
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Advise parents/carers of children with asthma not to smoke and not to allow smoking in rooms or cars that their children use.

(A)
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Assess patients with a >10 pack-year smoking history for COPD or asthma–COPD overlap, as additional treatment strategies may be required.

()
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Physical activity

Encourage people with asthma to engage in regular physical activity because of its general health benefits.

(A)
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However, regular physical activity confers no specific benefit on lung function or asthma symptoms per se, with the exception of swimming in young people with asthma.

(B)
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There is insufficient evidence to recommend one form of physical activity over another.

(D)
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Provide patients with advice about prevention and management of exercise-induced bronchoconstriction including with daily treatment with ICS

(A)
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  • plus SABA as-needed and pre-exercise

(A)
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  • or with low dose ICS-formoterol as-needed and before exercise,
(B)
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  • with warm-up before exercise if needed.
(A)
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Avoidance of occupational exposures

Ask all patients with adult-onset asthma about their work history and other exposures.

(D)
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In management of occupational asthma, identify and eliminate occupational sensitizers as soon as possible, and remove sensitized patients from any further exposure to these agents.

(A)
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Patients with suspected or confirmed occupational asthma should be referred for expert assessment and advice, if available, because of the economic and legal implications of the diagnosis.

(A)
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Avoidance of medications that may make asthma worse

Always ask people with asthma about concomitant medications, including eyedrops.

(D)
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Always ask about asthma and previous reactions before prescribing NSAIDs, and advise patients to stop using these medications if asthma worsens.

()
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Aspirin and NSAIDs are not generally contraindicated in asthma unless there is a history of previous reactions to these agents.

(A)
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For people with asthma who may benefit from oral or ophthalmic beta-blocker treatment, a decision to prescribe these medications should be made on a case-by-case basis, and treatment should only be initiated under close medical supervision by a specialist.

(D)
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Asthma should not be regarded as an absolute contraindication to use cardioselective beta-blockers when they are indicated for acute coronary events, but the relative risks and benefits should be considered.

(D)

The prescribing physician and patient should be aware of the risks and benefits of treatment.

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Box 3-10. Effectiveness of avoidance measures for indoor allergens

Measure

Evidence of effect on allergen levels

Evidence of clinical benefit

House dust mites

Some (A)

Adults - none (A) Children - some (A)

Encase bedding in impermeable covers

Wash bedding on hot cycle (55–60°C)

Some (C)

None (D)

Replace carpets with hard flooring

Some (B)

None (D)

Acaricides and/or tannic acid

Weak (C)

None (D)

Minimize objects that accumulate dust

None (D)

None (D)

Vacuum cleaners with integral HEPA filter and double- thickness bags

Weak (C)

None (D)

Remove, hot wash, or freeze soft toys

None (D)

None

Pets

Weak (C)

None (D)

Remove cat/dog from the home

Keep pet from the main living areas/bedrooms

Weak (C)

None (D)

HEPA-filter air cleaners

Some (B)

None (A)

Wash pet

Weak (C)

None (D)

Replace carpets with hard flooring

None (D)

None (D)

Vacuum cleaners with integral HEPA filter and double- thickness bags

None (D)

None (D)

Cockroaches

Minimal (D)

None (D)

Bait plus professional extermination of cockroaches

Baits placed in households

Some (B)

Some (B)

Rodents

Some (B)

Some (B)

Integrated pest management strategies

Fungi

A

A

Remediation of dampness or mold in homes

Air filters, air conditioning

Some (B)

None (D)

Allergen avoidance is not recommended as a general strategy for people with asthma.

(A)
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For sensitized patients, although it would seem logical to attempt to avoid allergen exposure in the home, there is some evidence for clinical benefit with single avoidance strategies

(A)
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  • and only limited evidence for benefit with multi-component avoidance strategies (in children).

(B)
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Although allergen avoidance strategies may be beneficial for some sensitized patients,

(B)
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  • they are often complicated and expensive, and there are no validated methods for identifying those who are likely to benefit.

(D)
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Healthy diet

Encourage patients with asthma to consume a diet high in fruit and vegetables for its general health benefits.

(A)
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Include weight reduction in the treatment plan for obese patients with asthma.

(B)
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Increased exercise alone appears to be insufficient.

(B)
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Breathing exercises

Breathing exercises may be considered as a supplement to conventional asthma management strategies for symptoms and quality of life, but they do not improve lung function or reduce exacerbation risk.

(A)
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Avoidance of indoor air pollution

Encourage people with asthma to use non-polluting heating and cooking sources, and for sources of pollutants to be vented outdoors where possible.

(B)
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Strategies for dealing with emotional stress

Encourage patients to identify goals and strategies to deal with emotional stress if it makes their asthma worse.

(D)
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There is insufficient evidence to support one strategy over another, but relaxation strategies and breathing exercises may be helpful in reducing asthma symptoms.

(B)
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Arrange a mental health assessment for patients with symptoms of anxiety or depression.

(D)
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Avoidance of outdoor allergens

For sensitized patients, closing windows and doors, remaining indoors when pollen and mold counts are highest, and using air conditioning may reduce exposure.

(D)
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The impact of providing information in the media about outdoor allergen levels is difficult to assess.

()
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Avoidance of outdoor air pollution

In general, when asthma is well-controlled, there is no need for patients to modify their lifestyle to avoid unfavorable outdoor conditions (air pollutants, weather).

()
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It may be helpful, where possible, during unfavorable environmental conditions (very cold weather, low humidity or high air pollution) to avoid strenuous outdoor physical activity and stay indoors in a climate-controlled environment; and to avoid polluted environments during viral infections.

(D)
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Avoidance of food and food chemicals

Ask people with asthma about symptoms associated with any specific foods.

(D)
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Food avoidance should not be recommended unless an allergy or food chemical sensitivity has been clearly demonstrated,

(D)

usually by carefully supervised oral challenges.

7057

If food chemical sensitivity is confirmed, complete avoidance is not usually necessary, and sensitivity often decreases when overall asthma control improves.

(D)
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If food allergy is confirmed, food allergen avoidance can reduce asthma exacerbations.

(D)
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SKILLS TRAINING FOR EFFECTIVE USE OF INHALER DEVICES

Checking and correcting inhaler technique using a standardized checklist takes only 2–3 minutes and leads to improved asthma control in adults and older children.

(A)
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ASTHMA INFORMATION

Asthma education and training, for both adults and children, can be delivered effectively by a range of health care providers including pharmacists and nurses.

(A)
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Trained lay health workers (also known as community health workers) can deliver discrete areas of respiratory care such as asthma self-management education. Asthma education by trained lay health workers has been found to improve patient outcomes and healthcare utilization compared with usual care, and to a similar extent as nurse-led education in primary care.

(B)
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TRAINING IN GUIDED ASTHMA SELF-MANAGEMENT

Self-management education that includes these components dramatically reduces asthma morbidity in both adults

(A)
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  • and children.

(A)
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Benefits include reduction of one-third to two-thirds in asthma-related hospitalizations, emergency department visits and unscheduled doctor or clinic visits, missed work/school days, and nocturnal wakening. It has been estimated that the implementation of a self-management program in 20 patients prevents one hospitalization, and successful completion of such a program by 8 patients prevents one emergency department visit. Less intensive interventions that involve self-management education but not a written action plan are less effective, and information alone is ineffective. A systematic meta-review of 270 RCTs on supported self-management for asthma confirmed that it reduces unscheduled healthcare use, improves asthma control, is applicable to a wide range of target groups and clinical settings, and does not increase health care costs.

(A)
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Self-monitoring of symptoms and/or peak flow

For patients carrying out PEF monitoring, use of a laterally compressed PEF chart (showing 2 months on a landscape format page) allows more accurate identification of worsening asthma than other charts. One such chart is available for download from www.woolcock.org.au/moreinfo/. There is increasing interest in internet or phone-based monitoring of asthma. Based on existing studies, the main benefit is likely to be for more severe asthma.

(B)
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Written asthma action plans

Asthma action plans should be provided for the family/carers of all children with asthma, including those aged 5 years and younger.

(D)
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INITIAL HOME MANAGEMENT OF ASTHMA EXACERBATIONS

Initial management includes an action plan to enable the child’s family members and carers to recognize worsening asthma and initiate treatment, recognize when it is severe, identify when urgent hospital treatment is necessary, and provide recommendations for follow up.

(D)

The action plan should include specific information about medications and dosages and when and how to access medical care.

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The parent/carer should initiate treatment with two puffs of inhaled SABA (200 mcg salbutamol or equivalent), given one puff at a time via a spacer device with or without a facemask.

(D)
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PRIMARY CARE OR HOSPITAL MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS IN CHILDREN 5 YEARS OR YOUNGER

Conduct a brief history and examination concurrently with the initiation of therapy. The presence of any of the features of a severe exacerbation listed in Box 6-9 are an indication of the need for urgent treatment and immediate transfer to hospital.

(D)
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Children with features of a severe exacerbation that fail to resolve within 1–2 hours despite repeated dosing with inhaled SABA must be referred to hospital for observation and further treatment.

(D)
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Treat hypoxemia urgently with oxygen by face mask to achieve and maintain percutaneous oxygen saturation 94–98%.

(A)

To avoid hypoxemia during changes in treatment, children who are acutely distressed should be treated immediately with oxygen and SABA (2.5 mg of salbutamol or equivalent diluted in 3 mL of sterile normal saline) delivered by an oxygen-driven nebulizer (if available). This treatment should not be delayed, and may be given before the full assessment is completed. Transient hypoxemia due to ventilation/perfusion mismatch may occur during treatment with SABAs.

7057
The initial dose of SABA may be given by a pMDI with spacer and mask or mouthpiece or an air-driven nebulizer; or, if oxygen saturation is low, by an oxygen-driven nebulizer (as described above). For most children, pMDI plus spacer is favored as it is more efficient than a nebulizer for bronchodilator delivery, (A)

and nebulizers can spread infectious particles. The initial dose of SABA is two puffs of salbutamol (100 mcg per puff) or equivalent, except in acute, severe asthma when six puffs should be given. When a nebulizer is used, a dose of 2.5 mg salbutamol solution is recommended, and infection control procedures should be followed. The frequency of dosing depends on the response observed over 1–2 hours.

7057

If symptoms persist after initial bronchodilator: a further 2–6 puffs of salbutamol (depending on severity) may be given 20 minutes after the first dose and repeated at 20-minute intervals for an hour. Consider adding 1–2 puffs of ipratropium. Failure to respond at 1 hour, or earlier deterioration, should prompt urgent admission to hospital, addition of nebulized ipratropium, and a short-course of oral corticosteroids.

(D)
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If symptoms have improved by 1 hour but recur within 3–4 hours: the child may be given more frequent doses of bronchodilator (2–3 puffs each hour), and oral corticosteroids should be given. The child may need to remain in the emergency department, or, if at home, should be observed by the family/carer and have ready access to emergency care. Children who fail to respond to 10 puffs of inhaled SABA within a 3–4 hour period should be referred immediately to hospital.

(D)
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If symptoms resolve rapidly after initial bronchodilator and do not recur for 1–2 hours: no further treatment may be required. Further SABA may be given every 3–4 hours (up to a total of 10 puffs/24 hours) and, if symptoms persist beyond 1 day, other treatments including inhaled and/or oral corticosteroids are indicated.

(D)
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Children who have been prescribed maintenance therapy with ICS, LTRA or both should continue to take the prescribed dose during and after an exacerbation.

(D)
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For children not previously on ICS, an initial dose of ICS twice the low daily dose may be given and continued for a few weeks or months.

(D)
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Some studies have used high dose ICS (1600 mcg/day, preferably divided into four doses over the day and given for 5–10 days) as this may reduce the need for  OCS. Addition of ICS to standard care (including OCS) does not reduce risk of hospitalization but reduces length of stay and acute asthma scores in children in the emergency department. However, the potential for sideeffects with high dose ICS should be taken into account, especially if used repeatedly, and the child should be monitored closely. For those children already on ICS, doubling the dose was not effective in a small study of mild-moderate exacerbations in children aged 6–14 years, nor was quintupling the dose in children aged 5–11 years with good adherence. This approach should be reserved mainly for individual cases, and should always involve regular follow up and monitoring of adverse effects.

(D)
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Oral corticosteroids

For children with severe exacerbations, a dose of OCS equivalent to prednisolone 1–2 mg/kg/day, with a maximum of 20 mg/day for children under 2 years of age and 30 mg/day for children aged 2–5 years, is currently recommended,

(A)
7057
  • although several studies have failed to show any benefits when given earlier (e.g. by parents) during periods of worsening wheeze managed in an outpatient setting.

(D)
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A recent meta-analysis demonstrated a reduced risk of hospitalization when oral corticosteroids were administered in the emergency department, but no clear benefit in risk of hospitalization when given in the outpatient setting. A course of 3–5 days is sufficient in most children of this age, and can be stopped without tapering,

(D)

but the child must be reviewed after discharge (as below) to confirm they are recovering.

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Discharge and follow up after an exacerbation

Children who have recently had an asthma exacerbation are at risk of further exacerbations and require follow up. The purpose is to ensure complete recovery, to establish the cause of the exacerbation, and, when necessary, to establish appropriate maintenance treatment and adherence.

(D)
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Prior to discharge from the emergency department or hospital, family/carers should receive the following advice and information:

• Instruction on recognition of signs of recurrence and worsening of asthma. The factors that precipitated the exacerbation should be identified, and strategies for future avoidance of these factors implemented.
• A written, individualized action plan, including details of accessible emergency services
• Careful review of inhaler technique
• Further treatment advice explaining that:
o SABAs should be used on an as-needed basis, but the daily requirement should be recorded to ensure it is being decreased over time to pre-exacerbation levels.
o ICS has been initiated where appropriate (at twice the low initial dose in Box 6-6 (p.160) for the first month after discharge, then adjusted as needed) or continued, for those previously prescribed controller medication.
• A supply of SABA and, where applicable, the remainder of the course of oral corticosteroid, ICS or LTRA
• A follow-up appointment within 1–2 days and another within 1–2 months, depending on the clinical, social and practical context of the exacerbation. (D)
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Primary prevention of asthma

FACTORS ASSOCIATED WITH INCREASED OR DECREASED RISK OF ASTHMA IN CHILDREN

Breastfeeding

Despite the existence of many studies reporting a beneficial effect of breastfeeding on asthma prevention, results are conflicting, and caution should be taken in advising families that breastfeeding will prevent asthma. Breastfeeding decreases wheezing episodes in early life. However, it may not prevent development of persistent asthma.

(D)
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Regardless of its effect on development of asthma, breastfeeding should be encouraged for all of its other positive benefits.

(A)
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Recommendation Grading

Overview

Title

Global Strategy for Asthma Management and Prevention

Authoring Organization

Publication Month/Year

March 1, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Childcare center

Intended Users

Physician

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D029424 - Pulmonary Disease, Chronic Obstructive, D001249 - Asthma

Keywords

chronic obstructive pulmonary disease (COPD), asthma, Exacerbations