Chronic asthma

Clinical features

– Asthma should be suspected in patients with episodic respiratory symptoms (wheezing, chest tightness, shortness of breath and/or cough) of variable frequency, severity and duration, disturbing sleep, and causing the patient to sit up to breathe. These symptoms may appear during or after exercise.

– Chest auscultation may be normal or demonstrate diffuse sibilant wheezes.

– Atopic disorders or a personal or family history of atopy (eczema, allergic rhinitis/conjunctivitis) or a family history of asthma increases probability of asthma but their absence does not exclude asthma.

Patients with typical symptoms of asthma and a history of disease that is characteristic of asthma should be considered as having asthma after exclusion of other diagnoses.

The assessment of the frequency of daytime and nigthtime symptoms and limitations of physical activity determines whether asthma is intermittent or persistent.

Treatment

Only patients with persistent asthma need long-term treatment. The mainstay of treatment is inhaled corticosteroids. Treatment is started at the step most appropriate to initial severity then, re-evaluated and adjusted according to clinical response. It aims to abolish symptoms with the lowest possible dose of inhaled corticosteroids. An intervening severe exacerbation or loss of control necessitates reassessment to re-evaluate treatment.

Long-term treatment does not mean treatment for life. Asthma attacks may occur over months or years, with intervening asymptomatic intervals when long-term treatment is not required.

Long-term treatment of asthma according to severity

Categories

Treatment

Intermittent asthma

  • Day time symptoms < once weekly
  • Night time symptoms < 2 times monthly
  • Normal physical activity

No long term treatment
Inhaled salbutamol when symptomatic

Mild persistent asthma

  • Day time symptoms > once weekly, but < once daily
  • Night time symptoms > 2 times monthly
  • Symptoms may affect activity

Continuous treatment with inhaled beclometasone
+
Inhaled salbutamol when symptomatic

Moderate persistent asthma

  • Daily symptoms
  • Symptoms affect activity
  • Night time symptoms > once weekly
  • Daily use of salbutamol

Continuous treatment with inhaled beclometasone
+
Inhaled salbutamol (1 puff 4 times daily)

Severe persistent asthma

  • Daily symptoms
  • Frequent night time symptoms
  • Physical activity limited by symptoms

Continuous treatment with inhaled beclometasone
+
Inhaled salbutamol (1-2 puff/s 4 to 6 times daily)

Inhaled corticosteroid treatment: beclometasone dose varies according to the severity of asthma. Find the minimum dose necessary to both control the symptoms and avoid local and systemic adverse effects:
Children: 50 to 100 micrograms 2 times daily depending on the severity; increase to 200 micrograms 2 times daily if necessary (max. 800 micrograms daily)
Adults: 100 to 250 micrograms 2 times daily depending on the severity; increase to 500 micrograms 2 times daily if necessary (max. 1500 micrograms daily)
 The number of puffs of beclometasone depends on its concentration in the inhaled aerosol: 50, 100 or 250 micrograms per puff.

Do not restrict exercise. If exercise is a trigger for asthma attacks, administer 1 or 2 puffs of salbutamol 10 minutes beforehand.

In pregnant women, poorly controlled asthma increases the risk of pre-eclampsia, eclampsia, haemorrhage, in utero growth retardation, premature delivery, neonatal hypoxia and perinatal mortality. Long-term treatment remains inhaled salbutamol and beclometasone at the usual dosage for adults. Whenever possible, avoid oral corticosteroids.

If symptoms are not well controlled during a period of at least 3 months, check the inhalation technique and adherence before changing to a stronger treatment.

If symptoms are well controlled for a period of at least 3 months (the patient is asymptomatic or the asthma has become intermittent): try a step-wise reduction in medication, finally discontinuing treatment, if it seems possible. Provide patients with a salbutamol inhaler for any possible attacks. Evaluate after 2 weeks. If the results are satisfactory, continue for 3 months and then re-evaluate. If the patient has redeveloped chronic asthma, restart long-term treatment, adjusting doses, as required.