Asthma in adults

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Your Organizational Guidance

ebpracticenet urges you to prioritize the following organizational guidance:

Astma bij volwassenen: diagnose en monitoring in de eerste lijnPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2020Asthme chez l’adulte : diagnostic et surveillance en soins de santé primairesPublished by: Groupe de Travail Développement de recommmandations de première ligneLast published: 2020

Therapy should aim for supported self-management where feasible. However, all patients with asthma should have at least annual medical and psychosocial reviews performed by a healthcare professional with appropriate training in asthma management.[3][296] Emphasize that attending follow-up is essential for a long and healthy life with asthma. Use the adjust (or start), review, assess approach for drug changes.

Supported self-management

Discuss patient preferences and goals, and consider likely adherence with a daily controller when deciding between initial treatments. Shared decision-making is a key element of effective supported self-management.[299][300][301] [ ]

Provide educational material that includes how to spot and manage symptom deterioration. Strongly encourage the use of an asthma action plan.[3][141][302] American Lung Association: create an asthma action plan Opens in new window [ ] [ ]

Ensure your patient understands that effective home management of symptoms greatly improves outcomes. Encourage daily self-monitoring by checking and recording peak expiratory flow (PEF) using a peak flow meter. See Monitoring. Use these records to inform decisions about subsequent drug adjustments.

Secondary prevention of modifiable risk factors should be discussed. See Prevention.

Asthma action plans

The use of a written, personalized, asthma action plan is encouraged to support self-management.[3][141] [ ] The asthma action plan can help your patient recognize when their asthma is deteriorating and how to respond appropriately: for example, increasing usual reliever and controller treatment, and determining when to seek medical help.[302] [ ] [ ] Examples of asthma action plans are available from the, but please check local preferences and availability. American Lung Association: create an asthma action plan Opens in new window

Optimize adherence

Proactively address common barriers to adherence. Multicomponent strategies offer the best approach, with benefit shown when including the following elements through shared decision-making:[295][301][303][304][305][306][307] [ ]

Written action plans
Digital eHealth interventions, including text/audiovisual message reminders
Educational interventions
Feedback on inhaler technique and drug use
Simplifying regimens (e.g., fewer inhalers)
Motivational interviewing

Clinical decision support aids may improve some outcomes, such as quality of life, spirometry values, and exacerbation rates, by improving the use of PEF measurements, ICS prescribing, and asthma action plans.[308] Adherence levels of at least 80% seem to be associated with the lowest risk of exacerbation.[309]

Remotely supported self-management, including asthma reviews, may be viable for patients who prefer this option (e.g., younger or in remote areas).[295][310][311] Monitoring digitally acquired data (e.g., adherence, inhaler technique, and peak flow) likely improves drug adherence and asthma control, lowers treatment burdens, reduces exacerbation frequency, and increases quality of life.[307][312][313] Telemedicine and eHealth interventions that combine mobile devices, audiovisual and text message reminders, and an in-person element appear to be optimal.[307][314][315][316][317]

Enhanced support may be required for patients transitioning into adulthood due to a risk of reduced adherence.[318] Targeted interventions may also improve disparities in outcomes for first-generation immigrants and for black and hispanic people, especially where poverty is present and is a key driver of exposure to environmental hazards.[44][319][320]

Inhaler technique and choice

Check inhaler technique at every opportunity.

Ensure the patient is using drugs and delivery devices correctly: a better technique is associated with better asthma outcomes.[321][322][323] Where possible, prescribe devices with integrated dose counters and prescribe the same type of inhaler device when more than one is prescribed.[324] Pharmacist-led interventions can improve inhaler technique and drug adherence in adults with asthma.[217][325][326]

Metered dose inhaler

A principal pharmacist shows a patient how to use a metered dose inhaler and discusses ways of improving inhaler technique.

Dry powder inhalers

A principal pharmacist shows a patient how to use dry powder devices and discusses ways of improving inhaler technique.

Metered dose inhaler plus spacer

A principal pharmacist shows a patient how to use a metered dose inhaler plus a spacer and discusses ways of improving inhaler technique.

Consider patient concerns about inhaler choice, including environmental issues. Asthma + Lung UK: inhaler choices Opens in new window[327] Addressing poorly controlled asthma, particularly curbing high short-acting beta-agonist use, most significantly affects asthma care-related carbon emissions.[328] Changing from a pressurized metered dose inhaler to a dry powder inhaler can more than halve the inhaler carbon footprint.[329] However, do not swap inhalers without proper discussion and follow-up.[330]

Asthma increases the risk of frailty, which in turn, may affect ongoing management.[331] Older people are more likely to have comorbidities, polypharmacy, impaired cognition, and impaired motor skills. Inhaler choice may be affected by limitations to inspiratory flow, coordination, and hand dexterity.[332]

Any review of the inhaler technique is ideally performed as part of a comprehensive review.[299][Figure caption and citation for the preceding image starts]: Guidance for optimising asthma reviews by healthcare professionals in adults and children over 12 years old. Adapted from the Greener Practice High Quality and Low Carbon Asthma Care Quality Improvement Toolkit (https://www.greenerpractice.co.uk/wp-content/uploads/Asthma-Visual-Guide-V1.5.2.pdf)Greener Practice CIC https://www.greenerpractice.co.uk/asthma-toolkit/; used with permission [Citation ends]. com.bmj.content.model.Caption@46954764

Modifiable risk factors

Treat modifiable risk factors and comorbidities (e.g., smoking, obesity, anxiety), and give advice about non-pharmacological therapies and strategies, as appropriate (e.g., physical activity, weight loss, avoidance of triggers).[3] Nonpharmacologic and behavioral interventions may be used to help improve asthma control and/or reduce future risk.[3][333]

Trigger avoidance

Environmental control strategies should be discussed, with efforts to identify and eliminate home and work/school exposure to allergens that can cause or worsen asthma, including house-dust mites, animals, cigarette smoke and other respiratory irritants, chemicals, and pollens and grasses.[3][334]

International guidelines vary in their recommendations regarding allergen mitigation, so local guidance should be consulted. For example, the 2020 US asthma guidelines conditionally recommend multicomponent, allergen-specific mitigation interventions for people with asthma who have symptoms related to identified indoor allergens, as confirmed by history or allergy testing.[111]Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC); Cloutier MM, Baptist AP, Blake KV, et al. 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020 Dec;146(6):1217-70.

Treat any comorbidities (e.g., gastro-oesophageal reflux, infections).

Consider the following targets for trigger avoidance on a case-by-case basis.

Smoking and vaping: counsel patients about the dangers of smoking and exposure to second-hand tobacco smoke, which adversely affect quality of life, lung function, rescue drug use, and long-term control. Strongly encourage smoking cessation for people with asthma who smoke. Access to counseling and/or smoking cessation programs should be provided, where available.[335] The increased use of vaping, particularly among teens and young adults, poses an important public health concern and should be addressed when discussing smoking cessation.[66][336][337]
Occupational exposures: patients with suspected or confirmed occupational asthma should be referred to a specialist, due to the legal implications of the diagnosis. Occupational sensitizers should be eliminated as soon as possible, and sensitized patients should be removed from further exposure.[334][338] See Occupational asthma.
Drugs
- Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs): should be used with caution, but are not absolutely contraindicated in asthma unless the patient has a history of reactions to these drugs or there is a diagnosis of aspirin- and/or NSAID-exacerbated respiratory disease (AERD), which includes cyclo-oxygenase-1 (COX-1) inhibitors.[3][23] AERD occurs in about 9% of the adult population with asthma, who typically develop sensitivity after a history of chronic rhinosinusitis and/or polyps.[24][25] Treatment comprises avoidance plus aspirin and NSAID desensitization under specialist care; biologics offer an alternative for long-term control and can be used in place of desensitization.[23] In treatment-naive patients, use oral or topical NSAIDs with caution and monitor for symptoms or exacerbation.
- Beta-blocker treatment (oral or ophthalmic): decisions should be made on a case-by-case basis, with treatment only started by a specialist.[3]
Allergens and environmental triggers
- Foods: avoidance of food allergen (e.g., containing sulfites) can reduce asthma exacerbations if food allergy is confirmed.[3]
- Indoor allergens: full control is not always feasible and allergen avoidance with a single intervention tends to produce insufficient reductions in allergen load.[339] Removal of mold and dampness at home improves asthma symptoms and use of drug in adults.
- Outdoor allergens: for patients sensitized to pollens and molds, closing windows and doors and remaining inside when pollen and mold counts are high, and using air conditioning, may reduce exposure.
Emotional stress
- Patients with asthma are at increased risk of depression and anxiety, and these comorbidities may worsen asthma control.[3][340] Help people with asthma find strategies to deal with emotional stress if the stress usually worsens their asthma control.
- Drug treatment and cognitive behavior therapy may be suitable, but evidence is limited.[341][342][343][344]
- Patients with asthma have a significantly increased risk of suicidal ideation, suicide attempts, and suicide mortality; this includes the risk associated with montelukast.[340][345][346]
- Make mental health referrals where necessary.

Exercise-based interventions

Patients with asthma can benefit from training in breathing exercises, engaging in regular physical exercise when stable, and participation in a formal pulmonary rehabilitation program.[347] In general, aerobic exercise is superior to breathing/stretching exercises for improving health-related physical fitness outcomes in asthma.[348]

Breathing exercises: may be considered as part of an integrated approach to management.
- The Papworth and Buteyko methods are commonly used in practice, which involve instruction by a trained therapist in exercises to reduce the respiratory rate and minute volume and to promote diaphragmatic breathing through the nose.
- Breathing exercises have little effect on lung function or airway inflammation, but may improve subjective symptoms.[333][349][350] [ ]
- Aerobic exercise is superior to breathing/stretching exercises for improving health-related physical fitness outcomes in asthma.[348]
Physical activity: during stable periods, people with asthma of all severities should engage in regular exercise for its general health benefits and the improvements it brings for lung function, asthma control, and quality of life.[351][352][353][354] Exercise-induced bronchoconstriction can usually be reduced by optimizing maintenance treatment.[3][355] Further research is needed to determine the optimal intervention.[354]
Pulmonary rehabilitation: Patients with limited exercise tolerance or dyspnea due to persistent airflow limitation may benefit from pulmonary rehabilitation.[349][356][357]
- One Cochrane review found that pulmonary rehabilitation programs comprising aerobic training, nutritional advice, psychological counseling, and education led to clinically meaningful short-term improvements in functional exercise capacity and quality of life; however, the benefits did not improve asthma symptom control.[358]
- The use of specific behavior change techniques increase the chance of success, including action planning, goal setting, clear instruction, clear demonstrations, and practice or rehearsal.[347]

Dietary interventions

Healthy diet: people with asthma should eat a diet high in fruit and vegetables for general health benefits.
Weight reduction: weight loss in people with obesity and asthma may improve asthma outcomes.[40][359] A systematic review and meta-analysis found that people with asthma and comorbid obesity have a higher use of asthma drug, including oral corticosteroids, than people of a healthy weight, despite similar lung function.[42] Bariatric surgery appears to be superior in improving asthma control compared with nonsurgical weight loss.[40][360]
It is prudent to manage low vitamin D levels as a matter of good clinical care, while vitamin D plus calcium supplementation may be indicated to prevent or treat osteoporosis secondary to steroid use. See Complications. Vitamin D supplementation may have a role in reducing the risk of asthma exacerbations and improving asthma control, but the available evidence is inconsistent. See Emerging treatments.[91][92][93][94]

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