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Asthma - Diagnosis and Management

Effective Date: June 30, 2010

Summary | Flow Sheet | Patient Guide | Full Guideline in PDF

Recommendations and Topics

Scope

Care Objectives

Diagnosis/Investigation of Asthma

Management

Rationale

References

Physician and Patient Resources

List of Abbreviations

Appendices

Scope

This guideline provides recommendations for the recognition, diagnosis, and management of asthma in patients age 6 and older, in an office setting.

Care Objectives

The objectives of this guideline are to assist the practitioner caring for a patient with asthma to:

  • improve diagnostic accuracy
  • provide effective treatment and monitoring plans
  • create a long-term plan of management, evaluation and care.

Diagnostic Code: 493 (Asthma)

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Diagnosis/Investigation of Asthma

Asthma is a syndrome that is characterized by paroxysmal or persistent symptoms such as breathlessness, chest tightness, wheezing and cough. It is associated with variable airflow limitation and airway hyperresponsiveness in response to endogenous and exogenous stimuli. Inflammation and its resultant effects on airway structure are considered to be the main mechanisms leading to the development and persistence of asthma.

a. Signs and symptoms of asthma in children and adults

Table 1 - Clinical Features to Assess the Probability of Asthma

CHILDREN ≥ 6 YEARS
Clinical Features that...
Increase the Probability of Asthma Lower the Probability of Asthma
  • >1 of the following symptoms: wheeze, cough, difficulty breathing, chest tightness - particularly if these are
    • frequent and recurrent;
    • worse at night and in the early morning;
    • occur in response to, or are worse after, exercise, allergen exposure, cold or damp air, or with emotions or laughter;
    • occur apart from colds
  • Personal history of atopic disorder
  • Family history of atopic disorder and/or asthma
  • Wheeze heard on auscultation
  • History of improvement in symptoms or lung function in response to adequate therapy
  • Symptoms with colds only, with no interval symptoms
  • Isolated cough in the absence of wheeze or difficulty breathing
  • History of moist or wet cough
  • Prominent dizziness, light-headedness, peripheral tingling
  • Repeatedly normal physical examination of chest when symptomatic
  • Normal peak expiratory flow (PEF) or spirometry when symptomatic
  • No response to a trial of asthma therapy
  • Clinical features pointing to alternative diagnosis
ADULTS
Clinical Features that...
Increase the Probability of Asthma Lower the Probability of Asthma
  • More than one of the following symptoms: wheeze, cough, breathlessness, chest tightness - particularly if:
    • symptoms are worse at night and in the early morning
    • symptoms in response to exercise, allergen exposure and cold air
    • symptoms after taking aspirin or beta blockers
  • History of atopic disorder
  • Family history of atopic disorder and/or asthma
  • Wheeze heard on auscultation
  • Otherwise unexplained low FEV1 or PEF
  • Otherwise unexplained peripheral blood eosinophilia
  • Prominent dizziness, light-headedness, peripheral tingling
  • Chronic productive cough in the absence of wheeze or breathlessness
  • Repeatedly normal physical examination of chest when symptomatic
  • Voice disturbance
  • Symptoms with colds only
  • Significant smoking history (i.e. > 20 pack-years)
  • Cardiac disease
  • Normal PEF or spirometry when symptomatic

* Table adapted from the BTS/SIGN British Guideline on the Management of Asthma - Quick Reference Guide1

b. Diagnosis of asthma

When asthma is suspected from clinical features, and other disorders have been considered and ruled out (e.g. tumours in adults, foreign body in children; don't assume the presence of wheeze means asthma), confirm the diagnosis by objective measures of variable airflow obstruction and assess severity. In most cases the following criteria would suffice as objective evidence of variable airflow obstruction:

Spirometry:

  • FEV1 - A 12 % or greater improvement in forced expiratory volume (FEV1) in children and adults, and > 200 ml in adults from the baseline 15 minutes after use of an inhaled short-acting beta2 agonist.2
  • PEF - Serial measures of peak expiratory flow (PEF): A > 20% change after administration of a bronchodilator; a 20% change in values over time. Typically pulmonary function normalizes after administration of a bronchodilator in asthmatic patients.2

When there is some probability of asthma and the above tests are non-diagnostic, the following tests may be used to help in the diagnosis of asthma:

  • Methacholine challenge
  • Exercise challenge
  • Inhaled corticosteroid trial: appropriate doses of inhaled steroids for 4-6 weeks
    (Refer Table 4 and Appendix A)
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Management

  1. Control of Asthma - Control of airway hyperresponsiveness is the key to success; most people with asthma should have minimal to no impact on their quality of life. Evaluate and assess impact and exposure to allergens and irritants in individual patients. Complete cessation of smoking and avoidance of environmental tobacco smoke is strongly recommended.

Table 2 - Levels of Asthma Control

LEVELS OF ASTHMA CONTROL
Characteristic Controlled (All of the following) Partly Controlled (Any measure present in any week) Uncontrolled
Daytime symptoms None (twice or less/week) More than twice/week Three or more features of partly controlled asthma present in any week.
Limitations of activities None Any
Nocturnal symptoms/awakening None Any
Need for reliever/rescue treatment None (twice or less/week) More than twice/week
Lung function (PEF or FEV1) * Normal ≥ 80% predicted or personal best (if known)
Exacerbations None One or more/year† One in any week‡

* Lung function testing is not reliable for children 5 years and younger.
† Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.
‡ By definition, an exacerbation in any week makes that an uncontrolled asthma week.
Table 2 used with permission from Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA) 2008. Available at: http://www.ginasthma.org3

  1. Pharmacological Management
    • If expiratory flows are normal and symptoms are controlled (refer Table 2) an inhaled short-acting beta2 agonist should be used as needed (refer Table 3 and Appendix A).
    • If a rescue beta2 agonist is needed more than 2 times per week (excluding preventative use prior to exercise) or if lung function is abnormal, an inhaled glucocorticosteroid (refer Table 3) is the next step.


      Spacers:

    • Technically, the most efficient way to maximize inhaled drug delivery to the lungs is through a metered dose inhaler (pMDI) and spacing device.4 For adults, however, a dry powdered inhaler (DPI) has demonstrated efficacy and is more convenient for most people. If using an inhaled corticosteroid pMDI, a spacer device, in addition to usual oral hygiene, will minimize the risk of oral thrush.
      Choice of Inhaler Device4 1st line 2nd line
      Children pMDI and spacer DPI
      Adults DPI pMDI and spacer
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Table 3 - Stepwise Approach to the Management of Chronic Asthma in Patients ≥ 6 years

Table 3 - Stepwise Approach to the Management of Chronic Asthma in Patients ≥ 6 years

* Frequent use of short-acting beta agonists (SABA) may increase exacerbation risk.
† Chronic, high dose of inhaled steroid use may be associated with a number of long term side effects and should prompt consideration of stepping down.6
Table 3 was adapted in part from the BTS/SIGN British Guideline on the Management of Asthma - Quick Reference Guide.1

Note: Long-acting beta agonists are contraindicated as monotherapy, but always used in combination with an appropriate dose of an inhaled corticosteroid.7

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Table 4 - Estimated Dose Equivalents for Inhaled Corticosteroids3,8,9,10,11

Name Adult
mcg per daya		 Children (6-11 years)
mcg per daya
Low Medium High
(Max LD)		 Low Medium High
(Max LD)
beclomethasone dipropionate HFA pMDI (Qvar™) ≤ 250 251-500 > 500
(800)		 ≤ 100 101-200b > 200b
(200)
budesonide DPI (Pulmicort® Turbuhaler®) ≤ 400 401-800 > 800
(2400)		 ≤ 200 201-400b > 400b
(400)
ciclesonide pMDI (Alvesco®) ≤ 200 201-400 > 400
(800)		 100 101-200b > 200b
(200)
fluticasone priopionate HFA pMDI (Flovent®) + spacer ≤ 250 251-500 > 500
(2000)		 ≤ 100 101-200b > 200b
(400)
fluticasone priopionate DPI (Flovent® Diskus) ≤ 250 251-500 > 500
(2000)		 ≤ 100 101-200b > 200b
(400)

Abbreviations: DPI = dry powder inhaler; HFA = hydrofluoroalkane; Max LD = maximum licensed dose; pMDI = pressurized metered dose inhaler (aerosol)

Notes:

  1. Dosage equivalents are approximate and depend on factors such as inhaler technique. Pediatric equivalency doses are less well established. Total daily doses usually divided into two doses. Once daily dosing may be effective in some patients with milder disease. Ciclesonide is given as a single daily dose except for 800 mcg/day which is given in two divided doses.
  2. Administration of ≥ 200 ug/day fluticasone or equivalent in pediatric patients may be associated with systemic side effects.6,12,13 Pediatric patients treated with high dose inhaled corticosteroids should be under the care of a paediatrician or pediatric respirologist.
  1. Lifestyle Management /Self Management
    • Refer patients to an asthma education program where available.
    • Patients should understand:
      • proper use of their prescribed medication;
      • techniques of administration;
      • what constitutes "control" of asthma; and
      • how to monitor control with PEF measurement or symptom monitoring.
    • Include a written action plan for asthma management (refer Appendix B).
    • Discuss strategies to assist patients to stop smoking. For assistance to quit, refer patients who smoke to smoking cessation programs such as QuitNow (refer Physician and Patient Resources).
    • At each office visit review:
      • asthma control,
      • action plan adequacy, and
      • inhaler technique.
    • Provide guidance about when to see the primary health care provider, and when to go to an emergency room if there is an asthma exacerbation.
    • Refer patients to resources for patient education tools (refer Physician and Patient Resources).
  2. Managing chronic asthma
    • Include an action plan to increase therapy when asthma is not controlled and to decrease therapy when asthma is well controlled (refer Appendix B).
    • Periodically discuss adequacy of asthma control with the patient.
    • Identify and eliminate barriers to effective control.
    • Consider measuring peak flow at each office visit.
    • Encourage the patient/family to actively manage their illness.
    • If a patient is not responding to therapy, and compliance and inhaler technique is appropriate, consider an alternative diagnosis and/or referral for further assessment.
    • Recommend annual influenza vaccination for the patient and their family.
    • In your office consider creating:
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Rationale

The incidence of asthma in British Columbia (B.C.) for patients between 5 and 54 years has remained constant since the year 2000, with an age standardized incidence rate for 2007/08 of 0.61%.14 This amounts to almost 24,000 new cases of asthma in B.C.14 The prevalence of asthma in B.C. has increased steadily since 2000 with an age standardized prevalence rate for 2007/08 of 8.78%, or an estimated 390,000 prevalent cases.14 Hospital and Medical Services Plan costs in 2007/08 attributed to asthma patients (5-54 years of age) amount to $490/patient and $552/patient respectively, amounting to over 400 million dollars.14

Early detection, appropriate treatment, and consistent application of guidelines for education, self-management and follow-up are expected to reduced morbidity and mortality due to asthma. Universally applied, this approach may reduce hospitalizations.15

The most important contributing factors for inadequate management may include: delayed diagnosis and insufficient patient education (including airflow measurements), under assessment of the severity of the disease, under treatment with anti-inflammatory agents, over-reliance on inhaled beta2 agonists, failure to consider co-morbid medical conditions (e.g. rhinosinusitis, gastro-esophageal reflux disease (GERD), cystic fibrosis (CF), depression), or social conditions (e.g. family discord, life stresses) as contributors. Medical care delivery can be improved by addressing these factors.

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References

  1. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma - Quick Reference Guide. Available at http://www.sign.ac.uk/pdf/qrg101.pdf Accessed June 14, 2010.
  2. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005;26:948-968.
  3. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention - Updated 2008. Available at www.ginasthma.org. Accessed June 14, 2010.
  4. Barry PW, O'Callaghan C. The influence of inhaler selection on efficacy of asthma therapies. Adv Drug Deliv Rev. 2003;55:879- 923.
  5. Pedersen S, O'Byrne P. A comparison of the efficacy and safety of inhaled corticosteroids in asthma. Allergy. 1997;52(39 Suppl):1-34.
  6. Randell, TL, Donaghue KC, Ambler GR, et al. Safety of the newer inhaled corticosteroids in childhood asthma. Pediatr Drugs. 2003;5(7):481-504.
  7. Rodrigo GJ, Moral VP, Marcos LG, et al. Safety of regular use of long-acting beta agonists as monotherapy or added to inhaled corticosteroids in asthma. A systematic review. Pulm Pharmacol Ther. 2009;22(1):9-19.
  8. e-CPS [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2009 [cited 2010 Feb16]. Available from http://www.e-cps.ca. Also available in paper copy from the publisher.
  9. Lemière C, Bai T, Balter M, et al. Adult Asthma Consensus Guidelines Update 2003. Can Respir J. 2004;11(Suppl A):16A- 18A.
  10. Manning P, Gibson PG, Lasserson TJ. Ciclesonide versus other inhaled steroids for chronic asthma in children and adults. [Cochrane review] In: The Cochrane Library, Issue 2. 2008.
  11. U.S. Department of Health and Human Services. National Heart, Lung, and Blood Institute. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. [Full Report 2007]. Available from http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf Accessed June 14, 2010.
  12. Health Canada. Fluticasone and adrenal suppression. Canadian Adverse Reaction Newsletter. 2003;13(4).
  13. Salvatoni A, Piantanida E, Nosetti L, et al. Inhaled corticosteroids in childhood asthma. Long-term effects on growth and adrenocortical function. Pediatr Drugs. 2003;5(6):351-61.
  14. British Columbia Ministry of Health. Primary Health Care (PHC) Registry. January 2009.
  15. Haahtela T, Tuomisto LE, Pietinalho A, et al. A 10 year asthma programme in Finland: major change for the better. Thorax 2006;61:663-670.
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Physician and Patient Resources

Alberta Health Services - ICAN: http://www.calgaryhealthregion.ca/ican/
Provides asthma information for kids, teens, and adults. Features asthma information translated into 11 languages.

Allergy and Asthma Information Association: http://aaia.ca/en/
Mission is to create safer environments and improve quality of life for Canadians affected by allergy, asthma, and anaphylaxis by empowering individuals and providing education, leadership, and a national voice.

The Asthma Society of Canada: http://www.asthma.ca/adults/
Toll free 1-866-787-4050
Provides a variety of free educational materials and resources that provide Canadians with the latest asthma news and information.

Asthma UK: http://www.asthma.org.uk/
Asthma UK's health information resources have been developed by healthcare professionals and tested by people with asthma. They provide health information, support and advice.

BC Lung Association: http://www.bc.lung.ca/
Greater Vancouver 604-731-5864
Toll free in B.C. 1-800-665-5864
A non-profit and volunteer-based health charity, the BC Lung Association offers in-depth information on asthma programs and educational resources.

The Canadian Lung Association: http://www.lung.ca/home-accueil_e.php
Toll Free 1-888-566-5864
Publishes the Lung Association Asthma Handbook (available at http://www.lung.ca/pdf/handbook_web.pdf ); a comprehensive guide that is written in a clear, easy-to-understand style for people with asthma.

HealthLink BC: www.HealthLinkBC.ca
In B.C. dial 8-1-1 for easy access to non-emergency health information and services.
TTY (deaf and hearing-impaired) call 7-1-1.
Translation services are available in over 130 languages on request.

QuitNow: www.quitnow.ca
An internet-based quit smoking service, available FREE-of-charge to all British Columbia residents.
Toll Free in B.C. 1-877-455-2233
Translation services are available in over 130 languages on request.

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List of Abbreviations

DPI dry powder inhaler
FEV1 forced expiratory volume in 1 second
ICS inhaled corticosteroid
PEF peak expiratory flow
pMDI pressurized metered dose inhaler
SABA short-acting beta2 agonist

Appendices

Appendix A: Asthma Inhalation Drug Dosing and Cost

Appendix B: Personal Action Plan

 

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This guideline is based on scientific evidence current as of the Effective Date.

This guideline was developed by the Guidelines and Protocols Advisory Committee, approved by the British Columbia Medical Association, and adopted by the Medical Services Commission.

The principles of the Guidelines and Protocols Advisory Committee are to:

  • encourage appropriate responses to common medical situations
  • recommend actions that are sufficient and efficient, neither excessive nor deficient
  • permit exceptions when justified by clinical circumstances.

Contact Information
Guidelines and Protocols Advisory Committee
PO Box 9642 STN PROV GOVT
Victoria BC V8W 9P1
E-mail: hlth.guidelines@gov.bc.ca
Web site: www.BCGuidelines.ca

 

Disclaimer The Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems.  We cannot respond to patients or patient advocates requesting advice on issues related to medical conditions. If you need medical advice, please contact a health care professional.

A mobile version of this and other guidelines is also available at www.BCGuidelines.ca

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