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Management of Chronic Asthma
Table 1: Differential Diagnoses of Asthma and Clinical Signs that Suggest Them
In Children In Adults As Part of the Asthmatic Diathesis
Diagnosis
Obliterative bronchiolitis Cystic fibrosis Allergic bronchopulmonary aspergillosis
Vocal cord dysfunction Bronchiectasis Pulmonary eosinophilic syndromes (for example
Bronchomalacia Inhaled foreign body Churg-Strauss)
Inhaled foreign bodies Tracheobronchomalacia
Cystic fibrosis Recurrent aspiration
Recent aspiration (particularly in Chronic obstructive pulmonary disease
handicapped children) Congestive cardiac failure
Developmental abnormalities of the Tumours in or impinging on central airways
upper airway Obstructive bronchiolitis
Immunoglobulin deficiencies Vocal cord dysfunction
Primary ciliary dyskinesia Bronchial amyloidosis
Signs
Severe upper respiratory tract disease Crackles in the chest Involvement of other organs in vasculitis
Persistent productive cough without wheeze Evidence of heart failure
Excessive vomiting Unilateral or fixed wheeze
Dysphagia Stridor
Abnormality of the voice/cry Persistent chest pain
Failure to thrive Productive cough
Focal signs in the chest Weight loss
Finger clubbing Non-resolving pneumonia
Finger clubbing
Asthma therapy is designed to address the pathophysiological There are five inhaled corticosteroids currently available for asthma
entities of airway inflammation and constriction. To reduce therapy in the UK: beclometasone, budesonide, fluticasone,
inflammation, the cornerstone of therapy is with a topical mometasone and ciclesonide. Fluticasone and mometasone are, as a
corticosteroid. This is referred to as ‘controller’ therapy to help rule of thumb, clinically twice as potent as beclometasone and
patients understand that they must take it regularly, even when budesonide. With ciclesonide, 160µg once daily (the standard licensed
asymptomatic. Inappropriate bronchospasm is treated with short- and dose) is probably at least as effective as beclometasone 400µg daily in
long-acting β-agonists (‘relievers’). divided dosages. At dosages of up to 800µg per day in adults and
400µg per day in children (beclometasone equivalent), inhaled
The management of asthma in adults and children is summarised in corticosteroids are extremely safe. The only commonly encountered
Table 2. Although this ‘stepwise’ approach implies tailoring treatment problems are oral thrush and hoarseness. From the point of view of
to symptoms, in practice patients are often over-treated initially to win efficacy (but not necessarily patient preference or suitability), there is
their confidence. After this, it is important to consider ‘stepping little to choose between them. Ciclesonide is activated only in the
down’: the BTS/SIGN guidelines suggest reduction of inhaled respiratory tract and may be helpful for patients with oropharyngeal
corticosteroid by 25–50% every three months (or moving to a lower side effects. Where higher dosages of inhaled corticosteroid are
therapy ‘step’) if symptoms remain controlled. necessary at step three and above, the lower bioavailability and higher
topical potency of fluticasone, mometasone and ciclesonide may offer
In patients at steps one to three, perfect control of asthma (absence a more favourable risk–benefit ratio.
of symptoms day and night, no or minimal need for extra reliever
medication, no exacerbations, no limitations on activities and normal The early addition of a regular long-acting β-agonist (salmeterol
lung function [FEV
1
or PEF >80% of the predicted value with <20% or formoterol) to existing corticosteroid therapy reduces the need to
variability]) is feasible. In patients with symptoms despite maximal increase this therapy and also results in fewer symptoms
step three therapy, perfect control is not always a realistic aim, and and disease exacerbations.
2,3
Consequently, for patients insufficiently
management becomes a question of balancing the requirements of a controlled at step two, the best course at step three is to add in a long-
reasonable quality of life against the risks of high-dose corticosteroids acting β-agonist before raising the inhaled corticosteroid dosage
and other medication. In the UK, approximately 85% of patients have above the safe threshold. Inhalers are available combining a fixed
mild disease controllable at steps one to three and are managed dosage of long-acting β-agonist with variable dosages of
largely in the community. The remainder (steps four to five) typically corticosteroid for this purpose. These preparations are convenient and
require specialist surveillance. may encourage compliance, and also ensure that a long-acting
β-agonist is never taken without a corticosteroid. A disadvantage is
Steps One to Three that inhaled corticosteroid dosages cannot be increased without an
Patients with mild intermittent symptoms may take a short-acting extra prescription. Alternatively, budesonide/formoterol combinations
β-agonist when required. Regular inhaled corticosteroids should be are licensed in some countries for additional ‘as required’ use for
considered in patients using β-agonist three times weekly or more, disease exacerbation, but this requires careful patient education and
waking with symptoms one night weekly or having had an caution to prevent over-usage.
4
Before adding on any therapy at step
exacerbation of asthma in the past two years. Abnormal spirometry is three or subsequently, compliance, inhaler technique and exposure to
also an indication, but not an absolute requirement. trigger factors should be reviewed.
EUROPEAN RESPIRATORY DISEASE 21
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