Management Stages

What are the stages of asthma management? Asthma management can also be broadly divided into five stages. These stages have been discussed below: Assess severity of asthma: Your doctor will assess the severity of asthma after the acute attack has been controlled. The severity of asthma is classified as mild intermittent, mild persistent, moderate persistent and severe persistent.

Mild intermittent: Features of mild intermittent asthma include:

• Symptoms occur irregularly, less than twice a week.
• Exacerbation of asthmatic symptoms last for few hours to few days and are of varying intensity.
• Night-time symptoms occur less than twice a month
• Lung function tests are normal between two episodes of asthma.
• Forced expiratory volume is more than eighty per cent.
• Forced expiratory volume is the measurement of the amount of air forced out from your lungs in one second.
Mild persistent: Features of mild persistent asthma includes:
• Symptoms occur at least once a week.
• Exacerbations of symptoms adversely affect normal activity and sleep.
• Night-time symptoms occur more than twice a month.
• Forced expiratory volume is greater than eighty per cent but may vary by less than twenty per cent.

Moderate persistent: Asthma is said to be moderate persistent if:
• Symptoms occur daily.
• Exacerbation disrupts normal activity and may last for a few days.
• Night-time symptoms occur more than once a week.
• Forced expiratory volume is between sixty to eighty per cent.
Severe persistent: Asthma is said to be severe persistent if there are continuous symptoms, frequent exacerbations and night-time symptoms or the forced expiratory volume is less than sixty per cent but may vary by thirty per cent. Achieve best lung function: Meter assessing the severity of asthma, your doctor win treat you intensively with asthma medicines so that your symptoms are controlled and you achieve the best lung function depending upon your age and other factors. Once the best lung function is achieved, medicines are reduced to the lowest dose that can control symptoms and also maintain best lung function.

The first goal is to reverse inflammation and obstruction of the airways as much as possible. If the spirometry detects that your forced expiratory volume is less than eighty per cent of the predicted value or your initial reading improves by more than fifteen minutes after taking bronchodilators, your doctor will recommend intensive therapy to reduce inflammation and obstruction of the airways. Spirometry is a simple machine that is used to measure lung functions.

The choice of medicines for achieving the best lung function depends upon its severity. Detailed below is the step wise approach to medical management of asthma.

Step 1 - Occasional use of inhaled short-acting beta2 agonists: In case of very mild asthma, your doctor is likely to recommend short-acting bronchodilators such as Salbutamol or terbutaline. These medicines are normally used as inhalers to relieve minor symptoms. Beta2 agonists alone are prescribed when its occasional use allows you to lead an active and normal life and you do not suffer from symptoms at night or after exercise. In case you need to use beta2 agonists inhalers more than once a day or three times a week, the treatment regimen will be as for step 2 of asthma management.

Step 2 - Regular use of inhaled steroids: Medicines recommended for this stage of asthma includes inhalation of short-acting beta2 agonists whenever necessary and inhaled steroidal anti ¬inflammatory medicines. These could be either beclomethasone or budesonide or fluticasone. The normal adult dose is about eight hundred micrograms per day. In case of children, sodium chromoglycate or nedochromil sodium may be used instead of inhaled steroids.

Step 3 - High dose of inhaled steroids: Medicines recommended in this stage of asthma severity include inhaled short acting beta2 agonists as required plus an inhaled steroid in a higher dose. The dose of inhaled steroid is normally in the range of eight hundred to two thousand micrograms per day for an adult. In case you need to inhale large doses of steroids through a metered dose inhaler, it is desirable that you use a large volume spacer, which has a hold chamber. In case you use dry powder inhalers, it is desirable that you rinse your mouth after every inhaler treatment in order to avoid candidiasis in the mouth or throat.

Step 4 - High dose of inhaled steroids and regular use of bronchodilators: Treatment of severe asthma involves inhalation of short-acting beta2 agonists as required, plus a high dose of inhaled steroids, plus regular use of bronchodilators.

Since there are several types of bronchodilators, and each of them act differently, your doctor is likely to try and manage your asthma with one or more of the following medicines:

• Inhaled long-acting beta2 agonists such as salmeterol or formoterol. Sustained release theophylline. Inhaled ipratropium bromide or oxitropium bromide
• Long-acting oral beta2 agonist such as sustained release salbutamol or terbutaline preparations
• High dose of inhaled bronchodilators. Sodium chromoglycate or nedochromil sodium
Step 5 - Addition of oral steroids: Treatment of very severe asthma includes (a) inhaled short-acting beta2 agonists as required, (b) inhaled steroid in a high dose of about eight hundred to two thousand micrograms per day, (c) one or more of the long acting bronchodilators and (d) oral steroids such as prednisolone. The dose of oral steroids is maintained at the minimum that is able to control asthmatic symptoms.

Maintain best lung function by avoiding asthma triggers: Once medicines have helped control symptoms of asthma and achieve best lung function, it is important that you identify and then avoid exposure to factors that trigger your asthmatic symptoms. Measures to prevent exposure to various asthma triggers have been described in detail in the section on control of environmental factors.
Maintain best lung function with minimum medicines: After your symptoms are controlled, and you have been stable for about three to six months, your doctor will reduce the medication and will decide if your asthma is in control with the help of the following:
• You have no or minimal symptoms.
• You need to take reliever medicines less than three times a week.
• There are no night-time or early morning symptoms.
• There are no or minimal side effects of asthma medicines.
• Your lung function tests are normal, or as close to normal as possible.
Develop an action plan: Since asthmatic symptoms are not constant, it is important that you learn to recognize the deterioration in your symptoms at the earliest and initiate appropriate treatment measures immediately. Preparation of an action plan will help you decide when to increase the dose of preventive medicines and when to seek your doctor’s support.

If your asthma worsens, you may have one or more of the following:
• Increased frequency and severity of symptoms, especially at night.
• Need for increasing the dose of bronchodilators very frequently.
• Bronchodilators fail to relieve the symptoms completely.
• Worsening peak flow.
Normally an action plan for asthma management is based on peak flow measurements. It is desirable that you keep a peak flow meter at home and measure its readings regularly. This is an inexpensive and simple device that can go a long way in helping you manage your asthma more effectively.

General guidelines for modifying asthmatic symptoms based on peak flow are as follows:

• You need to continue the usual treatment if the peak flow reading is more than eighty per cent of your best reading and there is no change in symptoms.
• You need to start taking preventive medicines or double their dose if the peak flow reading is sixty to eighty per cent of your best reading and the symptoms either increase or you begin to develop upper respiratory tract infection.
• You need to start oral steroids and consult your doctor immediately if the peak flow reading is four to sixty per cent of your best reading. At this stage you are likely to wake up in the middle of the night because of troublesome symptoms or need to use bronchodilators every three to four hours.
• If your peak flow reading is less than forty per cent of your best reading, and bronchodilators are not able to relieve symptoms, you need to seek medical help immediately.
• Asthma action plan should also include measures to prevent exposure to asthma triggers and a schedule for periodic review by your doctor.