Asthma Management Guidelines
I
Benjamin D. Francisco, PhD, PNP, AE-C Professor, Pulmonary Medicine & Allergy University of Missouri School of Medicine, Department of Child Health
12
n December of 2020, the National Heart, Lung and Blood Institute published updates to 2007 Expert Panel Report 3 (EPR-3) asthma guidelines (https://www.nhlbi.nih.gov/health-topics/ guidelines-for-diagnosis-management-of-asthma). Rather than issuing an entirely new set of guidelines, the committee identified six topics for which new evidence warranted critical reviews. Updated topics include: 1) use inhaled corticosteroids for intermittent or worsening asthma symptoms; 2) sublingual and subcutaneous immunotherapy; 3) modification of indoor trigger exposure; 4) longacting muscarinic antagonists; 5) use of fractional exhaled nitric oxide (FeNO) in asthma management; and 6) bronchial thermoplasty. The greatest change comes in revised therapy steps for the treatment of asthma. For ready access to documents that will be useful in your practice go to: https://www.nhlbi.nih.gov/health-topics/ asthma-management-guidelines-2020-updates/
MISSOURI FAMILY PHYSICIAN April - June 2021
digital-toolkit. The “Clinician’s Guide” is a readable 16 page synopsis of the 19 recommendations contained in the 2020 Updates, including the new therapy steps. “At-a Glance” guide only includes tables with annotations for the 6 therapy steps by age group (0-4, 5-11, 12 and older). You will probably want to print this document for quick reference when prescribing. Another useful resource found at the digital toolkit URL above is a set of fact sheets that summarize the 2020 Updates in language patients and staff will be able to understand. A brief overview of the 2020 Updates is discussed below in order of topics most likely to redefine best asthma practices. Italicized text indicates a direct quote from the 2020 Updates. One of the most debated aspects of asthma care is when and how to use inhaled corticosteroids (ICS). Advocates for intermittent ICS use have previously lacked support from expert guidelines. A related polarizing discussion has been the effectiveness of increasing ICS dose when asthma is not controlled. The 2020 Updates recommend intermittent ICS use for two age groups, 0-4 years and 12 years and older, under specific conditions. • In children ages 0-4 years with recurrent wheezing, a short (7-10 day) course of daily inhaled corticosteroids along with an as-needed short-acting bronchodilator (such as albuterol sulfate) is recommended at the start of a respiratory tract infection (conditional recommendation, high certainty of evidence). • People ages 12 and older with mild persistent asthma may benefit from inhaled corticosteroids with a short-acting bronchodilator for quick relief. Treatment may include inhaled corticosteroids daily or as needed when asthma gets worse (conditional recommendation, moderate certainly of evidence). Stepping up ICS dose during times when symptoms are present (loss of control) is recommended for ages 4 and older with moderate to severe asthma only when an ICS/formoterol inhaler is in use. • For people ages 4 and older with moderate to severe persistent asthma, the preferred treatment is a single inhaler that contains an inhaled corticosteroid and the bronchodilator formoterol. This should be used as both a daily asthma controller and quick-relief therapy (Strong recommendation, high certainty of evidence for individuals 12 years and older, moderate certainty of evidence for individuals 4-11 years)
