Asthma Management in Adults and Children PDF

Asthma Management in adults and children By: Dr Kim Watkins  WARNING This material has been reproduced and communicated to you by or on behalf of Curtin University in accordance with section 113P of the...

Asthma Management in adults and children By: Dr Kim Watkins  WARNING This material has been reproduced and communicated to you by or on behalf of Curtin University in accordance with section 113P of the Copyright Act 1968 (the Act) The material in this communication may be subject to copyright under the Act. Any further reproduction or communication of this material by you may be the subject of copyright protection under the Act. Do not remove this notice. Learning objectives n Ability to assess asthma n Recognition of the classification of asthma and measurement of asthma control n Understanding the aims and goals of asthma management n Appreciation of the guideline-based treatment of asthma for children and adults n Written asthma action plans n Guided self-management n The role of the pharmacist n Knowledge of the management of acute exacerbations of asthma n Understanding of the different types of inhalers and spacers Goals of managing asthma Desired patient outcomes n There is NO cure for asthma n Aim is to successfully manage asthma n Clinical control of asthma IS POSSIBLE for the majority of patients https://www.thelancet.com/pb- assets/Lancet/gbd/summaries/ diseases/asthma.pdf  Partnership care arrangement n Effective asthma management requires the development of a partnership between the person with asthma and their health care providers n Partnership leads to knowledge, confidence, ability to self-manage n Good communication is key n Outcomes are improved! n Self-management education reduces asthma morbidity in both adults and children Nigel Mathers, David Paynton Rhetoric and reality in n Shared decision making is person-centred care: introducing the House of Care framework. British Journal of General associated with improved Practice 2016; 66 (642): 1213. DOI: 10.3399/bjgp16X68 outcomes 3077 Where to start as a health professional Before offering treatment options and advice: n Find out what the person understands about their asthma (e.g. ask ‘Do you think you have asthma all the time or only when you have symptoms?’) n Check smoking status and asthma triggers, if known n Discuss the person’s goals for treatment n Gauge the person’s ability to self-manage. Long-term goals of asthma management n Clinical goals n Achieve good control of symptoms and maintain normal activity levels n Minimise the risk of asthma-related death, persistent airflow limitation and side-effects n Patient-centred goals n It is important to elicit the patient’s own goals regarding their asthma The variability of asthma requires ongoing clinical monitoring and treatment should be adjusted accordingly Guided self-management The key to success!  Effective self-management n Adherence to the agreed treatment regimen n Correct use of inhaler devices for asthma medicines n Monitoring asthma control (symptoms, with addition of peak expiratory flow for some patients) n Having an up-to-date written asthma action plan and following it when asthma worsens n Management of triggers or avoidance (if appropriate) n Regular medical review. Self-management – education, tools and resources Action Written asthma action plans n Every person with asthma should have and individualized written asthma action plan n Should be appropriate to n Treatment regimen (e.g., SMART) n Asthma severity n Culture n Language n Literacy level n Ability to self manage n Written asthma action plans allow patients to alter treatment in response to changes in asthma control Written asthma action plans n GPs develop and write plans - other health care professionals review and reinforce plans n Review plan every year and when there is a change in asthma treatment or status n Personalised written asthma action plans: n ↑ asthma control n ↓ in exacerbations n ↓ in hospitalisation, ED visits, emergency GP visits n ↓ in days off work or school n Australia has a low rate (~24%) of written asthma action plan ownership in people aged > 15 years Asthma action plan ownership by age https://www.aihw.gov.au/getmedia/3739946f-90c4-4299- 9144-3f50be030a46/Asthma.pdf.aspx?inline=true Self-management apps for iPhones n NAC’s Asthma Buddy n GSKMy Asthma n Can be useful but recommend with caution Self-management - Peak flow meters n Peak flow meters: n Measure the PEF and can assess variability in airflow obstruction (variation from best PEF) n Limited usefulness n Not used in diagnosis or in children < 7 yrs n PEF monitoring by patients at home useful: n When symptoms are intermittent n Patient unable to gauge asthma control based on symptoms n Diagnosis is uncertain n To monitor treatment response Assessment of asthma Asthma control and asthma severity Adult assessments Asthma control n The level of asthma control is the extent to which the features of asthma can be observed in the patient or have been reduced or removed by treatment n Asthma control is assessed in two domains: n Symptom control and n Future risk n Poor symptom control ↓ QOL and ↑ exacerbation risk n Even patients with few or no symptoms “mild asthma” can still have exacerbations n Patients can “get used to” living with poor asthma control Measuring asthma control Questionnaires/validated tools for use in primary care n Primary care asthma control screening tool (PACS) n Useful in pharmacy n Asthma Control Test (ACT) n Online tool available n Based on prior 4 weeks n Asthma Control Questionnaire (ACQ) n Good for researchers https://asthma.org.au/about- asthma/understanding- asthma/asthma-control-test/ Referral letter Date: Dear Re: Date of intervention: Discussed via phone: I have referred to you for review, following the identification of a potential issue concerning their care. Role of lung function testing in assessing asthma control n Lung function does not correlate strongly with asthma symptoms in adults and children n People may have few symptoms but poor lung function n Lung function is an important predictor of risk of exacerbations n Should be assessed at: n Diagnosis or start of treatment n After 3-6 months of preventer treatment to assess a person's best FEV1 n Every 1-2 years thereafter Assessing future exacerbation risk n Even if symptom control is good, you should assess the patient’s risk of future exacerbations n Risk factors for exacerbation, independent of symptom control include: n History of ≥ 1 exacerbation in previous year n Socioeconomic problems n Poor adherence n Incorrect inhaler technique n Low FEV1 n Smoking n Blood eosinophilia (>500 cells per microlitre) Good asthma control n The goal of asthma treatment is to achieve and maintain clinical control ü No daytime symptoms (twice or less/week) ü No limitations on daily activities (including exercise) ü No nocturnal symptoms or awakening from asthma ü No need for reliever treatment (twice or less/week) ü Normal or near normal lung function (PEF or FEV1) ü No exacerbations Reasons for poor asthma control Inhaler technique n Medication related issues Device-specific checklists Use these checklists to teach, check and/or confirm the way your patients use their inhalers. Assess patients’ inhaler technique at every opportunity. Preventer dose too low Pressurised metered-dose pMDI & spacer pMDI & spacer Accuhaler Aerolizer Autohaler n inhaler (pMDI) (single breath) (tidal breathing)** n Incorrect device technique 1. Remove cap 2. Check dose counter 1. Assemble spacer* (if necessary) 1. Assemble spacer* (if necessary) 1. Check dose counter 2. Open cover using thumb grip 1. Remove cap 2. Hold base and twist 1. Remove cap 2. Hold inhaler upright and (if applicable) 2. Remove inhaler cap 2. Remove inhaler cap 3. Hold horizontally, load dose mouthpiece to open shake well Poor adherence to preventer 3. Hold inhaler upright and 3. Check dose counter 3. Check dose counter by sliding lever until it clicks (follow arrows) 3. Push lever up n shake well (if applicable) (if applicable) 4. Breathe out gently, away 3. Remove capsule from blister 4. Breathe out gently, away 4. Breathe out gently, away 4. Hold inhaler upright and 4. Hold inhaler upright and from the inhaler and place in chamber from the inhaler from the inhaler shake well shake well 5. Place mouthpiece in mouth 4. Close mouthpiece 5. Put mouthpiece between 5. Put mouthpiece between 5. Insert inhaler upright 5. Insert inhaler upright and close lips to form a good 5. Press side buttons in teeth without biting and teeth without biting and into spacer into spacer seal, keep inhaler horizontal together once and release close lips to form good seal Over-reliance on reliever close lips to form good seal 6. Put mouthpiece between 6. Put mouthpiece between 6. Breathe in steadily 6. Breathe out gently, away 6. Breathe in slowly and deeply. 6. Breathe in slowly through teeth without biting and teeth without biting and and deeply from the inhaler Keep breathing in after n mouth and, at the same time, press down firmly on canister 7. Keep breathing in slowly close lips to form good seal 7. Breathe out gently, into the spacer close lips to form good seal 7. Breathe out gently, into the spacer 7. Hold breath for about 5 seconds or as long as comfortable 7. Place mouthpiece in mouth and close lips to form a good seal, keep inhaler horizontal hearing click 7. Hold breath for about 5 seconds or as long as comfortable 8. Hold spacer level and press 8. Hold spacer level and 8. While holding breath, 8. Breathe in quickly and deeply down firmly on inhaler press down firmly on inhaler remove inhaler from mouth and deeply 8. While holding breath, Medication interaction 8. Hold breath for about canister once canister once 9. Breathe out gently, away 9. Hold breath for about 5 remove inhaler from mouth n 5 seconds or as long as 9. Breathe in slowly and deeply 9. Breathe in and out normally from the inhaler seconds or as long 9. Breathe out gently, away comfortable for 3 or 4 breaths as comfortable from the inhaler 10. Hold breath for about 5 10. If an extra dose is prescribed¶ 9. While holding breath, seconds or as long 10. Remove spacer from mouth repeat steps 3 to 9 10. While holding breath, 10. Push lever down remove inhaler from mouth as comfortable remove inhaler from mouth 11. Breathe out gently 11. Close cover to click shut 11. If an extra dose is needed, 10. Breathe out gently, away 11. While holding breath, 11. Breathe out gently repeat steps 2 to 10 12. Remove inhaler from spacer from the inhaler remove spacer from mouth 13. If an extra dose is needed, 12. Open mouthpiece to check 12. Replace cap 11. If an extra dose is needed, 12. Breathe out gently if capsule is empty repeat steps 3 to 12 repeat steps 2 to 10 13. Remove inhaler from spacer 14. Replace cap and 13. If powder remains repeat 12. Replace cap steps 6 to 11 Uncontrolled trigger exposure 14. If an extra dose is needed, disassemble spacer repeat steps 3 to 13 14. Open mouthpiece and n 15. Replace cap and remove capsule disassemble spacer 15. Close mouthpiece and cap * New plastic spacers should be prewashed in warm water and dishwashing detergent (without rinsing), and air-dried before first use. ** Tidal breathing can be used for young children or during acute flare-ups. ¶ Not generally recommended n Comorbidities and complicating n Limited knowledge of conditions asthma and poor ability to self-manage n No asthma action plan or regular medical review n Diagnostic issues Asthma severity n Assessed retrospectively (after 2 to 3 months of treatment) n The level of treatment required to control symptoms and exacerbations n It is important to distinguish between severe asthma and asthma that is uncontrolled (e.g., due to incorrect inhaler technique and/or poor medication adherence) n Mild (treatment at Step 1 or 2) , Moderate (Step 3 or 4) or Severe (uncontrolled despite high dose treatments) n Severe asthma (as per GINA) n “Asthma that is uncontrolled despite high dose ICS-long acting beta2 agonist (LABA) or that requires high-dose ICS-LABA to remain controlled." Definitions of ICS dose levels in adults https://www.asthmahandbook.org.au/management/adults/severe-asthma/identifying Asthma management in adults Choosing and adjusting treatments  Initial treatment choices n Australian guidelines Clinical profile before treatment Suggested initial treatment Alternative option Symptoms less than twice per month and Consider SABA as needed As-needed low- NONE of: (N.B. It is RARE for patients to meet this criteria dose Waking due to asthma and start with this treatment) budesonide– Flare-up that required oral formoterol corticosteroids within previous 12 months Other risk factor for severe flare-ups The risk of severe flare-ups ANY of: Regularis higher daily indose) ICS (low patients: plus as-needed SABA Montelukast Ø Using Symptoms twice as-needed per month or more SABAsorin the absence of ICSs plus as- Waking due to asthma As-needed low-dose budesonide–formoterol needed SABA Ø With Flare-up poor oral that required adherence to ICSs Ø Patients corticosteroids withinwho are12dispensed three or more canisters of SABAs in a year previous months History (regardless of ICS of artificial ventilation or treatment) admission to an intensive care unit due to acute asthma* The Other risk risk factor of asthma-related for severe flare-ups. death is markedly increased among patients dispensed 11 or more canisters of SABAs in a year. n As-needed low-dose budesonide–formoterol is new to asthma guidelines Warn patients of these risks and document this discussion in the patient’s n notes. New recommendation is based on concerns about down-regulation of beta-2 receptors with SABAs alone leading to asthma flares Initial treatment choices n Australian guidelines Clinical profile before treatment Suggested initial treatment Alternative option Frequent daytime symptoms (e.g., Medium- to high-dose ICS plus as-needed SABA most days, or waking due to asthma (down-titrate when symptoms improve) once a week or more) or Regular daily maintenance low-dose ICS–LABA plus as- needed SABA or Low-dose ICS–formoterol maintenance-and-reliever therapy Severely uncontrolled High-dose ICS plus as-needed SABA (e.g., symptoms most days, frequent (down-titrate ICS when symptoms improve) waking due to asthma, poor lung or function) Regular daily maintenance ICS–LABA plus as- needed SABA or ICS–formoterol maintenance-and-reliever therapy n Review response of initiated treatments within 4–8 weeks and adjust, as necessary. n Where possible, avoid prescribing LABAs in single-agent inhalers separate from ICSs, to prevent patients using a LABA alone.  Initial treatment choice n GINA guidelines https://ginasthma.org/wp-content/uploads/2021/05/Whats-new-in-GINA-2021_final_V2.pdf  On-going management n The variable nature of asthma requires patients to continually monitor and adjust their treatment as necessary with the help of their clinician. https://ginasthma.org/wp-content/uploads/2021/05/Whats-new-in- GINA-2021_final_V2.pdf  n Australian guidelines Stepped management https://d30b7srod7pe7m.cloudfront.net/uploads/Figure_Selecting- and-adjusting-medication-for-adults-and-adolescents_web.pdf Stepped management n GINA guidelines https://ginasthma.org/wp-content/uploads/2021/05/Whats- new-in-GINA-2021_final_V2.pdf Key differences between guidelines n GINA has a stronger recommendation for using low-dose ICS- formoterol as the reliever option in asthma management n The Australian Asthma Handbook has taken a more conservative approach in recommending that either reliever option is appropriate n The key is to ensure that patients are not over-using SABAs and are compliant with ICS! n The situation might change is ICS-formoterol becomes available OTC in Australia n AstraZeneca which markets Symbicort® (budesonide-formoterol) is currently in the process of trying to license this product in Australia for OTC use. When to step-up treatment n Before considering any n Step-up option is appropriate dose increase (step-up) n Poor asthma control assess current asthma n Using prn SABA more than control and risk factors. twice per month (Step 1) and Carefully check: not using maintenance ICS – n Adherence even if control is scored as n Inhaler technique being good n Exposure to triggers n High risk of flare-up n Possibility that symptoms are due to comorbid or alternative diagnoses n May initiate treatment or step-up to manage predictable seasonal patterns of asthma When to step-down treatment n Before stepping down When stepping down, make n Find out how patient is using their medication small dose adjustments n Assess current asthma control and risk factors gradually (e.g., reduce ICS by 25–50% at intervals of n Make sure the patient has a current written 2–3 months) by stepping asthma action plan down through the available doses. n Stepping down is considered when the patient has experienced good asthma control for 2–3 months and is at low risk of flare- ups. n Steps down should be planned before the patient has finished their current inhaler, so that the previous dose can be resumed immediately if asthma control deteriorates. n Review response to step-down after 4 to 8 weeks S.M.A.R.T. therapy n Symbicort Maintenance And Reliever Therapy (SMART) n Symbicort® (budesonide and formoterol) n Can be used as both maintenance and reliever medication due to rapid onset of action of formoterol § Specific SMART action plans are available § Symbicort® turbuhaler (100/6, 200/6) § Symbicort® rapihaler (50/3, 100/3) § Need to be careful of dose equivalence when switching devices Factors associated with increased risk of flare-ups n Poor asthma control n Any asthma flare in previous 12 months n Dispensing ≥3 canisters in a year n Another concurrent lung disease n Poor lung function n Peripheral blood eosinophilia n Difficulty perceiving airways limitation or severity of exacerbations n Exposure to cigarette smoke n Use of illegal substances n Socioeconomic disadvantage n Major psycho-social problems n Mental illness Factors associated with increased risk of life- threatening asthma n Intubation or ICU admission (ever) n Sensitivity to unavoidable n ≥2 hospitalisations for asthma in allergens past 12 months n Inadequate treatment n ≥3 ED visits in the past year n Experience of side-effects with OCSs n Hospitalisation or ED visit in past n Lack or written asthma action month plan n High use of SABAs n Socio-economic disadvantage n Dispensing ≥12 canisters in a year n Living alone/social isolation n History of delayed presentation to n Mental illness hospital during a flare-up n Use of alcohol or illegal n History of sudden-onset asthma substances n CVD n Poor access to healthcare (rural/remote) Managing worsening asthma/acute flares in adults n Oral corticosteroid (OCS) use is accepted as part of the management of severe asthma flares n NB severe asthma flare = needing reliever again within 3 hours, difficulty with normal activity n A 5 to 10 day course of 37.5 to 50mg prednisolone n Other strategies Overall evidence does not support use of ICS as a n Quadrupling maintenance dose of ICS substitute of OCCs during most flare-ups in adults n Treating with high dose ICS for 7-14 days (in addition to regular maintenance therapy) n SMART – patients can increase “as-needed” inhalations n 200/6 or 100/6 DPI up to max 12 actuations per day n 50/3 or 100/3 pMDI up to 24 actuations per day (totals include maintenance and reliever dosing) Community first aid protocol n Rule of 4’s n Sit the patient comfortably in an upright position n Give 4 puffs of salbutamol n Give each puff one at a time, with 4 breaths after each puff n Use a spacer if possible n Wait 4 minutes n Bricanyl®/Symbicort® n Give 2 doses initially, n If no improvement give 4 more puffs wait 4 minutes then give 1 more dose n If still no improvement call 000 immediately n If no improvement call 000 and continue to n Continue to give 4 puffs every 4 give 1 dose every 4 minutes until the ambulance arrives minutes Treatment of an acute severe attack n Hospitalisation/ED management n Oxygen therapy: Oxygen saturation (SpO2) above 95%. n Bronchodilator therapy: n SABA plus ipratropium bromide n Nebuliser driven by oxygen n Adrenaline: - For anaphylaxis or imminent cardiorespiratory n IV salbutamol arrest n Corticosteroids: Oral or IV n IV magnesium: If response is poor n Further management: Chest X-ray and arterial blood gases performed Assessment of asthma in children Asthma control  Validated tools to measure asthma control in children n Test for Respiratory and Asthma Control in Kids (TRACK) n Children < 5 years n Childhood Asthma Control Test (C-ACT) n 4-11 years https://eprovide.mapi- trust.org/instruments/childhood-asthma- control-test/online- distribution/39606/download https://getasthmahelp.o rg/documents/track.pdf  Asthma control in children – defined Good control Partial control Poor control All of the following: Any of the following: Either of the following: Ø Daytime symptoms ≤ 2 Ø Daytime symptoms > 2 Ø Daytime symptoms > 2 days per week (lasting only days per week (lasting only days per week (lasting from a few minutes and rapidly a few minutes and rapidly minutes to hours or controlled by rapid-acting controlled by rapid-acting recurring, and partially or bronchodilator) bronchodilator) fully relieved by SABA reliever) Ø No limitations on activities Ø Any limitations on activities Ø ≥ 3 features of partial control within the same Ø No symptoms at night or Ø Any symptoms at night or week when wakes up when wakes up Ø No need for SABA reliever Ø No need for SABA reliever (≤ 2 days per week) (> 2 days per week) n Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future adverse asthma outcomes should also be assessed and considered in management. Asthma management in children Choosing and adjusting treatments Initial treatment (1-5 years) n Reliever medication: n For all children with asthma or salbutamol-responsive preschool wheeze, prescribe a reliever n Administer via a spacer (+ face mask for children 1-2 years) n Advise to always carry reliever + spacer n Preventer medication: n Not recommended for children < 12 months except on specialist advice n Consider regular preventer treatment for children with frequent symptoms (at least once per week) or a history of severe flare-ups n ICS preferred if atopy or raised eosinophil count n Montelukast is an alternative when child refuses MDI + spacer/mask; child has significant allergic rhinitis or parents refuse ICS (compliance likely to be an issue) Stepped management Australian guidelines https://d30b7srod7pe7m. cloudfront.net/uploads/20 20/08/Figure_Stepped- approach-to-adjusting- asthma-medication-in- children-aged-1-5- years_web.pdf n Initial treatment (≥6 years) n Reliever medication: n All school-aged children with asthma need a reliever to use when they have asthma symptoms. n Preventer medication: n Indicated for children with: n Frequent intermittent asthma (flare-ups every 6 weeks or more often) n Persistent asthma symptoms (daytime asthma symptoms > once per week or night-time symptoms > twice per month) n Severe flare-ups (irrespective of frequency) n Flare-ups and symptoms between flare-ups n Also follow general principles of asthma management Stepped management Australian guidelines https://d30b7srod7pe7m. cloudfront.net/uploads/20 20/08/Figure_Stepped- approach-to-adjusting- asthma-medication-in- n children-aged-6-11- years_web.pdf When to step-up treatment in children ≥6 years n If asthma symptoms remain uncontrolled despite maximal regular preventer treatment: n Assess adherence n Check inhaler technique n Review the diagnosis n Potential actions for partial or no response to treatment n Check that the dose and regimen is appropriate 1. Montelukast Ø Stop montelukast and initiate ICS n Assess comorbidities (e.g., starting with low dose allergic rhinitis) 2. Low dose ICS n Check whether the child is exposed to environmental Ø Add montelukast to ICS OR triggers (e.g., allergens, Ø Increase dose of ICS OR cigarette smoke) Ø Switch to ICS/LABA When to step-down preventer treatment in children ≥6 years n Can be considered n If a child is on lowest dose of ICS n When asthma has been well- can stop altogether or switch to controlled for 6 months montelukast when stepping down n Depends on severity of previous symptoms n If child is on ICS/LABA can reduce ICS dose or switch to ICS only n Close monitoring is required due to increased risk of flare- n There is a lack of evidence which up when stepping down strategy is best and how to proceed n Monitor symptom control n Arrange for spirometry within 4 to 6 weeks n Do not step down at the beginning of the school year n Montelukast can be stopped abruptly Definitions of ICS dose levels in children https://www.asthmahandbook.org.au/management/children How to administer medications in children n To use inhaler devices correctly, parents and children need training in inhaler technique and in the care and cleaning of inhalers and spacers. n Children need careful supervision when taking their inhaled medicine n MDIs cannot be used in pre-schoolers without a spacer (+ mask when required) n DPIs not appropriate in pre-schoolers n In acute attacks MDI + spacer is more effective than a nebuliser n Best method for MDI + spacer is tidal breathing n Recommended one actuation followed by 4-6 breaths in and out Managing acute asthma flares in children (1-5 years) n Children 1-5 years n Non-emergency bronchodilator is 2-4 puffs salbutamol (100mcg/puff) n Acute asthma associated with increased work of breathing give 1mg/kg prednisolone (max 50mg) each morning for 3 days n Reassess maintenance therapy if OCSs are required to manage flare-ups n If child is not taking a regular preventer, do not initiate ICS to manage flare-ups (not for intermittent use) n Where children have intermittent symptoms that don’t indicate a regular preventer, can use a short course of montelukast for 7 days or until symptoms have resolved for 48 hours Managing acute asthma flares in children (≥6 years) n Children 6 years and older n Non-emergency bronchodilator is 2-4 puffs salbutamol (100mcg/puff) n Advise parent/carer to get medical advice if reliever is needed within 4 hours of a dose n Consider short course of oral prednisolone (1mg/kg per day) for a child needing SABA every 4 hours over a period of 24 hours n Reassess maintenance therapy if OCSs are required to manage flare-ups n Overall, current evidence does not support increasing the dose of ICSs as part of a self-initiated action plan to manage flare- ups in children younger than 12 years First aid protocol for children n Sit child upright n Stay calm n Reassure the child n Give 4 puffs of salbutamol n Give each breath one at a time, with 4-6 breaths after each puff n Use a spacer if possible n Wait 4 minutes n If no improvement give 4 more puffs n If still no improvement call 000 immediately n Continue to give 4 puffs every 4 minutes until the ambulance arrives Special cases of asthma management Exercise-induced broncho-constriction n Previously called exercise-induced asthma n Transient narrowing of the lower airways that follows vigorous exercise n A reduction in FEV1 of ≥10% (adults) and 13% (children) from the value measured before exercise n May occur in people with or without an asthma diagnosis n Often first symptom when asthma is poorly controlled n Recovery is usually spontaneous within 30 -90 minutes Everyone, including people with asthma should exercise Strategies to prevent exercise-induced bronchoconstriction n Warming up before exercise n Increasing fitness levels n Exercising in a warm humid environment n Avoiding environments with high levels of allergens n Breathing through the nose n No evidence for one form n Cooling down exercises of exercise over another n ???? (clinical trials with poor evidence) n Low-sodium diet n Fish oil supplementation n Ascorbic acid supplementation  Strategies to manage exercise- induced bronchoconstriction Situation Adults Children Involved in Consult Sports Integrity Consult Sports Integrity Australia competitive sport Australia https://www.sportintegrity.gov.au https://www.sportintegrity.gov.au Not using a regular Salbutamol 15 minutes before ≥ 6 years: salbutamol 15 minutes preventer exercise – NOT daily OR before exercise – NOT daily Budesonide-formoterol as reliever Not using a regular Consider daily treatment with (6-14 years) Consider regular preventer but and ICS (keep taking montelukast exercising most salbutamol before exercise Give montelukast intermittently before days until full the effect of inhaled exercise (at least 2 hours before or on corticosteroid has been the night before morning exercise). achieved – usually 2-4 weeks (≥ 15 years) Consider regular but can be up to 12 weeks). montelukast or adding low-dose ICS Already using Adjust dose as appropriate Consider adding regular montelukast inhaled preventer (trial omitting pre-exercise (ICS) salbutamol) Already using Consider using ICS alone Consider using ICS alone and regular ICS/LABA (higher dose may be potentially adding montelukast required) and potentially (monitor closely when stepping down adding montelukast from LABA) Guidelines in asthma PSA protocol for supply of SABAs (OTC reliever guidelines) n Guidelines for non- prescription provision of asthma relievers n Available from PSA website and in APF 24 n Consider professional obligations – Schedule 3 n Referral points n Poor asthma control/worsening control n Last medical review > 6 months n No written asthma action plan n Experiencing acute attack Australian guidelines https://www.asthmahandbook.org.au Global guidelines https://ginasthma.org Summary n Aim is to achieve good control of symptoms and maintain normal activity levels. n Partnerships and guided self-management are important in asthma. Key elements: n Asthma control is the key measure to determine if asthma is being effectively managed and to determine pharmacotherapy required n Poor inhaler technique is a frequent reason for poor asthma control and inhaler technique training should be provided to patients regularly. n Written asthma action plans can improve health outcomes for people with asthma and provide the necessary information for patients to appropriately adjust pharmacotherapy when required in response to symptoms or lung function n Guideline based care and appropriate use of medications could reduce the burden of asthma n International and national guidelines recommend stepped management of asthma based on asthma control n Very few patients should be managed on SABAs alone. n Patients can step up and down their treatment in response to asthma control and risk of exacerbations n SMART therapy uses a preventer/reliever combination as for both maintenance therapy and ‘when required” dosing n New addition to the guidelines in use of “when required” budesonide/formoterol for mild asthma n Asthma first aid involves the rule of 4s n Oral corticosteroids can be use to manage acute asthma flares n Exercise-induced bronchoconstriction can often be managed by salbutamol 15 minutes before exercise (this is not included in calculations related to asthma control References n Lung foundation website n Australia Asthma Handbook n Asthma WA website n GINA guidelines 2021 n National Asthma Council of Australia website n Walker & Wittlesea 5th Edition n AIHW website n AUS-DI online n Severe Asthma Toolkit website n Therapeutic Guidelines online (eTG) n AMH 2021 Online n Harrison’s Internal Medicine 20th Edition