In the third part of severe asthma we explore strategies for the management and treatment of the condition.
Since asthma is a dynamic condition with frequent changes in disease status, it’s important to recognize when the disease should be identified and classified as severe asthma. This can actually be a bit challenging.
There is actually some disagreement among the organizations that set the guidelines for classification. The National Education and Prevention Program (NAEPP) and the Global Initiative for Asthma (GINA) describe severe asthma as a patient who has frequent and severe attacks of asthma but is not on high doses of controller medications. The American Thoracic Society (ATS) and the European Thoracic Society (ETS) require that the status of severe asthma be present in spite of being on high doses of controller medications.
When severe asthma is diagnosed, it is considered a serious health situation and the treatment requires more than just maximizing (current) medications.
First, patients need to establish with their physician a plan of preparedness for the possible emergency situation of severe asthma, when it’s not safe to remain at home because a higher grade of treatment is necessary. The patient must be empowered with the knowledge of when it is appropriate to go to the emergency room quickly and not waste time. That plan should include the time necessary to reach the facility that is familiar with the patient and where the treating doctor is on staff and can be reached to come in and administer treatment, or direct the therapeutic intervention by phone or other means. Having your doctor looped in is a best scenario for outcomes.
A facility that is familiar with this patient means the right modalities of treatment can be started without delay, individualized to the needs of the patient. Treatments may include intravenous magnesium sulfate which instigates smooth muscle relaxation to open up the airways effectively. The close observation that takes place in the emergency room can help to assess whether or when the patient is getting tired in the effort of breathing, which can lead to a dangerous and fast downward spiral and an even more serious health state. In this case, assistance in ventilation can be provided in a non-invasive form by positive pressure ventilation, and in worst case scenario, intubation and placement on the ventilator.
The prognosis for recovery in severe asthma, if weaning off the ventilator, is excellent so this treatment (though serious) should not be avoided if it’s necessary. The biggest danger lies in delay of treatment when these signs present - that is when terrible outcomes, including death, can occur.
Intravenous corticosteroids are often dispensed in high doses along with antibiotics if an infection is the trigger of severe asthma, and those two therapies combined will typically reverse the severe and sudden attack.
The transition from the acute attack to home care requires an individualized titration of steroids, usually over 10 to 12 days. The home management should also include education and avoidance of triggers and remediation of all possible irritants in the home environment.
Follow up should include more objective measures such as peak flow and spirometric measurements to assess progress and improvement of symptoms. There should also be an effort to quantize the (patient’s) subjective feelings of control using standard questionnaires such as the Asthma Control Questionnaire (ACQ) or Asthma Control Test (ACT). This will allow the treating physician to get a better sense of progress and help with identifying when the patient is truly out of danger.
Exhaled nitric oxide is one of the newer techniques that can be used to identify when an asthmatic has active airway inflammation even in the absence of symptoms. This can help to predict or identify when a patient may be moving to a more “severe” and acute state of disease.
All of these objective techniques are needed to prepare for the possible emergency state of severe asthma, since individuals may not be good judges of the progression or severity of their symptoms.
Typically when treating asthma, you monitor symptoms and add in treatment drugs as needed. Those medications can include inhaled corticosteroids (ICS), long-acting bronchodilators (LABA), and leukotriene modifiers. In the case of severe asthma you start full throttle with the full regimen of therapies and then deescalate the regimen as the patient improves.
If severe asthma persists, the next level of targeted medications are the biologicals which include Omazilumab, an anti-immunoglobulin E antibody and it’s indicated in patients who have elevated levels of antibody IgE between 300 and 800 UI/ml. If the patient has elevated eosinophils, a class of white blood cells (WBCs), treatment is (Interleukin) IL- 5 antagonist monoclonal antibody, Nucala.
For those severe cases where there is no response to either of these two treatment measures, there is a new technique called bronchial thermoplasty
It’s important to mention that when you are being treated for asthma, it’s also necessary to pay close attention to and manage co-morbidities that may be present since they can act as triggers and worsen asthma. Triggers include:
Allergic Rhinitis - Management includes avoidance of allergens and use of intranasal steroids. Surgery is sometimes necessary to remove polyps.
Gastro-esophageal reflux - If untreated this condition can cause slow, but persistent airway irritation that may go undetected for some time but which has the potential to instigate asthma severity.
Obstructive sleep apnea due to upper airway blockage has the potential to have an adverse effect during vulnerable moments for an asthmatic, causing more shallow breathing that also requires more effort.
Another condition, paradoxical vocal cord fold motion, when present with severe asthma, should be identified and treated by speech therapists. It too has the potential to contribute to severe asthma or to complicate the presentation.
The patient with severe asthma needs a multidisciplinary approach with close monitoring to limit acute exacerbations which will help to avoid serious health consequences.
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Eli Hendel, M.D., is a board-certified internist/pulmonary specialist with board certification in Sleep Medicine. An Assistant Clinical Professor of Medicine at Keck-University of Southern California School of Medicine, and Qualified Medical Examiner for the State of California Department of Industrial Relations, his areas include asthma, COPD, sleep disorders, obstructive sleep apnea, and occupational lung diseases. Favorite hobby? Playing jazz music. Find him on Twitter @Lung_doctor.