Comorbid Conditions
Asthma management should also address comorbid conditions, including gastroesophageal reflux disease (GERD), allergic rhinosinusitis, obesity, and obstructive sleep apnea (OSA). Gastroesophageal reflux disease is common in asthmatics, and treatment may reduce exacerbations and symptoms, particularly in severe asthma. 15 Allergic rhinitis/sinusitis is also common, and treatment may improve respiratory symptoms. Obesity is associated with an increased risk of developing asthma and may be associated with increased asthma severity. 16 Patients with asthma and comorbid OSA should be encouraged to use continuous positive airway pressure (CPAP) with regular compliance (> 4 hours per night on > 70% of nights). 17 Optimally, the goal for CPAP use should be 7 to 8 hours per night. Finally, patients with asthma are at higher risk for depression and other behavioral disorders, which may lead to poor compliance with therapy, adversely impacting disease severity and efficacy of medical care. 18
Triggers
The avoidance of triggers may reduce the need for controller medications. Inhaled allergens or irritants (tobacco or wood smoke) may be suggested by a history of worsening at home or in the workplace (or during the work week). 9 Allergy testing may be considered for identification of allergens— particularly indoor allergens such as dust mites, animal dander, molds, mice, and cockroaches. Nonselective beta blockers, aspirin, nonsteroidal anti-inflammatory drugs, or dietary sulfites may produce significant exacerbations in some patients with asthma. Administration of the flu vaccine is indicated in all asthma patients, and pneumococcal vaccination is indicated in all adult patients requiring controller medication due to significant risk of complications with pneumococcal infection or influenza. 4
Patient Education
Patient education is an integral part of asthma management. Patients should be educated on roles of medications, appropriate technique for using a metered dose inhaler and spacer, self-monitoring of disease, identification of triggers and environmental control measures, and a plan for care during exacerbations. Patient education programs have been shown to be effective in reducing hospitalizations. 19 Use of valved holding chambers is preferred. 4 Investigation and education into the role of allergens in the patient’s disease is recommended. However, there is insufficient evidence to advocate a single specific avoidance strategy. Comprehensive, as opposed to limited, strategies are recommended. Immunotherapy is effective for patients with persistent asthma and identified inhaled allergen sensitivities. 4 All patients should be queried about smoking history and advised strongly to quit smoking.
Pharmacotherapy
Medications used for asthma primarily include inhaled bronchodilators and ICS when controller therapy is required. Short-acting beta agonists should be used for quick relief of symptoms and can be used preemptively for triggers. The frequency of SABA use should be queried to assess control. In addition, patients should be instructed to seek medical attention should a SABA fail to achieve a quick and sustained response. Inhaled corticosteroids should be used as a first-line treatment to control persistent asthma with initial dosing based on severity. Long-acting beta agonists are the preferred add-on to ICS therapy for patients whose symptoms are not controlled with an ICS. Long-acting beta agonists should not be used for acute symptoms or without an ICS, regardless of asthma stage. They carry an FDA boxed warning regarding increased risk of severe asthma exacerbations and asthma-related deaths. 20