Asthma exacerbations - Self management

Question 1

What are exacerbations characterized by?

Answer 1

Exacerbations are characterized by progressively increasing shortness of breath, cough, wheezing or chest tightness, and decreasing lung function. In children, the onset is usually fast, but can develop over a week or more in adults.

Question 2

What is the typical self management strategy in general, when should patients reassess, and follow up with doctor after an exacerbation?

Answer 2

Self-Management of an exacerbation (i.e. not too sick that they need a hospital), use an action plan. Tell them to reassess after 48 hours and if things are worse seek medical attention. Regardless of how bad the exacerbation was, they should check in with their doctor within 1-2 weeks of starting their action plan. Remember, work with their doctor to find out why the exacerbations occurred. If they keep having them without any explainable reason, they will need to change therapy.

Question 3

What is the action plan for children <12 years if:
1. They are only on SABA
2. If they are on ICS, LTRA or ICS/LABA
3. SHOULD <6 years be on ICS/LABA

Answer 3

Not on maintenance therapy, increase use of SABA and consider starting regular controller therapy.
If they are on an ICS, LTRA, or ICS/LABA increase use of reliever and in those with a severe history of severe exacerbation in the last year or no relief from a SABA, consider prednisone or prednisolone 1mg/kg X 3-5 days.

Of note preschoolers ≤ 6 should not be on an ICS/LABA.

Question 4

For adults 12 years and older what is the recommended management for exacerbations if:
1. They are not on regular therapy

2. They are already on Budesonide/Formoterol
3. If they are on daily ICS or LTRA and are 12-15 years
4. If they are on daily ICS or LTR and are >16 years
5. What would extra therapy be?
6. If the patient uses daily Bud/form and are >12, or >16 years old
7. If the patient is on daily ICS/LABA and:
   a. 12-15 years old
   b. >16 years (first choice, and second choice)
8. When are oral steroids likely only used?

Answer 4

1. If they are not on regularly therapy - increase use of SABA and consider starting controller therapy or PRN Bud/form
2. If they are already on budesonide/formoterol increase to a maximum of 8 inhalations per day
3. 12-15 years old on daily ICS or LTRA - If they are on daily ICS or LTRA those 12-15 years old do not step-up controller therapy and just use their SABA prn to provide relief
4. Extra therapy is only in those ≥16 with a history of severe exacerbation in the last year.
5. This extra therapy can be:
   1st choice: trial of ≥4 fold increase in ICS for 7 to 14 days
   2nd choice: prednisone 30-50 mg for at least 5 days
6. If the patient is on Bud/Form and are >12 - or use budesonide/formoterol as reliever and a controller (maximum 8 inhalations per day) in those ≥12 years of age and older.
   1st choice: increase budesonide/formoterol to a maximum of 4 inhalations twice daily for 7 to 14 days (≥16 years of age and older)
   2nd choice: prednisone 30-50 mg for at least 5 days
7. If they are on a daily ICS/LABA
   a. 12-15 - do not step-up controller therapy and just use their SABA prn to provide relief
   b. 16> with a history of a severe exacerbation in the last year:
   1st choice: trial of ≥4 fold increase in ICS (higher ICS strength of ICS/LABA combination or extra ICS) for 7 to 14 days.
   2nd choice: prednisone 30-50 mg for at least 5 days
8. Oral steroids are probably only used when in children or adults when they have had recent severe exacerbations who fail to respond to inhaled SABA as part of their written action plan. Those who seem to need steroids a lot if not already should be referred to a specialist.