When addressing cases of asthma, management should be focused on bringing the disease under control safely and efficiently while using the least amount of medication as possible in order to reduce the risk of adverse effects. The stepwise approach to management dictates that medications should be increased only when necessary and decreased when possible.
Asthma is a heterogeneous disorder and is expressed in different ways, primarily based on recent activity and therapy. Long term treatments should be aimed at reducing inflammation throughout the airways and prevention of exacerbations. Stepwise decisions should be made for these goals and lessened drug use (Foggs, 2008).
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Stepwise management of asthma is used to reduce impairment by preventing chronic and troublesome symptoms such as coughing. It is also is aimed at needing quick relief drugs infrequently, generally less than twice a week. Reduced impairment by asthma is also indicated by near normal pulmonary function, maintained normal activity levels and patient and familial satisfaction in the care. Another goal is reduced the risk. Management should also reduce the exacerbations which in turn minimize the need for emergency visits and hospital stays. Reduction of risk prevents progressive loss of function. Pharmacotherapy should produce little to no adverse effects (National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma, 2007).
When asthma is diagnosed, it is also classified based on its severity. When considering this severity the doctor reviews the patient’s symptoms, frequency of use of short-acting beta2 agonist (SABA), the results of spirometry and forced expiratory volume in 1 second/forced vital capacity, quantity of nighttime awakenings, and the degree to which daily activity is limited. This level of severity is used to find where to start treatments along the stepwise approach (Holt, 2009).
The stepwise approach begins with intermittent asthma, which is step 1. This step should be treated with SABA when necessary. Steps 2 through 6 are indicative of persistent asthma and should be treated with daily medication as well as subcutaneous allergen immunotherapy for people with an allergic asthma condition. Step 2 should be addressed with a low-dose inhaled corticosteroid (ICS.) Alternative treatments for step 2 is Cromolyn, a leukotriene receptor antagonist (LTRA,) Nedocromil, or Theophylline. The preferred treatment for Step 3 is the use of a low-dose ICS and long-acting inhaled beta-agonist (LABA) or a medium-dose ICS. Alternatives include a low-dose ICS and either LTRA, Theophylline or Zileuton. At step 4 or higher an asthma specialist should be consulted. Step 4 should be treated with a medium-dose ICS and LABA. It can also be treated with a medium-dose ICS and either LTRA, Theophylline or Zileuton. Step 5 should be dealt with with a high-dose ICS and LABA or patients with allergies should be considered appropriate for Omalizumab. Step 6, the highest of all severities of asthma should be treated with a high-dose of ICS, LABA, and an oral corticosteroid. Again, Omalizumab should be considered for allergy patients. Patient education, environmental control, and management of comorbidities should be included in all the steps as well (National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma, 2007).
After a treatment has been selected, it should be evaluated two to six weeks later. This provides an opportunity to change the level at which the disease is progressing and can allow for a “step up” or a “step down” in the approach. For example, if a patient’s asthma is found to not well controlled verify the step they are on based on what medications are being taken. Patients with asthma that is not well-controlled move up one step. For those that have very poorly controlled asthma, consider moving up two phases, adding a course of oral corticosteroids or both. Before increasing pharmacologic therapy, consider poor medication use technique, adverse environmental exposures, poor compliance, or comorbidities as targets for intervention (National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma, 2007).
Regular follow-up screening is essential to continue to move the patient up and down the stepwise scale for asthma. Contact should be initiated at 1 to 6-month intervals depending on the level of control and need for improvement. Three-month intervals should be utilized if a step down is expected. Monitoring and reviewing the action plan, the patient’s self-management techniques, and the medications is necessary for monitoring. Step down can be considered after a three month time of adequate care (National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma, 2007).
If the control is not achieved at any step of the approach, then several different actions can be considered to rectify the problem. Patient adherence and compliance should be assessed. A brief increase in anti-inflammatory therapy may be used to reestablish control of the asthma. Identify and address other factors which have affected the decline. A temporary step up may be required. An asthma specialist may need to be consulted (National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma, 2007).
In an effort to appropriately treat asthma patients to increase results yet reduce the amount of medications used the stepwise management approach is utilized. The approach breaks down the severity of the disease and the best methods to use for each level and works towards reducing the amount of drugs that someone needs to take to lessen his risks and side effects.
