For the first time since 2007, healthcare experts have updated national guidelines for diagnosing and treating asthma. This is a clear sign that there are changes in the field of this chronic lung condition that affects about 25 million Americans.
The 2020 updates are focused on selected topics rather than a complete revision of this vast field to focus on areas with more recent research.
“There has been a lot of new research in certain areas, like allergy triggers, in the past few years,” says Monica Raquel Cardenas, M.D., a pediatric pulmonologist with the University of Miami Health System. “So we now have data to individualize treatment for our patients with allergic asthma.”
The 2020 Focused Updates to the Asthma Management Guidelines, published in the Journal of Allergy and Clinical Immunology, aims to do just that by focusing on six areas. Also, by incorporating the progress in better understanding the causes of various types of asthma, the panel recognized that many different approaches could treat the condition and lessen the flare-ups in patients.
While Dr. Cardenas treats pediatric patients, she points out that asthma can present at any age. What’s more, “symptoms can be different from person to person,” she says. “It’s a disease that varies in presentation.” For example, wheezing is considered a telltale sign of asthma, but not every patient she sees displays this symptom.
Of the 25 million Americans with asthma, about 5.5 million are children. For them, environmental triggers or certain behaviors cause airways to inflame, resulting in bronchospasms that narrow airways. Typical symptoms include breathlessness, tightening of the chest, coughing, and wheezing. A flare-up can be scary — and deadly. About 3,500 people die of asthma every year. There is no cure, just prevention, and management.
Patients should work closely with a primary care physician, allergist, or pulmonologist to develop a prevention and treatment plan. In fact, the guidelines urge health care providers to recruit patients and their caregivers into the disease-management process.
“We always use a step-ladder approach,” Dr. Cardenas says.
“We start with the lowest dose [and the fewest medications] based on the severity of the symptoms. If that doesn’t work, we increase and add. When symptoms improve, we step down.”
A common type in children is allergic asthma, in which an environmental allergen triggers airway inflammation and the corresponding labored breathing. Such triggers can be animal dander, dust mites, pollen, air pollutants, tobacco smoke, even cockroaches.
“Asthma remains prevalent in urban areas,” Dr. Cardenas adds, “and we see it locally more in African-American and Hispanic populations. In Miami, it is common given the humid South Florida weather and the associated environmental triggers.”
A viral infection can also serve as a trigger and is the most common trigger in pediatric patients. Interestingly, the result of masking and physical distancing during COVID-19 has meant fewer asthma flare-ups as exposure to viral infections, such as the common cold or flu, has also decreased.
In addition to these triggers, some medications, such as aspirin or beta-blockers, can worsen airway inflammation, reactivity, and the resulting asthma symptoms. And in children, so can exercise, weather changes, and emotional triggers such as fear, anger, or excitement.
Here are a few of the new guidelines.
- For those whose asthma is triggered by identified indoor allergens, a variety of strategies — not a single one — is recommended. Use mattress and pillow covers that prevent dust mites from coming through, along with a high-efficiency particulate air (HEPA) filtration vacuum cleaner and air purifier to lessen symptoms and flare-ups. Also suggested: regular application of pesticides against dust mites, cockroaches, and rodents, removal of wall-to-wall carpeting and/or area rugs, and mold mitigation.
- For those children four years and older with persistent asthma, classified as moderate to severe, a single inhaler should be used for both daily management and quick-relief therapy as needed. This single inhaler should include an inhaled corticosteroid and a bronchodilator, such as formoterol. The corticosteroid will help control inflammation over time while the bronchodilator keeps airway muscles relaxed.
- The panel believes using one inhaler for both maintenance and rescue therapy — instead of two and sometimes even three — is less cumbersome and disruptive. Also, this has been found to be a more effective approach than the use of multiple inhalers. In this same age group, for individuals with mild to moderate persistent asthma who are already taking inhaled corticosteroids daily, increasing the dose for short periods is not recommended for asthma exacerbations.
- For patients who are at least 12 years old and with mild but persistent asthma, an inhaled corticosteroid should be paired with a short-acting bronchodilator for quick relief.
In children under 5, recurrent wheezing (at least three episodes triggered by infection over their lifetime or two episodes in the past year) can be treated with a short (7-10 day) course of daily inhaled corticosteroid together with a short-acting bronchodilator such as albuterol as needed at the start of a respiratory tract infection.
- Subcutaneous immunotherapy (SCIT) also is recommended for those whose asthma has worsened after exposure to a specific antigen or allergen. These repeated allergy injections are delivered at regular intervals and as a supplemental treatment. They should never be administered when the patient has asthma symptoms, however.
- Negative results on an allergy test shouldn’t be the only measure to determine a potential trigger, especially if a patient experiences worsening symptoms when exposed. In addition, the panel recommended measuring exhaled nitric oxide (FeNO) for patients five years and older to confirm the diagnosis and evaluate treatment. It is important to note that this test is recommended to support a diagnosis of asthma in conjunction with a complete history, physical exam, and spirometry testing (used to pulmonary function). A FeNO test will measure the amount of nitric oxide, a byproduct of inflammation in the exhaled breath.
In the end, teamwork between the patient and the medical team is essential. If a patient does not comply with his asthma regimen, no treatment plan or new therapy will be of much help.
“Medications aren’t effective if you don’t take them,” says Dr. Cardenas. “That’s why I think education is one of the biggest components of treatment. A patient or caregiver has to understand what the medication is for, how it works, and why it’s important to take it. My suggestion is to make it part of a daily routine. I always tell them, ‘Put it next to your toothbrush.’”
For more details, visit the NIH's guidelines.
Ana Veciana-Suarez, Guest Columnist
Ana is a regular contributor to the University of Miami Health System. She is a renowned journalist and author who has worked at The Miami Herald, The Miami News, and The Palm Beach Post. Visit her website at anavecianasuarez.com or follow @AnaVeciana on Twitter.
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