How Do I Treat Asthma According to the NIH Guidelines?

Patient Presentation
A 7-year-old male came to clinic because the last 3 nights he has been having a cough that has been interfering with sleep.
During the day he is also having some problems running on the playground and in gym class, but no problems during rest.
He has had mild clear rhinorrhea for 4 days with no sore throat, or emesis. He has complained of feeling “warm” but his temperature was 99.0 degrees Fahrenheit.
The family is out of his albuterol metered-dose inhaler.
The past medical history reveals 1-2 asthma exacerbations a year for the last 5 years that occur with upper respiratory infections. He has never been hospitalized nor been to the emergency room. He has used oral corticosteroids for some exacerbations and in between exacerbations is well. . He had atopic dermatitis as an infant and has some dry skin in the wintertime.
He has no symptoms of allergies and there is no tobacco smoking around him.
The family history shows hayfever in both parents. His brother also had atopic dermatitis as an infant.
The review of systems is otherwise negative.
The pertinent physical exam shows an alert male in no acute distress. Respiratory rate is 26 and he is afebrile. He easily converses but coughs several times during the examination.
He has clear rhinorrhea in the nose and posterior pharynx. His lung examination shows a mildly prolonged end-expiratory phase with intermittent mild, end-expiratory wheezing.
The diagnosis of an acute exacerbation of his mild intermittent asthma is made. He is given another prescription for albuterol metered-dose inhalers with a spacer to be given 2 puffs for increased work of breathing, before bedtime, and before exercise. More than one inhaler was given so the patient would have an inhaler available at home and school.
A prescription for oral corticosteroids is given to be used if symptoms are increasing such as needing to use the albuterol more than every 4 hours. The family was again instructed on the role of the medication, how to use the medication and spacer properly, and when to call a physician or go to the emergency room for an exacerbation.
The patient’s clinical course over the next several days showed him using the inhaler ~ 4 times/day initially and then decreasing over the next 5 days. Oral corticosteroids were not begun.

Discussion
Asthma is a chronic inflammatory process of the airways where episodic, reversible airway obstruction occurs and alternative diagnoses are excluded.
In children it is commonly associated with atopy. Wheezing with viral infections, a family history of allergy are strongly associated with continued asthma during childhood
Various factors can make asthma difficult to control and should be screened for in each patient. If the factors are present patient and their families should be appropriately counseled and treatment recommendations made. Examples include:

• Allergens – indoor and outdoor
• Irritants – including tobacco smoke or occupational or recreational exposure
• Foods and medications – e.g. sulfites, beta-blockers, aspirin
• Gastroesophageal reflux
• Rhinitis and sinusitis
• Upper respiratory tract infections

Learning Point
According to the National Institutes of Health’s Expert Panel Report entitled “Guidelines for Asthma Diagnosis and Management,” asthma is classified by severity and treatment recommendations are made based upon those classifications. More recently, studies are beginning to look at classifications based upon how well the asthma symptoms are controlled.

Overall, the goals of asthma treatment include:

• No or minimal chronic symptoms
• No or minimal exacerbations
• No activities of daily living and school/work limitations
• Maintain normal or near normal pulmonary function
• Minimal use of short-acting inhaled beta-2 agonists
• No or minimal medication side-effects

Review treatment and step down every 1-6 months if possible. Step up if control is not maintained.

NIH’s asthma severity and long-term control treatment recommendations include: