Goals in the Management of Asthma

Goals In the Management of Asthma* Roy ltztterBon, M.D., F.C.C.l

~ sthma

is an acute or chronic problem of varying severity

.t1 occurring in a signmcant number of patients. It

is

defined physiologically as reversible obstructive airway disease, pharmacologically as reversing acutely with Psagonists or more slowly responding to corticosteroids. CIinicall~ the disease is characterized as intermittent wheezing dyspnea. The broad goals of asthma management are to reverse and prevent the bronchial obstruction, reverse and prevent the wheezing dyspnea, and to achieve these goals with a minimum of side effects and complications of therapy 1 BROAD GOALS IN THE MANAGEMENT OF AsTHMA

Goals for asthma management are listed in Table 1 whether or not it is possible to achieve them theoretically and practically in all patients. It is obvious that with current therapies available all the goals can be achieved but are not achieved in all patients. It is important that physicians managing patients with asthma approach both the diagnosis and individual therapy with an understanding of how to achieve maximum benefit for each type of disease. ACHIEVEMENT OF GOALS IN THE MANAGEMENT OF AsTHMA: CLASSIFICATION OF EACH PATIENT

Each patient with asthma should be assessed and the type ofasthma defined. The steps in classificationare summarized in 'Iable 2. It is equally important, as also shown in Table 2, to define the severity of the problem in each patient. ESTABUSHMENT OF INDIVIDUAL PATIENT REGIMENS

The guidelines for approaching these are listed in Table 3. The emphasis for designing an individual therapeutic regimen for each patient should be based on the type of asthma, the severity of the individual case, the importance or absence of allergicfactors, and the response to therapy in the past and as revised for current management. Additional factors of importance in asthma management as general approaches for all patients are summarized in Table 4. EVALUATION OF SUCCESS OF ASTHMA MANAGEMENT

Asthma management success can be judged by determining how close to the ideal goals listed in Table 1 each patient is doing, according to the patient's conception and the physician's assessment. The satisfactory achievement of the patient's education may be very important in setting reasonable expectations. For severe corticosteroid-dependent ·From the Division of Allergy-Immuno~ Department of Medicine, Northwestern University Medical School, Chicago. This study was supported by USPHS NIAID grant AI 11403 and the Ernest S. Bazley Grant to Northwestern Memorial Hospital and Northwestern Univenity. ~rint requests: Dr. Ibtterson, Al1ergy-lmmunology, 303 &ut Chicago Avenue, Chicago 60611

Table 1- Brood Goola in the MtJntJgement ofAnhma Goals Prevent death Prevent progression to severity requiring hospitalization Prevent frequent emergency room visits Prevent excessive loss of work or school absenteeism Limit side effects of medication Provide safety to fetus and mother in the pregnant patient with asthma Maintain good quality of life and good self image of patient

Theoretically Achievable

Achievable in all Cases

Yes Yes

No No

Yes

No

Yes

No

Yes Yes

No No

Yes

No

Table 2-Ae~ ofGoola in the MtJntJgement of AnIama: C1BaijicaIion ofEach lbtient 1. Individualize each patient's evaluation 2. Classify each case of asthma as to A. Type of asthma B. Allergic facton 3. Assessment of severity of asthma A. Therapy required in past and response B. Previous emergency room visits C. Hospitalizations D. Intubations 4. Complicating £acton A. Other medical illness B. Psychiatric disorders C. Cigarette smoking (current or past) D. Allergic bronchopulmonary aspergillosis 5. Ability of patient (or parent ofpatient) to follow defined program

Table 3-Ac~ ofGoola in the MtJntJgement of Aatlama: IndimdutJl Therapeutic Begimenl 1. Each patient should have initial management individualized according to classification of type of asthma (see Table 2). 2. The initial therapeutic regimen is a test of medical management to be altered depending on response of patient. 3. Initial pharmacotherapy may vary from intermittent inhaled beta-agonists for mild exercise-induced bronchospasm to initial higb-dose daily corticosteroid in potentially fatal asthma. 4. Management of allergic facton may vary from none (in nonallergic asthma) to removal of animals from the environment to allergen immunotherapy for inhalant allergens. 5. After a period of evaluation on an initial regimen, the program is continued or m0di6ed depending on response, and the patient isseenMd~inginte~als.

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Table 4-Atlditional FtJcton oflmportance ira Management

ofAalama

1. Annualinftuenza immunization. 2. Regular ambulatory visits. 3. Evaluation of compliance with prescribed medication at each visit. 4. Frequency of ambulatory visits is dependent on severity of

asthma.

5. A call service for exacerbation of asthma especially for respiratory infections. 6. Preparation of patient for surgery, parturition or foreign travel. 7. Encouragement of weight control. 8. Encouragement of regular exercise program. 9. Maintain a normal life-style and alter the management program to achieve this.

asthma, for example, it may not be possible to avoid undesirable side effects of corticosteroids even with alternate day prednisone and maximal doses of inhaled corticosteroids. The patient should understand that the side effects (usually limited to increased appetite and weight gain) may be a necessary alternative if the risk of fatality from asthma is to be avoided.

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CONCLUSIONS

The specific goals in management of asthma will vary markedly for each patient depending on the type and severity of the asthma. Broad goals include prevention of death, of status asthmaticus, and of frequent emergency room visits. Further goals include preventing excess absenteeism from work or school, limiting the side effects of medication used for control of asthma, and providing safety to fetus and mother in the pregnant patient with asthma. Finally a good quality of life and a good self image should be maintained by the patients who should think of themselves as normal people with asthma and not as chronically ill patients. These goals are all achievable in every patient with asthma in theorj, practically achievable in most patients, but not achievable in all patients. The degree of achievement depends on adequacy of evaluation of the patient and appropriateness of management by the physician and compliance and cooperation of the patient. REFERENCE

1 Greenberger PA. Asthma. In: Patterson R, ed. Allergic diseases: diagnosis and management. 4th ed. Philadelphia: JB Uppincott, in press

Go8Ia In MalNIg8I1lMd of AIIhma(Roy FWIetaon)