As soon as your doctor has confirmed a diagnosis of asthma and excluded all other possible causes of your symptoms, treatment will be advised according to the severity of your asthma. There are two sets of guidelines: one for adults and adolescents, and one for children. These guidelines are constantly updated by asthma experts in South Africa.
South African experts use international guidelines like the Global Initiative for Asthma (GINA, 2015) as a basis for treating asthma in children, adolescents and in adults. Although these guidelines are adapted for South African circumstances, the principles of these guidelines adhere to international guidelines. New management options had been implemented for children younger than five years, because they should not be treated exactly the same as older children.
There is now more emphasis on the use of controllers as the foundation of asthma treatment and the major change in emphasis to assess asthma control are evident in the new guidelines. New treatment options such as combination treatment (an inhaled corticosteroid plus a long-acting beta agonist in one single inhaler), the use of new formulations of inhaled corticosteroids, and the use of leukotriene inhibitors and immunotherapy are incorporated in the latest guidelines. These new advances in asthma management will benefit you as a patient because it is now possible to achieve excellent asthma control.
This is how your doctor will decide exactly how to manage your asthma in five main steps:
Step 1: Confirm the diagnosis of asthma.
Step 2: Identify and treat all relating conditions, aggravating factors and address the triggers.
It is important to treat (and prevent) hay fever and sinusitis, since about three quarters of people with asthma also have allergies of the nose and sinuses. It is also true that if this part of the problem is out of control, so will the asthma.
Allergies will be treated by limiting exposure to the identified allergens, and to control allergy symptoms with a new generation antihistamine.
Step 3: Classify the severity of your asthma, based on the latest guidelines for adults, adolescents and children (see section on Classification of asthma severity).
Step 4: Initiate your treatment based on the severity of your asthma and age.
Children usually require the same medication as adults. The amount and type of medication will depend on the severity of the asthma. The approach to treatment in children (as in adults) is to "Hit Early, Hit Hard and then Step Down" treatment.
In mild cases (intermittent asthma, with less than two acute asthma attacks per week, See table 4 below), only a bronchodilator may be necessary, while any child with persistent asthma needs daily preventer medication to help prevent attacks by reducing the chronic inflammatory reaction in the airways.
In infants, management of asthma presents unique problems. But it is always better to treat a child as if they have asthma than not to treat him at all. If a parent is unsure whether the infant's wheezing is because of asthma, or whether he is suffering an acute attack, it is better to give him a bronchodilator than to withhold treatment, if he has been diagnosed with asthma.
Because an infant’s airways are so small, the smallest amount of mucus or tissue swelling can cause significant airway narrowing. Infants also have proportionately less smooth muscle around their airways, resulting in less support for the airway, but also less spasm of the airway.
As a result, infants also respond less well to bronchodilators, which open up the airways and provide older asthmatics with quick relief. But there is no reason why a child's asthma cannot be managed and controlled to such an extent that he can live a normal life.
Parents often panic because they do not know whether their infant or toddler is really inhaling deep enough to get all the medication to his lungs. For infants and children, a spacer with a valve to ensure that no air escapes from the spacer, can be of great value.
A child often inhales in shallow and short breaths when using an inhaler, exhaling more than inhaling. As soon as your child can understand, you can teach them to relax before using his inhaler, and take long and slow breaths from the spacer, keeping his mouth on the spacer, while exhaling slowly through his nose, and then inhaling again. After four to five inhalations, chances are good that he inhaled all the medication he needs.
Step 5: Your doctor will re-assess your condition and control of your symptoms two to six weeks after you have started treatment.
After re-assessment he will classify your asthma (at this assessment and every following assessment) as either “controlled”, “partly controlled” or “uncontrolled”.
Based on this classification, they will either step up or step down your treatment (from your initial treatment – see table three) to achieve total control (no acute attacks at all, no need for reliever therapy due to worsened symptoms) as soon as possible.
Before stepping up therapy, your doctor must make sure that you are taking your medication regularly and not forgetting any doses, and that you know how to use your medications and pumps.
You should bring your medication with to the doctor and show them how you use it so that they can help you with your technique. Spacers with your pumps (or a dry powder inhaler) are necessary in people of any age who are experiencing very poor control.
If your asthma remains anything but well-controlled despite checking your use of the medicine, your technique and stepping up therapy, your doctor will refer you to a specialist pulmonologist.
You definitely need the advice of a specialist pulmonologist if you have initially been diagnosed with moderate persistent asthma (grade three) and total control has not been achieved with initial treatment. If total control is achieved and maintained for at least three months, therapy will be stepped down.
After re-assessment, the doctor will classify your child’s asthma (at this assessment and every following assessment) as controlled, partly controlled or uncontrolled (see table five).
Based on this classification, treatment will be stepped up or step down to achieve fully controlled asthma (no acute attacks at all, no need for relievers due to worsening of symptoms) as soon as possible.
Before stepping up therapy, your doctor must make sure that your child is taking the medication regularly and not forgetting any doses, and also that you know how to use the medications and pumps.
You should bring your medication with to the doctor in order to demonstrate how you are using it and if it is necessary, be advised about the correct technique. Spacers are necessary in all children to help them take their pumps effectively. Your child may do better with a mouthpiece or a mask. Ask your doctor which is best.
An acute asthma attack in any week makes that an uncontrolled asthma week. There should not even be one uncontrolled asthma week in your child’s life. Every time you child suffers an acute attack or exacerbation, you should inform their doctor, because any acute attack in any week should prompt immediate review of their treatment to ensure adequate control. An acute attack means that your child’s treatment is inadequate.
If your child’s asthma remains anything but well-controlled despite stepping up therapy, they should be referred to a paediatrician, pulmonologist or allergist.
If total control is achieved and maintained for at least 3 months, therapy should be stepped down. Asthma should be managed on a daily basis.
When should you be referred to a specialist?
Adults should be referred to a specialist and special care taken:
- When asthma is poorly controlled despite intensive treatment.
- When the asthma patient suffers from other medical conditions such as a peptic ulcer,heart failure or hypertension, or if the patient is pregnant. Poor asthma control is much more dangerous to the mother and the unborn baby than the possible side-effects of any asthma medication.
- When the patient suffers from occupational asthma
- When the patient is frequently absent from work
- When the patient needs immunotherapy. Note that elderly asthma patients should not use theophylline and oral corticosteroids due to possible adverse effects. Also asthma patients with heart problems and hypertension should rather not use beta agonists because this may affect their heart and blood pressure and diabetics should rather not use oral corticosteroids. Asthma patients with pulmonary tuberculosis should not take isoniazid (a TB medication) while using inhaled or oral corticosteroids.
Children should be referred to a specialist and special care taken:
- When asthma is poorly controlled despite treatment or has shown only slight improvement in control over the past year
- When a child regularly requires oral corticosteroids
- When a child has had one or more life-threatening episode
- When the child is frequently absent from school
- When the child needs immunotherapy
Reviewed and updated by Prof Eugene Weinberg, Paediatrician Health24. April 2015
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