Asthma reloaded!

GINA recommends that EVERY adolescent and adult with asthma use an ICS-containing inhaler, and that no adolescent or adult receive SABA-only treatment. But why?
- ICS markedly reduce the frequency of asthma exacerbations, hospitalizations, and death. Plus ICS are effective in reducing asthma symptoms, improving lung function, and preventing exercise-induced bronchoconstriction
- Compared with ICS, patients treated with SABA alone are at higher risk of asthma-related death and urgent asthma-related healthcare
- Want more info but don’t want to read GINA’s 200-page guideline? Here’s a GREAT summary of the evidence

It’s difficult to diagnose asthma in kids <5yo, but the modified Asthma Predictive Index and Pediatric Asthma Risk Score (both for kids ≤3yo) can help us predict its likelihood
- Allergic sensitization (by skin test) may be the strongest predictor of asthma
We don’t do a great job of checking PFTs in patients with a diagnosis of asthma
We also don’t do a great job of recognizing if adult patients still have asthma
The SMART thing to do is to never use a LABA alone in managing asthma
TALC: Adding tiotropium may be just as effective as adding salmeterol in patients with poorly-controlled asthma already on an ICS

Many studies show that most patients (maybe 80%!) don’t use their inhalers correctly, but maybe half of clinicians don’t know how to use them either
- But help is on the way! Our amazing clinic pharmacist (Kat!) is putting together a box of sample inhalers that we can use to learn and teach patients in clinic!
Many inhalers have dose-counters, but not all! Without a dose-counter, it may be difficult for patients to know how much medication is left in their inhaler
Inhalers are expensive!

Are there respiratory symptoms that make a diagnosis of asthma less likely?
Can you have asthma without wheezing?
Apart from chest auscultation, what physical exam findings should we look for when evaluating patients for asthma?
Should we always check PFTs in evaluating asthma? Is it better to check PFTs when asthma symptoms are well-controlled or uncontrolled? Should we ever recheck PFTs?
What comorbidities affect asthma control? How does pregnancy affect asthma?
What risk factors predict future asthma exacerbations?
What is the difference between metered-dose inhalers and dry powder inhalers? Does every inhaler need a spacer? And is it ever better to prescribe a nebulizer?
Which patients should we refer for allergy testing? And which to refer to pulmonology?

Brown Med-Peds Residency