Management of asthma in the elderly patient

Figures & data

Table 1 Diagnosis of asthma based on medical history, physical examination, and objective measurements^1–4

Key elements of medical history

– Cough

– Wheezing

– Breathlessness

– Chest tightness

– Family or personal history of allergic or atopic disease

Assess for symptom patterns typical of asthma

– Episodic or recurrent

– Occur or worsen upon exposure to allergens, respiratory infections, irritants such as pollutants, exercise, tobacco smoke, or drugs

– Good response to a bronchodilator

Physical examination

– Wheezing on lung auscultation

– Concomitant rhinitis

Objective measurements

– Spirometry showing reversible airway obstruction: reduced FEV1/FVC and increase in FEV1 after a bronchodilator ≥12% and ≥200 mL or after a course of controller therapy

– Alternative: peak expiratory flow variability: ≥60 lpm or ≥20% based on multiple daily readings

If spirometry (or PEF) is normal, but symptoms are present consider

– Challenge testing

Allergy testing

– Skin testing

– Specific serum IgE testing

Abbreviations: FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; IgE, serum immunoglobulin E; PEF, peak expiratory flow.

Table 2 Classification of asthma control according to guidelines³

Components of control	Controlled (all of the following)	Partly controlled	Uncontrolled
Symptoms	≤2 days per week	>2 days per week	Three or more features of partly controlled asthma present in any week
Night time awakenings	None	Any
Interference with normal activity	None	Any
SABA use for symptoms control	≤2 days per week	>2 days per week
FEV1 or PEF	Normal (>80% of predicted/personal best)	<80% of predicted/personal best
Validated questionnaires	Score
ATAQ°	0	1–2	3–4
ACQ°	≤0.75	0.75–1.5	≥1.5
ACT*	≥20	16–19	≤15

Notes:

° Higher score indicates worsening of asthma control

* lower score indicates worsening of asthma control.

Abbreviations: ACQ, Asthma Control Questionnaire; ACT, Asthma Control Test; ATAQ, Asthma Therapy Assessment Questionnaire; FEV₁, forced expiratory volume in 1 second; PEF, peak expiratory flow; SABA, short-acting β₂-agonists.

Table 3 Stepwise approach to asthma therapy^1–4

Step 1	Step 2	Step 3	Step 4	Step 5	Step 6
Preferred: SABA as needed	For 6–8 weeks Preferred: Low-dose ICS Alternative: LTRA	Preferred: Low-dose ICS + LABA or medium-dose ICS Alternative: Low-dose ICS + LTRA	Preferred: Medium-dose ICS + LABA Alternative: Medium-dose-ICS + LTRA	Preferred: High-dose ICS + LABA and LTRA. Consider omalizumab for patients with allergies	Preferred: High-dose ICS + LABA and LTRA. Consider tiotropium and omalizumab for patients with allergies	Step up when needed (first check adherence, inhaler technique, and environmental control) Assess control: Step down if possible when asthma is well-controlled for at least 3 months

Abbreviations: ICS, inhaled corticosteroids; LABA, long-acting β₂-agonists; LTRA, leukotriene receptor agonists; SABA, short-acting β₂-agonists.

Table 4 Estimated comparative daily dose of different ICS in milligrams for adults based upon the available efficiency data in the literature

Name	Low	Medium	High dose
BDP–CFC MDI	<0.4	0.4–0.8	>0.8
BDP–HFA MDI	<0.25	0.25–0.5	>0.5
Budesonide DPI	<0.4	0.4–0.8	>0.8
Ciclesonide–HFA MDI	<0.2	0.2–0.4	>0.4
Fluticasone–HFA MDI or DPI	<0.25	0.25–0.5	>0.5
Triamcinolone–CFC MDI	<0.75	0.75–1.5	>1.5
Flunisolide–CFC MDI	<1	1–2	>2
Flunisolide–HFA MDI	<0.32	0.32–0.64	>0.64
Mometasone DPI	<0.4	0.4–0.8	>0.8

Abbreviations: ICS, inhaled corticosteroids; CFC, chlorofluorocarbon; DPI, dry powder inhaler; HFA, hydrofluoroalkane; MDI, metered dose inhaler; BDP, beclomethasone dipropionate.

Table 5 Main asthma-related comorbidities

Rhinitis/rhinosinusitis

Gastroesophageal reflux disease

Obesity

Obstructive sleep apnea syndrome and other sleep-disordered breathing

Chronic obstructive pulmonary disease

Psychopathologies, mainly depression

Tobacco smoking

Osteoporosis

Dysfunctional breathing/vocal cord dysfunction

Hormonal disorders

Hypertension, diabetes, ischemic heart disease, degenerative joint disease/arthritis, cardiac arrhythmia, congestive heart failure, cerebrovascular disease/atherosclerosisa

Note:

a Probably increased.

Table 6 Key components of a personalized asthma education program

Develop good patient–doctor partnership

Discuss the nature of the disease and its pathophysiology

Evaluate patient’s triggers

Identify patient’s goals and preferences

Develop a self-monitoring plan in how to monitor symptoms and lung function

Discuss patient’s lifestyle and change options that are useful for better asthma control according to patient’s goals and preferences

Evaluate treatment regimen according to patient’s goals and preferences

Discuss comorbidities and their treatment including over-the-counter medications, drops, and health food preparations

Share and document decisions about treatment, lifestyle regimens, and trigger avoidance according to the patient’s goals

Share a written asthma action plan for the early recognition and treatment of exacerbations, including when and how early to access health care providers for unscheduled visits or emergencies

Teach proper inhaler technique with practical examples using the prescribed placebo inhaler

Schedule follow-up appointments according to patient’s availability

Control and document asthma control at each follow-up visit

Control and document comorbidities, their treatment, and possible drug–drug interactions at each follow-up visit

Control and document effectiveness of the trigger avoidance program at each follow-up visit

Control and document effectiveness of lifestyles program at each follow-up visit

Control and document adherence to shared treatment at each follow-up visit

Control and document inhaler technique at each follow-up visit

National Heart, Lung, and Blood InstituteNational Asthma Education and Prevention ProgramExpert Panel Report 3: Guidelines for the Diagnosis and Management of AsthmaBethesdaNational Heart, Lung, and Blood Institute2007 Available from: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdfAccessed March 31, 2013

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Global Initiative for Asthma [homepage on the Internet]Global strategy for asthma management and prevention [updated 2009] Available from: http://www.ginasthma.org/guidelines-gina-report-global-strategy-for-asthma.htmlAccessed March 31, 2013

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