Asthma, Chronic
Description Diagnostic criteria General and supportive measures Medicine treatment ICD-10 code: J45 DESCRIPTION Asthma is a chronic inflammatory airways disease in which many cells and cellular elements play a role. Susceptible individuals present with recurrent episodes of early morning wheezing, breathlessness, chest tightness and cough. There is widespread variable airflow obstruction th
Description
Diagnostic criteria
General and supportive measures
Medicine treatment
ICD-10 code: J45
DESCRIPTION
Asthma is a chronic inflammatory airways disease in which many cells and cellular elements play a role. Susceptible individuals present with recurrent episodes of early morning wheezing, breathlessness, chest tightness and cough.
There is widespread variable airflow obstruction that is reversible either spontaneously or with treatment. A variety of stimuli, e.g. allergens, viral infections, weather changes, emotional upsets or other irritants precipitate inflammation that is associated with increased bronchial hyper-responsiveness.
DIAGNOSTIC CRITERIA
- Chronic, persistent/recurrent cough and/or wheezing that responds to a bronchodilator.
- Objective evidence of reversible airway obstruction, as measured by > 15% improvement of the peak flow or > 12% improvement in the (FEV1) 20 minutes after administration of an inhaled bronchodilator confirms the diagnosis.
- A family history of atopy, night or exercise-induced coughing and/or wheezing.
Control of asthma
The severity of asthma can vary with time and regular reassessments (at least every 3 months) are necessary.
On treatment chronic asthma is classified as:
- controlled,
- partially controlled, or
- uncontrolled.
The following criteria are used to classify control:
| Controlled | Partially controlled (Any present in any week) | Uncontrolled | |
| Daytime symptoms | None (2 or less/ week) | More than twice/week |
3 or more features of partly controlled asthma present in any week |
| Limitations of activities | None | Any | |
| Nocturnal symptoms/ awakening | None | Any | |
| Need for ‘rescue’/ ‘reliever’ treatment | None (2 or less/ week) | More than twice/week | |
| Lung function (PEF or FEV1) | Normal | < 80% predicted or personal best (if known) on any day | |
| Exacerbation | None | One or more/year | |
Partially controlled or uncontrolled cases require escalation in therapy while cases controlled for > 4 months requires gradual reduction in therapy.
Assessment of severity and classification of chronic asthma
Before initiating treatment, classify the grade of severity of patient illness according to the presence of the most severe feature. This assists in choosing the most appropriate initial maintenance therapy.
Infrequent asthma: less than one acute exacerbation in 4–6 months.
Persistent asthma: mild, moderate or severe.
| Criteria | Mild | Moderate | Severe |
| Day time symptoms | 2–4/week | > 4/week | continuous |
| Night time symptoms | 2–4/month | > 4/month | frequent |
| Prior admission to hospital for asthma | None | one previous admission | > one previous admission or admission to ICU |
| PEFR* | > 80% | 60–80% | < 60% |
* Peak expiratory flow rate (PEFR) – patient’s best as percentage of predicted value.
GENERAL AND SUPPORTIVE MEASURES
- Environmental control, avoid triggers, e.g.:
- exposure to cigarette smoke,
- preservatives such as sulphites and benzoates,
- house pets such as cats and dogs,
- house-dust mites sensitisation: use plastic mattress covers, and remove bedroom carpets.
- Wash bedding covers in hot water (> 70 °C).
- Educate children, parents, caregivers and teachers.
MEDICINE TREATMENT
Medicine delivery systems
Use spacer devices with a metered dose inhaler. Prime all spacers with 2 doses of inhaled medication prior to first use. The size of the spacer is dependent on the tidal volume of the child:
| Spacer volume | Face mask/ mouthpiece | Valve | |
| Infants | 150–250 mL | face mask | mandatory |
| Children < 5 years Children > 5 years |
500 mL | face mask mouthpiece |
recommended |
| Adolescents | 750 mL | mouthpiece | not necessary |
The technique of using the spacer varies with age:
- Infants and young children: use tidal breathing of 10 long, deep, slow breaths.
- Older children and adolescents: breathe out fully, actuate the inhaler, inhale the entire contents in one long, slow breath and hold breath for 10 seconds.
Inhaled corticosteroid use
- Inhaled corticosteroids are indicated for all cases of persistent asthma.
- Spacer devices increase the efficacy of inhaled corticosteroids.
- Rinse the mouth after inhalation of inhaled corticosteroids to reduce systemic absorption and adverse effects.
- Wash face if a face mask is used.
- Use the lowest possible effective dose of steroids.
Standard Treatment Guidelines and Essential Medicines List for South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 15: Respiratory System, 15.4 Conditions With Predominant Wheeze, 15.4.2 Asthma, Chronic
Click here for 15.4.2.1 Infrequent Asthma
Click here for 15.4.2.2 Persistent Asthma