Neobook — clinical reference

Patient and caregiver education on inhaler and spacer techniques

J45.0-1/J45.8-9

DESCRIPTION

Asthma must be distinguished from chronic obstructive pulmonary disease, which is often mistaken for asthma. The history is a reliable diagnostic guideline and may be of value in assessing treatment response.

Asthma

COPD

Young age onset, usually < 20 years.
History of hay fever, eczema and/or allergies.
Family history of asthma.
Symptoms are intermittent with periods of normal breathing in between.
Symptoms are usually worse at night or in the early hours of the morning, during an upper respiratory tract infection, when the weather changes or when upset.
Increase >20% in PEF 10 minutes after receiving a ß₂-agonist.
LoE:II^xiv

Older age onset, usually > 40 years.
Symptoms slowly worsen over a long period of time.
Long history of daily/frequent cough, before the onset of shortness of breath.
Symptoms are persistent and not only at night or during the early morning.
History of heavy smoking (> 20 cigarettes/day for ≥ 15 years), heavy cannabis use or previous TB.
Little improvement in PEF with ß₂-agonist.

GENERAL MEASURES

Patient education: including advice on smoking cessation.
Decrease exposure to triggers, e.g. house dust mite, pollens, grasses, pets, smoke, fumes, etc.

MEDICINE TREATMENT

Nocturnal symptoms of cough and wheeze, the need for bronchodilators more than twice a week, or PEF <80% of the patient’s best value, indicates poor asthma control.
Patients with poorly controlled asthma need to step up their maintenance therapy as described below.
The Asthma Control Test®, a validated measure of clinical asthma control, can be completed by the patient (after initial instruction) at each visit to the clinic prior to consultation. A value of ≥20 suggests adequate asthma control (see Appendix V: Asthma monitoring).
See Appendix VI: Devices for Respiratory Conditions for guidance on inhaler, spacer and nebuliser device techniques.

A patient with poorly controlled asthma should be assessed for the following and identified problems addressed prior to stepping up therapy:

Correct inhaler technique should be demonstrated and checked regularly, as many asthmatic patients do not use their inhalers correctly.
Adherence to medication, especially the inhaled corticosteroid.
Ensure a spacer is being used for all MDIs and patient has been trained in its use.
Exposure to triggers of bronchospasm.
Use of medications that may aggravate asthma e.g. NSAIDS.
Other medical conditions such as cardiac disease.
Treat allergic rhinitis (see Rhinitis, allergic, persistent) and GORD (see Gastro-oesophageal reflux disease (GORD) and dyspepsia, if present.

Asthma Therapy

Inhaled corticosteroids (ICS) are the mainstay of treatment in asthma.

For patients with infrequent asthma symptoms < twice a month:

As reliever/rescue therapy:

Short acting β2-agonists, e.g.:
- Salbutamol, MDI, 200 mcg, as needed.

LoE:III^xv

AND

Inhaled corticosteroids, e.g.:
- Budesonide, inhalation, 200 mcg whenever salbutamol is taken.

In patients on protease inhibitors, beclomethasone is the preferred ICS as there are drug interactions between protease inhibitors and budesonide.

Beclomethasone, inhalation, 200 mcg whenever salbutamol is taken.

LoE:III^xvi

For patients with asthma symptoms ≥ twice a month

As controller therapy:

Inhaled corticosteroids, low dose, e.g.:
- Budesonide, inhalation, 200 mcg 12 hourly. o Well and stable after 6 months: can attempt to reduce budesonide dose to 200 mcg daily.
- Dose adjustments may be required at change of seasons.

LoE: I^xvii

Well and stable after 6 months: can attempt to reduce budesonide dose to 200 mcg daily.
Dose adjustments may be required at change of seasons.

In patients on protease inhibitors, beclomethasone is the preferred ICS as there are drug interactions between protease inhibitors and budesonide.

Beclomethasone, inhalation, 200 mcg 12 hourly for 6 months; reduced to 200 mcg daily once well and stable.

LoE:III^xviii

AND

As reliever/rescue therapy:

Short acting β2-agonists, e.g.:
- Salbutamol, MDI, 200 mcg, 6 hourly as necessary.

For patients with asthma symptoms almost daily or waking due to asthma at least once a week:

Long-acting β2-agonist/corticosteroid combination inhaler, e.g.:
- Salmeterol/fluticasone, inhalation, 50/250 mcg 12 hourly.
- Maximum dose: 50/500 mcg 12 hourly.
- Well and stable for 6 months: step down to budesonide, inhaled, 200 mcg 12 hourly.

LoE: I^xix

AND

As reliever/rescue therapy:

Short acting ß2-agonists, e.g.:
- Salbutamol, MDI, 200 mcg, 6 hourly as necessary.

In patients on protease inhibitors:

Beclomethasone, inhalation, 400 mcg 12 hourly.

LoE:III^xx

AND

Formoterol. inhalation, 12 mcg 12 hourly.

Failure of above therapy:

While awaiting appointment with specialist.

ADD

Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 10 mg daily.

Note:

Prednisone should not be used as maintenance therapy but only as a bridging step while awaiting review by a specialist.
LoE:III

For short-term exacerbations in patients not responding to the above, while awaiting review with specialist:

Corticosteroids (intermediate-acting) e.g.:
- Prednisone, oral, 40 mg daily for 10 days.

LoE:III

PATIENT AND CAREGIVER EDUCATION ON INHALER AND SPACER TECHNIQUES

See Appendix VI: Devices for Respiratory Conditions for guidance on inhaler, spacer and nebuliser device techniques.

Spacer devices

Patients on step 3 therapy and above, and patients on step 1 and 2 who are unable to use aerosol inhalers correctly after adequate counselling, may benefit from the use of a spacer with metered dose inhalers.

Click here to access the pdf.

Standard Treatment Guidelines and Essential Medicines List for South Africa, Adult Hospital Level, 2020-2024_Version 1.1_16 September 2024

Chapter 16: Respiratory Disorders _16.2 Asthma, Chronic Persistent

Asthma, Chronic Persistent

Drugs mentioned

ICD-10 codes