ReBaked Morsel on Asthma Control – The 2020 NIH Asthma Management Guidelines

Knowing how to manage a severe asthma exacerbation in the ER is a vital ingredient to being a successful ER doctor, but what about the more mild cases? The kids with a history of wheezing that are at the start of a viral URI but not yet in the midst of an exacerbation? What recommendations should we be giving these families? Lucky for us, in 2020 there were some updates made to the NIH Asthma Management Guidelines and we’re going to discuss which ones can help us in the Emergency Department! 

2020 NIH Asthma Management Guideline Updates

Asthma Control

In order to direct appropriate care, it is important to consider how well the patient’s control is normally:

Mild intermittent asthma

• Symptoms less than twice weekly
• Asymptomatic between flares
• Short flares (few hours to a few days)
• Nighttimes symptoms less than twice per month

Mild persistent asthma

• Symptoms more than twice per week, but not more than once per day
• Activity levels affected by flares
• Nighttime symptoms more than twice per month

Moderate persistent asthma

• Daily symptoms
• Rescue med used daily
• Flares at least twice weekly
• Activity level affected by flares
• Nighttime symptoms more than once per week

Severe persistent asthma

• Constant symptoms 
• Decrease in physical activity
• Frequent flares
• Frequent nighttime symptoms

Asthma Treatments

While it is important to understand how to classify your patient, the following recommendations apply mostly to kids with mild to moderate asthma. 

Intermittent ICS:

• If you have a patient 0 – 4 years old who has had at least 3 lifetime episodes of viral-induced wheezing or at least two in the past year, and who are asymptomatic between episodes…
  • Instead of daily inhaled corticosteroid (ICS) year round…
  • The new guidelines recommend a short course (7-10 days) of daily ICS with as needed Short Acting Beta Agonist (SABA) at the start of a viral upper respiratory illness!
• This recommendation can also apply to children 12 years and older with mild persistent asthma who are already on daily ICS, to have a joint decision to instead space to intermittent ICS with SABA during times of illness or seasons when they may be higher risk for exacerbations. 

SMART?! (Single Maintenance And Reliever Therapy)

• This intelligent treatment regimen is with an ICS and a Long Acting Beta Agonist (LABA) [formoterol] given both for daily and rescue therapy.
• For children at least 4 years of age who are not well controlled on ICS alone.
• Formoterol is the LABA of choice, because you can give this more than twice per day AND it has a short onset of action! 
• “Double win” = reduces exacerbation rates and overall steroid use which can help decrease the adverse effects on growth rates
  • Triple win = only one device is needed! No more SABA!

You’re probably asking yourself… is this really important for us in the Emergency Department to know? Isn’t this more relevant for the outpatient pediatricians? It matters for all of our patients… and therefore should matter to all of us. If we feel empowered to give these evidence based recommendations we can help families to prevent exacerbations, decrease exposure to steroids, and simplify care! 

Moral of the Morsel

• Are they controlled? Mild, moderate, severe, intermittent, persistent, OH MY!
• BE SMART! Intermittent ICS, SMART, or keep current regimen! 
• Can we decrease corticosteroid use? Take an extra couple minutes to evaluate their regimen and see if we can make adjustments to reduce exposure.
• Prevention is key! If we can reduce exacerbations, it is worth the extra few minutes to sit, discuss, and make these changes with family.

References

Licari A, Brambilla I, Marseglia A, De Filippo M, Paganelli V, Marseglia GL. Difficult vs. Severe Asthma: Definition and Limits of Asthma Control in the Pediatric Population. Front Pediatr. 2018 Jun 19;6:170. doi: 10.3389/fped.2018.00170. PMID: 29971223; PMCID: PMC6018103.

Colice GL. Categorizing asthma severity: an overview of national guidelines. Clin Med Res. 2004 Aug;2(3):155-63. doi: 10.3121/cmr.2.3.155. PMID: 15931352; PMCID: PMC1069088.