GINA 2015: How should asthma be evaluated
2015-11-03 14:59 Source: dingxiang garden Author: jennifer_jjy
Font size He Jingen, Department of Pediatrics, Anhui Provincial Hospital
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Assessment of asthma in adults, adolescents and children aged 6 – 11 years.
Key Points
1. Asthma assessment includes asthma control assessment and asthma treatment assessment (e.g., inhaler use, adherence, adverse effects, and comorbidities). The assessment of asthma control is subdivided into assessment of symptom control (previously referred to as “current clinical control”) and assessment of control of risk factors for future adverse events. 2.
The assessment of asthma symptom control includes: daytime and nighttime asthma symptoms and frequency, medication use, and the impact of asthma on activity. Unsatisfactory asthma symptom control can be burdensome for patients and is a risk factor for future acute exacerbations.
3. Even if a patient’s asthma symptoms are well controlled, the patient should be evaluated for control of future risk factors for acute exacerbations, fixed airflow limitation, and adverse drug reactions. Risk factor control is different from symptom control. Asthma risk factors include ≥ 1 acute exacerbation in the past 1 year, poor compliance, incorrect use of inhalers, poor lung function, smoking, and blood eosinophilia.
4. Pulmonary function is the most effective indicator of future risk factors for asthma once the diagnosis of asthma is clear. Pulmonary function tests should be used for asthma diagnosis, 3 – 6 months after initiation of treatment and for regular follow-up during later treatment. Further research is needed to clarify the reasons for the inconsistency between clinical symptoms and pulmonary function tests.
5. The causes of suboptimal control of asthma symptoms and acute exacerbations of asthma may vary, and therefore the treatment approach may be different.
6. The severity of asthma can only be assessed by retrospectively evaluating asthma symptom control and treatment at the time of acute exacerbation. A differential diagnosis of severe asthma and poorly controlled asthma, e.g., asthma due to misuse of inhalers and/or poor compliance, is required.
Overview
Each patient’s asthma evaluation should include an assessment of asthma control (assessment of symptom control and risk factors for future adverse outcomes) and an assessment of asthma treatment (e.g., inhaler use, adherence, and complications that exacerbate symptoms and reduce quality of life). Lung function, specifically exertional expiratory volume in 1 second (FEV1), as a predictive percentage, is an important component of future risk assessment.
What does “asthma control” mean?
The level of asthma control is the degree to which a patient’s symptoms improve with asthma treatment. Asthma control is closely related to the patient’s genetic background, the underlying disease course, the treatment used, and environmental and psychological factors.
Asthma control consists of 2 aspects: symptom control (previously referred to as ‘current clinical control’) and risk factors for future adverse regression (Figure 2 – 2). Both of these should be assessed. Lung function is an important component of the future risk assessment. Lung function tests should be performed at the start of treatment, at 3 – 6 months of treatment (to define the patient’s optimal individual lung function), and periodically at later treatment follow-up to assess risk factors.
(1) How to describe the patient’s asthma control?
The description of asthma control should include both symptom control and future risk factors.
Ms. X has good asthma control, but has had an acute asthma exacerbation in the last year and this patient is at increased risk for future acute asthma exacerbations.
Mr. Y’s asthma is not well controlled. He has several risk factors for future acute exacerbations: poor lung function, current smoking and poor medication adherence.
(2) What does “asthma control” mean to the patient?
Many studies point to a large discrepancy between patient self-assessment and physician assessment of asthma control. This does not mean that patients are ‘overestimating’ or ‘underestimating’ the severity of their asthma. It is likely that the patient’s understanding of asthma control is different from the doctor’s, e.g., based only on the time to symptom relief after taking medication. If patients need to self-assess “asthma control”, then they should be educated beforehand.
1. Asthma control assessment = assessment of symptom control and assessment of risk of future adverse regression
Assess symptom control over the past 4 weeks (Figure 2-2A).
Identify any risk factors for acute exacerbations, fixed airflow limitation, or side effects (Figure 2-2B).
Pulmonary function tests should be used for asthma diagnosis, at 3-6 months of initiation of treatment, and for regular follow-up in later treatment.
2. Assessment of asthma treatment
Document the patient’s existing treatment (Figure 3-5).
Observe the patient’s inhaler use and assess compliance and side effects.
Find out if the patient has a written asthma implementation plan.
Ask patients about their attitudes and goals regarding asthma and medication.
3. Assess comorbidities
Rhinitis, sinusitis, gastroesophageal reflux disease, obesity, obstructive sleep apnea, depression, and anxiety can lead to increased asthma symptoms, decreased quality of life, and suboptimal asthma control.
Figure 2-1: Asthma assessment in adults, adolescents and children aged 6-11 years
Assessment of asthma symptom control
Asthma symptoms, such as wheezing, chest tightness, shortness of breath, and cough, occur with varying frequency and intensity. Poorly controlled asthma symptoms can be burdensome to the patient and can significantly increase the risk of acute asthma exacerbation.
Targeted questioning is important. This is because asthma symptoms can be distressing for patients, making them difficult to accept; the frequency or severity of symptoms may vary depending on the purpose of asthma treatment, and there are individual differences between people. For example, a sedentary person with poor lung function may have few clinical symptoms and may appear to have ideal symptom control.
To assess asthma symptom control (Figure 2 – 2A), ask about the patient’s condition over the past 4 weeks, including: frequency of asthma symptoms (number of days per week), asthma-induced night awakenings, asthma-induced activity limitation, and use of emergency medications. In general, pre-exercise medication use should not be included, as this is routine medication use.
(1) Asthma symptom assessment tool for adults and adolescents
Rapid screening tool: can be used in a level 1 hospital to quickly identify those patients who need further detailed assessment. For example, the Royal College of Physicians (RCP) 3-question questionnaire, which asks about difficulty sleeping, daytime symptoms and activity limitation due to asthma. 30-second asthma control test also includes absence from school/inability to work due to asthma.
A symptom classification control tool such as the GINA symptom control tool (Figure 2 – 2A). Control by symptom classification and risk assessment helps to clarify treatment options (Figures 3 – 5). This classification is similar to the asthma control score using numerical values.
The numerical asthma control tool, which can be used to assess asthma symptom control by scoring The scores are useful for assessing the degree of symptom improvement in patients and are often used in clinical practice, but may be subject to copyright restrictions. Numerical asthma tools are more sensitive than categorical tools and include.
1. a numerical control questionnaire (ACQ) with a score from 0 – 6, with higher scores associated with less satisfactory symptom control. 0.0 – 0.75 means satisfactory asthma control; 0.75 – 1.5 is the ‘grey’ area; > 1.5 is less satisfactory asthma control. the ACQ score is an average. All ACQs include 5 symptom-related questions; ACQ – 6 also includes medication use; ACQ – 7 also includes pre-bronchodilator FEV1 levels. The minimum clinically important difference was 0.5. 2.
2. Asthma Control Test (ACT), scored from 5-25, with higher scores associated with better symptom control. 20-25, good asthma control; 16-20, fair asthma control; 5-15, poor asthma control. The minimum clinically important difference was 3.
When different assessment tools were used to assess asthma symptom control, the results were correlated, but not identical. Respiratory symptoms may be non-specific. Therefore, when assessing symptom control, it is important to first specify that the symptoms being assessed are due to asthma.
(2) Asthma symptom control assessment tool for children aged 6 – 11 years
In children, as in adults, the assessment of asthma symptom control is based on asthma symptoms, activity limitations, and use of emergency medications. The impact of asthma on the child’s daily life, including: exercise, play and social life, needs to be carefully assessed. Many children with poorly controlled asthma will avoid strenuous exercise, so their asthma symptoms appear well controlled. However, this may lead to an increased risk of physical ill health and obesity.
The degree of airflow limitation before treatment with medication or complaints of dyspnea varies greatly from child to child. Before parents notice asthma in children, the child’s lung function has often declined significantly. When asthma in children is not well controlled, children may experience fatigue, irritability and mood changes. Children can only recall the past few days, whereas parents can recall longer periods of time. Therefore, both parents and children need to be questioned when assessing asthma symptom control.
Several numerical asthma control scores are available for children, including: the Childhood Asthma Control Test (cACT), with separate questionnaires for children and parents; and the Asthma Control Questionnaire (ACQ).
Some asthma control scores for children include symptoms of acute asthma exacerbations, including: the Test of Respiratory and Asthma Control in Children (TRACK); and the Composite Asthma Severity Index (CASI).
There is a correlation between the different tests and also between them and the GINA symptom classification system. Figures 2 – 3 detail the assessment of asthma control in children.
A. Asthma symptom control Asthma control
In the last 4 weeks, the patient had
Good control
Fair control
Poor control
Daytime asthma symptoms more than 2 times/week?
Yes□No□
None of these
1-2 items
3-4
Have you ever had night waking due to asthma?
Yes□No□ Yes□No□ No
Do you use emergency medication more than 2 times/week?
Yes□No□ Yes□No□ No
Is there any limitation of activity due to asthma?
Yes□No□ B. Risk factors for poor asthma regression
Risk factors need to be assessed at diagnosis and periodically during treatment, especially in patients with a history of acute asthma exacerbation.
Assess FEV1 levels at initiation of treatment and follow up again at 3-6 months of asthma control therapy to clarify optimal lung function, followed by regular follow-up lung function (FEV1) for risk assessment
Independent risk factors for acute exacerbation of asthma.
Unsatisfactory control of asthma symptoms.
High dose of SABA use (increased risk of death if more than 200 doses are used per month)
Low FEV1 levels, especially <60% of predicted values. < p="">
Presence of significant psychological or socioeconomic problems.
Smoking, allergen exposure.
Comorbidities: obesity, sinusitis, confirmed food allergy.
Eosinophilia in sputum or blood.
Pregnancy.
Other common independent risk factors for acute exacerbation of asthma.
Previous intubation or intensive care treatment due to asthma exacerbation.
≥1 acute asthma exacerbation in the past 12 months.
The presence of one or more risk factors increases the risk of an acute asthma exacerbation, even if asthma symptoms are well controlled.
Risk factors for fixed, irreversible airflow limitation.
Not receiving ICS therapy.
Smoking, toxic chemical exposure, occupational exposure.
Low basal FEV1 levels, chronic increased mucus production, eosinophilia in sputum or blood.
Risk factors for adverse drug reactions.
Systemic: frequent use of oral hormones (OCS), high dose and/or potent ICS, concomitant use of p450 inhibitors.
Topical: high dose and/or potent ICS, incorrect inhaler use.
Figure 2 – 2: Assessment of asthma control in adults, adolescents and children aged 6 – 11 years
Asthma symptom control
Daytime symptoms
How often does cough, wheezing, dyspnea occur in children (number of times per day or week)? What triggers the symptoms? How is it managed once it occurs?
Nocturnal symptoms
Is there a cough at night? Are there night wakings? Do you feel weak during the day? (If only cough symptoms are present, consider rhinitis and GERD)
Medication use
How often are the medications used? (need to check when inhaler was activated and the last kitchen). Need to distinguish between pre-workout medication use and medication use for symptom relief.
Future risk factors
Acute exacerbations
What are the asthma attacks during viral infections? Can going to school or physical activity worsen asthma symptoms? How long do asthma attacks usually last? How many asthma attacks have occurred since the last visit? Have you had any emergency room visits for acute asthma exacerbations? Is there a written asthma implementation plan?
Pulmonary function
Pulmonary function results are assessed. Focus on FEV1 and FEV1/FVC and compare these values with predicted values to see changes in trends.
Side effects
Assess the child’s height per year. Ask about the dose and frequency of ICS and OCS use.
Treatment Factors
Inhalation methods
Ask the child to demonstrate how to use the inhaler. Compare with equipment list.
Adherence
Number of days in a week that the child uses the inhaled medication (e.g., 0 days, 2 days, 4 days, 7 days). Can remember whether to use it in the morning or at night? Where is the inhaler usually placed? Is it easily visible (not easily forgotten)? Check the activation time on the inhaler.
Goals/concerns
Does the child or parent have concerns about asthma (e.g., reluctance to use medications, side effects, impact on activity)? Child’s/parent’s/caregiver’s goals for asthma treatment.
Comorbidities
Allergic rhinitis
Any nasal itching, sneezing, nasal congestion symptoms? Can children breathe through the nose? What medications are used to relieve nasal symptoms?
Eczema
Does it affect sleep? Do you use topical glucocorticoids?
Food allergies?
Is the child allergic to any foods (studies have confirmed that food allergies are a risk factor for asthma-related deaths)?
Other assessments (if necessary)
2-week diary
If the assessment cannot be completed after the above questions are asked, the child or parent/caregiver needs to be asked to complete a 2-week diary detailing: asthma symptoms, medication use, and peak expiratory flow rate (most important).
Exercise test
Can provide insight into airway hyperresponsiveness and health. Should only be performed if asthma control is difficult to assess by other methods.
Figure 2 – 3: Asthma assessment questions for children aged 6 – 11 years
Assessment of risk factors for future adverse regression
The second component of the asthma control assessment is to assess the presence of risk factors for adverse regression in patients with asthma, such as acute exacerbations, fixed airflow limitation, and medication side effects (Figure 2 – 2B). Asthma symptoms, although they can be used as a marker to predict the risk of future acute exacerbations of asthma, are not sufficient to assess all adverse regressions of asthma because.
1. asthma symptoms can be controlled when placebo, “sham” therapy, or inappropriate long-acting β2 agonists (LABA) alone are used, but airway inflammation is not improved at this time.
2. Respiratory symptoms may be due to other diseases or comorbidities (e.g., upper airway dysfunction).
3. anxiety and depression may also produce asthma-like symptoms.
4. Some patients do not have significant respiratory symptoms despite poor levels of lung function.
The risk of asthma symptom control and acute exacerbation of asthma cannot simply be added together because the cause of poor asthma symptom control and acute exacerbation may not be the same and require different treatments.
(1) Acute exacerbation
Poorly controlled asthma symptoms significantly increase the risk of acute exacerbations. However, studies have demonstrated that several independent risk factors also increase the risk of acute exacerbations, even in the absence of significant asthma symptoms. These factors (Figure 2 – 2B) include: ≥ 1 acute exacerbation in the past 1 year, poor compliance, inhaler misuse, and smoking.
(2) Irreversible airflow limitation
In healthy adults who do not smoke, the average rate of decline in FEV1 is 15 – 20 ml/year. In asthmatics, there is an accelerated decline in lung function that progresses to incomplete reversible airflow limitation. This is often closely associated with symptoms of prolonged dyspnea. Independent risk factors for irreversible airflow limitation include: smoking, exposure to toxic substances, chronic mucus hypersecretion, and acute exacerbation of asthma in patients not using ICS.
(3) Medication side effects
The choice of any medication requires a balance of risks and benefits. Most patients with asthma do not experience any medication side effects. The risk of side effects increases when the dose of medication is increased; however, only a small percentage of patients require high-dose medication. Local side effects of ICS include thrush and dysphonia. Patients on high-dose or potent ICS formulations are at higher risk for side effects; inhaler misuse can lead to an increased risk of local side effects.
The role of lung function in assessing asthma control
(1) Relationship between lung function and other asthma control measures
For both adult and pediatric asthma patients, there is not a strong correlation between lung function levels and asthma symptoms. In some asthma assessment tools, lung function is often scored and then added to or subtracted from the symptom score. Low FEV1 remains an independent predictor of acute asthma exacerbation even after adjusting for frequency of symptoms.
Pulmonary function tests should be performed at the time of asthma diagnosis, at the start of treatment at 3 – 6 months (to obtain the patient’s personal best FEV1), and at regular follow-up visits later in treatment. Once a definitive diagnosis of asthma is made, there is no need to discontinue routine and emergency medications prior to each visit. It is best to keep medication use relatively stable at each visit.
(2) Interpretation of the patient’s periodic pulmonary function test results
A low FEV1 percentage predictive value means that
the patient is at risk for an acute exacerbation of asthma and that risk is independent of the patient’s clinical symptoms, especially when FEV1 < 60% of predicted value
is a risk factor for decreased lung function and that risk is independent of the patient’s clinical symptoms.
If the patient has no significant respiratory symptoms, it is an indication that the patient’s usual physical activity is limited or that the patient has difficulty perceiving or detecting airflow limitation (which may be due to untreated airway inflammation).
More frequent asthma symptoms and a normal or high FEV1 means that
An etiology other than asthma that causes respiratory symptoms needs to be considered, e.g., cardiac disease, cough due to postnasal drip or gastroesophageal reflux disease (Figures 1 – 3).
The presence of reversible changes in lung function after repeated use of bronchodilators means that
The presence of reversible changes in pulmonary function (> 12% increase in FEV1 from baseline and > 200 ml absolute increase from baseline) after bronchodilators in asthmatic patients on asthma control therapy or on short-acting β2 agonists within 4 hours or LABA within 12 hours; this is often indicative of suboptimal asthma control.
Pulmonary function test results are only reliable in children over 5 years of age. Pulmonary function testing in children is less helpful than in adults. Many children with poorly controlled asthma still have normal lung function between acute exacerbations.
(3) Application of pulmonary function results in clinical practice
After conventional ICS treatment, FEV1 may improve within a few days and plateau within 2 months. The patient’s highest FEV1 level (optimal value) should be recorded, as this value is more clinically valuable than the FEV1 percentage prediction. Pediatric asthma patients need to be followed up at each visit for height.
Some patients with asthma may have a higher than average rate of decline in lung function, progressing to fixed (not fully reversible) airflow limitation. Improvement in FEV1 can be assessed by high-dose ICS/LABA and/or systemic hormone tests. If the test results are negative, the high-dose medication should be discontinued.
Changes in FEV1 between follow-up visits (≤ 12% change per week and ≤ 15% change per year for healthy adults) are of limited help in adjusting asthma treatment regimens in clinical practice. the minimum clinically important difference in FEV1 change (improvement and worsening of lung function) is 10%.
(4) PEF monitoring
Once the diagnosis of asthma is clear, short-term PEF monitoring is useful to assess the efficacy of treatment, to assess triggers for worsening symptoms (including at work), and to help develop an asthma implementation plan. Individual optimal PEF is generally achieved in about 2 weeks after initiation of ICS therapy, and over 3 months, mean PEF continues to improve and diurnal PEF variability decreases; large PEF variability indicates a lack of optimal asthma control and an increased risk of acute exacerbations.
Long-term PEF monitoring is currently recommended only for patients with severe asthma or those with significant perceived airflow limitation. In clinical practice, monitoring of PEF helps to enhance the accuracy of pulmonary function interpretation.
Asthma severity assessment
(1) How to assess asthma severity in clinical practice
Asthma severity can be assessed by retrospectively evaluating asthma symptom control and treatment at the time of an acute exacerbation. Asthma severity can be assessed once a patient has been on asthma control therapy for several months. The minimum effective dose of medication needed to treat the patient can be specified by step-down therapy. Asthma severity is not a static characteristic and can change over time (months or years).
Asthma severity can be assessed several months after a patient receives asthma control therapy.
Mild asthma is defined as well-controlled asthma with Tier 1 or Tier 2 therapy (Figures 3 – 5), e.g., emergency medications only as needed or with low-intensity control medications (e.g., low-dose ICS, leukotriene receptor antagonists, or ketones).
Moderate asthma is defined as well-controlled asthma with Tier 3 therapy (Figures 3 – 5), e.g., low-dose ICS / LABA.
Severe asthma is asthma that requires Level 4 or Level 5 asthma therapy (Figures 3 – 5), e.g., high-dose ICS / LABA is required to control asthma symptoms, or asthma control is suboptimal after the above treatments. Many patients with suboptimal asthma control may be due to inappropriate treatment, poor compliance, or comorbidities (e.g., chronic sinusitis, obesity). The European Respiratory Society/American Thoracic Society Task Force on Severe Asthma states that severe asthma should specifically refer to asthma patients with refractory asthma and comorbidities that are not satisfactorily controlled despite symptomatic management of asthma symptoms.
(2) Assessment of asthma severity in other literature
In epidemiology and clinical trials, asthma severity is usually determined based on the level of treatment (Figures 3 – 5). For example, asthma treated with Level 2 is referred to as mild asthma; asthma treated with Levels 3 – 4 is referred to as moderate asthma; and asthma treated with Levels 4 – 5 is referred to as moderately severe asthma. This severity assessment assumes that all patients are receiving appropriate treatment and that increasing treatment intensity is positively associated with increasing disease severity.
However, this method of reflecting severity by treatment level is flawed. Because many of the subjects in the study had suboptimal control of asthma symptoms at the time of enrollment. Therefore, for epidemiological and clinical trials, it is not recommended to classify patients by severity, but generally by patient treatment class.
(3) Other ways to describe severe asthma
“Severity” usually refers to the intensity of asthma symptoms, the magnitude of airflow limitation, or acute exacerbations. There are many different ways of classifying severity in the past asthma literature. Many are similar to the existing concept of asthma control.
If the degree of asthma symptoms is severe or occurs frequently, it is often considered to be severe asthma. However, this is not absolute, as many of these asthma can be rapidly controlled with ICS. The physician should inform the patient in detail what severe/severe asthma really means.
(4) Differential diagnosis of severe asthma and poorly controlled asthma
Although most patients with asthma have good control of asthma symptoms and a significant reduction in acute exacerbations with treatment; there are still some patients with asthma who do not achieve ideal asthma control (with the most aggressive asthma treatment). Some patients may be due to refractory asthma, but a significant proportion is due to comorbidities, persistent environmental allergen/irritant exposure, or psychological factors.
A differential diagnosis is needed between severe asthma, which is a more common cause of asthma symptoms and acute exacerbations, and poorly controlled asthma, which is more likely to be controlled and improved. The differential diagnosis is presented in Figures 2 – 4. Before a diagnosis of severe asthma can be made, it is necessary to exclude
Incorrect use of inhalers (a problem in more than 80% of community patients) (Figures 3 – 11)
Poor medication adherence (Figures 3 – 12)
Misdiagnosis of other conditions such as upper airway dysfunction, heart failure or unhealthy states as asthma (Figures 1 – 3)
Presence of comorbidities such as: sinusitis, gastroesophageal reflux disease, obesity and sleep apnea (Chapter 3)
Exposure to allergens or irritants in the home or work environment
Figure 2 – 4: Clearly poorly controlled asthma symptoms and/or acute exacerbation of asthma