What is the management plan for severe persistent asthma?

Management of Severe Persistent Asthma: CHRONICLE Study Summary

The CHRONICLE study is a key observational research study focused on real-world management of severe persistent asthma, providing valuable insights into treatment patterns and outcomes for patients with this challenging condition.

Unfortunately, the provided evidence does not contain specific information about the CHRONICLE study. However, I can provide a comprehensive management plan for severe persistent asthma based on the available evidence.

Management Plan for Severe Persistent Asthma

Assessment and Diagnosis

• Objective measurement of severity is critical, as underestimation of severity is a common factor in preventable asthma deaths 1
• Key assessment parameters include:
  • Ability to complete sentences in one breath
  • Pulse rate (>110 beats/min indicates severe asthma)
  • Respiratory rate (>25 breaths/min indicates severe asthma)
  • Peak expiratory flow (PEF) (<50% of predicted or best indicates severe asthma) 1

Pharmacological Management

First-Line Therapy

• Daily inhaled corticosteroids (ICS) are the cornerstone of treatment for severe persistent asthma, with addition of other controller medications as needed 2, 3
• For severe persistent asthma, high-dose inhaled steroids combined with long-acting beta-agonists (LABAs) are recommended 2, 4
• Consider adding theophylline if symptoms remain uncontrolled on ICS+LABA combination 2

Add-on Therapies for Severe Asthma

• Long-acting muscarinic antagonists (e.g., tiotropium) can be beneficial as an add-on therapy 4, 3
• For patients with eosinophilic phenotype, biologics should be considered:
  • Mepolizumab (anti-IL-5): Indicated for severe asthma with eosinophilic phenotype in patients ≥6 years old 5
  • Omalizumab (anti-IgE): For moderate to severe persistent allergic asthma in patients ≥6 years old with positive skin or blood test to year-round allergens 6, 4

Management of Acute Exacerbations

• Immediate treatment with:
  • Oxygen (40-60%)
  • Nebulized salbutamol 5 mg or terbutaline 10 mg
  • Prednisolone 30-60 mg or IV hydrocortisone 200 mg
  • Consider nebulized ipratropium or IV terbutaline 1
• Monitor response 15-30 minutes after treatment 1
• If signs of severe asthma persist:
  • Arrange hospital admission
  • Repeat nebulized ipratropium 0.5 mg or give subcutaneous terbutaline 1

Hospital Admission Criteria

• Life-threatening features
• Features of acute severe asthma persisting after initial treatment, especially PEF <33% 1
• Lower threshold for admission if:
  • Attack occurs in afternoon/evening
  • Recent nocturnal symptoms
  • Recent hospital admission or previous severe attacks
  • Patient unable to assess own condition 1

ICU Transfer Criteria

• Deteriorating PEF
• Worsening exhaustion, feeble respirations
• Persistent hypoxia or hypercapnia
• Coma, respiratory arrest, confusion, or drowsiness 1

Discharge Criteria and Follow-up

• Patient should have been on discharge medication for 24 hours
• Inhaler technique checked and recorded
• PEF >75% of predicted or best with diurnal variability <25%
• Treatment plan including steroid tablets and inhaled steroids
• Own PEF meter and self-management plan
• GP follow-up within 1 week
• Specialist follow-up within 4 weeks 1

Special Considerations

• Assess for steroid resistance, which is common in severe asthma and may require alternative approaches 7, 4
• Evaluate for comorbidities that may worsen asthma control (e.g., gastroesophageal reflux, allergies, upper airway disease) 7, 8
• Consider referral to specialized severe asthma service for patients with uncontrolled symptoms despite maximal therapy 8, 3

Self-Management Education

• Provide written action plan for managing exacerbations at home 2
• Ensure proper inhaler technique and medication adherence 2, 7
• Regular monitoring of symptoms and PEF 1

Common Pitfalls to Avoid

• Underestimation of asthma severity by patients and healthcare providers 1
• Underuse of corticosteroids in severe asthma 1
• Poor adherence to therapy, particularly inhaled corticosteroids 7
• Using long-acting beta-agonists alone without inhaled corticosteroids 3
• Failure to identify and address environmental triggers and comorbidities 7, 8

By following this comprehensive approach to severe persistent asthma management, clinicians can help improve symptom control, reduce exacerbations, and enhance quality of life for patients with this challenging condition.