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  • image Asthma is a highly prevalent disease that is a result of genetic predisposition and environmental interactions; it is one of the most common chronic diseases of childhood.

  • image Asthma is primarily a chronic inflammatory disease of the airways of the lung for which there is no known cure or primary prevention; the immunohistopathologic features include cell infiltration by neutrophils, eosinophils, T-helper type 2 lymphocytes, mast cells, and epithelial cells.

  • image Chronic asthma is characterized by either the intermittent or persistent presence of highly variable degrees of airflow obstruction from airway wall inflammation and bronchial smooth muscle constriction; in some patients, persistent changes in airway structure occur.

  • image Variability in response to medications requires individualization of therapy within existing evidence-based guidelines for management. This is most evident in patients with severe asthma phenotypes.

  • image Ongoing patient education, for a partnership in asthma care, is essential for optimal patient outcomes and includes trigger avoidance and self-management techniques.

  • image The inflammatory process in asthma is treated most effectively with corticosteroids, with the inhaled corticosteroids (ICSs) having the greatest efficacy and safety profile for long-term management.

  • image Bronchial smooth muscle constriction is prevented or treated most effectively with inhaled β2-adrenergic receptor agonists.


Patient Care Process for the Management of Persistent Asthma



  • Patient characteristics (eg, age, race/ethnicity, sex, pregnant)

  • Patient history (eg, past medical, known triggers, psychosocial history, gastroesophageal reflux disease)

  • Family history (eg, asthma, allergy, atopic dermatitis)

  • Home/work environment (eg, environmental, occupational, tobacco smoke, carpet/bedding, pets) (see Table 43-1)

  • Current medications and prior response to controller therapies (eg, ICS+/−LABA; montelukast; LAMA; biologic therapies)

  • Subjective and objective data (see Table 43-2)

    • Symptoms (description and frequency)

    • Nocturnal awakenings

    • Albuterol use frequency for symptom control

    • Activity limitation

    • Exacerbation frequency

    • Peak expiratory flow readings


  • Comorbid conditions (eg, allergies, rhinosinusitis, obesity, obstructive sleep apnea, gastroesophageal reflux, smoking)

  • Symptom frequency including exercise tolerance (see Tables 43-2 and 43-3)

  • Exacerbation history (eg, oral corticosteroid use, emergency department visits, hospitalization)

  • Current medications that may contribute to or worsen asthma (eg, nonsteroidal anti-inflammatory drug [NSAID], aspirin) (see Table 43-1)

  • Appropriateness and effectiveness of current medications in controlling symptoms and preventing exacerbations

  • Inhaler technique (see Fig. 43-7) and adherence; potential barriers

  • Socioeconomic barriers to obtain medications

  • Adherence to nonpharmacologic recommendations (eg, allergen avoidance, environmental control)


  • Tailored environmental modifications (eg, pet removal, carpet removal, pillow and mattress covers, exercise pretreatment, occupational exposures) (see Table 43-1)

  • Medication therapy regimen: dose, route, frequency, duration, and MDI spacer; specify the continuation and discontinuation of existing therapies (see Tables 43-3, 43-4, 43-5, 43-6, 43-8, 43-9, and 43-13)

  • Monitoring parameters including efficacy (eg, daily symptoms, nocturnal awakenings, albuterol use, exercise tolerance, peak expiratory flow [in selected patients]), and time frame (see Table 43-2)

  • Patient/family education (eg, purpose of treatment, environmental modifications, drug therapies, inhaler technique)

  • Self-monitoring of symptoms, albuterol use, peak expiratory flow (in selected ...

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