Chapter 44: Asthma

Update Summary

September 2023

The following sections, tables, and figures were updated:

• Numerous revisions were made throughout the chapter based on the recommendations from the 2023 Updates to the Global Initiative for Asthma (GINA) guidelines, including revisions to:

  • Desired Outcomes

  • Recommendations for SMART/MART therapy in the General Approach to the Management of Chronic Asthma

  • Recommendations to the General Approach to the Management of Acute Severe Asthma

  • Addition of the term anti-inflammatory reliever (AIR) therapy

• Extensive revisions have been to the Coronavirus Disease (COVID-19) section based on Centers for Disease Control and Prevention (CDC) data from the past 2 years and the National Institutes of Health (NIH) treatment guidelines.

• Revisions are done regarding the safety of leukotriene modifiers.

KEY CONCEPTS

• Asthma is a highly prevalent disease resulting from genetic predisposition and environmental factors; it is one of the most common chronic diseases of childhood.

• 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.

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

• 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.

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

• The inflammatory process in asthma is treated most effectively with corticosteroids, with the inhaled corticosteroids (ICS) having the greatest efficacy and safety with long-term use. ICS may be used in combination with bronchodilators (short-acting or rapid-onset long-acting β₂-adrenergic receptor agonists) or with long-acting muscarinic agonists (LAMA) as daily maintenance therapy.

• Acute bronchial smooth muscle constriction is prevented or treated most effectively with inhaled short-acting β₂-adrenergic receptor agonists (SABA) alone or in combination with ICS; or with rapid-onset, long-acting β₂-adrenergic receptor agonists (LABA) in combination with ICS.

• Intermittent as-needed SABA with an ICS can be used concomitantly in mild persistent asthma. The combination of formoterol (a LABA) with ICS can be used as daily maintenance and reliever therapy in moderate persistent asthma to reduce exacerbation frequency.

BEYOND THE BOOK

Watch the five short videos in the series Asthma Management Academy https://www.youtube.com/watch?v=pC2BrtVTYrU. These videos provide a brief overview of the following topics:

• Module 1 Scope of Asthma

• Module 2 Triggers

• Module 3 Medications

• Module 4 Medication Devices

• Module ...