2023-05-26 14:15:10
When it comes to asthma, there’s a lot to consider when it comes to diagnosis and therapy – a new guideline helps. Is it too long for you? Then read an overview of the most important things here.
At the Bronchial asthma It is a widespread multifactorial, heterogeneous disease characterized by bronchial hyperresponsiveness and/or variable airway obstruction. There is a lot to consider when it comes to diagnosis and therapy – that’s why Dr. Franziska Vocht presented the most important points in the DocCheck CME “Breathless – the pneumological hit webinar” on Wednesday evening. It was largely based on the latest specialist guidelineswhich was only released this March.
Asthma is not just asthma
The disease can be divided into different forms. A fairly rough but helpful measure is the age at the onset of the disease. A distinction is made between “early onset” in childhood and adolescence and “adult onset”. Asthma of the early-onset type is usually allergic, although it can also progress to intrinsic, i.e. non-allergic asthma. Adult-onset asthma, on the other hand, is often intrinsic from the start.
It doesn’t stop there, of course – there are many different phenotypes that can be distinguished. As already mentioned, there is a distinction between allergic and non-allergic asthma. Also of note is type 2 inflammation, which occurs in some asthmatics; one Eosinophilie in the blood of > 150/mL and a FeNO of > 20 ppb indicate this. Other phenotypes are, for example, exercise-induced asthma or drug-induced asthma, which is caused by intolerance to, among other things COX-1-Hemmer or painkillers like Ibuprofen or ASS.
What influencing factors are there?
Asthma does not develop in a vacuum – there are various factors that influence the development and severity of the disease and can be divided into endogenous and exogenous factors. Endogenous factors include genetic predisposition and also obesity – This not only leads to mechanical compression of the airways, but also promotes bronchial hyperreactivity through inflammatory processes. Gender is also a risk factor: in adulthood, women are more frequently affected, while boys are more affected in childhood and adolescence. Psychological factors can also play a role.
The first exogenous factors to be mentioned are, of course, allergens such as house dust mites or animal hair. There are also infections and environmental conditions. Vocht comments: “Growing up with a lot of contact with animals and the environment on the farm is clearly considered protective”. However, due to conflicting data, it is not possible to make a general statement on the influence of infections: “Some are protective, some are identified as contributing to the development of asthma.” Not only the baking profession, but also other professions can influence the development and severity of asthma through exposure to noxae . Last but not least, diet, medication intake and tobacco exposure also play a role.
Severe Asthma – Or Just Difficult To Treat?
Some patients do not have well-controlled disease despite maximum inhaled therapy. But is the disease really that severe or is the therapy just not optimal yet? According to Vocht, the first step should always be to check whether asthma is actually present – or whether a differential diagnosis has been overlooked. If asthma is actually present, there may be optimization options:
- Is the patient adequately trained?
- Does the patient use the inhaler regularly and correctly? Does the device fit the patient?
- Are avoidable triggers such as allergens eliminated as far as possible?
- Are there comorbidities that have been overlooked and left untreated?
If at least one of the questions is answered with no, these basic measures have to be tackled first. If, on the other hand, all possibilities have been exhausted, the asthma really is severe – then further phenotyping should be carried out and corresponding, specific additional therapy options should be considered.
Diagnosis on two tracks: anamnesis and lung function
Without a thorough anamnesis – like everywhere – nothing works. The typical symptoms should be queried: Does the patient report obstructive breathing noises when exhaling, coughing, shortness of breath and chest tightness? If more than one of these symptoms occurs, the symptom burden is more frequent and maximum at night or in the morning, symptoms vary in intensity and there are triggers – then the diagnosis of bronchial asthma is very likely. However, the medical history, comorbidities and family history must also be queried in order to be able to rule out another diagnosis with certainty. Vocht cites as an example AAT-Mangel as a common differential diagnosis that presents itself very similarly.
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The lung function must also be checked before a clear diagnosis can be made. The easiest way to detect an airway obstruction is and remains the Spirometrie. If an obstruction is found, further diagnostics follow, such as a bronchospasmolysis test, typically by inhaling Salbutamolto determine the variability. If no variability is found or no obstruction – after all, asthma patients usually come to the practice when they are asymptomatic and show normal lung function – provocation testing should be considered to detect bronchial hyperreactivity. One is tried and tested in everyday life Methacholin-Inhalation as a direct stimulus. However, it should be noted that bronchial hyperreactivity is not a unique feature of bronchial asthma allergic rhinitis or cystic fibrosis there’s that too.
New trend: FeNO measurement
One Diffusion capacity measurement serves primarily to rule out the differential diagnosis COPD: Classically, there is no gas exchange disorder in asthma.
FeNO measurement is still essential and is becoming increasingly important. The focus is on exhaled nitric oxide as a biomarker for airway inflammation. “Anything below 25 ppb is considered normal,” says Vocht. Such a value means even more testing for differential diagnoses, and for therapy also indicates that a response to steroids is less likely. Asthma is more likely with FeNO readings between 25 and 50 ppb; “above 50 ppb it supports the suspected diagnosis enormously”.
The FeNO measurement is not only interesting for diagnosis, but also guides the therapy – are more or less steroids useful? For example, in a symptom-free patient who is undergoing therapy, reducing the steroid dose can be considered if the FeNO is below 25 ppb – above 50 ppb it would be refrained from. Incidentally, there is also an innovation in the new guideline on the subject of FeNO: If no bronchial obstruction or bronchial hyperreactivity can be determined in a patient, the diagnosis of asthma can still be made if the FeNO is above 50 ppb and the patient is clinically on inhalative corticosteroid (ICS) responds.
Further diagnostics include a differential blood count to check for eosinophilia and total IgE to be able to determine. A sputum cytology is possible, but rather uninteresting due to the expense and questionable informative value. More important is the allergological step-by-step diagnostics: In any case, at least a thorough allergy anamnesis should be taken and, in the best case, also one Prick-Test. If there are further indications of an allergic component, further tests can follow.
On steps to therapeutic success
Let’s get to therapy. Of course, the well-known continues to apply here stage scheme. Something has changed in the new guideline, especially in the first two stages. “Here we now find the fixed combination of low-dose ICS and Formoterol as on-demand therapy in stage 1 and stage 2.” Alternatively, the administration of low-dose ICS as long-term therapy is possible, with SABA as on-demand therapy. However, Vocht criticizes that SABA are still too often prescribed for on-demand therapy as monotherapy or even used as long-term therapy. However, this is strongly discouraged: Studies have shown that the regular use of SABA leads to an increase in inflammation and can result in increased and severe exacerbations.
From level 3, the above-mentioned fixed combination continues to apply as basic therapy with increasing dosage of the ICS. These are preferred TWO (preferred) and LAMA for use. At stage 5 and the maximum ICS dosage, add-on therapy with biologicals should also be considered at this point, depending on the phenotype. Oral corticosteroids should be avoided apart from an acute exacerbation, especially in long-term therapy. They should only be used if biological therapy has failed.
In proven allergic asthma, allergen immunotherapy should be considered, regardless of the stage. Incidentally, biological therapy is not a contraindication. However, the therapy is only possible in the case of partially controlled or well-controlled allergic asthma.
Drugs aren’t everything
Incidentally, when choosing the drug therapy, it’s not just about the pure selection of the active ingredients – the inhalation device itself is also crucial and must suit the patient. In terms of coordination, he must be able to operate it correctly, which often becomes a problem with very old and very young patients. And the lung function must also be taken into account: Especially with restricted lung function – keyword COPD as a comorbidity – no devices like powder inhalers in question, which require a lot of breathing work.
The home page of German Airway League helps with the decision: there are all kinds of devices according to the required work of breathing listed. QR codes, which can be found on all newly prescribed devices, provide further assistance for patients. These lead to corresponding demonstration videos from the German Airways League for the specific device, which can help to minimize application errors. Vocht thinks it is essential to point this out to the patient, because it is essential that patients are properly trained in their inhalation device.
The most important thing, however, is not the drug therapy. Rather, the take-home message of the lecture is: The focus is on non-drug therapy, no matter what the level. This includes thoroughly educating the patient about their illness and minimizing triggers and environmental factors – so quitting is high on the list for smokers. Furthermore, the patients should exercise and play sports, and if necessary reduce their weight. Comorbidities must always be considered and treated by the physician. And the vaccination according to STIKO should not be forgotten at the end: A good protection against Influenza, pneumococci, SARS-CoV-2 and varicella infections pays off for patients.
Image source: Wilhelm Gunkel, Unsplash
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