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Guidelines for Diagnosis and Management of Bronchial Asthma: Joint ICS/NCCP (I) Recommendations

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Guidelines for Diagnosis and Management of Bronchial Asthma: Joint ICS/NCCP (I) Recommendations [Downloaded free from http://www.lungindia.com on Friday, July 22, 2016, IP: 14.139.56.194] Guidelines for diagnosis and management of bronchial asthma: Joint ICS/NCCP (I) recommendations Ritesh Agarwal, Sahajal Dhooria, Ashutosh Nath Aggarwal, Venkata N Maturu, Inderpaul S Sehgal, Valliappan Muthu, Kuruswamy T Prasad, Lakshmikant B Yenge, Navneet Singh, Digambar Behera, Surinder K Jindal, Dheeraj Gupta*, Thanagakunam Balamugesh, Ashish Bhalla, Dhruva Chaudhry, Sunil K Chhabra, Ramesh Chokhani, Vishal Chopra, Devendra S Dadhwal, George D’Souza, Mandeep Garg, Shailendra N Gaur, Bharat Gopal, Aloke G Ghoshal, Randeep Guleria, Krishna B Gupta, Indranil Haldar, Sanjay Jain, Nirmal K Jain, Vikram K Jain, Ashok K Janmeja, Surya Kant, Surender Kashyap, Gopi C Khilnani, Jai Kishan, Raj Kumar, Parvaiz A Koul, Ashok Mahashur, Amit K Mandal, Samir Malhotra, Sabir Mohammed, Prasanta R Mohapatra, Dharmesh Patel, Rajendra Prasad, Pallab Ray, Jai K Samaria, Potsangbam Sarat Singh, Honey Sawhney, Nusrat Shafiq, Navneet Sharma, Updesh Pal S Sidhu, Rupak Singla, Jagdish C Suri, Deepak Talwar, Subhash Varma Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Indian Chest Society and National College of Chest Physicians, Chandigarh, Punjab, India *Author deceased after submission. Address for correspondence: Dr. Ritesh Agarwal, Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh ‑ 160 012, Punjab, India. E‑mail: [email protected] Contents: 1. When should a diagnosis of asthma be considered? Executive Summary • A clinical diagnosis of asthma should be suspected A. Introduction in the presence of recurrent/episodic wheezing, B. Methodology breathlessness, cough, and/or chest tightness with no C. Definition, Epidemiology and Risk Factors alternative explanation for these symptoms. (1A) D. Diagnosis of Asthma • None of the symptoms and signs are specific for E. Management of Stable Asthma asthma. (UPP) F. Management of Acute Exacerbations of Asthma • Absence of signs and symptoms at the time of G. Miscellaneous Issues in Asthma Management presentation does not rule out the presence of asthma. (1A) EXECUTIVE SUMMARY 2. What is the role of spirometry in the diagnosis of asthma? • Wherever available, spirometry is recommended for Asthma is defined as a chronic inflammatory disorder of all patients suspected to have asthma for confirming the airways which manifests itself as recurrent episodes diagnosis (3A), assessing severity of airflow of wheezing, breathlessness, chest tightness and cough. limitation (1A) and monitoring asthma control. (2A) It is characterized by bronchial hyper-responsiveness • A normal spirometry does not rule out asthma. (1A) and variable airflow obstruction, that is often reversible • The ratio of forced expiratory volume in the first either spontaneously or with treatment. The prevalence of second (FEV1) to forced vital capacity (FVC) below the asthma in India is about 2%, and asthma is responsible for lower limit of normal (lower 5th percentile of values significant morbidity. In India, the estimated cost of asthma from reference population) should be preferentially used treatment per year for the year 2015 has been calculated as the criterion to diagnose airflow obstruction. (1A) at about 139.45 billion Indian rupees. • When reference equations for lower limit of normal are not available a fixed cut off of FEV1/FVC <0.75 for Access this article online older subjects and <0.8 for younger individuals may Quick Response Code: be used to diagnose airflow obstruction. (UPP) Website: www.lungindia.com 3. What is the role of reversibility testing in asthma? • Bronchodilator reversibility is a useful investigation in DOI: the diagnostic workup for asthma and is recommended 10.4103/0970-2113.154517 if spirometry demonstrates presence of airflow limitation. (2A) Lung India • Vol 32 • Supplement 1 • Apr 2015 S3 [Downloaded free from http://www.lungindia.com on Friday, July 22, 2016, IP: 14.139.56.194] Agarwal, et al.: Asthma guidelines • If spirometry is not available, bronchodilator 11. What is the role of inhaled corticosteroids (ICSs) in reversibility may be assessed with peak expiratory asthma? flow (PEF) meters. (3B) • ICSs are the controller medication of choice for • Presence of bronchodilator reversibility is neither management of stable asthma. (1A) diagnostic of asthma nor its absence rules out asthma. (1A) • All the ICSs are equally efficacious when used in equipotent doses. (1A) 4. What is the role of PEF monitoring in asthma? • Most of the clinical benefit from ICS is obtained at low • PEF measurements should not be used interchangeably to moderate doses. Only a minority of patients benefit with FEV1 measurements. (1A) from increasing the dose beyond this. (1A) • Self‑monitoring of PEF by patients is recommended for • ICS should be started at low to moderate better asthma control. (1A) dose (depending on the severity of symptoms at presentation) and used at lowest possible dose 5. Do bronchoprovocative tests help in the diagnosis and required. (1A) management of asthma? • High-dose ICS use should preferably be avoided • Bronchoprovocative testing is not recommended as a to decrease the risk of side effects, both local and routine test in the diagnosis of asthma. (1A) systemic. (1A) • Methacholine challenge can be used to exclude • We recommend the use of valved holding chambers/ asthma as a differential especially when spirometry is spacers whenever using moderate to high-dose normal. (2A) ICS. (UPP) • Tests for bronchial hyper‑responsiveness are to be performed in specialized centers only. (UPP) 12. What is the role of long‑acting beta‑2 agonists (LABA) in stable asthma? 6. What is the role of chest radiography in asthma? • LABA monotherapy should not be used in the • Chest radiograph is not routinely recommended for management of stable asthma. (1A) patients suspected to have asthma. (2A) • Addition of LABA to ICS is the preferred choice when • A chest radiograph in a stable asthmatic may be symptoms are uncontrolled despite ICS monotherapy considered when alternate diagnosis or complication in moderate doses. (1A) of asthma is suspected. (UPP) 13. What is the role of leukotriene receptor antagonists 7. What is the role of non‑invasive markers of inflammation (LTRAs) in stable asthma? in asthma management? • Monotherapy with LTRA is inferior to monotherapy • Quantification of eosinophil count in sputum (<2% with ICS. (1A) normal, >2% suggestive of eosinophilic inflammation) • Monotherapy with LTRA might be an alternative can guide inhaled corticosteroid (ICS) therapy, thereby to ICS in patients with mild asthma if they are reducing the risk of exacerbations in adults with unwilling to use ICS or if they are not suitable for moderate to severe asthma. (2A) ICS therapy. (1B) • Measuring the exhaled breath fractional nitric • As add-on to ICS, LTRAs are inferior to LABA. (1A) oxide (FENO) is not recommended routinely in the • Addition of LTRA might be beneficial in patients whose management of asthma. (2A) asthma remain uncontrolled despite the ICS/LABA combination. (2B) 8. What is the role of testing the allergic status of an asthmatic patient? 14. What is the role of long‑acting anti‑muscarinic agent • Tests for allergic status by measurement of total IgE, tiotropium in the management of stable asthma? specific IgE to various environmental allergens, and Tiotropium may be used as add-on therapy if asthma skin prick tests are not recommended routinely for the diagnosis or management of asthma. (UPP) Level of current asthma control (over the preceding 4 • These tests may however be done in specialized centers weeks) when specific triggers are suspected. (UPP) Components Adequately controlled Inadequately (All 4 need to be present) controlled (any one) 9. How to categorize the severity of stable asthma? Day time symptoms or Twice or less in a week More than twice a We do not recommend classifying asthma based on severity rescue medication use week of asthma. Night time symptoms/ None Any awakening 10. How to assess asthma control during follow up? Limitation of activities None Any Pulmonary function Normal (FEV % >80% Decreased (FEV % Asthma control should be classified as adequate or 1 1 (PEF, FEV1%) predicted, PEF >80% <80% predicted, PEF inadequate based on day time symptoms (or rescue personal best*) <80% personal best*) medication use), night time symptoms/awakening, *when personal best is not known PEF <80% of the predicted limitation of activities and pulmonary function (PEF, FEV %) 1 can be used, FEV1: Forced expiratory volume in the first second, as described in the Table below. PEF: Peak expiratory flow S4 Lung India Vol 32 • Supplement 1 • Apr 2015 [Downloaded free from http://www.lungindia.com on Friday, July 22, 2016, IP: 14.139.56.194] Agarwal, et al.: Asthma guidelines remains uncontrolled despite moderate-to-high-dose ICS • Oral beta-agonists should not be used as rescue and LABA combination therapy. (1A) medications.(UPP) 15. What is the role of long‑acting methylxanthines in the 17. What is the role of using a single inhaler for management of stable asthma? maintenance and reliever therapy? • Methylxanthine monotherapy is inferior to ICS We prefer the use of single inhaler therapy (SiT) monotherapy. (1A) using an ICS/LABA combination (formoterol-based) as • When stepping up from ICS monotherapy, addition both maintenance and reliever medication whenever of methylxanthine to ICS is as effective as doubling feasible (steps 3-5, as described below). (1A) the dose of ICS (1A) but inferior to the ICS/LABA combination. (2A) 18. What should be the strategy for management of stable • Methylxanthines may be used as an add-on therapy asthma in the Indian context? in patients who remain uncontrolled on a moderate to We recommend a five-step approach for the management of high ICS/LABA combination. (2B) stable asthma with an aim to achieve and maintain asthma • Whenever used as an add-on to ICS, we recommend control as shown in the Table below. using low dose (200-400 mg/day) sustained release formulations of theophylline.
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