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Asthma

Primary Care of Veterans with HIV

Organ Systems and Metabolic

April 2009; Last reviewed/updated: October 28, 2011

Background
Evaluation
Management
References
Table 1: Chronic Asthma: Maintenance Treatment according to Severity of Symptoms
Table 2: Acute Asthma Exacerbation: Treatment according to Severity of Symptoms
Table 3: Medications and Other Therapies
Table 4: Potential ARV Interactions

Note: Some medications mentioned in this chapter may not be available on the VHA National Formulary. Consult VA pharmacists for alternatives.

Key Points

Asthma is characterized by airway hyperresponsiveness, inflammation, and reversible obstruction.
Stepwise, multimodal treatment of asthma may decrease symptoms.
Patients should know their baseline peak expiratory flow rate (PEFR) measurements and their PEFR thresholds for seeking medical care.
Drug-drug interactions between PIs and certain medications may affect treatment.

Background

Asthma is a chronic inflammatory disorder of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning.
These symptoms are associated with airflow limitation that typically is reversible and responsive to bronchodilator therapy, unlike chronic obstructive pulmonary disease (see COPD).
In asthma, airflow limitation is secondary to airway hyperresponsiveness and narrowing (increased resistance to flow) caused by inflammation and edema. In contrast, in COPD (particularly in the case of emphysema), airflow limitation is primarily caused by lung tissue destruction and loss of recoil, and is largely irreversible.
Asthma is best distinguished from COPD (emphysema and chronic bronchitis) by clinical features such as:
- Marked variability in symptoms
- No history of cigarette smoking (although some asthmatics may smoke)
- Onset early in life (although asthma may present in adulthood)
- History of allergies such as hay fever

Because COPD may demonstrate partially reversible airflow obstruction, the response to a bronchodilator, particularly a single administration in the pulmonary function laboratory, may not reliably distinguish asthma and COPD.

Epidemiology

The prevalence of asthma in the United States is approximately 6-11%, depending on the population surveyed (higher prevalence among people living in the inner city).
75% of patients with asthma are diagnosed before the age of 7, although asthma may develop at any age.
A small cross-sectional study of 83 HIV-infected children and young adults showed that 34% of the subjects carried a clinical diagnosis of asthma, and 42% were using rescue bronchodilators.

Veterans with HIV*

Asthma: 6%

*Veterans in the VA HIV Clinical Case Registry in care in 2007 who had an ICD-9 code corresponding to this condition

Evaluation

Clinical Signs and Symptoms

Risk factors	Atopy Passive smoking Upper respiratory tract infections Beta-blockers (including ophthalmic formulations)
History	Favoring diagnosis of asthma	Favoring other diagnosis (especially COPD)
History	Wheezing Cough often worse at night Shortness of breath Chest tightness Episodic symptoms: hours to days Triggers: exercise (after 10-15 minutes), cold air, exposure to allergens (dust, molds, furry animals, cockroaches, pollens), GERD, aspirin or NSAIDs Personal or family history of atopy (including allergic rhinitis) Asthmatic symptoms as a child	Onset of symptoms at age >50 History of cigarette smoking Sputum production Lack of marked improvement after beta-agonist inhaler or oral steroids
Physical examination	Normal between exacerbations Wheezes (nonspecific, and may not be present) Rhonchi Prolonged expiration In severe exacerbations (status asthmaticus): Use of accessory muscles Tachypnea Tachycardia Prolonged expiratory phase Disappearance of wheezing as airflow diminishes (suggests impending respiratory arrest)
Imaging	Chest X ray usually normal; may show hyperinflation in severe disease
Pulmonary function tests	Spirometry is the preferred way to measure airflow limitation (see below) Peak flow rate assessment can aid in diagnosis and monitoring (see below)
Differential diagnosis	COPD Diffuse bronchiectasis Allergic bronchopulmonary aspergillosis Constrictive bronchiolitis Eosinophilic bronchitis Postviral bronchiolitis (usually reversible with time but not bronchodilators) Upper airway obstruction (tumors) Congestive heart failure

Pulmonary Function Testing

Definitions

Irreversible airflow obstruction: a post-bronchodilator forced expiratory volume in 1 second (FEV₁) to forced vital capacity (FVC) ratio of <0.70 (note: may be less specific in older people).
Reversible airflow obstruction: increase in post-bronchodilator FEV₁ of ≥200 mL or >12% of predicted value.
Partially reversible airflow obstruction: post-bronchodilator FEV₁/FVC <70% of predicted value despite significant bronchodilator responsiveness.

Spirometry: Measure FEV1, FVC, and bronchodilator response.
PEFR: Measure brief, forceful exhalation on a peak flow meter. Peak flow meters are inexpensive, provide objective, reproducible assessments of airflow, and may be ordered through a facility's Prosthetics Service for home use by patients.

The test can be performed with the patient sitting or standing. Instruct the patient to breathe in maximally, put meter to mouth, seal lips around mouthpiece, and blow as hard and as fast as possible into meter.
- Record patients' personal best PEFR when they feel well and have had a number of good trials on the meter.
- Normal peak flow range is 80-100% of the personal best PEFR.
- Normal variability in PEFR is 15-20%. Unchanged PEFR in the presence of symptoms suggests a diagnosis other than asthma.
- Average PEFRs vary by age, sex, and height.

If initial pulmonary function test (PFT) results are normal or unobtainable, but asthma is still suspected:

Have the patient record serial PEFR measurements and symptoms in a diary to determine whether there is evidence of intermittent airflow limitation that correlates with symptoms such as dyspnea, chest tightness, or cough.
Repeat evaluation when patient is symptomatic.
Consider performing serial measurements before and after bronchodilator treatment (this is helpful only if there is baseline airflow limitation at the time of testing).
To diagnose occupational asthma, test before and after occupational exposures; this can be done with spirometry or PEFR. Taking repeated PEFR measurements and keeping a symptom diary are simple to do and may provide more useful information.
Consider performing bronchoprovocation testing (methacholine or exercise challenge) for patients with atypical symptoms, such as chronic (rather than intermittent) cough or with normal baseline pulmonary function. Provocative testing should not be performed in patients who have typical asthma symptoms.

Management

Chronic Asthma

Goals

≤2 episodes/week of symptoms requiring treatment with short-acting beta-agonist (SABA) medication
Prevent exacerbations and need for emergency department visits
Minimize limitations on activity
Minimize toxicities

Monitoring and Intervention

Patients with asthma who use tobacco should be counseled to stop. (see Smoking Cessation)
At each visit, ask patients whether asthma has woken them from sleep, necessitated more rescue bronchodilator use than usual, necessitated urgent care or emergency room visits, or limited participation in usual activities.
Ask about control of triggers.
Provide an annual flu vaccination.
Instruct patients to perform serial PEFR measurements at home and workplace.
Determine each patient's baseline PEFR.
Determine each patient's PEFR threshold and symptom threshold for escalating therapy or seeking medical evaluation; see Table 2. Patients should know their baseline PEFRs and their PEFR thresholds. Written plans based on symptoms or PEFR thresholds improve disease control.
Review and instruct on correct use of inhalers with spacers. Patients who are unable to use spacers properly may need a nebulized formulation of a SABA.
Use of SABA >2 times per week generally indicates inadequate chronic control and may necessitate a "step-up" in treatment. See below.

Table 1: Chronic Asthma: Maintenance Treatment according to Severity of Symptoms
Severity	Classification Criteria	Treatment
There are important interactions between some inhaled corticosteroids and certain ARVs. See Table 4: Potential ARV Interactions*.
Intermittent	Symptoms ≤2 days/week Nighttime awakenings ≤2/month SABA use ≤2 days/week No interference with normal activity FEV₁>80% predicted or PEFR >80% personal best; FEV₁/FVC normal 0-1 exacerbations requiring oral steroids per year	Step 1: SABA, (eg, albuterol, levalbuterol, pirbuterol)
Mild Persistent	Symptoms >2 days/week Nighttime awakenings 3-4/month SABA >2 days/week but not daily Minor limitation with normal activity FEV₁ or PEFR ≥80%; FEV₁/FVC normal ≥2 exacerbations requiring oral steroids per year	Step 2: Low-dose inhaled corticosteroid (ICS)* (use lowest effective dosage; see medication chart for details) SABA, as needed Alternatives: cromolyn, leukotriene receptor antagonist (montelukast, zafirlukast), nedocromil, theophylline
Moderate Persistent	Symptoms daily Nighttime awakenings >1/week but not daily SABA daily Some limitation with normal activity FEV₁ or PEFR >60% and <80%, or FEV₁/FVC reduced 5% ≥2 exacerbations requiring oral steroids per year	Step 3: Low-dose ICS* and long-acting beta-agonist (LABA) (eg, salmeterol or formoterol) OR Medium-dose ICS* Consider short course of oral steroids (eg, prednisone 40 mg QD for 5 days) when initiating treatment SABA, as needed Alternatives: low-dose ICS* with leukotriene receptor antagonist, theophylline, or zileuton
Severe Persistent	Symptoms throughout the day Nighttime awakenings daily SABA several times per day Extreme limitation with normal activity FEV1 or PEFR <60%, or FEV1/FVC reduced >5% ≥2 exacerbations requiring oral steroids per year	Step 4: High-dose ICS* and LABA Combination ICS and LABA options include budesonide/formoterol and fluticasone/salmeterol* Step 5 (add to above): Consider omalizumab for patients with allergies, as evaluated by an immunologist

Print table

When to Refer
Disease severity moderate persistent or greater: refer to Pulmonary Atypical symptoms: refer to Pulmonary Elevated IgE levels: refer to Pulmonary or Allergy/Immunology

Table 2: Acute Asthma Exacerbation: Treatment according to Severity of Symptoms
Severity	Signs and Symptoms	Treatment
Mild	Dyspnea with activity or PEFR ≥80% personal best/predicted	Can be managed at home SABA Possible short course of oral systemic corticosteroids (5 days)
Moderate	Dyspnea limits usual activity or PEFR 60-80% personal best/predicted	Usually requires emergency department or office visit Frequent SABA Reassess after 1-2 hours; a good response includes a normal exam, no distress, PEFR>70%, O2 saturation >90%, and a sustained response for 60 minutes after the last treatment Oral steroids (40-80 mg QD) until PEFR >70% personal best/predicted
Severe	Dyspnea at rest, or lack or response to treatments for moderate-severity acute asthma or PEFR <60% personal best/predicted	Usually requires emergency department or office visit Frequent nebulized SABA with reassessments Oral steroids (40-80 mg QD) until PEFR >70% personal best/predicted
Life Threatening	Too dyspneic to speak, drowsy or confused	Requires emergency department visit, usually hospitalization Nebulized SABA and ipratropium hourly or continuous PO or IV steroids Consider magnesium sulfate infusion (2 g), heliox delivered albuterol Consider intubation in patients with persistent hypercapnia, exhaustion, depressed mental status