Evaluation of patients with asthma should include a history with questions about seasonal increases in pulmonary symptoms; other allergic symptoms; exposure to tobacco; and exposure to allergens at home, at work, or outdoors.
Initial work up for asthma should include
a) Spirometry with reversibility testing by a bronchodilator.
b) Allergy testing ( blood/ skin) testing is one of the most useful ways to determine specific allergen sensitivity. The National Asthma Education and Prevention Programme (NAEPP) Expert Panel guidelines for the management of asthma recommend that patients who require daily asthma medications have allergy testing for aeroallergens, including perennial indoor allergens. Testing is recommended for allergens to which the patient is exposed rather than testing with a standard panel. A negative test result generally rules out the possibility that an allergen is having an impact on the patient’s asthma.
c) Chest radiographs are taken only if pneumonia, large airway lesions, or heart failure is suggested.
d) Consider CT scans of the sinuses if chronic sinusitis is suggested. About 65 per cent of people with severe asthma have concomitant sinusitis.
The goals of treatment are to minimize symptoms, improve quality of life, decrease the need for urgent care or hospitalizations, normalize pulmonary function test results, and decrease the inflammatory process that leads to airway remodelling. Asthma treatment plan should be customized and patient specific. The treatment plan should be written down and adjusted according to changes in symptoms.
Medications used to treat asthma are divided into two general classes: quick-relief medications used to treat acute symptoms; and long-term control medications used to prevent further exacerbation. Short acting beta2-adrenoceptor agonists (SABA), such as salbutamol is the first line treatment for asthma symptoms. Anticholinergic medications, such as ipratropium bromide provide addition benefit when used in combination with SABA in those with moderate or severe symptoms. To achieve long-term control, glucocorticoids are the most effective treatment available for long-term control. Inhaled forms are usually used except in the case of severe persistent disease, in which oral steroids may be needed. Inhaled formulations may be used once or twice daily, depending on the severity of symptoms. Long acting beta-adrenoceptor agonists (LABA) have at least a 12-hour effect. They are however not to be used without a steroid due to an increased risk of severe symptoms. Leukotriene antagonists is an alternative to inhaled glucocorticoids, but is not preferred.
Treatment focused on controlling the allergic component depends on education about avoiding allergen exposure. Physicians should consider the potential benefits and the ability of the patient to comply when deciding whether to recommend this approach. The avoidance measure should be allergy specific, communicated effectively and time bound.
Allergen immunotherapy should be considered only if specific allergens have a proven relationship to symptoms; the individual is sensitized (i.e., positive skin test or RAST findings); the allergen cannot be avoided and is present year-round (e.g., occupational); or symptoms are poorly controlled with medical therapy. This treatment is especially useful if asthma is associated with allergic rhinitis.
Allergen-specific immunotherapy is aimed at modifying the natural history of allergy by inducing tolerance to the causative allergen. In its traditional, subcutaneous form, immunotherapy has complete evidence of efficacy in allergic asthma. Sublingual Immunotherapy is the method of allergy treatment that uses an allergen solution given under the tongue, which over the course of treatment reduces sensitivity to allergens. Sublingual immunotherapy, or SLIT, has a very good safety profile and is given at home in adults and children.