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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2804_Библиотеки_им_академика_М_И_Перельмана
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severityofCOPD.
Supplementaloxygenshouldbeadministeredwithatargetoxygensaturationof88%–92%.
Thromboprophylacticmeasuresshouldbeusedgiventheincreasedriskofdeepvenousthrombosisin
patientshospitalizedforCOPDexacerbations.
37
NIV(Table9-8)shouldbeconsideredthefirstmodeofventilatorsupportasitreducesintubationrate,
improvesrespiratoryacidosis,decreasesrespiratoryrate,anddecreaseshospitallengthofstay.
TABLE9-8
INDICATIONSANDCONTRAINDICATIONSFORNONINVASIVEVENTILATIONINACUTE
EXACERBATIONSOFCHRONICOBSTRUCTIVEPULMONARYDISEASE
Indications Contraindications
Moderatetoseveredyspneawithevidenceofincreased
workofbreathing
Respiratoryarrest
Hemodynamicinstability
Alteredmentalstatus,inabilityto
cooperate
AcuterespiratoryacidosiswithpH≤7.35and/orPaCO
2
>45mmHg(6kPa)
Highriskofaspiration
Viscousorcopioussecretions
Recentfacialor
gastroesophagealsurgery
Respiratoryrate>25/min Craniofacialtrauma
Fixednasopharyngeal
abnormalities
Burns
Extremeobesity
DatafromtheGlobalStrategyforDiagnosis,Management,andPreventionofCOPD;2021.©GlobalInitiativeforChronic
ObstructiveLungDisease(GOLD).
Endotrachealintubationandinvasivemechanicalventilationarerequiredinsomepatients(Table9-
9).
TABLE9-9
INDICATIONSFORINVASIVEMECHANICALVENTILATIONINACUTEEXACERBATIONS
OFCHRONICOBSTRUCTIVEPULMONARYDISEASE
Failuretoimprovewithornotacandidatefornoninvasiveventilation(seeTable9-8)
Severedyspneawithevidenceofincreasedworkofbreathing
AcuterespiratoryacidosiswithpH<7.25and/orPaCO2>60mmHg(8kPa)
PaO2<40mmHg(5.3kPa)
Respiratoryrate>35/min
Coexistingconditionssuchascardiovasculardisease,metabolicabnormalities,sepsis,
pneumonia,pulmonaryembolism,pneumothorax,andlargepleuraleffusion
DatafromtheGlobalStrategyforDiagnosis,Management,andPreventionofCOPD;2021.©GlobalInitiativeforChronic
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ObstructiveLungDisease(GOLD).
Discharge criteria for patients with acute exacerbations of COPD include the need for inhaled
bronchodilatorslessfrequentlythanevery4hours;clinicalandABGstabilityforatleast12–24hours;
the ability to eat, sleep, and ambulate fairly comfortably; adequate patient understanding of home
therapy;andadequatehomearrangements.Beforedischargingfromthehospital,chronictherapyissues
should bereaddressed,includingsupplementaloxygenrequirements,vaccinations,smokingcessation,
assessmentofinhalertechnique,andreferraltopulmonaryrehabilitation.
Asthma
GENERALPRINCIPLES
Definition
Asthma is a common airway disease characterized by chronic airway inflammation and variable
obstruction wherein patients frequently have paroxysms of cough, dyspnea, chest tightness, and
wheezing.
Patients with asthma frequently have episodic acute exacerbations that are interspersed with
periods of symptomatic variability. Exacerbations are characterized by a progressive increase in
asthma symptoms that can last minutes to hours and are frequently associated withviral infections,
allergens,andoccupationalexposures.
Classification
Whentreating asthma,severityshouldbecarefullyclassified bythe clinicianbased onboth level of
impairment (symptoms, lung function, daily activities, and rescue medication use) and risk
(exacerbations,lungfunctiondecline,andmedicationsideeffects).
Attheinitialclinicalevaluation,aclinicianshoulddetermineapatient’s asthmaseveritylevel.Ifthe
patient is not already on controller medications, severity is determined based on the most severe
categoryinwhichanyfeatureappears(Table9-10).Onsubsequentvisits,orifthepatientisalreadyon
acontrollermedicationattheinitialencounter,severityisbasedontheloweststepoftherapyrequired
tomaintainclinicalcontrol(Table9-11).
TABLE9-10
CLASSIFICATIONOFASTHMASEVERITYONINITIALASSESSMENT
Intermittent MildPersistent Moderate
Persistent
Severe
Persistent
Daytime
symptoms
≤2d/wk ≥2d/wkbutnot
daily
Daily Throughout
theday
Nighttime
symptoms
≤2×/mo 3–4×/mo ≥1×/wkbut
notnightly
Nightly
Activity None Minor Some Extreme
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limitations
Reliever
medicineuse
≤2d/wk ≥2d/wkbutnot
daily
Daily Several
timesper
day
FEV
1
≥80% ≥80% 60%–80% <60%
Exacerbations 0–1×/y ≥2×/y ≥2×/y ≥2×/y
Management Step1 Step2 Step3 Step4 Step5
Preferred SABAas
neededor
low-doseICS
+rapidonset
LABAas
needed
Low-doseICS+
SABAasneeded
orlow-doseICS+
rapidonsetLABA
asneeded
Low-dose
ICS-LABAor
medium-dose
ICSwith
SABAas
needed
Medium-or
high-dose
ICS+LABA
Add-on
therapy:i.e.,
anti-IL-5/α,
anti-IL-4α,
omalizumab
Alternative Low-doseICS
+SABAas
needed
Low-doseICS+
SABAasneeded
ordailyLTRA
Low-dose
ICSwith
LTRA
High-dose
ICS+LTRA
or
theophylline
Consider
LAMA,shortcourseOCS,
chronic
macrolide,
bronchial
thermoplasty
In2–6wk,evaluatelevelofasthmacontrolandadjusttherapyaccordingly.
Datafromthe2020GINAReport:GlobalStrategyforAsthmaManagementandPrevention.GlobalInitiativeforAsthma–GINA.
Updated2020.AccessedFebruary24,2021.https://ginasthma.org/gina-reports/andNAEPPThirdExpertPanelonthe
DiagnosisandManagementofAsthma.https://www.jacionline.org/action/showPdf?pii=S0091-6749%2820%2931404-4.
AccessedFebruary24,2021.
FEV1,forcedexpiratoryvolumein1second;ICS,inhaledcorticosteroid;IL,interleukin;LABA,long-actingβ2-agonist;LAMA,longactingmuscarinicantagonist;LTRA,leukotrienereceptorantagonist;OCS,oralcorticosteroid;SABA,short-actingβ2-agonist.
TABLE9-11
ASSESSMENTOFASTHMACONTROL
WellControlled NotWell
Controlled
VeryPoorlyControlled
Daytime
symptoms
≤2d/wk >2d/wk Throughouttheday
Nighttime
symptoms
None 1–3×/wk ≥4×/wk
Activity
limitations
None Some Extreme
Reliever
medicineuse
≤2×/wk >2×/wk Frequent
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FEV1orPEF ≥80% 60%–80% <60%
Validated
questionnaire
ACT≥20
ACQ<0.75
ACT16–19
ACQ>1.5
ACT≤15
Exacerbations 0–1/y ≥2×/y ≥2×/y
Management Maintainatloweststep
possible
Considerstepdownifwell
controlledfor≥3mo
Stepupone
step
Stepuponetotwostepsand
considershort-courseOCS
Follow-up 1–6mo 2–6wk 2wk
Datafromthe2020GINAReport:GlobalStrategyforAsthmaManagementandPrevention.GlobalInitiativeforAsthma–GINA.
Updated2020.AccessedFebruary24,2021.https://ginasthma.org/gina-reports/andNAEPPThirdExpertPanelonthe
DiagnosisandManagementofAsthma.AccessedFebruary24,2021,https://www.jacionline.org/action/showPdf?pii=S0091-
6749%2820%2931404-4
ACQ,AsthmaControlQuestionnaire;ACT,AsthmaControlTest;FEV1,forcedexpiratoryvolumein1second;OCS,oral
corticosteroids;PEF,peakexpiratoryflow.
Theseverityofanasthma exacerbationshouldbeclassifiedbasedonsymptoms,signs, andobjective
measuresoflungfunction(Table9-12).
TABLE9-12
CLASSIFICATIONOFASTHMAEXACERBATIONSEVERITY
Moderate Severe ImpendingRespiratoryArrest
FEV1orPEF
predictedor
personalbest
40%–69% <40% <25%orunabletomeasure
Symptoms DOEorSOB
withtalking
SOBatrest SevereSOB
Examination Expiratory
wheeze
Some
accessory
muscleuse
Inspiratoryand
expiratory
wheeze
Increased
accessory
muscleuse
Chestretraction
Agitationor
confusion
Wheezemaybecomeabsent
Accessorymuscleusewithparadoxical
thoracoabdominalmovement
Depressedmentalstatus
Vitals RR<28/min
HR<110bpm
O2sat>91%
RA
Nopulsus
RR>28/min
HR>110bpm
O2sat<91%RA
Pulsus
paradoxus>25
Sameasseverebutcoulddevelop
respiratorydepressionand/or
bradycardia
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paradoxus mmHg
PaCO
2
Normalto
hypocapnia
>42mmHg Hypercapniaisalatesign
Datafromthe2020GINAReport:GlobalStrategyforAsthmaManagementandPrevention.GlobalInitiativeforAsthma–GINA.
Updated2020.AccessedFebruary24,2021.https://ginasthma.org/gina-reports/andNAEPPThirdExpertPanelonthe
DiagnosisandManagementofAsthma.AccessedFebruary24,2021.https://www.jacionline.org/action/showPdf?pii=S0091-
6749%2820%2931404-4
DOE,dyspneaonexertion;FEV1,forcedexpiratoryvolumein1second;HR,heartrate;O2sat,oxygensaturation;PEF,peak
expiratoryflow;RA,roomair;RR,respiratoryrate;SOB,shortnessofbreath.
While the majority of patients with asthma can achieve disease control with controller therapy,
approximately 5% of patients with asthma have severe persistent disease that remains inadequately
controlled despiteadherence to standardtreatments. These patients carrya significantamount ofthe
morbidity,mortality,andhealthcareutilizationthatisassociatedwithasthma.
Epidemiology
IntheUS
Asthmaishighlyprevalentaffectingmorethan300millionpeopleworldwide andapproximately8%
oftheAmericanpopulation.
38
The prevalence of asthma is highest among African-Americans, is inversely associated with
socioeconomicstatus,andisawell-recognizedhealthinequityintheUS.
39
Etiology
Possiblefactorsassociatedwithasthmadevelopmentcanbebroadlydividedintohost,genetic,and
environmentalfactors.
There have been multiple genes, chromosomal regions, and epigenetic changes associated with the
developmentofasthma.Racialandethnicdifferenceshavealsobeenreportedinasthmaandarelikely
theresultofacomplexinteractionbetweengenetic,socioeconomic,andenvironmentalfactors.
Therearemultipleenvironmentalfactorsthatcontributetothedevelopmentandpersistenceofasthma.
Severe viral infections early in life, particularly respiratory syncytial virus and rhinovirus, are
associatedwiththedevelopmentofasthmainchildhoodandplayaroleinitspathogenesis.
Childhoodexposureandsensitizationtoavarietyofaeroallergensandirritants(e.g.,cigarettesmoke,
mold,petdander,dustmites,cockroaches)mayplayaroleinthedevelopmentofasthma,buttheexact
nature of this relationship is not yet fully elucidated. By contrast, early-life exposure to indoor
allergens together with certain bacteria (microbiota) may be protective for urban children. The
prevalenceofasthmainchildrenraisedinaruralsettingisreduced,althoughthereasonforthisisnot
fullyknown.
Pathophysiology
Asthmaischaracterizedbyvariableairflowobstruction,hyperinflation,andairflowlimitationresulting
frommultipleprocessesincludingthefollowing:
Acuteandchronicairwayinflammationcharacterizedbyinfiltrationofthe airwaywall, mucosa,and
lumenby activated eosinophils, mast cells, macrophages, andT lymphocytes. Components ofinnate
immunity including natural killer T cells, neutrophils, and innate lymphoid lymphocytes are also
implicated.
Bronchial smooth muscle contraction resulting from mediators released by a variety of cell types
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includinginflammatory,localneural,andepithelialcells.
Epithelialdamagemanifestedbydenudationanddesquamationoftheepitheliumleadingtomucusplugs
thatobstructtheairway.
Airwayremodelingcharacterizedbythefollowingfindings:
Subepithelialfibrosis,specificallythickeningofthelaminareticularisfromcollagendeposition.
Smoothmusclehypertrophyandhyperplasia.
Gobletcellandsubmucosalglandhypertrophyandhyperplasiaresultinginmucushypersecretion.
Airwayangiogenesis.
Airwaywallthickeningduetoedemaandcellularinfiltration.
RiskFactors
Anumberoffactorsincreaseairwayhyperresponsivenessandcancauseanacuteandchronicincreasein
theseverityofasthma:
Allergenssuchasdustmites,cockroaches,pollens,molds,andpetdanderinsusceptiblepatients.
Viralupperrespiratorytractinfections.
Many occupational allergens and irritants such as perfumes, cleaners, or detergents, even in small
doses.
Changesinweather(i.e.,fromwarmtocold),strongemotionalstimuli,andexercise.
Indoorandoutdoorpollutants,suchasnitrogendioxide(NO2)andtobaccoandwoodsmoke.
Obesity.
Medicationssuch asβ-blockers (includingophthalmicpreparations),aspirin,andNSAIDscancause
thesuddenonsetofsevereairwayobstruction.
Prevention
Rigoroustreatmentadherenceandappropriatefollow-upcanhelppreventworseningofasthmacontrol.
Identificationandavoidanceofriskfactors(allergens,irritants)thatexacerbatesymptoms playakey
roleinprevention.
Recognitionandmanagement of comorbidities such as obesity, sinonasal diseases, gastroesophageal
refluxdisease(GERD),andpsychiatricdisordersisimportant.
AssociatedConditions
Rhinosinusitis,withorwithoutnasalpolyps,isfrequentlypresentandshouldbetreatedwithintranasal
or oral corticosteroids, saline rinses, and/or antihistamines. Antibiotics should be reserved for
superimposedbacterialinfections.
Vocalcorddysfunction(VCD)orparadoxicalvocalfoldmovementcancoexistwithormasquerade
severe, uncontrolled asthma. Diagnosis often requires provocation testing with laryngoscopy by
otolaryngologyspecialists.Treatmentconsistsofspeechand,ifneeded,behavioraltherapy.
Symptomatic GERD can cause worsening asthma control and treatment with H2 blockers or proton
pumpinhibitorsisrecommendedinthesecases.However,empirictreatmentofGERDinasymptomatic
patientswithuncontrolledasthmaisnotaneffectivestrategy.
Obesityis increasinglyrecognizedas animportantcomorbidconditionanditspresence is inversely
correlated with asthma control. This association may be related to altered lung mechanics, altered
respiratorypatterns,oranincreaseinsystemicinflammation.Healthyweightlossshouldbeanintegral
partofacomprehensiveasthmatreatmentplan.
Smoking prevalence in patients with asthma is the same as the general population. Although no
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convincingevidencelinkstobaccousewithdevelopingasthma,itmaymakepatientslessresponsiveto
ICSandmoredifficulttocontrol.Tobaccocessationshouldbeencouragedinallpatients.
OSA may make asthma more difficult to control and should be addressed with an overnight
polysomnogramifsuspected.
DIAGNOSIS
ClinicalPresentation
HISTORY
Recurring episodes of cough, dyspnea, chest tightness, and wheezing are suggestive of asthma.
Symptomsareoftenworseatnightorearlymorning,inthepresenceofpotentialtriggers,and/orina
seasonalpattern.
Apersonalorfamilyhistoryofatopyincreasesthelikelihoodofanasthmadiagnosis.
Patientsolderthan50yearspresentingforthefirsttime,patientswith>20pack-yearsofsmoking,and
patientswithalackofresponsetoasthmatherapyarefeaturesthatmakeasthmalesslikelyasthesole
cause of respiratorysymptoms. Alternative diagnoses including COPD,ACO, andothers should be
carefullyconsideredinthesepatients.
PHYSICALEXAMINATION
Chronicasthma
Auscultationof wheezing anda prolonged expiratory phase canbe presenton examination,but a
normalchestexaminationdoesnotexcludeasthma.
Signsofatopy,suchaseczema,rhinitis,ornasalpolyps,oftencoexistwithasthma.Thepresenceof
nasalpolypsshouldpromptquestioningregardingthepossibilityofaspirin-exacerbatedrespiratory
disease(AERD).
Asthmaexacerbation
Duringasuspectedasthmaexacerbation,arapidassessmentshouldbeperformedtoidentifypatients
whorequireimmediateintervention(Table9-12).
Thepresenceorintensityofwheezingisanunreliableindicatoroftheseverityofanattack.
DiagnosticCriteria
In general,the diagnosis issupportedbythepresenceofsymptoms consistent withasthmacombined
withdemonstrationofvariableexpiratoryairflowobstruction.
Adequateresponsetoasthmatreatmentassistswithmakingthediagnosis.
Methacholine challenge testcan be considered when the diagnosis is in question. Note that airway
hyperresponsivenesscanbeseenindiseasesotherthanasthma(e.g.,COPD,sarcoidosis)andeffective
asthmacontrollermedications(suchasICS)cannormalizetheresult(see“DiagnosticTesting”below).
DifferentialDiagnosis
Otherconditionsmaypresentwithwheezingandmustbeconsidered,especiallyinpatientswhoarenot
responsivetotherapy(Table9-13).
TABLE9-13
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CONDITIONSTHATCANPRESENTASREFRACTORYASTHMA
UpperAirwayObstruction
Tumor
Epiglottitis
Vocalcorddysfunction
Obstructivesleepapnea
LowerAirwayDisease
Allergicbronchopulmonaryaspergillosis
Chronicobstructivepulmonarydisease
Cysticfibrosis
α1-Antitrypsindeficiency
Bronchiectasis
Bronchiolitisobliterans
Tracheomalacia
Endobronchiallesion
Foreignbody
Herpetictracheobronchitis
AdverseDrugReaction
Aspirin
β-Adrenergicantagonist
Angiotensin-convertingenzymeinhibitors
Inhaledpentamidine
Congestiveheartfailure
Gastroesophagealreflux
Sinusitis
Hypersensitivitypneumonitis
Eosinophilicgranulomatosiswithpolyangiitis(Churg–Strauss)
Eosinophilicpneumonia
Hyperventilationwithpanicattacks
Dysfunctionalbreathlessness
DiagnosticTesting
LABORATORYSTUDIES
Chronicasthma
Althoughlaboratoryanalysisisnotnecessaryforadiagnosis,acompletebloodcountwithcellular
differential should be obtained to assist with clinical phenotyping (i.e., to identify those with
predominanteosinophilia—absoluteperipheralbloodeosinophillevelof0.3×109/mm3orgreater).
Adiagnosisofallergicbronchopulmonaryaspergillosis(ABPA),whichisduetoahypersensitivity
reactiontoAspergillusfumigatus,shouldbecarefullyconsideredineachpatient andis present in
1%–2%ofasthmapatientswithpersistentdisease. SerumIgElevels,precipitatingantibodiestoA.
fumigatus,orelevatedA.fumigatus–specificantibodiesshouldbetestedtoaidinthediagnosis.
Allergyskintestsor immunoassaysforallergen-specificIgEarehelpfultoidentifysensitizationto
specific inhalant allergens when allergen exposures are being concerned as a trigger. Results of
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allergytestsmustcorrelatewithhistoryandclinicalpresentation.
Fractionalconcentrationof exhaled nitric oxide (FeNO)may be usedas a markerof eosinophilic
airwayinflammationinasthma.AnFeNOlevel>50partsperbillion(ppb)isassociatedwithagood
responsetoICStherapy.
Asthmaexacerbation
During an exacerbation, monitor oxygen saturation. ABG measurement should be considered in
patientsinseveredistressorwithanFEV1of<40%ofpredictedvaluesafterinitialtreatment.
APaO2<60mmHgisasignofseverebronchoconstrictionorofacomplicatingcondition,suchas
pulmonaryedema,pulmonaryembolism,orpneumonia.
Initially, during an exacerbation,the PaCO2 is low due toanincrease in respiratoryrate. With a
prolongedattack,thePaCO2mayriseasaresultofsevereairwayobstruction,increaseddeadspace
ventilation,andrespiratorymusclefatigue. AnormalorincreasedPaCO2isa signof impending
respiratoryfailureandnecessitateshospitalizationandclosemonitoring.
IMAGING
Althoughnotnecessaryforthe diagnosis ofasthma,CXRs maybe helpful toexaminefor alternative
diagnoses that are associated with wheezing such as emphysema, pulmonary edema, or
tracheobronchialobstruction.CXRsareoftennormalinpatientswithasthma.
CTsofthechestcanbeconsideredinpatientswithseverediseasewhereinthediagnosisisnotentirely
clear or alternativediagnoses are being seriouslyconsidered. Patientswith asthma mayhavemucus
plugging,airtrapping,bronchialwallthickening,andluminalnarrowingonCT.
DIAGNOSTICPROCEDURES
PFTs are essential to the diagnosis of asthma. In patients with asthma, PFTs often, but not always,
demonstrateanobstructivepattern—thehallmarkofwhichisadecreaseinexpiratoryflowrates.
A reduction in FEV1 and a proportionally smaller reduction in the FVC occur. This produces a
decreased FEV1/FVC ratio (generally <0.7 or the lower limit of normal value). With mild
obstructivediseasethatinvolvesonlythesmall airways,the FEV1/FVCratio maybenormal, with
theonlyabnormalitybeingadecreaseinairflowatmidlungvolumes(forcedexpiratoryflow25%–
75%).
The clinical diagnosis of asthma is supported by an obstructive pattern that improves after
bronchodilator therapy. Improvement is defined as anincrease in FEV1 of >12% and 200 mL
aftertwotofourpuffsofashort-actingbronchodilator.Bronchodilatorresponseishelpfulinthe
diagnosis ofasthma, butabsence will notexcludethe diagnosis assomepatientsmayneedrepeat
testingtodemonstratereversibility.
In patients with chronic, severe asthma, the airflow obstruction may no longer be completely
reversible. In these patients, the most effective way to establish the maximal degree of airway
reversibilityis torepeatPFTsaftera courseoforalcorticosteroids(usually40 mg/dayfor10–14
days) and to use the same criteria as above for reversibility. The lack of demonstrable airway
obstructionorreactivitydoesnotruleoutadiagnosisofasthma.
In cases inwhichspirometryis normal, thediagnosis canbe madebyshowing heightenedairway
responsivenesstoamethacholinechallenge.Amethacholinechallengeisconsideredpositivewhen
aprovocativeconcentrationof8mg/mLorlesscausesadropinFEV1of20%(PC20).Ifthepatient
is on an ICS, a PC20 of 8–16 mg/mL is considered borderline positive. A PC20 >16 mg/mL is
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consideredanegativetest.RepeattestingwiththepatientoffoftheirICSmaybenecessary.
Anobjectivemeasurementofairflowobstructionisessentialtotheevaluationofanexacerbation.The
severityoftheexacerbationshouldbeclassifiedasfollows:
Mild(peakexpiratoryflow[PEF]orFEV1>70%ofpredictedorpersonalbest)
Moderate(PEForFEV140%–69%)
Severe(PEForFEV1<40%)
Life-threatening/impendingrespiratoryarrest(PEForFEV1<25%).
PrinciplesofManagementofChronicAsthma
Medicalmanagementinvolveschronicmanagementandaplanforacuteexacerbations,otherwiseknown
asanasthmaactionplan.Mostoften,managementincludesthedailyuseofananti-inflammatory,
disease-modifyingmedication(long-termcontrolmedications)andas-neededuseofashort-acting
bronchodilator(quick-reliefmedications).
Thegoalsofdailymanagementaretoavoidimpairment(lackofsymptomswhilemaintainingnormal
activityandpulmonaryfunction)andtominimizerisk(preventingexacerbations,lossoflungfunction,
and medication side effects). Successful management requires patient education, objective
measurementofairflowobstruction,andamedicationplanfordailyuseandforexacerbations.
When initiating therapy for a patient not already on a controller medicine, one should assess the
patient’sseverityandassignthepatienttothehighestlevelinwhichanyonefeaturehasoccurredover
theprevious2–4weeks(seeTable9-10).
Assessmentofcontrolonsubsequentvisitsisusedtomodifytherapywhenfollowingpatientsalready
oncontrollermedication(seeTable9-11).
A clinician should address the following issues before stepping up therapy when there is a poor
responsetoacontroller:
Nonadherencetomedications:Specifically,pooradherence toICStherapy is associated withan
increased frequency of asthma exacerbations, accelerated longitudinal lung function decline, a
greaternumberofmissedschoolandworkdays,asthma-relatedhospitalizations,andasthma-related
death
Incorrectinhalertechnique
Ongoingexposuretoallergensand/orirritants
Comorbidities:Obesity,sinonasaldiseases,GERD,OSA,anddepression
Alternativediagnoses(seeTable9-13)
Thegoalofthestepwiseapproachistogaincontrolofsymptomsasquicklyaspossible.Atthesame
time,levelofcontrolvariesovertimeand,consequently,medicationrequirementsmayvaryovertime
aswell.Therapyshouldbereviewedregularlytocheckwhetherstepwisereductionispossible(Figure
9-1).
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