Asthma: Diagnosis and Management ____________________________________________________________
Quite often, aspirin-sensitive patients with asthma have other related respiratory conditions, including sinusitis, severe rhi- nitis, and nasal polyps. Nasal polyps are benign inflammatory growths that begin in the sinuses but protrude into the nos- tril. However, the absence of sinusitis and nasal polyps does not automatically rule out the presence of aspirin sensitivity. Aspirin sensitivity can develop suddenly and produce a reac- tion similar to anaphylaxis, but it usually builds over many years. Patients with asthma found to have a sensitivity, usually by an aspirin challenge test, are advised to avoid all NSAIDs even if they have not reacted to these medications in the past. Also, patients with aspirin-sensitive triad will often have cross intolerances with sulfides, particularly wine and other alcoholic beverages containing sulfides, and naturally occurring salicy- lates, which are found in citrus fruit, nuts, and grapes. Food additives may also be problematic [9; 33]. NARES is caused by the invasion of eosinophils into the nasal passages, resulting in severe inflammation. Nasal secretions testing positive for the presence of eosinophils (usually greater than 20% of the cells on nasal smears) are used to confirm a positive diagnosis of NARES. NARES may develop as part of aspirin-sensitive triad or completely separately from any aspirin sensitivities. The cause of the eosinophil infiltration is not clear [9; 33]. In general, a diagnosis of asthma may be reached if a patient has a strong family history, has repeated episodes of wheezing or other breathing difficulties, and responds to bronchodilators. However, because a wide spectrum of diseases and disorders have strikingly similar symptomatology, it is vital that those avenues are exhausted prior to establishing an asthma diagnosis [9; 33].
MEDICAL TREATMENT AND MANAGEMENT
The treatment of asthma is generally divided into one of two categories, either short- or long-term management. Short-term treatments are used only in the case of an asthma attack for immediate relief from the devastating symptoms. The focus of treatment for stable asthma is long-term prevention, planning ahead for emergencies, and being alert to increased symptoms [11]. Asthma may be controlled with early, accurate diagnosis and a treatment plan that involves a patient’s, and perhaps an entire family’s, active participation. Asthma exacerbations can be frightening experiences for both patients and their caregivers, especially the first time an attack occurs. A thorough explanation of all the treatments administered will better educate patients for future attacks and prepare them for future treatment. CREATING A TREATMENT PLAN The NAEPP advocates the use of a stepwise approach to asthma management [9; 10]. In this program, the asthma classifications are treated as separate steps, beginning with mild intermittent at step 1 and advancing to severe persistent at step 6. Asthma is classified based on symptom severity and frequency (Table 1) [9; 10]. Patients for whom symptoms occur more frequently (i.e., more than two times per week) and who experience interference with normal activity as a result of asthma symptoms are classified as having persistent asthma. Patients who experience asthma less than two times per week, have less than two night-time awakenings due to asthma per month, use rescue inhalers less than two times per week, have no interference with normal activity, and have “normal” peak FEV 1 are categorized as having intermittent asthma. The asthma is then further classified as mild, moderate, or severe based on the extent of interference in daily life, lung function tests, and use of rescue medications. After asthma severity has been classified, the treatment step is determined and initiated (Table 2) [9; 10].
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