[Guides and standards: asthma management in children and adults]

Tétreault C
Record ID 32018005164
Original Title: Prise en charge de l’asthme chez les enfants et les adultes
Authors' objectives: Asthma is a chronic, heterogeneous disease characterized by the presence of typical respiratory symptoms caused by bronchial inflammation, which leads to airway obstruction and hyperresponsiveness. In 2014, INESSS published an asthma treatment decision-support tool. Since this publication, several asthma management clinical practice guidelines have been updated following the emergence of new scientific data. Consequently, INESSS has undertaken to update its asthma treatment recommendations and to present them in the form of a management-support tool to assist front-line health professionals.
Authors' results and conclusions: RESULTS: (#1 CLINICAL MANIFESTATIONS): Although these symptoms are not exclusive, the presence of wheezing, exaggerated shortness of breath, breathing difficulties, chest tightness, coughing or expectoration points to the need to consider asthma in adults and children. (#2 DIAGNOSTIC APPROACH): Asthma is diagnosed in three steps: 1) document airway obstruction by confirming the presence of symptoms suggestive of asthma and the consistent clinical presentation; 2) confirm airway obstruction or involvement; 3) confirm airway obstruction reversibility or airway hyperresponsiveness. Whenever possible, airway obstruction and reversibility should be confirmed by objective tests, such as spirometry or challenge testing. In children aged 5 and under, diagnosis is more complex, since spirometry is not feasible. It is based primarily on direct observation of the symptoms and of the response to treatment. (#3 CLINICAL ASSESSMENT): The clinical assessment of a person with asthma should include an evaluation of asthma control and an assessment of the exacerbation risk. This helps to guide or optimize therapeutic decision-making (#4 TREATMENT PRINCIPLE ): The long-term treatment goals are to optimize symptom control and to minimize complications, such as exacerbations, the loss of lung function, the treatment’s adverse effects, and mortality. The use of short-acting beta-agonists (SABAs) as reliever monotherapy should be avoided in adults and adolescents, even in those with occasional mild symptoms. To optimize symptom control from the start of management and to minimize the exacerbation risk, an inhaled corticosteroid (ICS) should be included in the therapy as soon as possible, either by adding an ICS component to the reliever therapy (as-needed budesonide-formoterol or an ICS whenever the SABA is used) or by initiating daily lowdose ICS. When optimal symptom control is not achieved with reliever therapy alone, maintenance therapy with an ICS should be instituted. In children under 12 years of age, SABA reliever monotherapy is the first-line therapy if they do not have any risk factors for severe exacerbation and only experience occasional symptoms. (#5 EDUCATION): Asthmatics should receive a complete asthma management education follow-up, including frequent reviews. (#6 MANAGEMENT OF EXACERBATIONS WITH A WRITTEN ACTION PLAN): An exacerbation indicates treatment failure and requires a reassessment of the asthma patient and the treatment. Every asthma patient should have a written action plan that is reviewed on a regular basis. (#7 FOLLOW-UP): Health professionals should take every clinical opportunity to reassess asthma patients. The frequency of their follow-up appointments should be individualized, but they should be reassessed at least every 3 to 12 months. CONCLUSION: Uncontrolled asthma has significant repercussions on the quality of life of the patient and their family and can lead to an increased exacerbation risk, even in asthmatics with mild and infrequent symptoms. When severe, these exacerbation episodes have a significant impact on resource utilization in the form of repeated emergency room visits, or hospital or even ICU stays. Without replacing clinical judgment, this work should support early identification and diagnosis of the disease, promote the optimal choice and use of medications and inhalation devices, and, ultimately, improve asthma sufferers’ care experience. However, the practice improvement will depend on the dissemination of the clinical tool stemming from this report, on adherence to these changes, and on the uptake of the recommendations by the health professionals concerned.
Authors' recommendations: Upon completion of our work, and following an iterative process with the advisory committee’s members, in which data and recommendations from the literature consulted, contextual information and the perspectives of different stakeholders consulted were triangulated, a series of recommendations were drawn up. These recommendations are at the heart of this report and have also been incorporated into the management support tool stemming from our work. The recommendations are intended primarily for front-line clinicians.
Authors' methods: The methods used to address the evaluation questions were in accordance with INESSS’s quality standards and included the triangulation of information and best clinical practice recommendations published by other organizations, contextual information, and stakeholder perspectives. A systematic search of the scientific literature was conducted in collaboration with a scientific information consultant in the PubMed, Embase and EBM Reviews databases. In addition, a manual search of the grey literature was carried out by consulting, among others, the websites of learned societies in the field related to the topic of our project and by scanning the bibliographies of the selected publications. Document selection, data extraction and methodological quality assessment were carried out independently by two scientific professionals, while the analysis of the contextual information gathered was performed by one professional and validated by a second. An advisory committee consisting of clinicians from different specialties and areas of expertise was created to gather stakeholder perspectives. Lastly, the overall quality of the clinical tool, its acceptability and its applicability were assessed by external reviewers who are specialialists in the field of interest and by future users who had not participated in this project.
Project Status: Completed
Year Published: 2023
English language abstract: An English language summary is available
Publication Type: Other
Country: Canada
Province: Quebec
MeSH Terms
  • Asthma
  • Child
  • Adult
  • Disease Management
  • Practice Guideline
  • Practice Guidelines as Topic
Organisation Name: Institut national d'excellence en sante et en services sociaux
Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369
Contact Name: demande@inesss.qc.ca
Contact Email: demande@inesss.qc.ca
Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.