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Critical updates in diagnosis and therapy for asthma management

Bronchial asthma Bronchial asthma
Bronchial asthma Bronchial asthma

What's new?

A more personalized, evidence-based approach now guides asthma care—enhancing diagnosis accuracy, refining treatment steps, and improving long-term control for patients at every stage.

The Chinese Thoracic Society has released an extensively revised edition of the “Guidelines for the Prevention and Management of Bronchial Asthma (2020 Edition)”, intended to align asthma care with the most recent global evidence and modify it to national needs. This updated guidance marks a pivotal step in modernizing how bronchial asthma—a common and often debilitating chronic respiratory disease—is diagnosed, staged, and treated.

The revised document includes 34 major recommendations, introducing clarity in diagnosis, refinement in asthma severity classification, expansion of treatment pathways, and modern approaches to complex phenotypes like severe asthma, atypical variants, and asthma with fungal sensitization. These are:

Diagnosis and Evaluation

  1. Bronchial Provocation Test: Consider this test when forced expiratory volume, FEV1 is ≥70% predicted, excluding recent respiratory infections.
  2. Presumptive Diagnosis: In the absence of a bronchial provocation test, initiate a presumptive diagnostic pathway to improve accuracy.
  3. Diagnostic Anti-Inflammatory Therapy: May be initiated if specific criteria are met, such as; ≥20% peak expiratory flow improvement post-bronchodilator (no recent infection); FEV1 variability ≥12% and ≥200 mL change between tests; Small airway dysfunction (2 of maximal expiratory flow at 25% of forced vital capacity [MEF25], maximal expiratory flow at 50% of forced vital capacity [MEF50], maximal mid-expiratory flow [MMEF] ≤65%) and FEV1 ↑ ≥10% with fractional exhaled nitric oxide (FeNO) ≥35 ppb (baseline FEV1 ≥80%).​
  4. Clinical Remission: Described as ≥1 year without symptoms, no exacerbations, normal/near-normal lung function, and no need for oral corticosteroids (OCS). ​
  5. Severity Classification: Rank asthma severity as per the treatment steps needed to attain control, rather than pre-treatment status.

Inflammatory Phenotypes and Biomarkers

  1. Type 2 Inflammation: Characterized by elevated eosinophils, FeNO, atopy, or IgE; non-type 2 inflammation should be identified after excluding confounders. ​
  2. Psychosocial Assessment: Evaluate for anxiety/depression and comorbidities in patients with normalized lung function but persistent symptoms. ​
  3. Airway Hyperresponsiveness: A 20% reduction in FEV1 during bronchial provocation may reflect this and can be used in disease monitoring. ​
  4. Induced Sputum Eosinophils: Considered a gold standard for assessing airway inflammation and predicting corticosteroid response. ​
  5. Peripheral Blood Eosinophils: ≥150/μl can recognize eosinophil phenotype and envisage biologic therapy responses.

Therapy and Maintenance

  1. Inhaled Corticosteroids (ICS): Long-term use is safe within advised doses; adverse effects can arise as a result of prolonged high-dose therapy. ​
  2. OCS: Low-dose OCS (Prednisone ≤7.5 mg daily equivalent) may be added for severe asthma as a last resort. ​
  3. ICS-long-acting β2-agonists (LABA) Combination: Proves synergistic effects and is recommended for long-term treatment of moderate to severe asthma. ​
  4. Triple Combination Inhalers: Prescribed to ease symptoms and ameliorate exacerbations when asthma remains uncontrolled on ICS-LABA therapy. ​
  5. Subcutaneous Immunotherapy: May allow for less ICS use, with better breathing and improved daily well-being. ​
  6. House dust mite (HDM) Sublingual Immunotherapy: Recommended as an add-on for adolescents or adults sensitized to HDM who have preserved lung function (FEV₁ >70%) but remain symptomatic on low-to-moderate ICS.​

Stepwise Asthma Treatment

  1. Step 1: Use low-dose ICS-formoterol as needed for mild, occasional symptoms with no night issues or flare-up risk and FEV1 >80%.
  2. Step 2: Continue as-needed low-dose ICS-formoterol—it’s more effective than short-acting β2-agonist (SABA) alone in preventing serious flare-ups.
  3. Specialist Referral: Refer if symptoms persist or worsen despite correct inhaler use and full Step 4 treatment.
  4. Follow-Up: Recheck every 2–4 weeks after starting, then every 1–3 months. Ongoing inhaler training is key for good control.

Risk Factors and Exacerbation Management

  1. Risk Factors for Asthma-Related Death: Include a history of intubation and mechanical ventilation, hospitalization for exacerbation in the past year, current or recent OCS termination, no ICS use at present, overuse of SABA, psychiatric illness, poor adherence, food allergy history, and comorbidities like pneumonia, diabetes, and irregular heartbeat (arrhythmias).​
  2. Early Exacerbation Management: In mild to moderate exacerbations, 1-2 additional inhalations of budesonide-formoterol may be taken, but should not exceed 8 inhalations when taken on a daily basis.​
  3. Severe Asthma Description: Asthma that remains uncontrolled after at least 3 months of regular treatment with medium- or high-dose ICS-LABA, even when comorbid conditions are properly managed. ​
  4. Biologic Therapy for Severe Type 2 Asthma: This can be used to decrease exacerbations and improve asthma control; consider decreasing or stopping maintenance OCS therapy, but do not completely stop ICS-LABA therapy. ​
  5. Azithromycin Therapy: May be prescribed to reduce exacerbations in adult patients with ongoing symptomatic asthma despite Step 5 therapy. ​

Advanced and Alternative Treatments

  1. Bronchial Thermoplasty: Indicated for adults with uncontrolled asthma despite optimized treatment and referral to a dedicated severe asthma centre. ​
  2. Cough Variant Asthma (CVA): Treated like classic asthma—ICS-LABA is first-line and should be continued for over 8 weeks. ​
  3. Leukotriene Receptor Antagonist Therapy: May be considered for CVA sufferers with inadequate therapeutic response and intense inflammation in the airway. ​
  4. Antifungal Therapy: In fungal-sensitized asthma, antifungals may reduce inflammation and lower the need for systemic steroids. ​
  5. Targeted Biologic Therapies in Fungal Sensitization: Can reduce exacerbations and improve asthma control and quality of life; further large-scale trials are needed.

Special Asthma Populations

  1. Aspirin-Induced Asthma: Re-exposure to aspirin should be avoided; desensitization therapy may be regarded in those needing ICS in high doses or with inflammation and polyposis in the nose.
  2. Severe asthma with nasal polyps may benefit from biologics such as anti-IgE, anti-IL-5, or anti-IL-4Rα antibodies.
  3. Consider asthma-COPD overlap in patients with irreversible airflow constraint, smoking history, pulmonary emphysema signs, and modest diffusing capacity despite treatment.
  4. Asthma care must be personalized, considering cultural background, medication access, healthcare system limitations, and patient preferences when setting control goals.

Source:

Zhonghua Jie He He Hu Xi Za Zhi

Article:

Guidelines for the prevention and management of bronchial asthma (2024 edition)

Authors:

Shen Huahao et al.

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