What to Know About the New Asthma Guidelines if You Use an Inhaler

如果你在美国2在5与哮喘who use an inhaler with a daily controller medication or the nearly 1 in 4 who regularly use an inhaled “rescue medicine” for asthma flare-ups, updated guidelines from the National Institutes of Health (NIH) could mean it’s time to talk with your doctor about upgrading your asthma action plan. (Those inhaler statistics come from a报告于2017年12月发布The哮喘杂志）

NIH国家哮喘教育与预防计划（NAEPP）和国家心脏，肺和血液研究所（NHLBI）的新准则是于2020年12月出版The Journal of Allergy and Clinical Immunology和on theNHLBI website。This is the first update since 2007 and covers six areas of asthma management, with the biggest impacts for kids, teens, and adults who use inhalers.

“This update is important for all healthcare practitioners who treat asthma — family medicine clinicians, pediatricians, internal medicine specialists, allergy/immunology specialists, and pulmonologists,” saysGiselle S. Mosnaim, MD, who helped develop the new guidelines as the representative from the American Academy of Allergy, Asthma, and Immunology (AAAAI) on the NAEPP coordinating committee. “I think it will improve the way asthma is managed and help people with asthma and their doctors make decisions together.”

Here, four asthma experts weigh in on questions you may have about how the new guidelines could affect your asthma care.

1. I Use a Daily Inhaler for Asthma Control. Which Recommendations Apply to Me?

The new guidelines recommend that adults and teens with moderate to severe persistent asthma switch to a one-inhaler treatment strategy called SMART (single maintenance and reliever therapy). This recommendation also applies to some children ages 5 to 11, so parents of kids in this range should talk with their child’s doctor about whether it’s best to switch to SMART. (People with thesetypes of asthmawho have well-controlled disease may not need to switch therapy immediately. See below.)

“目前,大多数哮喘行动计划for moderate to severe persistent asthma include two inhalers: a daily controller medication, plus a second inhaler with a rescue medication for flare-ups,” says Dr. Mosnaim, incoming president of the AAAAI and an allergist and immunologist with the NorthShore University HealthSystem in Chicago。“新指南建议一个吸入器pecific combination of medications for both. This streamlines daily asthma care. You don’t have to keep track of two different inhalers. Research shows it has real benefits for asthma control.”

2.智能如何工作？

The inhaled asthma drug used in SMART therapy is a corticosteroid plusformoterol。This combination is already widely used as a daily controller drug, as the medicationsbudesonideplus formoterol (Symbicort) andmometasoneplus formoterol (Dulera)。What’s new is that the federal guidelines endorse their use as a rescue medicine, too.

“The corticosteroid reduces inflammation in your airways, which is important for keeping asthma under control and helps during a flare,” explainsMichael E. Wechsler, MD, a pulmonologist and director of the Cohen Family Asthma Institute at National Jewish Health in Denver. “The formoterol is a long-acting beta-agonist that assists in keeping airways open for 6 to 14 hours. Formoterol starts acting within minutes. That means it can also provide quick relief during a flare-up.”

Dr. Weschler warns that other combination inhalers with a corticosteroid and other long-acting bronchodilators don’t work that fast and could make an asthma flare worse. They cannot be used as a substitute for SMART therapy.

3.有什么证据表明智能比单独的吸入器更好？

SMART has been used around the world for more than a decade and is increasingly used in the United States, too, says Weschler.

In three studies cited in the new guidelines, SMART reduced the risk for worsening asthma — measured by rates of hospital and emergency room care, doses of inhaled and oral steroids required, or lung function status — by 37 to 40 percent compared with the conventional treatment of a corticosteroid inhaler for daily control plus a rescue inhaler with a short-acting beta-agonist drug.

Mosnaim解释说：“当哮喘膨胀并加剧时，人们可能最终会使用更高剂量的吸入皮质类固醇或需要皮质类固醇药丸。”这些剂量减少了炎症，但随着时间的流逝，这些剂量会增加严重副作用的风险，尤其是儿童的发育迟缓，骨质疏松症,glaucoma,cataracts, and high blood pressure in adults. Adults and children on SMART needed less corticosteroid, which could reduce risk for these side effects.

The report notes that in children ages 4 to 11, there may be a lower risk of stunted growth with SMART compared with conventional treatment using a higher daily dose of an inhaled corticosteroid.

4. Who Specifically Should Make the Switch to SMART?

Wondering if you’re in the group with a SMART recommendation? Moderate persistent asthma means that, without treatment, you have daily symptoms that interfere with activities (likewheezing,呼吸急促, chest tightness, or chronic coughing); you have symptoms that wake you up more than once a week at night; or your肺功能测试根据异常University of Michigan和theaaaai。

Severe asthma means that, without treatment, you have symptoms throughout the day, it severely limits your daily activities, it happens frequently at night, or your lung function tests are abnormal.

如果您使用药物仍有症状，哮喘病是无法控制的。

For adults, teens, and some kids (remember to check with your child’s doctor for kids between 5 and 11) with moderate to severe persistent asthma that’s not well controlled, the switch to SMART is recommended. The recommendation applies to those who now use low- or moderate-dose皮质类固醇as part of their asthma treatment.

用于管理中度至严重持续性哮喘的常规治疗方法是每天的控制剂药物，可能是一种吸入的皮质类固醇 - 例如莫莫酮（例如Asmanex), ciclesonide (Alvesco),fluticasone(Flovent), budesonide (Pulmicort),beclomethasoneHFA（QVAR）和其他人 - 或组合皮质类固醇加长效β-激动剂，例如氟替卡酮和Salmeterol（Advair Diskus，Advair HFA），Fluticasone和Vilanterol（Breo Ellipta），Symbicort或Dulera，或根据AAAAI，。常规疗法还包括第二次吸入器，具有短效β动力学（SABA）作为救援药物，例如Albuterol(ProAir HFA, Ventolin HFA, others),levalbuterol(Xopenex HFA), or pirbuterol (Maxair Autohaler). If you have moderate to severe persistent asthma, you’re following one of these treatments, and your asthma is well controlled, you may not have to switch to SMART. Check with your doctor.

SMART involves a medium dose of inhaled corticosteroid plus formoterol. SMART is not recommended for people who already take high-dose inhaled corticosteroids, who may benefit from otherasthma medications, saysPayel Gupta, MD，美国肺部协会的全国志愿医学发言人，以及与纽约市西奈山相关的过敏症患者。

5.明智的建议适用于我，但是我现在使用的吸入器对我的哮喘进行了很好的控制。我需要切换吗？

You don’t have to switch to SMART if your asthma is well managed with the inhalers you have right now. But if you like the idea of one inhaler instead of two, talk to your doctor, Mosnaim suggests. Even though SMART is preferred, the guidelines say there’s no need to switch if asthma is under control.

“并非每个人都适合它。”穆罕默德·尤纳斯（Mohammad Younus），医学博士, medical director of Hackensack Meridian Health’s Center for Allergy in New Jersey. “If you’re on separate inhaled corticosteroid and short-acting beta-agonist inhalers and are well controlled, you don’t have to change.”

RELATED:您的日常哮喘生活指南

6. I Think the New Guideline Applies to Me. Do I Need to Switch Treatment Right Away?

如果您的哮喘没有得到很好的控制，最好尽快去看医生。Mosnaim说，在这次访问中，您可以讨论这种新的疗法选择，而不是增加较高剂量的皮质类固醇。

If you’re in good control, there’s no need to switch unless you want to. In that case, discuss it with your doctor at your next regular appointment.

7.我的健康保险会涵盖智能疗法吗？

If your doctor recommends SMART, it’s a good idea to check with your health plan about insurance coverage.

“I’m finding with my patients that the inhalers for SMART therapy aren’t covered by their insurance with enough doses for daily use and for use as a rescue medication for one month,” Mosnaim says. “That could make SMART very expensive. We hope patients, patient advocates, and doctors will talk with health insurance companies about this need.”

You may be able to get coverage by working with your doctor to get a prior use authorization to show your health insurer, says Dr. Gupta.

8. Do Any of the New Guidelines Apply to Young Children?

For children up to age 4 who wheeze only when they have a cold or other upper respiratory tract infection (regardless of whether they’ve been diagnosed with asthma or not), one of the new recommendations says these kids should be prescribed a short-acting beta-agonist rescue medication plus a few days of an inhaled corticosteroid. “This can prevent breathing problems in young children from becoming so severe that they need an oral corticosteroid or need to be hospitalized,” Dr. Younus says.

这项针对4岁及以下的孩子的建议适用于在过去一年或两年中呼吸道感染期间在呼吸道感染期间有三个或更多喘息的孩子。

While the therapy has benefits, it could also stunt growth, the guideline notes. But the research isn’t conclusive: Onestudy该报告引用的发现，这种疗法的年轻儿童的身高和体重降低了5％，但其他research发现对这些增长措施没有影响。

People with mild persistent asthma who are 12 or older can continue using a low-dose inhaled corticosteroid for controlling their asthma and a rescue medication as needed. You have mild persistent asthma if symptoms occur on fewer than two days per week and do not interfere with everyday activities, nighttime symptoms occur two or fewer days per month, or lung function tests yield normal results when you’re not having a flare. If you have thistype of asthma，您不建议您切换到SMART。

But it’s worth noting that now this group also has the option of using those two medications only at times when symptoms begin to flare up, Mosnaim says.

The guidelines say this “use as needed” strategy could be a good treatment option for people with mild persistent asthma who currently use no medication. (It’s not recommended in kids age 11 and younger because it hasn’t been well studied.)

但是，如果您倾向于不注意到，则每天的皮质类固醇可用于控制（加上需要的救援吸入器），可以使肺健康保持轻度持续性哮喘的更好选择哮喘症状until they’re really bothering you or if you’re extremely aware of breathing changes and might overdo rescue treatments, the guidelines say.

RELATED:帮助您的孩子管理哮喘的提示

9. Are There Any New Treatment Guidelines for Severe Asthma?

对于12岁及12岁以上的青少年，如果您患有中度至严重的哮喘，仅由吸入的皮质类固醇控制，您的医生应考虑添加长效的β-激动剂（LABA）。如果这无济于事，或者由于其他原因您无法使用LABA，您的医生可能会考虑在您的吸入性皮质类固醇中添加另一种长效支气管扩张剂：长效的毒蕈碱拮抗剂（LAMA）。尤纳斯说：“我们在喇嘛上看到的改善并不重要，但是这些药物确实有助于缓解其一些症状。”

LAMAs open the airways just as LABAs do, but they work on a different cell receptor to do this, the muscarinic receptor, Gupta explains (which is why they may be a good alternative for people who don’t do well with LABAs).

The guidelines note that LAMAs shouldn’t be used by people who have glaucoma or are at risk for glaucoma. And one study suggests that LAMAs may not be a good choice for Black patients with asthma, due to a higher risk for hospitalization due to asthma.

LAMAs have been used for慢性阻塞性肺疾病for a while but were only approved in 2015 for asthma, adds Weschler. “They aren’t a new treatment, but including them is important because this will be a go-to asthma treatment guideline for many doctors,” he says.

LAMAs are inhaled drugs. They include umeclidinium (Incruse),glycopyrrolate（见），tiotropium（Spiriva）和Aclidinium（Tudorza）。

10. My Asthma Is Triggered by Allergies. How Could the New Guidelines Help Me?

The guidelines recommend taking steps to reduce your exposure to triggers like pollen, pet dander, dust mites, mold, cockroaches, rodents, or others if an allergy provokes your asthma symptoms.

Immunotherapy (allergy shots) can also help. Typically your allergist will do a skin test to pinpointallergy triggers。Based on that, your doctor will determine the appropriate allergy shots, explains Younus. “It’s been around for years, and research shows it's very effective.”

The process is lengthy, including weekly in-office shots for six to seven months, followed by monthly shots for four to five years. But it makes a difference. “I see big improvements inallergic asthmain a year,” he says. “Children can play with the family pet; people can go outside in the spring comfortably.”

11. Will My Medical Visits for Asthma Change Because of the Guidelines?

Mosnaim说，一些医生可能会使用称为分数呼出的一氧化氮来帮助诊断和管理哮喘的呼吸测试。

该测试通过测量其副产品一氧化氮来寻找气道炎症。它可以与有关您的症状的信息以及称为肺活量测定法的信息一起使用，以帮助您的医生告诉您的哮喘治疗计划是否有效。当其他迹象不清楚时，它也可能有助于检测哮喘。

“If we think there’s inflammation, the person can start asthma medication and we’ll retest to see if it makes a difference,” Younus says. “It’s a good tool for asthma management.”