Management of Asthma & Its Exacerbations in smaller settings
Authors: Kishanrao Suresh 
Published: August 2024

Asthma is a common heterogeneous lung disease that affects people of all ages, characterized by chronic airway inflammation, diagnosed mostly by the history of shortness of breath, wheeze, cough, and chest tightness that vary over time and in intensity, with variable expiratory airflow limitation. When symptoms make breathing hard, due to a trigger or severe inflammation it is known as Asthma exacerbation or attack. A trigger is defined as an exposure which elicits an exacerbation in a stable or previously asymptomatic patient of asthma. Although food and environmental allergens are common triggers for asthma, but for asthma attacks allergens or air pollutants are responsible and not food. Asthma affects more than 300 million people worldwide; it is responsible for over 1000 deaths a day. India contributes to about 39 million (13%) cases and 450 (42%) of global deaths. While deaths due to asthma in most developed countries have declined steadily, in India it has increased by 33% over last 3 decades indicating timely accessibility and poor management of acute attacks. Bengaluru city is considered as asthma capital of India due to sheer numbers it reports every year. Disparity between the perception of an Indian patient and the objective criteria in asthma control also contribute. Two main categories of severe asthma are identified in India based on a person's response to treatment i) Type-2 inflammation e.g., Allergic asthma and eosinophilic asthma and ii) non-type-2 inflammation e.g., non-eosinophilic asthma (NEA). NEA is characterized by airway inflammation with the absence of eosinophils, after activation of non-predominant type 2 immunologic pathways, defined by an eosinophil count <2% in sputum and poor response to known therapeutic options. The differential diagnosis in Filaria endemic districts globally and in India need to include Tropical Pulmonary Eosinophilia (TPE), a hyperresponsive pulmonary syndrome to trapped microfilariae of lymphatic filariasis caused by filarial nematode Wuchereria bancrofti within the lung tissue. The general approach to treatment of an acute asthma exacerbation includes administration of inhaled bronchodilators (beta-agonist therapy -e.g., Albuterol), as well as systemic glucocorticoids in most patients. Asthma medications in inhaled form is considered better as compared to systemic formulations (oral/IV) to improve clinical outcomes, as Inhaled medicines work faster to improve the symptoms and outcomes and are safer as compared to oral or IV route. Initial treatment of acute asthma exacerbations can be provided in the primary care setting or even at home. However, children with moderate-to-severe exacerbations need to be managed in an inpatient setting as they require close observation for clinical deterioration, frequent treatments, and repeated evaluation. Materials and Methods: This review is based on personal experience of managing three anecdotes of three varieties of Asthma cases in adults, over last 5 decades, literature review and latest national guidelines and GINA recommendation of Asthma management.