Overcoming gaps in the management of asthma in older patients: new insights.

Barua P; OMahony MS

摘要

Asthma is under-recognised and undertreated in older populations. This is not surprising, given that one-third of older people experience significant breathlessness. The differential diagnosis commonly includes asthma, chronic obstructive pulmonary disease (COPD), heart failure, malignancy, aspiration and infections. Because symptoms and signs of several cardiorespiratory diseases are nonspecific in older people and diseases commonly co-exist, investigations are important. A simple strategy for the investigation of breathlessness in older people should include a full blood count, chest radiograph, ECG, peak flow diary and/or spirometry with reversibility as a minimum. If there are major abnormalities on the ECG, an echocardiogram should also be performed. Diurnal variability in peak flow readings >or=20% or >or=15% reversibility in forced expiratory volume in 1 second, spontaneously or with treatment, support a diagnosis of asthma. Distinguishing asthma from COPD is important to allow appropriate management of disease based on aetiology, accurate prediction of treatment response, correct prognosis and appropriate management of the chest condition and co-morbidities. The two conditions are usually readily differentiated by clinical features, particularly age at onset, variability of symptoms and nocturnal symptoms in asthma, supported by the results of reversibility testing. Full lung function tests may not necessarily help in differentiating the two entities, although gas transfer factor is characteristically reduced in COPD and usually normal or high in asthma. Methacholine challenge tests previously mainly used in research are now also used widely and safely to confirm asthma in clinical settings. Interest in exhaled nitric oxide as a biomarker of airways inflammation is increasing as a noninvasive tool in the diagnosis and monitoring of asthma. Regular inhaled corticosteroids (ICS) are the mainstay of treatment of asthma. Even in mild disease in older adults, regular preventive treatment should be considered, given the poor perception of bronchoconstriction by older asthmatic patients. If symptoms persist despite ICS, addition of long-acting beta(2)-adrenoceptor agonists (LABA) should be considered. Addition of LABA to ICS improves asthma control and allows reduction in ICS dose. However, older people have been grossly under-represented in trials of LABA, many trials having excluded those >or=65 years of age. On meta-analysis, beta(2)-adrenoceptor agonists (both short acting and long acting) are associated with increased cardiovascular mortality and morbidity in asthma and COPD. While the evidence for excess cardiovascular mortality is stronger for short-acting beta(2)-adrenoceptor agonists, it would be prudent to exercise particular care in using beta(2)-adrenoceptor agonists (long acting and short acting) in those at risk of adverse cardiovascular outcomes, including older people. Regular review of cardiovascular status (and monitoring of serum potassium concentration) in patients taking beta(2)-adrenoceptor agonists is crucial. The response to LABA should be carefully monitored and alternative 'add-on' therapy such as leukotriene receptor antagonists (LRA) should be considered. LRA have fewer adverse effects and in individual cases may be more effective and appropriate than LABA. Long-term trials evaluating beta(2)-adrenoceptor agonists and other bronchodilator strategies are needed particularly in the elderly and in patients with cardiovascular co-morbidities. There is no evidence that addition of anticholinergics improves control of asthma further, although the role of long-acting anticholinergics in the prevention of disease progression is currently being researched. Older patients need to be taught good inhaler technique to improve delivery of medications to lungs, minimise adverse effects and reduce the need for oral corticosteroids. Nurse-led education programmes that include a written asthma self-management plan h

机译：在老年人口中，哮喘的认识不足，治疗不足。鉴于三分之一的老年人会感到严重的呼吸困难，这不足为奇。鉴别诊断通常包括哮喘，慢性阻塞性肺疾病（COPD），心力衰竭，恶性肿瘤，误吸和感染。由于几种心肺疾病的症状和体征在老年人中是非特异性的，并且通常并存于多种疾病中，因此调查很重要。研究老年人呼吸困难的简单策略应包括全血细胞计数，胸部X光片，心电图，峰值流量日记和/或肺活量测定法，且可逆性最低。如果心电图出现重大异常，还应进行超声心动图检查。峰值呼气量的自然变化或自发或经治疗在1秒内≥20％或≥15％的可逆性可支持哮喘的诊断。将哮喘与COPD区别开来对于根据病因学适当控制疾病，准确预测治疗反应，正确预后以及对胸部疾病和合并症进行适当管理非常重要。这两种情况通常可以通过临床特征轻松区分，特别是发病年龄，哮喘的症状变化和夜间症状，以及可逆性测试的结果。完全肺功能检查不一定有助于区分这两种情况，尽管COPD的特征是气体转移因子降低，而哮喘通常是正常的或较高的。以前主要用于研究中的甲胆碱激发试验现在也被广泛安全地用于临床中确认哮喘的发生。呼出气一氧化氮作为气道炎症的生物标志物的兴趣正在作为诊断和监测哮喘的非侵入性工具而增加。定期吸入皮质类固醇（ICS）是治疗哮喘的主要手段。鉴于老年人哮喘患者对支气管收缩的认识较差，即使在老年人的轻度疾病中，也应考虑定期进行预防性治疗。如果尽管有ICS症状仍持续，应考虑添加长效β（2）-肾上腺素受体激动剂（LABA）。在ICS中添加LABA可改善哮喘控制，并减少ICS剂量。但是，老年人在LABA试验中的代表性明显不足，许多试验都排除了≥65岁的人群。在荟萃分析中，β（2）-肾上腺素受体激动剂（短效和长效）与心血管疾病死亡率和哮喘和COPD发病率增加相关。虽然短期作用的β（2）-肾上腺素受体激动剂对心血管过度死亡的证据更强，但谨慎使用谨慎使用β（2）-肾上腺素受体激动剂（长效和短效）的患者。不良心血管结果，包括老年人。定期复查服用β（2）-肾上腺素受体激动剂的患者的心血管状况（并监测血清钾浓度）至关重要。应仔细监测对LABA的反应，并应考虑使用替代的“附加”疗法，例如白三烯受体拮抗剂（LRA）。 LRA的不良反应较少，在个别情况下可能比LABA更为有效和适当。需要长期评估β（2）-肾上腺素受体激动剂和其他支气管扩张剂策略的试验，特别是在老年人和心血管合并症患者中。尽管目前正在研究长效抗胆碱药在预防疾病进展中的作用，但没有证据表明添加抗胆碱药可以进一步改善哮喘的控制。需要教导老年患者良好的吸入技术，以改善药物向肺部的输送，最大程度地减少不良反应，并减少对口服皮质类固醇的需求。由护士领导的教育计划，其中包括书面的哮喘自我管理计划h

Overcoming gaps in the management of asthma in older patients: new insights.

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