8.1 Asthma & COPD Management

Pharmacist-Led Asthma Care

Asthma is a chronic inflammatory airway disease whose day-to-day outcomes depend far more on assessment, adherence, and inhaler technique than on any single drug. The DHA exam expects you to think like a disease-state manager: assess control, identify red flags, apply stepwise logic, and counsel.

Assessing Asthma Control

Assess two domains at every review:

• Symptom control: daytime symptoms more than twice a week, night waking, activity limitation, and reliever use more than twice a week all point to inadequate control.
• Future risk: previous exacerbations, poor adherence, incorrect inhaler technique, comorbid rhinitis, smoking, obesity, and low lung function.

A classic exam red flag is SABA overuse. Dispensing more than 2 short-acting beta-agonist (SABA, e.g., salbutamol) 200-dose canisters per year is associated with an increased risk of exacerbation, and use averaging one or more canisters per month is associated with a markedly increased risk of asthma death. The community pharmacist is uniquely placed to spot over-ordering at the dispensing counter and refer for review.

The Asthma Control Test (ACT) is a validated 5-item questionnaire covering daytime symptoms, night waking, activity limitation, reliever use, and self-rated control, scoring 5 to 25; a score of 20 or above suggests well-controlled asthma, while a score below 20 should prompt review of adherence, technique, and controller therapy.

Stepwise Therapy — the GINA Concept

The cornerstone of the Global Initiative for Asthma (GINA) strategy is that inhaled corticosteroid (ICS)-containing therapy is recommended at every step — SABA-only treatment is no longer advised, even for mild asthma, because it treats symptoms without addressing the underlying inflammation and leaves patients exposed to exacerbation risk.

• Track 1 (preferred): low-dose ICS-formoterol used as the reliever, with or without maintenance dosing. In steps 3–5 this becomes MART (maintenance and reliever therapy), where a single ICS-formoterol inhaler is used both daily and for symptom relief, simplifying regimens and reducing severe exacerbations compared with conventional ICS-LABA plus SABA.
• Track 2 (alternative): daily maintenance ICS (or ICS-LABA at higher steps) with a SABA reliever taken as needed.

Before stepping up, always check adherence and technique and address modifiable risk factors; after about 3 months of good control, consider stepping down to the lowest dose that maintains control, keeping the patient on some ICS-containing therapy.

Inhaler Technique, Devices, Spacers, and Action Plans

• Check technique at every opportunity; common errors include poor actuation–inhalation coordination, no breath-hold, failure to exhale before inhaling, and inadequate inspiratory effort.
• Device selection matters: dry-powder inhalers require a sufficiently forceful inhalation, so frail or elderly patients with low inspiratory flow may do better with a pressurised metered-dose inhaler (pMDI) plus spacer.
• Spacers with pMDIs improve lung deposition, reduce oropharyngeal ICS side effects (candidiasis, dysphonia), and are especially valuable in children and the elderly. Advise rinsing the mouth and spitting after ICS doses, and washing spacers with detergent and air-drying to reduce static.
• Every patient should have a written personalised asthma action plan: how to recognise deterioration, how to adjust reliever and controller doses, when to start oral corticosteroids, and when to seek urgent care.

Managing Exacerbations

An exacerbation is managed with frequent SABA (preferably via spacer), early short-course oral prednisolone 40–50 mg daily for 5–7 days in adults, and controlled oxygen. Escalate to emergency care if the patient cannot speak in sentences, has a peak flow below 50% of best or predicted, oxygen saturation below 92%, or a silent chest. Arrange follow-up within a week of discharge and revise the action plan. Address triggers (house dust mite, pollen, tobacco smoke, occupational sensitizers) and support smoking cessation with behavioural support plus pharmacotherapy such as nicotine replacement therapy, varenicline, or bupropion.

COPD: Diagnosis and Assessment

Chronic obstructive pulmonary disease (COPD) is confirmed by spirometry showing a post-bronchodilator FEV1/FVC ratio below 0.7, indicating persistent airflow limitation; the FEV1 percentage then grades severity. Suspect it in symptomatic patients (chronic cough, sputum production, progressive dyspnoea) with a smoking or biomass-fuel exposure history.

GOLD ABE Grouping and Inhaled Therapy

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) groups patients by symptoms (mMRC breathlessness score or CAT score) and exacerbation history:

The long-acting muscarinic antagonist/long-acting beta-agonist (LAMA/LABA) combination is the backbone for groups B and E. ICS is added for frequent exacerbators with blood eosinophils ≥300 cells/µL, where benefit is greatest; weigh this against the ICS-associated pneumonia risk, and consider withdrawal of ICS if pneumonia occurs without a strong exacerbation indication. Follow-up is guided by treatable traits — persistent dyspnoea versus recurrent exacerbations — with inhaler technique rechecked at every step.

Beyond Inhalers

• Pulmonary rehabilitation improves exercise capacity and quality of life and reduces hospital admissions — refer every symptomatic patient.
• Vaccination: influenza, pneumococcal, and COVID-19 vaccines are recommended for all patients with COPD; smoking cessation remains the single most effective disease-modifying intervention.
• Selected patients with chronic productive cough may benefit from mucolytics; long-term oxygen therapy is reserved for those meeting severe resting hypoxaemia criteria assessed by arterial blood gases.
• Exacerbations: increase short-acting bronchodilators, give oral prednisolone 40 mg daily for 5 days, and add an antibiotic (e.g., amoxicillin or doxycycline for 5–7 days) when there is increased dyspnoea plus increased sputum volume and purulence (the Anthonisen criteria).
• Controlled oxygen: in acute exacerbations target SpO2 88–92% to avoid worsening hypercapnia in CO2 retainers — a frequently tested number.