Indoor Allergen Mitigation Strategies
• Dust mite o o o o
Use bare flooring instead of wall to wall carpet Use allergen-resistant impermeable coverings for pillows and mattresses Wash bedding weekly in hot water Vacuum weekly with high quality vacuum cleaner
• Pet dander o o o
• Mold o o o
Keep pets out of the bedroom Wash pet toys and bedding frequently Brush pets frequently
Use a dehumidifier or air conditioning unit to reduce humidity Address water leaks or damp areas Minimize the number of indoor plants
• Cockroach o o
Do not leave food uncovered Remove garbage and transfer to an outdoor trash bin regularly
Figure 1 . Indoor allergen mitigation strategies
only for newly diagnosed asthmatics that are prescribed either Dulera or Symbicort . Importantly , medication tolerance , insurance coverage , and cost must be considered when implementing SMART .
Long-acting Muscarinic Antagonists
Long-acting muscarinic antagonists ( LAMA ) utilize an anticholinergic approach to achieve bronchodilation . While previously utilized only for COPD , LAMAs ( tiotropium , specifically ) are now recommended as treatment for asthma . 3 In patients 12 years and older with uncontrolled , severe persistent asthma ( Step 5 ), the Expert Panel recommends adding LAMA as an adjunct therapy to ICS-LABA . However , the Expert Panel recommends against adding LAMA to ICS prior to adding LABA to ICS . If a LABA is unable to be prescribed ( patient choice , insurance issues , etc .), the Expert Panel recommends adding LAMA to ICS controller therapy versus continuing the same dose of ICS alone . Given the anticholinergic effects , LAMA therapy should be avoided in patients at risk for urinary retention and with co-existing glaucoma .
Indoor Allergen Mitigation An important aspect of asthma control involves identification and reduction of environmental triggers . The updated guidelines focus on indoor allergens such as dust mites , mold , pet dander , and pests . Environmental tobacco smoke and outdoor allergens were not addressed , although mitigation of these triggers is also recommended . Indoor allergen mitigation should be used in patients who are exposed to a specific allergen and are sensitized to that allergen or develop symptoms upon exposure . Testing for sensitization to indoor allergens should be considered if these criteria are met and the testing is done under the supervision of a board-certified allergist . Allergen mitigation is more effective when using multiple strategies to address offending allergens ( Figure 1 ). For example , mitigation of dust mites should include impermeable pillow or mattress covers as well as frequent washing of bed sheets and reductions in humidity . The only exception to a multi-component strategy is regarding integrated pest management . While the benefit may be small , integrated pest management , as a single or part of a multi-component strategy , should be routinely recommended given its broader beneficial impact on public health . 1
Conclusions
The proposed changes in management by the Expert Panel Report should improve the care of all asthmatics . Implementation poses significant challenges both to primary care providers and asthma specialists alike . Multiple barriers , such as wide-spread distribution of these recommendations to health care providers , consensus adoption by insurance payers , and education of patients and families , must be addressed . In addition , these recommendations may not be appropriate for all patients , and shared decision making between clinicians and patients / families will be important . In the future , the panel will need to address other important aspects of asthma care , particularly the use of biologics in the treatment of moderate-to-severe disease . Despite these challenges , this update represents an important step in improving asthma management . For further information and resources online , visit the NHLBI ’ s Digital Toolkit for the 2020 Focused Updates to the Asthma Management Guidelines .
References
1 . 2020 Focused Updates to the Asthma Management Guidelines : A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group . Journal of Allergy and Clinical Immunology , 146 ( 6 ), 1217-1270 . doi : 10.1016 / j . jaci . 2020.10.003
2 . Kiley , J ., Cloutier , M ., Dixon , A ., Schatz , M ., Lemanske , R ., & Mensah , G . ( 2021 , February ). National Asthma Education and Prevention Program Expert Panel Report on Selected Topics in Asthma Management 2020 . 2021 AAAAI Annual Meeting .
3 . Halpin , D . M . G ., Criner , G . J ., Papi , A ., Singh , D ., Anzueto , A ., Martinez , F . J ., Agusti , A . A ., & Vogelmeier , C . F . ( 2021 ). Global Initiative for the Diagnosis , Management , and Prevention of Chronic Obstructive Lung Disease . The 2020 GOLD Science Committee Report on COVID-19 and Chronic Obstructive Pulmonary Disease . American Journal of Respiratory and Critical Care Medicine , 203 ( 1 ), 24 – 36 . https :// doi . org / 10.1164 / rccm . 202009-3533so
4 . University of Wisconsin Hospitals and Clinics Authority . ( 2015 , July ). Related : Estimated comparative daily dosages for inhaled corticosteroids in children and adults . Retrieved April 05 , 2021 , from https :// www . uwhealth . org / cckm / cpg / respiratory / related / name-97743-en . html
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