2010 national institutes of health (nih) naepp 2007 … national institutes of health (nih) naepp...

11

National Institutes of Health (NIH)National Institutes of Health (NIH) NAEPP 2007 Asthma GuidelineNAEPP 2007 Asthma Guideline

Expert Panel Report (EPR) Expert Panel Report (EPR) ‐‐33

Susan K. Ross RN, AESusan K. Ross RN, AE‐‐CC

MDH Asthma Program MDH Asthma Program

651651‐‐201201‐‐5629 5629

[email protected]@state.mn.us

mailto:[email protected]

22

National Institutes of HealthNational Institutes of Health National Asthma Education Prevention ProgramNational Asthma Education Prevention Program

(NAEPP)(NAEPP)

http://www.nhlbi.nih.gov/guidelines/asthma/index.htmhttp://www.nhlbi.nih.gov/guidelines/asthma/index.htm

20072007Guidelines for the Diagnosis and Guidelines for the Diagnosis and Management of Asthma (EPRManagement of Asthma (EPR--3)3)

National Asthma Education and Prevention Program

http://www.nhlbi.nih.gov/guidelines/asthma/index.htm

33

What is Asthma?What is Asthma?

““Asthma is a common chronic disorder of the Asthma is a common chronic disorder of the airways that involves a complex interaction airways that involves a complex interaction of airflow obstruction, bronchial of airflow obstruction, bronchial

hyperresponsiveness and an underlying hyperresponsiveness and an underlying inflammation. This interaction can be highly inflammation. This interaction can be highly

variable among patients and within patients variable among patients and within patients over timeover time””..

EPR 3EPR 3‐‐

Section 2, p 12.Section 2, p 12.

44

Characteristics of AsthmaCharacteristics of Asthma

••

Airway Inflammation Airway Inflammation

••

Airway Obstruction (reversible) Airway Obstruction (reversible)

••

Hyperresponsiveness (irritability of airways)Hyperresponsiveness (irritability of airways)

55

Normal & Asthmatic BronchioleNormal & Asthmatic Bronchiole

66

Why Do We Need Asthma Guidelines?Why Do We Need Asthma Guidelines?

77

Asthma:Asthma:

––

In 2008, it was estimated that 23.3 million Americans currently In 2008, it was estimated that 23.3 million Americans currently

have asthma have asthma ––

Is one of the most common chronic disorders in childhood, Is one of the most common chronic disorders in childhood,

affecting an approx.affecting an approx.

7.1 million children under 18 years (9.6%) 7.1 million children under 18 years (9.6%)

11

––

In 2007, 3,447 deaths were attributed to asthma, 152 deaths In 2007, 3,447 deaths were attributed to asthma, 152 deaths

were children under the age of 15 were children under the age of 15

22

––

Is the Is the thirdthird

leading cause of hospitalization among children leading cause of hospitalization among children

under the age of 15 under the age of 15

66

––

Is one of the leading causes of school absenteeism Is one of the leading causes of school absenteeism

33

In 2008 In 2008

asthma accounted for approx.asthma accounted for approx.

14.4 million lost school days14.4 million lost school days

44

––

The annual health care costs of asthma is approx. $20.7 billion The annual health care costs of asthma is approx. $20.7 billion

dollars dollars

55

From ALA website 11/2010 www.Lungusa.org1 CDC: National Center for Health Statistics, National Health Interview Survey Raw Data, 20092 CDC. National Center for Health Statistics. Final Vital Statistics Report. Deaths: Final Data for 2007. April 17, 2009. Vol 58 No 19.3 CDC. National Center for Chronic Disease Prevention and Health Promotion. Healthy Youth! Health Topics: Asthma. August 14, 20094 CDC: National Center for Health Statistics, National Health Interview Survey Raw Data, 2008.5 NHLBI Chartbook, U.S. Department of Health and Human Services, National Institute of Health, 20096 CDC: National Center for Health Statistics, National Hospital Discharge Survey, 2006.

http://www.lungusa.org/lung-disease/asthma/resources/facts-and-figures/asthma-children-fact-sheet.html#1

http://www.lungusa.org/lung-disease/asthma/resources/facts-and-figures/asthma-children-fact-sheet.html#7

http://www.lungusa.org/

http://www.cdc.gov/healthyyouth/asthma/index.htm

88

2007 2007 ‐‐

Guidelines for the Diagnosis Guidelines for the Diagnosis && Management of AsthmaManagement of Asthma

Expert Review Panel (EPRExpert Review Panel (EPR‐‐3)3)

99

Asthma Guidelines:Asthma Guidelines: History History &&

ContextContext

Initial guidelines released in 1991 and updated in 1997Initial guidelines released in 1991 and updated in 1997

Updated again in 2002 (EPRUpdated again in 2002 (EPR‐‐2) with a focus on several 2) with a focus on several key questions about medications, monitoring and key questions about medications, monitoring and

preventionprevention––

LongLong‐‐term management of asthma in childrenterm management of asthma in children

––

Combination therapyCombination therapy

––

Antibiotic useAntibiotic use

––

Written asthma action plans (AAP) and peak flow meters Written asthma action plans (AAP) and peak flow meters

(PFM)(PFM)––

Effects of early treatment on the progression of asthmaEffects of early treatment on the progression of asthma

1010

Old Old &&

New Asthma Guidelines:New Asthma Guidelines: What has What has notnot

changedchanged

Initial asthma therapy is determined by assessment of asthma Initial asthma therapy is determined by assessment of asthma

severityseverity–– Ideally, before the patient is on a longIdeally, before the patient is on a long‐‐term controllerterm controller

Stepping therapy up or down is based on how well asthma is Stepping therapy up or down is based on how well asthma is

controlled or not controlledcontrolled or not controlled

Inhaled corticosteroids (ICS) are the preferred firstInhaled corticosteroids (ICS) are the preferred first‐‐line therapy for line therapy for

asthmaasthma

Systemic steroids can still be used to treat asthma exacerbationSystemic steroids can still be used to treat asthma exacerbationss

Peak flows and written asthma action plans are recommended for Peak flows and written asthma action plans are recommended for

asthma self managementasthma self management––

Especially in moderate and severe persistent asthma, or for thosEspecially in moderate and severe persistent asthma, or for those e

with a history of severe exacerbations or poorly controlled asthwith a history of severe exacerbations or poorly controlled asthmama

1111

Asthma Therapy GoalsAsthma Therapy Goals

““The goal of asthma therapy is to control The goal of asthma therapy is to control asthma so patients can live active, full lives asthma so patients can live active, full lives while minimizing their risk of asthma while minimizing their risk of asthma exacerbations and other problemsexacerbations and other problems””

Dr. William Dr. William BusseBusse, MD., chairman of the NAEPP EPR , MD., chairman of the NAEPP EPR ‐‐33

1212

2007 2007 ‐‐

Guidelines for the Diagnosis & Guidelines for the Diagnosis & Management of Asthma (EPRManagement of Asthma (EPR‐‐3)3)

––

(Almost) no new medications(Almost) no new medications

––

Restructuring into Restructuring into ““severityseverity””

and and ““controlcontrol””

––

Domains of Domains of ““impairmentimpairment””

and and ““riskrisk””

––

Six treatment steps (stepSix treatment steps (step‐‐up/stepup/step‐‐down)down)

––

More careful thought into ongoing management issuesMore careful thought into ongoing management issues

––

Summarizes extensivelySummarizes extensively‐‐validated scientific evidence that validated scientific evidence that

the guidelines, when followed, lead to a significant the guidelines, when followed, lead to a significant

reduction in the frequency and severity of asthma reduction in the frequency and severity of asthma

symptoms and improve quality of lifesymptoms and improve quality of life

1313

New Strategies of the EPR‐3

Assessment Management Severity The intrinsic intensity of

the disease process A clinical guide most useful for initiating controller therapy

Control The degree to which symptoms are minimized & goals are met

(After therapy is initiated) a clinical guide used to maintain or adjust therapy

Responsiveness The ease of which prescribed therapy achieves asthma control

(Variable) frequent follow-up to step-up and step-down therapy to achieve the goal of control

1414

– Asthma is a chronic inflammatory disorder of the

airways

– The immunohistopathologic

features of asthma include

inflammatory cell infiltration

– Airway inflammation contributes to airway

hyperresponsiveness, airflow limitation, respiratory

symptoms, and disease chronicity

– In some patients, persistent changes in airway structure

occur, including sub‐basement fibrosis, mucus

hypersecretion, injury to epithelial cells, smooth muscle

hypertrophy, and angiogenesis (remodeling)

Key Points: Definition, Key Points: Definition, PathophysiologyPathophysiology

&& Pathogenesis Pathogenesis

1515

Key Points: cont..Key Points: cont..

–

Gene‐by‐environment interactions are important to the

expression of asthma

–

Atopy, the genetic predisposition for the development of an

immunoglobulin E (IgE)‐mediated response to common

aeroallergens, is the strongest identifiable predisposing

factor for developing asthma

–

Viral respiratory infections are one of the most important

causes of asthma exacerbation and may also contribute to

the development of asthma

EPR 3, Section 2: Page 11

1616

Causes Causes ––

We DonWe Don’’t Knowt Know……Yet!Yet!

––

Asthma has dramatically risen worldwide over the past Asthma has dramatically risen worldwide over the past

decades, particularly in developed countries, and experts decades, particularly in developed countries, and experts

are puzzled over the cause of this increaseare puzzled over the cause of this increase

––

Not all people with allergies have asthma, and not all cases Not all people with allergies have asthma, and not all cases

of asthma can be explained by allergic responseof asthma can be explained by allergic response

––

Asthma is most likely caused by a convergence of factors Asthma is most likely caused by a convergence of factors

that can include genes that can include genes (probably several)(probably several)

and various and various

environmental and biologic triggers environmental and biologic triggers ––

e.g., infections, dietary patterns, hormonal changes in women, ae.g., infections, dietary patterns, hormonal changes in women, and nd

allergens allergens

1717

4 Components of Asthma Management 4 Components of Asthma Management

Component 1Component 1: Measures of Asthma Assessment & : Measures of Asthma Assessment & MonitoringMonitoring

Component 2Component 2::

Education for a Partnership in Education for a Partnership in Asthma CareAsthma Care

Component 3Component 3::

Control of Environmental Factors & Control of Environmental Factors & ComorbidComorbid

Conditions that Affect Conditions that Affect

AsthmaAsthma

Component 4Component 4: Medications: Medications

1818

Component 1Component 1

Measures of Asthma Assessment Measures of Asthma Assessment && MonitoringMonitoring

1919

Key Points Key Points ‐‐ Overview: Measures of Asthma Assessment Overview: Measures of Asthma Assessment &&

MonitoringMonitoring

Assessment and monitoring are closely linked to the concepts of Assessment and monitoring are closely linked to the concepts of

severity, controlseverity, control, and , and responsivenessresponsiveness

to treatment:to treatment:

–– SeveritySeverity

‐‐

intensity of the disease process. Severity is intensity of the disease process. Severity is

measured most easily and directly in a patient not receiving measured most easily and directly in a patient not receiving

longlong‐‐termterm‐‐control therapy.control therapy.–– Control Control ‐‐

degree to which asthma degree to which asthma (symptoms, functional (symptoms, functional

impairments, and risks of untoward events)impairments, and risks of untoward events)

are minimized and the are minimized and the

goals of therapy are met.goals of therapy are met.–– ResponsivenessResponsiveness

‐‐

the ease with which asthma control is the ease with which asthma control is

achieved by therapy. achieved by therapy.

EPR EPR ‐‐3 , Pg. 36,3 , Pg. 36,

2020

Key Points Key Points ––

cont. cont. Domains Domains

ImpairmentImpairment

(Present): (Present):

––

Frequency and intensity of symptoms Frequency and intensity of symptoms ––

Functional limitations (quality of life)Functional limitations (quality of life)

RiskRisk

(Future):(Future):

–– Likelihood of asthma exacerbations orLikelihood of asthma exacerbations or–– Progressive loss of lung function (reduced lung growth) Progressive loss of lung function (reduced lung growth)

–– Risk of adverse effects from medicationRisk of adverse effects from medication

EPR EPR ‐‐3, Pg. 383, Pg. 38‐‐80, 27780, 277‐‐345345

Assess Severity and Control based on:

2121

Key Points Key Points ‐‐

cont. cont. SeveritySeverity

&&

ControlControl

If the patient is If the patient is notnot

currently on a longcurrently on a long‐‐term controller at the term controller at the

first visit:first visit:

–– Assess asthma severity to determine the appropriate Assess asthma severity to determine the appropriate

medication & treatment planmedication & treatment plan

Once therapy is initiated, the emphasis is changed to the Once therapy is initiated, the emphasis is changed to the

assessment of assessment of asthma controlasthma control

–– The level of asthma control will guide decisions either to The level of asthma control will guide decisions either to

maintain or adjust therapymaintain or adjust therapy

Are used as follows for managing asthma:Are used as follows for managing asthma:

2222

Assessing Impairment Assessing Impairment (Present) Domain(Present) Domain

Assess by taking a careful, directed history and lung

function measurement

Assess Quality of Life using standardized questionnaires– Asthma Control Test (ACT)– Childhood Asthma Control Test– Asthma Control Questionnaire– Asthma Therapy

Assessment

Questionnaire (ATAQ)

control index

Some patients may perceive the severity of airflow

obstruction poorly

2323

Assessing Risk (Future)Assessing Risk (Future) DomainDomain

––

Of adverse events in the future, especially of Of adverse events in the future, especially of

exacerbations and of progressive, exacerbations and of progressive, irreversibleirreversible

loss of loss of pulmonary functionpulmonary function——is more problematic (airway is more problematic (airway

remodeling) remodeling)

––

The test most used for assessing the risk of future The test most used for assessing the risk of future

adverse events is adverse events is spirometryspirometry

2424

Measures of Assessment Measures of Assessment && MonitoringMonitoring

DiagnosisDiagnosis

2525


Diagnosis of AsthmaDiagnosis of Asthma

To establish a diagnosis of asthma the clinician should To establish a diagnosis of asthma the clinician should determine thatdetermine that::

––

Episodic symptoms of airflow obstruction or airway Episodic symptoms of airflow obstruction or airway

hyperresponsiveness are presenthyperresponsiveness are present

––

Airflow obstruction is at least partially reversibleAirflow obstruction is at least partially reversible

––

Alternative diagnoses are excludedAlternative diagnoses are excluded

2626


Methods to Establish Diagnosis Methods to Establish Diagnosis

Recommended methods to establish the diagnosis areRecommended methods to establish the diagnosis are: :

–– Detailed medical historyDetailed medical history

–– Physical exam focusing on the upper respiratory tract, Physical exam focusing on the upper respiratory tract,

chest, and skinchest, and skin

–– Spirometry to demonstrate obstruction and assess Spirometry to demonstrate obstruction and assess

reversibility, including in children 5reversibility, including in children 5

years of age or years of age or

olderolder

–– Additional studies to exclude alternate diagnosesAdditional studies to exclude alternate diagnoses

2727

Key Indicators: Diagnosis of AsthmaKey Indicators: Diagnosis of Asthma

Has/does the patient:Has/does the patient:––

had an attack or recurrent attacks of wheezing?had an attack or recurrent attacks of wheezing?

––

have a troublesome cough at night?have a troublesome cough at night?

––

wheeze or cough after exercise?wheeze or cough after exercise?

––

experience wheezing, chest tightness, or cough after experience wheezing, chest tightness, or cough after

exposure to airborne allergens or pollutants?exposure to airborne allergens or pollutants?

––

colds colds ‘‘go to the chestgo to the chest’’

or take more than 10 days to clear or take more than 10 days to clear

up?up?

––

symptoms improved by appropriate asthma treatment?symptoms improved by appropriate asthma treatment?

Adapted from the GINA guidelines 2008

2828

Characterization Characterization &&

Classification of Classification of AsthmaAsthma

SeveritySeverity

2929


Initial Assessment: Initial Assessment: SeveritySeverity

Once a diagnosis is established:Once a diagnosis is established:

––

Identify precipitating factors (triggers)Identify precipitating factors (triggers)

––

Identify comorbidities that aggravate asthmaIdentify comorbidities that aggravate asthma

––

Assess the patientAssess the patient’’s knowledge and skills for selfs knowledge and skills for self‐‐ managementmanagement

––

Classify severity using impairment and risk domainsClassify severity using impairment and risk domains

Pulmonary function testing (spirometry) to assess Pulmonary function testing (spirometry) to assess severityseverity

EPR EPR ‐‐3, Sec. 3, pg. 473, Sec. 3, pg. 47

3030

Assessment of Asthma SeverityAssessment of Asthma Severity

Previous GuidelinesPrevious Guidelines

Frequency of daytime Frequency of daytime

symptomssymptoms

Frequency of nighttime Frequency of nighttime

symptomssymptoms

Lung functionLung function

2007 Guidelines2007 Guidelines

ImpairmentImpairment––

Frequency of daytime /nighttime Frequency of daytime /nighttime

symptomssymptoms

––

Quality of life assessmentsQuality of life assessments

––

Frequency of SABA useFrequency of SABA use

––

Interference with normal activityInterference with normal activity

––

Lung function (FEVLung function (FEV

11

/FVC) /FVC)

RiskRisk––

Exacerbations (frequency and Exacerbations (frequency and

severity)severity)

NOT Currently Taking ControllersNOT Currently Taking Controllers

Level of severity is determined by both impairment and risk. Assess impairment by caregivers recall of previous 2‐4 weeks.

Step 3 and consider short course of oral system ic corticostero idsStep 2Step 1Recom m ended Step for

Initiating Therapy

(See figure 41a fortreatm ent steps.)

In 26 weeks, depending on severity, evaluate level of asthm a contro l that is achieved. If no clear benefit is observed in 46 weeks, consider adjusting therapy or a lternative d iagnoses.

Extrem ely lim itedSom e lim itationM inor lim itationNoneInterference w ith norm al activ ity

Several tim esper dayDaily>2 days/week

but not daily2 days/week

Short-actingbeta2-agonist use

for sym ptom contro l (not

prevention of EIB)

Consider severity and interval since last exacerbation.Frequency and severity m ay fluctuate over tim e.

Exacerbations of any severity m ay occur in patients in any severity category.

Exacerbationsrequiring oral

system ic corticostero ids

Risk

Im pairm ent

>1x/week34x/m onth12x/m onth0N ighttim eawakenings

Classification of Asthm a Severity(04 years of age)

Persistent

Com ponents ofSeverity

2 exacerbations in 6 m onths requiring oral system ic corticostero ids, or 4 wheezing episodes/1 year lasting

>1 day AND risk factors for persistent asthm a01/year

Throughoutthe dayDaily>2 days/week

but not daily2 days/weekSym ptom s

SevereM oderateM ildInterm ittent


Extremely limitedSome limitationMinor limitationNoneInterference withnormal activity

Step 1and consider short course oforal systemic corticosteroids

Step 3, medium-dose ICS option

In 26 weeks, evaluate level of asthma control that is achieved, and adjust therapy accordingly.

Step 3, medium-dose ICS option, or step 4

RiskExacerbationsrequiring oral

systemic corticosteroids

• FEV1/FVC <75%• FEV1/FVC = 7580%• FEV1/FVC >80%• FEV1/FVC >85%

• FEV1 <60% predicted

• FEV1 = 6080% predicted

• FEV1 = >80% predicted

• FEV1 >80% predicted

Lung function

2/year (see note)01/year (see note)

• Normal FEV1between exacerbations

Several timesper dayDaily>2 days/week

but not daily2 days/week

Short-actingbeta2-agonist use for symptom control (not

prevention of EIB)

Consider severity and interval since last exacerbation.Frequency and severity may fluctuate over time for patients in any severity category.

Step 2

Classification of Asthma Severity(511 years of age)

Impairment

Recommended Step for Initiating Therapy

(See figure 41b fortreatment steps.)

Persistent

Components of Severity

Relative annual risk of exacerbations may be related to FEV1.

Often 7x/week>1x/week butnot nightly34x/month2x/monthNighttime

awakenings

Throughoutthe day

Daily>2 days/week but not daily

2 days/weekSymptoms

SevereModerateMildIntermittent

and consider short course oforal systemic corticosteroids

Step 4 or 5Step 3Step 2Step 1

Recommended Stepfor Initiating Treatment

(See figure 45 for treatment steps.) In 26 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.

• Normal FEV1between exacerbations

Extremely limitedSome limitationMinor limitationNoneInterference with normal activity

Several timesper day

Daily>2 days/weekbut not daily, and

not more than1x on any day

2 days/weekShort-actingbeta2-agonist use for symptom control (not

prevention of EIB)

2/year (see note)01/year (see note)

• FEV1 <60% predicted

• FEV1 >60% but <80% predicted



• FEV1/FVCreduced >5%

• FEV1/FVC reduced 5%

• FEV1/FVC normal• FEV1/FVC normal

Risk

Relative annual risk of exacerbations may be related to FEV1.

Classification of Asthma Severity12 years of age

Consider severity and interval since last exacerbation.Frequency and severity may fluctuate over time for patients in any severity category.

Impairment

Normal FEV1/FVC:819 yr 85%

20 39 yr 80%40 59 yr 75%60 80 yr 70%

PersistentComponents of Severity

Exacerbationsrequiring oral

systemic corticosteroids

Lung function

Often 7x/week>1x/week butnot nightly

34x/month2x/monthNighttime awakenings

Throughout the dayDaily>2 days/week but not daily

2 days/weekSymptoms

SevereModerateMildIntermittent


Classifying Severity AFTER Control Classifying Severity AFTER Control is Achieved is Achieved ––

All AgesAll Ages

Lowest level Lowest level of treatment of treatment required to required to

maintain maintain controlcontrol

Classification of Asthma SeverityClassification of Asthma Severity

IntermittentIntermittent PersistentPersistent

Step 1Step 1

MildMild ModerateModerate SevereSevere

Step 2Step 2 Step 3 Step 3

or 4or 4Step 5 Step 5

or 6or 6

(already on controller)(already on controller)

3535

Periodic Assessment Periodic Assessment &&

MonitoringMonitoring

Asthma ControlAsthma Control

3636

Key Points Key Points –– Asthma Control (Goals of Therapy)Asthma Control (Goals of Therapy)

Reducing Reducing impairmentimpairment––

Prevent chronic & troublesome symptomsPrevent chronic & troublesome symptoms

––

Prevent frequent use (Prevent frequent use (< < 2 days /wk) of inhaled SABA for 2 days /wk) of inhaled SABA for

symptomssymptoms

––

Maintain (near) Maintain (near) ““normalnormal””

pulmonary functionpulmonary function

––

Maintain normal activity levels (including exercise and Maintain normal activity levels (including exercise and

other physical activity and attendance at work or school)other physical activity and attendance at work or school)

––

Meet patientsMeet patients’’

and familiesand families’’

expectations of and expectations of and

satisfaction with asthma caresatisfaction with asthma care

EPREPR‐‐

3, p. 503, p. 50

3737


contcont. .

Reducing Reducing RiskRisk––

Prevent recurrent exacerbations of asthma and minimize Prevent recurrent exacerbations of asthma and minimize

the need for ER visits and hospitalizationsthe need for ER visits and hospitalizations––

Prevent progressive loss of lung function Prevent progressive loss of lung function ‐‐

for children, for children,

prevent reduced lung growthprevent reduced lung growth––

Provide optimal pharmacotherapy with minimal or no Provide optimal pharmacotherapy with minimal or no

adverse effectsadverse effects

Periodic assessments at 1Periodic assessments at 1‐‐6 month intervals6 month intervals

Patient selfPatient self‐‐assessment (w/clinician)assessment (w/clinician)

Spirometry testingSpirometry testing

EPEP‐‐3 3 , sec. 3, p. 53, sec. 3, p. 53

3838

Key Points cont. Key Points cont. ‐‐

Written Written AAPAAP’’ss

&&

PFM PFM

Provide to all patients a written AAP based on signs and Provide to all patients a written AAP based on signs and

symptoms and/or PEFsymptoms and/or PEF

––

Written AAPs are particularly recommended for patients Written AAPs are particularly recommended for patients

who have moderate or severe persistent asthma, a history who have moderate or severe persistent asthma, a history

of severe exacerbations or poorly controlled asthmaof severe exacerbations or poorly controlled asthma..

Whether PF monitoring, symptom monitoring (available data Whether PF monitoring, symptom monitoring (available data

show similar benefits for each), or a combo of approaches is show similar benefits for each), or a combo of approaches is

used, selfused, self‐‐

monitoring is important to the effective selfmonitoring is important to the effective self‐‐

management of asthma.management of asthma.

EPR EPR ‐‐3 Sec. 3, P.533 Sec. 3, P.53

3939

Peak Flow MonitoringPeak Flow Monitoring

LongLong‐‐term daily PF monitoring can be helpful toterm daily PF monitoring can be helpful to::

––

Detect early changes in asthma control that require Detect early changes in asthma control that require

adjustments in treatment:adjustments in treatment:––

Evaluate responses to changes in treatmentEvaluate responses to changes in treatment

––

Provide a quantitative measure of impairmentProvide a quantitative measure of impairment

EPREPR‐‐3 , Sec. 3, P.543 , Sec. 3, P.54

4040

Asthma Control = Asthma GoalsAsthma Control = Asthma Goals

Definition of asthma control is the same as asthma Definition of asthma control is the same as asthma goalsgoals

reducing impairment and riskreducing impairment and risk

Monitoring quality of life, any:Monitoring quality of life, any:

–– work or school missed because of asthma?work or school missed because of asthma?

–– reduction in usual activities?reduction in usual activities?

–– disturbances in sleep due to asthma?disturbances in sleep due to asthma?

–– Change in caregivers activities due to a child's Change in caregivers activities due to a child's asthma?asthma?

4141

Responsiveness ‐Questions for Assessing Asthma Control

Ask the patient:

–

Has your asthma awakened you at night or early morning?–

Have you needed more quick‐relief medication (SABA) than

usual?–

Have you needed any urgent medical care for your asthma,

such as unscheduled visits to your provider, an UC clinic, or

the ER?–

Are you participating in your usual and desired activities?–

If you are measuring your peak flow, has it been belowyour personal best?

Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.”

1995

4242

Actions to consider:

– Assess whether the medications are being taken as

prescribed– Assess whether the medications are being inhaled with

correct technique– Assess lung function with spirometry and compare to

previous measurement– Adjust medications, as needed; either step up if control is

inadequate or step down if control is maximized, to achieve

the best control with the lowest dose of medication

Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.”

1995

Responsiveness ‐

Actions

Assessing Asthma Control in Children 0 Assessing Asthma Control in Children 0 ‐‐

44

Years of AgeYears of Age

>3/year23/year01/yearExacerbations

requiring oral system ic corticostero ids

Risk

Several times per day>2 days/week2 days/week


for sym ptom control (not prevention

of EIB)

Extrem ely lim itedSome lim itationNoneInterference w ith norm al activ ity

Medication side effects can vary in intensity from none to very troublesome and worrisom e. The leve l of intensity does not corre late to specific leve ls of contro l but should be consideredin the overall assessm ent of risk.

Classification of Asthm a Control(Children 04 years of age)

Im pairm ent

Com ponents of Control

Treatment-re lated adverse effects

>1x/week>1x/month1x/monthN ighttim e awakenings

Throughout the day>2 days/week2 days/weekSym ptom s

Very Poorly Contro lled

N ot W ell Contro lled

W ell Contro lled

Assessing Asthma Control in Children 5 Assessing Asthma Control in Children 5 ‐‐

1111

Years of AgeYears of Age

Im p a irm en t

2/yea r (see no te )01 /yea rExace rba tions requ iring o ra l system ic

co rtico ste ro ids

Lung function

< 60% p red ic ted /pe rsona l best

6080% p red ic ted /pe rsona l best

> 80% p red ic ted /pe rsona l best

FEV 1 o r peak flow

Eva lua tion requ ires long -te rm fo llow up.

M ed ica tion s ide e ffec ts can va ry in in tensity from none to ve ry troub lesom e and w orrisom e. The leve l o f in tens ity does no t co rre la te to spec ific leve ls o f con tro l bu t shou ld be cons ide red in the ove ra ll a ssessm ent o f r isk .

T rea tm en t-re la ted adve rse e ffects

Consider seve rity and in te rva l s in ce la st e xace rba tion

R isk

Severa l tim es pe r day> 2 days/w eek2 days/w eek

Sho rt-actingbeta 2-agon ist u se

fo r sym ptom con tro l(no t p reven tion o f E IB )

Extrem e ly lim itedSom e lim ita tionN oneIn te rfe rence w ithno rm a l activ ity

C la ss ifica tio n o f A sth m a C o n tro l(C h ild ren 51 1 years o f a g e)C o m p o n en ts o f C o n tro l

Reduction in lung g row th

< 75%7580%> 80% FEV 1/FVC

2x/w eek2x/m onth1x/m onthN igh ttim eaw aken ings

Throughou t the day> 2 days/w eek o r

m u ltip le tim es on2 days/w eek

2 days/w eek bu t no t m ore than

once on each daySym ptom s

V ery P o o rly C o n tro lled

N o t W ell C o n tro lledW ell C o n tro lled

Consider severity and in terva l s ince last exacerbation

Evaluation requ ires long-te rm fo llow up care

M edication s ide e ffects can vary in in tensity from none to very troub lesom e and w orrisom e. The leve l o f in tensity does not co rre late to specific leve ls of con tro l but shou ld be considered in the overa ll assessm ent of risk.

Treatm ent-re la ted adverse e ffects

Progressive loss of lung functionR isk

Validated Questionnaires

2/year (see note)

Throughou t the day> 2 days/w eek2 days/w eekSym ptom s

Im pairm ent

3–4N/A15

1–21.51619

00.75*20

ATAQACQACT

< 60% pred icted/personal best

6080% pred icted/personal best

> 80% pred icted/personal best

FEV 1 or peak flow

Severa l tim es pe r day> 2 days/w eek2 days/w eekShort-acting beta2-agon ist use for sym ptom contro l (not prevention o f E IB)

01/yearExacerbations

Classification o f A sthm a Contro l(Youth s 12 years of ag e and adu lts)

Com ponents o f Contro l

Extrem ely lim itedSom e lim itationNoneInte rfe rence w ith norm al activ ity

4x/w eek13x/w eek2x/m onthN ighttim e aw aken ing

Very PoorlyContro lled

N otW ell-Contro lledW ell-Contro lled

Assessing Asthma Control in YouthsAssessing Asthma Control in Youths

1212

Years of Age Years of Age &&

AdultsAdults

4646


Education for a Partnership in Education for a Partnership in Asthma CareAsthma Care

4747


EducationEducation

Self management education is essential and should be Self management education is essential and should be

integrated into all aspects of care; requires repetition and integrated into all aspects of care; requires repetition and

reinforcementreinforcement

Provide Provide allall

patients with a patients with a writtenwritten

asthma action plan that asthma action plan that

includes 2 aspects:includes 2 aspects:––

Daily managementDaily management

––

How to recognize & handle worsening asthma symptomsHow to recognize & handle worsening asthma symptoms

Regular review of the status of patients asthma controlRegular review of the status of patients asthma control––

Teach and reinforce at every opportunityTeach and reinforce at every opportunity

Develop an active partnership with the patient and familyDevelop an active partnership with the patient and family

EPR EPR ––

3, Section 3, Pg. 933, Section 3, Pg. 93

4848


Education cont.Education cont.

Encourage adherence by:Encourage adherence by:–– Choosing a Choosing a txtx

regimen that achieves outcomes and regimen that achieves outcomes and

addresses preferences important to the addresses preferences important to the patientpatient

–– Review the success of Review the success of txtx

plan and make changes as plan and make changes as

neededneeded

Tailor the plan to needs of each patientTailor the plan to needs of each patient

Encourage community based interventionsEncourage community based interventions

Asthma education provided by trained health Asthma education provided by trained health

professionals should be reimbursed and considered an professionals should be reimbursed and considered an

integral part of effective asthma care ! integral part of effective asthma care ! (AE(AE‐‐C)C)

4949

Key Educational MessagesKey Educational Messages

––

Significance of diagnosisSignificance of diagnosis––

Inflammation as the underlying cause Inflammation as the underlying cause ––

Controllers vs. quickControllers vs. quick‐‐relieversrelievers––

How to use medication delivery devicesHow to use medication delivery devices––

Triggers, including 2Triggers, including 2ndnd

hand smokehand smoke––

Home monitoring/ selfHome monitoring/ self‐‐managementmanagement––

How/when to contact the providerHow/when to contact the provider––

Need for continuous, onNeed for continuous, on‐‐going interaction w/the clinician going interaction w/the clinician

to step up/down therapyto step up/down therapy––

Annual influenza vaccine Annual influenza vaccine

5050

Other Educational Points of Care Other Educational Points of Care

ER Department and hospital based ER Department and hospital based

Medication therapy management (Pharmacist)Medication therapy management (Pharmacist)

Community basedCommunity based

Home based for caregivers including home based Home based for caregivers including home based allergen/ environmental assessmentallergen/ environmental assessment

Computer based technology Computer based technology

Case management for highCase management for high‐‐risk patientsrisk patients

5151

Maintaining the PartnershipMaintaining the Partnership

Promote open communication w/patient and family by Promote open communication w/patient and family by

addressing at each visitaddressing at each visit::

––

Ask what concerns they have and what they want Ask what concerns they have and what they want

addressed during the visitaddressed during the visit––

Review short Review short ––

term goals agreed to at the initial visitterm goals agreed to at the initial visit

––

Review written AAP and steps to take Review written AAP and steps to take ––

adjust as neededadjust as needed

––

Encourage parents to take a copy of AAP to the school or Encourage parents to take a copy of AAP to the school or

childcare setting or childcare setting or sendsend

a copy to the school nursea copy to the school nurse

––

Teach and reinforce key educational messagesTeach and reinforce key educational messages––

Provide simple, brief, written materials that reinforce the Provide simple, brief, written materials that reinforce the

actions and skills taughtactions and skills taught

5252


Control of Environmental Factors Control of Environmental Factors && ComorbidComorbid

Conditions that Affect AsthmaConditions that Affect Asthma

5353


Environmental FactorsEnvironmental Factors

All patients with asthma shouldAll patients with asthma should::––

Reduce, if possible, exposure to allergens & irritants they are Reduce, if possible, exposure to allergens & irritants they are

sensitive toosensitive too

––

Understand effective allergen avoidance is multifaceted and Understand effective allergen avoidance is multifaceted and

individual steps alone are ineffectiveindividual steps alone are ineffective

––

Avoid exertion outdoors when levels of air pollution are highAvoid exertion outdoors when levels of air pollution are high

––

Avoid use of nonselective betaAvoid use of nonselective beta‐‐blockersblockers

––

Avoid sulfiteAvoid sulfite‐‐containing and othercontaining and other

foods they are sensitive tofoods they are sensitive to

––

Avoid use of humidifiers (generally)Avoid use of humidifiers (generally)

5454


Environmental ContEnvironmental Cont..

Clinicians shouldClinicians should::––

Evaluate a patient for other chronic coEvaluate a patient for other chronic co‐‐morbid conditions morbid conditions

when asthma cannot be well controlledwhen asthma cannot be well controlled––

Encourage their asthma patients to receive a yearly Encourage their asthma patients to receive a yearly

influenza vaccination (inactivated)influenza vaccination (inactivated)––

Consider allergen immunotherapy when appropriateConsider allergen immunotherapy when appropriate––

Ask about possible occupational exposures, particularly Ask about possible occupational exposures, particularly

those who have newthose who have new‐‐onset disease (work related asthma)onset disease (work related asthma)

5555


MedicationsMedications

5656


MedicationsMedications

2 general classes:2 general classes:–– LongLong‐‐term control medicationsterm control medications–– QuickQuick‐‐Relief medicationsRelief medications

Controller medicationsController medications::–– Corticosteroids Corticosteroids –– Long Acting Beta Agonists (Long Acting Beta Agonists (LABALABA’’ss))–– LeukotrieneLeukotriene

modifiers (LTRA)modifiers (LTRA)

–– CromolynCromolyn

& & NedocromilNedocromil

–– MethylxanthinesMethylxanthines::

((SustainedSustained‐‐release release theophyllinetheophylline) )

5757


Medications contMedications cont..

QuickQuick‐‐

relief medicationsrelief medications

–– Short acting bronchodilators (Short acting bronchodilators (SABASABA’’ss))

–– Systemic corticosteroidsSystemic corticosteroids

–– AnticholinergicsAnticholinergics

5858

Key Points: Safety of ICSKey Points: Safety of ICS’’ss

––

ICSICS’’s are the most effective longs are the most effective long‐‐term therapy available, are term therapy available, are

well tolerated & safe at recommended doseswell tolerated & safe at recommended doses

––

The potential but small risk of adverse events from the use The potential but small risk of adverse events from the use

of ICS treatment is well balanced by their efficacyof ICS treatment is well balanced by their efficacy

––

The doseThe dose‐‐response curve for ICS treatment begins to flatten response curve for ICS treatment begins to flatten

at low to medium dosesat low to medium doses

––

Most benefit is achieved with relatively low doses, whereas Most benefit is achieved with relatively low doses, whereas

the risk of adverse effects increases with dosethe risk of adverse effects increases with dose

5959

Key Points: Key Points: Reducing Potential Adverse Effects Reducing Potential Adverse Effects

Spacers or Spacers or valvedvalved

holding chambers (holding chambers (VHCsVHCs) used with non) used with non‐‐breathbreath‐‐

activated activated MDIsMDIs

reduce local side effectsreduce local side effects

––

There is little or no data on use of spacers with There is little or no data on use of spacers with hydrofluoroalkanehydrofluoroalkane

(HFA) (HFA) MDIsMDIs

Patients should rinse their mouths (rinse and spit) after (ICS) Patients should rinse their mouths (rinse and spit) after (ICS)

inhalationinhalation

Use the lowest dose of ICS that maintains asthma control: Use the lowest dose of ICS that maintains asthma control: ––

Evaluate patient adherence and inhaler technique as well as Evaluate patient adherence and inhaler technique as well as

environmental factors before increasing the dose of ICSenvironmental factors before increasing the dose of ICS

To achieve or maintain control of asthma, add a LABA to a low orTo achieve or maintain control of asthma, add a LABA to a low or

medium dose of ICS rather than using a higher dose of ICS medium dose of ICS rather than using a higher dose of ICS

Monitor linear growth in childrenMonitor linear growth in children

6060

Key Points:Key Points: Safety of LongSafety of Long‐‐Acting BetaActing Beta

22

‐‐Agonists Agonists ((LABALABA’’ss))

––

Adding a LABA to the Adding a LABA to the txtx

of patients whose asthma is not well of patients whose asthma is not well

controlled on lowcontrolled on low‐‐

or mediumor medium‐‐dose ICS improves lung function, dose ICS improves lung function,

decreases symptoms, and reduces exacerbations and use of SABA decreases symptoms, and reduces exacerbations and use of SABA

for quick relief in most patientsfor quick relief in most patients

––

The FDA determined that a Black Box warning was warranted on allThe FDA determined that a Black Box warning was warranted on all

preparations containing a LABApreparations containing a LABA

––

For patients who have asthma not sufficiently controlled with ICFor patients who have asthma not sufficiently controlled with ICS S

alone, the option to increase the ICS dose should be given alone, the option to increase the ICS dose should be given equal equal

weightweight

to the option of the addition of a LABA to ICSto the option of the addition of a LABA to ICS

––

It is not currently recommended that LABA be used for treatment It is not currently recommended that LABA be used for treatment of of

acute symptoms or exacerbationsacute symptoms or exacerbations

––

LABAs are not to be used as monotherapy for longLABAs are not to be used as monotherapy for long‐‐term controlterm control

6161

FDA Recommendations for FDA Recommendations for LABALABA’’ss February 2010February 2010

––

Are contraindicated without the use of an asthma controller Are contraindicated without the use of an asthma controller

medication such as an ICSmedication such as an ICS

––

SingleSingle‐‐ingredient ingredient LABAsLABAs

should only be used in combination should only be used in combination

with an asthma controller medication; they should not be with an asthma controller medication; they should not be

used aloneused alone

––

Should only be used longShould only be used long‐‐term in patients whose asthma term in patients whose asthma

cannot be adequately controlled on asthma controller cannot be adequately controlled on asthma controller

medicationsmedications

6262

FDA Recommendations for FDA Recommendations for LABALABA’’ss

Cont.Cont.

––

Should be used for the shortest duration of time required to Should be used for the shortest duration of time required to

achieve control of asthma symptoms and discontinued, if achieve control of asthma symptoms and discontinued, if

possible, once asthma control is achievedpossible, once asthma control is achieved––

Patients should then be maintained on an asthma controller Patients should then be maintained on an asthma controller

medicationmedication––

Pediatric and adolescent patients who require the addition Pediatric and adolescent patients who require the addition

of a LABA to an ICS should use a combination product of a LABA to an ICS should use a combination product

containing both an ICS and a LABA, to ensure compliance containing both an ICS and a LABA, to ensure compliance

with both medicationswith both medications

6363

Key Points: Key Points: Safety of Short Safety of Short ‐‐Acting BetaActing Beta

22

‐‐Agonists (Agonists (SABASABA’’ss))

––

SABAsSABAs

are the most effective medication for relieving are the most effective medication for relieving

acute bronchospasm acute bronchospasm

––

Increasing use of SABA treatment or using SABA >2 days Increasing use of SABA treatment or using SABA >2 days

a week for symptom relief (not prevention of EIB) a week for symptom relief (not prevention of EIB)

indicates inadequate control of asthmaindicates inadequate control of asthma

––

Regularly scheduled, daily, chronic use of SABA is Regularly scheduled, daily, chronic use of SABA is notnot

recommendedrecommended

6464

Section 4 Section 4

Managing Asthma Long Term Managing Asthma Long Term

““The Stepwise ApproachThe Stepwise Approach””

6565

Key Points: Managing Asthma Long TermKey Points: Managing Asthma Long Term

The goal of therapy is to control asthma by:The goal of therapy is to control asthma by:–– Reducing impairmentReducing impairment

–– Reducing riskReducing risk

A stepwise approach to medication therapy is A stepwise approach to medication therapy is recommended to gain and maintain asthma controlrecommended to gain and maintain asthma control

Monitoring and followMonitoring and follow‐‐up is essentialup is essential

6666

Treatment: Treatment: Principles of Principles of ““StepwiseStepwise””

Therapy Therapy

““The goal of asthma therapy is to maintain longThe goal of asthma therapy is to maintain long‐‐ term control of asthma with the least amount of term control of asthma with the least amount of medication and hence minimal risk for adverse medication and hence minimal risk for adverse

effectseffects””..

EPR EPR ‐‐3, Section 4, P. 2843, Section 4, P. 284

6767

Principles of Step Therapy to Maintain Principles of Step Therapy to Maintain ControlControl

Step upStep up

medication dose if symptoms are not controlledmedication dose if symptoms are not controlled

If very poorly controlled, consider an increase by 2 steps, If very poorly controlled, consider an increase by 2 steps,

add oral corticosteroids, or bothadd oral corticosteroids, or both

Before increasing medication therapy, evaluate:Before increasing medication therapy, evaluate:

––

Exposure to environmental triggers Exposure to environmental triggers

––

Adherence to therapyAdherence to therapy

––

For proper device techniqueFor proper device technique

––

CoCo‐‐morbiditiesmorbidities

6868

FollowFollow‐‐up Appointmentsup Appointments

Visits every 2Visits every 2‐‐6 weeks until asthma control is achieved6 weeks until asthma control is achieved

When control is achieved, followWhen control is achieved, follow‐‐up every 3up every 3‐‐6 months6 months

StepStep‐‐down in therapydown in therapy::

––

When asthma is wellWhen asthma is well‐‐controlled for at least 3 monthscontrolled for at least 3 months

Patients may relapse with total discontinuation or Patients may relapse with total discontinuation or

reduction of inhaled corticosteroidsreduction of inhaled corticosteroids

• Consider short course of oral system ic corticosteroids,

• Step up (12 steps), and• Reevaluate in 2 weeks. • If no clear benefit in 46

weeks, consider alternative diagnoses or adjusting therapy.

• For side effects, consider alternative treatment options.

• Step up (1 step) and• Reevaluate in

26 weeks.• If no clear benefit in

46 weeks, consider alternative diagnoses or adjusting therapy.

• For side effects, consider alternative treatment options.

• Maintain current treatment.

• Regular followupevery 16 months.

• Consider step down if well controlled for at least 3 months.

Recom m ended Actionfor Treatm ent

(See figure 41a fortreatm ent steps.)

>3/year23/year01/yearExacerbations requiring

oral system ic corticosteroids

Risk



for sym ptom control (not prevention of EIB)

Extremely lim itedSome lim itationNoneInterference w ith normal activity

Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

Classification of Asthm a Control (04 years of age)

Im pairm ent


Treatment-related adverse effects

>1x/week>1x/month1x/monthN ighttime awakenings

Throughout the day>2 days/week2 days/weekSymptoms

Very Poorly ControlledNot W ell Controlled

W ellControlled

Assessing Control Assessing Control &&

Adjusting Therapy Adjusting Therapy Children 0Children 0‐‐4 Years of Age4 Years of Age

IntermittentAsthma

Persistent Asthma: Daily MedicationConsult asthma specialist if step 3 care or higher is required.

Consider consultation at step 2

Step 1

PreferredSABA PRN

Step 2

PreferredLow dose ICSAlternative Montelukast or Cromolyn

Step 3

PreferredMedium Dose ICS

Step 4

PreferredMedium Dose ICS

AND

Either:Montelukast or LABA

Step 5

PreferredHigh Dose ICS

AND


Step 6

PreferredHighDose ICS

AND


ANDOral corticosteroid

Patient Education and Environmental Control at Each Step

Stepwise Approach for Managing Asthma in Children 0-4 Years of Age

Quick-relief medication for ALL patients -SABA as needed for symptoms.With VURI: SABA every 4-6 hours up to 24 hours. Consider short course of corticosteroids with (or hx of) severe exacerbation

Step down if possible

(and asthma is well

controlled at least 3

months)

Assess control

Step up if needed

(first check adherence, environment al control)


Adjusting Therapy Adjusting Therapy Children 5Children 5‐‐11 Years of Age11 Years of Age

Consider severity and interval since last exacerbation


• Step up 12 steps, and• Reevaluate in 2 weeks.• For side effects, consider

alternative treatment options.

• Step up at least 1 step and

• Reevaluate in 26 weeks.

• For side effects: consider alternative treatment options.

• Maintain current step.• Regular followup

every 16 months.• Consider step down if

well controlled for at least 3 months.


(See figure 41b fortreatm ent steps.)

Lung function

<60% predicted/personal best

6080% predicted/personal best

>80% predicted/personal best

• FEV1 or peak flow

Evaluation requires long-term followup.



2/year (see note)01/yearExacerbations requiring oral system ic

corticosteroids

Risk



for symptom control(not prevention of EIB)


Classification of Asthm a Control (511 years of age)

Im pairm ent


Reduction inlung growth

<75% 7580% >80% • FEV1/FVC

2x/week2x/month1x/monthNighttimeawakenings

Throughout the day>2 days/week or multiple times on2 days/week

2 days/week but not more than once on each

daySymptoms

Very Poorly ControlledNot W ell Controlled

W ellControlled

IntermittentAsthma



Patient Education and Environmental Control at Each Step

Stepwise Approach for managing asthma in children 5-11 years of age

Quick-relief medication for ALL patientsSABA as needed for symptoms.Short course of oral corticosteroids maybe needed.


(and asthma is well


months)

Assess control

Step up if needed

(first check adherence, environmen tal control,

and comorbid

conditions)

Preferred

SABA PRN

Step 1

Preferred

Low dose ICS

AlternativeLTRA, CromolynNedocromil orTheophylline

Step 2 PreferredEitherLow Dose ICS + LABA, LTRA, or Theophylline

OR

Medium Dose ICS

Step 3 Preferred

Medium Dose ICS + LABA

AlternativeMedium dose ICS + either LTRA, or Theophylline

Step 4 Preferred

High Dose ICS + LABA

AlternativeHigh dose ICS + either LTRA, or Theophylline

Step 5 Preferred

High Dose ICS + LABA + oral corticosteroid

AlternativeHigh dose ICS + either LTRA, or Theophylline+ oral corticosteroid

Step 6


Adjusting Therapy Adjusting Therapy in Youths > in Youths > 1212

Years of Age Years of Age &&

AdultsAdults

2/year (see note)01/year


• Step up 12 steps, and• Reevaluate in 2 weeks.• For side effects,

consider alternative treatment options.

• Step up 1 step and• Reevaluate in

26 weeks.• For side effects,

consider alternative treatment options.

• Maintain current step.• Regular followups

every 16 months to maintain control.

• Consider step down if well controlled for at least 3 months.


(see figure 45 for treatm ent steps)

Evaluation requires long-term followup care



Progressive loss of lung functionRisk

Validated questionnaires

Throughout the day>2 days/week2 days/weekSymptoms

Im pairm ent

3–4N/A15

1–21.51619

00.75*20

ATAQACQACT

<60% predicted/personal best

6080% predicted/personal best

>80% predicted/personal best

FEV1 or peak flow

Several times per day>2 days/week2 days/weekShort-acting beta2-agonist use for symptom control (not prevention of EIB)

Consider severity and interval since last exacerbationExacerbations requiring oral system ic corticosteroids

Classification of Asthm a Control(12 years of age)



4x/week13x/week2x/monthNighttime awakenings

Very PoorlyControlled

NotW ell ControlledW ell Controlled

IntermittentAsthma



Step 1Preferred:SABA PRN

Step 2Preferred:Low dose ICS

Alternative: Cromolyn, LTRA, Nedocromil or Theophylline

Step 3Preferred:

Low-dose ICS + LABA OR – Medium dose ICS

Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton

Step 4

Preferred:Medium Dose ICS + LABA

Alternative:Medium-dose ICS + either LTRA, Theophylline, or Zileuton

Step 5

PreferredHigh Dose ICS + LABA

AND

Consider Omalizumab for patients who have allergies

Step 6

PreferredHigh dose ICS + LABA + oral corticosteroid

AND

Consider Omalizumab for patients who have allergies

Each Step: Patient Education and Environmental Control and management of comorbiditiesSteps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma

Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults

•Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 tx @ 20 minute intervals prn. Short course of o systemic corticosteroids may be needed.• Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control & the need to step up treatment.


(and asthma is well


months)

Assess control

Step up if needed

(first check adherence, environmental control & comorbid conditions)

7575

Section 5Section 5

Managing Exacerbations of AsthmaManaging Exacerbations of Asthma

7676

Key Points Key Points –– Managing Exacerbations Managing Exacerbations

Early treatment of asthma exacerbations is the best strategy Early treatment of asthma exacerbations is the best strategy

for management:for management:

Patient education includes a written asthma action plan (AAP) toPatient education includes a written asthma action plan (AAP) to

guide patient selfguide patient self‐‐management of exacerbationsmanagement of exacerbations–– especially for patients who have moderate or severe especially for patients who have moderate or severe

persistent asthma and any patient who has a history of severe persistent asthma and any patient who has a history of severe

exacerbationsexacerbations

A peakA peak‐‐flowflow‐‐based plan for patients who have difficulty perceiving based plan for patients who have difficulty perceiving

airflow obstruction and worsening asthma is recommendedairflow obstruction and worsening asthma is recommended

EPR EPR ‐‐3 Pg. 3733 Pg. 373

7777


cont.cont.

––

Recognition of early signs of worsening asthma & taking Recognition of early signs of worsening asthma & taking

prompt actionprompt action

––

Appropriate intensification of therapy, often including a Appropriate intensification of therapy, often including a

short course of oral corticosteroidsshort course of oral corticosteroids

––

Removal or avoidance of the environmental factors Removal or avoidance of the environmental factors

contributing to the exacerbationcontributing to the exacerbation

––

Prompt communication between patient and clinician about Prompt communication between patient and clinician about

any serious deterioration in symptoms or peak flow, any serious deterioration in symptoms or peak flow,

decreased responsiveness to decreased responsiveness to SABAsSABAs, or decreased duration , or decreased duration

of effectof effect

7878

Exacerbations Defined Exacerbations Defined ‐‐

RISKRISK

Are acute or Are acute or subacutesubacute

episodes of progressively worsening episodes of progressively worsening

shortness of breath, cough, wheezing, and chest tightness?shortness of breath, cough, wheezing, and chest tightness?

—— or some combination of these symptoms or some combination of these symptoms

Are characterized by decreases in expiratory airflow that can Are characterized by decreases in expiratory airflow that can

be documented and quantified by spirometry or peak be documented and quantified by spirometry or peak

expiratory flowexpiratory flow

–– These objective measures more reliably indicate the These objective measures more reliably indicate the

severity of an exacerbation than does the severity of severity of an exacerbation than does the severity of

symptomssymptoms

Classifying Severity of Asthma Exacerbations in the UC or ER SetClassifying Severity of Asthma Exacerbations in the UC or ER Settingting

SeveritySeverity Symptoms & Signs

Initial PEF (or FEV1 )

Clinical Course

MildDyspnea only with activity (assess tachypnea in young

children)

PEF 70 percent predicted or personal best

Usually cared for at home

Prompt relief with inhaled SABA

Possible short course of oral systemic corticosteroids

Moderate Dyspnea interferes with or limits usual activity

PEF 4069 percent predicted or personal best

Usually requires office or ED visit

Relief from freq. inhaled SABA

Oral systemic corticosteroids; some symptoms last 1–2 days after treatment is begun

Severe

Dyspnea at rest; interferes with conversation

PEF <40 percent predicted or personal best

Usually requires ED visit and likely hospitalization

Partial relief from frequent inhaled SABA

PO systemic corticosteroids; some symptoms last >3 days after treatment is begun

Adjunctive therapies are helpful

Subset: Life threatening Too dyspneic to speak;

perspiring

PEF <25 percent predicted or personal best

Requires ED/hospitalization; possible ICU

Minimal or no relief w/ frequent inhaled SABA

Intravenous corticosteroids

Adjunctive therapies are helpful

A s s e s s S e v e r i t y P a t ie n t s a t h ig h r is k f o r a f a ta l a t t a c k (s e e f ig u r e 5 – 2 a ) r e q u i r e im m e d ia t e m e d ic a l a t te n t io n

a f t e r in i t ia l t r e a t m e n t .

S y m p to m s a n d s ig n s s u g g e s t iv e o f a m o r e s e r io u s e x a c e r b a t io n s u c h a s m a rk e d b r e a th le s s n e s s , in a b i l i t y t o s p e a k m o r e t h a n s h o r t p h ra s e s , u s e o f a c c e s s o r y m u s c le s , o r d ro w s in e s s ( s e e f ig u re 5 – 3 ) s h o u ld r e s u l t in in i t ia l t r e a tm e n t w h i le im m e d ia te ly c o n s u l t in g w i t h a c l in ic ia n .

L e s s s e v e r e s ig n s a n d s y m p to m s c a n b e t r e a te d in i t ia l l y w i th a s s e s s m e n t o f r e s p o n s e to t h e r a p y a n d fu r t h e r s te p s a s l is t e d b e lo w .

I f a v a i la b le , m e a s u r e P E F — v a lu e s o f 5 0 – 7 9 % p r e d ic t e d o r p e r s o n a l b e s t in d ic a te th e n e e d fo r q u ic k - r e l ie f m e d ia t io n . D e p e n d in g o n t h e re s p o n s e to t r e a tm e n t , c o n ta c t w i th a c l in ic ia n m a y a ls o b e in d ic a te d . V a lu e s b e lo w 5 0 % in d ic a te t h e n e e d fo r im m e d ia te m e d ic a l c a r e .

I n i t ia l T r e a t m e n t I n h a le d S A B A : u p to tw o t r e a tm e n ts 2 0 m in u te s a p a r t o f 2 – 6 p u f fs

b y m e te re d - d o s e in h a le r ( M D I ) o r n e b u l iz e r t r e a tm e n ts . N o te : M e d ic a t io n d e l iv e r y is h ig h ly v a r ia b le . C h i ld r e n a n d

in d iv id u a ls w h o h a v e e x a c e r b a t io n s o f le s s e r s e v e r i t y m a y n e e d f e w e r p u f f s t h a n s u g g e s te d a b o v e .

G o o d R e s p o n s e

N o w h e e z in g o r d y s p n e a( a s s e s s t a c h y p n e a in y o u n g c h i ld r e n ) .P E F 8 0 % p re d ic te d o r p e r s o n a l b e s t . C o n ta c t c l in ic ia n f o r

f o l lo w u p in s t r u c t io n s a n d f u r t h e r m a n a g e m e n t .

M a y c o n t in u e in h a le d S A B A e v e r y 3 – 4 h o u rs fo r 2 4 – 4 8 h o u r s .

C o n s id e r s h o r t c o u r s e o f o r a l s y s te m ic c o r t ic o s te ro id s .

In c o m p le t e R e s p o n s e

P e r s is t e n t w h e e z in g a n d d y s p n e a ( t a c h y p n e a ) .P E F 5 0 – 7 9 % p r e d ic te d o r p e r s o n a l b e s t . A d d o ra l s y s te m ic

c o r t ic o s te ro id . C o n t in u e in h a le d S A B A . C o n ta c t c l in ic ia n u r g e n t ly

( t h is d a y ) f o r f u r th e r in s t ru c t io n .

P o o r R e s p o n s e

M a r k e d w h e e z in g a n d d y s p n e a .P E F < 5 0 % p r e d ic te d o r p e r s o n a l b e s t . A d d o ra l s y s te m ic

c o r t ic o s te ro id . R e p e a t in h a le d S A B A

im m e d ia te ly . I f d is t r e s s is s e v e r e a n d

n o n r e s p o n s iv e to in i t ia l t r e a tm e n t :

— C a l l y o u r d o c to r A N D— P R O C E E D T O E D ;— C o n s id e r c a l l in g 9 – 1 – 1

( a m b u la n c e t r a n s p o r t ) .

T o E D .

Managing Asthma Exacerbations at Home

8181

What the EPR What the EPR ‐‐3 Does 3 Does NOTNOT

RecommendRecommend

––

Drinking large volumes of liquids or breathing warm, Drinking large volumes of liquids or breathing warm,

moist air moist air (e.g., the mist from a hot shower)(e.g., the mist from a hot shower)––

Using overUsing over‐‐thethe‐‐counter products such as antihistamines counter products such as antihistamines

or cold remediesor cold remedies––

Although pursedAlthough pursed‐‐lip and other forms of controlled lip and other forms of controlled

breathing may help to maintain calm during respiratory breathing may help to maintain calm during respiratory distress, these methods do distress, these methods do not not bring about improvement bring about improvement

in lung functionin lung function

EPR EPR ‐‐3 , P.3843 , P.384

8282

Many Thanks To Many Thanks To ‐‐

Colleagues who shared their power point presentations and/or

provided feedback on the foundation for this presentation:

––

Dr. Gail M Brottman MD, Director, Dr. Gail M Brottman MD, Director,

Pediatric Pulmonary Medicine, HCMCPediatric Pulmonary Medicine, HCMC––

Dr. Don Uden, Pharm. D., Professor, Dr. Don Uden, Pharm. D., Professor,

University of Minnesota, College of Pharmacy University of Minnesota, College of Pharmacy ––

Dr. Barbara P. Yawn, MD, Dr. Barbara P. Yawn, MD, MScMSc, ,

Director of Research, Olmsted Medical ClinicDirector of Research, Olmsted Medical Clinic––

Dr. Mamta Reddy, MD, ChiefDr. Mamta Reddy, MD, ChiefAllergy/ Immunology, Bronx Lebanon Hospital Center, NYAllergy/ Immunology, Bronx Lebanon Hospital Center, NY

––

Mary Mary BielskiBielski, RN, LSN, CNS, , RN, LSN, CNS,

Nursing Service Manager, Minneapolis Public SchoolsNursing Service Manager, Minneapolis Public Schools

8383

Minnesota Department of HealthMinnesota Department of Health Asthma ProgramAsthma Program

www.health.state.mn.us/asthmawww.health.state.mn.us/asthma

2010 national institutes of health (nih) naepp 2007 … national institutes of health (nih) naepp...

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