1 1 National Institutes of Health (NIH) National Institutes of Health (NIH) NAEPP 2007 Asthma Guideline NAEPP 2007 Asthma Guideline Expert Panel Report (EPR) Expert Panel Report (EPR) ‐ ‐ 3 3 Susan K. Ross RN, AE Susan K. Ross RN, AE ‐ ‐ C C MDH Asthma Program MDH Asthma Program 651 651 ‐ ‐ 201 201 ‐ ‐ 5629 5629 [email protected][email protected]
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11
National Institutes of Health (NIH)National Institutes of Health (NIH) NAEPP 2007 Asthma GuidelineNAEPP 2007 Asthma Guideline
““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
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.
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
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
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
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.
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
Short-actingbeta2-agonist use
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
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
Component 2Component 2
Education for a Partnership in Education for a Partnership in Asthma CareAsthma Care
4747
Key Points Key Points ‐‐
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
Key Points Key Points ––
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
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
Component 3Component 3
Control of Environmental Factors Control of Environmental Factors && ComorbidComorbid
Conditions that Affect AsthmaConditions that Affect Asthma
5353
Key Points Key Points ––
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
Key Points Key Points ––
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
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
Several times per day>2 days/week2 days/week
Short-actingbeta2-agonist use
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
Com ponents of Control
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
Either:Montelukast or LABA
Step 6
PreferredHighDose ICS
AND
Either:Montelukast or LABA
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)
Assessing Control Assessing Control &&
Adjusting Therapy Adjusting Therapy Children 5Children 5‐‐11 Years of Age11 Years of Age
Consider severity and interval since last exacerbation
• Consider short course of oral system ic corticosteroids,
• 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.
Recom m ended Actionfor Treatm ent
(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.
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.
Treatment-related adverse effects
2/year (see note)01/yearExacerbations requiring oral system ic
corticosteroids
Risk
Several times per day>2 days/week2 days/week
Short-actingbeta2-agonist use
for symptom control(not prevention of EIB)
Extremely lim itedSome lim itationNoneInterference w ith normal activity
Classification of Asthm a Control (511 years of age)
Im pairm ent
Com ponents of Control
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
Persistent Asthma: Daily MedicationConsult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
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.
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
Assessing Control Assessing Control &&
Adjusting Therapy Adjusting Therapy in Youths > in Youths > 1212
Years of Age Years of Age &&
AdultsAdults
2/year (see note)01/year
• Consider short course of oral system ic corticosteroids,
• 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.
Recom m ended Actionfor Treatm ent
(see figure 45 for treatm ent steps)
Evaluation requires long-term followup care
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.
Treatment-related adverse effects
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)
Com ponents of Control
Extremely lim itedSome lim itationNoneInterference w ith normal activity
4x/week13x/week2x/monthNighttime awakenings
Very PoorlyControlled
NotW ell ControlledW ell Controlled
IntermittentAsthma
Persistent Asthma: Daily MedicationConsult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
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.
Step down if possible
(and asthma is well
controlled at least 3
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
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
Key Points Key Points ––
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,