Asthma Guidelines: Stepwise Approach to Managing Asthma Karen Meyerson, MSN, RN, FNP-C, AE-C Asthma Network of West Michigan April 21, 2009 Acknowledgements: LeRoy M. Graham, MD, Atlanta, GA Allan T. Luskin, MD, Madison, WI
Asthma Guidelines:Stepwise Approach to Managing Asthma
Karen Meyerson, MSN, RN, FNP-C, AE-CAsthma Network of West Michigan
April 21, 2009
Acknowledgements: LeRoy M. Graham, MD, Atlanta, GA
Allan T. Luskin, MD, Madison, WI
PREVIOUS NHLBI/GINA GUIDELINES
Severity Symptoms Nocturnal
Symptoms
FEV1 or
PEF
Mild Intermittent < 1 x/week , asymptomatic between attacks
< 2 x / month > 80% predicted variability < 20%
Mild Persistent > 1 x/week but not daily
> 2 x / month > 80% predicted variability 20-30%
Moderate Persistent
Daily, affecting activity > 1 time / week 60 -80% predicted variability > 30%
Severe Persistent Continuous, limiting activity
Frequent < 60% predicted variability > 30%
Asthma Severity
Asthma severity is the intrinsic intensity of disease.
Initial assessment of patients who have confirmed asthma begins with a severity classification because the therapy should then correspond to the level of asthma severity.
This initial assessment of asthma severity is made immediately after diagnosis, or when the patient is first encountered, generally before the patient is taking some form of long-term control medication.
Assessment is made on the basis of current spirometry and the patient’s recall of symptoms over the previous 2–4 weeks, because detailed recall of symptoms decreases over time.
Asthma Severity
Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
Classification of Asthma Severity
PersistentIntermittentMild Moderate Severe
Components of Severity
Impairment
Risk
Recommended Step for Initiating Treatment
Symptoms
Nighttime Awakenings
SABA use for sx control
Interference with normal activity
Exacerbations
(consider frequency and
severity)
In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly
Step 1 Step 2 Step 3
0-1/year
<2 days/week >2 days/week not daily Daily Continuous
0 1-2x/month 3-4x/month >1x/week
none Minor limitation Some limitation Extremely limited
<2 days/week >2 days/week not daily Daily Several times daily
Consider short course of oral steroids
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
CHILDREN 0-4 YEARS OF AGE
>2 exacerbations in 6 months requiring oral steroids, or >4 wheezing episodes/ year lasting >1 day AND risk factors for persistent asthma
Frequency and severity of may fluctuate over time
Exacerbations of any severity may occur in patients in any category
EPR-3, p72, 307
Pulmonary Function Tests
FEV1 (Forced Expiratory Volume in 1 Second) – this is the volume of air expired in the first second during maximal expiratory effort. The FEV1 is reduced in both obstructive and restrictive lung disease.
FVC (Forced Vital Capacity) – this is the total volume of air expired after a full inspiration.
FEV1/FVC – this is the percentage of the vital capacity which is expired in the first second of maximal expiration.
Classification of Asthma Severity
PersistentIntermittentMild Moderate Severe
Components of Severity
Impairment
Risk
Recommended Step for Initiating Treatment
Symptoms
Nighttime Awakenings
SABA use for sx control
Interference with normal activity
Lung Function
Exacerbations
(consider frequency and
severity)
In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
Step 2
Relative annual risk of exacerbations may be related to FEV
0-2/year > 2 /yearFrequency and severity may vary over time for patients in any category
<2 days/week >2 days/week not daily Daily Continuous
<2x/month 3-4x/month >1x/week
not nightlyOften nightly
none Minor limitation Some limitation Extremely limited
<2 days/week >2 days/week not daily Daily Several times daily
•Normal FEV1 between exacerbations
• FEV1 > 80%
• FEV1/FVC> 85%
• FEV1 >80%
•FEV1/FVC> 80%
• FEV1=60% -80%
•FEV1/FVC=75%-80%
•FEV1 <60%
•FEV1/FVC < 75%
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
CHILDREN 5 - 11 YEARS OF AGE
Step 1 Step3 medium-dose ICS option
Step 3 or 4
Consider short course of oral steroids
EPR-3, p73, 308
Classification of Asthma Severity
PersistentIntermittentMild Moderate Severe
Components of Severity
Impairment
Normal FEV1/FVC
8-19 yr 85%
20-39 yr 80%
40-59 yr 75%
60-80 yr 70%
Risk
Recommended Step for Initiating Treatment
Symptoms
Nighttime Awakenings
SABA use for sx control
Interference with normal activity
Lung Function
Exacerbations
(consider frequency and
severity)
In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly
Step 1 Step 2 Step 3 Step 4 or 5
Relative annual risk of exacerbations may be related to FEV
0-2/year > 2 /year
Frequency and severity may vary over time for patients in any category
<2 days/week >2 days/week not daily Daily Continuous
<2x/month 3-4x/month >1x/week
not nightlyOften nightly
none Minor limitation Some limitation Extremely limited
<2 days/week >2 days/week not daily Daily Several times daily
Consider short course of oral steroids
•Normal FEV1 between exacerbations
• FEV1 > 80%
• FEV1/FVC normal
• FEV1 >80%
•FEV1/FVC normal
• FEV1 >60% but< 80%
•FEV1/FVC reduced 5%
•FEV1 <60%
•FEV1/FVC reduced> 5%
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
YOUTHS > 12 YEARS AND ADULTS EPR-3, p74, 344
Asthma Control
The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma therapy are being achieved and asthma is controlled.
Well Controlled
Not Well Controlled
Very Poorly Controlled
Asthma Control
Reducing Current Impairment
Reducing Future Risk
Classification of Asthma ControlComponents of Control
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
CHILDREN 0 - 4 YEARS OF AGE
IMPAIRMENT
RISK
Recommended Action
For Treatment
Well ControlledNot Well
ControlledVery Poorly Controlled
Symptoms
Nighttime awakenings
Interference with normal activity
SABA use
Exacerbations
Progressive loss of lung function
Rx-related adverse effects Consider in overall assessment of risk
Evaluation requires long-term follow up care
0- 1 per year 2 - 3 per year > 3 per year
none Some limitation Extremely limited
< 2 days/week > 2 days/week Throughout the day
< 1/month > 2 x/month >2x/week
< 2 days/week > 2 days/week Several times/day
•Maintain current step
•REGULAR FOLLOW UP EVERY 3 - 6
MONTHS
•Consider step down if well controlled at least
3 months
•Step up 1 step
•Reevaluate in 2 - 6 weeks
•If no clear benefit in 4-6 weeks ,
consider alternative dx or adjust therapy
•Consider oral steroids
•Step up (1-2 steps) and reevaluate in 2
weeks
•If no clear benefit in 4-6 weeks , consider
alternative dx or adjust therapy
EPR-3, p75, 309
Classification of Asthma ControlComponents of Control
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
CHILDREN 5 - 11 YEARS OF AGE
IMPAIRMENT
RISK
Recommended Action
For Treatment
Well ControlledNot Well
ControlledVery Poorly Controlled
Symptoms
Nighttime awakenings
Interference with normal activity
SABA use
FEV1or peak flow
ExacerbationsProgressive loss of lung
functionRx-related adverse effects Consider in overall assessment of risk
Evaluation requires long-term follow up care
0- 1 per year 2 - 3 per year > 3 per year
none Some limitation Extremely limited
< 2 days/week > 2 days/week Throughout the day
< 1/month > 2 x/month >2x/week
< 2 days/week > 2 days/week Several times/day
> 80% predicted/ personal best
60-80% predicted/ personal best
<60% predicted/ personal best
•Maintain current step
•Consider step down if well controlled at least
3 months
•Step up 1 step
•Reevaluate in 2 - 6 weeks
•Consider oral steroids
•Step up 1-2 weeks and reevaluate in 2
weeks
FEV1/FVC > 80% predicted 75-80% predicted <75% predicted
EPR-3, p76, 310
Classification of Asthma ControlComponents of Control
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
YOUTHS > 12 YEARS OF AGE AND ADULTS
IMPAIRMENT
RISK
Recommended Action
For Treatment
Well ControlledNot Well
ControlledVery Poorly Controlled
Symptoms
Nighttime awakenings
Interference with normal activity
SABA use
FEV1or peak flow
Validated questionnaires
ATAQ/ACTExacerbations
Progressive loss of lung function
Rx-related adverse effects Consider in overall assessment of risk
Evaluation requires long-term follow up care
0- 1 per year 2 - 3 per year > 3 per year
none Some limitation Extremely limited
< 2 days/week > 2 days/week Throughout the day
< 2/month 1-3/week > 4/week
< 2 days/week > 2 days/week Several times/day
> 80% predicted/ personal best
60-80% predicted/ personal best
<60% predicted/ personal best
0/> 20 1-2/16-19 3-4/< 15
•Maintain current step
•Consider step down if well controlled at least
3 months
•Step up 1 step
•Reevaluate in 2 - 6 weeks
•Consider oral steroids
•Step up 1-2 weeks and reevaluate in 2
weeks
EPR-3, p77, 345
Asthma Control Test™ (ACT) for Patients 12 Years and Older
1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?
2. During the past 4 weeks, how often have you had shortness of breath?
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning?
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?
5. How would you rate your asthma control during the past 4 weeks?
Score
Patient Total Score
Copyright 2002, QualityMetric Incorporated.Asthma Control Test Is a Trademark of QualityMetric Incorporated.
Childhood Asthma Control Test™ (ACT): Questions Completed by Child
3210
3. Do you cough because of your asthma?
4. Do you wake up during the night because of your asthma?
3210
3210
1. How is your asthma today?
2. How much of a problem is your asthma when you run, exercise or play sports?
3210
It’s a big problem, I can’t do what I want to do. It’s a problem and I don’t like it. It’s a little problem but it’s okay. It’s not a problem
Very bad Bad Good Very Good
Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time
Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time
SCORE
Childhood Asthma Control Test™ (ACT): Questions Completed by Parent/Caregiver
5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms?
5
Not at all
6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma?
7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma?
4
1-3 days/mo
3
4-10 days/mo
1
19-24 days/mo
0
Everyday
2
11-18 days/mo
5
Not at all
4
1-3 days/mo
3
4-10 days/mo
1
19-24 days/mo
0
Everyday
2
11-18 days/mo
5
Not at all
4
1-3 days/mo
3
4-10 days/mo
1
19-24 days/mo
0
Everyday
2
11-18 days/mo
TOTAL
Monitoring Asthma Control
Ask the patient Has your asthma awakened you at night or early morning? Have you needed more rescue inhaler than usual? Have you needed urgent care for asthma? (office, ED, etc) Are you participating in your usual or desired activities? What are your triggers? (and how can we manage them?)
Actions to consider Assess whether medications are being taken as prescribed Assess whether inhalation technique is correct Assess spirometry and compare to previous measurements Adjust medications, as needed to achieve best control with
the lowest dose needed to maintain control Environmental mitigation strategy
NAEPP Draft Report, ERP 2007
EPR-3, Page 78
Intermittent Asthma
Persistent Asthma: Daily MedicationConsult with asthma specialist if step 3 or higher care is required
Consider consultation at step 2
Patient Education and Environmental Control at Each Step
Step 1Preferred:SABA prn
Step 2Preferred:
Low-dose ICS
Alternative:LTRA
Cromolyn
Step 3Preferred:
Medium-doseICS
Step 4
Preferred:Medium-dose
ICS
AND
either LTRAOr LABA
Step 5Preferred:
High dose ICS
AND
either LTRAOr LABA
Step 6
AND
either LTRAOr LABA
AND
Oral Corticosteroid
AssessControl
STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 0 - 4 YEARS OF AGE
Step up if needed (check adherence, environmental control )
Step down if possible
(asthma well controlled for 3 months)
EPR-3, p291-296
Intermittent Mild Persistent Moderate Persistent Severe Persistent
Intermittent Asthma
Persistent Asthma: Daily MedicationConsult with asthma specialist if step 4 or higher care is required
Consider consultation at step 3
Patient Education and Environmental Control at Each Step
Step 1Preferred:SABA prn
Step 2Preferred:
Low-dose ICSAlternative:
LTRACromolyn
Theophylline
Step 3Preferred:
Medium-doseICS
ORLow-dose ICS+
either LABA,LTRA, or
Theophylline
Step 4
Preferred:Medium-dose
ICS+LABA
Alternative:Medium-dose
ICS+eitherLTRA, or
Theophlline
Step 5Preferred:
High dose ICS+ LABA
Alternative:High-dose ICS+
either LTRAor Theophylline
AND
ConsiderOlamizumab for
patients withallergies
Step 6
Preferred:High-dose ICS+ LABA + oralCorticosteroid
Alternative:High-dose ICS
+either LTRA orTheophylline
+ oral corticosteroid
ANDConsider
Olamizumab for patients with
allergies
AssessControl
STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5-11 YEARS OF AGE
Step up if needed (check adherence, environmental control and comorbidities)
Step down if possible
(asthma well controlled for 3 months)
EPR-3, p296-304
Intermittent Asthma
Persistent Asthma: Daily MedicationConsult with asthma specialist if step 4 or higher care is required
Consider consultation at step 3
Patient Education and Environmental Control at Each Step
Step 1Preferred:SABA prn
Step 2Preferred:
Low-dose ICSAlternative:
LTRACromolyn
Theophylline
Step 3Preferred:
Medium-doseICSOR
Low-dose ICS+either LABA,
LTRA, Theophylline
Or Zileutin
Step 4
Preferred:Medium-dose
ICS+LABA
Alternative:Medium-dose
ICS+eitherLTRA,
TheophllineOr Zileutin
Step 5Preferred:
High dose ICS+ LABA
AND
ConsiderOlamizumab for
patients withallergies
Step 6
Preferred:High-dose ICS+ LABA + oralCorticosteroid
AND
ConsiderOlamizumab for
patients withallergies
AssessControl
STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS > 12 YEARS AND ADULTS
Step up if needed (check adherence, environmental control and comorbidities)
Step down if possible
(asthma well controlled for 3 months)
EPR-3, p333-343
Recommended Action for Treatment Based on Assessment of Control
WellWell
ControlledControlled
Not WellNot Well
ControlledControlled
Very Poorly Very Poorly ControlledControlled
Maintain current step Step up 1 step and reevaluate in 2-6 weeks
Consider short course of oral corticosteroids
Consider step down if well controlled for at least 3 months
For side effects, consider alternative treatment options
Step up 1-2 steps and reevaluate in 2 weeks
For side effects, consider alternative treatment options
NAEPP Draft Report, ERP 2007Before stepping up check adherence and environmental control
EPR-3, Page 330
Treatment Strategies
Gain Control!!!Aggressive, intensive initial therapy to
suppress airway inflammation and gain prompt control
Maintain ControlFrequent follow-up, clinically and
physiologically
Therapeutic modifications depending on severity and clinical course
“Step down” long-term control medications to maintain control with minimal side effects
Patients Are Candidates for Maintenance Therapy if
The “RULES OF TWO”™* Apply…
They are using a quick-relief inhaler more than 2 times per week
They awaken at night due to asthma more than 2 times per month
They refill a quick-relief inhaler Rx more than 2 times per year
*“RULES OF TWO”™ is a trademark of the Baylor Health Care System.
Out of Control!
Rules of Two TM
If your patient can answer “YES” to ANY of these questions, his/her asthma is probably not under good control.
These rules define persistent asthma.
Asthma Pharmacotherapy
Quick-relief
Short-acting beta-agonists
Inhaled anticholinergics
Systemic corticosteroids
Long-term control
Corticosteroids
Cromolyn sodium/nedocromil
Long-acting inhaled beta-agonists
Theophylline
Leukotriene modifiers
Quick-Relief Medications
Short-acting beta2-agonists (SABA): Albuterol, Ventolin®, Proventil®, Maxair®, Xopenex®, etc.
Relax bronchial smooth muscles
Short-acting Work within 10 - 15 minutes Last 4 - 6 hours
Side effects can include shakiness (tremors), tachycardia
Danger of over-use
Short-acting 2-agonists
Most effective medication for relief of acute symptoms RED FLAG
more than 1 canister per month
Regularly scheduled use not generally recommendedMay “lower” effectivenessMay increase airway hyperresponsiveness
Anticholinergics
Not specifically indicated for “usual” quick-relief medication in asthmacontrast with COPD
Now well-studied as adjunct to beta-agonists in emergency departments i.e., acute exacerbations
Long-term Control Medications
Inhaled corticosteroids (ICS): Advair®, Flovent®, Azmacort®, Q-Var®, Pulmicort®, Asmanex®, Aerobid®, Symbicort®
Non-steroidal anti-inflammatories: Intal®, Tilade®
Leukotriene modifiers (LTM): Singulair®, Accolate®
Theophylline: Theo-Dur®, Slo-bid
Long-acting beta2-agonists (LABA): Serevent®, Foradil®
Taken daily and chronically to maintain control of persistent asthma and to prevent exacerbations:
Soothes airway swelling Helps prevent asthma flares - very effective for long-
term control but must be taken daily Often under-used
Inhaled Corticosteroids
Actions:potentiate -receptor responsivenessreduce mucus production and hypersecretioninhibit inflammatory response at all levels
Best effects if started early after diagnosis
Symptomatic and spirometric improvement within 2 weeksmaximum effects within 4-8 weeks
Inhaled Corticosteroids (continued)
Most effective long term control medication for persistent asthma
Small risk for adverse events at usual doses
Risk can be reduced even further by:
Using spacer and rinsing mouth
Using lowest effective dose
Using with long-acting 2-agonist when appropriate
Monitoring growth in children
Low dose ICS and the Prevention of Asthma Deaths
•ICS protects patients from asthma-related deaths•Users of > 6 canisters/yr. had a death rate ~ 50% lower than non-users of ICS•Death rate decreased by 21% for each additional ICS canister used during the previous year.
Suissa et al. N Eng J Med 2000;343:332-336.
ICS May Help Prevent the Risk of Asthma Related Hospitalizations
Adapted from Donahue et. al. JAMA 1997;277(11):887-891.
Short-acting B2 prescriptions dispensed per person-year
8
7
6
5
4
3
2
1
0
Rel
ati
ve
Ris
ko
f H
osp
ital
iza
tio
n
None 1-2 2-3 3-5 5-8 8+0-1
Total
Inhaled Steroids
2-agonists
Total
Inhaled Corticosteroids (continued)
HPA Suppressionno need to test in children receiving < 400
mcg/day (BEC), or adults < 1500 mcg/day (BEC)
Cataracts
Long bone growthgrowing understanding of this risk
Osteoporosis/Bone Fracturessome attention at high doses, high risk
patients
Candidiasis
Dysphonia
Leukotriene Modifiers
Two mechanisms5-lipoxygenase inhibitors
zileution (Zyflo)Cysteinyl leukotriene receptor antagonists
zafirlukast (Accolate), montelukast (Singulair)
IndicationsGenerally, alternative therapy in mild persistent
asthma or as add-on in higher stagesImprove lung function
Decrease short-acting 2-agonist use
Prevent exacerbations
Methylxanthines (Theophylline) (continued)
Places in therapy:primary therapy when inhaled corticosteroids not possible
patient’s who can’t/won’t use inhalers
additive therapy at later Stages
ADR’s/Serum Levels/Drug InteractionsTherapeutic Range 5-15 mcg/mL, or 10-20 mcg/mL
levels > 20 mcg/mL: N/V/D, HA, irritability, insomnia, tachycardia
levels > 30 mcg/mL: seizures, toxic encephalopathy, hyperthermia, brain damage
ADR’s/Serum Levels/Drug Interactions Drug Interactions: PLENTY!!
Long-acting 2-agonists
Not a substitute for anti-inflammatory therapy
Not appropriate for monotherapy RED FLAG
Literature supporting role in addition to inhaled corticosteroids
Not for acute symptoms or exacerbations
Salmeterol (Serevent) first of class in US
Formoterol (Foradil) Newer long-acting beta-agonist Has rapid onset and long duration Available as dry powder inhaler and in combination with
inhaled steroid (Symbicort)
Long-acting 2-agonists
Salmeterol Multicenter Asthma Research Trial (SMART)
A comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol.
Nelson HS, Weiss ST, Bleecker ER, et al.
Chest 2006; 129:15-26.
Patients > 12 years old with asthma
Sought to evaluate the effects of salmeterol or placebo added to usual asthma care on respiratory and asthma related deathslife-threatening episodes
Initial aim to enroll 30,000 patients; later changed with aim to enroll 60,000
Long-acting 2-agonists
Two methods of recruitmentPhase 1 1996-1999
Recruited by advertising and assigned to study investigator by geography
Phase 2 2000-2003Recruitment by study investigators and
more investigators added
Long-acting 2-agonists
Increase in adverse events in salmeterol group during SMART trial:Particularly in those recruited in Phase 1Particularly among African-Americans who were noted to have
markers of more severe asthma and less likely to be using ICS
Increase in adverse events in salmeterol groupDue to adverse effect of salmeterol?Due to inappropriate bronchodilator use? (affected patients were
more severe at baseline and less likely to be using ICS)
Long-acting 2-agonists
FDA Advisory Panel Recommends Ban of Long-acting 2-agonists in Asthma
A panel of outside advisers has told the FDA that two long-acting asthma drugs -- Serevent and Foradil -- should be banned for use in asthma treatment because they are alleged to be more dangerous than they are helpful, particularly in children and adolescents.
If the FDA takes this advice, it would remove the indication for asthma from the label for these drugs but they could still be prescribed for chronic obstructive pulmonary disease.
But the advisers unanimously supported the continued use of the far more popular drugs Advair and Symbicort. Advisers overwhelmingly agreed these drugs provided great benefits to patients, though they expressed some concern about lack of information about how safe they are for adolescents and children.
~December 2008
Conclusions:Black Box warning
Do not use long-acting bronchodilators alone
Always use with inhaled corticosteroids
Long-acting 2-agonists
Xolair® Indication
Xolair is indicated for adults and adolescents (12 years of age and above)
With moderate to severe, persistent asthma
Who have a positive skin test or in vitro reactivity to a perennial aeroallergen
Whose symptoms are inadequately controlled with inhaled corticosteroids
Elevated serum IgE level (≥30-700 IU/mL)
Xolair has been shown to decrease the incidence of asthma exacerbations in these patients
Safety and efficacy have not been established in other allergic conditions
Referral to an Asthma Specialist for Consultation and Co-Management
Patient has had a life-threatening asthma exacerbation (hospitalization is a risk factor for mortality)
Patient is not meeting the goals of therapy after 3-6 months
Signs and symptoms are atypical; differential diagnosis ?
Co-morbid conditions complicate asthma (GERD, VCD etc)
Additional diagnostic studies are indicated (allergy skin testing, pulmonary function studies, bronchoscopy)
Patient requires additional education/guidance
Patient has required more than two bursts of oral corticosteroids in 1 year
Patient requires “Step 4” care or higher (“Step 3” for children 0–4 years of age). Consider referral if patient requires step 3 care (“Step 2” for children 0–4 years of age)
Expert Panel Report-3, Page 68
The Outpatient Asthma Visit
Assess “severity” and “control” (NAEPP Classification Criteria) Reduce current impairment Reduce future risk
Address “Inflammation vs. bronchoconstriction”
Differentiate “controller vs. rescue medication”
Prescribe an inhaled steroid for all patients with persistent asthma
Teach spacer device technique
Write an Asthma Action Plan Daily management and recognizing early s/s of worsening Step-up “Yellow Zone” plan for home management
Follow-up in 4-6 weeks: step-up/step-down & modify Action Plan
Inhaler Law; Albuterol and spacer for school
Annual Influenza vaccine, regardless of severity
EPR-3, p121-139
What is Success: How do we measure it and how do we get there?
Begin therapy based on SeveritySeverity
Monitor and adjust therapy based on Control and Risk and Responsiveness to Therapy
Use routine standardized multifaceted measures
The goal of therapy is to achieve control
Individualize therapy based on likelihood of response and patient needs, desires, and goals
Inhaler Technique
Metered-dose inhalers:Proper MDI techniqueProper inhaler/spacer techniqueCare and cleaningMethods to determine amount of medication left in
inhaler
Dry-powder inhalers:Proper techniqueCare and cleaningMethods to determine amount of medication left in
inhaler
Nebulizers
Six Key Messages
Most Important:
1. Inhaled corticosteroids are the most effective anti-inflammatory medication for long term management of persistent asthma.
All patients should receive:
2. Written asthma action plan
3. Initial assessment of asthma severity
4. Review of the level of asthma control (impairment and risk) at all follow up visits
5. Periodic, follow-up visits (at least every 6 months)
6. Assessment of exposure and sensitivity to allergens and irritants and recommendation to reduce relevant exposures.
Guidelines for the Diagnosis and Management
of Asthma
NAEPP/NHLBI Expert Panel Report-3
Case Scenarios
A 3-year old male currently not on any asthma medications has visited your outpatient clinic 3 times in the past 6 months for acute wheezing, each episode lasting 2-3 days. In between episodes, his mother reports nighttime cough about 4 nights per month. This patient’s asthma severity can be BEST classified as:
A. Mild Persistent Asthma (Step 2)
B. Moderate Persistent Asthma (Step 3)
C. Severe Persistent Asthma (Step 4)
D. I would not diagnose this child with asthma
Case # 1
A 3-year old male currently not on any asthma medications has visited your outpatient clinic 3 times in the past 6 months for acute wheezing, each episode lasting 2-3 days. In between episodes, his mother reports nighttime cough about 4 nights per month. This patient’s asthma severity can be BEST classified as:
A. Mild Persistent Asthma (Step 2)
B. Moderate Persistent Asthma (Step 3)
C. Severe Persistent Asthma (Step 4)
D. I would not diagnose this child with asthma
Case # 1
A 7-year old female with asthma reports nighttime awakenings about 2 times per week and requires albuterol about 3 times per week. She is currently taking fluticasone 44 mcg 2 puffs twice daily. The BEST next step in your step-up treatment plan would be to:
A. Increase the dose of the inhaled steroid
B. Add a leukotriene modifier
C. Add a long-acting B-agonist
D. Encourage albuterol more frequently, every 4 hours
Case # 2
Classification of Asthma ControlComponents of Control
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
CHILDREN 5 - 11 YEARS OF AGE
IMPAIRMENT
RISK
Recommended Action
For Treatment
Well ControlledNot Well
ControlledVery Poorly Controlled
Symptoms
Nighttime awakenings
Interference with normal activity
SABA use
FEV1or peak flow
ExacerbationsProgressive loss of lung
functionRx-related adverse effects Consider in overall assessment of risk
Evaluation requires long-term follow up care
0- 1 per year 2 - 3 per year > 3 per year
none Some limitation Extremely limited
< 2 days/week > 2 days/week Throughout the day
< 1/month > 2 x/month >2x/week
< 2 days/week > 2 days/week Several times/day
> 80% predicted/ personal best
60-80% predicted/ personal best
<60% predicted/ personal best
•Maintain current step
•Consider step down if well controlled at least
3 months
•Step up 1 step
•Reevaluate in 2 - 6 weeks
•Consider oral steroids
•Step up 1-2 steps and reevaluate in 2
weeks
FEV1/FVC > 80% predicted 75-80% predicted <75% predicted
EPR-3, p76, 310
Recommended Action for Treatment Based on Assessment of Control
WellWell
ControlledControlled
Not WellNot Well
ControlledControlled
Very Poorly Very Poorly ControlledControlled
Maintain current step Step up 1 step and reevaluate in 2-6 weeks
Consider short course of oral corticosteroids
Consider step down if well controlled for at least 3 months
For side effects, consider alternative treatment options
Step up 1-2 steps and reevaluate in 2 weeks
For side effects, consider alternative treatment options
NAEPP Draft Report, ERP 2007Before stepping up check adherence and environmental control
Intermittent Asthma
Persistent Asthma: Daily MedicationConsult with asthma specialist if step 4 or higher care is required
Consider consultation at step 3
Patient Education and Environmental Control at Each Step
Step 1Preferred:SABA prn
Step 2Preferred:
Low-dose ICSAlternative:
LTRACromolyn
Theophylline
Step 3Preferred:
Medium-doseICS
ORLow-dose ICS+
either LABA,LTRA, or
Theophylline
Step 4
Preferred:Medium-dose
ICS+LABA
Alternative:Medium-dose
ICS+eitherLTRA, or
Theophlline
Step 5Preferred:
High dose ICS+ LABA
Alternative:High-dose ICS+
either LTRAor Theophylline
AND
ConsiderOlamizumab for
patients withallergies
Step 6
Preferred:High-dose ICS+ LABA + oralCorticosteroid
Alternative:High-dose ICS
+either LTRA orTheophylline
+ oral corticosteroid
ANDConsider
Olamizumab for patients with
allergies
AssessControl
STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5-11 YEARS OF AGE
Step up if needed (check adherence, environmental control and comorbidities)
Step down if possible
(asthma well controlled for 3 months)
EPR-3, p296-304
A 7-year old female with asthma reports nighttime awakenings about 2 times per week and requires albuterol about 3 times per week. She is currently taking fluticasone 44 mcg 2 puffs twice daily. The BEST next step in your step-up treatment plan would be to:
A. Increase the dose of the inhaled steroid
B. Add a leukotriene modifier
C. Add a long-acting B-agonist
D. Encourage albuterol more frequently, every 4 hours
Case # 2
Referral to an asthma specialist for consultation and co-management should be sought when a patient:
A. Is hospitalized twice in the past year or once in
the past month
B. Requires more than two bursts of oral
corticosteroids in one year
C. Requires “Step 3” care or higher or is not
responding to a treatment plan that is appropriate for
patient with “Moderate Persistent Asthma”
D. Any of the above
Case # 3
Referral to an asthma specialist for consultation and co-management should be sought when a patient:
A. Is hospitalized twice in the past year or once in the past month
B. Requires more than two bursts of oral corticosteroids in one year
C. Requires “Step 3” care or higher or is not responding to a treatment plan that is appropriate for patient with “Moderate Persistent Asthma”
D. Any of the above
Case # 3
Questions?
Download the Guidelines at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf
Download the Summary Report at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf