2011. Jesus Ramon Guajardo

8/9/2011 If it shines  Is it gold? Is wheezing = asthma? • Seems that there is some “magic” in the  asthma world – “You can’t call it ‘asthma’ until...
Author: Theodore Murphy
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8/9/2011

If it shines  Is it gold? Is wheezing = asthma? • Seems that there is some “magic” in the  asthma world – “You can’t call it ‘asthma’ until the child is 2 years  of age” – “a one year old child can’t have asthma yet” – “you need to wait for PFT’s in order to call it  asthma”

Asthma and Wheezing in the young children y g Jesus Ramon Guajardo

• It may be very difficult to give a diagnosis of  “asthma” to a young child “Spirometry is needed to establish a diagnosis of  asthma” (2007 NIH guidelines p42)

Asthma Lecture I will Review • • • • • •

Not today

History of Asthma Definition Diagnosis of Asthma Physiopathology (briefly) Physiopathology  (briefly) Differential Diagnosis Four components of care

Basically: where asthma comes from historically and a general road map re. outpatient care

• Extensive physiopathology • Details of specific studies • Theories about its increased  prevalence • Specific medicines • Case‐based treatment  examples • In‐patient management

History • Hippocrates school (460‐360 B.C.)  independent medical term or only a symptom?

• Aretaeus of Cappadocia: the greatest clinical  of Cappadocia: the greatest clinical description of asthma in later antiquity  • Galen description in conformity with the  Hippocratic manuscript and to some level with  the declarations of Aretaeus

History • Greek verb “aazein” (“Asthmenein”): to  breathe out with open mouth or to breathe  heavily (special thanks to Dr. Mangos for Greek language expertise) • The Iliad: first appearance: short‐drawn  inhalation • First used as medical word:  Corpus  Hippocraticum.

History • Asthma patients’ and their treatments from  ancient Egyptian times.  • Georg Ebers Papyrus (1870 Egypt) prescriptions in  hieroglyphics (700 remedies for asthma) hieroglyphics (700 remedies for asthma) • An asthma medication to be prepared by mixing  few herbs and heating them on a brick. This was  done so that the patient can inhale the fumes • Chinese started inhaling beta‐agonists obtained  from herbs that contained ephedrine http://www.copewithasthma.com/history‐of‐asthma/

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History • Early 20th century asthma: psychosomatic  disease • During the 1930s to 1950s, asthma was known  as one of the holy seven y psychosomatic  p y Alexander’s  (1950) illnesses 1. Gastric ulceration • A child's wheeze was seen as a suppressed cry  2. Ulcerative colitis for his or her mother  3. Bronchial asthma • Psychoanalysts thought that patients with  4. Essential hypertension asthma should be treated for depression  5. Eczema

History‐William Osler 1982 First edition of the textbook  Principles and Practice of  Medicine: • Runs in families. • Often beginning in childhood  and sometimes lasting into old  age Paroxysms by  • Climate and atmosphere e.g.  hay, dust, cat • Fright or violent emotion • Diet (overloading of the  stomach) or certain foods • Upper or lower resp infection

• Spasm of the bronchial  muscles • Swelling of the bronchial  mucous membrane • Inflammation of the smaller  bronchioles • Resemblance to hay fever • Sputum is distinctive:  rounded gelatinous masses  ("perles") and Curschmann spirals & octahedral crystals  of Leyden

6. Hyperthyroidism 7. Rheumatoid arthritis

History 1960’s • Recognized as an inflammatory disease  • Anti‐inflammatory medications started being  used

Definition From the 2007 NIH guidelines(p 11) “Asthma is a common chronic disorder of the  airways that is complex and characterized by  variable and recurring symptoms, airflow  obstruction, bronchial hyperresponsivenes,  and an underlying inflammation”

http://www.medicalnewstoday.com/info/asthma/asthma‐history.php NHBLI. Asthma Guidelines 2007. p 13 

Physiopathogenesis Just 3 slides (not the focus of this presentation)

NHBLI. Asthma Guidelines 2007. p 15 

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Factors Influencing the  Development  and Variability of Asthma Genetic ancestry

Genes

Environmental factors

Gene-gene interactions

Demographic factors

Social factors Gene-environment interactions

Asthma

NHBLI. Asthma Guidelines 2007. p 17 

Adapted with permission. Drake KA et al. Pharmacogenomics. 2008;9:453–462.

Asthma Prevalence (6‐7 years)

How common is it? >20%

Asthma Prevalence (13‐14 years)

5‐10%

Almost 50% of children wheeze during the first 6 years of life

20%  14% Persistent wheezers (Symptoms 3 to 6 years) 15% Late wheezers (>3 to 20%

10‐20%

Stein, RT. Thorax 1997.

Martinez, FD. NEJM 1995.

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Chances of Persistent Asthma 2‐3 yo child with recurrent wheezing

Major

Minor

Parental Asthma

Allergic Rhinitis

Eczema

Wheezing (not with colds)

Diagnosis

Eosinophils>4%

1 major criteria or 2 minor have a 77% PPV of persistent  asthma (97% specificity)  Castro, JA. Am J Respir Crit Care Med 2000.

How to make the diagnosis

Key Indicators

(2007 NIH guidelines p40)

From the NHBLI guidelines: The clinician should determine that 1. Episodic symptoms of airflow obstruction or  airway hyperresponsiveness i h i are present 2. Airflow obstruction is at least partially  reversible 3. Alternative diagnosis are excluded

• Wheezing • History: cough, wheeze, difficulty breathing,  chest tightness • Symptoms occur or worsen with S ih – Exercise, viral infection, pet dander, dust mites,  smoke, pollen, weather changes, crying/laughing,  airborne chemicals, menstrual signs, etc

• Night symptoms NHBLI guidelines 2007 p42

Asthma and Allergic Disease 

Diagnosis

DDx of cough and wheezing in children

• “Recurrent episodes of cough and wheezing  are due most often to asthma in both children  and adults” • “Underdiagnosis Underdiagnosis of asthma is a frequent  of asthma is a frequent problem” (BUT persistent cough  most likely is not  • “bronchitis”, “recurrent bronchiolitis”,  asthma in young  “pneumonia”, “wheezy bronchitis”, “RAD”,  children!!) “recurrent upper airway infections” NHBLI guidelines 2007 p45

• • • • • • • • • • •

Allergic Rhinitis Infectious Rhinitis Sinusitis Adenoidal Hypertrophy yp p y Foreign Body Laryngomalacia Laryngeal Web Tracheomalacia TEF Tracheal Stenosis Vascular Ring

• • • • • • • • • • •

Pertussis Epiglottis Toxic Inhalation Vocal Cord Dysfunction y Cystic Fibrosis GERD, Aspiration Persistent Bact Bronchitis Pulmonary Hemosiderosis Tumors Hyperventilation Syndrome Bronchiolitis NHBLI guidelines 2007 p45

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Considerations

DDx‐Adults COPD Congestive Heart Failure Pulmonary Embolism Pulmonary Embolism Mechanical Obstruction  Eosinophilic Pneumonia Cough sec. to drugs (e.g. ACE inh) VCD

URI, cough, wheeze

Birth

URI, cough, wheeze

URI, cough, wheeze

URI, cough, wheeze

URI, cough, wheeze

2 mo

4 mo

7 mo

10 mo

13 mo

Dx?

Dx?

Dx?

Dx?

Dx?

URI, cough, wheeze

URI, cough, wheeze

No readily available PFT’s No readily available PFT’s

URI, cough, wheeze

30 yo

URI, cough, wheeze

URI, cough, wheeze

2 mo

4 mo

7 mo

10 mo

13 mo

Dx?

Dx?

Dx?

Dx?

Dx?

PFTs to assist Dx

NHBLI guidelines 2007 p45

Cases 3 mo old first  URI, wheezing

30 yo persistent  cough after bad  URI

15 yo  wheezing after  20 min of  running

15 yo  wheezing after  4 hours of  swimming

Bronchiolitis?

Atypical Bronchitis?

EIB with Asthma?

EIB without Asthma?

40 yo baker  40 yo baker wheezes with  flour

29 yo truck  driver driver  wheezing post  chlorine  exposure

10 yo  persistent non‐ reversible  wheezing

Occupational Asthma

RADS?

Airway Lesion?

7 yo chronic  cough,  crackles,  wheezing,  clubbing

10 yo hives,  vomiting,  wheezing with  peanuts

2 mo with 6  weeks  persistent  cough

CF?

Anaphylaxis?

PBB?

10 yo  10 yo recurrent  wheezing Asthma?

Other Scenario

4 Components of Care (The Fantastic 4 Components of Care?)

Other?

The 4 Components of Asthma  Management

Assessment  & Monitoring

Education

Figure 1 Asthma Guidelines 2007 Asthma Guidelines 2007 Summary Report Journal of Allergy and Immunology Triggers &  Comorbidities

Management

• Component 1: Measures of Asthma  Assessment and Monitoring • Component 2: Education for a Partnership  in Asthma Care in Asthma Care  • Component 3: Control of Environmental  Factors and Comorbid Conditions That  Affect Asthma  • Component 4: Medications

Medications

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Assessment of the Disease 2 domains

Assessment & Monitoring

• Impairment (present) – Frequency and intensity of symptoms – Functional limitations (quality of life) – Divided on Severity (at Dx) or Control (at f/u)



Risk (from past  predict future) – Asthma exacerbations (utilization) – Progressive loss of pulmonary function (lung growth) – Risk of adverse reaction from medication

Assessment of Severity

Monitoring of Control

• Initial Evaluation • When Dx is made – Intermittent – Persistent • Mild • Moderate • Severe

• F/u visits • How well controlled is  i? it? – Well Controlled – Not Well Controlled – Poorly Controlled

EPR‐3 2007, p38‐80, 277‐345

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN 

A&M Domains

EPR‐3, p72, 307

CHILDREN 0‐4 YEARS OF AGE

Classification of Asthma Severity Kitchen sink (OCS + else) and very frequent visits (1-2 weeks)?

Juana Banana

Big  Differences in  Management!

Components of  Severity Symptoms

Intermittent 80%

• FEV1=60% ‐80%

•FEV1  80%

•FEV1/FVC=75%‐80%

•FEV1/FVC  1x/wk, not nightly

Often, 7x/week Several times

Daily

daily

Some limitation

Extremely limited

• FEV1 >80%

• FEV1=60% ‐80%

•FEV1  80%

•FEV1/FVC=75%‐80%

•FEV1/FVC   85%

>2/ year

0‐1/year

Consider severity and interval since last exacerbation. Frequency and severity may  fluctuate over time for any patient in any severity category. Relative annual risk of exacerbations maybe related to FEV1

Step 1

>2 exacerbations in 6 months requiring oral steroids, or  >4 wheezing episodes/ year lasting >1 day AND risk  factors for persistent asthma

Symptoms

• FEV1/FVC> 85%

Risk

Extremely 

Classification of Asthma Severity

Impairment

Nighttime  Awakenings

Lung Function

>2 days/wk, not daily

daily

Some limitation

YOUTHS > 12 YEARS AND ADULTS

Classification of Asthma Severity Persistent Mild

>1x/week

Daily

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN  EPR‐3, p72, 307

Intermittent

Continuous

3‐4x/month

Several times >2 days/wk not daily >2 days/wk not daily

Interference with  normal activity

Risk

Severe

Daily

Exacerbations of any severity may occur in patients in any category

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN 

Components of  Severity

1‐2x/month

Moderate

Impairment

Recommended Step for  Initiating Treatment

CHILDREN 5 ‐ 11 YEARS OF AGE

>2 days/wk not daily

2/ year

Consider severity and interval since last exacerbation. Frequency and severity may  fluctuate over time for any patient in any severity category. Relative annual risk of exacerbations maybe related to FEV1

Step 1

Step 2

Step 3

Re‐evaluate asthma control in 2‐6 weeks and adjust therapy accordingly

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ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN 

ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN 

CHILDREN 0 ‐ 4 YEARS OF AGE

EPR‐3, p75, 309

CHILDREN 5 ‐ 11 YEARS OF AGE

EPR‐3, p76, 310

Classification of Asthma Control Components of Control Well Controlled

Very Poorly Controlled

Components of Control Well Controlled

< 2 days/week              > 2 days/week                     Throughout the day

Symptoms Nighttime awakenings

< 1/month                 > 2 x/month  

Interference with normal  activity SABA use SABA use

IMPAIRMENT

Not  Well  Controlled

Classification of Asthma Control

none

Symptoms Nighttime awakenings

>2x/week

Some limitation

Extremely limited

0‐1 per year

2 ‐3 per year

SABA use FEV1or peak flow

> 3 per year

oral steroids

FEV1/FVC Medication‐related sides effects can vary from none to to very troublesome 

Treatment‐related 

and worrisome. The level of intensity does not correlate to specific levels of  

adverse effects

control but should be considered in the overall assessment of risk. •Maintain current step •REGULAR FOLLOW UP EVERY 

Recommended Action

•Step up 1 step

•Consider oral steroids

•Reevaluate in 2 ‐ 6 weeks

•Step up (1‐2 steps) and 

Exacerbations lung growth

RISK

Treatment‐related  adverse effects

reevaluate in 2 weeks •If no clear benefit in 4‐6  0-43 ‐ 6 MONTHS y: If no clear benefit is observed: STOP Rx weeks , consider  alternative dx or adjust  therapy

(EPR-3 JACI 2007 pp S116) •Consider step down if well 

For Treatment

controlled at least 3 months

•If no clear benefit in 4‐6  weeks , consider alternative  dx or adjust therapy 

Not  Well  Controlled >2 days/wk or multiple times on < 2 days/wk

< 1/month                 > 2 x/month  

Interference with normal  activity

IMPAIRMENT

< 2 days/week              > 2 days/week                      Several times/day 2 days/week > 2 days/week Several times/day

Exacerbations requiring 

RISK

< 2 days/wk, 2x/week Extremely limited

< 2 days/week              > 2 days/week                    Several times/day 2 days/week > 2 days/week Several times/day > 80% predicted/  personal best

60‐80% predicted/  personal best

 80% predicted               75‐80% predicted                 12 YEARS OF AGE AND ADULTS

EPR‐3, p77, 345

Classification of Asthma Control Components of Control Well Controlled Symptoms

Interference with normal  activity

Validated questionnaires  ATAQ/ACT

Exacerbations

Treatment‐related 

For Treatment

> 4/week

Some limitation

Extremely limited

60‐80% predicted/  personal best

20                       1‐2/16‐19                             3‐4/< 15 0‐ 1 per year

Progressive     lung function

Recommended Action

none

> 80% predicted/  personal best

FEV1or peak flow

adverse effects

< 2/month                     1‐3/week

>2 per year

Evaluation requires long‐term follow up care Medication‐related sides effects can vary from none to 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. •Maintain current step •Consider step down if well  controlled at least 3 months

•Consider oral steroids

•Step up 1 step •Reevaluate in 2 ‐ 6 weeks

•Step up 1‐2 weeks and  reevaluate in 2 weeks

EPR‐3, Page 330

Recommended Action for Treatment  Based on Assessment of Control Well Controlled

A Few Basic  and Essential  Questions

y/ y/ / y < 2 days/week              > 2 days/week                      Several times/day

SABA use

RISK

Very Poorly Controlled

< 2 days/week              > 2 days/week                     Throughout the day

Nighttime awakenings

IMPAIRMENT

Not  Well  Controlled

Not Well Controlled

Very Poorly Controlled

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

Before stepping up check adherence and environmental control NAEPP Draft Report, ERP 2007

The 4 Components of Asthma  Management • Component 1: Measures of Asthma  Assessment and Monitoring • Component 2: Education for a  Partnership in Asthma Care  • Component 3: Control of  Environmental Factors and Comorbid  Conditions That Affect Asthma  • Component 4: Medications

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EPR‐3, p121‐139

Component 2: Education for a Partnership in Asthma Care •

Asthma Self‐Management Education at Multiple Points of Care – – – – – –

clinic/office‐based education emergency department/ hospital‐based education education by pharmacists education in school settings community‐based interventions home‐based interventions



Tools for Asthma Self‐Management



Establish and Maintain a Partnership – jointly develop treatment goals – health literacy (read, count, measure, time, schedule) – cultural sensitivity/ ethnic considerations

Provider Education – – – –

implementing guidelines communication techniques clinical decision support systems‐based interventions

Significance of the diagnosis Cause: Inflammation Controllers vs. quick‐relievers How to use medication delivery devices How to use medication delivery devices Triggers, including second‐hand tobacco smoke Home monitoring/ self‐management How/ when to reach the provider The need for continuous on‐going interaction with the  clinician to step‐up and step‐down therapy • Annual Influenza vaccine (year‐round reminder)

• • • • • • • •

– asthma action plans asthma action plans – peak flow meters



Key Educational Messages

EPR‐3, P 93‐164

WHAT OUR PROGRAM PROVIDES

Asthma Action Plan

An Asthma Counselor will provide support to your family and help develop effective communication with your doctor and school.

Happy Lungs: The Family Asthma Program

An Asthma Counselor will be your partner, assisting with problems of daily obstacles related to asthma. Providing information to you and your child in group and individual meetings. Individual meetings focus on environment, school and skills for managing asthma.

EPR‐3, p115‐123

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The 4 Components of Asthma  Management • Component 1: Measures of Asthma  Assessment and Monitoring • Component 2: Education for a  Partnership in Asthma Care  • Component 3: Control of  Environmental Factors and Comorbid  Conditions That Affect Asthma  • Component 4: Medications

Indoor

Outdoor

Irritants •Smoke (tobacco,  stove, candles) gp • Cleaning products •Perfumes,  insecticides •Other chemicals •Pollution •Exercise •Weather changes •Infections •Etc

Allergens •Pet Dander (cat,  dog) •Cockroaches •Mold •Dust mites •Pollen •Trees •Grasses •Weeds •Mold

The 4 Components of Asthma  Management

Guidance on Environmental Control • Dust mite interventions – impermeable encasings for pillows/mattresses – wash linens in hot water – HEPA filtration • Animal allergens – keep outside/ out of bedroom – similar interventions like for dust mites • Roach control – integrated pest management – clean up food, spills, trash, leaks • Mold and mildew interventions – air conditioning – avoid humidifiers – repair pipes and leaks • Second‐hand smoke exposure • Air Pollution

Environmental  Factors

EPR‐3, P167‐177

• Component 1: Measures of Asthma  Assessment and Monitoring • Component 2: Education for a  Partnership in Asthma Care  • Component 3: Control of  Environmental Factors and Comorbid  Conditions That Affect Asthma  • Component 4: Medications

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2. No Neck Depression …OSA!

Comorbid Conditions That Affect Asthma • • • • • •

Allergic Bronchopulmonary Aspergillosis Gastroesophageal Reflux Disease Obesity  Obstructive Sleep Apnea Rhinitis/Sinusitis Stress, Depression, and Psychosocial Factors

The 4 Components of Asthma  Management • Component 1: Measures of Asthma  Assessment and Monitoring • Component 2: Education for a  Partnership in Asthma Care  • Component 3: Control of  Environmental Factors and Comorbid  Conditions That Affect Asthma  • Component 4: Medications

STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 0 ‐ 4  YEARS OF AGE EPR‐3, p291‐296 Intermittent  Asthma

Persistent Asthma: Daily Medication Consult with asthma specialist if step 3 or higher care is required Consider consultation at step 2

Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. • Use of beta2-agonist >2 days a week for symptom control (not prevention of EIB) indicates inadequate control co t o aand d tthee need eed to step up treatment. t eat e t

Step 3 Step 2 Preferred: Low‐dose ICS

Step 1 Preferred: SABA prn

Alternative: LTRA Cromolyn

Preferred: Medium‐dose ICS

Step 5 Preferred: High dose ICS

Step 4 Step 4 Preferred: Medium‐dose  ICS

AND

AND either LTRA Or LABA

Preferred: High dose ICS

Step up if      needed (check  adherence,  environmental  control )

AND either LTRA Or LABA

AND Oral  Corticosteroid

3. GERD

Simplified step up drug plan for asthma Young Children

MICS

either LTRA Or LABA

SABA  LICS  MICS  MICS/LABA  HICS/LABA  Systemic Corticosteroids

HICS + LABA

MICS + LABA

Older Asthmatics

SABA

STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5‐11  EPR‐3, p296‐304 YEARS OF AGE Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3

Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. • Use of beta2-agonist >2 days a week for symptom control (not prevention of EIB) indicates inadequate control co t o aand d tthee need eed to step up treatment. t eat e t

Step 3

Step down if  possible

Patient Education and Environmental Control at Each Step

OCS + Else!

LICS + LABA

LICS

Assess Control

(asthma well  controlled for  3 months)

Rhinitis & Sinusitis ABPA

1. Obesityy

Intermittent  Asthma

Step 6

Allergic

4. Anxiety 

EPR‐3, p177‐184

Step 2 Step 1 Preferred: SABA prn

Preferred: Low‐dose ICS Alternative: LTRA Cromolyn Theophylline

Preferred : Low‐dose ICS+ either LABA, LTRA, or Theophylline

OR Medium‐dose ICS

Step 6 Step 5 Step 4 Step 4 Preferred: Medium‐dose  ICS+LABA

Preferred: High dose ICS + LABA Alternative: High‐dose ICS+ either LTRA or Theophylline

Preferred: High‐dose ICS + LABA + oral Corticosteroid Alternative: High‐dose ICS +either LTRA or Theophylline + oral corticosteroid

Alternative: Medium‐dose ICS+either LTRA, or Theophlline

Step up if      needed (check  adherence,  environmental  control and  comorbidities)

Assess Control Step down if  possible (asthma well  controlled for  3 months)

Patient Education and Environmental Control at Each Step SABA  LICS  MICS (LICS/LABA)  MICS/LABA  HICS/LABA  Systemic Corticosteroids

10

8/9/2011

STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS > EPR‐3, p333‐343 12 YEARS AND ADULTS Intermittent  Asthma

Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. • Use of beta2-agonist >2 days a week for symptom control (not prevention of EIB) indicates inadequate control and the need to step up treatment.

Step 3 Step 2 Step 1 Preferred: SABA prn

Simplified step up drug plan for asthma

Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3

Preferred: Low‐dose ICS Alternative: LTRA Cromolyn Theophylline

Preferred : Preferred: Low‐dose ICS+ Low‐dose ICS either LABA, OR LTRA, or Medium‐dose  Theophylline ICS+ either LABA, OR LTRA,  Medium‐dose Theophylline ICS Or Zileutin

Step 6 Step 5 Step 4 Step 4 Preferred: Medium‐dose  ICS+LABA Alternative: Medium‐dose ICS+either LTRA,  Theophlline Or Zileutin

Preferred: High dose ICS + LABA

Preferred: High‐dose ICS + LABA + oral Corticosteroid

AND AND Consider Olamizumab for patients with allergies 

Consider Olamizumab for patients with allergies 

Step up if      needed (check  adherence,  environmental  control and  comorbidities)

Young Children

MICS

Assess Control Step down if  possible (asthma well  controlled for  3 months)

Patient Education and Environmental Control at Each Step

LICS

OCS + Else! HICS + LABA

MICS + LABA

LICS + LABA Older Asthmatics

SABA

Conclusions

Many Slides Showing the Road  Map for Outpatient management p p g Let’s Wrap it up.

Conclusions 5. Asthma is currently managed according to the four  components of care (A&M, Ed, Trig/CoMorb, Meds) 6. Young children are evaluated and managed  differently than older children and adults 7. Keep in mind the domains of impairment (5  questions) and risk when seeing pts with asthma 8. Education of the patient/family is essential. AAP,  inhaler technique, etc.

1. Making the diagnosis of asthma in the young  patient is not easy 2. Better to over‐diagnose than under‐diagnose 3. Always make sure other conditions are ruled out  Always make sure other conditions are ruled out in the young child 4. Young children with persistent symptoms may  have a different diagnosis than those with  recurrent symptoms

Conclusions

9. Triggers and co‐morbidities need to be  addressed (if not, asthma symptoms will persist)  10 Medicines need to be frequently titrated  10. Medicines need to be frequently titrated according to disease activity and risk assessment 11. If something is not working, stop and re‐assess.  There is plenty help around

11

8/9/2011

Jesús Ramón Guajardo MD MHPE

Thanks!

Questions ?

END

Asthma and Allergic Disease The development of allergies and asthma is common during childhood

Oswald, H. Pediatr Pulmonol, 1997.

Does asthma produce permanent  lung changes after 6 years of  age? The difference in pulmonary  function between asthmatic and  healthy subjects persists in healthy subjects persists in  parallel, independently of the  severity of the disease. This is  why it is very important to  correctly manage asthma in the  early childhood period

Several studies have shown the existence of an “allergic march” during childhood:  AD  Food allergy  AR Asthma  Allergy to inhaled allergens

Asthma and Allergic Disease • The role of the pediatrician  is essential if there is going  to be a modification on the  natural history of asthma natural history of asthma • Most children with asthma  have permanent damage by  age 6 years • We most intervene early !

Asthma and Allergic Disease • There are 3 important studies about the  natural history of asthma and allergic disease  in children: – Respiratory, Tucson (1980) Respiratory Tucson (1980) – Kaiser, San Diego (1981) – German Multicentric (1990)

• The most important findings were:

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Asthma and Allergic Disease

Asthma and Allergic Disease • The early development of allergic disease is signaled  by positive skin tests to food allergens during the first  years of life

The highest incidence of AD is during the first two years of life It is commonly believed that infants have few allergies, but AD, food  allergy, and wheezing are common by the time an infant reaches 3  months of age Whan, U. JACI 1999.

Asthma and Allergic Disease

Whan, U. JACI 1999.

Asthma and Allergic Disease

As children get older there is an incremental rise in the  prevalence of sensitization to inhaled allergens

The incidence of the  allergic march has  been increasing  during the last  decades

Pediatricians need to  be alert to the  manifestations of  allergic disease if they  want to influence its  natural history

Whan, U. JACI 1999. Zeiger, RS. JACI 1989.

Asthma and Allergic Disease • What predisposes an infant to develop  allergies? – Intrauterine Th2 skewing of the immune system   (Prescott, SL. J. Immunology 1998, and Lancet 1999).

– High IgE in umbilical cord (Martinez, FD. JACI 1995). – Parental history – Gender:  • Males develop “transient asthma” and also “persistent”  more than females during childhood • Females: asthma associated with obesity and early  puberty

Asthma and Allergic Disease • What predisposes an infant to develop  allergies? – URI’s • If If RSV+ history there is increased wheezing at 6 years of  RSV+ history there is increased wheezing at 6 years of age, but not at 11 years • Pneumonia and croup increase risk of asthma at 11  years

– Cigarette smoke – Prematurity

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Asthma and Allergic Disease • What protects from developing allergic  disease?

Asthma and Allergic Disease •

– Breast Feeding: Associated to less AD, but... One  study showed an increase in asthma if mother had study showed an increase in asthma if mother had  asthma. Current recommendation: Breast Feed  anyway. – Microbial exposure: endotoxin, nurseries/child  care, hep. A. – Pets. Are they good or bad?

Studies about prevention of allergic disease 1. Avoidance of allergenic foods:

Children with risk factors to develop AD avoided  milk, peanut, egg, and fish, during the last  intrauterine trimester until 24 mo of age The intervened children had a lower incidence of  eczema at 1 year of age, but not when they reached  4 years

Zeiger, RS. JACI 1995.

Asthma and Allergic Disease •

Studies about prevention of allergic disease 2. Cigarette Exposure:

It is difficult to perform adequate studies on cigarette  t s d cu t to pe o adequate stud es o c ga ette smoke avoidance, but it has been shown that smoke  exposure increases the incidence and severity of  asthma

Asthma and Allergic Disease •

Studies about allergic disease prevention 3. Antihistamines:

Zyrtec used prophylactically diminished the incidence  of asthma in children with positive skin tests to dust  and pollen. By 18 months after stopping Zyrtec, only  children with pollen allergy continued to showed less  incidence of asthma

Warner, JO. JACI 2001.

Asthma and Allergic Disease •

Studies about allergic disease prevention 4. Rx with Inhaled Meds (cromolyn, steroids)

“CAMP” (The Childhood Asthma Management Program Research Group, NEJM  Oct 12, 2000)

CAMP Study This study demonstrated  the lack of improvement on  FEV1 post‐bronchodilator in  the treatment groups, but it  showed an improvement in  symptoms

Multicentric study, randomized, prospective, placebo controlled 1041 children ages 5 to 12 years with mild to moderate asthma 311“Pulmicort” (Budesonide) 100 ug 2 puffs inh BID  (400 ug/day) 312 “Tilade” (Nedocromil) 2 mg 4 puffs inh BID (16 mg/day)

It is quite possible that the  study group age was too old  and permanent lung  changes took place already

418 placebo: 208 Pulmicort‐like placebo and 210 Tilade‐like placebo

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8/9/2011

Asthma and Allergic Disease •

Studies about allergic disease prevention 5. Immunotherapy:

Asthma and Allergic Disease •

Studies about allergic disease prevention 6. Lactobacillus:

Immunotherapy against specific allergens reduces the  u ot e apy aga st spec c a e ge s educes t e incidence of asthma in children that have allergic  rhinitis, modifying the “allergic march”

Lactobacillus oral supplementation during the first 6  actobac us o a supp e e tat o du g t e st 6 months of life has shown to decrease the incidence of  AD at 2 years of age

We need to considerer the risks and benefits of  immunotherapy before placing anybody on it

Lactobacillus have not shown to decrease any other  allergic disease (i. e. asthma, allergic rhinitis)

Moller, C. JACI 2002.

2007 NHLBI Guidelines for the Diagnosis & Management of Asthma Expert Panel Report-3

BRONX-LEBANON HOSPITAL CENTER Department of Pediatrics

Mamta Reddy, MD Chief, Allergy/Immunology Director, South Bronx Asthma Partnership

Kalliomaki, M. Lancet  2001.

The N The  National  ational A Asthma  sthma EEducation  and  revention P Program (NAEPP) Prevention  • Established in 1989 by the National Heart,  Lung, and Blood Institute (NHLBI), a  component of the U.S. National Institutes of  Health (NIH) • 1991 Expert Panel Report: “The role of  inflammation in disease development”

www.nhlbi.nih.gov/guidelines/asthma

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8/9/2011

Guidelines For The Diagnosis and  Management of Asthma (EPR‐3)

Guidelines for the Diagnosis & Management of Asthma

released: August 28, 2007  (Almost) no new medications  Restructuring into “severity” and “control”   Domains of “impairment” and “risk”

NAEPP/NHLBI Expert Panel Report-3

 Six treatment steps (step‐up/step‐down)  More careful thought into the ongoing management issues

Case Scenarios

 440 pages: Summarizes the extensively‐validated scientific 

evidence that the guidelines, when followed, lead to a significant  reduction in the frequency and severity of asthma symptoms and  improve quality of life

www.nhlbi.nih.gov/guidelines/asthma

Case # 1

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN  EPR‐3, p72, 307

CHILDREN 0‐4 YEARS OF AGE

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 3) 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 3) D. I would not diagnose this child with  asthma

Classification of Asthma Severity Components of  Severity Symptoms

Intermittent 2 days/wk not daily 1‐2x/month

Moderate Daily 3‐4x/month

>2 days/wk not daily >2 days/wk not daily

none

Minor limitation

Interference with  normal activity

Daily

>1x/week

Some limitation

daily Extremely  limited

0‐1/year Exacerbations  requiring oral  systemic  corticosteroids

Continuous

Several times 2 exacerbations in 6 months requiring oral steroids, or  >4 wheezing episodes/ year lasting >1 day AND risk  factors for persistent asthma

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

Recommended Step for  Initiating Treatment

Step 1

Step 2

Step 3

Re‐evaluate asthma control in 2‐6 weeks and adjust therapy accordingly

Case # 2 A 7‐year old male presents to your clinic in November  complaining of daily nocturnal cough for 2 months.  He denies  symptoms of GE Reflux.  He has visited the emergency room  twice in the past year where he received albuterol with good  symptomatic relief.  The BEST choice of treatment would be to: A Start A. Start fluticasone 44 mcg 2 puffs twice daily for 4 fluticasone 44 mcg 2 puffs twice daily for 4‐6 6  weeks and then reassess B. Start fluticasone 110 mcg 2 puffs twice daily for 4‐6  weeks and then reassess C. Start a leukotriene modifier as you suspect his  symptoms are likely due to post‐nasal drainage from  allergic rhinitis D. I cannot feel confident at this time that this patient  should be treated with asthma medications

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8/9/2011

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN  EPR‐3, p72, 307

CHILDREN 5 ‐ 11 YEARS OF AGE

Intermittent  Asthma

Classification of Asthma Severity Components of  Severity

Intermittent  80%

STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5‐11  EPR‐3, p296‐304 YEARS OF AGE

Daily

Severe Continuous

>1x/wk, not nightly

Often, 7x/week Several times

Daily

daily

Some limitation

Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. • Use of beta2-agonist >2 days a week for symptom control (not prevention of EIB) indicates inadequate control and the need to step up treatment.

Extremely limited

• FEV1=60% ‐80%

•FEV1  80%

•FEV1/FVC=75%‐80%

•FEV1/FVC  2/ year

Consider severity and interval since last exacerbation. Frequency and severity may  fluctuate over time for any patient in any severity category. Relative annual risk of exacerbations maybe related to FEV1

Recommended Step for  Initiating Treatment

Step 1

Step 2

Preferred: SABA prn

Medium‐dose ICS

Alternative: Medium‐dose ICS+either LTRA, or Theophlline

Assess Control Step down if  possible (asthma well  controlled for  3 months)

Step 3 Preferred: Low‐dose ICS

OR Medium‐dose  ICS+ either LABA, LTRA,  Theophylline Or Zileutin

Step 6 Step 5 Step 4 Step 4 Preferred: Medium‐dose  ICS+LABA Alternative: Medium‐dose ICS+either LTRA,  Theophlline Or Zileutin

Preferred: High dose ICS + LABA

Preferred: High‐dose ICS + LABA + oral Corticosteroid

AND AND Consider Olamizumab for patients with allergies 

Consider Olamizumab for patients with allergies 

A 13‐year old girl presents to your office in May and is  currently taking fluticasone 110 mcg 2 puffs twice daily  and montelukast 5 mg 1 tablet at bedtime daily.  She  denies any report of daytime or nighttime asthma  symptoms for the past 4 months.  Her asthma severity  classification is:

A. B. C. D.

Intermittent Asthma (Step 1) Mild Persistent Asthma (Step 2) Moderate Persistent Asthma (Step 3 or 4) All medications should be immediately discontinued

Classifying Severity for Patients Currently  Taking Controller Medications

Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3

Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of systemic oral corticosteroids may be needed. • Use of beta2-agonist >2 days a week for symptom control (not prevention of EIB) indicates inadequate control co t o aand d tthee need eed to step up treatment. t eat e t

Preferred: SABA prn

OR

Preferred: Medium‐dose  ICS+LABA

Case # 3

STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS > EPR‐3, p333‐343 12 YEARS AND ADULTS

Step 1

Preferred : Low‐dose ICS  + either LABA, LTRA, or Theophylline

Preferred: High dose ICS + LABA Alternative: High‐dose ICS+ either LTRA or Theophylline

Patient Education and Environmental Control at Each Step

A Start A. Start fluticasone 44 mcg 2 puffs twice daily for 4 fluticasone 44 mcg 2 puffs twice daily for 4‐6 6  weeks and then reassess B. Start fluticasone 110 mcg 2 puffs twice daily for 4‐6  weeks and then reassess C. Start a leukotriene modifier as you suspect his  symptoms are likely due to post‐nasal drainage from  allergic rhinitis D. I cannot feel confident at this time that this patient  should be treated with asthma medications

Preferred: Low‐dose ICS Alternative: LTRA Cromolyn Theophylline

Step 4 Step 4

adherence,  environmental  control and  comorbidities)

Step 3 or 4

Case # 2

Step 2

Step 5

Preferred: High‐dose ICS + LABA + oral Corticosteroid Alternative: High‐dose ICS +either LTRA or Theophylline + oral corticosteroid

Re‐evaluate asthma control in 2‐6 weeks and adjust therapy accordingly

A 7‐year old male presents to your clinic in November  complaining of daily nocturnal cough for 2 months.  He denies  symptoms of GE Reflux.  He has visited the emergency room 3  times in the past year where he received albuterol with good  symptomatic relief.  The BEST choice of treatment would be to:

Intermittent  Asthma

Step up if      needed (check 

Step 6

Step 3

• FEV1 >80%

• FEV1/FVC> 85%

Exacerbations  requiring oral  systemic  corticosteroids

Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3

Step up if      needed (check  adherence,  environmental  control and  comorbidities)

Assess Control Step down if  possible (asthma well  controlled for  3 months)

Classification of Asthma Severity Lowest level of treatment required to maintain control

Intermittent

Persistent Mild

Moderate

Severe

Step 2

Step 3 or 4

Step 5 or 6

Step 1

Patient Education and Environmental Control at Each Step NAEPP Draft Report, ERP 2007

EPR‐3, Page 72‐74

17

8/9/2011

ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN 

Case # 3

YOUTHS > 12 YEARS OF AGE AND ADULTS

A 13‐year old girl presents to your office in May and is  currently taking fluticasone 110 mcg 2 puffs twice daily  and montelukast 5 mg 1 tablet at bedtime daily.  She  denies any report of daytime or nighttime asthma  symptoms for the past 4 months.  Her asthma severity  classification is:

Components of Control Symptoms Nighttime awakenings

< 2/month                     1‐3/week

Interference with normal  activity

IMPAIRMENT

Well

Not Well Controlled

Maintain current step

Consider step down if well controlled for at least 3 months

Step up 1 step and reevaluate in 2-6 weeks For side effects, consider alternative treatment options

60‐80% predicted/ personal  EPR‐3, p333‐343 12 YEARS AND ADULTS Intermittent  Asthma

Persistent Asthma: Daily Medication Consult with asthma specialist if step 4 or higher care is required Consider consultation at step 3 Step up if      needed (check  adherence,  environmental  control and  comorbidities)

Step 6

Consider short course of oral corticosteroids

Step 5 Step 4 Step 4 Preferred: Medium‐dose  ICS+LABA

Step 3

Step up 1-2 steps and reevaluate in 2 weeks

Before stepping up check adherence and environmental control NAEPP Draft Report, ERP 2007

> 3 per year

Evaluation requires long‐term follow up care

Very Poorly Controlled

For side effects, consider alternative treatment options

Extremely limited

0/> 20                       1‐2/16‐19                     3‐4/< 15

For Treatment

Controlled

> 4/week

Some limitation

< 2 days/week              > 2 days/week            Several times/day 2 days/week > 2 days/week Several times/day

Recommended Action

Recommended Action for Treatment  Based on Assessment of Control

none

> 80% predicted/  personal best

Validated questionnaires 

RISK

Very Poorly Controlled

< 2 days/week              > 2 days/week         Throughout the day

FEV1or peak flow

Intermittent Asthma (Step 1) Mild Persistent Asthma (Step 2) Moderate Persistent Asthma (Step 3 or 4) All medications should be immediately discontinued

Not  Well  Controlled

Well Controlled

SABA use

A. B. C. D.

EPR‐3, p77, 345

Classification of Asthma Control

Step 2 Step 1 Preferred: SABA prn

Preferred: Low‐dose ICS Alternative: LTRA Cromolyn Theophylline

Preferred: Medium‐dose ICS

Alternative: Medium‐dose ICS+either LTRA,  Theophlline Or Zileutin

OR Low‐dose ICS+ either LABA, LTRA,  Theophylline Or Zileutin

Preferred: High dose ICS + LABA

Preferred: High‐dose ICS + LABA + oral Corticosteroid

Assess Control

AND

AND Consider Olamizumab for patients with allergies 

Step down if  possible

Consider Olamizumab for patients with allergies 

(asthma well  controlled for  3 months)

Patient Education and Environmental Control at Each Step

ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN 

Case # 4

CHILDREN 5 ‐ 11 YEARS OF AGE

EPR‐3, p76, 310

Classification of Asthma Control

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 BEST next step in your step up treatment plan  treatment plan would be to:

Components of Control Well Controlled

Nighttime awakenings

IMPAIRMENT

SABA use FEV1or peak flow

Increase the dose of the inhaled steroid Add a leukotriene modifier Add a long‐acting B‐agonist Encourage albuterol more frequently, every 4 hours

Exacerbations

RISK

lung growth Treatment‐related  adverse effects

Not  Well  Controlled >2 days/wk or multiple times on < 2 days/wk

< 1/month                 > 2 x/month  

Interference with normal  activity

FEV1/FVC

A. B. C. D.

< 2 days/wk, 2x/week Extremely limited

< 2 days/week              > 2 days/week            Several times/day 2 days/week > 2 days/week Several times/day > 80% predicted/  personal best

60‐80% predicted/ personal   80% predicted         75‐80% predicted         2 days a week for symptom control (not prevention of EIB) indicates inadequate control and the need to step up treatment.

Step 5 Step 4 Step 4

Step 3 Step 2 Step 1 Preferred: SABA prn

Preferred: Low‐dose ICS Alternative: LTRA Cromolyn Theophylline

Preferred: High dose ICS + LABA Alternative: High‐dose ICS+ either LTRA or Theophylline

adherence,  environmental  control and  comorbidities)

Preferred: High‐dose ICS + LABA + oral Corticosteroid Alternative: High‐dose ICS +either LTRA or Theophylline + oral corticosteroid

Assess Control Step down if  possible

Alternative: Medium‐dose ICS+either LTRA, or Theophlline

OR Medium‐dose ICS

(asthma well  controlled for  3 months)

Patient Education and Environmental Control at Each Step

Case # 5

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 BEST next step in your step up treatment plan  treatment plan would be to:

A 5‐year old male with asthma reports nocturnal cough 3  nights per week during October through February, but  only 3 nights per month during March through September.   This patient’s asthma severity can be classified and treated  as follows: A. Moderate Persistent during winter only, Mild Persistent  remainder of the year B. Moderate Persistent year‐round in order to prevent winter  exacerbations C. Mild Persistent year‐round in order to prevent long‐term  decrease in lung function D. This patient does not have asthma but is at high‐risk for  frequent upper respiratory tract infections with the change  of seasons

Increase the dose of the inhaled steroid Add a leukotriene modifier Add a long‐acting B‐agonist Encourage albuterol more frequently, every 4 hours

Summary of the

Preferred: Medium‐dose  ICS+LABA

Preferred : Low‐dose ICS+ either LABA, LTRA, or Theophylline

Case # 4

A. B. C. D.

Step up if      needed (check 

Step 6

EPR‐3, Page 36‐38

New Strategies of the EPR‐3

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN  EPR‐3, p72, 307

CHILDREN 5 ‐ 11 YEARS OF AGE

Classification of Asthma Severity Components of  Severity

Severity

Control

Responsiveness

Assessment

Management

the intrinsic intensity of the disease

a clinical guide most useful for initiating controller therapy

the degree to which symptoms are minimized

Impairment

Persistent Mild

1x/wk, not nightly

Often, 7x/week Several times

Interference with  normal activity

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

(variable) frequent follow-up the ease of which to step-up and step-down prescribed therapy achieves asthma control therapy to achieve the goal of control

Intermittent

Symptoms

• FEV1 > 80%

Daily

daily

Some limitation

Extremely limited

• FEV1 >80%

• FEV1=60% ‐80%

•FEV1  80%

•FEV1/FVC=75%‐80%

•FEV1/FVC   85%

0‐1/year

Risk

Exacerbations  requiring oral  systemic  corticosteroids

Recommended Step for  Initiating Treatment

>2/ year

Consider severity and interval since last exacerbation. Frequency and severity may  fluctuate over time for any patient in any severity category. Relative annual risk of exacerbations maybe related to FEV1

Step 1

Step 2

Step 3

Re‐evaluate asthma control in 2‐6 weeks and adjust therapy accordingly

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8/9/2011

Case # 5

A 5‐year old male with asthma reports nocturnal cough 3  nights per week during October through February, but  only 3 nights per month during March through September.   This patient’s asthma severity can be classified and treated  as follows:

Case # 6

A spacer device can be equally as effective as, and  perhaps more effective than, a nebulizer machine in the  delivery of inhaled medication.

(circle one) TRUE or FALSE A. Moderate Persistent during winter only, Mild Persistent  remainder of the year B. Moderate Persistent year‐round in order to prevent winter  exacerbations C. Mild Persistent year‐round in order to prevent long‐term  decrease in lung function D. This patient does not have asthma but is at high‐risk for  frequent upper respiratory tract infections with the change  of seasons

Case # 6

A spacer device can be equally as effective as, and  perhaps more effective than, a nebulizer machine in the  delivery of inhaled medication.

(circle one) TRUE or FALSE

Case # 7

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.  All of the above

Case # 7

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.  All of the above EPR‐3, P 165

20

8/9/2011

EPR‐3, Page 166 EPR‐3, Page 166

DDx‐Children (2007 NIH guidelines p45)

Allergic  Rhinitis  Prevalence

21