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

PREVIOUS NHLBI/GINA GUIDELINES Severity Mild Intermittent

Mild Persistent Moderate Persistent Severe Persistent

Symptoms

Nocturnal

FEV1 or

Symptoms

PEF

< 1 x/week , asymptomatic between attacks

< 2 x / month

> 80% predicted variability < 20%

> 1 x/week but not daily

> 2 x / month

> 80% predicted variability 20-30%

Daily, affecting activity

> 1 time / week

60 -80% predicted variability > 30%

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

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 0-4 YEARS OF AGE

EPR-3, p72, 307

Classification of Asthma Severity Components of Severity

Impairment

Intermittent Mild 2 days/week not daily

Nighttime Awakenings

0

1-2x/month

SABA use for sx control

2 days/week not daily

Daily

Several times daily

Interference with normal activity

none

Minor limitation

Some limitation

Extremely limited

Exacerbations (consider frequency and severity)

3-4x/month

Continuous >1x/week

>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

Step 1

Recommended Step for Initiating Treatment

Daily

Severe

Symptoms

0-1/year

Risk

Persistent Moderate

Step 2

Step 3

Consider short course of oral steroids In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly

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.

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 5 - 11 YEARS OF AGE

EPR-3, p73, 308

Classification of Asthma Severity Components of Severity

Impairment

Intermittent Mild

Severe

Symptoms

2 days/week not daily

Daily

Nighttime Awakenings

1x/week

SABA use for sx control

2 days/week not daily

Daily

Several times daily

Interference with normal activity

none

Minor limitation

Some limitation

Extremely limited

not nightly

•Normal FEV1 between exacerbations Lung Function

• FEV1 > 80%

• FEV1 >80% •FEV1/FVC> 80%

Exacerbations (consider frequency and severity)

Continuous Often nightly

•FEV1 2 /year Frequency and severity may vary over time for patients in any category Relative annual risk of exacerbations may be related to FEV

Step 1 Recommended Step for Initiating Treatment

• FEV1=60% 80% •FEV1/FVC=75% -80%

• FEV1/FVC> 85%

Risk

Persistent Moderate

Step 2

Step3

medium- Step 3 or 4 dose ICS option Consider short course of oral steroids

In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS > 12 YEARS AND ADULTS

EPR-3, p74, 344

Classification of Asthma Severity Components of Severity

Intermittent Mild

Persistent Moderate

Severe

Symptoms

2 days/week not daily

Daily

Nighttime Awakenings

1x/week

Normal FEV1/FVC

SABA use for sx control

2 days/week not daily

Daily

Several times daily

8-19 yr 85%

Interference with normal activity

none

Minor limitation

Some limitation

Extremely limited

Impairment

20-39 yr 80%

•Normal FEV1 between exacerbations

40-59 yr 75% 60-80 yr 70%

not nightly

Lung Function

• FEV1 > 80%

• FEV1 >80% •FEV1/FVC normal

•FEV1/FVC reduced 5%

• FEV1/FVC normal Exacerbations

Risk

(consider frequency and severity)

Often nightly

•FEV1 5%

0-2/year > 2 /year Frequency and severity may vary over time for patients in any category Relative annual risk of exacerbations may be related to FEV

Step 1

Recommended Step for Initiating Treatment

• FEV1 >60% but< 80%

Continuous

Step 2

Step 3

Step 4 or 5

Consider short course of oral steroids In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordingly

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

ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 0 - 4 YEARS OF AGE

EPR-3, p75, 309

Classification of Asthma Control Components of Control Well Controlled Symptoms Nighttime awakenings

IMPAIRMENT

Interference with normal activity SABA use Exacerbations

RISK

Progressive loss of lung function Rx-related adverse effects

< 2 days/week < 1/month none < 2 days/week 0- 1 per year

Not Well Controlled > 2 days/week

>2x/week

Some limitation

Extremely limited

> 2 days/week 2 - 3 per year

Several times/day > 3 per year

Evaluation requires long-term follow up care Consider in overall assessment of risk •Maintain current step

For Treatment

Throughout the day

> 2 x/month

•Step up 1 step

Recommended Action

Very Poorly Controlled

•REGULAR FOLLOW UP EVERY 3 - 6 MONTHS •Consider step down if well controlled at least 3 months

•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

ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 5 - 11 YEARS OF AGE

EPR-3, p76, 310

Classification of Asthma Control Components of Control Well Controlled Symptoms Nighttime awakenings

IMPAIRMENT

Interference with normal activity SABA use FEV1or peak flow FEV1/FVC

RISK

Exacerbations Progressive loss of lung function Rx-related adverse effects

Recommended Action For Treatment

< 2 days/week < 1/month none < 2 days/week > 80% predicted/ personal best

Not Well Controlled > 2 days/week

Throughout the day

> 2 x/month

>2x/week

Some limitation

Extremely limited

> 2 days/week

Several times/day

60-80% predicted/ personal best

80% predicted 0- 1 per year

Very Poorly Controlled

75-80% predicted

2 - 3 per year

3 per year

Evaluation requires long-term follow up care Consider in overall assessment of risk •Maintain current step

•Step up 1 step

•Consider step down if well controlled at least 3 months

•Reevaluate in 2 - 6 weeks

•Consider oral steroids •Step up 1-2 weeks and reevaluate in 2 weeks

ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS > 12 YEARS OF AGE AND ADULTS

EPR-3, p77, 345

Classification of Asthma Control Components of Control Well Controlled Symptoms Nighttime awakenings

IMPAIRMENT

Interference with normal activity SABA use FEV1or peak flow Validated questionnaires

RISK

ATAQ/ACT Exacerbations Progressive loss of lung function Rx-related adverse effects

Recommended Action For Treatment

< 2 days/week < 2/month none

Not Well Controlled > 2 days/week 1-3/week Some limitation

< 2 days/week > 80% predicted/ personal best 0/> 20 0- 1 per year

Very Poorly Controlled Throughout the day > 4/week Extremely limited

> 2 days/week

Several times/day

60-80% predicted/ personal best

3 per year

Evaluation requires long-term follow up care Consider in overall assessment of risk •Maintain current step

•Step up 1 step

•Consider step down if well controlled at least 3 months

•Reevaluate in 2 - 6 weeks

•Consider oral steroids •Step up 1-2 weeks and reevaluate in 2 weeks

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?

Score

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?

Copyright 2002, QualityMetric Incorporated. Asthma Control Test Is a Trademark of QualityMetric Incorporated.

Patient Total Score

Childhood Asthma Control Test™ (ACT): Questions Completed by Child

1. How is your asthma today?

0

SCORE

1

2

3

Very bad

Bad

Good

Very Good

0

1

2

3

2. How much of a problem is your asthma when you run, exercise or play sports?

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

3. Do you cough because of your asthma?

0

1

2

Yes, all of the time.

Yes, most of the time.

0

1

2

3

Yes, all of the time.

Yes, most of the time.

Yes, some of the time.

No, none of the time

Yes, some of the time.

3 No, none of the time

4. Do you wake up during the night because of your asthma?

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

4

3

2

1

0

Not at all

1-3 days/mo

4-10 days/mo

11-18 days/mo

19-24 days/mo

Everyday

6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma?

5

4

3

2

1

0

Not at all

1-3 days/mo

4-10 days/mo

11-18 days/mo

19-24 days/mo

Everyday

7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma?

5

4

3

2

1

0

Not at all

1-3 days/mo

4-10 days/mo

11-18 days/mo

19-24 days/mo

Everyday TOTAL

Monitoring Asthma Control

EPR-3, Page 78

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

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

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

Step 6

adherence, environmental control )

Step 5 Preferred: High dose ICS

Step 4 Step 3 Step 2 Preferred: Low-dose ICS

Step 1 Preferred: SABA prn

Alternative: LTRA Cromolyn

Preferred: Medium-dose ICS

Preferred: Medium-dose ICS

AND

AND either LTRA Or LABA

AND AND either LTRA Or LABA

Oral Corticosteroid

either LTRA Or LABA

Patient Education and Environmental Control at Each Step Intermittent

Mild Persistent

Moderate Persistent

Step up if needed (check

Severe Persistent

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

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

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

Step 6 Step 5 Step 4 Step 3 Step 2 Step 1 Preferred: SABA prn

Preferred: Medium-dose ICS

Preferred: Low-dose ICS OR Alternative: Low-dose ICS+ LTRA either LABA, Cromolyn LTRA, or Theophylline Theophylline

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

AND Alternative: Medium-dose ICS+either LTRA, or Theophlline

AND Consider Consider Olamizumab for Olamizumab for patients with patients with allergies allergies

Patient Education and Environmental Control at Each Step

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

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

STEPWISE APPROACH FOR MANAGING ASTHMA IN EPR-3, p333-343 YOUTHS > 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 6 Step 5 Step 4 Step 3 Step 2 Step 1 Preferred: SABA prn

Preferred: Medium-dose ICS

Preferred: OR Low-dose ICS Low-dose ICS+ Alternative: either LABA, LTRA LTRA, Cromolyn Theophylline Theophylline Or Zileutin

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 Consider patients with Olamizumab for allergies patients with allergies

Patient Education and Environmental Control at Each Step

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

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

EPR-3, Page 330

Recommended Action for Treatment Based on Assessment of Control Well

Not Well

Controlled

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

Treatment Strategies  Gain Control!!!  Aggressive, intensive initial therapy to

suppress airway inflammation and gain prompt control  Maintain Control  Frequent 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 betaagonists 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 β2-agonists  Most effective medication for relief of acute

symptoms  RED FLAG more than 1 canister per month  Regularly scheduled use not generally

recommended May “lower” effectiveness May increase airway hyperresponsiveness

Anticholinergics  Not specifically indicated for “usual” quick-

relief medication in asthma contrast 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 longterm control but must be taken daily  Often under-used

Inhaled Corticosteroids  Actions:  potentiate β-receptor responsiveness  reduce mucus production and hypersecretion  inhibit inflammatory response at all levels  Best effects if started early after diagnosis  Symptomatic and spirometric improvement within

2 weeks  maximum 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 β2-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 8 7

β2-agonists

Relative Risk of Hospitalization

6

Total

5 4

Inhaled Steroids

3

Total

2 1 0

None 0-1 1-2

2-3

3-5 5-8

8+

Short-acting B2 prescriptions dispensed per person-year Adapted from Donahue et. al. JAMA 1997;277(11):887-891.

Inhaled Corticosteroids (continued)  HPA Suppression  no need to test in children receiving < 400

mcg/day (BEC), or adults < 1500 mcg/day (BEC)  Cataracts  Long bone growth  growing understanding of this risk  Osteoporosis/Bone Fractures  some attention at high doses, high risk

patients  Candidiasis  Dysphonia

Leukotriene Modifiers  Two mechanisms  5-lipoxygenase inhibitors  zileution (Zyflo)  Cysteinyl leukotriene receptor antagonists  zafirlukast (Accolate), montelukast (Singulair)

 Indications  Generally, alternative therapy in mild persistent

asthma or as add-on in higher stages  Improve lung function  Decrease short-acting β2-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 Interactions  Therapeutic 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 β2-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 β2-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.

Long-acting β2-agonists  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 deaths  life-threatening episodes  Initial aim to enroll 30,000 patients; later changed

with aim to enroll 60,000

Long-acting β2-agonists  Two methods of recruitment  Phase 1 1996-1999  Recruited by advertising and assigned to

study investigator by geography  Phase 2 2000-2003  Recruitment by study investigators and

more investigators added

Long-acting β2-agonists  Increase in adverse events in salmeterol

group during SMART trial:  Particularly in those recruited in Phase 1  Particularly 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

group  Due to adverse effect of salmeterol?  Due to inappropriate bronchodilator use? (affected

patients were more severe at baseline and less likely to be using ICS)

FDA Advisory Panel Recommends Ban of Long-acting β2-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

Long-acting β2-agonists  Conclusions: Black Box warning Do not use long-acting bronchodilators alone Always use with inhaled corticosteroids

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

EPR-3, p121-139

 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

What is Success: How do we measure it and how do we get there?  Begin therapy based on Severity  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 technique  Proper inhaler/spacer technique  Care and cleaning  Methods to determine amount of medication left in inhaler 



Dry-powder inhalers: Proper technique  Care and cleaning  Methods 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

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 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 # 2

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

ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 5 - 11 YEARS OF AGE

EPR-3, p76, 310

Classification of Asthma Control Components of Control Well Controlled Symptoms Nighttime awakenings

IMPAIRMENT

Interference with normal activity SABA use FEV1or peak flow FEV1/FVC

RISK

Exacerbations Progressive loss of lung function Rx-related adverse effects

Recommended Action For Treatment

< 2 days/week < 1/month none

Not Well Controlled > 2 days/week > 2 x/month Some limitation

< 2 days/week > 80% predicted/ personal best

Throughout the day >2x/week Extremely limited

> 2 days/week

Several times/day

60-80% predicted/ personal best

80% predicted 0- 1 per year

Very Poorly Controlled

75-80% predicted

2 - 3 per year

3 per year

Evaluation requires long-term follow up care Consider in overall assessment of risk •Maintain current step

•Step up 1 step

•Consider step down if well controlled at least 3 months

•Reevaluate in 2 - 6 weeks

•Consider oral steroids •Step up 1-2 steps and reevaluate in 2 weeks

Recommended Action for Treatment Based on Assessment of Control Well

Not Well

Controlled

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

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

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

Step 6

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

AND

AND

Step 5 Step 4 Step 3 Step 2 Step 1 Preferred: SABA prn

Preferred: Medium-dose ICS

Preferred: Low-dose ICS OR Alternative: Low-dose ICS+ LTRA either LABA, Cromolyn LTRA, or Theophylline Theophylline

Preferred: Medium-dose ICS+LABA Alternative: Medium-dose ICS+either LTRA, or Theophlline

Consider Consider Olamizumab for Olamizumab for patients with patients with allergies allergies

Patient Education and Environmental Control at Each Step

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

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

Case # 2

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 # 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

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

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