1 National Institutes of Health (NIH) NAEPP 2007 Asthma Guideline UPDATE Susan K. Ross RN, AE-C MDH...

11

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

UPDATEUPDATE

Susan K. Ross RN, AE-CSusan K. Ross RN, AE-C

MDH Asthma Program MDH Asthma Program

651-201-5629 651-201-5629

[email protected]@health.state.mn.us

mailto:[email protected]

22

National Institutes of HealthNational Institutes of HealthNational Asthma Education Prevention National Asthma Education Prevention

ProgramProgram (NAEPP)(NAEPP)

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

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

National Asthma Education

and Prevention Program

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

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

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School NursesSchool Nurses

““School nurses are an important School nurses are an important component of the health care system for component of the health care system for children and play a critical role in children and play a critical role in identifying solutions to the health problems identifying solutions to the health problems faced by today’s children and families”.faced by today’s children and families”.

The Journal of School Nursing, June 2007, Vol.23, Num. 3The Journal of School Nursing, June 2007, Vol.23, Num. 3

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What Is Asthma?What Is Asthma?

““Asthma is a common chronic disorder of Asthma is a common chronic disorder of the airways that involves a complex the airways that involves a complex interaction of airflow obstruction, interaction of airflow obstruction, bronchial hyperresponsiveness and an bronchial hyperresponsiveness and an underlying inflammation. This interaction underlying inflammation. This interaction can be highly variable among patients can be highly variable among patients and within patients over time”.and within patients over time”.

2007 NAEPP Guidelines, EPR 3- 2007 NAEPP Guidelines, EPR 3- Section 2, p 12.Section 2, p 12.

55

Characteristics of AsthmaCharacteristics of Asthma

• Airway Inflammation Airway Inflammation • Airway Obstruction (reversible) Airway Obstruction (reversible) • Hyperresponsiveness (irritability of Hyperresponsiveness (irritability of

airways)airways)

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Normal & Asthmatic Normal & Asthmatic BronchioleBronchiole

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

88

Asthma:Asthma:

Accounts for 12.8 million lost school days Accounts for 12.8 million lost school days annually annually 11 (2003)(2003)

67% of US children with asthma have had at 67% of US children with asthma have had at least one attack in the past year least one attack in the past year 11 (2005)(2005)

Is the 3rd leading cause of hospitalizations Is the 3rd leading cause of hospitalizations among children under 15 among children under 15 22

Close to 1 in 11 (8.9%) children have asthma Close to 1 in 11 (8.9%) children have asthma 1 1 (2005)(2005)

6.5 million children under 18 have asthma 6.5 million children under 18 have asthma 11

1 1 National Health Interview Survey; Asthma Prevalence, Health Care Use, and Mortality, 2000-01, National Center for Health Statistics, CDCNational Health Interview Survey; Asthma Prevalence, Health Care Use, and Mortality, 2000-01, National Center for Health Statistics, CDC2 National Hospital Discharge Survey, 2002; American Lung Association Asthma and Children Fact Sheet, August 20062 National Hospital Discharge Survey, 2002; American Lung Association Asthma and Children Fact Sheet, August 2006

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Asthma PrevalenceAsthma Prevalence

AgeAge Current asthma Current asthma prevalence (%)prevalence (%)

2004-20052004-2005

Deaths per Deaths per 1,000,0001,000,000

0-4 yrs0-4 yrs 6.26.2 2.02.0

5-10 yrs5-10 yrs 9.39.3 2.32.3

11-17 11-17 yrsyrs

10.010.0 3.33.3

TotalTotal 8.78.7 2.62.6

Adapted from Akinbami L. Advance Data 2006

1010

This means..This means..

In a class of 30 children, you can In a class of 30 children, you can expect expect

2 to 3 students 2 to 3 students WILLWILL have asthma have asthma

This number will vary depending on age This number will vary depending on age and geographical locationand geographical location

1111

“ “Children & Asthma In Children & Asthma In America” America” Survey - 2004Survey - 2004

The The Children and Asthma in AmericaChildren and Asthma in America survey focused on survey focused on children children 4 to 184 to 18 years of age with asthma, which years of age with asthma, which represents about 5.8 million children in the country based represents about 5.8 million children in the country based on figures from the 2002 National Health Interview Survey. on figures from the 2002 National Health Interview Survey.

A survey of a national probability sample of 801 children 4 A survey of a national probability sample of 801 children 4 to 18 years of age who currently have asthma, conducted to 18 years of age who currently have asthma, conducted from February to May 2004. from February to May 2004.

The survey found that nearly 1 out of 10 (9.2%) American The survey found that nearly 1 out of 10 (9.2%) American children 18 years of age and younger currently suffer from children 18 years of age and younger currently suffer from asthma. asthma.

The The Children and Asthma in AmericaChildren and Asthma in America survey concludes that survey concludes that a significant number of children with asthma do not have a significant number of children with asthma do not have their condition under control, falling far short of national their condition under control, falling far short of national treatment goals. treatment goals.

Excerpts taken from Excerpts taken from www.asthmainamerica.comwww.asthmainamerica.com, “Children & Asthma in America”, 2004 Glaxo-, “Children & Asthma in America”, 2004 Glaxo-SmithKlineSmithKline

http://www.asthmainamerica.com/

1212

2007 - Guidelines For The 2007 - Guidelines For The Diagnosis & Management Of Diagnosis & Management Of

AsthmaAsthma

Expert Review Panel (EPR-3)Expert Review Panel (EPR-3)

1313

Asthma Guidelines: Asthma Guidelines: History and ContextHistory and Context

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

Updated again in 2002 (EPR-2) with a focus on Updated again in 2002 (EPR-2) with a focus on several key questions about medications, several key questions about medications, monitoring and prevention.monitoring and prevention.– Long-term management of asthma in childrenLong-term management of asthma in children– Combination therapyCombination therapy– Antibiotic useAntibiotic use– Written asthma action plans (AAP) and peak Written asthma action plans (AAP) and peak

flow meters (PFM)flow meters (PFM)– Effects of early treatment on the progression Effects of early treatment on the progression

of asthmaof asthma

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Old and New Asthma Guidelines:Old and New Asthma Guidelines:What Has What Has NOTNOT Changed Changed

Initial asthma therapy is determined by assessment of Initial asthma therapy is determined by assessment of asthma severity.asthma severity. – Ideally, before the patient is on a long-term controller.Ideally, before the patient is on a long-term controller.

Stepping therapy up or down is based on how well Stepping therapy up or down is based on how well asthma is asthma is controlledcontrolled or not controlled . or not controlled .

Inhaled corticosteroids (ICS) are the preferred first-Inhaled corticosteroids (ICS) are the preferred first-line therapy for asthma.line therapy for asthma.

Systemic steroids can still be used to treat asthma Systemic steroids can still be used to treat asthma exacerbations.exacerbations.

Peak flows and written asthma action plans are Peak flows and written asthma action plans are recommended for asthma self managementrecommended for asthma self management . .– Especially in moderate and severe persistent asthma, or those Especially in moderate and severe persistent asthma, or those

with a history of severe exacerbations or poorly controlled with a history of severe exacerbations or poorly controlled asthma.asthma.

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Asthma Therapy GoalsAsthma Therapy Goals

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

Dr. William Busse, MD., chairman of the NAEPP EPR -3Dr. William Busse, MD., chairman of the NAEPP EPR -3

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2007 - Guidelines For The 2007 - Guidelines For The Diagnosis & Management of Diagnosis & Management of Asthma (EPR-3)Asthma (EPR-3)

(Almost) no new medications.(Almost) no new medications. Restructuring into “severity” and “control” .Restructuring into “severity” and “control” . Domains of “impairment” and “risk”.Domains of “impairment” and “risk”. Six treatment steps (step-up/step-down).Six treatment steps (step-up/step-down). More careful thought into ongoing More careful thought into ongoing

management issues.management issues. Summarizes extensively-validated scientific Summarizes extensively-validated scientific

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

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New Strategies of the EPR-3Summary

EPR-3, Page 36-38

1818

Asthma is a chronic inflammatory disorder of the airways.

The immunohistopathologic features of asthma include inflammatory cell infiltration.

Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity.

In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis. (remodeling)

Key Points: Definition, Key Points: Definition, Pathophysiology & Pathogenesis Pathophysiology & Pathogenesis

1919

Key Points: Continued..Key Points: Continued..

Gene-by-environment interactions are important to the expression of asthma.

Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma.

Viral respiratory infections are one of the most important causes of asthma exacerbation and may also contribute to the development of asthma.

EPR 3, Section 2: Page 11

2020

Key Key DifferencesDifferences from 1997 & from 1997 & 2002 Reports2002 Reports

The critical role of inflammation is validated - there is The critical role of inflammation is validated - there is considerable variability in the pattern of inflammation considerable variability in the pattern of inflammation indicating phenotypic differences that may influence indicating phenotypic differences that may influence treatment responses. treatment responses. (in other words – genetics(in other words – genetics))

Gene-by-environmental interactions are affect the Gene-by-environmental interactions are affect the development of asthma. Of the environmental factors, development of asthma. Of the environmental factors, allergic reactions are important. Viral respiratory infections allergic reactions are important. Viral respiratory infections are key and have an expanding role in these processesare key and have an expanding role in these processes. .

The onset of asthma for most patients begins early in life The onset of asthma for most patients begins early in life with the pattern of disease persistence determined by with the pattern of disease persistence determined by early, recognizable risk factors including atopic disease, early, recognizable risk factors including atopic disease, recurrent wheezing, and a parental history of asthmarecurrent wheezing, and a parental history of asthma. .

Current asthma treatment with anti-inflammatory therapy Current asthma treatment with anti-inflammatory therapy does not appear to prevent progression of the underlying does not appear to prevent progression of the underlying disease severity.disease severity.

EPR 3 – section 2, p. 12EPR 3 – section 2, p. 12

2121

Causes – We Don’t Know…Causes – We Don’t Know…Yet!Yet!

Asthma has dramatically risen worldwide over the Asthma has dramatically risen worldwide over the past decades, particularly in developed countries, past decades, particularly in developed countries, and experts are puzzled over the cause of this and experts are puzzled over the cause of this increase. increase.

Not all people with allergies have asthma, and Not all people with allergies have asthma, and not all cases of asthma can be explained by not all cases of asthma can be explained by allergic response.allergic response.

Asthma is most likely caused by a convergence of Asthma is most likely caused by a convergence of factors that can include genes factors that can include genes (probably several)(probably several) and various environmental and biologic triggers and various environmental and biologic triggers (e.g., infections, dietary patterns, hormonal changes (e.g., infections, dietary patterns, hormonal changes in women, and allergens). in women, and allergens).

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The 4 Components Of Asthma The 4 Components Of Asthma Management - (Section 3)Management - (Section 3)

Component 1Component 1: Measures of Asthma : Measures of Asthma Assessment and MonitoringAssessment and Monitoring

Component 2Component 2:: Education for a Education for a Partnership in Asthma CarePartnership in Asthma Care

Component 3Component 3:: Control of Control of Environmental Factors and Comorbid Environmental Factors and Comorbid Conditions That Affect AsthmaConditions That Affect Asthma

Component 4Component 4: Medications: Medications

2323

Component 1Component 1

Measures of Asthma Measures of Asthma Assessment & MonitoringAssessment & Monitoring

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Key Points -Key Points - Overview: Measures Of Asthma Overview: Measures Of Asthma Assessment & MonitoringAssessment & Monitoring

Assessment and monitoring are closely linked to the Assessment and monitoring are closely linked to the concepts of concepts of severity, controlseverity, control, and , and responsivenessresponsiveness to treatment:to treatment:

– SeveritySeverity - - intensity of the disease process. Severity intensity of the disease process. Severity is measured most easily and directly in a patient not is measured most easily and directly in a patient not receiving long-term-control therapy.receiving long-term-control therapy.

– Control Control - - degree to which asthma degree to which asthma (symptoms, (symptoms, functional impairments, and risks of untoward events)functional impairments, and risks of untoward events) are are minimized and the goals of therapy are met.minimized and the goals of therapy are met.

– ResponsivenessResponsiveness - - the ease with which asthma the ease with which asthma control is achieved by therapy. control is achieved by therapy.

EPR -3 , Pg. 36, Section 3, Component 1: Measures of Asthma Assessment and MonitoringEPR -3 , Pg. 36, Section 3, Component 1: Measures of Asthma Assessment and Monitoring

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Key Points – Key Points – Cont. Cont. 22Severity & Control Are Assessed Based Severity & Control Are Assessed Based

On 2 Domains On 2 Domains

Impairment Impairment (Present): (Present): – Frequency and intensity of symptoms Frequency and intensity of symptoms – Functional limitations Functional limitations (quality of life)(quality of life)

Risk Risk (Future):(Future):– Likelihood of asthma exacerbations orLikelihood of asthma exacerbations or– Progressive loss of lung function Progressive loss of lung function (reduced lung (reduced lung

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

EPR -3, Pg. 38-80, 277-EPR -3, Pg. 38-80, 277-345345

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Key Points - Key Points - Cont. 3Cont. 3SSeverityeverity & & ControlControl are used as follows for are used as follows for managing asthma:managing asthma:

If the patient is If the patient is notnot currently on a long-term currently on a long-term controller at the first visit:controller at the first visit:– Assess asthma severity to determine the Assess asthma severity to determine the

appropriate medication & treatment plan.appropriate medication & treatment plan. Once therapy is initiated, the emphasis is Once therapy is initiated, the emphasis is

changed to the assessment of changed to the assessment of asthma asthma controlcontrol. . – The level of asthma control will guide The level of asthma control will guide

decisions either to maintain or adjust therapy.decisions either to maintain or adjust therapy.

2727

Key Key Differences:Differences: Component 1 - Component 1 - OverviewOverview

The key elements of assessment and monitoring The key elements of assessment and monitoring include the concepts of severity, control, and include the concepts of severity, control, and responsiveness to treatment:responsiveness to treatment: – Classifying severity for initiating therapy.Classifying severity for initiating therapy.– Assessing control for monitoring and adjusting therapy.Assessing control for monitoring and adjusting therapy.– Asthma severity and control are defined under domains Asthma severity and control are defined under domains

of impairment and risk.of impairment and risk.

The distinction between the domains of The distinction between the domains of impairmentimpairment and and riskrisk for assessing severity and for assessing severity and control emphasizes the need to consider separately control emphasizes the need to consider separately asthma’s effects on quality of life and functional asthma’s effects on quality of life and functional capacity on an ongoing basis and the risks it capacity on an ongoing basis and the risks it presents for adverse events in the future, such as presents for adverse events in the future, such as exacerbations and progressive loss of pulmonary exacerbations and progressive loss of pulmonary functionfunction. .

2828

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

Assess by taking a careful, directed history and lung function measurement.

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

(ATAQ) control index. Some patients, appear to perceive the

severity of airflow obstruction poorly.

2929

Assessing Risk (Future)Assessing Risk (Future)DomainDomain

Of adverse events in the future, especially Of adverse events in the future, especially of exacerbations and of progressive, of exacerbations and of progressive, irreversibleirreversible loss of pulmonary function—is loss of pulmonary function—is more problematic (airway remodeling). more problematic (airway remodeling).

The test most used for assessing the risk The test most used for assessing the risk of future adverse events is of future adverse events is spirometry.spirometry.

3030

Measures of Assessment & Measures of Assessment & MonitoringMonitoring

DiagnosisDiagnosis

3131

Key Points – Diagnosis of AsthmaKey Points – Diagnosis of Asthma

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

Episodic symptoms of airflow obstruction or airway Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present.hyperresponsiveness are present.

Airflow obstruction is at least partially reversible.Airflow obstruction is at least partially reversible. Alternative diagnoses are excluded.Alternative diagnoses are excluded.

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

– Detailed medical history.Detailed medical history.– Physical exam focusing on the upper respiratory tract, Physical exam focusing on the upper respiratory tract,

chest, and skin.chest, and skin.– Spirometry to demonstrate obstruction and assess Spirometry to demonstrate obstruction and assess

reversibility, including in children 5 years of age or reversibility, including in children 5 years of age or older. older.

– Additional studies to exclude alternate diagnoses.Additional studies to exclude alternate diagnoses.

3232

Key Key DifferencesDifferences – Diagnosis – Diagnosis

Discussions added on use of spirometry, Discussions added on use of spirometry, especially in children and on criteria for especially in children and on criteria for reversibility.reversibility.

Information added on vocal cord Information added on vocal cord dysfunction and cough variant asthma as dysfunction and cough variant asthma as alternative diagnosis. alternative diagnosis.

References added about conditions that References added about conditions that complicate diagnosis and treatment.complicate diagnosis and treatment.

EPR -3, Sec.3, Pg. 41EPR -3, Sec.3, Pg. 41

3333

Key Indicators:Key Indicators:Diagnosis of AsthmaDiagnosis of Asthma

Wheezing – high-pitched whistling sounds when Wheezing – high-pitched whistling sounds when breathing out.breathing out.

History of (any):History of (any):– Cough, worse particularly at nightCough, worse particularly at night– Recurrent wheezeRecurrent wheeze– Recurrent difficulty in breathingRecurrent difficulty in breathing– Recurrent chest tightnessRecurrent chest tightness

Symptoms occur or worsen in the presence of Symptoms occur or worsen in the presence of known triggers.known triggers.

Symptoms occur or worsen at night awakening Symptoms occur or worsen at night awakening patient.patient.

3434

Characterization & Characterization & Classification of AsthmaClassification of Asthma

SEVERITYSEVERITY

3535

Key Points - Initial Assessment: Key Points - Initial Assessment: SeveritySeverity

Once diagnosis is established:Once diagnosis is established:– Identify precipitating factors Identify precipitating factors (triggers).(triggers).– Identify comorbidities that aggravate Identify comorbidities that aggravate

asthmaasthma– Assess patient’s knowledge & skills for Assess patient’s knowledge & skills for

self-management.self-management.– Classify severity using impairment & risk Classify severity using impairment & risk

domains.domains. Pulmonary function testing Pulmonary function testing (spirometry)(spirometry) to to

assess severity.assess severity.

EPR -3, EPR -3,

Sec. 3, pg. 47Sec. 3, pg. 47

3636

Key Key DifferencesDifferences – – Initial Assessment & SeverityInitial Assessment & Severity

Severity class for asthma changed Severity class for asthma changed mildmild intermittentintermittent to intermittent. to intermittent.

Severity class is defined in terms of 2 domains Severity class is defined in terms of 2 domains – – impairmentimpairment & & riskrisk . .

New emphasis on using FEVNew emphasis on using FEV1 1 /FVC is added to /FVC is added to classify severity in children because it may be a classify severity in children because it may be a more sensitive measure than FEVmore sensitive measure than FEV1.1.

EPR-3 Sec.3, Pg. 48EPR-3 Sec.3, Pg. 48

3737

Assessment of Asthma Assessment of Asthma SeveritySeverity

Previous GuidelinesPrevious Guidelines Frequency of daytime Frequency of daytime

symptomssymptoms Frequency of Frequency of

nighttime symptomsnighttime symptoms Lung functionLung function

2007 Guidelines2007 Guidelines ImpairmentImpairment

– Frequency of daytime Frequency of daytime /nighttime symptoms/nighttime symptoms

– Quality of life assessmentsQuality of life assessments– Frequency of SABA useFrequency of SABA use– Interference with normal Interference with normal

activityactivity

– Lung function (FEVLung function (FEV11/FVC) /FVC)

RiskRisk– Exacerbations (frequency Exacerbations (frequency

and severity)and severity)

Classification of Asthma Severity: Clinical Classification of Asthma Severity: Clinical Features Before Treatment – 2002 “Old” Features Before Treatment – 2002 “Old” GuidelinesGuidelines

Days With Nights With PEF or PEFDays With Nights With PEF or PEFSymptoms SymptomsSymptoms Symptoms FEV FEV11 Variability Variability

Step 4Step 4 Continuous Frequent Continuous Frequent 60% 60% 30%30%SevereSeverePersistentPersistentStep 3Step 3 Daily Daily >>1night/week 1night/week 60%-<80% 60%-<80% 30%30%ModerateModeratePersistentPersistentStep 2Step 2 >2/week, <1x/day >2 nights/month >2/week, <1x/day >2 nights/month 80% 20-30%80% 20-30%MildMildPersistentPersistentStep 1Step 1 2 days/week 2 days/week 2/month 2/month 80% 80% 20%20%MildMildIntermittentIntermittent

Footnote: The patient’s step is determined by the most severe feature. Footnote: The patient’s step is determined by the most severe feature.

NOT Currently Taking ControllersNOT Currently Taking Controllers

Level of severity is determined by both impairment a & risk. Assess impairment by caregivers recall of previous 2-4 weeks.

Step 3 and consider short course of oral systemic corticosteroids

Step 2Step 1Recommended Step for Initiating Therapy

(See figure 4 1a fortreatment steps.)

In 2 6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is observed in 4 6 weeks, consider adjusting therapy or alternative diagnoses.

Extremely limitedSome limitationMinor limitationNoneInterference with normal activity

Several timesper day

Daily>2 days/weekbut not daily

2 days/week

Short-actingbeta2-agonist use

for symptom control (not

prevention of EIB)

Consider severity and interval since last exacerbation.Frequency and severity may fluctuate over time.

Exacerbations of any severity may occur in patients in any severity category.

Exacerbationsrequiring oral

systemic corticosteroids

Risk

Impairment

>1x/week3 4x/month1 2x/month0Nighttime

awakenings

Classification of Asthma Severity(0 4 years of age)

Persistent

Components ofSeverity

2 exacerbations in 6 months requiring oral systemic corticosteroids, or 4 wheezing episodes/1 year lasting

>1 day AND risk factors for persistent asthma0 1/year

Throughoutthe day

Daily>2 days/week

but not daily2 days/weekSymptoms

SevereModerateMildIntermittent


Extremely limitedSome limitationMinor limitationNoneInterference withnormal activity

Step 1and consider short course oforal systemic corticosteroids

Step 3, medium-dose ICS option

In 2 6 weeks, evaluate level of asthma control that is achieved, and adjust therapy accordingly.

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

Risk



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

• FEV1 <60% predicted

• FEV1 = 60 80% predicted

• FEV1 = >80% predicted

• FEV1 >80% predicted

Lung function

2/year (see note)0 1/year (see note)

• Normal FEV1between exacerbations

Several timesper dayDaily>2 days/week

but not daily2 days/week

Short-actingbeta2-agonist use for symptom control (not

prevention of EIB)

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

Step 2

Classification of Asthma Severity(5 11 years of age)

Impairment

Recommended Step for Initiating Therapy

(See figure 4 1b fortreatment steps.)

Persistent

Components of Severity

Relative annual risk of exacerbations may be related to FEV1.

Often 7x/week>1x/week butnot nightly3 4x/month2x/monthNighttime

awakenings

Throughoutthe day

Daily>2 days/week but not daily

2 days/weekSymptoms


and consider short course oforal systemic corticosteroids

Step 4 or 5Step 3Step 2Step 1

Recommended Stepfor Initiating Treatment

(See figure 4 5 for treatment steps.)In 2 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly.

• Normal FEV1between exacerbations

Extremely limitedSome limitationMinor limitationNoneInterference with normal activity

Several timesper day

Daily>2 days/weekbut not daily, and

not more than1x on any day

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

prevention of EIB)

2/year (see note)0 1/year (see note)

• FEV1 <60% predicted

• FEV1 >60% but <80% predicted



• FEV1/FVCreduced >5%

• FEV1/FVC reduced 5%

• FEV1/FVC normal• FEV1/FVC normal

Risk

Relative annual risk of exacerbations may be related to FEV1.

Classification of Asthma Severity12 years of age

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

Impairment

Normal FEV1/ FVC:8 19 yr 85%

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

PersistentComponents of Severity



Lung function

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

3 4x/month2x/monthNighttime awakenings

Throughout the dayDaily>2 days/week but not daily

2 days/weekSymptoms



Classifying Severity AFTER Control Classifying Severity AFTER Control is Achieved – All Ages is Achieved – All Ages

Lowest Lowest level of level of treatmentreatment required t required to to maintain maintain controlcontrol

Classification of Asthma Classification of Asthma SeveritySeverity

IntermittenIntermittentt

PersistentPersistent

Step 1Step 1

MildMild ModeratModeratee

SevereSevere

Step Step 22

Step 3 Step 3

or 4or 4Step 5 Step 5

or 6or 6(already on controller)(already on controller)

4343

Periodic Assessment & Periodic Assessment & MonitoringMonitoring

Asthma ControlAsthma Control

4444

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

Reducing Reducing impairmentimpairment– Prevent chronic & troublesome symptoms.Prevent chronic & troublesome symptoms.– Prevent frequent use Prevent frequent use ((< < 2 days /wk)2 days /wk) of inhaled of inhaled

SABA for symptoms.SABA for symptoms.– Maintain Maintain (near)(near) “normal” pulmonary function. “normal” pulmonary function.– Maintain normal activity levels Maintain normal activity levels (including (including

exercise & other physical activity & attendance at exercise & other physical activity & attendance at work or school).work or school).

– Meet patients’ and families’ expectations of Meet patients’ and families’ expectations of and satisfaction with asthma care.and satisfaction with asthma care.

EPR- 3, p. 50EPR- 3, p. 50

4545

Key Points – Cont. Key Points – Cont.

Reducing Reducing RiskRisk– Prevent recurrent exacerbations of asthma and Prevent recurrent exacerbations of asthma and

minimize the need for ER visits and minimize the need for ER visits and hospitalizations.hospitalizations.

– Prevent progressive loss of lung function - Prevent progressive loss of lung function - for for children, prevent reduced lung growth.children, prevent reduced lung growth.

– Provide optimal pharmacotherapy with minimal Provide optimal pharmacotherapy with minimal or no adverse effects.or no adverse effects.

Periodic assessments at 1-6 month intervals.Periodic assessments at 1-6 month intervals. Patient self-assessment Patient self-assessment (w/clinician).(w/clinician). Spirometry testing.Spirometry testing.

NAEPP 2007 guidelines, sec. 3, p. NAEPP 2007 guidelines, sec. 3, p. 5353

4646

Key Points Cont. - Written AAP’s & Key Points Cont. - Written AAP’s & PFM PFM

Provide to all patients a written AAP based on signs Provide to all patients a written AAP based on signs and symptoms and/or PEF.and symptoms and/or PEF.– Written AAPs are particularly recommended for Written AAPs are particularly recommended for

patients who have moderate or severe patients who have moderate or severe persistent asthma, a history of severe persistent asthma, a history of severe exacerbations or poorly controlled asthma”.exacerbations or poorly controlled asthma”.

““Whether PF monitoring, symptoms monitoring Whether PF monitoring, symptoms monitoring (available data show similar benefits for each),(available data show similar benefits for each), or a or a combo of approaches is used, self- monitoring is combo of approaches is used, self- monitoring is important to the effective self-management of important to the effective self-management of asthma” .asthma” .

EPR -3 Sec. 3, P.53EPR -3 Sec. 3, P.53

4747

Peak Flow MonitoringPeak Flow Monitoring

Long-term daily PF monitoring can be helpful Long-term daily PF monitoring can be helpful toto::

Detect early changes in asthma control that Detect early changes in asthma control that require adjustments in treatmentrequire adjustments in treatment::– Evaluate responses to changes in treatmentEvaluate responses to changes in treatment– Provide a quantitative measure of impairmentProvide a quantitative measure of impairment

NAEPP 2007 guidelines Sec. 3, P.54NAEPP 2007 guidelines Sec. 3, P.54

4848

Key Key Differences Differences – – Assessing/ Monitoring ControlAssessing/ Monitoring Control

Periodic assessment of asthma Periodic assessment of asthma control control is is emphasized.emphasized.

A stronger distinction between classifying asthma A stronger distinction between classifying asthma severity and assessing asthma control. severity and assessing asthma control.

EPR-3 clarifies the issueEPR-3 clarifies the issue::– For initiating treatment, asthma severity should be For initiating treatment, asthma severity should be

classified, and the initial treatment should classified, and the initial treatment should correspond to the appropriate severity category.correspond to the appropriate severity category.

– Once treatment is established, the emphasis is on Once treatment is established, the emphasis is on assessing asthma control to determine if the goals assessing asthma control to determine if the goals for therapy have been met and if adjustments in for therapy have been met and if adjustments in therapy therapy (step up or step down)(step up or step down) would be would be appropriateappropriate..

EPR-3, Sec.3 EPR-3, Sec.3 Pg.54Pg.54

4949

Key Key DifferencesDifferences Cont. Cont.

Assessment of asthma control includes the two Assessment of asthma control includes the two domains of domains of impairmentimpairment and and riskrisk..

Peak flow monitoring:Peak flow monitoring: – Assessing diurnal variation was deleted. Assessing diurnal variation was deleted. – Patients are most likely to benefit from routine Patients are most likely to benefit from routine

peak flow monitoring. peak flow monitoring. – Evidence suggests equal benefits to either peak Evidence suggests equal benefits to either peak

flow or symptom-based monitoring; flow or symptom-based monitoring; the the important issue continues to be having a important issue continues to be having a monitoring plan in place.monitoring plan in place.

Parameters for lung function, specifically Parameters for lung function, specifically FEV1/FVC, were added as measures of asthma FEV1/FVC, were added as measures of asthma control for children.control for children.

5050

Asthma Control = Asthma Asthma Control = Asthma GoalsGoals

Definition of asthma control is the same Definition of asthma control is the same as asthma goalsas asthma goals (slides #44 & 45) (slides #44 & 45) reducing reducing impairment and risk.impairment and risk.

Monitoring quality of life, any:Monitoring quality of life, any:– work or school missed because of asthma?work or school missed because of asthma?– reduction in usual activities?reduction in usual activities?– disturbances in sleep due to asthma?disturbances in sleep due to asthma?– Change in caregivers activities due to a Change in caregivers activities due to a

child's asthma?child's asthma?There are quality of life assessment tools listed There are quality of life assessment tools listed

(p.62)(p.62)

5151

Responsiveness - Questions for Assessing Asthma Control

Ask the patient:

Has your asthma awakened you at night or early morning?

Have you needed more quick-relief medication (SABA) than usual?

Have you needed any urgent medical care for your asthma, such as unscheduled visits to your provider, an UC clinic, or the ER?

Are you participating in your usual and desired activities?

If you are measuring your peak flow, has it been below

your personal best? Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.” 1995

5252

Actions to consider: Assess whether the medications are being taken as

prescribed. Assess whether the medications are being inhaled

with correct technique. Assess lung function with spirometry and compare to

previous measurement. Adjust medications, as needed; either step up if

control is inadequate or step down if control is maximized, to achieve the best control with the lowest dose of medication.

Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.” 1995

Responsiveness - Actions

Figure 3–5a. Assessing Asthma Control In Figure 3–5a. Assessing Asthma Control In Children 0 - 4 Years of AgeChildren 0 - 4 Years of Age

>3/year2 3/year0 1/yearExacerbations

requiring oral systemic corticosteroids

Risk

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


for symptom control (not prevention

of EIB)

Extremely limitedSome limitationNoneInterference with normal activity

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

Classification of Asthma Control(Children 0 4 years of age)

Impairment

Components of Control

Treatment-related adverse effects

>1x/week>1x/month1x/monthNighttime awakenings

Throughout the day>2 days/week2 days/weekSymptoms

Very Poorly Controlled

Not Well Controlled

Well Controlled

Figure 3–5b. Assessing Asthma Control In Figure 3–5b. Assessing Asthma Control In Children 5 - 11 Years of AgeChildren 5 - 11 Years of Age

Impairment

2/year (see note)0 1/yearExacerbations requiring oral systemic corticosteroids

Lung function

<60% predicted/personal best

60 80% predicted/personal best

>80% predicted/personal best

FEV1 or peak flow

Evaluation requires long-term followup.

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


Consider severity and interval since last exacerbation

Risk



for symptom control(not prevention of EIB)

Extremely limitedSome limitationNoneInterference withnormal activity

Classification of Asthma Control(Children 5 11 years of age)Components of Control

Reduction in lung growth

<75%75 80%>80% FEV1/FVC

2x/week2x/month1x/monthNighttimeawakenings

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

2 days/week

2 days/week but not more than

once on each daySymptoms

Very Poorly Controlled

Not Well Controlled

Well Controlled


Evaluation requires long-term followup care



Progressive loss of lung functionRisk

Validated Questionnaires

2/year (see note)


Impairment

3–4N/A15

1–21.516 19

00.75*20

ATAQACQACT




FEV1 or peak flow

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

0 1/yearExacerbations

Classification of Asthma Control(Youths 12 years of age and adults)



4x/week1 3x/week2x/monthNighttime awakening

Very PoorlyControlled

NotWell-ControlledWell-Controlled

Figure 3–5c. Assessing Asthma Control In Figure 3–5c. Assessing Asthma Control In Youths Youths 12 Years of Age & Adults12 Years of Age & Adults

5656


Education For A Education For A Partnership In Asthma Partnership In Asthma

CareCare

5757

Key Points - EducationKey Points - Education

Self management education is essential and should be Self management education is essential and should be integrated into all aspects of care & requires repetition integrated into all aspects of care & requires repetition and reinforcement.and reinforcement.

Provide Provide allall patients with a patients with a writtenwritten asthma action plan asthma action plan that includes 2 aspects:that includes 2 aspects:– Daily managementDaily management– How to recognize & handle worsening asthma How to recognize & handle worsening asthma

symptomssymptoms Regular review of the status of patients asthma control. Regular review of the status of patients asthma control.

– Teach & reinforce at every opportunityTeach & reinforce at every opportunity Develop an active partnership with the patient and Develop an active partnership with the patient and

family. family.

EPR – 3, Section 3, Pg. 93EPR – 3, Section 3, Pg. 93

5858

Key Points – Education Cont.Key Points – Education Cont.

Encourage adherence by:Encourage adherence by:– Choosing a tx regimen that achieves outcomes Choosing a tx regimen that achieves outcomes

and addresses preferences important to the and addresses preferences important to the patient.patient.

– Review the success of tx plan and make changes Review the success of tx plan and make changes as needed.as needed.

Tailor the plan to needs of each patient.Tailor the plan to needs of each patient. Encourage community based interventions.Encourage community based interventions. Asthma education provided by trained health Asthma education provided by trained health

professionals should be reimbursed and professionals should be reimbursed and considered an integral part of effective asthma considered an integral part of effective asthma care ! care ! (AE-C)(AE-C)

5959

Key Key DifferencesDifferences –- Patient –- Patient EducationEducation

Emphasis on the many points of care & sites Emphasis on the many points of care & sites available to provide education including efficacy available to provide education including efficacy of self management education outside the office of self management education outside the office setting.setting.

Greater emphasis on the 2 aspects of written Greater emphasis on the 2 aspects of written AAP: AAP: 1) daily management 1) daily management

2) how to recognize & handle worsening 2) how to recognize & handle worsening symptoms including adjustment of medication symptoms including adjustment of medication dose.dose.

New sections on impact of cultural and ethnic New sections on impact of cultural and ethnic factors & health literacy that affect education.factors & health literacy that affect education.

6060

Educational Interventions In Educational Interventions In The School SettingThe School Setting

Implementation of comprehensive, Implementation of comprehensive, proven school-based asthma education proven school-based asthma education programs should be provided to programs should be provided to children who have asthma to learn children who have asthma to learn asthma self-management skills and asthma self-management skills and help provide an “asthma-friendly” help provide an “asthma-friendly” learning environment.learning environment.

EPR -3, Sec. 3, Pg. 107EPR -3, Sec. 3, Pg. 107

6161

Key Educational MessagesKey Educational Messages

Significance of diagnosisSignificance of diagnosis Inflammation as the underlying cause Inflammation as the underlying cause Controllers vs. quick-relieversControllers vs. quick-relievers How to use medication delivery devicesHow to use medication delivery devices Triggers, including 2Triggers, including 2ndnd hand smoke hand smoke Home monitoring/ self-managementHome monitoring/ self-management How/when to contact the providerHow/when to contact the provider Need for continuous, on-going interaction Need for continuous, on-going interaction

w/the clinician to step up/down therapyw/the clinician to step up/down therapy Annual influenza vaccine Annual influenza vaccine

6262

Other Educational Points of Other Educational Points of CareCare

ER Department & hospital based ER Department & hospital based Pharmacist Pharmacist Community basedCommunity based Home based for caregivers including Home based for caregivers including

home based allergen/ environmental home based allergen/ environmental assessmentassessment

Computer based technology Computer based technology Case management for high-risk patientsCase management for high-risk patients

6363

Maintaining The PartnershipMaintaining The Partnership

Promote open communication w/patient & Promote open communication w/patient & family by addressing at each visit:family by addressing at each visit:

Ask early in each visit what concerns they have and Ask early in each visit what concerns they have and what they especially want addressed during the visit.what they especially want addressed during the visit.

Review short – term goals agreed at initial visit.Review short – term goals agreed at initial visit. Review written AAP & steps to take – adjust as Review written AAP & steps to take – adjust as

needed.needed. Encourage parents to take a copy of the AAP to the Encourage parents to take a copy of the AAP to the

school or childcare setting or school or childcare setting or sendsend a copy to the a copy to the school nurse!!school nurse!!

Teach & reinforce key educational messages.Teach & reinforce key educational messages. Provide simple, brief, written materials that reinforce Provide simple, brief, written materials that reinforce

the actions and skills taught.the actions and skills taught.

6464


Control Of Environmental Control Of Environmental Factors & Comorbid Factors & Comorbid

Conditions That Affect Conditions That Affect AsthmaAsthma

6666

Key Points – Environmental Key Points – Environmental FactorsFactors

For patients w/persistent asthma, evaluate the For patients w/persistent asthma, evaluate the role of allergens.role of allergens.

All patients w/ asthma should:All patients w/ asthma should:– Reduce, if possible, exposure to allergens they are Reduce, if possible, exposure to allergens they are

sensitized and exposed to.sensitized and exposed to.– Understand effective allergen avoidance is Understand effective allergen avoidance is

multifaceted and individual steps alone are multifaceted and individual steps alone are ineffective.ineffective.

– Avoid exertion outdoors when levels of air pollution Avoid exertion outdoors when levels of air pollution are high.are high.

– Avoid use of nonselective beta-blockers.Avoid use of nonselective beta-blockers.– Avoid sulfite-containing and other foods they are Avoid sulfite-containing and other foods they are

sensitive to.sensitive to.– Consider allergen immunotherapyConsider allergen immunotherapy..

6767

Key Points – Environmental Key Points – Environmental Cont.Cont.

Evaluate a patient for other chronic comorbid Evaluate a patient for other chronic comorbid conditions when asthma cannot be well controlled.conditions when asthma cannot be well controlled.

Consider inactivated influenza vaccination for Consider inactivated influenza vaccination for patients w/ asthma.patients w/ asthma.

Use of humidifiers are not generally recommended.Use of humidifiers are not generally recommended. Employed asthmatics should be asked about Employed asthmatics should be asked about

possible occupational exposures, particularly those possible occupational exposures, particularly those who have new-onset disease. who have new-onset disease. (work related asthma)(work related asthma)

There is insufficient evidence to recommend any There is insufficient evidence to recommend any specific environmental strategies to specific environmental strategies to preventprevent the the development of asthma.development of asthma.

6868

Key Key DifferencesDifferences – –EnvironmentalEnvironmental

Reducing exposure to inhalant indoor allergens can Reducing exposure to inhalant indoor allergens can improve asthma control, a multifaceted approach is improve asthma control, a multifaceted approach is required; single steps to reduce exposure are required; single steps to reduce exposure are generally ineffective. generally ineffective.

Formaldehyde and volatile organic compounds (VOCs) Formaldehyde and volatile organic compounds (VOCs) are potential risk factors for asthma. are potential risk factors for asthma.

Influenza vaccine does not appear to reduce the Influenza vaccine does not appear to reduce the frequency or severity of asthma exacerbations during frequency or severity of asthma exacerbations during the influenza season.the influenza season.

Discussion is included on ABPA, obesity, OSA, and Discussion is included on ABPA, obesity, OSA, and stress as chronic comorbid conditions, in addition to stress as chronic comorbid conditions, in addition to rhinitis, sinusitis, and gastroesophageal reflux, that rhinitis, sinusitis, and gastroesophageal reflux, that may interfere with asthma management. may interfere with asthma management.

6969


MedicationsMedications

7070

Key Points - MedicationsKey Points - Medications

2 general classes:2 general classes:– Long-term control medicationsLong-term control medications– Quick-Relief medicationsQuick-Relief medications

Controller medicationsController medications::– Corticosteroids Corticosteroids – Long Acting Beta Agonists (LABA’s)Long Acting Beta Agonists (LABA’s)– Leukotriene modifiers (LTRA)Leukotriene modifiers (LTRA)– Cromolyn & NedocromilCromolyn & Nedocromil– Methylxanthines:Methylxanthines: ( (Sustained-release theophylline) Sustained-release theophylline)

7171

Key Points – Medications Key Points – Medications Cont.Cont.

Quick- relief medicationsQuick- relief medications– Short acting bronchodilators (SABA’s)Short acting bronchodilators (SABA’s)– Systemic corticosteroidsSystemic corticosteroids– AnticholinergicsAnticholinergics

7272

Key Key DifferencesDifferences - Medications - Medications

The most effective medications for long-term The most effective medications for long-term therapy are those shown to have anti-inflammatory therapy are those shown to have anti-inflammatory effects.effects.

New medications—immunomodulators—are New medications—immunomodulators—are available for long-term control of asthma. available for long-term control of asthma.

New data on the safety of LABAs are discussed, and New data on the safety of LABAs are discussed, and the position of LABA in therapy has been revised.the position of LABA in therapy has been revised.

The estimated clinical comparability of different ICS The estimated clinical comparability of different ICS preparations is updated. preparations is updated.

The significant role of ICSs in asthma therapy The significant role of ICSs in asthma therapy continues to be supported. continues to be supported.

EPR-3, pg. EPR-3, pg. 215215

7373

Key Points: Safety of ICS’sKey Points: Safety of ICS’s

ICS’s are the most effective long-term therapy ICS’s are the most effective long-term therapy available, are well tolerated & safe at available, are well tolerated & safe at recommended doses.recommended doses.

The potential but small risk of adverse events The potential but small risk of adverse events from the use of ICS treatment is well balanced from the use of ICS treatment is well balanced by their efficacy.by their efficacy.

The dose-response curve for ICS treatment The dose-response curve for ICS treatment begins to flatten at low to medium doses.begins to flatten at low to medium doses.

Most benefit is achieved with relatively low Most benefit is achieved with relatively low doses, whereas the risk of adverse effects doses, whereas the risk of adverse effects increases with dose.increases with dose.

7474

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

Spacers or valved holding chambers (VHCs) used with Spacers or valved holding chambers (VHCs) used with non-breath-activated MDIs reduce local side effects.non-breath-activated MDIs reduce local side effects.– But there is no data on use of spacers with ultra fine But there is no data on use of spacers with ultra fine

particle hydrofluoroalkane (HFA) MDIsparticle hydrofluoroalkane (HFA) MDIs. . Advise patients to rinse their mouths (rinse and spit) Advise patients to rinse their mouths (rinse and spit)

after (ICS) inhalation.after (ICS) inhalation. Use the lowest dose of ICS that maintains asthma Use the lowest dose of ICS that maintains asthma

control: control: – Evaluate patient adherence and inhaler technique as well Evaluate patient adherence and inhaler technique as well

as environmental factors that may contribute to asthma as environmental factors that may contribute to asthma severity before increasing the dose of ICS. severity before increasing the dose of ICS.

To achieve or maintain control of asthma, add a LABA to To achieve or maintain control of asthma, add a LABA to a low or medium dose of ICS rather than using a higher a low or medium dose of ICS rather than using a higher dose of ICS. dose of ICS.

Monitor linear growth in children.Monitor linear growth in children.

7575

Key Points:Key Points:Safety of Long-Acting BetaSafety of Long-Acting Beta22--Agonists Agonists (LABA’s)(LABA’s)

Adding a LABA to the tx of patients whose asthma is Adding a LABA to the tx of patients whose asthma is not well controlled on low- or medium-dose ICS not well controlled on low- or medium-dose ICS improves lung function, decreases symptoms, and improves lung function, decreases symptoms, and reduces exacerbations and use of SABA for quick relief reduces exacerbations and use of SABA for quick relief in most patients.in most patients.

The FDA determined that a Black Box warning was The FDA determined that a Black Box warning was warranted on all preparations containing a LABA.warranted on all preparations containing a LABA.

For patients who have asthma not sufficiently For patients who have asthma not sufficiently controlled with ICS alone, the option to increase the controlled with ICS alone, the option to increase the ICS dose should be given ICS dose should be given equal weightequal weight to the option of to the option of the addition of a LABA to ICS.the addition of a LABA to ICS.

It is not currently recommended that LABA be used for It is not currently recommended that LABA be used for treatment of acute symptoms or exacerbations.treatment of acute symptoms or exacerbations.

LABAs are not to be used as monotherapy for long-LABAs are not to be used as monotherapy for long-term control.term control.

7676

Key Points: Safety of SABA’sKey Points: Safety of SABA’s

SABAs are the most effective medication for SABAs are the most effective medication for relieving acute bronchospasm relieving acute bronchospasm

Increasing use of SABA treatment or using Increasing use of SABA treatment or using SABA >2 days a week for symptom relief SABA >2 days a week for symptom relief (not prevention of EIB)(not prevention of EIB) indicates inadequate indicates inadequate control of asthma.control of asthma.

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

7777

Section 4 Section 4

Managing Asthma Managing Asthma Long Term Long Term

““The Stepwise Approach”The Stepwise Approach”

2007 NAEPP Guidelines, EPR-3, pg. 2772007 NAEPP Guidelines, EPR-3, pg. 277

7878

Key Key DifferencesDifferences - -Managing Asthma Long TermManaging Asthma Long Term

1.1. Recommendations for managing asthma in children Recommendations for managing asthma in children 0–40–4 and and 5–115–11 years of age are presented separately years of age are presented separately from youths from youths ≥12≥12 years of age and adults. years of age and adults.

2.2. Treatment decisions for Treatment decisions for initiatinginitiating long-term control long-term control therapy are based on classifying severity therapy are based on classifying severity (considering (considering both impairment and risk domains)both impairment and risk domains) and selecting a and selecting a corresponding step for treatment. corresponding step for treatment.

– Recommendations on when to initiate therapy in Recommendations on when to initiate therapy in children 0–4 years of age have been revisedchildren 0–4 years of age have been revised..

3.3. Treatment decisions for Treatment decisions for adjustingadjusting therapy and therapy and maintaining control are based on assessing the level maintaining control are based on assessing the level of asthma control. of asthma control.

EPR -3, Pg. 279EPR -3, Pg. 279

7979

Key Key DifferencesDifferences – Cont. – Cont.

4.4. Stepwise approach to managing asthma is expanded Stepwise approach to managing asthma is expanded to include to include sixsix steps of care. Previous guidelines had steps of care. Previous guidelines had several progressive actions within step 3 - updated several progressive actions within step 3 - updated guidelines separate the actions into different steps.guidelines separate the actions into different steps.

5.5. Treatment options within the steps have been Treatment options within the steps have been revised: revised:

– For patients not well controlled on low-dose ICS’s, For patients not well controlled on low-dose ICS’s, increasing the dose of ICSs to medium dose is increasing the dose of ICSs to medium dose is recommended before adding adjunctive therapy in recommended before adding adjunctive therapy in the 0–4 years age group.the 0–4 years age group.

– For children 5–11 years and youths For children 5–11 years and youths 12 years and 12 years and adults, increasing the dose of ICS to medium dose adults, increasing the dose of ICS to medium dose or adding adjunctive therapy to a low dose of ICS or adding adjunctive therapy to a low dose of ICS are considered as equal options.are considered as equal options.

8080

Key Key DifferencesDifferences – – Cont. Cont.

– Evidence for the selection of adjunctive Evidence for the selection of adjunctive therapy is limited in children under 12 years.therapy is limited in children under 12 years.

– Recommendations vary according to the Recommendations vary according to the assessment of impairment or risk.assessment of impairment or risk.

– Steps 5–6 for youths Steps 5–6 for youths 12 years of age and 12 years of age and adults include consideration of omalizumabadults include consideration of omalizumab..

6.6. Managing special situations expanded to Managing special situations expanded to

include racial and ethnic disparitiesinclude racial and ethnic disparities..

8181

Treatment: Treatment: Principles of “Stepwise” Principles of “Stepwise” Therapy Therapy

The goal of asthma therapy is to maintain The goal of asthma therapy is to maintain long-term control of asthma with the long-term control of asthma with the least amount of medication and hence least amount of medication and hence

minimal risk for adverse effects.minimal risk for adverse effects.

EPR -3, Section 4, Managing Asthma Long Term in Children 0–4 Years of Age and 5–11 Years of Age, P. 284EPR -3, Section 4, Managing Asthma Long Term in Children 0–4 Years of Age and 5–11 Years of Age, P. 284

8282

Principles Of Step Therapy To Principles Of Step Therapy To Maintain ControlMaintain Control

Step upStep up if not controlled. if not controlled. If very poorly controlled, consider If very poorly controlled, consider

increase by 2 steps, oral corticosteroids, increase by 2 steps, oral corticosteroids, or both.or both.

Before increasing pharmacologic Before increasing pharmacologic therapy, consider as targets for therapy.therapy, consider as targets for therapy.– Adverse environmental exposuresAdverse environmental exposures– Poor adherencePoor adherence– Co-morbiditiesCo-morbidities

8383

Follow-UpFollow-Up

Visits every 2-6 weeks until control Visits every 2-6 weeks until control achieved.achieved.

When control achieved, contact every 3-6 When control achieved, contact every 3-6 months.months.

Step-down in therapyStep-down in therapy::– With well-controlled asthma for at least 3 With well-controlled asthma for at least 3

months.months.– Patients may relapse with total Patients may relapse with total

discontinuation or reduction of inhaled discontinuation or reduction of inhaled corticosteroids.corticosteroids.

• Consider short course of oral systemic corticosteroids,

• Step up (1 2 steps), and

• Reevaluate in 2 weeks.

• If no clear benefit in 4 6 weeks, consider alternative diagnoses or adjusting therapy.

• For side effects, consider alternative treatment options.

• Step up (1 step) and

• Reevaluate in2 6 weeks.

• If no clear benefit in 4 6 weeks, consider alternative diagnoses or adjusting therapy.

• For side effects, consider alternative treatment options.

• Maintain current treatment.

• Regular followupevery 1 6 months.

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

Recommended Actionfor Treatment

(See figure 4 1a fortreatment steps.)

>3/year2 3/year0 1/yearExacerbations requiring

oral systemic corticosteroids

Risk



for symptom control (not prevention of EIB)



Classification of Asthma Control (0 4 years of age)

Impairment



>1x/week>1x/month1x/monthNighttime awakenings


Very Poorly ControlledNot Well

ControlledWell

Controlled

Assessing Control & Adjusting Therapy Assessing Control & Adjusting Therapy Children 0-4 Years of AgeChildren 0-4 Years of Age

IntermittentAsthma

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

Consider consultation at step 2

Step 1

PreferredSABA PRN

Step 2

PreferredLow dose ICSAlternative Montelukast or Cromolyn

Step 3

PreferredMedium Dose ICS

Step 4

PreferredMedium Dose ICS

AND

Either:Montelukast or LABA

Step 5

PreferredHigh Dose ICS

AND


Step 6

PreferredHighDose ICS

AND


ANDOral corticosteroid

Patient Education and Environmental Control at Each Step

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

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

Step down if

possible

(and asthma is well

controlled at least 3

months)

Assess control

Step up if needed

(first check adherence, environmental control)

Assessing Control & Adjusting Therapy Assessing Control & Adjusting Therapy Children 5-11 Years of AgeChildren 5-11 Years of Age



• Step up 1 2 steps, and• Reevaluate in 2 weeks.• For side effects, consider

alternative treatment options.

• Step up at least 1 step and

• Reevaluate in 2 6 weeks.

• For side effects: consider alternative treatment options.

• Maintain current step.• Regular followup

every 1 6 months.• Consider step down if

well controlled for at least 3 months.


(See figure 4 1b fortreatment steps.)

Lung function




• FEV1 or peak flow

Evaluation requires long-term followup.



2/year (see note)0 1/yearExacerbations requiring oral systemic

corticosteroids

Risk



for symptom control(not prevention of EIB)


Classification of Asthma Control (5 11 years of age)

Impairment


Reduction inlung growth

<75% 75 80% >80% • FEV1/FVC

2x/week2x/month1x/monthNighttimeawakenings

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

2 days/week

2 days/week but not more than once on each

daySymptoms

Very Poorly ControlledNot Well

ControlledWell

Controlled

IntermittentAsthma



Patient Education and Environmental Control at Each Step

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

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

Step down if possible

(and asthma is well


months)

Assess control

Step up if needed

(first check adherence, environmental control,

and comorbid

conditions)

Preferred

SABA PRN

Step 1

Preferred

Low dose ICS

AlternativeLTRA, CromolynNedocromil orTheophylline

Step 2Preferred

EitherLow Dose ICS + LABA, LTRA, or Theophylline

OR

Medium Dose ICS

Step 3 Preferred

Medium Dose ICS + LABA

AlternativeMedium dose ICS + either LTRA, or Theophylline

Step 4 Preferred

High Dose ICS + LABA

AlternativeHigh dose ICS + either LTRA, or Theophylline

Step 5Preferred

High Dose ICS + LABA + oral corticosteroid

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

Step 6

Assessing Control & Adjusting Therapy Assessing Control & Adjusting Therapy In Youths > In Youths > 1212 Years of Age & Adults Years of Age & Adults

2/year (see note)0 1/year


• Step up 1 2 steps, and• Reevaluate in 2 weeks.• For side effects,

consider alternative treatment options.

• Step up 1 step and• Reevaluate in

2 6 weeks.• For side effects,

consider alternative treatment options.

• Maintain current step.• Regular followups

every 1 6 months to maintain control.

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


(see figure 4 5 for treatment steps)

Evaluation requires long-term followup care



Progressive loss of lung functionRisk

Validated questionnaires


Impairment

3–4N/A15

1–21.516 19

00.75*20

ATAQACQACT




FEV1 or peak flow

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


Exacerbations requiring oral systemic corticosteroids

Classification of Asthma Control(12 years of age)



4x/week1 3x/week2x/monthNighttime awakenings

Very PoorlyControlled

NotWell ControlledWell Controlled

IntermittentAsthma



Step 1

Preferred:SABA PRN

Step 2

Preferred:Low dose ICS

Alternative: Cromolyn, LTRA, Nedocromil or Theophylline

Step 3Preferred:

Low-dose ICS + LABA OR – Medium dose ICS

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

Step 4

Preferred:Medium Dose ICS + LABA

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

Step 5

PreferredHigh Dose ICS + LABA

AND

Consider Omalizumab for patients who have allergies

Step 6

PreferredHigh dose ICS + LABA + oral corticosteroid

AND

Consider Omalizumab for patients who have allergies

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

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

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

Step down if

possible

(and asthma is well


months)

Assess control

Step up if needed

(first check adherence, environmental control & comorbid conditions)

9090

Section 5Section 5

Managing Exacerbations of Managing Exacerbations of AsthmaAsthma

2007 Asthma Guidelines, EPR – 3, Pg. 3732007 Asthma Guidelines, EPR – 3, Pg. 373

9191

Key Points –Key Points –Managing Exacerbations Managing Exacerbations

Early treatment of asthma exacerbations Early treatment of asthma exacerbations is the best strategy for management.is the best strategy for management.

Patient education includes a written asthma Patient education includes a written asthma action plan to guide patient self‑management of action plan to guide patient self‑management of exacerbations.exacerbations.– especially for patients who have moderate or especially for patients who have moderate or

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

A peak‑flow‑based plan for patients who have A peak‑flow‑based plan for patients who have difficulty perceiving airflow obstruction and difficulty perceiving airflow obstruction and worsening asthma.worsening asthma.

EPR -3 Pg. 373EPR -3 Pg. 373

9292

Key Points – Cont.Key Points – Cont.

Recognition of early signs of worsening asthma Recognition of early signs of worsening asthma & taking prompt action.& taking prompt action.

Appropriate intensification of therapy, often Appropriate intensification of therapy, often including a short course of oral corticosteroids. including a short course of oral corticosteroids.

Removal of the environmental factors Removal of the environmental factors contributing to the exacerbation. contributing to the exacerbation.

Prompt communication between patient and Prompt communication between patient and clinician about any serious deterioration in clinician about any serious deterioration in symptoms or peak flow, decreased symptoms or peak flow, decreased responsiveness to SABAs, or decreased duration responsiveness to SABAs, or decreased duration of effect.of effect.

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Key Differences From 1997 & Key Differences From 1997 & 2002 Expert Panel Reports2002 Expert Panel Reports

For the treatment of exacerbations, the current For the treatment of exacerbations, the current update:update:

Simplifies classification of severity of asthma Simplifies classification of severity of asthma exacerbations.exacerbations.

Adds levalbuterol as a SABA treatment for asthma Adds levalbuterol as a SABA treatment for asthma exacerbations.exacerbations.

For home management of exacerbations, For home management of exacerbations, no longer no longer recommendsrecommends doublingdoubling the dose of ICSs. the dose of ICSs.

For prehospital management (e.g., emergency transport), For prehospital management (e.g., emergency transport), encourages standing orders for albuterol and—for encourages standing orders for albuterol and—for prolonged transport—repeated treatments and protocols to prolonged transport—repeated treatments and protocols to allow consideration of ipratropium and oral corticosteroids.allow consideration of ipratropium and oral corticosteroids.

For ED management, reduces dose and frequency of oral For ED management, reduces dose and frequency of oral corticosteroids in severe exacerbations, adds consideration corticosteroids in severe exacerbations, adds consideration of magnesium sulfate or heliox for severe exacerbations, of magnesium sulfate or heliox for severe exacerbations, and adds and adds consideration of initiating an ICS upon discharge.consideration of initiating an ICS upon discharge.

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Exacerbations DefinedExacerbations Defined (Risk)(Risk)

Are acute or subacute episodes of progressively Are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, worsening shortness of breath, cough, wheezing, and chest tightness — or some combination of and chest tightness — or some combination of these symptoms. these symptoms.

Are characterized by decreases in expiratory Are characterized by decreases in expiratory airflow that can be documented and quantified airflow that can be documented and quantified

by spirometry or Peak expiratory flow.by spirometry or Peak expiratory flow. – These objective measures more reliably indicate These objective measures more reliably indicate

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

severity of symptomsseverity of symptoms..

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

SettingSetting

SeveritySeverity Symptoms & Signs

Initial PEF (or FEV1)

Clinical Course

Mild

Dyspnea only with activity (assess tachypnea in young children)

PEF 70 percent predicted or personal best

Usually cared for at home Prompt relief with inhaled SABA Possible short course of oral


Moderate Dyspnea interferes with or limits usual activity

PEF 4069 percent predicted or personal best

Usually requires office or ED visit Relief from freq. inhaled SABA Oral systemic corticosteroids;

some symptoms last 1–2 days after treatment is begun

Severe

Dyspnea at rest; interferes with conversation

PEF <40 percent predicted or personal best

Usually requires ED visit and likely hospitalization

Partial relief from frequent inhaled SABA

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

Adjunctive therapies are helpful

Subset: Life threatening

Too dyspneic to speak; perspiring

PEF <25 percent predicted or personal best

Requires ED/hospitalization; possible ICU

Minimal or no relief w/ frequent inhaled SABA

Intravenous corticosteroids Adjunctive therapies are helpful

Assess Severity

Patients at high risk for a fatal attack (see figure 5–2a) require immediate medical attention after initial treatment.

Symptoms and signs suggestive of a more serious exacerbation such as marked breathlessness, inability to speak more than short phrases, use of accessory muscles, or drowsiness (see figure 5–3) should result in initial treatment while immediately consulting with a clinician.

Less severe signs and symptoms can be treated initially with assessment of response to therapy and further steps as listed below.

If available, measure PEF—values of 50–79% predicted or personal best indicate the need for quick-relief mediation. Depending on the response to treatment, contact with a clinician may also be indicated. Values below 50% indicate the need for immediate medical care.

Initial Treatment

Inhaled SABA: up to two treatments 20 minutes apart of 2–6 puffs by metered-dose inhaler (MDI) or nebulizer treatments.

Note: Medication delivery is highly variable. Children and individuals who have exacerbations of lesser severity may need fewer puffs than suggested above.

Good Response

No wheezing or dyspnea(assess tachypnea in young children).

PEF 80% predicted or personal best.

Contact clinician for followup instructions and further management.

May continue inhaled SABA every 3–4 hours for 24–48 hours.

Consider short course of oral systemic corticosteroids.

Incomplete Response

Persistent wheezing and dyspnea (tachypnea).

PEF 50–79% predicted or personal best.

Add oral systemic corticosteroid.

Continue inhaled SABA.

Contact clinician urgently (this day) for further instruction.

Poor Response

Marked wheezing and dyspnea.

PEF <50% predicted or personal best.

Add oral systemic corticosteroid.

Repeat inhaled SABA immediately.

If distress is severe and nonresponsive to initial treatment:

—Call your doctor AND—PROCEED TO ED;—Consider calling 9–1–1

(ambulance transport).

To ED.

Managing Asthma Exacerbations At Home

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What The EPR -3 What The EPR -3 Does Does NOT NOT RecommendRecommend

Drinking large volumes of liquids or breathing Drinking large volumes of liquids or breathing warm, moist air warm, moist air (e.g., the mist from a hot (e.g., the mist from a hot shower).shower).

Using over-the-counter products such as Using over-the-counter products such as antihistamines or cold remedies. antihistamines or cold remedies.

Although pursed-lip and other forms of controlled Although pursed-lip and other forms of controlled breathing may help to maintain calm during breathing may help to maintain calm during respiratory distress, these methods do respiratory distress, these methods do not not bring bring about improvement in lung function.about improvement in lung function.

EPR -3 , P.384EPR -3 , P.384

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Many Thanks To -Many Thanks To -

Colleagues who shared their power point presentations and/or provided feedback on this presentation:

Dr. Gail M Brottman MD, Director, Dr. Gail M Brottman MD, Director, Pediatric Pulmonary Pediatric Pulmonary Medicine, HCMCMedicine, HCMC

Dr. Don Uden, Pharm. D., Professor, Dr. Don Uden, Pharm. D., Professor, University of University of Minnesota, College of Pharmacy Minnesota, College of Pharmacy

Dr. Barbara P. Yawn, MD, MSc, Dr. Barbara P. Yawn, MD, MSc, Director of Research, Director of Research, Olmsted Medical ClinicOlmsted Medical Clinic

Dr. Mamta Reddy, MD, ChiefDr. Mamta Reddy, MD, Chief Allergy/ Immunology, Bronx Lebanon Hospital Center, NYAllergy/ Immunology, Bronx Lebanon Hospital Center, NY Mary Bielski, RN, LSN, CNS, Mary Bielski, RN, LSN, CNS,

Nursing Service Manager, Nursing Service Manager, Minneapolis Public SchoolsMinneapolis Public Schools

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Minnesota Department of HealthMinnesota Department of HealthAsthma ProgramAsthma Program

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

1 National Institutes of Health (NIH) NAEPP 2007 Asthma Guideline UPDATE Susan K. Ross RN, AE-C MDH...

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