Asthma Guidelines: Stepwise Approach to Managing Asthma Karen Meyerson, MSN, RN, FNP-C, AE-C Asthma...

Asthma Guidelines:Stepwise Approach to Managing Asthma

Karen Meyerson, MSN, RN, FNP-C, AE-CAsthma Network of West Michigan

April 21, 2009

Acknowledgements: LeRoy M. Graham, MD, Atlanta, GA

Allan T. Luskin, MD, Madison, WI

PREVIOUS NHLBI/GINA GUIDELINES

Severity Symptoms Nocturnal

Symptoms

FEV1 or

PEF

Mild Intermittent < 1 x/week , asymptomatic between attacks

< 2 x / month > 80% predicted variability < 20%

Mild Persistent > 1 x/week but not daily

> 2 x / month > 80% predicted variability 20-30%

Moderate Persistent

Daily, affecting activity > 1 time / week 60 -80% predicted variability > 30%

Severe Persistent Continuous, limiting activity

Frequent < 60% predicted variability > 30%

Asthma Severity

Asthma severity is the intrinsic intensity of disease.

Initial assessment of patients who have confirmed asthma begins with a severity classification because the therapy should then correspond to the level of asthma severity.

This initial assessment of asthma severity is made immediately after diagnosis, or when the patient is first encountered, generally before the patient is taking some form of long-term control medication.

Assessment is made on the basis of current spirometry and the patient’s recall of symptoms over the previous 2–4 weeks, because detailed recall of symptoms decreases over time.

Asthma Severity

Intermittent

Mild Persistent

Moderate Persistent

Severe Persistent

Classification of Asthma Severity

PersistentIntermittentMild Moderate Severe

Components of Severity

Impairment

Risk

Recommended Step for Initiating Treatment

Symptoms

Nighttime Awakenings

SABA use for sx control

Interference with normal activity

Exacerbations

(consider frequency and

severity)

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

Step 1 Step 2 Step 3

0-1/year

<2 days/week >2 days/week not daily Daily Continuous

0 1-2x/month 3-4x/month >1x/week

none Minor limitation Some limitation Extremely limited

<2 days/week >2 days/week not daily Daily Several times daily

Consider short course of oral steroids

CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN

CHILDREN 0-4 YEARS OF AGE

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

Frequency and severity of may fluctuate over time

Exacerbations of any severity may occur in patients in any category

EPR-3, p72, 307

Pulmonary Function Tests

FEV1 (Forced Expiratory Volume in 1 Second) – this is the volume of air expired in the first second during maximal expiratory effort. The FEV1 is reduced in both obstructive and restrictive lung disease.

FVC (Forced Vital Capacity) – this is the total volume of air expired after a full inspiration.

FEV1/FVC – this is the percentage of the vital capacity which is expired in the first second of maximal expiration.




Impairment

Risk


Symptoms




Lung Function

Exacerbations


severity)

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

Step 2

Relative annual risk of exacerbations may be related to FEV

0-2/year > 2 /yearFrequency and severity may vary over time for patients in any category


<2x/month 3-4x/month >1x/week

not nightlyOften nightly



•Normal FEV1 between exacerbations

• FEV1 > 80%

• FEV1/FVC> 85%

• FEV1 >80%

•FEV1/FVC> 80%

• FEV1=60% -80%

•FEV1/FVC=75%-80%

•FEV1 <60%

•FEV1/FVC < 75%


CHILDREN 5 - 11 YEARS OF AGE

Step 1 Step3 medium-dose ICS option

Step 3 or 4


EPR-3, p73, 308




Impairment

Normal FEV1/FVC

8-19 yr 85%

20-39 yr 80%

40-59 yr 75%

60-80 yr 70%

Risk


Symptoms




Lung Function

Exacerbations


severity)

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

Step 1 Step 2 Step 3 Step 4 or 5

Relative annual risk of exacerbations may be related to FEV

0-2/year > 2 /year

Frequency and severity may vary over time for patients in any category


<2x/month 3-4x/month >1x/week

not nightlyOften nightly




•Normal FEV1 between exacerbations

• FEV1 > 80%

• FEV1/FVC normal

• FEV1 >80%

•FEV1/FVC normal

• FEV1 >60% but< 80%

•FEV1/FVC reduced 5%

•FEV1 <60%

•FEV1/FVC reduced> 5%


YOUTHS > 12 YEARS AND ADULTS EPR-3, p74, 344

Asthma Control

The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma therapy are being achieved and asthma is controlled.

Well Controlled

Not Well Controlled

Very Poorly Controlled

Asthma Control

Reducing Current Impairment

Reducing Future Risk

Classification of Asthma ControlComponents of Control

ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN


IMPAIRMENT

RISK

Recommended Action

For Treatment

Well ControlledNot Well

ControlledVery Poorly Controlled

Symptoms

Nighttime awakenings


SABA use

Exacerbations

Progressive loss of lung function

Rx-related adverse effects Consider in overall assessment of risk

Evaluation requires long-term follow up care

0- 1 per year 2 - 3 per year > 3 per year

none Some limitation Extremely limited

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

< 1/month > 2 x/month >2x/week

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

•Maintain current step

•REGULAR FOLLOW UP EVERY 3 - 6

MONTHS

•Consider step down if well controlled at least

3 months

•Step up 1 step

•Reevaluate in 2 - 6 weeks

•If no clear benefit in 4-6 weeks ,

consider alternative dx or adjust therapy

•Consider oral steroids

•Step up (1-2 steps) and reevaluate in 2

weeks

•If no clear benefit in 4-6 weeks , consider

alternative dx or adjust therapy

EPR-3, p75, 309




IMPAIRMENT

RISK

Recommended Action

For Treatment



Symptoms



SABA use

FEV1or peak flow

ExacerbationsProgressive loss of lung

functionRx-related adverse effects Consider in overall assessment of risk







> 80% predicted/ personal best

60-80% predicted/ personal best

<60% predicted/ personal best



3 months

•Step up 1 step



•Step up 1-2 weeks and reevaluate in 2

weeks

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

EPR-3, p76, 310



YOUTHS > 12 YEARS OF AGE AND ADULTS

IMPAIRMENT

RISK

Recommended Action

For Treatment



Symptoms



SABA use

FEV1or peak flow

Validated questionnaires

ATAQ/ACTExacerbations

Progressive loss of lung function

Rx-related adverse effects Consider in overall assessment of risk





< 2/month 1-3/week > 4/week





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



3 months

•Step up 1 step



•Step up 1-2 weeks and reevaluate in 2

weeks

EPR-3, p77, 345

Asthma Control Test™ (ACT) for Patients 12 Years and Older

1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?

2. During the past 4 weeks, how often have you had shortness of breath?

3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning?

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?

5. How would you rate your asthma control during the past 4 weeks?

Score

Patient Total Score

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

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

3210

3. Do you cough because of your asthma?

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

3210

3210

1. How is your asthma today?

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

3210

It’s a big problem, I can’t do what I want to do. It’s a problem and I don’t like it. It’s a little problem but it’s okay. It’s not a problem

Very bad Bad Good Very Good

Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time

Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time

SCORE

Childhood Asthma Control Test™ (ACT): Questions Completed by Parent/Caregiver

5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms?

5

Not at all

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

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

4

1-3 days/mo

3

4-10 days/mo

1

19-24 days/mo

0

Everyday

2

11-18 days/mo

5

Not at all

4

1-3 days/mo

3

4-10 days/mo

1

19-24 days/mo

0

Everyday

2

11-18 days/mo

5

Not at all

4

1-3 days/mo

3

4-10 days/mo

1

19-24 days/mo

0

Everyday

2

11-18 days/mo

TOTAL

Monitoring Asthma Control

Ask the patient Has your asthma awakened you at night or early morning? Have you needed more rescue inhaler than usual? Have you needed urgent care for asthma? (office, ED, etc) Are you participating in your usual or desired activities? What are your triggers? (and how can we manage them?)

Actions to consider Assess whether medications are being taken as prescribed Assess whether inhalation technique is correct Assess spirometry and compare to previous measurements Adjust medications, as needed to achieve best control with

the lowest dose needed to maintain control Environmental mitigation strategy

NAEPP Draft Report, ERP 2007

EPR-3, Page 78

Intermittent Asthma

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

Consider consultation at step 2

Patient Education and Environmental Control at Each Step

Step 1Preferred:SABA prn

Step 2Preferred:

Low-dose ICS

Alternative:LTRA

Cromolyn

Step 3Preferred:

Medium-doseICS

Step 4

Preferred:Medium-dose

ICS

AND

either LTRAOr LABA

Step 5Preferred:

High dose ICS

AND

either LTRAOr LABA

Step 6

AND

either LTRAOr LABA

AND

Oral Corticosteroid

AssessControl

STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 0 - 4 YEARS OF AGE

Step up if needed (check adherence, environmental control )

Step down if possible

(asthma well controlled for 3 months)

EPR-3, p291-296

Intermittent Mild Persistent Moderate Persistent Severe Persistent

Intermittent Asthma





Step 2Preferred:

Low-dose ICSAlternative:

LTRACromolyn

Theophylline

Step 3Preferred:

Medium-doseICS

ORLow-dose ICS+

either LABA,LTRA, or

Theophylline

Step 4


ICS+LABA

Alternative:Medium-dose

ICS+eitherLTRA, or

Theophlline

Step 5Preferred:

High dose ICS+ LABA

Alternative:High-dose ICS+

either LTRAor Theophylline

AND

ConsiderOlamizumab for

patients withallergies

Step 6

Preferred:High-dose ICS+ LABA + oralCorticosteroid

Alternative:High-dose ICS

+either LTRA orTheophylline

+ oral corticosteroid

ANDConsider

Olamizumab for patients with

allergies

AssessControl

STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5-11 YEARS OF AGE

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



EPR-3, p296-304

Intermittent Asthma





Step 2Preferred:


LTRACromolyn

Theophylline

Step 3Preferred:

Medium-doseICSOR

Low-dose ICS+either LABA,

LTRA, Theophylline

Or Zileutin

Step 4


ICS+LABA


ICS+eitherLTRA,

TheophllineOr Zileutin

Step 5Preferred:

High dose ICS+ LABA

AND



Step 6


AND



AssessControl

STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS > 12 YEARS AND ADULTS




EPR-3, p333-343

Recommended Action for Treatment Based on Assessment of Control

WellWell

ControlledControlled

Not WellNot Well


Very Poorly Very Poorly ControlledControlled

Maintain current step Step up 1 step and reevaluate in 2-6 weeks

Consider short course of oral corticosteroids

Consider step down if well controlled for at least 3 months

For side effects, consider alternative treatment options

Step up 1-2 steps and reevaluate in 2 weeks


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

EPR-3, Page 330

Treatment Strategies

Gain Control!!!Aggressive, intensive initial therapy to

suppress airway inflammation and gain prompt control

Maintain ControlFrequent follow-up, clinically and

physiologically

Therapeutic modifications depending on severity and clinical course

“Step down” long-term control medications to maintain control with minimal side effects

Patients Are Candidates for Maintenance Therapy if

The “RULES OF TWO”™* Apply…

They are using a quick-relief inhaler more than 2 times per week

They awaken at night due to asthma more than 2 times per month

They refill a quick-relief inhaler Rx more than 2 times per year

*“RULES OF TWO”™ is a trademark of the Baylor Health Care System.

Out of Control!

Rules of Two TM

If your patient can answer “YES” to ANY of these questions, his/her asthma is probably not under good control.

These rules define persistent asthma.

Asthma Pharmacotherapy

Quick-relief

Short-acting beta-agonists

Inhaled anticholinergics

Systemic corticosteroids

Long-term control

Corticosteroids

Cromolyn sodium/nedocromil

Long-acting inhaled beta-agonists

Theophylline

Leukotriene modifiers

Quick-Relief Medications

Short-acting beta2-agonists (SABA): Albuterol, Ventolin®, Proventil®, Maxair®, Xopenex®, etc.

Relax bronchial smooth muscles

Short-acting Work within 10 - 15 minutes Last 4 - 6 hours

Side effects can include shakiness (tremors), tachycardia

Danger of over-use

Short-acting 2-agonists

Most effective medication for relief of acute symptoms RED FLAG

more than 1 canister per month

Regularly scheduled use not generally recommendedMay “lower” effectivenessMay increase airway hyperresponsiveness

Anticholinergics

Not specifically indicated for “usual” quick-relief medication in asthmacontrast with COPD

Now well-studied as adjunct to beta-agonists in emergency departments i.e., acute exacerbations

Long-term Control Medications

Inhaled corticosteroids (ICS): Advair®, Flovent®, Azmacort®, Q-Var®, Pulmicort®, Asmanex®, Aerobid®, Symbicort®

Non-steroidal anti-inflammatories: Intal®, Tilade®

Leukotriene modifiers (LTM): Singulair®, Accolate®

Theophylline: Theo-Dur®, Slo-bid

Long-acting beta2-agonists (LABA): Serevent®, Foradil®

Taken daily and chronically to maintain control of persistent asthma and to prevent exacerbations:

Soothes airway swelling Helps prevent asthma flares - very effective for long-

term control but must be taken daily Often under-used

Inhaled Corticosteroids

Actions:potentiate -receptor responsivenessreduce mucus production and hypersecretioninhibit inflammatory response at all levels

Best effects if started early after diagnosis

Symptomatic and spirometric improvement within 2 weeksmaximum effects within 4-8 weeks

Inhaled Corticosteroids (continued)

Most effective long term control medication for persistent asthma

Small risk for adverse events at usual doses

Risk can be reduced even further by:

Using spacer and rinsing mouth

Using lowest effective dose

Using with long-acting 2-agonist when appropriate

Monitoring growth in children

Low dose ICS and the Prevention of Asthma Deaths

•ICS protects patients from asthma-related deaths•Users of > 6 canisters/yr. had a death rate ~ 50% lower than non-users of ICS•Death rate decreased by 21% for each additional ICS canister used during the previous year.

Suissa et al. N Eng J Med 2000;343:332-336.

ICS May Help Prevent the Risk of Asthma Related Hospitalizations

Adapted from Donahue et. al. JAMA 1997;277(11):887-891.

Short-acting B2 prescriptions dispensed per person-year

8

7

6

5

4

3

2

1

0

Rel

ati

ve

Ris

ko

f H

osp

ital

iza

tio

n

None 1-2 2-3 3-5 5-8 8+0-1

Total

Inhaled Steroids

2-agonists

Total

Inhaled Corticosteroids (continued)

HPA Suppressionno need to test in children receiving < 400

mcg/day (BEC), or adults < 1500 mcg/day (BEC)

Cataracts

Long bone growthgrowing understanding of this risk

Osteoporosis/Bone Fracturessome attention at high doses, high risk

patients

Candidiasis

Dysphonia

Leukotriene Modifiers

Two mechanisms5-lipoxygenase inhibitors

zileution (Zyflo)Cysteinyl leukotriene receptor antagonists

zafirlukast (Accolate), montelukast (Singulair)

IndicationsGenerally, alternative therapy in mild persistent

asthma or as add-on in higher stagesImprove lung function

Decrease short-acting 2-agonist use

Prevent exacerbations

Methylxanthines (Theophylline) (continued)

Places in therapy:primary therapy when inhaled corticosteroids not possible

patient’s who can’t/won’t use inhalers

additive therapy at later Stages

ADR’s/Serum Levels/Drug InteractionsTherapeutic Range 5-15 mcg/mL, or 10-20 mcg/mL

levels > 20 mcg/mL: N/V/D, HA, irritability, insomnia, tachycardia

levels > 30 mcg/mL: seizures, toxic encephalopathy, hyperthermia, brain damage

ADR’s/Serum Levels/Drug Interactions Drug Interactions: PLENTY!!

Long-acting 2-agonists

Not a substitute for anti-inflammatory therapy

Not appropriate for monotherapy RED FLAG

Literature supporting role in addition to inhaled corticosteroids

Not for acute symptoms or exacerbations

Salmeterol (Serevent) first of class in US

Formoterol (Foradil) Newer long-acting beta-agonist Has rapid onset and long duration Available as dry powder inhaler and in combination with

inhaled steroid (Symbicort)


Salmeterol Multicenter Asthma Research Trial (SMART)

A comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol.

Nelson HS, Weiss ST, Bleecker ER, et al.

Chest 2006; 129:15-26.

Patients > 12 years old with asthma

Sought to evaluate the effects of salmeterol or placebo added to usual asthma care on respiratory and asthma related deathslife-threatening episodes

Initial aim to enroll 30,000 patients; later changed with aim to enroll 60,000


Two methods of recruitmentPhase 1 1996-1999

Recruited by advertising and assigned to study investigator by geography

Phase 2 2000-2003Recruitment by study investigators and

more investigators added


Increase in adverse events in salmeterol group during SMART trial:Particularly in those recruited in Phase 1Particularly among African-Americans who were noted to have

markers of more severe asthma and less likely to be using ICS

Increase in adverse events in salmeterol groupDue to adverse effect of salmeterol?Due to inappropriate bronchodilator use? (affected patients were

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


FDA Advisory Panel Recommends Ban of Long-acting 2-agonists in Asthma

A panel of outside advisers has told the FDA that two long-acting asthma drugs -- Serevent and Foradil -- should be banned for use in asthma treatment because they are alleged to be more dangerous than they are helpful, particularly in children and adolescents.

If the FDA takes this advice, it would remove the indication for asthma from the label for these drugs but they could still be prescribed for chronic obstructive pulmonary disease.

But the advisers unanimously supported the continued use of the far more popular drugs Advair and Symbicort. Advisers overwhelmingly agreed these drugs provided great benefits to patients, though they expressed some concern about lack of information about how safe they are for adolescents and children.

~December 2008

Conclusions:Black Box warning

Do not use long-acting bronchodilators alone

Always use with inhaled corticosteroids


Xolair® Indication

Xolair is indicated for adults and adolescents (12 years of age and above)

With moderate to severe, persistent asthma

Who have a positive skin test or in vitro reactivity to a perennial aeroallergen

Whose symptoms are inadequately controlled with inhaled corticosteroids

Elevated serum IgE level (≥30-700 IU/mL)

Xolair has been shown to decrease the incidence of asthma exacerbations in these patients

Safety and efficacy have not been established in other allergic conditions

Referral to an Asthma Specialist for Consultation and Co-Management

Patient has had a life-threatening asthma exacerbation (hospitalization is a risk factor for mortality)

Patient is not meeting the goals of therapy after 3-6 months

Signs and symptoms are atypical; differential diagnosis ?

Co-morbid conditions complicate asthma (GERD, VCD etc)

Additional diagnostic studies are indicated (allergy skin testing, pulmonary function studies, bronchoscopy)

Patient requires additional education/guidance

Patient has required more than two bursts of oral corticosteroids in 1 year

Patient requires “Step 4” care or higher (“Step 3” for children 0–4 years of age). Consider referral if patient requires step 3 care (“Step 2” for children 0–4 years of age)

Expert Panel Report-3, Page 68

The Outpatient Asthma Visit

Assess “severity” and “control” (NAEPP Classification Criteria) Reduce current impairment Reduce future risk

Address “Inflammation vs. bronchoconstriction”

Differentiate “controller vs. rescue medication”

Prescribe an inhaled steroid for all patients with persistent asthma

Teach spacer device technique

Write an Asthma Action Plan Daily management and recognizing early s/s of worsening Step-up “Yellow Zone” plan for home management

Follow-up in 4-6 weeks: step-up/step-down & modify Action Plan

Inhaler Law; Albuterol and spacer for school

Annual Influenza vaccine, regardless of severity

EPR-3, p121-139

What is Success: How do we measure it and how do we get there?

Begin therapy based on SeveritySeverity

Monitor and adjust therapy based on Control and Risk and Responsiveness to Therapy

Use routine standardized multifaceted measures

The goal of therapy is to achieve control

Individualize therapy based on likelihood of response and patient needs, desires, and goals

Inhaler Technique

Metered-dose inhalers:Proper MDI techniqueProper inhaler/spacer techniqueCare and cleaningMethods to determine amount of medication left in

inhaler

Dry-powder inhalers:Proper techniqueCare and cleaningMethods to determine amount of medication left in

inhaler

Nebulizers

Six Key Messages

Most Important:

1. Inhaled corticosteroids are the most effective anti-inflammatory medication for long term management of persistent asthma.

All patients should receive:

2. Written asthma action plan

3. Initial assessment of asthma severity

4. Review of the level of asthma control (impairment and risk) at all follow up visits

5. Periodic, follow-up visits (at least every 6 months)

6. Assessment of exposure and sensitivity to allergens and irritants and recommendation to reduce relevant exposures.

Guidelines for the Diagnosis and Management

of Asthma

NAEPP/NHLBI Expert Panel Report-3

Case Scenarios

A 3-year old male currently not on any asthma medications has visited your outpatient clinic 3 times in the past 6 months for acute wheezing, each episode lasting 2-3 days. In between episodes, his mother reports nighttime cough about 4 nights per month. This patient’s asthma severity can be BEST classified as:

A. Mild Persistent Asthma (Step 2)

B. Moderate Persistent Asthma (Step 3)

C. Severe Persistent Asthma (Step 4)

D. I would not diagnose this child with asthma

Case # 1

A 7-year old female with asthma reports nighttime awakenings about 2 times per week and requires albuterol about 3 times per week. She is currently taking fluticasone 44 mcg 2 puffs twice daily. The BEST next step in your step-up treatment plan would be to:

A. Increase the dose of the inhaled steroid

B. Add a leukotriene modifier

C. Add a long-acting B-agonist

D. Encourage albuterol more frequently, every 4 hours

Case # 2




IMPAIRMENT

RISK

Recommended Action

For Treatment



Symptoms



SABA use

FEV1or peak flow

ExacerbationsProgressive loss of lung

functionRx-related adverse effects Consider in overall assessment of risk












3 months

•Step up 1 step



•Step up 1-2 steps and reevaluate in 2

weeks

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

EPR-3, p76, 310

Recommended Action for Treatment Based on Assessment of Control

WellWell


Not WellNot Well


Very Poorly Very Poorly ControlledControlled

Maintain current step Step up 1 step and reevaluate in 2-6 weeks

Consider short course of oral corticosteroids

Consider step down if well controlled for at least 3 months


Step up 1-2 steps and reevaluate in 2 weeks


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

Intermittent Asthma





Step 2Preferred:


LTRACromolyn

Theophylline

Step 3Preferred:

Medium-doseICS

ORLow-dose ICS+

either LABA,LTRA, or

Theophylline

Step 4


ICS+LABA


ICS+eitherLTRA, or

Theophlline

Step 5Preferred:

High dose ICS+ LABA

Alternative:High-dose ICS+

either LTRAor Theophylline

AND



Step 6


Alternative:High-dose ICS

+either LTRA orTheophylline

+ oral corticosteroid

ANDConsider

Olamizumab for patients with

allergies

AssessControl

STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5-11 YEARS OF AGE




EPR-3, p296-304

A 7-year old female with asthma reports nighttime awakenings about 2 times per week and requires albuterol about 3 times per week. She is currently taking fluticasone 44 mcg 2 puffs twice daily. The BEST next step in your step-up treatment plan would be to:

A. Increase the dose of the inhaled steroid

B. Add a leukotriene modifier

C. Add a long-acting B-agonist

D. Encourage albuterol more frequently, every 4 hours

Case # 2

Referral to an asthma specialist for consultation and co-management should be sought when a patient:

A. Is hospitalized twice in the past year or once in

the past month

B. Requires more than two bursts of oral

corticosteroids in one year

C. Requires “Step 3” care or higher or is not

responding to a treatment plan that is appropriate for

patient with “Moderate Persistent Asthma”

D. Any of the above

Case # 3

Referral to an asthma specialist for consultation and co-management should be sought when a patient:

A. Is hospitalized twice in the past year or once in the past month

B. Requires more than two bursts of oral corticosteroids in one year

C. Requires “Step 3” care or higher or is not responding to a treatment plan that is appropriate for patient with “Moderate Persistent Asthma”

D. Any of the above

Case # 3

Questions?

Download the Guidelines at:

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

Download the Summary Report at:

http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf

http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf

http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf

Asthma Guidelines: Stepwise Approach to Managing Asthma Karen Meyerson, MSN, RN, FNP-C, AE-C Asthma...

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Transcript of Asthma Guidelines: Stepwise Approach to Managing Asthma Karen Meyerson, MSN, RN, FNP-C, AE-C Asthma...