Bronchial asthma - Primary Care Pages · PDF file• MANAGEMENT OF ACUTE ASTHMA...

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• PRESENTATIONANDDIAGNOSIS

• CLASSIFICATIONOFASTHMABYLEVELOFCONTROL

• ASSESSMENTOFASTHMACONTROLUSINGTHEASTHMACONTROLTEST

• ASTHMAMANAGEMENTBASEDONLEVELSOFCONTROL

• MANAGEMENTOFASTHMAEXACERBATIONS:-HOWSEVEREISTHEASTHMAATTACK?

• MANAGEMENTOFACUTEASTHMAEXACERBATIONSINCHILDREN

• MANAGEMENTOFACUTEASTHMAEXACERBATIONSINADULTS

• WHENTOREFER

Bronchial asthma

Contributors: DrChongPhuiNahDrTangWernEe

Advisors: ProfLimTowKeangA/ProfJohnAbisheganadenA/ProfDanielGohYamThiamA/ProfLynetteShek

nhg_guideline_14102010_1112.indd 56 23/11/2010 6:20 PM

PRESENTATION AND DIAGNOSIS

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Bronchial asthma

Adult:

•Calung,bronchiectasis

•COPD,emphysema

•Pulmonarytuberculosis

•Suppurativelungdisease

•Pulmonaryoedema

•Upperairwayobstruction/

inhaledforeignbody

•Vocalcorddysfunction

Reversible episodic wheeze and cough

Nocturnal symptoms

YES YES

Features supportive of diagnosis of asthma

•Frequentepisodesof wheeze(morethanoncea month)

•Activityinducedcoughor wheeze

• Nocturnalcoughinperiods withoutviralinfections

•Symptomspersistafterage3

Children

•Recurrentviralinfectionswith wheezing

•Chronicrhino-sinusitis

• Gastro-oesophagealreflux

•Bronchopulmonarydysplasia

•Chroniclungdiseaseof prematurity

•Aspirationsyndromes includingforeignbody aspiration/recurrentsilent aspiration

•Congenitalmalformationsof lung

•Congenitalheartdisease

Supportive Evidence

• Atopicfeatures • Familyhistoryofasthma/atopy

*Home PEF Variability (PEFdiary) >20%diurnalvariation

*Reversible airway obstruction Bronchodilatorresponse: >20%FEV1&≥200ml increaseinFVCorFEV1after bronchodilatorchallenge

*Bronchial provocation

•Exercise •Methacholine • Histamine

<5yearsold

Exclude Alternative Diagnosis

≥5yearsold

*Eitherofthesetestscanbeused

• PEFistheleastreliableasPEFis highlyeffortdependent

• Officespirometrymaybeusedto assessbronchodilatorresponse

Do CXR if other diagnosis suspected or consider

other diagnostic tests in the presence of:

•Neonatal/earlyonset

•Failuretothrive,LOW

•Frequentvomiting/choking

•Focallungsigns,haemoptysis

•Vocalcorddysfunction

Commence on trial of asthma therapy

Review diagnosis if response is poor

BronchialAsthma


BronchialAsthma

Notes

1. Investigations

Investigationsareusuallynotnecessaryexceptinsevereoratypicalcases,andinpatientswhodonotrespondtotherapy.

Someinvestigationswhichmaybeconsideredare

(i) ChestX-raytoexcludeforeignbodyorchronic chestinfectionortoexcludecomplicationsin severeacuteepisodes.

(ii) PulmonaryFunctionTests-Peakexpiratory flowrate(PEFR)/Spirometry.

• Thedemonstrationofdiurnalvariation ofPEFR≥20orbronchodilatorresponse resultinginimprovementofFEV1(Forced expiratoryvolumeinonesecond)by≥12% isindicativeofairwayhyper-responsiveness andairflowreversibility.

(iii) SkinPrickTest:

• Thisisusefulforthedemonstrationofatopy, especiallyinpatientswithnoclinicalsignsof eczemaorfamilyhistoryofatopy.

• Skinpricktestsmaybeusefulinguiding patientadviceonenvironmentalcontrol.

• Otherallergytestssuchasantigenspecific IgG,IgG4,intradermalskintestsarenot useful.Foodallergytestingisalsonotuseful forevaluationofasthmaperse.

(iv) Exhalednitricoxide

• Thisprovidesanon-invasiveassessmentof airwayinflammationthatisnotspecificbut usefulformonitoringofdiseaseand compliancetoinhaledcorticosteroids.

(v) AirwayChallengeTests–usingexerciseorwith inhalationofmethacholineorhistamine.

• Exercisechallengeisalsousefulforevaluation ofexercise-inducedasthma.

(vi) Otherteststoexcludeothermedicalconditions

• Mantouxtest–toexcludeMycobacteria infection

• Otolaryngologicevaluationofthesinusesand/ orCTscanofthesinuses

• Gastroesophagealrefluxstudies,e.g. esophagealpHmonitoring

• Bronchoscopytoexcludestructuralanomalies

• Immunologicalinvestigations,e.g.HIV,Serum Immunoglobulintitres

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BronchialAsthma

2. Other Modes of Presentation

• Coughvariantasthmawithoutwheezing Maybethegroupover-diagnosedasasthma. Ruleoutrhinitisandsinusitis

• ‘Hypersecretoryasthma’–Coughandexcessive secretions.Usuallyyoungpatients;more crepitationsthanwheezing

• ‘Firstacutewheeze’–Excludeinfections,foreign bodyaspiration

• Recurrentviralwheezingin0-2yearagegroup withoutatopymaynotrespondtoasthma treatment

• Incigarettesmoker,considerCOPDwithasthma

• Exercise-inducedbronchoconstruction

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3. Asthma Management should include:

• Gooddoctor-patientrelationship

• Identificationandreductionofexposuretorisk factorssuchasdustmites,molds,pets,pollen andcigarettesmoke

• Assessment,treatmentandmonitoringof Asthma

• Manageasthmaexacerbations

• PatienteducationincludingWrittenAsthma ActionPlan


BronchialAsthma

CLASSIFICATION OF ASTHMA BY THE LEVEL OF CONTROL

TheGlobalInitiativeforAsthma(GINA)guidelinesdefinethecontrolofasthmainto3categories:

• Controlled

• PartlyControlledand

• Uncontrolled

* Anyexacerbationshouldpromptreviewofmaintenancetreatmenttoensurethatitisadequate.† Bydefinition,anexacerbationinanyweekmakesthatanuncontrolledasthmaweek.‡ Lungfunctionisnotareliabletestforchildren5yearsandyounger

Bronchial asthma

Level of Asthma Control

High Risk Patients are patients who:

• Have2ormoreexacerbationspermonthrequiringacutecare

• Have2ormorehospitalizationsforasthmain3months

• Requiretheuseofrescuemedication3ormoretimesaweek

• HavehistoryofsevereasthmaexacerbationsrequiringcareintheHighDependencyorIntensiveCareUnit

CHARACTIERISTIC

Daytimesymptoms

Limitationsofactivities

Nocturnalsymptoms/awakening

Needforreliever/rescuetreatment

Lungfunction(PEForFEV1)‡

Exacerbations

CONTROLLED(All of the following)

None(twiceorless/week)

None

None

None(twiceorless/week)

Normal

None

PARTLY CONTROLLED(Any Measure Present In Any Week)

Morethantwice/week

Any

Any

Morethantwice/week

<80%predictedorpersonalbest(ifknown)

oneormore/year*

UNCONTROLLED

Threeormorefeaturesofpartlycontrolled

asthmapresentinanyweek

Oneinanyweek†

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BronchialAsthma

Thisisa5-item,patient-administeredquestionnaireforassessingasthmacontrol(Figure1).Itisasimple,objective,robustandvalidatedmethodformonitoringcontrolbydoctors(andpatients),whichisbeingusedinternationally.AmanagementplanbasedonACTassessmentisprovidedbelow(Figure3).

Thereisalsoa7-itemAsthma Control Test For Children Aged 4-11 Years Old©(Figure2).

Figure1:AsthmaControlTest(ACT)©foradultsandchildrenaged12andabove

Asthma Control Test (ACT)

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ASSESSMENT OF ASTHMA CONTROL USING THE ASTHMA CONTROL TEST

© 2002, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated.

© 2001 - 2005, GlaxoSmithKline Group of Companies. All Rights Reserved.

Basedonafive-pointscoringsystem,amaximumscoreof25willindicate‘totalcontrol’ofasthma.‘Wellcontrolled’asthmaisdefinedasascoreof20-24,andascoreoflessthan20willimply‘poorcontrol’.


BronchialAsthma

Figure 2: Asthma Control Test For Children Aged 4-11 Years Old©

© 2001 - 2005, GlaxoSmithKline Group of Companies. All Rights Reserved.

Ascoreof19orlesssuggestspoorasthmacontrol.Ascoreof20orabovesuggeststhechild’sasthmamaybeundercontrol.Ascoreof27indicates‘Totalcontrol’ofasthma.

Bronchial asthma

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BronchialAsthma

*ICS(inhaledglucocorticosteroids) **Receptorantagonistorsynthesisinhibitors ***Preferredcontrolleroptionsareshowninshadedboxes

Alternativerelievertreatmentsincludeinhaledanticholinergics,short-actingoralβ2-agonists,somelong-actingβ2-agonists,andshort-actingtheophylline.

Regulardosingwithshortandlong-actingβ2-agonistisnotadvisedunlessaccompaniedbyregularuseofaninhaledglucocorticosteroid.

Bronchial asthma

Management Approach Based on Control For Children Older Than 5 Years, Adolescents and Adults

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Level of Control

Step 1 Step 2 Step 3 Step 4 Step 5

Controlled

TreatmentSteps

Maintainandfindlowestcontrollingstep

Considersteppinguptogaincontrol

Stepupuntilcontrolled

Treatasexacerbation

ACTscore<20ACTscore>20

PartlyControlled

Uncontrolled

Exacerbation

Treatment Action

Red

uce

Incr

ease

IncreaseReduce

AsthmaEducationEnvironmentalControl

ControllerOptions***

Selectone

Low-doseinhaledICS*

Leukotrienemodifier**

Medium-orhigh-doseICS

Leukotrienemodifier

Anti-IgETreatment

Selectone Addoneormore Addoneorboth

Low-doseICSplusleukotrienemodifier

Sustainedreleasetheophylline

Low-doseICSplussustainedreleasetheophylline

Figure3:ManagementofAsthmatoAchieveControl

Oralglucocorticosteroid

(lowestdose)


BronchialAsthma

ASTHMA MANAGEMENT BASED ON LEVELS OF CONTROLManagement in Adults, Adoloscents and Children Older Than 5 Years

Thepatient’scurrenttreatmentandlevelofcontroldeterminetheselectionofpharmacologictreatment.Ifasthmaisnotcontrolledonthecurrenttreatment,treatmentshouldbesteppedupuntilcontrolisachieved.Controlisusuallymaintainedforatleast3monthsbeforeanattemptismadetostepdownthetreatment,withtheaimtoestablishtheloweststepanddoseoftreatmentthatmaintainscontrol.

Figure3showsthesteps1-5forachievingcontrol. Eachsteprepresentstreatmentoptionsinstepsofincreasingefficacy.InthemanagementschemedescribedinFigure3,thedoseofdailyasthmamedicationisadjustedaccordingtheACTscoresevaluatedateachclinicvisit.

Patients who do not achieve good asthma control despite Step 4 levels of treatment have refractory asthma and should be reviewed by a specialist. Management at Step 5 should be supervised directly by specialists.

PatientsshouldalsobetaughthowtoimplementaWrittenAsthmaActionPlanforself-managementofexacerbationsbetweenvisits.Patientsmayalsobeadvisedtoperformmonthlyself-monitoringusingtheACTbetweenclinicvisits.

Management in Children aged 5 and younger

• Theavailableliteratureontreatmentofasthmainchildrenaged5andyoungerprecludesdetailedtreatment recommendations.

• Thebestdocumentedtreatmentisinhaledglucocorticosteroids.

• ConsiderreferraltoPaediatricspecialistifthepatient’sresponsetotreatmentisnotasgoodasexpectedorif thechildremainssymptomatic.

Recommended inhaler devices for children

<4years MDIwithspacer+afacemask

4-6years MDIwithspacerwithmouthpiece

>6years MDIwithspacerwithmouthpieceoraccuhaler

>9years MDIwithspacerwithmouthpieceorturbuhaler

Bronchial asthma

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BronchialAsthma

Addontherapy:

• Tobeconsideredifnotachievingadequatecontroldespite:

i. goodcompliance;and

ii. satisfactoryinhalertechnique;and

iii. propertriggeravoidance

• Alternativesasadd-ontherapyinclude:

i. Inhaledlongactingβ2-agonists(LABA)

ii. Leukotrienemodifier

Note: LABAs should NOT be used without concomitant inhaled corticosteroids.

Indications for referral to the Paediatric specialist for further evaluation and management:

1. Patientswithhighriskasthmawithpoorcontrol

2. Patientsagedlessthan3yearsoldrequiringhighdosesofinhaledsteroids

3. Patientswhoremainsymptomaticdespitesuboptimalresponsetotherapy

4. PatientsrequiringhighdosesofinhaledsteroidsBDP/BUD≥400mcg/day

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Bronchial asthma

Management in Children Aged 5-12

EstimatedEquipotentDailyDosesofInhaledGlucocorticosteroidsforChildren

Drug

Beclomethasone Diproprionate 100-200 >200-400 >400

>400

>500

>200-400

>200-500

100-200

100-200

Budesonide

Fluticasone

Low Daily Dose (mcg) Medium Daily Dose (mcg) High Daily Dose (mcg)


BronchialAsthma

MANAGEMENT OF ASTHMA EXACERBATIONS: HOW SEVERE IS THE ASTHMA ATTACK?

*Thepresenceofseveralparameters,butnotnecessarilyall,indicatethegeneralclassificationoftheattacks.Notealsoanypriorusageof bronchodilatorasthismayalterthepresentingclinicalpictures.Please refer to the Guide to Normal Respiratory and Pulse Rates in Infants and Children, found on the last page of this Bronchial Asthma chapter.

Bronchial asthma

SEVERITY

SYMPTOMS

Breathless

Feeding(infant)

Talksin….

Alertness

SIGNS

Respiratoryrate*

Useofaccessorymuscles/suprasternalretractions

Wheezes

Pulserate*

FUNCTIONAL ASSESSMENT

PEF

PulseOximetryPaO2(onair)

MILD

Whilewalking

Canliedown

Feedsnormally

Sentences

Maybeagitated

Increased

Usuallynot

Moderate,oftenonlyendexpiratory

<100/min(adults

>80%

>95%

MODERATE

Whiletalking(infant-softer,shortercry)

Prefersitting

Difficultyfeeding

Phrases

Usuallyagitated

Increased

Usually

Loud

100-200/min(adult)

Approx.60%-80%

91%-95%

RESPIRATORY/ASSEST IMMINENT

Drowsyorconfused

Paradoxicalthoraco–abdominalmovement

Absenceofwheeze Bradycardia

SEVERE

Whileatrest

Hunchedforward

Stopsfeeding

Words

Usuallyagitated

Often>30/min(inadults)

Usually

Usuallyloud,throughoutinhalationandexhalation >120/min(adults)

<60%predictedorpersonalbestinservreasthmaexacerbation

<90%

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BronchialAsthma

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Assess Severity Assessmentintheveryyoungmaybedifficult.Childrenwithsevereattackmaynotappeardistressed.

Bearinmindforeignbodyaspiration.

1.HighflowO2viamask(6-10L/min)toachieveSaO2>95%2.IVaccess3.IVhydrocortisone4mg/kgstat(max100mg)4.Nebulizedsalbutamolwithipratropiumevery20minuteswhileawaitingtransfertohospital

Neb: Salbutamol: Ipratropium: Normal Saline:Weight≤10kg: 0.5mls0.5mls 3mlsWeight>10kg: 1ml1ml 2mls

s/corETTadrenaline1:10000.1-0.3ml(0.01ml/kg)onlyforthoseabove2yrold

Using a spacer with a metered-dose inhaler has been shown in clinical studies to be as effective as using a nebulizer in the delivery of a bronchodilator in the treatment of an acute asthma exacerbation.

*Ashortcourseoforalsteroidsshouldbeconsideredifthechildmeetsoneofthefollowingcriteria:1. requiresfrequentβ2–agoniststherapy(morefrequentlythan4hourly)2. hasapasthistoryoflife-threateningasthmaexacerbation3. isonhighdoseinhaledsteroidorlowdoseoralmaintenancesteroidtherapy.For patients with moderate to severe exacerbations, a dose of prednisolone 1-2 mg/kg/day [max 40mg] can be given for 3 to 5 days without a need to taper the dose. Paediatric patients requiring prolonged or repeated courses of oral steroid to control their asthma should be referred to a specialist for further evaluation and management.

Life-threatening Asthma Exacerbation

Respiratory:Cyanosis/Tachypnea,Exhaustion/ SilentChest/SaO2<91%

Neurological:Confusion/drowsiness

Cardiovascular:Pulsusparadoxus

Deteriorationinconditiondespitemaximaltherapy

Mild / Moderate Asthma Exacerbation

Mild/modtachypnea,no/minimumchestretractions,

No/minimumuseofaccessorymuscles,SaO291-95%

Arrange transfer to Hospital immediately

Severe Asthma Exacerbation

Tachypneic+,chestretractions,

Useofaccessorymuscles++,SaO2<91%

Bronchial asthma

Neb: Salbutamol : Ipratropium : Normal Saline Weight≤10kg: 0.5mls 0.5mls 3mlsWeight>10kg: 1ml 1ml 2mls

1. Repeatx1-2cyclesasneeded2. Oralprednisolone1mg/kg(max40mg)stat3. HighflowO2viamask(6-10L/min)toachieve SaO2>95%4. Reviewafter1-2cycles,refertohospitalA&Eifno improvement/deterioration

Improved

Improved

Improved

No improvement

Some improvement

Reassess after 15 min – 30min

Discharge with appropriate advice and follow-up*

CheckMDItechniqueKIVspacerandsetaTCUdate Repeat salbutamol MDI via

spacer or Neb

No improvement

Refer to Hospital A&E

No improvement

1.Weight≤10kg:SalbutamolMDI5puffsx2cyclesat15minintervalsWeight>10kg:SalbutamolMDI10puffsx2cyclesat15minintervals

2.Formoderateexacerbation: a. Oralprednisolone1mg/kg(max40mg)stat b. AddIpratropium(Atrovent®)2puffs

3.KeepSaO2>95%,addO2@4L/minvianasalprongsifnecessary

4.Reviewafter2cycles

5.ConverttoNebulizerifchildisfatigued

Neb: Salbutamol : Ipratropium : Normal Saline Weight≤10kg: 0.5mls 0.5mls 3mlsWeight>10kg: 1ml 1ml 2mls

MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS IN CHILDREN


BronchialAsthma

68

Mild / Moderate Asthma ExacerbationMild/modtachypnea,

No/minimumuseofaccessorymuscles,SaO291-95%

1.MDIbronchodilatorviaSpacersteps#*:

4puffsSalbutamol+ i.e.8puffsevery10-15minutes

4puffsIpratropium Patienttoinhale2-3xviathemouth/lipsafterevery2puffs.Repeat2-4cyclesasneeded

2.Doctortoreviewafterevery2ndor3rdcycle

3.Maystopbefore4thcycleifpatientisnolonger symptomatic

4.Torepeatcyclesasneeded5.Oralprednisolone30-60mgstat

6.TorefertohospitalA&Eifnoimprovementafter8 cycles(orearlierasclinicallyindicated)

*Converttonebulizerifpatientisfatigued:Neb Salbutamol : Ipratropium : Normal Saline

1ml 2mls 1ml

RefertoA&Eifnoimprovementafter2roundsofnebulizationorequivalent

1. HighflowO2viamask6-10L/mintoachieveSaO2>95%2. IVaccess3. IVhydrocortisone200mgstat4. Nebulizedsalbutamolwithipratropiumevery15-20 minutes whileawaitingtransfertohospital5. Neb Salbutamol : Ipratropium : Normal Saline 1ml 2mls 1ml

6.Considers/cadrenaline1:10000.5ml(0.01ml/kg)

ArrangetransfertoHospitalimmediately

Severe Asthma ExacerbationCan’tcompletesentences,TachypneicPulse>110/minRespRate>25/minPEF<50%predictedorbestSaO2<91%

Life-threatening Asthma Exacerbation

Respiratory:Cyanosis/Tachypnea,Exhaustion/ SilentChest/SaO2<91%

PEF<33%predictedorbestNeurological:Confusion/drowsinessCardiovascular:PulsusparadoxusDeteriorationinconditiondespitemaximaltherapy

1. HighflowO2viamask6-10L/mintoachieveSaO2>95%

2. IVaccess

3. IVhydrocortisone200mgstat

4. Neb Salbutamol : Ipratropium :NormalSaline 1ml 2mls 1ml

5. Torepeatabovenebulizationifindicated

6. Reviewafter30minutes

7. RefertoA&Eifnoimprovementafter2roundsof nebulization.

#Clinicalequivalencetosingle“round”ofnebulisation(neb):

1“round”ofneb=3-4cyclesofthefollowingtreatment:

4puffssalbutamol+4puffsIpratropium i.e.8puffsevery10-15minutes

MDI+SpacerMethod

a. Primethespacerwith8to10puffsofSalbutamol

b. Loadthespacerwith2puffseachtime,patienttoinhale2–3times(tidal breaths)afterevery2puffs(ifpatientcancooperate,deepbreathswithbreath holdingrecommended).

c. Oxygencanbeadministeredconcurrentlyvianasalprongsifrequired– maintainSAO2>95%forpatientswithasthma.

d. Nursetoadministerpuffs,ensureinhalationviathemouth/lips

e. Patientcanself-administerbronchodilatortreatmentwithsupervisionby medicalstaff

Bronchial asthma

Assess Severity of Asthma Exacerbation

MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS IN ADULTS


BronchialAsthma

69

Clinical Assessment after Bronchodilator TreatmentSymptoms,physicalexamination,O2saturation,PEF,othertestsasneeded

Good Response

•Responsesustained60minutesafterlasttreatment•Physicalexaminationisnormal•PEF>70%predicted•Nostress•O2saturation>90%

Historyofhigh-riskpatientPhysicalexamination:•Mildtomoderatesymptoms•PEF>50%-70%•O2saturationnotimproving

Historyofhigh-riskpatientPhysicalexamination:• Symptomssevere, drowsiness,confusion•PEF<30%•pCO2>45mmHg•O2saturation<90%

Action:

•RefertoHospitalA&E

•O2viamask6-10L/mintoachieveSaO2>95%

•Nebulizedsalbutamolwithipratropiumevery 15-20minuteswhileawaitingtransfertohospital

•i/vHydrocortisone200mgstatifnotalreadyadministeredearlier

Incomplete Response Poor Response

Action:

•Discharged

•Continuetreatmentwithinhaledβ2–agonists

•Considercourseofprednisolone30mgomfor5-7daysinmostcases

•Initiateorcontinueinhaledglucocorticosteroids

•Reinforcepatienteducation,actionplanandclosefollow-up

Action:

•ARRANGEURGENTTRANSFERTOHOSPITALviaambulanceimmediately

•HighflowO2viamask6-10L/mintoachieveSaO2>95%

•Nebulizedsalbutamolwithipratropiumevery15-20minuteswhileawaitingtransfertohospital

•i/vHydrocortisone200mgifnotalreadyadministeredearlier

•Considers/cadrenaline1:10000.5ml(0.01ml/kg)

•Possibleintubation&mechanicalventilation

Bronchial asthma

MANAGEMENT OF ACUTE ASTHMA EXACERBATIONS IN ADULTS (Continued)


BronchialAsthma

Risk factors for death from asthma

• Priorintubationandmechanicalventilation forasthma

• Hospitalizationoremergencycarevisitfor asthmainthepastyear

• Currentuseofsystemiccorticosteroidsorrecent withdrawalfromsystemiccorticosteroids

• Notcurrentlyusinginhaledcorticosteroids

• Useof>1canisterofinhaledshort-acting β2–agonistswithin1month

• Historyofpsychiatricdiseaseor psychosocialproblems

Patients at high risk of dying with asthma require special attention, monitoring and care, particularly intensive education, including advice to seek medical care early during an exacerbation.

Bronchial asthma

WHEN TO REFERAcute Asthma – Severe or Frequent Exacerbations

1. Alife-threateningasthmaexacerbation.

2. Frequentexacerbations: • acuteexacerbations2-3timesayear,or • morethanonceeverysixmonths,despite compliancewithmedicationsandgood inhaler(orinhaleranddevice)technique

3. Needforcontinuousoralcorticosteroid therapyorStep5therapy

Chronic Asthma – Difficult or Poor Control

1. Failinggoalsoftherapyafter3to6monthsof treatment.

2. UncontrolledAsthma

3. Underage3andrequiringstep3or4care.

4. Steroiduse: • continuousoralcorticosteroidtherapy,or • requiremorethantwoburstsoforal corticosteroidsin1year,or • high-doseinhaledcorticosteroids

Diagnosis

1. Atypicalsignsandsymptoms.

2. Otherconditionscomplicateasthmaorits diagnosis,e.g.heartfailure,COPD,unsure ofdiagnosis.

3. Additionaldiagnostictestingisindicated.

4. Suspicionofoccupationalasthma.

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Abbreviations < Lessthan ≤ Lessthanorequalto> Morethan ≥ MorethanorequaltoBDP Beclomethasonediproprionate BUD BudesonideCa Carcinoma COPD ChronicobstructivepulmonarydiseaseCXR Chestx-ray ETT Endotrachealtube FEV1 Forcedexpiratoryvolumein1second

References1. MinistryofHealth,Singapore.MOHClinicalPracticeGuidelinesManagementofAsthma,January20082. GlobalInitiativeforAsthma.Globalstrategyforasthmamanagementandprevention,Updated2009.3. NathanRA,SorknessCA,KosinskiM,SchatzM,LiJT,MarcusP,etal.DevelopmentoftheAsthmaControlTest:asurveyforassessing asthmacontrol.JAllergyClinImmunol2004;113:59-65.4. CatesCC,BaraA,CrillyJA,RoweBH.Holdingchambersversusnebulisersforbeta-agonisttreatmentofacuteasthma.Cochrane DatabaseSystRev.2003;(3):CD000052.5. TurnerMO,NoertjojoK,VedalS,BaiT,CrumpS,FitzGeraldJM.Riskfactorsfornear-fatalasthma.Acase-controlstudyinhospitalized patientswithasthma.AmJRespirCritCareMed1998;157(6Pt1):1804-9.6. SuissaS,BlaisL,ErnstP.Patternsofincreasingbeta-agonistuseandtheriskoffatalornear-fatalasthma.EurRespirJ1994;7(9):1602-9.7. ErnstP,SpitzerWO,SuissaS,CockcroftD,HabbickB,HorwitzRI,etal.Riskoffatalandnear-fatalasthmainrelationtoinhaled corticosteroiduse.JAMA1992;268(24):3462-4.5. SuissaS,BlaisL,ErnstP.Patternsofincreasingbeta-agonistuseandtheriskoffatalornear-fatalasthma.EurRespirJ1994;7(9):1602-9.6. JosephKS,BlaisL,ErnstP,SuissaS.Increasedmorbidityandmortalityrelatedtoasthmaamongasthmaticpatientswhousemajor tranquillisers.BMJ1996;312(7023):79-82.

i/v Intravenous LOW Lossofweight MDI Metereddoseinhaler mths Month(s) O2 Oxygen PEF Peakexpiratoryflow s/c Subcutaneous TCU To-see-you(i.e.reviewappointment)Yr Year(s)

Guide to Normal Respiratory and Pulse Rates in Infants and Children

AGE

<2months <60

<50 <1602-12months 2-12months

<40 <1201-5years 1-2years

<30 <1106-8years 2-8years

RESP RATE (MIN) PULSE RATE (MIN)AGE


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