Caribbean Asthma Guidelines - Revised March 2011

8/18/2019 Caribbean Asthma Guidelines - Revised March 2011

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MANAGING ASTHMA IN THE CARIBBEAN

© 2009


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Disclaimer

These are general guidelines only and may not apply in the case of any parcular individual paent. They should be applied bearing

in mind the local situaon. The health care worker should always use his/her clinical judgement and experse.

Duality of Interest

No duality of interest was idened.

ST. AUGUSTINE. TRINIDAD & TOBAGO

http://www.chrc-caribbean.org

CARIBBEAN HEALTH RESEARCH COUNCIL


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The aim of the Clinical Guidelines, Managing Asthma in the Caribbean, is to improve the care provided forpaents with asthma. This would be accomplished through improved diagnosc and monitoring skills; bet-ter and more appropriate use of available medicaons to alleviate symptoms and control the condion over the

long term; and involving the paent and his/her family in managing and prevenng the condion.

The Caribbean Health Research Council (CHRC) has been producing Clinical Guidelines for prevalent chronic

diseases in the Caribbean since 1995, as it fulls one of its mandates i.e. to promote evidence based clinical

pracce in the Caribbean. To date, condions addressed include Diabetes, Hypertension and Asthma. These

Asthma Guidelines are an update of those produced in 1997 by the CHRC (then known as the Commonwealth

Caribbean Medical Research Council (CCMRC)) in collaboraon with Global Iniave for Asthma (GINA) and

other experts from both within and outside the Caribbean. The current, revised guidelines were developed in

collaboraon with the University of the West Indies, St. Augusne, Trinidad and Tobago and other partners.

As was the case with the other CHRC Clinical Guidelines, Managing Asthma in the Caribbean was developed to

take into account the culture, economic situaon and health care systems of the Caribbean while ensuring that

internaonal best pracces are applied to paent care.

The process for the development of the Guidelines was as follows:

• Expert workshop to review the original Caribbean Asthma Guidelines as well as other crical publicaons

such as the latest GINA Guidelines. Parcipants included representaves of both public and private sector

organizaons from 13 Caribbean countries. It was facilitated by CHRC with some support from the Oce

of Caribbean Program Coordinaon, Pan American Health Organizaon.

• Agreement on the necessary changes in content as well as the format to facilitate easier use of the

Guidelines.

• Individual specialist teams developed the various secons of the revised Guidelines. Dras were circulated

to team members by round-robin to achieve concord.

• Before the document was nalized, it was disseminated to a wide cross-secon of stakeholders for

comment, including the Chief Medical Ocers from 19 Caribbean countries.

• Comments were incorporated and the Guidelines published

The revised Guidelines have been extensively modied to now comprise 4 secons:

• Core Informaon Regarding Asthma and its Management

• Asthma In Young Children (


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ACKNOWLEDGEMENTS

The Caribbean Health Research Council and the Faculty of Medical Sciences, The University of theWest Indies acknowledge with appreciaon the contribuon of several persons to the successfuldevelopment of these Guidelines to manage asthma in the Caribbean. In parcular:

• Dr. Kay Bailey, Dr. Avery Hinds, Prof. Lexley Pinto Pereira, Dr. Rohan Maharaj, Prof. Terence

Seemungal and Dr. Donald Simeon who were responsible for the compilaon and the eding

of the various versions of the document.

• The persons who contributed technical input and invaluable comments:

o Parcipants of the April 2007 workshop to revise the rst edion of the Caribbean Asthma

Guidelines

o Pan American Health Organizaon for funding the aendance of some of the workshop

parcipants

o Chief Medical Ocers of the English-speaking Caribbean and Suriname

o Dr Sonia Roache and other members of the Caribbean College of Family Praconers.


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Contents

PART 1: OVERVIEW OF ASTHMA CARE

1.1 Asthma In The Caribbean ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 3

1.2 Diagnosing Asthma . ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... .. 4

1.3 General Issues In The Management Of Asthma . ... ... ... ... ... ... ... ... ... ... ... ... ... .. 8

PART 2: MANAGEMENT OF ASTHMA IN YOUNG CHILDREN (


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LIST OF TABLES

Table 1. Common Asthma Triggers and Avoidance Strategies .. ... ... ... ... ... ... ... ... ... . 13

Table 2. Management of Acute Asthma in Children . ... ... ... ... ... ... ... ... ... ... ... ... ... . 28

Table 3. Features of Near Fatal Adult Asthma... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . 43

Table 4. Levels of Severity of Acute Asthma Exacerbaons in Adults .. ... ... ... ... ... ... . 46

Table 5. Inial Assessment – the Role of Symptoms, Signs and

Measurements in Adults .. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . 47

Table 6. Features of Acute Asthma in Adults. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . 56

LIST OF FIGURES

Figure 1. Example of Contents of an Acon Plan to Maintain Asthma Control. ... ... ... . 11

Figure 2. Levels of Asthma Control . ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . 14

Figure 3. Assessment of Severity and Treatment in the A & E... ... ... ... ... ... ... ... ... ... . 30

Figure 4. Discharge Criteria. ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... ... . 32

Figure 5. Management Approach Based on Control .. ... ... ... ... ... ... ... ... ... ... ... ... ... . 33

Figure 6. Esmated Equipotent Doses of Inhaled Glucocorcosteroids ... ... ... ... ... ... . 35

Figure 7. Management of Acute Severe Asthma in Adults – A & E and. ... ... ... ... ... ... . 57


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Part 1:Overview of Asthma Care


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Overview of Asthma Care

2


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1.1 ASTHMA IN THE CARIBBEAN

Asthma is characterized by paroxysmal or persistent symptoms such as dyspnea, chest

ghtness, wheezing, sputum producon and cough; there is variable airow limitaon and

a variable degree of hyper-responsiveness of airways to endogenous or exogenous smuli

[Boulet, 1999].

Asthma is a serious chronic disease and a major public health problem in the Caribbean.Populaon based surveys of Caribbean adolescents report that over 13% of parcipants

admied to having a past or present diagnosis of asthma [Tam Tam 1998, Howi 1998, Monteil

2006, Kahwa 2006]. Surveys of pediatric hospitals’ emergency rooms report that as many as

23% of the cases were acute asthmacs [Longsworth 1986]. At the Port-of Spain General

Hospital in Trinidad and Tobago, asthma has been reported as accounng for between 8-10%

of admissions to the emergency room [Kirsch 1995, Mungrue 1997, Mahabir 1999], while in

Barbados 13% [Naidu 2000] has been documented. Such rates mean that there is a high costto the care of this disease. In Barbados it has been calculated that asthma drug costs in 1997

accounted for 6% of that naon’s drug service [Howi 2000].

Compounding these stascs, the major contributory factors to asthma morbidity and

mortality are under-diagnosis and inappropriate or inadequate treatment. For example, a

drug ulizaon review in asthma treatment in three Caribbean countries revealed a gross

underulizaon of inhaled steroids, which is the preferred treatment for controlling the

disease, and the frequent prescripon of medicaons of dubious ecacy [Burne and Howi,

1997]. Even when paents had the appropriate medicaons, they were oen not taking it.

Naidu reported that 63% of paents with ‘preventer’ medicaon were not taking it [2000].

Further in specialty chest clinics as many as 33% of paents were not using their inhalers

correctly [Pinto Pereira 2002].

Asthmac admissions to hospitals are highest in the last quarter of the year but fall to their

lowest levels in April [Depradine 1983 and 1995, Monteil 2000, Ivey 2003]. Admission rates are

inuenced by climac variables such as relave humidity and wind speed [Depradine1983 and

1995, Ivey 2000] and African dust clouds [Depradine 1983, Gyan 2005].


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There is a high prevalence of other allergic diseases in the paents studied, with skin reacvity

to at least one allergen in 50 - 81 percent of subjects. Reacvity to house dust mite, especially

Dermatophagoides pteronyssinus, occurred most commonly and sensivity to this mite

correlated with high levels of mite proteins in maress and bedroom dust [Barnes 1992,

Knight-Madden 2006].

These have been major advances in our understanding of the pathophysiology of asthma which

has led to more eecve treatment and management of the condion. It is now accepted

that asthma is a long term inammatory disorder accompanied by exacerbaons of coughing,wheezing and diculty in breathing.

The approach to treatment and long-term management of asthma includes avoidance of

common trigger factors and medicaons for long-term control of the inammatory response,

for relief of asthma symptoms and to improve lung funcon. This comprehensive approach

involves paent educaon and involvement in monitoring disease acvity, avoidance of risk

factors and compliance and long-term medicaon to control the disease.

1.2 DIAGNOSING ASTHMA

Medical History

• Symptoms: Episodic breathlessness, wheezing, cough (especially at nights), and chestghtness.

• Symptoms may occur or worsen at night, awakening the paent.

• Symptoms occur or worsen in the presence of:

-Exercise

-Viral infecon

-Animals with fur -Domesc dust mites (in maresses, pillows upholstered carpets)

-Smoke (tobacco, wood)

-Pollen

-Change in temperature

-Strong emoonal expression (laughing or crying hard)

-Aerosol chemicals


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• Reversible and variable airow limitaon—as measured by using a peak expiratory ow

(PEF) meter in any of the following ways (refer to secon on the peak ow meter on Page17 for informaon on its uses and technique):

PEF increases more than 15 percent 15 to 20 minutes aer inhalaon of a short•acng beta-2 agonist or

PEF varies more than 20 percent from morning measurement upon arising to•measurement 12 hours later in paents taking a bronchodilator (more than 10percent in paents who are not taking a bronchodilator) or

PEF decreases more than 15 percent aer 6 minutes of running or exercise.•

Quesons to consider in the diagnosis of asthma

Has the paent had an aack or a recurrent aack of wheezing?•

Does the paent have a troublesome cough at night?•Does the paent wheeze or cough aer exercise?•

Does the paent experience wheezing, chest ghtness, or cough•

aer exposure to airborne allergens or pollutants?

Do the paent’s colds “go to the chest” or take more than 10 days•

to clear up?

Are symptoms improved by appropriate asthma treatment?•

N.B. Episodic symptoms aer an incidental allergen exposure, seasonal variability of

symptoms and a posive family history of asthma and atopic disease are also helpful

diagnosc guides.

Because asthma symptoms are variable, the physical examinaon of the respiratory system may

be normal. The most usual abnormal physical nding is wheezing on auscultaon, a nding that

conrms the presence of airow limitaon. However, in some people with asthma, wheezing

may be absent or only detected when the person exhales forcibly, even in the presence ofsignicant airow limitaon.

Occasionally, in severe asthma exacerbaons, wheezing may be absent owing to severely

reduced airow and venlaon. However, paents in this state usually have other physical signs

reecng the exacerbaon and its severity, such as cyanosis, drowsiness, diculty in speaking,

tachycardia, hyper-inated chest, use of accessory muscles, and inter-costal recession.

Physical Examinaon


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Other clinical signs are only likely to be present if paents are examined during symptomac

periods. Features of hyperinaon result from paents breathing at a higher lung volumein order to increase outward retracon of the airways and maintain the patency of smaller

airways (which are narrowed by a combinaon of airway smooth muscle contracon, edema,

and mucus hyper-secreon). The combinaon of hyperinaon and airow limitaon in an

asthma exacerbaon markedly increases the work of breathing.

Diagnosc challenges:

1. Young children whose primary symptoms is cough or who wheeze with respiratoryinfecons are oen misdiagnosed as having bronchis or pneumonia (including acute

respiratory disease—ARD) and thus ineecvely treated with anbiocs or cough

suppressants. Treatment with asthma medicaon can be benecial and diagnosc.

2. Asthma should be considered if the paent’s colds repeatedly “go to the chest” or take

more than 10 days to clear up, or if the paent improves when asthma medicaon isgiven.

3. Tobacco smokers and elderly paents frequently suer from chronic obstrucve pulmonarydisease with symptoms similar to asthma.

4. Yet they may also have asthma and benet from treatment. Improvement in PEF aerasthma treatment is diagnosc.

5. Workers who are exposed to inhalant chemicals or allergens in the workplace can developasthma and may be misdiagnosed as having chronic bronchis or chronic obstrucve

pulmonary disease. Early recognion (PEF measurements at work and home), strict

avoidance of further exposure, and early treatment are essenal.

NOTE

Wheeze is NOT equal to Asthma

In children always consider the dierenal diagnosis of wheeze:

• Bronchiolis

Congesve Cardiac Failure•

Tracheomalacia•


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Bronchomalacia•

Bronchopulmonary dysplasia•Bronchopneumonia•

Foreign Body•

Recurrent aspiraon•

◊ Gastroesophageal reux

◊ Tracheoesphageal stula

◊ Pharyngeal incoordinaon

◊ Muscle weakness

Worms•

Congenital Disorders - webs, cysts, vascular rings, lung disorders•

Immune deciencies•

• Congenital

• Acquired: HIV

Vocal cord paralysis•

Chronic infecons•

• TB

• HIV-Pneumocyss carinii (P jiroveci)

• Bronchiectasis

Tumors, Lymph nodes•

Cysc brosis•

Disorders of cilia•

ALWAYS perform a complete examinaon to rule out other causes of wheeze. The following

signs suggest causes other than asthma.

Failure to Thrive•

Clubbing•

Cyanosis•

Chest deformity•

Tracheal deviaon•

Unilateral wheeze•

Tachycardia•

Hepatomegaly +/- Splenomegaly•


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Pialls In the Diagnosis of Asthma

Don’t assume the diagnosis of asthma correct•

Consider Stridor vs. Wheeze•

Consider other diagnoses, especially if not responding•

Beware a “normal” respiratory rate•

Beware silent chest•

Do not neglect history examinaon and invesgaons•

1.3 GENERAL ISSUES IN THE MANAGEMENT

OF ASTHMA

1.3.1 Overall aims in the management of asthma

New approaches to asthma therapy help paents prevent most aacks; remain free oftroublesome night and day symptoms, and keep physically acve.

Achieving control of asthma requires:

Educang paents and caregivers to manage the condion1.

Idenfying and avoiding triggers that make asthma worse2.

Selecng appropriate medicaons3.

Stopping asthma aacks4.

Monitoring and modifying asthma care for eecve long-term control5.

Asthma is considered to be controlled if the following criteria are met:

Dayme symptoms:


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1.3.2 Paent Educaon

There is good to excellent evidence that educaon is an essenal component of asthma

therapy. But asthma educaon should not rely on wrien or videotape material only. Paent

self monitoring may be eecve by measurement of peak expiratory ow (PEF). With your

help, and the help of others on the health care team, paents can be acvely involved in

managing their asthma to prevent problems and can live producve, physically acve lives.

With your help, asthma paents can learn to:

* Take medicaons correctly

* Understand the dierence between “relievers” and “controllers” medicaon

* Avoid triggers

* Monitor their status using symptoms and importantly if available, PEF indicators

* Recognize signs that asthma is worsening and take acon

* Seek medical help as appropriate.

Working together, you and your paent should prepare a wrien asthma management plan

that is not only medically appropriate but also praccal.

An Asthma Management Plan should cover:

Prevenon steps for long term control1.

What daily medicaon to take2.

What asthma triggers to avoid3.

Acon steps to stop aacks4.

How to recognize worsening asthma:5.

List indicators such as increasing cough, chest ghtness, wheeze, dicult

breathing, talking in incomplete phrases/sentences, sleep disturbance, or PEF

measurements below personal best despite increased use of medicaons.

6. How to treat worsening asthma:

List the names and doses of quick-relief bronchodilator medicaons and when to

use them.


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7. How and when to seek medical aenon:

List indicators such as feeling panicky, an aack with sudden onset, shortness

of breath while resng or speaking a few words, PEF readings below a specied

level, or a history of severe aacks.

8. List the name, locaon and telephone number of the physician’s oce or clinic.

Educaonal methods should be appropriate for your paents. Using a variety of methods

helps reinforce your educaon. These include:

Discussion with a physician, nurse, outreach worker, counselor, or educator1.

Demonstraons, wrien materials, group classes, video audio tapes, drama2.

Paent support groups3.

Ongoing educaon, presented at every paent visit, is the key to success in all aspects of4.

asthma management.

Working together, you and your paent should prepare a wrien personal asthma acon plan

that is medically appropriate and praccal. A sample asthma plan is shown in Figure 1.

Addional self-management plans can be found on several Websites, including:

hp://www.asthma.org.uk

hp://nhlbisupport.com/asthma/index.html

hp://www.asthmanz.co.nz


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Figure 1.

Example of Contents of an Acon Plan to Maintain Asthma Control

Your Regular Treatment:

1. Each day take …………………………..

2. Before exercise, take ……………………

WHEN TO INCREASE TREATMENT

Assess your level of Asthma Control

In the past week have you had:

Daytime asthma symptoms more than 2 times: No Yes

Activity or exercise limited by asthma? No Yes

Waking at night because of asthma? No Yes

The need to use your [rescue medication] more than 2 times: No Yes

If you are monitoring peak flow, peak flow less than …….? No Yes

If you answered YES to three or more of these questions, your asthma is uncontrolled

and you may need to step up your treatment.

HOW TO INCREASE TREATMENT

STEP UP your treatment as follows and assess improvement every day:

…………………………………………. [Write in next treatment step here]

Maintain this treatment for …………. .days [specify number]

WHEN TO CALL THE DOCTOR/CLINIC

Call your doctor/clinic: …………………..[provide phone numbers]

If you don’t respond in ……… days [specify number]

……………………………….. [optional lines for additional information]

EMERGENCY/SEVERE LOSS OF CONTROL

If you have severe shortness of breath, and can only speak in short sentences.

If you are having a severe attack of asthma and are frightened.

If you need your reliever medication more than every 4 hours and are not improving.

1. Take 2 to 4 puffs ………………… [reliever medication]

2. Take ………mg of ………………...[oral glucocorticosteroid]

3. Seek medical help: Go to …………………..: Address ………………….

Phone: …………………………………….

4. Continue to use your ………………[reliever medication] until you are able to get

medical help.


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1.3.3 Idenfying and Avoiding Triggers

When paents avoid exposure to asthma triggers (allergens and irritants that make their

asthma worse), asthma symptoms and aacks can be prevented and medicaons reduced.

Viral infecons have been shown to be associated with exacerbaons of wheeze in children in

Trinidad and Tobago (Mathew 2009). Common triggers are listed in Table 1.

When paents reduce exposure to tobacco smoke and indoor allergens, parcularly domesc

dust mites, they also help other members of their family. The inial development of asthma,

especially in infants may be prevented.

Specic immunotherapy, directed at treang underlying allergy to grass and other pollen,

domesc mites, animal dander, or alternaria, may be considered when avoiding allergens is not

possible or appropriate medicaons fail to control asthma symptoms. Specic immunotherapy

should be performed only by trained health professionals.

Paents with new asthma that may be related to their occupaon should be adequately

invesgated and managed.


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Table 1.

Common Asthma Triggers and Avoidance StrategiesCommon asthma triggers Avoidance strategies

Domesc dust mite allergens Wash bed linens and blankets once a week inhot water and dry in a hot dryer or sun. Encasepillows and maresses in air ght covers.Remove carpets, especially in sleeping rooms.Use vinyl, leather, or plain wooden furnitureinstead of fabric covered furniture.

Tobacco smoke Stay away from tobacco smoke. Paents andparents should not smoke.

Allergens from animals with fur Remove animals from the home, or at leastfrom the sleeping area

Cockroach allergen Clean the home thoroughly and oen; makeevery eort to reduce the availability of food.Use pescide spray-but make sure the paentis not at home when spraying occurs. Restrict

potenal havens by caulking and sealing cracksin the plasterwork and ooring

Outdoor pollens and mold Close windows and doors and remain indoorswhen pollen and mold counts are highest.

Physical acvity Do not avoid physical acvity. Symptoms canbe prevented by taking short- or long- acnginhaled beta-2-agonist or sodium cromoglycatebefore strenuous exercise.

Medicaon: avoid or use with cauon Aspirin, non steroidal an-inammatory drugs,beta-blockers (oral or intra-ocular (closesupervision is essenal))

Viral upper respiratory tract infecons,inuenza.

For the child with recurrent, severe asthmaexacerbaons related to viral URIs, considerliming exposure to viral infecons. Inuenzavaccines for children with persistent asthma(who are not allergic to eggs).

Occupaonal asthma Consider this in all adults with new onsetasthma e.g. isocyanates, allergens from grainand others.

Emoons Avoid emoonal and psychological stress

Foods Food allergies (e.g. peanut), food addives


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Classicaon of Asthma by Level of Control

Tradionally, the degree of symptoms, airow limitaon, and lung funcon variability have

allowed asthma to be classied by severity (e.g., as Intermient, Mild Persistent, Moderate

Persistent, or Severe Persistent).

However, it is important to recognize that asthma severity involves both the severity of the

underlying disease and its responsiveness to treatment. In addion, severity is not an unvarying

feature of an individual paent’s asthma, but may change over months or years.

Therefore, for ongoing management of asthma, classicaon of asthma by level of control is

more relevant and useful (Figure 2).

Figure 2.

Levels of Asthma Control

Characterisc Controlled(All of the following)

Partly controlled

(Any measure present in any

week)

Uncontrolled

Dayme symptoms None (twice or less/

week)

More than twice/week

Three or more

features of

partly controlled

asthma present

in any week

Limitaons of acvies None Any

Nocturnal symptoms/

awakening

None Any

Need for reliever/

rescue treatment

None (twice or less/

week)

More than twice/week

Lung funcon (PEF or

FEV1)‡

Normal < 80% predicted or personal

best (if known)

Exacerbaons None One or more/year* One in any week†

* Any exacerbaon should prompt review of maintenance treatment to ensure that it is adequate

† By denion, an exacerbaon in any week makes that an uncontrolled asthma week.

‡ Lung funcon is not a reliable test for children 5 years and younger.

Taken from Global Iniave for Asthma Guidelines, 2008


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1.3.5 Quesons for monitoring asthma care

1. Is the asthma management plan meeng expected goals?

Ask the paent:

Has your asthma awakened you at night?•

Are you parcipang in your usual physical acvies?•

Have you had a need for more quick relief medicaons than usual?•

Have you needed any urgent medical care?•

Has your peak ow been below your personal best?•

Acon to consider:

Adjust medicaons and management plan as needed (step up or step down) aer

compliance was assessed.

2. Is the paent using inhalers, spacers, or peak ow meters correctly?

Ask the paent: ‘Please show me how you take your medicaon.’

Acon to consider:

Demonstrate correct technique then have the paent pracce what you have taught

them. Give them feedback on their technique.

3. Is the paent taking the medicaons and avoiding triggers according to the asthma

management plan?

Ask the paent, for example:

So that we may plan your therapy please tell me exactly how oen you take your•

medicine.

What problems have you had in following the management plan or in taking your•

medicine?In the past month, have you ever stopped taking your medicine because you felt•

beer?

Acon to consider:

Adjust the plan to be more praccal.

Negoate with paent to overcome barriers to following the plan.


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4. Does the paent have any concerns?

Ask the paent:

• What concerns might you have about asthma, medicines, or the management plan?

Acon to consider:

Provide addional educaon to relieve concern and discussion to overcome barriers.

1.3.6 Reasons For Non-compliance

Medicaon-related factors

Misunderstanding the need for both ‘controllers’ and ‘preventers’.•

Impraccal regimen•

Diculty with inhaler device•

Side eects•

Fear of side eects•Cost of medicaon•

Dislike of medicaon•

Distant pharmacies•

Non-Medicaon factors

Disbelief or denial of cause of symptoms or aacks•

Misunderstanding of management plan•

Inappropriate expectaons•

Lack of guidance for self-management•

Dissasfacon/ Un-discussed fears or concerns•

Poor supervision, training or follow up•

Cultural issues and family Issues•

Occupaonal issues•

Long waing mes at pharmacies in health centers•

1.3.7 Selecng Devices

Devices available to deliver inhaled medicaon include pressurized metered-dose inhalers

(MDI’s), breath-actuated metered dose inhalers, dry powder inhalers, and nebulizers.


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Spacers

Spacers also reduce systemic absorpon and side eects of inhaled corcosteroids.

For each paent, select the most appropriate devices. In general:

For paents using spacers, the spacer must t the inhaler.•

Paents of any age over 5 years who have diculty using pressurized MDI’s should use•a pressurized MDI with a spacer, a breath –actuated inhaler, a dry powder inhaler, or a

nebulizer. Dry powder inhalers require an inspiratory eort that may be dicult duringsevere aacks.

Paents who are having severe aacks should use a pressurized MDI with a spacer or•a nebulizer. However, the supervised use of MDIs with spacer devices has proved aseecve in the emergency seng as nebulizer therapy for both adults [Turner and Patel1997] and children [Kelly and Murphy 1992, Amirav 1997].

Teach paents (and parents) how to use inhaler devices.•

Dierent devices need dierent inhalaon techniques.•

Give demonstraons and illustrated instrucons.•

Ask paents to show their technique at every visit.•

Peak ow meters: uses and techniques

Lung funcon measurements assess airow limitaon and help diagnose and monitor•

the course of asthma. Such objecve measurements are important because paents

and physicians oen do not recognize asthma symptoms or their severity. Lung funcon

measurements for asthma management are used in the same manner as blood pressure

measurements for diagnosing and monitoring hypertension.

Peak Flow Meters are portable handheld devices that are used to measure the peak•expiratory ow (PEF). PEF is the maximum air ow achieved during a forced expiraon.

These devices can be used as a non-invasive form of self-monitoring of respiratory

status for paents with asthma. They can be used not only in hospital and clinic sengs

but also in home and oce sengs to help diagnose asthma, assess its severity and

evaluate response to therapy. There are several kinds available but the technique for

use is similar for all:

O A C


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Technique for use

Stand up straight with the head up. Make sure the marker is at zero. Make sure you do1.

not touch the marker while blowing into the mouthpiece.

Take a deep breath, place the meter in your mouth, seal your lips around the2.

mouthpiece, and breathe out as hard and fast as possible. Do not put your tongue into

the mouthpiece.

Record the result on your chart, and return the marker to zero.3.

Repeat twice more. Choose the highest of the three readings.4.

PEF is usually measured at least twice daily over a two to three week period. The

personal best is the highest PEF measurement achieved when the paent’s asthma is

under control. Aer the personal best is established and symptoms are stable, PEF is

measured daily. A reading of less than 80% of one’s personal best is an alert. Morefrequent monitoring may be needed for paents whose condions are severe, poorly

controlled, or who have experienced an exacerbaon. Long-tern PEF monitoring is

useful, along with review of symptoms, for evaluang a paent’s response to therapy.

Normal peak ow values for children are presented in the Appendix.

1.3.8 Notes

Paents and caregivers should start treatment at the step most appropriate to the inial•

severity of their condion

Establish control as soon as possible; then decrease treatment to the least medicaon•

necessary to maintain control.

A rescue course of prednisolone may be needed at any me and step.•

Paents and caregivers should avoid or control triggers at each step.•

All therapy must include paent and caregiver educaon•



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Part 2:Management of Asthma in

Young Children (


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Management of Asthma in Children


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2.1 DIAGNOSTIC CHALLENGES

The diagnosis of asthma in children < 6 years presents a dicult problem. The younger the

child the greater the likelihood that an alternate diagnosis may explain recurrent wheeze.

2.2 CLINICAL INDEX OF RISK

Major criteria

Parent with asthma

Personal history of eczema

Allergic sensizaon to ≥ 1 aeroallergen

Minor criteria

Wheeze apart from colds

Eosinophilia ≥ 4%

Allergic Rhinis

Allergic sensizaon to eggs, milk, peanuts

Stringent Index for the predicon of Asthma: Early wheeze greater than 3 mes before

age 3 years plus 1 major OR 2 minor criteria suggest risk of 4-10 mes that of populaon

without wheeze

Loose Index for the predicon of Asthma: Single episode of early wheeze before age

3 years plus 1 major OR 2 minor criteria suggest risk of 3-6 mes that of populaon

without wheeze.

95% of children with negave stringent index did not have wheeze at school age.

Of paents who wheeze before age 3 years, wheezing persists through age 6 years in

approximately 40 percent. In addion more than half of all cases of persistent asthma start

before age 3 years and eighty percent start before age 6 years.

Marnez and colleagues found that of 826 newborns followed from birth to 6 years 51%

never wheezed, 20% wheezed by 3 years but had no wheeze at 6 years (transient wheezers)

14% wheezed before 3 years and were sll wheezing at 6 years of age (persistent wheezers)

and 15% did not wheeze before 3 years but were wheezing at 6 years (late onset wheezers).

(Marnez 1995).



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Management of Asthma in Children 6 years

22

Asthma and Wheezing in the rst 6 years of life (Tuscon Children’s Respiratory Study)

Transient Wheeze

20%

Never Wheezed

51%

Persistent Wheeze

14%

Late Wheeze

15%

Below are factors associated with transient and persistent wheeze.

Transient wheeze Persistent wheeze

Smaller airway caliber with Atopy

low lung funcon at birth Deterioraon of lung funcon by age 6yrNo bronchial hyper-responsiveness Bronchial hyper-responsiveness

Prognosis of wheezing in childhood

Sixty percent of children who wheeze before age 3 years stop wheezing by age 6 years. Sixty

percent of children who are wheezing at 6 years are not wheezing in adulthood. The most

signicant risk factor for wheezing in adult hood is wheezing in childhood.

2.3 MANAGEMENT OF THE ACUTE ATTACK

Management of the acute aack in primary care, in the emergency and on the ward is the

same as for 6-13 year olds.



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2.4 MANAGEMENT APPROACH BASED ON CONTROL

See Figure 2 for assessment of control.

Asthma Educaon

Environmental Control

As needed rapid-acng β2-agonist

Controlled on needed

rapid-acng β2-agonist

Partly controlled onneeded rapid-acngβ

2-agonist

Uncontrolled or partlycontrolled on low doseICS

Uncontrolled or partlycontrolled on medium

dose ICS

↓ ↓ CONTROLLER OPTIONS ↓ ↓

Step 1 Step 2 Step 3 Step 4-5

As needed rapid-acngβ

2-agonist only

Low dose ICS Double dose of ICS(Medium dose)

Consult with asthmaspecialist

Leukotriene modier Low dose ICS plusLeukotriene modier

ICS = Inhaled corcosteroid

• Control is assessed aer resoluon of the acute aack.

• Step up if no response in 4-6 weeks. First check inhaler technique, adherence, controlof allergic rhinis and environmental control. Consider possibility of gastro-eosophagealreux. Consider alternate diagnosis.

• Step down if possible if controlled for at least 3 months.

• Maintain control using the lowest dose of inhaled corcosteroid and/or leukotriene

modier possible

Management of paents who do not have symptoms between aacks

Treat a child with risk factors for persistent asthma (atopy or parental asthma) but without

symptoms between aacks as an asthmac requiring control of asthma if

o Two or more aacks requiring oral steroids occur in 6 months

OR

o 4 or more wheezing episodes occur in one year

For further details and a guide on managing asthma in children younger than 5 years please refer toGINA 2009 Guidelines “Global Strategy for the Diagnosis and Management in Children 5 Years andYounger” and “Pocket Guide to Asthma Management and Prevenon in Children 5 Years and Younger”

www.ginasthma.com.



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Part 3:Management of Asthma in

Children 6-13 years

Management of Asthma in Children 6-13 years


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3.1 MANAGEMENT OF ACUTE ASTHMA IN THE PRIMARY

CARE SETTING

Basis of Treatment

Severity of Symptoms1.

Response to treatment2.

Management Issues

Hypoxia•

Bronchospasm•

Inammaon•

Assessment of Severity and Treatment

Lower threshold for admission if:Aack in late aernoon or night•

Two or more hospitalizaons for asthma in the past year•

Previous severe exacerbaons requiring ICU admission or intubaon.•

Hospital or emergency department visit in the last month•

Concern about social circumstances or ability to cope at home•



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Table 2:

Management of Acute Asthma in Children

Mild Moderate Severe Life threatening

Symptoms/Signs SpO2 > 95%

PEF ≥ 80%

Able to talksentences

HR ≤ 100

RR Increased

No use ofaccessory muscles

Wheeze endexpiratory

SpO2 > 92%

PEF 60-80%

Able to talkphrases

HR ≤ 120

RR Increased

Use of accessorymuscles

Wheezeexpiratory

SpO2 < 92%

PEF < 60%

Too breathlessto talk

HR >120

RR > 30

Use of accessorymuscles

Wheezeinspiratory andexpiratory

SpO2 < 90%

PEF < 33%

Poor respiratory eort

BradycardiaAgitaon

Confusion

Silent Chest

Cyanosis

Treatment β2 agonist 4 pus

via spacer(Max 3 doses inone hour at 20minute intervals)

Consider oralcorcosteroid(OCS) 1-2 mg/kgat least one dose

Reassess aereach treatment

If respondingconnue β

2

agonist 1-4 hourly

If no responsearrange transferto hospital

O2 to maintain

SpO2 > 95%

β2 agonist 4-8

pus via spacer ornebulizedβ

2 agonist

0.03mls/kg(2.5mg-5mg)(Max 3 doses at20 minuteintervals)

Consideripratropiumbromide125-250μg(Max 3 dosesin one hour at 20minute intervals)

OCS 2 mg/kg(Max 40mg)

Reassess aereach treatment If no responsearrange transferto hospital

O2 to maintain

SpO2 > 95%

Nebulizedβ

2 agonist

0.03mls/kg(2.5mg-5mg)

Nebulizedipratropiumbromide125-250μg

OCS 2 mg/kg(Max 40mg)

Assess responseaer treatment If poor responsetransfer tohospital.Maximum oftwonebulizaons

before decisionto transfer.

O2 to maintain SpO

2

> 95%

Nebulized β2 agonist

0.03mls/kg(2.5mg-5mg)

Nebulized ipratropiumbromide 125-250μg

IV hydrocorsone4-6mg/kg orOCS 2 mg/kg

Immediate transfer tohospital



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3.2 MANAGEMENT OF ACUTE ASTHMA IN THE

EMERGENCY ROOM

Invesgaons and comments on these are as follows:

Peak ow

Upon presentaon•

At intervals depending on response to therapy•

Aer rst beta2-agonist dose•

Aer third beta2-agonist dose•Before discharge•

Pulse oximetry

Reects PaO•2

SaO•2 < 91% associated with CO

2 retenon

Blood gases

If SaO•2 < 91 %

Chest X-ray: Look for other causes with similar presentaon

Congenital malformaons•

Congesve Cardiac Failure•Atelectasis•

Pneumonia•

Pneumothorax•

Pneumomediasnum•



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Figure 3:

Assessment of Severity and Treatment in the A&E

Initial Treatment

Oxygen to achieve O2 saturation ≥90% (95% in children)

Inhaled rapid-acting β2-agonist continuously for one hour.

Systemic glucocorticosteroids if no immediate response, or if patient recently took oral glucocorticosteroid, or if

episode is severe.

Sedation is contraindicated in the treatment of an exacerbation.

Reassess after 1 Hour Physical Examination,PEF,O2 saturation and other tests as needed

Criteria for Moderate Episode:

PEF 60-80% predicted/personal best

Physical exam: moderate symptoms, accessory muscle use

Treatment:

Oxygen

Inhaled β2-agonist and inhaled anticholonergic every 60 min

Oral glucocorticosteroids

Continue treatment for 1-3 hours, provided there is

improvement

Criteria for Severe Episode:

History of risk factors for near fatal asthma

PEF < 60% predicted/personsal best

Physical exam: severe symptoms at rest, chest

retraction

No improvement after initial treatment

Treatment:

Oxygen

Inhaled β2-agonist and inhaled anticholinergic

Systemic glucocorticosteroids

Intravenous magnesium

Initial Assessment

History, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate, PEF or FEV1,

oxygen saturation, arterial blood gas if patient in extremis)

Reassess after 1-2 Hours

Good Response within 1-2 Hours:

Response sustained 60 min after last

treatment

Physical exam normal: No distress

PEF > 70%

O2 saturation > 90% (95% children)

Poor Response within 1-2 Hours:

Risk factors for near fatal asthma

Physical exam: symptoms severe,

drowsiness, confusion

PEF < 30%

PCO2 > 45 MM Hg

PO2 < 60 MM HgAdmit to Intensive Care

Oxygen

Inhaled β2-agonist + anticholinergic

Intravenous glucocortocosteroids

Consder intravenous β2-against

Consider intravenous theophylline

Possible intubation and mechanical

ventilation

Incomplete Response within 1-2

Hours:

Risk factors for near fatal asthma

Physical exam: mild to moderate

signs

PEF < 60%

O2

saturation not improving

Admit to Acute Care Setting

Oxygen

Inhaled β2-agonist ±

anticholinergic

Systemic glucocorticosteriod

Intravenous magnesium

Monitor PEF, O2 saturation, pulse

Reassess at intervals

Poor Response (see above):

Admit to Intensive Care

Incomplete response in 6-12 hours (see

above)

Consider admission to Intensive Care

if no improvement within 6-12 hours

Improved: Criteria for Discharge HomePEF > 60 % predicted/personal best

Sustained on oral/inhaled medication

Improved (see opposite)

Home Treatment:

Consider inhaled β2-agonist

Consider, in most cases, oral glucocorticosteroids

Consider adding a combination inhaler

Patient education: Take medicine correctly

Review action plan

Close medical follow-up



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3.3 MANAGEMENT ON THE MEDICAL WARD

Admission Criteria

Severe life threatening aack•

Pretreatment SaO•2 < 90%

Normal or high CO•2 aer treatment

Persistent metabolic acidosis•

Severe obstrucon that does not increase by 30-40%•

Paents who fail inial management and/or have an incomplete or poor response aer 1-2•

hours

Hospital or emergency department visit within the last month•

Concern about social circumstances or ability to cope at home•

Consider admission in the High Risk Asthmac i.e. paent with any ONE of the following:•Past history of sudden severe exacerbaons•

Prior intubaon or admission to ICU for asthma•

Two or more hospitalizaons for asthma in the past year•

Three or more A&E visits for asthma in the past year•

Hospitalizaon or an A&E visit for asthma in the past month•

Use of >2 canisters per month of inhaled short-acng beta2-agonist•

Current use of systemic corcosteroids or recent withdrawal from systemic•

corcosteroids

Diculty perceiving airow obstrucon or its severity•

Comorbidity, as from cardiovascular diseases or chronic pulmonary disease•

Serious psychiatric disease or psychosocial problems•

Management:

Connue nebulized β•2 agonist connuously or q1-4 hourly as needed

Connue ipratropium bromide 125-250-μg q6-8hrly•

Give oxygen to maintain O•2 saturaon >95%



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Give IV hydrocorsone for 48 hours or ll respiratory distress is improving then give•

oral prednisone 2 mg/kg to maximum of 40mg for an addional 3-5 days. Prednisone is

most eecve given three mes per day. Connue prednisone for longer if exacerbaonis prolonged. No need to wean if total duraon less than two weeks.

Admit to ICU if poor response and imminent respiratory failure.

Figure 4:

Discharge Criteria

PEF > 80%•

SaO•2 > 95%

Minimal/Absent signs and symptoms•

Sucient medicaons (bronchodilator and an-inammatory) can•

be obtained

Outpaent care can be obtained•

Acon/Management plan wrien•

Educaon re spacer and inhaler devices provided•

Follow up arranged•

Educaon re triggers and trigger avoidance•

Educaon re monitoring: peak ow and symptom diary•



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3.4 MANAGEMENT APPROACH, BASED ON CONTROL

See Figure 2 for assessment of control.

Figure 5:

Management Approach Based on Contol

For Children Older Than 5 Years, Adolescents and Adults

Level of Control Treatment Action

Controlled Maintain and find lowest controlling step

Partly controlled Consider stepping up to gain control

Uncontrolled Step up until controlled

Exacerbation Treat as exacerbation

R e d u c

I n c r e a s e

Reduce Increase

Step 1 Step 2 Step 3 Step 4 Step 5 Asthma education

Environment control

As needed rapid‐

acting ß2 agonist As needed rapid‐acting ß2 agonist

Select one Select one Add one or more Add one or both

Low‐dose

inhaled ICS* Low‐dose ICS

plus long‐acting

ß2 agonist

Medium‐or high‐

dose ICS plus long‐

acting ß2 agonist

Oral

glucocorticosteroid

(lowest dose)

Leukotriene

modifier ** Medium‐or high‐

dose ICS Leukotriene

modifier

Anti‐IgE

treatment

Low‐dose ICS

plus Leukotriene Sustained release

theophylline

Controller

Option ***

Low‐dose ICS

plus sustained

release

theophylline

* ICS inhaled glucocorscosteroids

** Receptor antagonist or synthesis inhibitors*** Preferred controller opons are shown in shaded boxes

Alternave reliever treatments include inhaled ancholinergics, short-acng oral ß2-agonists,

some short-acng ß2-agonists, and short-acng theophylline. Regular dosing with short

and long-acng ß2-agonist is not advised unless accompanied by regular use of an inhaled

glucocorcosteroid.

Treatment Steps

Oral

glucocorcosteroid

(lowest dose)



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• Control is assessed aer resoluon of the acute aack.

Some paents might not have symptoms between aacks. Paents who have 2 or more

exacerbaons/year requiring oral steroids are considered to have uncontrolled asthma.

• Step up if no response in 4-6 weeks. First check inhaler technique, adherence, control

of allergic rhinis and environmental control. Consider possibility of gastro-eosophageal

reux. Consider alternate diagnosis.

• Step down if possible if controlled for at least 3 months.

• Consult with asthma specialist at step 4 or higher.

• Maintain control using the lowest dose of inhaled corcosteroid and/or long acng β2-

agonist and/or leukotriene modier possible.



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Figure 6:

Esmated Equipotent Doses of Inhaled Glucocorcosteroids

Drug Adults

Daily dose ((µg)†

Children

Daily dose (µg) †

Low Medium High‡ Low Medium High‡

Beclomethasone

dipropionate

200-500 >500 -1000 >1000-2000 100-200 >200-400 >400

Budesonide* 200-400 >400-800 >800-1600 100-200 >200-400 >400

Budesonide-Neb ----- ----- ----- 250-500 >500-1000 >1000

Ciclesonide* 80-160 >160-320 >320-1280 80-160 >160-320 >320

Flunisolide 500-1000 >1000-2000 >2000 500-750 >750-1250 >1250

Flucasone 100-250 >250-500 >500-1000 100-200 >200-500 >500

Mometasone

furoate*

200-400 >400-800 >800-1200 100-200 >200-400 >400

Triamcinolone

acetonide

400-1000 >1000-2000 >2000 400-800 >800-1200 >1200

† Comparisons based upon ecacy data.

‡ Paents considered for high daily doses except for short periods should be referred to specialist for

assessment to consider alternave combinaons of controllers. Maximum recommended doses are

arbitrary but with prolonged use are associated with increased risk of systemic side eects.

* Approved for once-daily dosing in mild paents.

Addional Notes:

• The most important determinant of appropriate dosing is the clinician’s judgment of the paent’s response

to therapy. The clinician must monitor the paent’s response in terms of clinical control and adjust the

dose accordingly. Once control of asthma is achieved, the dose of medicaon should be carefully trated

to the minimum dose required to maintain control, thus reducing the potenal for adverse eects.

• Designaon of low, medium, and high doses is provided from manufacturers’ recommendaons where

possible. Clear demonstraon of dose-response relaonships is seldom provided or available. Theprinciple is therefore to establish the minimum eecve controlling dose in each paent, as higher doses

may not be more eecve and are likely to be associated with greater potenal for adverse eects.

• As CFC preparaons are taken from the market, medicaon inserts for HFA preparaons should be

carefully reviewed by the clinician for the equivalent correct dosage.



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Part 4:Management of Asthma

in the Adult

Management of Asthma in the Adult


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4.1 MANAGEMENT ADULT ASTHMA IN PRIMARY CARE

4.1.1 Assess severity

Cough, breathlessness, wheeze, chest ghtness, use of accessory muscles, suprasternal

retracons, and sleep disturbances. The PEF is less than 80% of personal best or predicted.

• Inhaled rapid-acng ß2-agonists in adequate doses are essenal.

(Begin with 2 to 4 pus every 20 minutes for the rst hour; then mild exacerbaons will

require 2 to 4 pus every 3 to 4 hours, and moderate exacerbaons 6 to 10 pus every 1 to 2

hours.)

• Oral glucocorcosteriods (0.5 to 1 mg of prednisolone/kg or equivalent during a 24-hour

period) introduced early in the course of a moderate or severe aack help to reverse theinammaon and speed recovery.

• Oxygen is given at health centers or hospitals if the paent is hypoxemic (achieve O2

saturaon of 95%).

• Combinaon ß2-agonists/ancholinergic therapy is associated with lower hospitalizaon rates

and greater improvement in PEF and FEV1.

• Methylxanthines are not recommended if used in addion to high doses of inhaled ß2-

agonists. However, theophylline can be used if inhaled ß2-agonists are not available. If

the paent is already taking theophylline on a daily basis, serum concentraon should be

measured before adding short-acng theophylline.

Therapies not recommended for treang asthma aacks include:

• Sedaves (strictly avoid)

• Mucolyc drugs (may worsen cough)

• Chest physical therapy/physiotherapy (may increase paent discomfort)

• Hydraon with large volumes of uid for adults and older children (may be necessary for

younger children and infants).

4.1.2 Response to Inial Treatment is….

Good if …. symptoms subside aer inial beta 2 agonist and relief is sustained for 4 hours. PEF

is greater than 80% of personal best or predicted.

Acons: May connue beta-2 agonist every 3-4 hours for 1-2 days.

Contact physician for follow up instrucon.

Incomplete if …symptoms decrease but return in less than 3 hours aer inial beta 2 agonisttreatment. PEF is 60-80% of personal best or predicted.

Acons: Add corcosteroid tablet or syrup

Connue beta-2 agonist

Consult physician urgently for instrucons.



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Poor if …Symptoms persist or worsen despite inial beta 2 agonist treatment

Acons: Add corcosteroid tablet or syrup

Repeat beta-2 agonist immediatelyImmediate transport to hospital emergency department.

4.1.3 Selecng medicaons

Environmental control and educaon should be instuted for all asthma paents.

Two types of medicaon help control asthma: relievers are medicaons (short-acng

bronchodilators) that work fast to stop aacks or relieve symptoms and controllers aremedicaons (especially an-inammatory agents) that keep symptoms and aacks from

starng.

Inhaled medicaons: In the Caribbean tablets and liquids were inially widely used, but

inhaled medicaons are the most eecve treatment today. High concentraons of drugs

are delivered directly to the airways with patent therapeuc eects and minimal side eects.

A stepwise approach is used to classify asthma severity and guide treatment. The number andfrequency of medicaons increase (step up) as the need for asthma therapy increases, and

decreases (step down) when asthma is under control.

The recommended treatments are guidelines only. Local resources and individual paent

circumstances determine specic therapy. Generic forms of salbutamol have been found to

be as eecve as branded products in improving pulmonary funcon but in 1 study, 88%

of paents reported throat irritaon and cough sensaon aer inhaling Asthalin (a generic

salbutamol). This may reduce paent compliance with treatment (Pinto-Pereira 2002).

Start treatment at the step most appropriate to the inial severity of the paent’s asthma. The

goal is to establish control as soon as possible; then decrease treatment to the least medicaon

necessary to maintain control.

Persistent asthma is more eecvely controlled by long-term treatment to suppress and reverse

the inammaon than by only treang acute bronchoconstricon and related symptoms.

An-inammatory agents, parcularly inhaled corcosteroids, are currently the most

eecve long-term preventor medicaons. Paents who use inhaled glucocorcosteroids

regularly should be encouraged to rinse and expectorate to reduce oropharyngeal deposion

and systemic absorpon.



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The inial daily dose of beclomethasone dipropionate or the equivalent is 400-1000 micrograms.

Higher doses or oral therapy may be required for more severe asthma.

A short course (7 to 10 days) of oral corcosteroids may be needed at any step to establish

prompt control

Step up if control is not achieved. Generally, improvement should be achieved within 1 month.

But rst review the paent’s medicaon technique, compliance and avoidance of triggers.

Step down if control is sustained for at least 3 months; follow a gradual stepwise reducon in

treatment.

Review treatment every 3 to 6 months once asthma is under control.

Consult with an asthma specialist when clinical condions complicate asthma (e.g., sinusis),

the paent does not respond opmally to therapy, or treatment at step 4 is required.

In paents poorly controlled on connuous steroid use, adding a regular long acng beta

agonist improves symptoms and reduces rescue medicaon use as opposed to increasing the

dose of inhaled steroids.

Benets of low dose inhaled steroid and slow-release theophylline (200mg b.i.d.)

In paents with mild to moderate persistent asthma poorly controlled on inhaled steroids,

adding a slow-release theophylline 200mg twice a day and connuing the inhaled steroids was

beer (improved morning and evening PEF) than placebo aer 6 months.

In paents with mild to moderate persistent asthma poorly controlled on inhaled steroids,

adding a slow-release theophylline 200mg twice a day and connuing the inhaled steroids was

the same as high dose inhaled steroids (similar morning and evening PEF).

In paents with moderate persistent asthma poorly controlled on budesonide daily > 800

micrograms/day, adding a slow-release theophylline 200mg twice a day and connuing the

inhaled steroids gave the same result as either using a leukotriene antagonist or adding a long-

acng beta agonist (formoterol) (no signicant dierences in decrease in daily PEF variability,

day or night me asthma symptoms morning and evening PEFR).

For further details of management based on control and doses of inhaled steroids please see

gures 5 and 6.



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4.2 MANAGEMENT ADULT ASTHMA IN THE EMERGENCY

ROOM

4.11 Overview of Acute Care of Asthma in the Adult with Evidence Base

Lessons from studies of asthma deaths and near fatal asthma

Condenal enquires into over 200 asthma deaths in the UK have concluded there

are factors associated with the disease, the medical management and the paent’s

behaviour or psychosocial status which contributed to the death. Most occurredbefore admission to hospital (Wareham 1993).

Disease factors

Most paents who died of asthma had chronically severe asthma. In a minority

the fatal aack occurred suddenly in a paent with only mild or moderately severe

background disease. (Wareham 1993, Harrison 2000)

Medical management

Many of the deaths occurred in paents who had received inadequate treatment

with inhaled steroid tablets and/or inadequate objecve monitoring of their asthma.

Follow-up was inadequate in some and others should have been referred earlier for

specialist advice. There was widespread under-use of wrien management plans.

Heavy increasing use of beta-2 agonist therapy was associated with asthma death.

(Wareham 1993, Spitzer 1992, Suissa 1994)

Deaths have connued to be reported following inappropriate prescripon of

ß-blocker therapy or heavy sedaon. A small proporon of paents with asthma

were sensive to non-steroidal an-inammatory agents; all asthma paents should

be asked about past reacons to these agents and to be cauous about their use.

Adverse psychosocial and behavioral factors Behavioral and adverse psychosocial factors were recorded in the majority of

paents who died of asthma. (Wareham 1993). The most important are shown in

Table 3.

Case control studies support most of these observaons (Rea 1986, Jalaludin 1999).



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Compared with control paents admied to hospital with asthma, those who died

were signicantly more likely to have learning dicules; psychosis or prescribed

anpsychoc drugs; nancial or employment of problems; repeatedly failed toaend appointments or discharged themselves from hospital; drug or alcohol

abuse; obesity; or a previous near fatal aack.

Compared with control paents with asthma in the community, paents who died

had more severe disease; more likelihood of a hospital admission or visit to A&E for

their asthma in the previous year; more likelihood of a previous near fatal aack;

poor medical management; failure to measure pulmonary funcon; and non-

compliance.

Health care professionals must be aware that paents with severe asthma and

one or more adverse psychosocial factors are at risk of death.

Table 3:

Features of Near Fatal Adult Asthma

A COMBINATION OF SEVERE ASTHMA RECOGNISED BY ONE OR MORE OF:

previous near fatal asthma, e.g. previous venlaon or respiratory acidosis•

previous admission for asthma especially if in the last year•

requiring three or more classes of asthma medicaon•

heavy use of ß•2 agonist

repeated aendances at A&E for asthma care especially if in the last year•

brile asthma.•

AND ADVERSE BEHAVIOURAL OR PSYCHOSOCIAL FEATURES RECOGNISED BY ONE OR MORE OF :

non-compliance with treatment or monitoring•

failure to aend appointments•

self -discharge from hospital•

psychosis, depression, other psychiatric illness or deliberate self-harm•

current or recent major tranquilliser use•

denial•

alcohol or drug abuse•obesity•

learning dicules•

employment problems•

income problems•

social isolaon•

childhood domesc, marital or legal stress.•



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Studies comparing near fatal asthma with deaths from asthma have concluded that

paents with near fatal asthma have idencal adverse factors to those described in Table

3, and that these contribute to the near fatal asthma aack. (Richards 1993, Innes 1998).Compared with paents who die, those with near fatal asthma are signicantly younger,

are signicantly more likely to have had a previous near fatal asthma aack, are less

likely to have concurrent medical condions, are likely to experience delay in receiving

medical care, and more likely to have ready access to acute medical care.

Not all paents with near fatal asthma require intermient posive pressurevenlaon.

For those with near fatal asthma, adults as well as children, it is always wise to involve aclose relave when discussing future management.

Paents with brile asthma should also be idened (see Table 4)

Where services allow keep paents who have had near fatal asthma or brile asthma

under specialist supervision indenitely.

Seasonal factors

In the UK there is a peak of asthma deaths in younger people (aged up to 44 years) in July

and August and in December and January in older people. (Campbell 1997, Khot 1983).

Predicon and prevenon of a severe asthma aack

Most (88-92%) aacks of asthma severe enough to require hospital admission develop

relavely slowly over a period of six hours or more. In one study, over 80% of aacksdeveloped over more than 48 hours. (Kolbe 1998, Kolbe 2000). There should therefore

be me for eecve acon and the potenal to reduce the number of aacks requiring

hospitalizaon. There are many similaries between paents who die from asthma,

paents with near fatal asthma and asthmac controls who are admied to hospital.

Where feasible, a respiratory specialist or specialist physician should follow up

paents admied with severe asthma for at least one year aer the admission.

Criteria for referral

Refer to hospital any paents with features of acute severe or life threatening asthma.

Other factors, such as failure to respond to treatment, social circumstances or concomitant

disease, may warrant hospital referral.



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4.1.2 Inial Assessment and Invesgaon of Acute Asthma in the Adult

Acute asthma in adults

Recommendaons for paents presenng with acute or uncontrolled asthma in primary

care are shown elsewhere in this document. We proceed now with care in those seen in the

emergency department and on the medical wards.

Recognion of acute asthma

Denions of increasing levels of severity of acute asthma exacerbaons are provided in Table

4. Predicted PEF values (Nunn 1989)) should be used only if the recent best PEF (within two

years) is unknown .

Self-treatment by paents developing acute or uncontrolled asthma

Many paents with asthma and all paents with severe asthma should have an agreed wrien

acon plan and their own peak ow meter, with regular checks of inhaler technique andcompliance. They should know when and how to increase their medicaon and when to seek

medical assistance. Asthma acon plans have been shown to decrease hospitalizaon for and

deaths from asthma (Abramson 2001).

Inial assessment

All possible inial contact personnel, e.g. pracce receponists, ambulance call takers, should

be aware that asthma paents complaining of respiratory symptoms may be at risk and should

have immediate access to a doctor or trained asthma nurse if available. The assessments

required to determine whether the paent is suering from an acute aack of asthma, the

severity of the aack and the nature of treatment required are detailed in Tables 4 and 5. It

may also be helpful to use a systemac recording process. Proformas have proved useful in

the A&E seng (Robinson 1996).


Table 4:


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Table 4:

Levels of severity of actue asthma exacerbaons in adults

Near fatal asthma Raised PaCO2 and/or requiring mechanical venlaon with raised inaon

pressures (Richards 1993, Innes 1998)

Life threatening asthma Any one of the following in a paent with severe asthma

- PEF 50-75% best or predicted

- no features of acute severe asthma

Brile asthma - Type l: wide PEF variability (>40% diurnal variaon for 50% of the me over a

period >150 days) despite intense therapy

- Type 2: sudden severe aacks on a background of apparently well controlled

asthma

Prevenon of acute deterioraon

A register of paents at risk may help primary care health professionals to idenfy paents

who are more likely to die from their asthma. Where possible, a system should be in place to

ensure that these paents are contacted if they fail to aend for follow up.



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Table 5:

Inial assessment - the role of symptoms, signs and measurements in adults

Clinical features Clinical features, symptoms and respiratory and cardiovascular signs are helpful

in recognizing some paents with severe asthma, e.g. severe breathlessness

(including too breathless to complete sentences in one breath), tachypnoea,

tachycardia, silent chest, cyanosis or collapse.

None of these singly or together is specic and their absence does not exclude

a severe aack.

PEF or FEV Measurements of airway caliber improve recognion of the degree of severity,the appropriateness or intensity of therapy and decisions about management

in hospital or at home. (Shim 1980, Emerman 1995).

PEF or FEV, are both useful and valid measures of airway caliber. PEF is more

convenient and cheaper.

PEF expressed as a percentage of the paent’s previous best value is most

useful clinically. PEF as a percentage of predicted gives a rough guide in the

absence of a known previous best value. Dierent peak ow meters give

dierent readings. Where possible the same or similar type of peak ow metershould be used. The Nunn& Gregg nomogram is recommended for use with

peak ow meter. (Gregg 1973).

Pulse oximetry Measurement of oxygen saturaon (SpO2) with a pulse oximeter is necessary

in acute severe asthma to determine the adequacy of oxygen therapy and the

need for arterial blood gas (ABG) measurement. The aim of oxygen therapy is

to maintain SpO2>92%.

Blood gases (ABG) Paents with SpO2


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4.3 MANAGEMENT OF ADULT ASTHMA ON THE MEDICAL

WARD

4.3.1 Criteria for admission to the ward

Admit paents with any feature of a life threatening or near fatal aack

Admit paents with any feature of a severe aack persisng aer inial treatment

(Wareham 1993, Mohan 1996, Campbell 1997, Innes 1998)

Paents whose peak ow is greater than 75% best or predicted one hour aer inial

treatment may be discharged from A&E, unless they meet any of the following criteria,

when admission may be appropriate:

• Sll have signicant symptoms

• Concerns about compliance

• Living alone/socially isolated

• Psychological problems

• Physical disability or learning dicules

• Previous near fatal or brile asthma

• Exacerbaon despite adequate dose steroid tablets pre-presentaon

• Presentaon at night

• Pregnancy

4.3.2 Treatment of acute asthma in adults (Evidence Base and Recommendaons)

A) Oxygen

Paents with acute severe asthma are hypoxaemic (Malna 1991, Jenkins 1981). This

should be corrected urgently using high concentraons of inspired oxygen (usually40-60%) and a high ow mask (e.g. Hudson mask). Unlike paents with COPD there

is lile danger of precipitang hypercapnea with high ow oxygen. Hypercapnea

indicates the development of near fatal asthma and the need for emergency specialist/

anaesthec intervenon. Oxygen saturaons of at least 92% must be achieved.


Give high ow oxygen to all paents with acute severe asthma


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Give high ow oxygen to all paents with acute severe asthma.

In view of the theorecal risk of oxygen desaturaon while using air driven compressors to

nebulise β2 agonist bronchodilators, oxygen-driven nebulisers are the preferred method

of delivery in hospitals, ambulances and primary care. (Gleeson, 1998) (NB: In order to

generate the ow rate of 61/ min required to drive most nebulisers, a high ow regulator

must be ed at the oxygen cylinder). The absence of supplemental oxygen should not

prevent nebulised therapy from being administered where appropriate. (Douglas 1985).

In hospital, ambulance and primary care, nebulised β•2 agonist bronchodilators

should be driven by oxygen.

Outside hospital, high dose β•2 agonist bronchodilators may be delivered via

large volume spacers or nebulisers.

Whilst supplemental oxygen is recommended, its absence should not preventnebulised therapy being given if indicated.

B) Beta-2 agonist bronchodilators

In most cases of acute asthma inhaled β2 agonists given in high doses act quickly to relievebronchospasm with few side-eects (Sigel 1985). There is no evidence for any dierence

in ecacy between salbutamol and terbutaline, although rarely paents may express

preference.

In acute asthma without life threatening features, β2 agonists can be administered by

repeated acvaons of a pMDI via an appropriate large volume spacer or via spacer (4

to 6 pus each inhaled separately; this dose can be repeated at 10-20 minute intervals)

or by wet nebulisaon driven by oxygen, if available. Inhaled β2 agonists are at least

as ecacious and preferable to intravenous β2 agonists (meta-analysis has excluded

subcutaneous trials) in adult acute asthma in the majority of cases. (Travers 2001).

Use high dose inhaled β2 agonists as rst line agents in acute asthma and administer

as early as possible. Intravenous β2 agonists should be reserved for those paents

in whom inhaled therapy cannot be used reliably.

In acute asthma with life threatening features the nebulised route (oxygen-driven)is recommended.

Parenteral β2 agonists, in addion to inhaled β

2 agonists, may have a role in venlated

paents or those paents in extremis in whom nebulised therapy may fail; however there

is limited evidence to support this.


Connuous nebulisaon of β agonists is at least as ecacious as bolus nebulisaon


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Connuous nebulisaon of β2 agonists is at least as ecacious as bolus nebulisaon

in relieving acute asthma. It is more eecve in airow obstrucon that is severe or

unresponsive to inial treatment. (Rudinsky 1993). However, most cases of acute asthmawill respond adequately to bolus nebulisaon of β

2 agonists.

In severe asthma (PEF)


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Inhaled steroids do not provide benet in addion to the inial treatment, but should

be connued (or started as soon as possible) to form the start of the chronic asthma

management plan.

D) Ipratropium bromide

Combining nebulised ipratropium bromide with a nebulised β2 agonist has been shown to

produce signicantly greater bronchodilaon that a β2 agonist alone, leading to a faster

recovery and shorter duraon of admission. Ancholinergic treatment is not necessary

and may not be benecial in milder exacerbaons of asthma or aer stabilizaon(Stoodley, 1999).

Nebulised ipratropium bromide (0.5mg 4-6 hourly) should be added to β2 agonist

treatment for paents with acute severe or life threatening asthma or those with a

poor inial response to β agonist therapy.

E) Intravenous magnesium sulphate

A single dose of IV magnesium sulphate has been shown to be safe and eecve in acute

severe asthma who have not had a good inial response to treatment. (Rowe 2001).

The safety and ecacy of repeated doses have not been assessed in paents with

asthma. Repeated doses could give rise to hypermagnesaemia with muscle weakness

and respiratory failure.

Consider giving a single dose of IV magnesium sulphate for paents with

Acute severe asthma who have not had a good inial response to inhaled•

bronchodilator therapy

Life threatening or near fatal asthma.•

IV magnesium sulphate (1.2-2.0 g IV infusion over 20 minutes should only be used

following consultaon with senior medical sta.

More studies are needed to determine the opmal frequency and dose of IV magnesium

sulphate therapy.


F) Intravenous aminophylline


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) p y

In acute asthma, the use of IV aminophylline is not likely to result in any addionalbronchodilaon compared to standard care with inhaled bronchodilators and steroid

tablets. Side-eects such as palpitaons, arrhythmias and voming are increased if IV

aminophylline is used. (Parameswaran 2001)

Use of IV aminophylline only aer consultaon with senior medical sta.

Some individual paents with near fatal asthma or life threatening asthma with a poor

response to inial therapy may gain addional benet from IV aminophylline (5mg/kg

loading dose over 20 minutes unless on maintenance oral therapy, then infusion of 0.5-

0.7mg/kg/hr). Such paents are probably rare and could not be idened in a meta-

analysis of trials involving 739 subjects. If IV aminophylline is given to paents on oral

aminophylline or theophylline, blood levels should be checked on admission. Levels

should be checked daily for all paents on aminophylline infusions. (Maintain between

10-20mg/L)

G) Anbiocs

When an infecon precipitates an exacerbaon of asthma it is likely to be viral in type.

The role of bacterial infecon has been overesmated.

Roune prescripon of anbiocs is not indicated for acute asthma.

H) Intravenous uids

There are no controlled trials or even observaonal or cohort studies of diering uid

regimes in acute asthma. Some paents with acute asthma require rehydraon and

correcon of electrolyte imbalance. Hypokalaemia can be caused or exacerbated by β2

agonist and/or steroid treatment and must be corrected.

I) Referral to intensive care

Indicaons for admission to intensive care facilies or a high dependency unit include

paents requiring venlatory support and those with severe acute or life threatening

asthma who are failing to respond to therapy, as evidenced by:

deteriorang PEF•persisng or worsening hypoxia•


hypercapnoea•


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arterial blood gas analysis showing fall in pH or rising H• + concentraon

exhauson, feeble respiraon•drowsiness, confusion•

coma or respiratory arrest.•

Not all paents referred to the Intensive Care Unit (ICU) need venlaon, but those with

worsening hypoxia or hypercapnea, drowsiness or unconsciousness and those who have

had a respiratory arrest require intermient posive pressure venlaon. Intubaon in

such paents referred may be very dicult. Intensive care management is not within the

remit of these guidelines.

All paents transferred to intensive care units should be accompanied by a

doctor suitably equipped and skilled to intubate if necessary.

J) Further invesgaon and monitoring

Measure and record PEF 15-30 minutes aer starng treatment, and thereaer•

according to the response. Measure and record PEF before and aer nebulised or

inhaled β agonist bronchodilator (at least four mes daily) throughout the hospital

stay and unl controlled aer discharge

Record oxygen saturaon by oximetry and maintain arterial SaO•2 > 92%

Repeat measurements of blood gas tensions within two hours of starng treatment•

if:

the inial PaO• 2 is 92%; orthe inial PaCO•2 is normal or raised; or

the paent’s condion deteriorates•

Measure them again if the paent’s condion has not improved by 4-6 hours•

Measure and record the heart rate.•

Measure serum potassium and blood glucose concentraons•

Measure the serum theophylline concentraon if aminophylline is connued for•more than 24 hours (aim at a concentraon of 55-110μmol/L).


K) Asthma management protocols and proformas


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The use of structured proformas has been shown to facilitate improvements in the processof care in A&E departments and hospital wards and to improve paent outcomes. The

use of this type of documentaon can assist data collecon aimed at determining quality

of care and outcomes.

L) HOSPITAL DISCHARGE AND FOLLOW UP (see Table 7)

Criteria for and ming of discharge from hospital and emergency departments have beenstudied. The key events in recovery appear to be improved symptoms and peak ow rather

than a complete return to normality. Discharge when improvement is apparent may be

as safe as discharge when full stability is achieved. Asthma specialist nurse educaon of

adults and school-age (but not pre-school) children at or shortly aer hospital aendance

improves symptom control, self-management and re-aendance rates. (Wesseldine 1999,

Smith 2000, Levy 2000, Greineder 1995).

4.3.3 Discharge Timing, Educaon and Follow-up

Timing of discharge

There is no single physiological parameter that denes absolutely the ming of

discharge from an admission with acute asthma. Paents should have clinical signs

compable with home management, be on reducing amounts of β agonist (preferably

no more than four hourly) and be on medical therapy they can connue safely at

home.

Although diurnal variability of PEF is not always present during an exacerbaon,

evidence suggests that paents discharged with PEF 25% are at greater risk of early relapse and readmission.

(Udwadia 1990).

Paent educaon

Following discharge from hospital or A&E departments, a proporon of paents re-

aend A&E departments with more than 15% re-aending within two weeks. Some

repeat aendees need emergency care, but many delay seeking help, and are under-

treated and/or under-monitored. (Emerman 1999)


Prior to discharge, trained sta should give asthma educaon. This should include

d i h l h i d PEF d k i i h i PEF d


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educaon on inhaler technique and PEF record keeping; with a wrien PEF and

symptom-based acon plan being provided allowing the paent to adjust theirtherapy within recommendaons. These measures have been shown to reduce

morbidity aer the exacerbaon and reduce relapse rates. (Cowie 1997).

There is some experience of a discrete populaon of paents who inappropriately

use A&E departments rather than the primary care services for their asthma care

(Nat. Asthma Task Force UK ).

For the above groups there is a role for a trained asthma liaison nurse based in, orassociated with the A&E department.

Follow-up

A careful history should elicit the reasons for the exacerbaon and explore possible

acon

Caribbean Asthma Guidelines - Revised March 2011

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