Classification of Chronic Asthma Severity on Treatment

Classification of Chronic Asthma Classification of Chronic Asthma Severity on TreatmentSeverity on Treatment

Domains/Estimates

Intermittent Persistent

Mild to Moderate

Severe**

Daytime symptoms

Monthly Weekly Daily

Nocturnal awakening

Less than monthly

Monthly to weekly

Nightly

Rescue 2

agonist useLess than

weeklyWeekly to

dailySeveral

times a day

PEF or FEV1* > 80 % predicted

60 to 80 % of predicted

< 60 % of predicted

Treatment needed to control asthma

Occasional prn

2 only

Regular ICS + LABA

combination

Combination ICS + LABA +

OCS

PCCP Council on Asthma

PCRADM 2004

*Objective measures take precedence over subjective complaints. The higher severity level of any domain will be the basis of the final severity level. **Patients who are high risk for asthma-related deaths are initially classified here

P

Controller MedicationsController MedicationsInhaled glucocorticosteroidsLong-acting inhaled β2-agonistsSystemic glucocorticosteroidsLeukotriene modifiers (Sustained Release) TheophyllineCromonesLong-acting oral β2-agonistsAnti-IgE


P

Reliever MedicationsReliever MedicationsRapid-acting inhaled β2-agonistsSystemic glucocorticosteroids (acute setting)

AnticholinergicsTheophyllineShort-acting oral β2-agonists


Characteristic

ControlledPartly controlled(Any present in any

week)

Uncontrolled

Daytime symptoms

None (2 or less / week)

More than twice / week

3 or more features of partly

controlled asthma

present in any week

Limitations of activities

None Any

Nocturnal symptoms / awakening

None Any

Need for rescue /

“reliever” treatment

None (2 or less / week)

More than twice / week

Lung function (PEF or FEV1)

Normal< 80% predicted or

personal best (if known) on any day

Exacerbation None One of more/yearOne in any

week

Assessing

Control

Levels of Asthma Levels of Asthma ControlControl


GINA. 2007. Available at: http://www.ginaasthma.org

Treatment ActionLevel of Control

Treatment Steps (in the order of increasing efficacy to attain control)

Controlled Maintain and find lowest controlling step

Partly Controlled Consider stepping up to gain control

Uncontrolled Step up until controlled

Exacerbation Treat as exacerbation

Incre

asee

Red

uce

Step 2 Step 3 Step 4 Step 5Step 1

Asthma Education / Environmental ControlAs needed

rapid-acting ß2-agonist

As needed rapid-acting ß2-agonist

Controller Options

Select One Select One Add one or more

Add one or more

Low-dose

ICSLow dose

ICS+LABAMedium or high-dose

ICS+LABA

Oral glucocorticosteroid (lowest

dose)

Leukotriene modifier

Medium or high-dose ICS


Anti IgE treatment

Low-dose ICS plus Leukotriene

modifier Sustained release

theophyllineLow dose ICS plus sustained release

theophylline

ReduceReduce IncreaseIncrease

Treating toachieve Control

GINA. 2007. Available at: http://www.ginaasthma.org.


Treatment Steps (in the order of increasing efficacy to attain control)

Step 2 Step 3 Step 4 Step 5Step 1

Asthma Education / Environmental ControlAs needed

rapid-acting ß2-agonist

As needed rapid-acting ß2-agonist

Controller Options

Select One Select One Add one or more

Add one or more

Low-dose

ICSLow dose

ICS+LABAMedium or high-dose

ICS+LABA

Oral glucocorticosteroid (lowest

dose)


Medium or high-dose ICS


Anti IgE treatment

Low-dose ICS plus Leukotriene

modifier Sustained release

theophyllineLow dose ICS

plus sustained release

theophylline

GINA. 2007. Available at: http://www.ginaasthma.org.

Increase Reduce

In the local setting, for the majority of symptomatic patients, the consensus is to start at step 3, with low doses of a fixed-dose ICS+LABA combination inhaler.


P

Single inhaler maintenance and Single inhaler maintenance and relief therapy strategyrelief therapy strategy

If a combination inhaler containing formoterol and budesonide is selected, it may be used for both rescue and maintenance.

This approach has been shown to result in : Reductions in exacerbations Improvements in asthma control in adults and

adolescents at relatively low doses of treatment (Evidence A)


P

Additional Step 3 Options for Adolescents and Adults :

Increase to medium-dose inhaled gluco-corticosteroid (Evidence A)

Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)

Low-dose sustained-release theophylline (Evidence B)

Treating to Achieve Asthma Treating to Achieve Asthma ControlControl


P

Asthma control should be monitored by the health care professional & by the patient.

Improvement begins within days of initiating controller treatment but the full benefit may only be evident after 3 to 4 months

When control as been achieved, ongoing monitoring is essential to:

- maintain control

- establish lowest step/dose treatment

Treating to Achieve Asthma Treating to Achieve Asthma ControlControl


Stepping Down Treatment when Asthma is Controlled

Reduce by 50 %

Every 3 months

Monitoring to

maintain Control

Med to high-dose ICS

Low-dose ICS

Decrease to Once daily

dosing

Decrease to Once daily

dosing

ICS-LABA

Reduce ICS by 50 %

Maintain LABA dose

Further reduce ICS dose or

Stop LABA and continue ICS or

Decrease ICS-LABAto Once daily dosing


P

Stepping Up Treatment in Stepping Up Treatment in Response to Loss of ControlResponse to Loss of Control

Treatment has to be adjusted periodically in response to worsening control which may be recognized by the minor recurrence or worsening of symptoms

Treatment options : Rapid-onset, short-acting or long-acting

bronchodilators : repeated dosing provides temporary relief

A four-fold or greater increase in inhaled gluco-corticosteroids


No

Classify and Treat based on Severity Classification of

Asthma in Acute Exacerbation

YesIn Acute exacerbatio

n ?

Patient with Asthma

presenting with symptoms

No

No

Yes

Go 2 steps higher

Go 1 step higher

Assess level of control

Partly controlled?

YesCurrently onController

Medications?

Classify according to

PCRADM Chronic Severity

Controller medication

naive ?

Treat as Severe

Persistent Asthma

Yes

Treat as Mild-to-ModeratePersistent Asthma

No

Algorithmic Approach to Asthma Assessment and Management

YesPoorly or

uncontrolled?

Yes Classified as Severe

?


P

Asthma ExacerbationsAsthma ExacerbationsEpisodes of progressive worsening of SOB,

cough, wheezing or chest tightness or some combination of these symptoms

Significant decreases in PEF or FEV1 which are more reliable indicators of severity of airflow obstruction than degree of symptoms

Range from mild to life-threatening deterioration usually progresses over hours or days, or precipitously over some minutes


Severity of Asthma ExacerbationsSeverity of Asthma Exacerbations

Mild Moderate SevereRespiratory

arrest imminent

Breathless Walking Talking At rest

Talks in Sentences Phrases Words

Alertness May be agitatedUsually agitated

Usually agitatedDrowsy or confused

Respiratory rate

Increased Increased Often > 30/min

Accessory muscles & suprasternal retractions

Usually not Usually Usually

Paradoxical thoraco-

abdominal movement

WheezeModerate, often

only end-expiratory

Loud Usually loudAbsence of

wheeze

Pulse/min <100 100 - 120 > 120 Bradycardia

Pulsus paradoxus

Absent < 10 mmHg

May be present

10-25 mmHg

Often present> 25 mmHg

PEF after initial BD % predicted or % personal best

Over 80 %Approx 60 – 80

%

< 60 % predicted or personal best(<100/min or

response lasts 2 hrs

PaO2

and/or PaCO2

Normal

< 42 mmHg < 42 mm Hg

< 60 mmHg Possible cyanosis

> 42 mmHgPossible resp failure

SaO2 > 95 % 91 – 95 % < 90 %


P

Features of Patients at high-risk Features of Patients at high-risk for for Asthma-Related DeathAsthma-Related Death Current use of or recent withdrawal from systemic

corticosteroids ER visit for asthma in the past year History of near-fatal asthma requiring intubation

or mechanical intubation Not currently using inhaled steroids Overdependence on rapid acting inhaled 2

agonists, esp. those with more than one canister monthly

Psychiatric disease or psychosocial problems, incl. the use of sedatives

Noncompliance with asthma medication plan


P

Management of Asthma Management of Asthma ExacerbationsExacerbations Primary therapies for exacerbations:

Repetitive administration of rapid-acting inhaled β2-agonist

Early introduction of systemic glucocorticosteroids

Oxygen supplementation

Closely monitor response to treatment with serial measures of lung function


P

Criteria for Criteria for hospitalizationhospitalization Inadequate response to therapy within 1-

2 hoursPersistent PEF <50% after 1 hour of

treatmentPresence of risk factorsProlonged symptoms prior to ER consult Inadequate access to medical care and

medicationsDifficult home conditionDifficulty in obtaining transport to

hospital in event of further deterioration


P

Asthma Exacerbations & Asthma Exacerbations & HospitalizationHospitalization• Despite appropriate therapy, ~ 10 to 25

% of ER patients with acute asthma will require hospitalization.

• Response to initial treatment in the ER is a better predictor of the need for hospitalization than is severity on presentation

• FEV1 or PEF appears to be more useful in adults for categorizing severity of exacerbation & response to treatment.


Initial Assessment : History, PE, PEF or FEV1, SaO2

Repeat Assessment:PE, PEF, SaO2 , other tests as needed

Moderate Episode: PEF or FEV1 =40 – 69 % predicted or personal best

• PE : Moderate symptoms •Treatment :

•Inhaled SABA every 60 minutes •Oral systemic corticosteroids•Continue treatment 1-3 hrs provided there is improvement ; make decision in < 4 hrs

Severe Episode:PEF or FEV1 < 40 % predicted or personal best

• PE : Severe symptoms at rest, accessory muscle use, chest retraction• History : high-risk for asthma- related death• No improvement after initial treatment•Treatment :

•Oxygen• NebulizedSABA + ipratropium hourly or continuous • Oral systemic corticosteroids• Consider adjunct therapies

Management of Acute Exacerbations : Hospital Setting

PEF or FEV1 ≥ 40 % predicted•Oxygen to achieve SaO2 ≥ 90%•Inhaled SABA by nebulizer or MDI with valve holding chamber up to 3 doses in 1st hour

PEF or FEV1 40 % predicted•Oxygen to achieve SaO2 ≥ 90%•High-dose inhaled SABA + ipratropium by nebulizer or MDI with valve holding chamber every 20 min or continuously for 1 hour

Impending or actual respiratoryarrest

•Intubation and mechanical ventilation with 100% O2

•Nebulized SABA and ipratropium •Intravenous corticosteroids•Consider adjunct therapies

Admit to hospital intensive care


Moderate Episode Severe Episode

Good Response Response sustained for 1 hr

after last treatment No risk factors

• S/Sx : No distress, normal PE• PEF > 70 % predicted or personal best• SaO2 > 90 %

Incomplete Responsewithin 1 hr &/or (+) risk factors

•S/Sx : Mild to moderate• PEF > 50 % but < 70 % predicted or personal best• SaO2 not improving

Poor Responsewithin 1 hr &/or (+) risk factors

• S/Sx : severe, drowsiness, confusion• PEF < 30 % predicted or personal best• ABG : paCO2 > 45 mm Hg paO2 < 60 mm Hg

Discharge Home• Continue inhaled SABA q 3-4 hrs (or oral 2- agonist or theophylline)• Continue oral steroids• Patient education

Admit to Hospital

Improved• PEF > 70 %• Sustained on meds

Discharge Home

Not Improved within 6 – 12 hrs

Admit to ICU

Admit to ICU:• Continue inh SABA + inh. anti-cholinergic• Consider SQ,IV, or IM 2- agonist• IV steroids• IV aminophylline• Continue oxygen• Possible intubation/ mechanical ventilation

Management of Acute Exacerbations : Hospital Setting


Asthma Action PlanName:____________________________________________________Date of issue:___________________My Dr.:___________________________________________________Tel #: _________________________Clinic Address:___________________________________________________________________________

Chronic Asthma Severity Mild, intermittent Mild, persistent Moderate, persistent Severe, persistent

PEF: Personal best (done ___/___/___): _______liters/min Predicted: ________liters/min

PEAK FLOW STATUS ACTION80 % of predicted or personal bestAbove:____________

GOOD CONTROL(GREEN )

ZONE

Continue my present treatment:Regular controller/s:___________________________

___________________________As needed reliever: ___________________________Visit my doctor on next appointment :_____________

60-80% of predicted or personal bestFrom:______________To: ______________

WARNING(YELLOW)

ZONE

Add or double the dose of controller drug :_____________________________Take reliever regularly:________________________As needed reliever; (inhaled):___________________*If improved (back to green zone), continue maintenance drugs for 3 days.*If unimporved, visit my doctor as soon as possible.

Below 60 % pred or personal bestBelow: ____________

DANGER(RED)ZONE

Take Prednisone _____tablets every ________hrsTake reliever regularly:________________________+ as needed reliever (inhaled):__________________*Once improved, follow the yellow or green zone instructionsCall or see my doctor immediately

Below 50 % pred or personal bestBelow:____________

EMERGENCY(RED)ZONE

GO DIRECTLY TO HOSPITALor call ambulanceTake Prednisone ___________ tablets now or ____________________TAke 2 puffs of inhaled reliever every 10-15 mins on the way to hospital


P

Thank you for your attention!

Classification of Chronic Asthma Severity on Treatment

Documents

Transcript of Classification of Chronic Asthma Severity on Treatment