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ACADEMY OF MEDICINE OF MALAYSIAMALAYSIAN THORACIC SOCIETY
A JOINT STATEMENT OF THE
REVISED 2002
MINISTRY OF HEALTH MALAYSIA
CLINICAL PRACTICE GUIDELINES
FOR MANAGEMENT OFADULT ASTHMA
CLINICAL PRACTICE GUIDELINES
FOR MANAGEMENT OFADULT ASTHMA
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COMMITTEE MEMBERS:
Zainudin Md. Zin, FRCP (Chairman)
Damansara Specialist Hospital, Selangor
Aziah Ahmad Mahayiddin, FCCP
Hospital Kuala Lumpur
Abdul Wahab Sufarlan, FRCP
Ampang Puteri Specialist Hospital, Selangor
Hooi Lai Ngoh, FRCP
Hospital Pulau Pinang, Pulau Pinang
George Kutty Simon, FRCP
Hospital Alor Setar, Kedah
Kuppusamy Iyawoo, FRCP
Institute of Respiratory Medicine, Kuala Lumpur
Kwa Siew Kim, FRACGP
Academy of Family Physicians, Malaysia
Leong Kwok Chi, FRACGP
Academy of Family Physicians, Malaysia
Liam Chong Kin, FRCP
University Malaya Medical Centre, Kuala Lumpur
Roslan Harun, PhD
Hospital Universiti Kebangsaan Malaysia, Kuala Lumpur
Wong Wing Keen, MRCP
Sunway Medical Centre, Selangor
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Foreword
Asthma is a major global health problem. Its prevalence is increasing everywhere both in
children and adults. The World Health Organization (WHO) estimated in 1998 that asthmaaffected 155 million people worldwide. In Malaysia, it is estimated about 1.5-1.8 million
people are affected by the disease. The burden of asthma on economy is considerable
both in terms of direct medical costs such as hospitalization and pharmaceuticals and
indirect medical costs such as time lost from work and premature deaths. Asthma
morbidity too is considerable with many patients have symptoms that affect their quality of
life such as sleep, exercise and social activities. Asthma accounted for 0.4% of all deaths,
or 1 in 250 and many of these deaths were thought to be preventable if asthma was
managed properly or patients acted appropriately. The morbidity and economic burden of
asthma can be substantially reduced if asthma is under control and one way to achieve
that is to equip doctors with the necessary knowledge on asthma management.
Guidelines for management of adult asthma was first published by the Malaysian Thoracic
Society in 1996 with the aim of providing up-to-date information on asthma management
for doctors at all level of care. Several years have gone and many new findings and
scientific information are now available which necessitates the revision of the guidelines.
It is a privilege for me to be able to work with a group of highly dedicated and motivated
people to revise these guidelines. I wish to acknowledge the good work of the committee
members who had contributed towards the success of the revision and the contribution of
others through their comments.
The revision of the guidelines and the activities for the dissemination of the document
were conducted through educational grants from AstraZeneca, Boehringer Ingelheim,
GlaxoSmithKline and Merck Sharp & Dohme. I wish to express my gratitude and thanks to
these companies for their generous support. The committee members are however, solely
responsible for the statements and conclusions presented in this document. These
guidelines are meant to serve as guides and doctors are expected to use their best
judgement and act accordingly when treating their patients based on patients clinical
conditions, the availability of facilities and resources.
Zainudin Bin Md Zin, MD,FRCP,FCCP,FAMM
Chairman of the Committee
Guidelines for Management of Adult Asthma (Revision 2002)
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Contents
Foreword
Introduction
1. EPIDEMIOLOGY
2. DEFINITION
3. PATHOGENESIS
4. DIAGNOSING ASTHMA
5. MANAGEMENT OF CHRONIC ASTHMA
5.1 The aims of management
5.2 Approach to management
5.3 Drug treatment
5.3a Anti-inflammatory medications
5.3b Long acting bronchodilators
5.3c Short acting bronchodilators
5.4 Drug delivery
6. EDUCATION OF PATIENT AND FAMILY
7. AVOIDANCE OF PRECIPITATING FACTORS
8. ASSESSMENT OF SEVERITY AND RESPONSE TO TREATMENT
8.1 Clinical assessment
8.1a Measuring peak expiratory flow (PEF)
i
1
1
1
2
3
3
3
3
3
33
4
4
44
45
5
5
9
9
10
11
11
12
Long acting beta2-agonists(i)
(ii) Sustained-release theophyllines
(iii)
Corticosteroids(i)
(ii) Cromones
Antileukotrienes
Beta2-agonists(i)
(ii) Anticholinergic drugs
(iii) Methylxanthines
(iv) Other treatment
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9. APPROACH TO DRUG THERAPY - STEPWISE APPROACH
10. RESCUE COURSE OF STEROID TABLETS
11. FOLLOW-UP AND MONITORING
12 MANAGEMENT OF ASTHMA IN PREGNANCY
12.1 Introduction
12.2 Management
12.3 Labour
12.4 Breastfeeding
13. GUIDELINES FOR THE MANAGEMENT OF ACUTE ASTHMA
IN ADULTS
13.1 Aims of management
13.2 Assessment
13.3 Features of mild asthma attack
13.4 Features of moderately severe asthma attack
13.5 Features of very severe asthma attack
13.6 Features of life-threatening asthma
14. MANAGEMENT OF ACUTE ASTHMA IN AN OUTPATIENT SETTING
(i) INITIAL PEF >75% (Mild acute asthma)
(ii) INITIAL PEF < 75% (this includes moderately severe to life-
threatening asthma)
15. SUBSEQUENT MANAGEMENT IN THE WARD
15.1 Monitoring the response to treatment
15.2 Other investigations
16. MANAGEMENT IN INTENSIVE CARE UNIT
17. DISCHARGE PLAN FOR HOSPITALISED PATIENT
18. MANAGEMENT OF ACUTE ASTHMA IN GENERAL PRACTICE
Appendix 1 Example of a written asthma management plan
Appendix 2 PEF normogram
References
14
14
12
15
15
15
1616
17
17
1717
18
18
18
1919
19
22
2222
23
23
23
25
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28
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Asthma is a common disease causing significant morbidity and mortality worldwide. With
appropriate treatment and care most of this morbidity can be avoided and many deaths
attributable to asthma can be prevented. Since the last decade, clinical practice guidelineshave become an important tool to improve knowledge in the management of various
common diseases including asthma. In 1995, the Malaysian Thoracic Society set up an
expert committee to work on the guidelines for the management of asthma in adults with
the aim of providing up-to-date information on asthma management to health care
providers taking into account local practices and the availability of resources. The
guidelines were completed and published in 1996 and circulated to doctors working in the
government and private sector. Since then many new findings and advances have been
made in asthma management which necessitated the revision of the guidelines.
In one of its council meetings, the Malaysian Thoracic Society decided to invite all the
previous expert committee members to once again sit in the new committee to revise the
guidelines. In addition, a few new members including two representatives from the
Academy of Family Physicians of Malaysia were invited to ensure views of family
physicians were given due consideration. The committee held four meetings, each for
duration of one and a half days on 4 weekends from early 2000. The committee was
divided into 4 groups and each group was responsible to revise its assigned section.
Group 1 covered epidemiology, definition, pathogenesis and diagnosis; group 2 covered
non-pharmacological management, assessment of severity and asthma in pregnancy;
group 3 covered pharmacotherapy and drug treatment of chronic asthma; and group 4
covered management of acute asthma.
Unlike the first guidelines, in which treatment recommendations were mainly by
consensus, the present guidelines emphasised recommendations based on scientific
evidence as far as possible. Members had agreed to assign levels of evidence tostatements based on the system developed by the National Heart, Lung and Blood
Institute, Maryland, USA (Table A). The draft of the guidelines was circulated to members
of the Malaysian Thoracic Society and selected physicians for their comments. The
guidelines were also discussed at a Clinical Practice Guidelines Workshop jointly
organised by the Ministry of Health and the Academy of Medicine of Malaysia on October
12, 2002. The revised draft was circulated again to the expert committee after all the
comments from the reviewers were deliberated before the document was sent to Health
Technology Assessment Unit, Medical Development Division, Ministry of Health for
approval for adoption as national policy prior to publication and distribution.
The committee realised that an effective mechanism for dissemination of the guidelines is
important to ensure that the guidelines reach as many practitioners as possible and a
follow up study is needed to determine its effectiveness.
Introduction
i
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ii
Table A: Description of Level of Evidence
Sources of EvidenceEvidence
CategoryDefinition
Randomised controlled trials(RCTs). Rich body of data.
A Evidence is from endpoints of welldesigned RCTs that provide a consistentpattern of findings in the population forwhich the recommendation is made.Category A requires substantial numbersof studies involving substantial numbers ofparticipants.
Randomised controlled trials
(RCTs). Limited body of data.B Evidence is from endpoints of
intervention studies that include only
limited number patients, post hoc or
subgroup analysis of RCTs, or meta-
analysis of RCTs. In general, category
B pertains when few randomised trials
exist, they are small in size, they were
undertaken in a population that differs
from the target population of the
recommendation, or the results are
somewhat inconsistent.
Nonrandomised trials.
Observational studies.C Evidence is from outcomes of
uncontrolled or nonrandomised trials or
from observational studies.
Panel consensus judgement.D This category is used only in caseswhere the provision of some guidance
was deemed valuable but the clinical
literature addressing the subject was
insufficient to justify placement in one of
the other categories. The panel
consensus isbasedonclinicalexperience or knowledge that does not
meet the above-listed criteria.
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mucosal oedema and increased
vascular permeability
1. EPIDEMIOLOGY
Asthma is a common disease with unacceptably high morbidity and mortality. Asthma
prevalence is increasing worldwide and it is commonly under diagnosed and under-
treated. In a large survey of asthmatics in 8 areas in the Asia Pacific region, only 13.6% of
respondents were on inhaled corticosteroids despite almost half of them having symptoms
of persistent asthma1. Many asthma deaths and morbidity have been associated with
inadequate treatment, under-use of objective measurement of severity and inadequate
supervision2-4.
In Malaysia, the prevalence of asthma in primary school children is reported as 13.8%5
and in children aged 13-14 years is 9.6%6 . The prevalence of self-reported asthma in
adults as reported in a Ministry of Health Second National Health and Morbidity Survey is
4.1%7. In the same study, the Chinese recorded significantly lower prevalence of asthma
(2.4%) than other races (5.6%). This survey and other studies also confirmed under-
diagnosis of the disease, inappropriate treatment and under-use of peak flow
measurements8,9. Only 36.1% of adult asthmatics ever had their peak flow measured.
The survey also reported that the prevalence of asthma was higher in rural (4.5%) than in
urban areas (4.0%)7. There was a higher prevalence of asthma in those with lower
educational status (5.6%) and lower income (4.7%). The majority of patients (87.3%) had
mild asthma; 9.9% had moderate asthma and 2.7% had severe asthma. Among the
severe asthmatics, only 19.4% were on inhaled corticosteroids. The duration of days ill
due to asthma was 4.2 days per episode while days off work or school were 2.4 days per
episode, indicating significant morbidity and socio-economic impact of the disease.
2. DEFINITION
Asthma, irrespective of severity, is a chronic inflammatory disorder of the airways10. This
has implication in the diagnosis, management and prevention of the disease. Insusceptible individuals, this inflammation causes recurrent episodes of wheezing,
breathlessness, chest tightness and cough particularly at night and in the early morning.
These episodes are usually associated with widespread but variable airflow obstruction
that is often reversible either spontaneously or with treatment.
3. PATHOGENESIS
The inflammatory features of asthma include:
1
denudation of airway epithelium
collagen deposition beneath
the basement membrane
hypertrophy and hyperplasia of bronchial
smooth muscles and mucus glands
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2
inflammatory cell infiltration and activation of
Airway inflammation contributes to bronchial hyper-responsiveness, airflow limitation,
respiratory symptoms and disease chronicity. Acute inflammation causes airwayobstruction as a result of smooth muscle bronchospasm, mucosal oedema and mucus
plug formation. Persistent chronic airway inflammation may result in airway remodeling
which leads to irreversible bronchial obstruction. Atopy, the genetic predisposition for the
development of an IgE-mediated response to common allergens, is the strongest
identifiable predisposing factor for developing asthma.
4. DIAGNOSING ASTHMA
Consider asthma if any of the following signs or symptoms are present:
Wheezing high-pitched whistling sounds when breathing out (A normal chest examination does not exclude asthma).
History of any of the following:
Note: Eczema, hay fever, or a family history of asthma or atopic diseases is often associated with
asthma.
Symptoms occur or worsen at night/early morning, awakening the patient Symptoms occur or worsen in the presence of:
Reversible and variable airflow limitation-as measured by a peak expiratory flow (PEF) meter in any of the following ways:
PEF increases more than 15% 15 to 20 minutes after inhaling a short-acting
beta2-agonist, or PEF varies more than 20% from morning measurement upon arising to
measurement 12 hours later in patients who are taking a bronchodilator (more
than 10% in patients who are not taking a bronchodilator), or
PEF decreases more than 15% after 6 minutes of running or exercise
cough, worse particularly at
night/early morning
recurrent wheeze
recurrent difficulty in breathing recurrent chest tightness
neutrophils-
mast cells-
eosinophils-
T and B lymphocytes-
cytokine production
exercise respiratory tract infection
animals smoke (tobacco, wood)
pollen changes in temperature
aerosol chemicals drugs (aspirin, beta blockers)
dust mites (in mattress, pillows,
upholstered furniture, carpets)
strong emotional expression
(laughing or crying hard)
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5. MANAGEMENT OF CHRONIC ASTHMA
5.1 The aims of management are
To abolish day and night symptoms of asthma
To restore normal or best possible long term airway function To prevent most acute attacks To prevent mortality
5.2 Approach to management
In order to achieve those aims the approach to management should include:-
Educating patient and family members Identifying and avoiding trigger factors Assessing severity and monitoring response to treatment Selecting appropriate medications and using the lowest effective dose to
minimise short and long term side effects
5.3 Drug treatment
There are 3 major groups of medications to treat asthma (refer to table 1)
a) Anti-inflammatory medications
b) Long-acting bronchodilators
c) Short-acting bronchodilators
5.3a) Anti-inflammatory medications
As asthma is a chronic inflammatory condition, anti-inflammatory drugs should be
a logical treatment for most patients except for those with intermittent asthma.
Reducing the inflammation will decrease bronchial hyper-responsiveness. The
types of anti-inflammatory medications include:
(i) Corticosteroids
Corticosteroids are the main prophylactic drugs in adult asthmatics11-15
(Evidence A). They should be taken by inhalation and the dosage should be kept
to a minimum to reduce side effects (usually local side effects)16. Long-term oral
steroids may be required for severe persistent asthma.
(ii) Cromones
This group of medications is safe with no significant side effects. It is given by
inhalation (powder Spinhaler or metered dose inhaler). It is effective in the
symptomatic and prophylactic management of mild persistent asthma but less
effective than inhaled corticosteroids in more severe asthma17-20(Evidence A).
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4
(iii) Antileukotrienes
This new group of anti-inflammatory medication has been shown to have some
effect in controlling mild persistent asthma21(Evidence A). Compared to low
dose inhaled corticosteroids they have similar efficacy in reducing the rate of
asthma exacerbations but low dose inhaled corticosteroids appear to be more
effective in improving lung function, quality of life, reducing symptoms and the
need for rescue beta2-agonists22(Evidence A). They have also been shown to
reduce the requirement for high doses of inhaled corticosteroids23(Evidence B).
They may also be used for aspirin sensitive asthma24(Evidence A) and exercise-
induced asthma25(Evidence B).
5.3b) Long-acting bronchodilators
These medications should be used concomitantly with anti-inflammatory
medications for long-term control of symptoms. This group consists of long-
acting beta2-agonists and sustained-release theophyllines.
(i) Long-acting beta2-agonists
Long-acting beta2-agonists should be used in combination with inhaled
corticosteroids. The combination of long-acting beta2-agonists with inhaled
corticosteroids usually gives more effective control than increasing the dose of
inhaled corticosteroids alone26-31
(Evidence A).
These medications, except formoterol, are not recommended for treatment of
acute symptoms or exacerbations32.
Fixed dose combination inhaler of corticosteroid with long-acting beta2-agonists
(e.g. fluticasone/salmeterol, budesonide/formoterol) improves patient compliance
and hence control.
(ii) Sustained-release theophyllinesThis group of drugs may be used with inhaled corticosteroids for persistent
asthma when long-acting beta2-agonists are not available. Their usefulness is
limited by variable metabolism and a narrow therapeutic window. Sustained
release preparations may be used in nocturnal asthma33,34(Evidence B).
5.3c) Short-acting bronchodilators
These medications are used to relieve symptoms of acute asthma. They should
be used as required rather than regularly. This group consists of beta2-agonists,anticholinergic drugs and methylxanthines.
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(i) Beta2-agonists
These drugs are the most effective bronchodilators available. They are safe with
few side effects when taken by inhalation. The therapeutic effect is felt within a
few minutes of inhalation.
(ii) Anticholinergic drugsInhaled anticholinergics have slower onset but longer duration of action than
short-acting beta2-agonists. In asthma, they are generally weakerbronchodilators
than beta2-agonists. They have few side effects.
(iii) Methylxanthines
These drugs are available in oral and parenteral forms. Parenteral forms are
used in the management of acute severe asthma. Oral short-acting theophyllines
have limited role in the management of asthma.
NB: Inhaled beta2-agonists are the bronchodilator of choice. As far as
possible avoid using anti-cholinergics or xanthines as first line
bronchodilator drugs.
(iv) Other treatment
Anti-histamines including ketotifen have been shown to be of limited efficacy in
many clinical trials in asthma35-37. The role of hyposensitisation or allergen-
specific immunotherapy has been studied but the results are conflicting38-40. At
the moment it cannot be recommended as standard treatment.
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6
Table 1. Types Of Asthma Medications
Table 1a ANTI-INFLAMMATORY MEDICATIONS
Generic namesDrug class Side effects Remarks
(i) Corticosteroids Inhaled:
Beclomethasone
Budesonide
Fluticasone
Inhaled:
Oral candidiasis and
dysphonia. More than
1 mg a day may be
associated with skin
thinning, easy bruising,
adrenal suppression and
cataracts (Evidence C).
Inhaled:
Potential but small risk of
side effects is outweighed by
efficacy. Spacer devices and
mouth washing after
inhalation decreases oral
candidiasis.
(ii) CromonesSodium
cromoglycate
None or minimal May take 4-6 weeks to
achieve maximum effect.
(iii) Anti-
leukotrienes
Montelukast Possible elevation of liver
enzymes and bilirubin
Possible role as an
alternative to low dose
inhaled corticosteroids an
as add-on therapy to
inhaled corticosteroids.
Oral:
Prednisolone
Dexamethasone
Oral:
Long-term use may
lead to osteoporosis,
hypertension, diabetes,
cataracts, adrenal
suppression, obesity,
skin thinning and myopathy.
Oral:
If used long term, alternate
day morning dosing
produces less toxicity. For
short-term use, a 3 to 10
day course is effective for
gaining control.
Parenteral:
Hydrocortisone
Methylprednisolone
Parenteral:
To be used only in the
treatment of acute severe
asthma.
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Nausea, vomiting,
headache, tremor and
insomnia. Serious side
effects such as seizures
and arrhythmias can occur
especially at higher serum
concentrations.
Table 1b LONG-ACTING BRONCHODILATORS
Generic namesDrug class Side effects Remarks
(i) Long-acting
beta2-agonists
Inhaled:
Formoterol
Salmeterol
Inhaled:
Beta2-agonists have fewer
side effects than oral
formulations.
Inhaled:
These formulations are not
to be used to treat acute
attacks with the exception
of formoterol.
(ii) Long-acting
methylxanthines
Sustained-release
theophylline
Serum theophylline levels
should be monitored when
high doses are used and in
special circumstances,
eg. liver failure and cardiac
failure. Interactions with
other drugs such as
cimetidine,macrolides and
rifampicin can occur.
Oral:
Bambuterol
Salbutamol SR
Terbutaline SR
Clenbuterol
Oral:
Oral beta2-agonists may
cause tachycardia,
palpitations, tremors,
anxiety, headache and
hypokalaemia.
Should always be used in
combination with inhaled
corticosteroids.
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Table 1c SHORT-ACTING BRONCHODILATORS
Generic namesDrug class Side effects Remarks
(i) Short-acting
beta2-agonists
Salbutamol
Terbutaline
Fenoterol
Beta2-agonists may cause
tachycardia, tremor and
irritability. Inhaled beta2-
agonists have fewer side
effects than oral and
parenteral preparations.
Drugs of choice for relief of
acute bronchospasm. Inhaled
route has faster onset and is
more effective than oral route.
Parenteral salbutamol or
terbutaline may be used in
acute severe attacks.
(ii) Anti-
cholinergics
Ipratropium
bromide
Minimal mouth dryness. May provide additive effect
to beta2-agonists. Onset of
action is slower.
(iii) Short-acting
methylxanthines
Short acting
theophylline
Nausea, vomiting,
headache, tremor and
insomnia. Serious side
effects such as seizures
and arrhythmias can occur
especially at higher serum
concentrations.
May be used if beta2-agonists
are not available.
(iv) Nonselective
adrenergic
agonists
Adrenaline/
epinephrine
injection
Similar but more
significant side effects
than beta2-agonists.
Not recommended for treating
asthma attacks if beta2-
agonists are available.
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5.4 Drug delivery
The inhaled route is preferred for beta2-agonists and steroids as it produces the same
benefit with fewer side effects as compared to the oral route. In addition, inhaled
medications exert their effects at lower doses41,42. The pressurised metered dose inhaler
(MDI) is suitable for most patients as long as the inhalation technique is correct.
For patients with poor coordination, alternative methods for drug inhalation include spacer
devices, dry powder inhalers and breath-actuated pressurised MDI42-47.
The nebulised route is preferred in the management of acute attacks.
6. EDUCATION OF PATIENT AND FAMILY
This is an important but often neglected aspect in the management of asthma. It isessential in ensuring the patients cooperation and compliance with therapy. As far as
possible patients and their families should be encouraged and trained to actively
participate in the management of their own asthma. Patient education should include the
following information:
Nature of asthma
Preventive measures/avoidance of triggersDrugs used and their side-effects
Proper technique of using inhaled drugs
Peak flow monitoring
Knowledge of the difference between relieving and preventive medications
Recognition of features of worsening asthma (increase in brochodilator requirement,
development of nocturnal symptoms, deteriorating peak flow rates)
Self management plan (appendix 1)
The danger of non-prescribed self medication including certain traditional medicines
i.
ii.iii.
iv.
v.
vi.
vii.
viii.
ix.
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10
7. AVOIDANCE OF PRECIPITATING FACTORS
Exposure of asthmatic patients to irritants and allergens to which they are sensitive has
been shown to increase asthma symptoms and precipitate asthma episodes.
Table 2. Common Asthma Triggers
Beta blockers1 Avoid using beta-blockers (Evidence C)
Tobacco smoke
(active or passive
smoking)
2 Stay away from tobacco smoke. Patients should not smoke
Air pollution3 Physical exertion should be avoided when levels of airpollution are high (Evidence C)
House dust mites4 Avoid whenever possible but current chemical and physicalmethods aimed at reducing exposure seem to be ineffectiveand cannot be recommended as prophylaxis for mitesensitive asthmatics48(Evidence A)
Allergens fromanimals with fur5
Remove animals from the home, or at least from thesleeping area (Evidence C)
Physical activity6 Do not avoid physical activity. Symptoms can be preventedby taking short or long-acting inhaled beta2-agonist atappropriate time before strenuous exercise
Aspirin and
nonsteroidalanti-inflammatory
drugs
7 Adult patients with severe persistent asthma, nasal polypsor a history of sensitivity to aspirin or nonsteroidalanti-inflammatory drugs should be counseled regarding
the risk of severe and even fatal exacerbations from usingthese drugs (Evidence C)
Other identifiedallergens e.g. food,
pollen, cockroachallergen
8 Should be avoided whenever possible (Evidence C)
Occupationalexposure
9 Change of occupation may be necessary (Evidence C)
Rhinitis, sinusitis and
gastroesophagealreflux
10 These conditions should be treated (Evidence C)
Trigger factors Recommendations
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8. ASSESSMENT OF SEVERITY AND RESPONSE TO TREATMENT
Assessment shouldbe done as follows:
8.1 Clinical assessment
This should include patients symptoms, sleep disturbances, disturbance ofdaily activities and the frequency of bronchodilator drug and/or rescue courses of steroid used.
Table 3. Classification of Asthma Severity
> 80% predicted
Variability 20-30%
Symptoms
CLASSIFICATION OF ASTHMA
SEVERITY
BEFORE TREATMENT
SeverePersistent
DailyFrequent exacerbationsLimitation of physical activity
Frequent < 60% predicted
Variability> 30%
Moderate
PersistentDailyDaily use of beta2-agonistExacerbations affect activityand sleep
> 1 time aweek
> 60% - < 80%predicted
Variability > 30%
MildPersistent
> 1 time a weekbut < 1 time a dayExacerbations may affectactivity and sleep
> 2 times amonth
Intermittent < 1 time a weekBrief exacerbations
Asymptomatic andnormalPEF between exacerbations
< 2 times amonth
> 80% predicted
Variability < 20%
PEF
Night time
Symptoms
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a. Measuring peak expiratory flow (PEF)
This can be measured by a peak flow meter.
PEF Measurements
(i) During periods of well-being
This allows measurement of the patients best PEF valuewhich will provide the target for
the doctor and the patient to aim for. Twicedaily measurements (morning andevening)
before any inhaled bronchodilator treatment will determine the diurnal variability of airway
calibre. This is calculated as the range divided by the highest value and expressed as a
percentage.
PEF (max) PEF (min) x 100 = _______ % PEF (max)
Good control of asthma means PEF variability is maintained at less than 10%.
(ii) During symptomatic episodes
During an attack of asthma PEF fairly accurately measures the degree of bronchospasm.
A PEF of less than50% of normal orbest suggests a very severe attack and a PEF of less
than 30% suggests a life-threatening attack. When the best PEF value is not known, a
single reading of less than 200 L/min usually indicates a severe attack.
In addition to history and physical findings the PEF helps the doctor decides on the
appropriate therapy. As far as possible patients with moderate and severe persistent
asthma should regularly measure their PEF twice a day. Comparison to local normal
values should be made49 (appendix 2). The classification of asthma severity based on
symptoms, bronchodilator usage and PEF reading is summarised in Table 3.
9. APPROACH TO DRUG THERAPY - STEPWISE APPROACH
Treatment should be carried out in a stepwise manner. Patients should be started on
treatment at the step most appropriate for the initial severity of their condition (Table 4).
Treatment would then be changed (stepped-up or stepped-down) according to their
progress.
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Table 4. Treatment of Adult Asthma
13
Long-Term Preventive Quick-Relief
Daily medications:
Inhaled corticosteroid*, 800-2000 mcg, and
Long-acting bronchodilator: eitherinhaled
long-acting beta2-agonist and/or sustained-
release theophylline, and/or oral long acting
beta2-agonist, and
Oral corticosteroid long term
Short-acting bronchodilator:
inhaled beta2-agonist as
needed for symptoms
Daily medications:
Inhaled corticosteroid*,500-1000 mcg AND,
if needed
Long-acting bronchodilator: eitherinhaled
long-acting beta2-agonist, sustained-release
theophylline, or oral long acting beta2-agonist
(Inhaled long-acting beta2-agonist may provide
more effective symptom control when added to
low-medium dose steroid compared to
increasing the steroid dose)
Consider adding anti-leukotriene, especially for
aspirin-sensitive patients and forpreventing
exercise-induced bronchospasm
Short-acting bronchodilator:
inhaled beta2-agonist as
needed for symptoms
Daily medications:
EitherInhaled corticosteroid*, 200-500 mcg,
or cromoglycate or sustained-release
theophylline or anti-leukotrienes
Short-acting bronchodilator:
inhaled beta2-agonist as
needed for symptoms
None needed Short-acting bronchodilator:
inhaled beta2-agonist as
needed for symptoms, but less
than once a week
Inhaled beta2-agonist or
cromoglycate before exercise
or exposure to allergen
TREATMENT OF ADULT ASTHMA
Preferred treatments are in bold print
Patient education is essential at every step
STEP 4
Severe
Persistent
STEP 3
Moderate
Persistent
STEP 2
Mild
Persistent
STEP 1
Intermittent
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14
*Inhaled corticosteroid: Beclomethasone dipropionate (BDP) or budesonide.
Forfluticasone the equivalent dose is half of BDP/budesonide.
Step down
Patients should be reviewed regularly. When the patients condition hasbeen stable for 3-6
months, drug therapy may be stepped down gradually. The monitoring of symptoms and
peak flow rate should be continued during drug reduction.
10. RESCUE COURSE OF STEROID TABLETS
Rescue courses of oral steroids may be needed to control exacerbations of asthma at any
step. Indications include:-
(i) Symptoms and peak expiratory flow (PEF) progressively getting worse day by day
(ii) PEF falls below 60% of patients best
(iii) Sleep is frequently disturbed by asthma
(iv) Morning symptoms persist untilmidday despite usual treatment
(v) Diminishing response to inhaled bronchodilators
(vi) Emergency treatment with nebulised or injected bronchodilators is required
Method
Give 30-60 mg of prednisolone immediately. This daily dose can be tapered off overa period
of 7-14 days or stopped abruptly. It is necessary to review the adequacy of the patients
usual medications.
11. FOLLOW-UP AND MONITORING
Follow-up and monitoring include review of symptoms and measurement of lung function.
PEF monitoring at every visit along with review of symptoms helps in evaluating the
patients response to therapy and adjusting treatment (step-up orstep-down) accordingly.
PEF consistently > 80% of the patient's personal best suggests good control.
Regular visits (at 1 to 6 month interval as appropriate)are essential even after control of
asthma is established. At each visit reviewthe following questions:
1) Is the asthma management plan meeting the expected goals?
2) Is the patient using inhalers, spacers or peak flow metercorrectly?
3) Is the patient compliant to the medication and avoiding triggers?
4) Does the patient have any concern?
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15
12. MANAGEMENT OF ASTHMA IN PREGNANCY
12.1 Introduction
In general, during pregnancy, asthma becomes worse in a third of women, is stable in
another third and improves in the remaining third50
. Women should be reassured that theirasthma medication carries less risk to the foetus than a severe asthma attack. Inadequately
treated asthma can cause maternal and foetal hypoxaemia, which leads to complications
during pregnancy and poorer birth outcomes. Poorly controlled asthma is associated with an
increased incidence of low birthweight and premature babies, neonatal hypoxia,
complications during labour, and perinatal and maternal mortality51-54. Hyperemesis
gravidarum, maternal haemorrhage and pre-eclampsia are more common in this group51.
12.2 Management
The management of asthma during pregnancy is similar to that at any other time: treatment
should be aggressive, with the aim of eliminating symptoms and restoring and maintaining
normal lung function. Cooperation between the respiratory physician and obstetrician is
important throughout pregnancy for women with severe asthma.
Beta2-agonists:
There is no evidence ofa teratogenic risk with the commonly used inhaled beta2-agonists
salbutamol, terbutaline and fenoterol. Delayed labour does not occur with bronchodilators
administered by metered-dose inhaler ornebulisation.
Ipratropium bromide:
It appears to be safe for use during pregnancy, as it is poorly absorbed when administered
by the inhaled route.
Salmeterol/formoterol:
These long-acting agents have not been tested extensively in pregnant women.
Theophyllines:
They may aggravate the nausea and gastroesophageal reflux suffered by some pregnant
women and can cause transient neonatal tachycardia and irritability55,56. Teratogenicity has
been shown in animals57,58 and there are occasional case reports of cardiovascular
abnormalities in humans59. However, largerhuman studies have not shown any significant
increase in foetal abnormalities60,61.
Theophylline metabolism may be altered during pregnancy leading to increased serum
levels62.
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16
Sodium cromoglycate:
This drug appears to have no adverse foetal effects.
Inhaled corticosteroids:
Inhaled corticosteroids are the mainstay of treatment in persistent asthma and appear to
have a good safety profile in pregnancy. Although beclomethasone is a known animal
teratogen, its use in pregnant women has not been associated with teratogenicity. The
largest human experience of inhaled corticosteroids is with beclomethasone and it is
therefore the inhaledsteroid of choice in pregnancy63,64.
Experience with fluticasone in pregnancy is limited.
Oral corticosteroids:
These are sometimes necessaryfor severe asthma in pregnancy but usually only forshortperiods. An increased risk of cleft palate has been reported in animals given huge doses of
oral steroids65,66. The results of animal studies should not deter the practising clinician from
using oral corticosteroids if required.
Anti-leukotrienes:
No data is available on theuse of this agent in pregnant women.
12.3 Labour
Women with very severe asthma may be advised to have an elective caesarean section at a
time when their asthma control is good. Symptoms ofasthma during labour are generally
easily controlled with standard asthma therapy.
12.4 Br eastfeeding
Breastfeeding should be continued in women with asthma. Breast milk may contain very
small amounts of the drugs used to treat asthma, but, in general, these are not known to be
harmful to the infant. Corticosteroids are about 90% protein bound in the blood and are not
secreted into breast milk in any significant quantity. Less than 1% of maternal theophylline is
transferred to the infant67.
In general, asthma medications are safe during pregnancy and lactation and the benefits
outweigh any potential risks to the foetusand baby.
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17
13. GUIDELINES FOR THE MANAGEMENT OF ACUTE ASTHMA IN ADULTS
The presentation of a patient with acute asthma requires rapid assessment of its severity so
that the appropriate treatment can be instituted.
Although an acute severe attack of asthma may occasionally develop within afew minutesor hours, it usually occurs against a background of long term poorly controlled asthma that
has been worsening for some days or weeks. The severity of acute asthma attacks is
usually underestimated by patients, theirrelatives and their doctors, mainly due to failure to
assess the condition objectively. Inadequateassessment of such attacks and inappropriate
treatment with over reliance on bronchodilators and underuse of steroids contribute to
morbidity and deaths2,3.
13.1 Aims of management
The aims of management are:
Toprevent death
To relieve symptoms
To restore the patients lung function to the best possible level as soon as possible
To prevent early relapse
13.2 Assessment
The severity of the attack should be assessed by:
History
Physical examination
PEF measurement
13.3 Features of mild asthma attack are:
persistent cough
increased chesttightness
br eathless when walking
normalspeech
pulse rate 75% of predicted orbest value
SpO2 > 95% (on room air)
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18
13.4 Features of moderately severe asthma attack are:
breathless when talking
talks in phrases
pulse rate100-120/min
respiratory rate 25-30 breaths/min loud wheeze
PEF between 50 to 75%of predicted or best value
SpO2 91-95% (on room air)
13.5 Features of very severe asthma attack are:
breathless at rest
talks in words
pulse rate> 120/min
respiratory rate > 30 breaths/min
loud wheeze
PEF
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14. MANAGEMENT OF ACUTE ASTHMA IN AN OUTPATIENT SETTING
(i) INITIAL PEF > 75% (Mild acute asthma)
Give the patients usual inhaled bronchodilatoror nebulised bronchodilator. Multiple doses
(5-20 puffs) ofinhaled bronchodilator using a large volume spacer can be given in place ofnebulised bronchodilator70-72.
Observe for 60 minutes. If the patient shows clinical improvement and PEF remains > 75%,
discharge.
Before discharge:
review adequacy ofusual treatment and step up if necessary according toguidelines fortreatment of chronic persistent asthma
ensure patient has enough supply of medications
check and correct inhaler technique
advise patient to return immediately if asthma worsens
ascertain and address precipitating factors
make sure that patient has a clinic follow-up appointment within 2 weeks
(ii) INITIAL PEF < 75% (this includes moderately severe to life-threatening asthma)
Patients with more severe degrees of acute asthma should be managed as follows:
Immediate treatment with:
a) High concentration oxygen (> 40%)
b) High doses of inhaled beta2-agonist (salbutamol 5 mg or terbutaline 5 mg orfenoterol 5
mg) in combination with anticholinergic (ipratropium bromide 0.5 mg)73-77 (Evidence A)
should be administered via nebuliser driven by oxygen. If compressed air nebuliser is
used, administration of supplemental oxygen should be continued.
Alternatively, beta2-agonists may be given by multiple actuations of a pressurised aerosol
inhaler into a large spacer device (2-5 mg, i.e. 20-50 puffs, five puffs at a time) preferably in
combination with an anticholinergic.
If there is poor response to inhaled bronchodilators, subcutaneous terbutaline or salbutamol
0.25-0.50 mg can be given.
19
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20
c) Prednisolone tablets at 30-60 mg should be commenced immediately. If patient is
unable to tolerate orally, intravenous hydrocortisone 200 mg stat or other forms of
parenteral steroids should be given.
High dose inhaled corticosteroids (2.4 mg budesonide daily in 4 divided doses) has been
shown to achieve a relapse rate similar to 40 mg prednisone daily78
. However, furtherstudies are required to document the potential benefits of inhaled corticosteroids in acute
asthma.
NB: Sedatives should not be prescribed.
Antibiotics are indicated only if there is evidence of bacterial infection. Chest
radiograph shouldbe done ifpneumothorax or pneumonia is suspected.
Assessment of response to initial treatment
The response to treatment is monitored by:
the patients symptoms
physical findings
measurement ofPEF 15-30 minutes after initiating treatment
a) Good response to initial treatment
The patient should:
be relieved of dyspnoea
have improved clinical status
have a post bronchodilator PEF which is > 75% of predicted or best value
b) Incomplete response to initial treatment
The patient has:
persistent symptoms and signs post bronchodilator PEF which is 50-75% of predicted or best value
c) Poorresponse to initial treatment
The patient has:
persistent ordeteriorating symptoms and signs
a post bronchodilator PEF < 50% of predicted orbest value
The subsequent management of patients with an initial PEF < 75% predicted or best value issummarised in Figure 1.
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FIGURE 1
MANAGEMENT 30 MINUTES AFTER INITIAL TREATMENT OF ACUTE
ASTHMA WITH AN INITIAL PEF < 75% PREDICTED OR BEST
NB: Patients requiring admission should preferably be accompanied by a nurse
and/ora doctor.
Before discharge:
give prednisolone 30-60 mg daily for 7-14 days, plus regular inhaled steroids and
inhaled beta2-agonist to be taken as needed
review adequacy of usual treatment and step up if necessary according to
guidelines for treatment of chronic persistent asthma
ensure patient has enough supply ofmedications
check inhaler technique and correct if faulty
arrange for follow-up within 2 weeks
advise patients to return immediately if asthma worsens
NB: Patients should be considered for admission if there is concern over the social
circumstances such as patient staying alone and lack of transport for emergency visit
to hospital.
Good response andPEF > 75% predicted
or best value
Observe for another
60 minutes
If patient is stable or
improving and PEF
remains > 75%,
DISCHARGE
Incomplete response andPEF 50-75% predicted
or best value
Repeat nebulised beta2-
agonist and anticholinergic
1)If PEF is still < 75%, ADMIT
2)If patient improves andPEF > 75%, DISCHARGE
Observe for 60 minutes.
Poor response and PEF
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22
15. SUBSEQUENT MANAGEMENT IN THE WARD
Continue oxygen > 40%
Intravenous hydrocortisone 100-200 mg 6 hourly orprednisolone 30-60 mg daily
Nebulised beta2-agonist 2-4 hourly preferably in combination with anticholinergic (it
may be necessary to give nebulised beta2-agonist more frequently up to every 15minutes)
If patient is still not improving, commence aminophylline infusion (0.5-0.9 mg/kg/
hour); monitor blood levels (where facility is available) if aminophylline infusion is
continued for more than 24 hours. Terbutaline or salbutamol infusion at 3-20 mcg/
min after an initial intravenous bolus dose of 250 mcg over 10 minutes can be
given as an alternative
In cases where response to the above treatment is inadequate, intravenous
magnesium sulphate 2 g in 50 ml normal saline infused over 10-20 minutes may be
given79
15.1 Monitoring the response to treatment
- repeat measurement of PEF 15-30 minutes after starting treatment
- aim to maintain arterial oxygen saturation above 92%
- repeat arterial blood gas measurements if initial results are abnormal or if patient
deteriorate
- monitor PEF at least 4 times daily throughout the hospital stay
15.2 Other investigations
a) Serum electrolytes, as hypokalaemia is a recognised complication of treatment with
beta2-agonists and corticosteroids
b) Electrocardiogram if indicated
Transfer patient to the intensive care unit or prepare to intubate ifthere is:
- deteriorating PEF
- worsening hypoxaemia, or hypercapnia
- exhaustion or feeble respiration
- confusion or drowsiness
- coma or respiratory arrest
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16. MANAGEMENT IN INTENSIVE CARE UNIT
continue with oxygen supplementation
continue with intravenous hydrocortisone
if the patient is mechanically ventilated, administernebulised beta2- agonist with
anticholinergic via the endotracheal tube. This can be given up to every 15-30
minutes
Intravenous aminophylline infusion or terbutaline or salbutamol infusion should be continued
and magnesium sulphate infusion may be added.
17. DISCHARGE PLAN FOR HOSPITALISED PATIENT
Before discharge, the patient should be:
started on inhaled steroids for at least 48 hours in addition to a short course of oral
prednisolone and bronchodilators
stable on the medications he is going to take outside the hospital for at least 24
hours
having PEF of > 75% ofpredicted or best value and PEF diurnal variability of < 20%
able to use the inhalercorrectly and if necessary, alternative inhaler devices could
be prescribed
educated on the discharge medication, home peak flow monitoring and self
management plan (for selected, motivated patients), and the importance of regular
follow up
given an early follow-up appointment within 2-4 weeks for reassessment ofthe
condition and for adjustment ofthe medicines
18. MANAGEMENT OF ACUTE ASTHMA IN GENERAL PRACTICE
The clinic should preferably have facility for oxygen administration and equipment for
resuscitation.
The following are indications for immediate referral to hospital
1. Any life-threatening features
2. Any features of a severe attack that persist after initial treatment
3. PEF 15-30 minutes after nebulisation, which is < 50% of predicted or best value
Threshold forreferral to hospital should be lowered for patients80:
seen in the afternoon or evening rather than earlier in the day
with previous severe attacks, especially if the onset of the current attack was rapid
in whom there is concern over the social circumstances or relatives ability to
respond appropriately
23
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24
FIGURE 2
SUMMARY OF OUTPATIENT MANAGEMENT OF ACUTE ASTHMA
NB:Before discharge ensure that patients treatment plan is reviewed, the medicine is
adequate, the inhaler technique is correct, the appointment for review is given, and
patient is advised to return if condition deteriorates. If patient was given steroids,
continue with oral prednisolone for7-14 days81-84.
Mild acute asthma
PEF > 75% predicted/best
Moderate to severe
acute asthma
PEF < 75%
predicted/best
Give oxygen > 40%
Give nebulised beta2-agonist or
multiple puffs of MDI via a large
spacer in combination with
inhaled ipratropium
Give oral prednisolone
30-60 mg or i.v. hydrocortisone
100-200 mg stat
Give oxygen > 40%
Give nebulised beta2-agonist or
multiple puffs of MDI via a large
spacer in combination with
inhaled ipratropium
Give oral prednisolone
30-60 mg or i.v. hydrocortisone
100-200 mg stat
Life threatening acute asthma
PEF < 30% predicted/best
Give inhaled or nebulised
beta2-agonist
Observe for 60 mins.
If PEF > 75% and
clinically improved,
discharge patient
Good response
PEF > 75% and
clinically improved
Incomplete response
PEF 50-75% with
persistent symptoms
and signs
Poor response
PEF < 50% with
deteriorating or
persistent symptoms
and signs
Give i.v.
aminophylline 250
mg slowly over
20 mins or i.v
terbutaline/salbutamol 0.25 mg
over 10 mins.
AND ADMIT patient
to ICU. Do not give
bolus aminophylline
if patient is on oral
theophylline
Observe for 60 mins.
If PEF > 75%
discharge patient*
Repeat nebulised beta2-
agonist and ipratropium
Observe for 60 mins
Admit patient
PEF > 75%, discharge PEF < 75%, admit
Assess asthma severity clinically and with PEF
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Example ofa written asthma managementplan
Name :
Address :
Tel Numbers
General Practitioner :
Specialist :
Ambulance :
Hospital :
Usual Medication :
1.
2.
3.
4.
Best Peak Flow Reading L/min
25
Appendix 1
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26
YOUR ASTHMA IS WELL CONTROLLED IF:
You have no wheeze, shortness of breath nor cough
You are able to do usual activities
You sleep well
You do not need yourbronchodilator more than once a day
Your peak flow is more than (80% of best)
You should continue your usual medications:
(Preventer):
(Reliever):
Keep your appointment with your doctor.
YOURASTHMA IS UNCONTROLLED IF:
You notice wheeze and difficulty in breathing more than usual during the day
Your usual activities are affected
You wake up once or twice a night with asthma
You need yourbronchodilator more than 2 times a day
Your peak flow is less than (80% of best)
You should increase the dose of
and consult your doctor as soon as possible.
YOUR ASTHMA IS SEVERE IF:
You notice wheeze and difficulty in breathing most of the day
You are unable to carry out usual activities such as talking and walking
You are awake most of the night
You need your bronchodilator more than 6 times a day
Your peak flow is less than (60% of best)
You should take 2-4 puffs of your reliever inhaler and take tablets of
prednisolone ( mg) and seek immediate medical help.
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460
450
440
430
420
410
400
390
380
490
480
470
510
500
520
610
600
590
580
570
560
550
540
530
520
510
500
490
480
470
460
450
440
430
10
20
30
40
50
60
70
53
54
55
59
57
56
58
63
67
68
69
70
64
65
66
60
61
62
71
72
73
140
150
160
170
180
Male SD + 59.4
Female SD + 46.3
PEF normogram
Appendix 2
P.E.F.R.
NOMOGRAM FOR ADULT
CHINESE IN SINGAPORE
(USE HEIGHT & AGE)
Regression
Formula
Male PEF(L/min) - 72.1+9.8 H (ins) - 12 A (yrs)
Female PEF(L/min) - 159+5 H (ins) - A (yrs)
HEIGHTCM INS
FEMALEL/min
MALEL/min
27
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28
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