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Transcript of SULTANATE OF OMAN OMAN RESPIRATORY SOCIETY & OMAN isaac.· gratitude to Oman Respiratory Society and

  • SULTANATE OF OMAN

    OMAN RESPIRATORY SOCIETY & OMAN FAMCO SOCIETY

    In association with

    MINISTRY OF HEALTH

    GUIDELINES FOR THE MANAGEMENT OF ASTHMA

    SECOND EDITION

    2009

  • 1

    CONTRIBUTORS

    OMAN RESPIRATORY SOCIETY OMAN FAMCO SOCIETY

    Ms. Sawsan Baddar, Senior Respiratory Therapist, Respiratory Medicine, SQUH

    Dr. Zahir Al Anqoudi, Senior Specialist, Family Medicine, MOH

    Dr. B. Jayakrishnan, Consultant, Respiratory Medicine, SQUH

    Dr. Faiza Al Fadhil, Senior Specialist, Family Medicine, MOH

    Dr. Yaqoob Al Mahrooqi Senior Consultant, Respiratory Medicine, Royal Hospital

    Dr. Mohamed Redha Al Lawati, Senior Specialist, Internal & Respiratory Medicine, Al-Nahdha Hospital

    Dr. Qasem Al Salmi, Senior Consultant, Pediatric Respiratory Medicine, Royal Hospital

    Dr. Hussein Al Kindy, Consultant, Pediatric Respiratory Medicine, SQUH

    Dr. Sunil Bhatnagar, Senior Specialist Pediatric Respiratory Medicine, Royal Hospital

    Dr. Omar Al Rawas, Associate Professor, Respiratory Medicine, SQU

    REVIEWERS

    Professor Bazdawi Al Riyami, Respiratory Medicine, SQU

    Dr. Mohammed Al Shafaee, Assistant Professor, FM & PH, SQU

    Dr. Nasser Al Busaidi, Senior Consultant, Respiratory Medicine, Royal Hospital

    Dr. Thord Theodorsson, Senior Consultant, FM & PH, SQUH

    Ms. Badriya Al Zadjali Clinical Pharmacist, SQUH

    Dr. Rahma Al Kindi, Senior Registrar, FM & PH, SQUH

    Dr. Najah Al Hashmi, Family Physician, MOH

    ACKNOWLEGMENT

    Dr. Said Al Lamki, Director of PHC Affairs , MOH

    Dr. Mezon Tufail Elrahman, Senior Specialist, Family Medicine, MOH

    Dr. Muna Al Zakwani, Family Medicine, MOH

    Dr. Maryam Al Khussaibi, Senior Specialist. Family Medicine, MOH

    Dr. Hanan Al Khalili, Senior Specialist, Family Medicine, MOH

    Dr. Yaqoub Al Maghderi , Senior Specialist, Family Medicine, MOH

    Mrs. Catherine Lonie, Assistant Lecturer, Language Centre, SQU

  • 2

    PREFACE

    Despite the advances in understanding asthma pathophysiology and the availability of

    effective treatment, asthma remains a major burden worldwide to individuals, communities

    and health systems.

    This is the second edition of the national asthma guidelines, covering adults and children. In

    addition it includes "Educational" and "Special Considerations" sections to assist health care

    providers in the management of asthma.

    The first guideline was produced by the Ministry of Health in 1998. The current guideline is a

    combined effort by Oman Respiratory Society and Oman FAMCO Society.

    We hope that all concerned will implement these guidelines to achieve better asthma control.

    Professor Bazdawi M. Al Riyami Dr. Mohammed Al Shafaee

    President Oman Respiratory Society President Oman FAMCO Society

  • 3

    PREFACE

    Asthma is a major cause of chronic morbidity throughout the world and there is evidence that its prevalence has increased considerably over the past few decades, especially in children. It is a disorder that affects physical, physiological, psychological and socioeconomic functions. Because of the social disabilities that relate both directly and indirectly to the persons affected, improving health status and thereby improving quality of life are the principle goals in asthma care.

    Asthma can be controlled through appropriate prevention and management strategies. This manual outlines the principles and policies of the Ministry of Health in providing asthma care services at all levels of health care.

    The aim of this guideline is to provide the approaches and techniques in early detection and diagnosis and to standardize the treatment patterns among all the health care providers.

    Ministry of Health strongly endorses and hereby adopts these management guidelines. In recognition to the great efforts done, The Ministry would like to express its appreciation and gratitude to Oman Respiratory Society and Oman FAMCO Society for their initiative in updating the guideline.

    Dr. Ahmed bin Mohammed Al-Saidi

    The Undersecretary of Health Affairs

  • 4

    TABLE OF CONTENTS

    ABBREVIATIONS 8

    TABLES 9

    INTRODUCTION 10

    PART ONE : ASTHMA MANAGEMENT IN ADULTS

    SECTION 1: Diagnosis

    1. Definition 12

    2. When to Suspect Asthma 12

    3. Medical History 13

    4. Examination 15

    5. Investigations 15

    6. Differential Diagnoses 16

    SECTION 2: Assessment & Classification

    1. Assessing Severity 18

    A. Intermittent Asthma 18

    B. Mild Persistent Asthma 18

    C. Moderate Persistent Asthma 18

    D. Severe Persistent Asthma 19

    2. Assessing Control 19

    SECTION 3: Management

    1. Treatment Steps 20

    2. Stepping Down 23

    3. Step Care Chart 24

    SECTION 4: Management of Exacerbation

    1. Assessment 25

    2. Treatment 27

    3. Admission to Intensive Care Unit 28

    4. Discharge 28

    5. Management of Exacerbation Chart 29

  • 5

    TABLE OF CONTENTS

    SECTION 5: Management in Primary Health Care

    1. Introduction 30

    2. Diagnosis 30

    3. Investigations 30

    4. Management 30

    5. Follow Up 30

    6. When to Refer to Specialist 31

    7. When to Refer Acute Asthma Exacerbation to Secondary Care 31

    SECTION 6: Special Considerations

    1. Exercise Induced Asthma 32

    2. Pregnancy 32

    3. Respiratory Infection 32

    4. Surgery 33

    5. Rhinitis/ Sinusitis/ Nasal Polyps 33

    6. Occupational Asthma 34

    7. Gastroesophageal Reflux 34

    8. Aspirin Induced Asthma 34

    SECTION 7: Education

    1. Managing Asthma During Travel & Holidays 35

    2. Peak Expiratory Flow Meter 35

    3. Asthma Action Plan 36

    4. Special Instructions 36

    5. Quality Management in Asthma 37

    PART TWO: ASTHMA MANAGEMENT IN CHILDREN

    SECTION 8: Diagnosis in Children

    1. Diagnosis 39

    A. Asthma Diagnosis in Children 0-4 Years of Age 39

    B. Asthma Diagnosis in Children 5-12 Years of Age 39

    2. Investigations 40

  • 6

    TABLE OF CONTENTS

    3. Differential Diagnosis 40

    SECTION 9: Classification and Management in Children

    1. Classification of Asthma Severity 41

    a. Age 0 4 Years 42

    b. Age 5 -12 Years 43

    2. Goals of Asthma Therapy 44

    3. Principles of Stepwise Therapy in Children 44

    4. Inhaled Corticosteroids in Children 44

    5. Reducing Risks with Inhaled Corticosteroid Therapy 45

    6. Monitoring Asthma Progression 45

    7. Levels of Asthma Control 46

    8. Indicators of Poor Asthma Control 46

    9. Main Reasons for Poor Control of Asthma 46

    10. What to Do if Control is not Achieved 47

    11. When to Refer to Specialist 47

    SECTION 10: Management of Asthma Exacerbations In Children

    1. Assessment of Severity of Exacerbations 48

    2. Management of Mild to Moderate Exacerbation 49

    3. Management of Severe Exacerbation 50

    4. Drug Doses for Asthma Exacerbations in Children 51

    PART THREE: REFERENCES & APPENDICES

    SECTION 11: REFERENCES 53

    SECTION 12: APPENDICES

    Appendix 1: Asthma Control Test in Arabic 54

    Appendix 2: Asthma Control Test in English 55

    Appendix 3: Asthma action Plan in Arabic 56

    Appendix 4: Asthma action Plan in English 57

    Appendix 5: Selecting Inhaler Devices 58

  • 7

    TABLE OF CONTENTS

    Appendix 6: Inhaler Technique Steps 59

    Appendix 7: How to Use Peak Flow Meter 60

    Appendix 8: Peak Flow Follow-up Chart 61

    Appendix 9: How to Find Personal Best Value 62

    Appendix 10: Asthma Management Protocol

    a. Clinical History 63

    b. Medical Assessment 64

    c. Medication Section 65

    d. Quick Management Reference 66

  • 8

    TABLES

    Table 1: Interpreting Spirometry

    16

    Table 2: Levels of Asthma Control 19 Table 3: Equipotent Daily Doses of Inhaled Corticosteroid for Adults 22 Table 4: Stepping Down Options 23 Table 5: Factors Influencing the Development of Near Fatal or Fatal Asthma 25 Table 6: Levels of Severity of Asthma Exacerbations 26 Table 7: Classification of Asthma Severity and Therapy in Children 0-4 Years 42 Table 8: Classification of Asthma Severity and Therapy in Children 5-12 Years 43

  • 9

    ABBREVIATION LIST

    Abbreviation Terminology AIA Aspirin-Induced Asthma A&E Accident and Emergency BPD Bronchopulmonary Dysplasia CO2 Carbon Dioxide COPD Chronic Obstructive Pulmonary Disease COX-1 Cyclooxygenase-1 ED Emergency Department EIA Exercise-Induced Asthma FEV1 Forced Expiratory Volume In One Second FVC Forced Vital Capacity FAMCO Family and Community Medicine FM & PH Family Medicine And Public Health GERD Gastro Esophageal Reflux GINA The Global Initiative For Asthma H Hour HD High Dependency ICS Inhaled Corticosteroids ICU Intensive Care Unit IgE Immunoglobulin E INH Inhalation IV Intra-Venous LABA Long Acting 2 Agonist Max Maximum Min Minute NSAIDs Non Steroidal Anti-Inflammatory Drugs PaCO2 Partial Pressure of Carbon Dioxide PEF Peak Expiratory Flow PEFM Peak Expiratory Flow Meter PHC Primary Health Care PICU Pediatric Intensive Care Unit Pred Predicted PRN When Needed SABA Short