2007 NHLBI Guidelines for the Diagnosis Management of by badboyben

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									          2007 NHLBI
     Guidelines for the
  Diagnosis & Management
        of Asthma
      Expert Panel Report-3


        Mamta Reddy, MD
      Bronx-Lebanon Hospital Center
         Department of Pediatrics
        Chief, Allergy/Immunology



www.nhlbi.nih.gov/guidelines/asthma
     The National Asthma Education and
       Prevention Program (NAEPP)

 Established in 1989 by the National Heart, Lung,
  and Blood Institute (NHLBI), a component of the
  U.S. National Institutes of Health (NIH)
 1991 Expert Panel Report: “The role of
  inflammation in disease development”
     Guidelines For The Diagnosis and
      Management of Asthma (EPR-3)
                 released: August 28, 2007

 (Almost) no new medications

 Restructuring into “severity” and “control”

 Domains of “impairment” and “risk”

 Six treatment steps (step-up/step-down)

 More careful thought into the ongoing management issues

 Summarizes the extensively-validated scientific evidence
  that the guidelines, when followed, lead to a significant
  reduction in the frequency and severity of asthma
  symptoms and improve quality of life
The 4 Components of Asthma Management

 Component 1: Measures of Asthma Assessment and Monitoring



 Component 2: Education for a Partnership in Asthma Care



 Component 3: Control of Environmental Factors and Comorbid
  Conditions That Affect Asthma


 Component 4: Medications
                  Summary of the                           EPR-3, Page 36-38



   New Strategies of the EPR-3

                 Assessment                   Management
Severity         the intrinsic intensity of   a clinical guide most useful
                 the disease                  for initiating controller
                                              therapy

Control          the degree to which          (after therapy is initiated) a
                 symptoms are                 clinical guide used to
                 minimized                    maintain or adjust therapy

Responsiveness   the ease of which       (variable) frequent follow-up
                 prescribed therapy      to step-up and step-down
                 achieves asthma control therapy to achieve the goal
                                         of control
          Severity & Control  EPR-3, p38-80, 277-345

  are assessed based on 2 domains:

 Impairment (present)
   frequency and intensity of symptoms
   functional limitations (quality of life)


 Risk (future)
   asthma exacerbations (utilization)
   progressive loss of pulmonary function (lung growth)
   risk of adverse reaction from medication



NAEPP Draft Report, ERP 2007
         The Goals of Asthma Therapy:
              (Asthma Control)                          EPR-3, p284

    Reducing impairment
      prevent chronic and troublesome symptoms
      require infrequent use (≤ 2 days a week) of inhaled SABA
      for symptoms
      maintain (near) “normal” pulmonary function
      maintain normal activity levels
      meet patients’ and families’ satisfaction with care



    Reducing risk
      prevent recurrent exacerbations of asthma (ED/inpatient)
      prevent progressive loss of lung function
      provide optimal pharmacotherapy

NAEPP Draft Report, ERP 2007
                  Summary of the                       EPR-3, Page 36-38



   New Strategies of the EPR-3

                 Assessment               Management
Severity         the intrinsic            a clinical guide most
                 intensity of the         useful for initiating
                 disease                  controller therapy

Control          the degree to which      (after therapy is initiated) a
                 symptoms are             clinical guide used to
                 minimized                maintain or adjust therapy

Responsiveness   the ease of which       (variable) frequent follow-up
                 prescribed therapy      to step-up and step-down
                 achieves asthma control therapy to achieve the goal
                                         of control
2002/1997 Expert Panel Report-2
  CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
                         CHILDREN 0-4 YEARS OF AGE                                         EPR-3, p72, 307

                                           Classification of Asthma Severity
   Components of
                                 Intermittent                              Persistent
     Severity
                                                            Mild            Moderate               Severe
               Symptoms          <2 days/week        >2 days/week not daily        Daily            Continuous

                Nighttime              0                  1-2x/month             3-4x/month
               Awakenings                                                                           >1x/week

             SABA use for sx
                control           <2 days/week       >2 days/week not daily        Daily        Several times daily

Impairment   Interference with
                                      none              Minor limitation      Some limitation   Extremely limited
              normal activity



                                    0-1/year          >2 exacerbations in 6 months requiring oral
                                                      steroids, or >4 wheezing episodes/ year
                                                      lasting >1 day AND risk factors for persistent
              Exacerbations                           asthma
   Risk          (consider                       Frequency and severity of may fluctuate over time
              frequency and
                  severity)           Exacerbations of any severity may occur in patients in any category

                                    Step 1               Step 2                 Step 3
                                                                            Consider short course of oral steroids
Recommended Step for
                                  In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
  Initiating Treatment                                          accordingly
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
                    CHILDREN 5 - 11 YEARS OF AGE                                              EPR-3, p73, 308

                                             Classification of Asthma Severity
   Components of
                                   Intermittent                               Persistent
     Severity
                                                               Mild            Moderate               Severe
               Symptoms             <2 days/week        >2 days/week not daily        Daily            Continuous

                Nighttime                                                          >1x/week
                                      <2x/month              3-4x/month
               Awakenings                                                                             Often nightly
                                                                                   not nightly
             SABA use for sx
                control              <2 days/week       >2 days/week not daily        Daily        Several times daily

Impairment   Interference with
                                         none              Minor limitation      Some limitation   Extremely limited
              normal activity
                                 •Normal FEV1 between        • FEV1 >80%         • FEV1=60% -        •FEV1 <60%
                                     exacerbations                                   80%
             Lung Function                                •FEV1/FVC> 80%                            •FEV1/FVC <
                                    • FEV1 > 80%                               •FEV1/FVC=75%            75%
                                  • FEV1/FVC> 85%                                   -80%
              Exacerbations              0-2/year             > 2 /year
   Risk          (consider             Frequency and severity may vary over time for patients in any category
              frequency and                 Relative annual risk of excaerbations may be related to FEV
                  severity)
                                       Step 1               Step 2            Step3    medium- Step 3 or 4
                                                                              dose ICS option
Recommended Step for
                                                                              Consider short course of oral steroids
  Initiating Treatment
                                     In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
                   YOUTHS > 12 YEARS AND ADULTS                                                  EPR-3, p74, 344

                                                Classification of Asthma Severity
    Components of
                                      Intermittent                               Persistent
      Severity
                                                                  Mild            Moderate               Severe
                  Symptoms             <2 days/week        >2 days/week not daily        Daily            Continuous
Impairment
                   Nighttime                                                          >1x/week
                                         <2x/month              3-4x/month
                  Awakenings                                                                             Often nightly
                                                                                      not nightly
   Normal       SABA use for sx
  FEV1/FVC         control              <2 days/week       >2 days/week not daily        Daily        Several times daily

 8-19 yr 85%    Interference with
                                            none              Minor limitation      Some limitation   Extremely limited
 20-39 yr 80%    normal activity
                                    •Normal FEV1 between
 40-59 yr 75%                                                   • FEV1 >80%                             •FEV1 <60%
                                        exacerbations                               • FEV1 >60%
 60-80 yr 70%   Lung Function                                •FEV1/FVC normal         but< 80%          •FEV1/FVC
                                       • FEV1 > 80%                                                    reduced> 5%
                                                                                     •FEV1/FVC
                                     • FEV1/FVC normal                              reduced 5%
                 Exacerbations              0-2/year            > 2 /year
     Risk           (consider             Frequency and severity may vary over time for patients in any category
                 frequency and                   Relative annual risk of excaerbations may be related to FEV
                     severity)
                                          Step 1               Step 2                 Step 3            Step 4 or 5
                                                                                  Consider short course of oral steroids
 Recommended Step for
                                        In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
   Initiating Treatment                                               accordingly
Classifying Severity for Patients Currently Taking
             Controller Medications


                     Classification of Asthma Severity
  Lowest level
  of treatment   Intermittent             Persistent
   required to
    maintain
     control                     Mild    Moderate       Severe
                    Step 1
                                Step 2   Step 3 or 4   Step 5 or 6


                                                  EPR-3, Page 72-74
 NAEPP Draft Report, ERP 2007
                  Summary of the                          EPR-3, Page 36-38



   New Strategies of the EPR-3

                 Assessment                   Management
Severity         the intrinsic intensity of   a clinical guide most useful
                 the disease                  for initiating controller
                                              therapy

Control          the degree to which (after therapy is
                 symptoms are        initiated) a clinical
                 minimized           guide used to maintain
                                     or adjust therapy
Responsiveness   the ease of which       (variable) frequent follow-up
                 prescribed therapy      to step-up and step-down
                 achieves asthma control therapy to achieve the goal
                                         of control
     Asthma Control

 Reducing Current Impairment

 Reducing Future Risk
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
              CHILDREN 0 - 4 YEARS OF AGE                                              EPR-3, p75, 309

                                                   Classification of Asthma Control
Components of Control                                                Not Well                  Very Poorly
                                           Well Controlled           Controlled                Controlled
                   Symptoms                 < 2 days/week           > 2 days/week          Throughout the day

              Nighttime awakenings            < 1/month             > 2 x/month              >2x/week
               Interference with                   none             Some limitation          Extremely limited
IMPAIRMENT     normal activity
                   SABA use                < 2 days/week           > 2 days/week            Several times/day

                 Exacerbations               0- 1 per year            2 - 3 per year            > 3 per year
              Progressive loss of lung                 Evaluation requires long-term follow up care
   RISK               function
             Rx-related adverse effects                   Consider in overall assessment of risk
                                                                                              •Consider oral
                                                                     •Step up 1 step             steroids
                                          •Maintain current step
                                                                   •Reevaluate in 2 - 6    •Step up (1-2 steps)
                                          •REGULAR FOLLOW                weeks
   Recommended Action                       UP EVERY 3 - 6
                                                                                           and reevaluate in 2
                                                                    •If no clear benefit          weeks
                                              MONTHS
      For Treatment                                                    in 4-6 weeks ,      •If no clear benefit in
                                          •Consider step down             consider         4-6 weeks , consider
                                           if well controlled at     alternative dx or        alternative dx or
                                              least 3 months           adjust therapy          adjust therapy
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
              CHILDREN 0 - 4 YEARS OF AGE                                              EPR-3, p75, 309

                                                   Classification of Asthma Control
Components of Control                                                Not Well                  Very Poorly
                                           Well Controlled           Controlled                Controlled
                   Symptoms                 < 2 days/week           > 2 days/week          Throughout the day

              Nighttime awakenings            < 1/month             > 2 x/month              >2x/week
               Interference with                   none             Some limitation          Extremely limited
IMPAIRMENT     normal activity
                   SABA use                < 2 days/week           > 2 days/week            Several times/day

                 Exacerbations               0- 1 per year            2 - 3 per year            > 3 per year
              Progressive loss of lung                 Evaluation requires long-term follow up care
   RISK               function
             Rx-related adverse effects                   Consider in overall assessment of risk
                                                                                              •Consider oral
                                                                     •Step up 1 step             steroids
                                          •Maintain current step
                                                                   •Reevaluate in 2 - 6    •Step up (1-2 steps)
                                          •REGULAR FOLLOW                weeks
   Recommended Action                       UP EVERY 3 - 6
                                                                                           and reevaluate in 2
                                                                    •If no clear benefit          weeks
                                              MONTHS
      For Treatment                                                    in 4-6 weeks ,      •If no clear benefit in
                                          •Consider step down             consider         4-6 weeks , consider
                                           if well controlled at     alternative dx or        alternative dx or
                                              least 3 months           adjust therapy          adjust therapy
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
               CHILDREN 5 - 11 YEARS OF AGE                                             EPR-3, p76, 310

                                                   Classification of Asthma Control
Components of Control                                                 Not Well                Very Poorly
                                           Well Controlled            Controlled              Controlled
                    Symptoms                < 2 days/week            > 2 days/week         Throughout the day

               Nighttime awakenings           < 1/month             > 2 x/month             >2x/week
                Interference with                  none              Some limitation         Extremely limited
IMPAIRMENT      normal activity
                    SABA use               < 2 days/week            > 2 days/week           Several times/day

                 FEV1or peak flow            > 80% predicted/       60-80% predicted/       <60% predicted/
                                               personal best          personal best         personal best

                FEV1/FVC                               > 80% predicted        75-80% predicted         <75% pre
                   Exacerbations             0- 1 per year            2 - 3 per year           > 3 per year
              Progressive loss of lung
   RISK                function                     Evaluation requires long-term follow up care
             Rx-related adverse effects                   Consider in overall assessment of risk
                                          •Maintain current step      •Step up 1 step         •Consider oral
                                                                                                 steroids
  Recommended Action                      •Consider step down       •Reevaluate in 2 - 6
                                           if well controlled at          weeks             •Step up 1-2 weeks
                                              least 3 months                                and reevaluate in 2
     For Treatment                                                                                weeks
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
          YOUTHS > 12 YEARS OF AGE AND ADULTS                                           EPR-3, p77, 345

                                                   Classification of Asthma Control
Components of Control                                                 Not Well                Very Poorly
                                           Well Controlled            Controlled              Controlled
                    Symptoms                < 2 days/week            > 2 days/week         Throughout the day

               Nighttime awakenings           < 2/month                1-3/week                 > 4/week
                Interference with                  none              Some limitation         Extremely limited
IMPAIRMENT      normal activity
                    SABA use               < 2 days/week            > 2 days/week           Several times/day

                 FEV1or peak flow            > 80% predicted/       60-80% predicted/       <60% predicted/
                                               personal best          personal best         personal best
              Validated questionnaires
                                                 0/> 20               1-2/16-19                3-4/< 15
              ATAQ/ACT
                   Exacerbations             0- 1 per year            2 - 3 per year           > 3 per year
              Progressive loss of lung
   RISK                function                     Evaluation requires long-term follow up care
             Rx-related adverse effects                   Consider in overall assessment of risk
                                          •Maintain current step      •Step up 1 step         •Consider oral
                                                                                                 steroids
  Recommended Action                      •Consider step down       •Reevaluate in 2 - 6
                                           if well controlled at          weeks             •Step up 1-2 weeks
                                              least 3 months                                and reevaluate in 2
     For Treatment                                                                                weeks
                 Summary of the                           EPR-3, Page 36-38



   New Strategies of the EPR-3
                 Assessment                   Management
Severity         the intrinsic intensity of   a clinical guide most useful
                 the disease                  for initiating controller
                                              therapy

Control          the degree to which          (after therapy is initiated) a
                 symptoms are                 clinical guide used to
                 minimized                    maintain or adjust therapy

Responsiveness the ease of which    (variable) frequent
                 prescribed therapy follow-up to step-up
                 achieves asthma    and step-down
                 control            therapy to achieve the
                                    goal of control
                                                        EPR-3, Page 78
     Monitoring Asthma Control
Ask the patient
   Has your asthma awakened you at night or early morning?
   Have you needed more rescue inhaler than usual?
   Have you needed urgent care for asthma? (office, ED, etc)
   Are you participating in your usual or desired activities?
   What are your triggers? (and how can we manage them?)

Actions to consider
   Assess whether medications are being taken as prescribed
   Assess whether inhalation technique is correct
   Assess spirometry and compare to previous measurements
   Adjust medications, as needed to achieve best control with
    the lowest dose needed to maintain control
   Environmental mitigation strategy

NAEPP Draft Report, ERP 2007
STEPWISE APPROACH FOR MANAGING ASTHMA IN
CHILDREN 0 - 4 YEARS OF AGE EPR-3, p291-296

                                Persistent Asthma: Daily Medication
Intermittent
                  Consult with asthma specialist if step 3 or higher care is required
  Asthma
                                   Consider consultation at step 2
                                                                                            Step up if
                                                                              Step 6        needed (check
                                                                                            adherence,
                                                                                            environmental
                                                              Step 5                        control )
                                                             Preferred:        AND
                                                           High dose ICS
                                              Step 4                        either LTRA
                                                                             Or LABA         Assess
                                             Preferred:        AND
                                Step 3                                                       Control
                                            Medium-dose
                               Preferred:       ICS
                                                                               AND
                 Step 2       Medium-dose                   either LTRA                     Step down
                Preferred:        ICS                        Or LABA            Oral        if possible
               Low-dose ICS                     AND
                                                                           Corticosteroid   (asthma well
   Step 1      Alternative:                  either LTRA                                    controlled
  Preferred:                                  Or LABA                                       for 3
                  LTRA
  SABA prn                                                                                  months)
                Cromolyn



 Patient Education and Environmental Control at Each Step
STEPWISE APPROACH FOR MANAGING ASTHMA IN
CHILDREN 5-11 YEARS OF AGE   EPR-3, p296-304

                                Persistent Asthma: Daily Medication
Intermittent
                  Consult with asthma specialist if step 4 or higher care is required
  Asthma
                                   Consider consultation at step 3
                                                                                                 Step up if
                                                                                  Step 6         needed (check
                                                                                                 adherence,
                                                                                  Preferred:     environmental
                                                                Step 5          High-dose ICS    control and
                                                                Preferred:      + LABA + oral    comorbidities)
                                                              High dose ICS     Corticosteroid
                                               Step 4            + LABA          Alternative:
                                                               Alternative:     High-dose ICS
                                                             High-dose ICS+
                                                                                                  Assess
                                                                               +either LTRA or
                               Step 3         Preferred:       either LTRA      Theophylline      Control
                              Preferred:
                                             Medium-dose     or Theophylline        + oral
                 Step 2      Medium-dose                                                          Step down
                                              ICS+LABA                          corticosteroid
                                 ICS                                                              if possible
                Preferred:                                       AND
               Low-dose ICS                   Alternative:                         AND
                                   OR                                                             (asthma well
                Alternative:                 Medium-dose        Consider       Consider
   Step 1          LTRA      Low-dose ICS+    ICS+either     Olamizumab for Olamizumab for
                                                                                                  controlled
  Preferred:                  either LABA,                                                        for 3
                 Cromolyn                      LTRA, or       patients with  patients with
  SABA prn                      LTRA, or                                                          months)
               Theophylline                  Theophlline        allergies      allergies
                              Theophylline


 Patient Education and Environmental Control at Each Step
STEPWISE APPROACH FOR MANAGING ASTHMA IN
YOUTHS > 12 YEARS AND ADULTS EPR-3, p333-343

                                Persistent Asthma: Daily Medication
Intermittent
                  Consult with asthma specialist if step 4 or higher care is required
  Asthma
                                   Consider consultation at step 3
                                                                                              Step up if
                                                                                              needed (check
                                                                               Step 6         adherence,
                                                                                              environmental
                                                                               Preferred:     control and
                                                                Step 5       High-dose ICS    comorbidities)
                                                               Preferred:    + LABA + oral
                                               Step 4        High dose ICS   Corticosteroid
                                                                + LABA                         Assess
                                              Preferred:
                               Step 3        Medium-dose                                       Control
                              Preferred:                                         AND
                                              ICS+LABA
                 Step 2      Medium-dose                         AND                           Step down
                                 ICS                                           Consider        if possible
                Preferred:                    Alternative:
               Low-dose ICS        OR        Medium-dose        Consider    Olamizumab for
                             Low-dose ICS+                   Olamizumab for  patients with     (asthma well
                Alternative:                  ICS+either
   Step 1          LTRA       either LABA,       LTRA,        patients with    allergies       controlled
  Preferred:                     LTRA,                          allergies                      for 3
                 Cromolyn                    Theophlline
  SABA prn                    Theophylline                                                     months)
               Theophylline                   Or Zileutin
                               Or Zileutin


 Patient Education and Environmental Control at Each Step
                                                             EPR-3, Page 330


     Recommended Action for Treatment
      Based on Assessment of Control
            Well                  Not Well              Very Poorly
        Controlled                Controlled            Controlled
   Maintain current step    Step up 1 step and     Consider short course
                            reevaluate in 2-6      of oral corticosteroids
                            weeks
   Consider step down if    For side effects,      Step up 1-2 steps and
   well controlled for at   consider alternative   reevaluate in 2 weeks
   least 3 months           treatment options
                                                   For side effects,
                                                   consider alternative
                                                   treatment options
  Before stepping up check adherence and environmental control
NAEPP Draft Report, ERP 2007
            Treatment Strategies

 Gain Control!!!
   Aggressive, intensive initial therapy to
    suppress airway inflammation and gain prompt
    control
 Maintain Control
   Frequent follow-up, clinically and
    physiologically
   Therapeutic modifications depending on
    severity and clinical course
   “Step down” long-term control medications to
    maintain control with minimal side effects
     Referral to an Asthma Specialist for
     Consultation and Co-Management
 Patient has had a life-threatening asthma exacerbation
   (hospitalization is a risk factor for mortality)
 Patient is not meeting the goals of therapy after 3-6 months
 Signs and symptoms are atypical; differential diagnosis ?
 Co-morbid conditions complicate asthma (GERD, VCD etc)
 Additional diagnostic studies are indicated (allergy skin testing,
   pulmonary function studies, bronchoscopy)
 Patient requires additional education/guidance
 Patient has required more than two bursts of oral corticosteroids
   in 1 year
 Patient requires “Step 4” care or higher (“Step 3” for children 0–4
   years of age). Consider referral if patient requires step 3 care
   (“Step 2” for children 0–4 years of age)

 Expert Panel Report-3, Page 68
                                                     EPR-3, p121-139
     The Outpatient Asthma Visit
 Assess “severity” and “control” (NAEPP Classification Criteria)
    Reduce current impairment
    Reduce future risk
 Address “Inflammation vs bronchoconstriction”
 Differentiate “controller vs rescue medication”
 Prescribe an inhaled steroid (for at least 4-6 weeks)
 Teach spacer device technique
 Write an Asthma Action Plan
   Daily management & recognizing early s/s of worsening
   Step-up “Yellow Zone” plan for home management
 Follow-up in 4-6 weeks: step-up/step-down & modify Action Plan
 School MAF/504b; Albuterol & spacer for school
 Annual Influenza vaccine, regardless of severity
The 4 Components of Asthma Management

 Component 1: Measures of Asthma Assessment and Monitoring



 Component 2: Education for a Partnership in Asthma Care



 Component 3: Control of Environmental Factors and Comorbid
  Conditions That Affect Asthma


 Component 4: Medications
Component 2: Education for a Partnership in Asthma Care
       Asthma Self-Management Education at Multiple Points of Care
            clinic/office-based education
            emergency department/ hospital-based education
            education by pharmacists
            education in school settings
            community-based interventions
            home-based interventions
       Tools for Asthma Self-Management
          asthma action plans
          peak flow meters

       Establish and Maintain a Partnership
          jointly develop treatment goals
          health literacy (read, count, measure, time, schedule)
          cultural sensitivity/ ethnic considerations

       Provider Education
            implementing guidelines
            communication techniques
            clinical decision support
            systems-based interventions                            EPR-3, P 93-164
                                               EPR-3, p121-139


       Key Educational Messages
 Significance of the diagnosis

 Inflammation as the underlying cause of symptoms

 Controllers versus quick-relievers

 How to use medication delivery devices

 Triggers, including second-hand tobacco smoke

 Home monitoring/ self-management

 How/ when to reach the provider

 The need for continuous on-going interaction with the
  clinician to step-up and step-down therapy
 Annual Influenza vaccine (yearround reminder)
NAEPP Guidelines: every patient with persistent
asthma should have a written home management
                                               EPR-3, p115-123
plan
The 4 Components of Asthma Management

 Component 1: Measures of Asthma Assessment and Monitoring



 Component 2: Education for a Partnership in Asthma Care



 Component 3: Control of Environmental Factors and Comorbid
  Conditions That Affect Asthma


 Component 4: Medications
EPR-3, P 165
EPR-3, Page 166
EPR-3, Page 166
   Provide Specific Guidance                        EPR-3, P167-177
   on Environmental Controls
 Dust mite interventions
    impermeable encasings for pillows/mattresses
    wash linens in hot water
    HEPA filtration

 Animal allergens
    keep outside/ out of bedroom
    similar interventions like for dust mites

 Roach control
    integrated pest management
    clean up food, spills, trash, leaks

 Mold and mildew interventions
    air conditioning
    avoid humidifiers
    repair pipes and leaks

 Second-hand smoke exposure

 Air Pollution
The 4 Components of Asthma Management

 Component 1: Measures of Asthma Assessment and Monitoring



 Component 2: Education for a Partnership in Asthma Care



 Component 3: Control of Environmental Factors and Comorbid
  Conditions That Affect Asthma


 Component 4: Medications
                                          EPR-3, p177-184



Comorbid Conditions That Affect Asthma

 Allergic Bronchopulmonary Aspergillosis

 Gastroesophageal Reflux Disease

 Obesity

 Obstructive Sleep Apnea

 Rhinitis/Sinusitis

 Stress, Depression, and Psychosocial Factors

 Medications, sulfites, infections, hormones
The 4 Components of Asthma Management

 Component 1: Measures of Asthma Assessment and Monitoring



 Component 2: Education for a Partnership in Asthma Care



 Component 3: Control of Environmental Factors and Comorbid
  Conditions That Affect Asthma


 Component 4: Medications
       Guidelines for the
         Diagnosis &
         Management
          of Asthma
           NAEPP/NHLBI
        Expert Panel Report-3



         Case Scenarios


www.nhlbi.nih.gov/guidelines/asthma
                Case # 1
A 3-year old male currently not on any
asthma medications has visited your
outpatient clinic 3 times in the past 6
months for acute wheezing, each episode
lasting 2-3 days. In between episodes, his
mother reports nighttime cough about 4
nights per month. This patient’s asthma
severity can be BEST classified as:

 A. Mild Persistent Asthma (Step 2)
 B. Moderate Persistent Asthma (Step 3)
 C. Severe Persistent Asthma (Step 3)
 D. I would not diagnose this child with asthma
  CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
                         CHILDREN 0-4 YEARS OF AGE                                         EPR-3, p72, 307

                                           Classification of Asthma Severity
   Components of
                                 Intermittent                              Persistent
     Severity
                                                            Mild            Moderate               Severe
               Symptoms          <2 days/week        >2 days/week not daily        Daily            Continuous

                Nighttime              0                  1-2x/month             3-4x/month
               Awakenings                                                                           >1x/week

             SABA use for sx
                control           <2 days/week       >2 days/week not daily        Daily        Several times daily

Impairment   Interference with
                                      none              Minor limitation      Some limitation   Extremely limited
              normal activity



                                    0-1/year          >2 exacerbations in 6 months requiring oral
                                                      steroids, or >4 wheezing episodes/ year
                                                      lasting >1 day AND risk factors for persistent
              Exacerbations                           asthma
   Risk          (consider                       Frequency and severity of may fluctuate over time
              frequency and
                  severity)           Exacerbations of any severity may occur in patients in any category

                                    Step 1               Step 2                 Step 3
                                                                            Consider short course of oral steroids
Recommended Step for
                                  In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
  Initiating Treatment                                          accordingly
                Case # 1
A 3-year old male currently not on any
asthma medications has visited your
outpatient clinic 3 times in the past 6
months for acute wheezing, each episode
lasting 2-3 days. In between episodes, his
mother reports nighttime cough about 4
nights per month. This patient’s asthma
severity can be BEST classified as:

 A. Mild Persistent Asthma (Step 2)
 B. Moderate Persistent Asthma (Step 3)
 C. Severe Persistent Asthma (Step 3)
 D. I would not diagnose this child with asthma
                     Case # 2
A 7-year old male presents to your clinic in November
complaining of daily nocturnal cough for 2 months. He
denies symptoms of GE Reflux. He has visited the
emergency room twice in the past year where he
received albuterol with good symptomatic relief. The
BEST choice of treatment would be to:
  A. Start fluticasone 44 mcg 2 puffs twice daily for
     4-6 weeks and then reassess
  B. Start fluticasone 110 mcg 2 puffs twice daily for
     4-6 weeks and then reassess
  C. Start a leukotriene modifier as you suspect his
     symptoms are likely due to post-nasal drainage
     from allergic rhinitis
  D. I cannot feel confident at this time that this
     patient should be treated with asthma
     medications
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
                    CHILDREN 5 - 11 YEARS OF AGE                                              EPR-3, p73, 308

                                             Classification of Asthma Severity
   Components of
                                   Intermittent                               Persistent
     Severity
                                                               Mild            Moderate               Severe
               Symptoms             <2 days/week        >2 days/week not daily        Daily            Continuous

                Nighttime                                                          >1x/week
                                      <2x/month              3-4x/month
               Awakenings                                                                             Often nightly
                                                                                   not nightly
             SABA use for sx
                control              <2 days/week       >2 days/week not daily        Daily        Several times daily

Impairment   Interference with
                                         none              Minor limitation      Some limitation   Extremely limited
              normal activity
                                 •Normal FEV1 between        • FEV1 >80%         • FEV1=60% -        •FEV1 <60%
                                     exacerbations                                   80%
             Lung Function                                •FEV1/FVC> 80%                            •FEV1/FVC <
                                    • FEV1 > 80%                               •FEV1/FVC=75%            75%
                                  • FEV1/FVC> 85%                                   -80%
              Exacerbations              0-2/year             > 2 /year
   Risk          (consider             Frequency and severity may vary over time for patients in any category
              frequency and                 Relative annual risk of excaerbations may be related to FEV
                  severity)
                                       Step 1               Step 2            Step3    medium- Step 3 or 4
                                                                              dose ICS option
Recommended Step for
                                                                              Consider short course of oral steroids
  Initiating Treatment
                                     In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
STEPWISE APPROACH FOR MANAGING ASTHMA IN
CHILDREN 5-11 YEARS OF AGE   EPR-3, p296-304

                                Persistent Asthma: Daily Medication
Intermittent
                  Consult with asthma specialist if step 4 or higher care is required
  Asthma
                                   Consider consultation at step 3
                                                                                  Step 6         Step up if
                                                                                                 needed (check
                                                                                  Preferred:     adherence,
                                                                                High-dose ICS    environmental
                                                                Step 5          + LABA + oral    control and
                                                                Preferred:      Corticosteroid   comorbidities)
                                                              High dose ICS      Alternative:
                                               Step 4            + LABA         High-dose ICS
                                                               Alternative:
                                                             High-dose ICS+
                                                                               +either LTRA or    Assess
                               Step 3         Preferred:       either LTRA
                                                                                Theophylline
                                                                                                  Control
                              Preferred:                                            + oral
                                             Medium-dose     or Theophylline    corticosteroid
                 Step 2      Medium-dose                                                          Step down
                                              ICS+LABA
                                 ICS                                                              if possible
                Preferred:                                       AND               AND
               Low-dose ICS                   Alternative:
                                   OR                                          Consider           (asthma well
                Alternative:                 Medium-dose        Consider
   Step 1          LTRA      Low-dose ICS+    ICS+either     Olamizumab for
                                                                            Olamizumab for        controlled
  Preferred:                  either LABA,                                   patients with        for 3
                 Cromolyn                      LTRA, or       patients with
  SABA prn                      LTRA, or                                       allergies          months)
               Theophylline                  Theophlline        allergies
                              Theophylline


 Patient Education and Environmental Control at Each Step
                     Case # 2
A 7-year old male presents to your clinic in November
complaining of daily nocturnal cough for 2 months. He
denies symptoms of GE Reflux. He has visited the
emergency room 3 times in the past year where he
received albuterol with good symptomatic relief. The
BEST choice of treatment would be to:
  A. Start fluticasone 44 mcg 2 puffs twice daily for
     4-6 weeks and then reassess
  B. Start fluticasone 110 mcg 2 puffs twice daily for
     4-6 weeks and then reassess
  C. Start a leukotriene modifier as you suspect his
     symptoms are likely due to post-nasal drainage
     from allergic rhinitis
  D. I cannot feel confident at this time that this
     patient should be treated with asthma
     medications
                    Case # 3

A 7-year old female with asthma reports
nighttime awakenings about 2 times per
week and requires albuterol about 3 times
per week. She is currently taking
fluticasone 44 mcg 2 puffs twice daily. The
BEST next step in your step-up treatment
plan would be to:
A. Increase the dose of the inhaled steroid
B. Add a leukotriene modifier
C. Add a long-acting B-agonist
D. Encourage albuterol more frequently, every 4 hours
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
               CHILDREN 5 - 11 YEARS OF AGE                                             EPR-3, p76, 310

                                                   Classification of Asthma Control
Components of Control                                                 Not Well                Very Poorly
                                           Well Controlled            Controlled              Controlled
                    Symptoms                < 2 days/week            > 2 days/week         Throughout the day

               Nighttime awakenings           < 1/month             > 2 x/month                 >2x/week
                Interference with                  none              Some limitation         Extremely limited
IMPAIRMENT      normal activity
                    SABA use               < 2 days/week            > 2 days/week           Several times/day

                 FEV1or peak flow            > 80% predicted/       60-80% predicted/       <60% predicted/
                                               personal best          personal best         personal best

                FEV1/FVC                               > 80% predicted        75-80% predicted         <75% pre
                   Exacerbations             0- 1 per year            2 - 3 per year           > 3 per year
              Progressive loss of lung
   RISK                function                     Evaluation requires long-term follow up care
             Rx-related adverse effects                   Consider in overall assessment of risk
                                          •Maintain current step      •Step up 1 step         •Consider oral
                                                                                                 steroids
  Recommended Action                      •Consider step down       •Reevaluate in 2 - 6
                                           if well controlled at          weeks             •Step up 1-2 steps
                                              least 3 months                                and reevaluate in 2
     For Treatment                                                                                weeks
     Recommended Action for Treatment
      Based on Assessment of Control

            Well                  Not Well              Very Poorly
        Controlled                Controlled            Controlled
   Maintain current step    Step up 1 step and     Consider short course
                            reevaluate in 2-6      of oral corticosteroids
                            weeks
   Consider step down if    For side effects,      Step up 1-2 steps and
   well controlled for at   consider alternative   reevaluate in 2 weeks
   least 3 months           treatment options
                                                   For side effects,
                                                   consider alternative
                                                   treatment options
  Before stepping up check adherence and environmental control
NAEPP Draft Report, ERP 2007
STEPWISE APPROACH FOR MANAGING ASTHMA IN
CHILDREN 5-11 YEARS OF AGE   EPR-3, p296-304

                                Persistent Asthma: Daily Medication
Intermittent
                  Consult with asthma specialist if step 4 or higher care is required
  Asthma
                                   Consider consultation at step 3
                                                                                  Step 6         Step up if
                                                                                                 needed (check
                                                                                  Preferred:     adherence,
                                                                                High-dose ICS    environmental
                                                                Step 5          + LABA + oral    control and
                                                                Preferred:      Corticosteroid   comorbidities)
                                                              High dose ICS      Alternative:
                                               Step 4            + LABA         High-dose ICS
                                                               Alternative:
                                                             High-dose ICS+
                                                                               +either LTRA or    Assess
                               Step 3         Preferred:       either LTRA
                                                                                Theophylline
                                                                                                  Control
                              Preferred:                                            + oral
                                             Medium-dose     or Theophylline    corticosteroid
                 Step 2      Medium-dose                                                          Step down
                                              ICS+LABA
                                 ICS                                                              if possible
                Preferred:                                       AND               AND
               Low-dose ICS                   Alternative:
                                   OR                                          Consider           (asthma well
                Alternative:                 Medium-dose        Consider
   Step 1          LTRA      Low-dose ICS+    ICS+either     Olamizumab for
                                                                            Olamizumab for        controlled
  Preferred:                  either LABA,                                   patients with        for 3
                 Cromolyn                      LTRA, or       patients with
  SABA prn                      LTRA, or                                       allergies          months)
               Theophylline                  Theophlline        allergies
                              Theophylline


 Patient Education and Environmental Control at Each Step
                    Case # 3

A 7-year old female with asthma reports
nighttime awakenings about 2 times per
week and requires albuterol about 3 times
per week. She is currently taking
fluticasone 44 mcg 2 puffs twice daily. The
BEST next step in your step-up treatment
plan would be to:
A. Increase the dose of the inhaled steroid
B. Add a leukotriene modifier
C. Add a long-acting B-agonist
D. Encourage albuterol more frequently, every 4 hours
                    Case # 4

A 13-year old girl presents to your office in May
and is currently taking fluticasone 110 mcg 2
puffs twice daily and montelukast 5 mg 1 tablet at
bedtime daily. She denies any report of daytime
or nighttime asthma symptoms for the past 4
months. Her asthma severity classification is:


 A. Intermittent Asthma (Step 1)
 B. Mild Persistent Asthma (Step 2)
 C. Moderate Persistent Asthma (Step 3 or 4)
 D. All medications should be immediately discontinued
Classifying Severity for Patients Currently Taking
             Controller Medications


                     Classification of Asthma Severity
  Lowest level
  of treatment   Intermittent             Persistent
   required to
    maintain
     control                     Mild    Moderate       Severe
                    Step 1
                                Step 2   Step 3 or 4   Step 5 or 6


                                                  EPR-3, Page 72-74
 NAEPP Draft Report, ERP 2007
                    Case # 4

A 13-year old girl presents to your office in May
and is currently taking fluticasone 110 mcg 2
puffs twice daily and montelukast 5 mg 1 tablet at
bedtime daily. She denies any report of daytime
or nighttime asthma symptoms for the past 4
months. Her asthma severity classification is:


 A. Intermittent Asthma (Step 1)
 B. Mild Persistent Asthma (Step 2)
 C. Moderate Persistent Asthma (Step 3 or 4)
 D. All medications should be immediately discontinued
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
          YOUTHS > 12 YEARS OF AGE AND ADULTS                                           EPR-3, p77, 345

                                                   Classification of Asthma Control
Components of Control                                                 Not Well                Very Poorly
                                           Well Controlled            Controlled              Controlled
                    Symptoms                < 2 days/week            > 2 days/week         Throughout the day

               Nighttime awakenings           < 2/month                1-3/week                 > 4/week
                Interference with                  none              Some limitation         Extremely limited
IMPAIRMENT      normal activity
                    SABA use               < 2 days/week            > 2 days/week           Several times/day

                 FEV1or peak flow            > 80% predicted/       60-80% predicted/       <60% predicted/
                                               personal best          personal best         personal best
              Validated questionnaires
                                                 0/> 20               1-2/16-19                3-4/< 15
              ATAQ/ACT
                   Exacerbations             0- 1 per year            2 - 3 per year           > 3 per year
              Progressive loss of lung
   RISK                function                     Evaluation requires long-term follow up care
             Rx-related adverse effects                   Consider in overall assessment of risk
                                          •Maintain current step      •Step up 1 step         •Consider oral
                                                                                                 steroids
  Recommended Action                      •Consider step down       •Reevaluate in 2 - 6
                                           if well controlled at          weeks             •Step up 1-2 weeks
                                              least 3 months                                and reevaluate in 2
     For Treatment                                                                                weeks
     Recommended Action for Treatment
      Based on Assessment of Control

            Well                  Not Well              Very Poorly
        Controlled                Controlled            Controlled
   Maintain current step    Step up 1 step and     Consider short course
                            reevaluate in 2-6      of oral corticosteroids
                            weeks
   Consider step down if    For side effects,      Step up 1-2 steps and
   well controlled for at   consider alternative   reevaluate in 2 weeks
   least 3 months           treatment options
                                                   For side effects,
                                                   consider alternative
                                                   treatment options
  Before stepping up check adherence and environmental control
NAEPP Draft Report, ERP 2007
STEPWISE APPROACH FOR MANAGING ASTHMA IN
YOUTHS > 12 YEARS AND ADULTS EPR-3, p333-343

                                Persistent Asthma: Daily Medication
Intermittent
                  Consult with asthma specialist if step 4 or higher care is required
  Asthma
                                   Consider consultation at step 3
                                                                                              Step up if
                                                                                              needed (check
                                                                                              adherence,
                                                                               Step 6         environmental
                                                                                              control and
                                                                               Preferred:
                                                                Step 5       High-dose ICS
                                                                                              comorbidities)
                                                               Preferred:
                                               Step 4        High dose ICS
                                                                             + LABA + oral
                                                                             Corticosteroid
                                                                + LABA                         Assess
                                              Preferred:
                               Step 3        Medium-dose                                       Control
                              Preferred:
                                              ICS+LABA                           AND
                 Step 2      Medium-dose                         AND           Consider        Step down
                                 ICS                                                           if possible
                Preferred:                    Alternative:                  Olamizumab for
               Low-dose ICS        OR        Medium-dose        Consider     patients with
                             Low-dose ICS+                   Olamizumab for                    (asthma well
                Alternative:                  ICS+either                       allergies
   Step 1          LTRA       either LABA,       LTRA,        patients with                    controlled
  Preferred:                     LTRA,                          allergies                      for 3
                 Cromolyn                    Theophlline
  SABA prn                    Theophylline                                                     months)
               Theophylline                   Or Zileutin
                               Or Zileutin


 Patient Education and Environmental Control at Each Step
                    Case # 5

A 5-year old male with asthma reports nocturnal
cough 3 nights per week during October through
February, but only 3 nights per month during
March through September. This patient’s asthma
severity can be classified and treated as follows:

  A. Moderate Persistent during winter only, Mild
     Persistent remainder of the year
  B. Moderate Persistent year-round in order to prevent
     winter exacerbations
  C. Mild Persistent year-round in order to prevent long-
     term decrease in lung function
  D. This patient does not have asthma but is at high-
     risk for frequent upper respiratory tract infections
     with the change of seasons
                  Summary of the                           EPR-3, Page 36-38



   New Strategies of the EPR-3

                 Assessment                   Management
Severity         the intrinsic intensity of   a clinical guide most useful
                 the disease                  for initiating controller
                                              therapy

Control          the degree to which          (after therapy is initiated) a
                 symptoms are                 clinical guide used to
                 minimized                    maintain or adjust therapy

Responsiveness   the ease of which       (variable) frequent follow-up
                 prescribed therapy      to step-up and step-down
                 achieves asthma control therapy to achieve the goal
                                         of control
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
                    CHILDREN 5 - 11 YEARS OF AGE                                              EPR-3, p73, 308

                                             Classification of Asthma Severity
   Components of
                                   Intermittent                               Persistent
     Severity
                                                               Mild            Moderate               Severe
               Symptoms             <2 days/week        >2 days/week not daily        Daily            Continuous

                Nighttime                                                          >1x/week
                                      <2x/month              3-4x/month
               Awakenings                                                                             Often nightly
                                                                                   not nightly
             SABA use for sx
                control              <2 days/week       >2 days/week not daily        Daily        Several times daily

Impairment   Interference with
                                         none              Minor limitation      Some limitation   Extremely limited
              normal activity
                                 •Normal FEV1 between        • FEV1 >80%         • FEV1=60% -        •FEV1 <60%
                                     exacerbations                                   80%
             Lung Function                                •FEV1/FVC> 80%                            •FEV1/FVC <
                                    • FEV1 > 80%                               •FEV1/FVC=75%            75%
                                  • FEV1/FVC> 85%                                   -80%
              Exacerbations              0-2/year             > 2 /year
   Risk          (consider             Frequency and severity may vary over time for patients in any category
              frequency and                 Relative annual risk of excaerbations may be related to FEV
                  severity)
                                       Step 1               Step 2            Step3    medium- Step 3 or 4
                                                                              dose ICS option
Recommended Step for
                                                                              Consider short course of oral steroids
  Initiating Treatment
                                     In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
               CHILDREN 5 - 11 YEARS OF AGE                                             EPR-3, p76, 310

                                                   Classification of Asthma Control
Components of Control                                                 Not Well                Very Poorly
                                           Well Controlled            Controlled              Controlled
                    Symptoms                < 2 days/week            > 2 days/week         Throughout the day

               Nighttime awakenings           < 1/month             > 2 x/month             >2x/week
                Interference with                  none              Some limitation         Extremely limited
IMPAIRMENT      normal activity
                    SABA use               < 2 days/week            > 2 days/week           Several times/day

                 FEV1or peak flow            > 80% predicted/       60-80% predicted/       <60% predicted/
                                               personal best          personal best         personal best

                FEV1/FVC                               > 80% predicted        75-80% predicted         <75% pre
                   Exacerbations             0- 1 per year            2 - 3 per year           > 3 per year
              Progressive loss of lung
   RISK                function                     Evaluation requires long-term follow up care
             Rx-related adverse effects                   Consider in overall assessment of risk
                                          •Maintain current step      •Step up 1 step         •Consider oral
                                                                                                 steroids
  Recommended Action                      •Consider step down       •Reevaluate in 2 - 6
                                           if well controlled at          weeks             •Step up 1-2 weeks
                                              least 3 months                                and reevaluate in 2
     For Treatment                                                                                weeks
                    Case # 5

A 5-year old male with asthma reports nocturnal
cough 3 nights per week during October through
February, but only 3 nights per month during
March through September. This patient’s asthma
severity can be classified and treated as follows:

  A. Moderate Persistent during winter only, Mild
     Persistent remainder of the year
  B. Moderate Persistent year-round in order to prevent
     winter exacerbations
  C. Mild Persistent year-round in order to prevent long-
     term decrease in lung function
  D. This patient does not have asthma but is at high-
     risk for frequent upper respiratory tract infections
     with the change of seasons
                 Case # 6

A spacer device can be equally as effective as,
and perhaps more effective than, a nebulizer
machine in the delivery of inhaled medication.


       (circle one) TRUE or FALSE
                 Case # 6

A spacer device can be equally as effective as,
and perhaps more effective than, a nebulizer
machine in the delivery of inhaled medication.


       (circle one) TRUE or FALSE
                   Case # 7
Referral to an asthma specialist for
consultation and co-management should
be sought when a patient:

 A. Is hospitalized twice in the past year or once in
   the past month
 B. Requires more than two bursts of oral
   corticosteroids in one year
 C. Requires “Step 3” care or higher or is not
   responding to a treatment plan that is appropriate
   for patient with “Moderate Persistent Asthma”
 D. All of the above
                   Case # 7
Referral to an asthma specialist for
consultation and co-management should
be sought when a patient:

 A. Is hospitalized twice in the past year or once in
   the past month
 B. Requires more than two bursts of oral
   corticosteroids in one year
 C. Requires “Step 3” care or higher or is not
   responding to a treatment plan that is appropriate
   for patient with “Moderate Persistent Asthma”
 D. All of the above

								
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