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					 Creating a
Medical Home
     for
  Asthma




    An Asthma Management
         Program for
     Healthcare Providers

 Instructor’s Guide – Session 3
Creating a Medical Home for Asthma

     An Asthma Management Program
        For Health Care Providers
    Web site address: http://www.nyc.gov/html/doh/html/cmha/ig_session3.html


                                      By

                       David Evans, PhD, AE-C1
                         Robert Mellins, MD1
                Sandra Wiesemann, RN-CS, MSN, MPH2
                      Marcia Pinkett-Heller, MPH3
                      Barry J. Zimmerman, PhD4
                        Katherine Lobach, MD5
                     Carmen Ramos-Bonoan, MD6
                      1
                       College of Physicians & Surgeons
             Pediatric Pulmonary Division, Columbia University
       2
        Medical and Health Research Association of New York City, Inc
                          3
                           New Jersey City University
                4
                 City University of New York Graduate Center
                     5
                       Albert Einstein College of Medicine
          6
           New York City Department of Health and Mental Hygiene

              NYC Department of Health & Mental Hygiene
                Bureau of Chronic Disease Prevention
                     Childhood Asthma Initiative

                                          th
                     2 Lafayette Street, 20 Floor, CN #36A
                              New York, NY 10007
                        Telephone: 212-676-2137/2178
                               Fax: 212-676-2161

                             Lorna E. Davis, M.S.
                      Director, Childhood Asthma Initiative

                          Andrew Goodman, M.D., M.P.H.
                             Associate Commissioner
Partners



           Columbia University College of Physicians &
           Surgeons
           http://cpmcnet.columbia.edu/dept/ps/

           New Jersey City University Health Sciences
           Department
           http://www.njcu.edu/dept/ProfStudies/hs/default.htm

           New York City Department of Health and Mental
           Hygiene
           http://www.nyc.gov/html/doh/home.html

           National Heart, Lung, and Blood Institute
           http://www.nhlbi.nih.gov/

           RTI International
           http://www.rti.org/
(This page intentionally left blank.)
Table of Contents
Session 3 Using Medications for the Prevention of Asthma ...................................... ii
      Introduction to CMHA Training ............................................................................... ii
      Session 3: Using Medications for the Prevention of Asthma .................................. ii
Preparing for the Sessions ............................................................................................. 1
      Making Arrangements ............................................................................................ 1
      Group Size.............................................................................................................. 1
      Facilities ................................................................................................................. 1
      Audiovisual Equipment ........................................................................................... 2
      Creating an Alternative Plan: Questions to Consider ....................................................2
Tips for Running the Session ........................................................................................ 3
       Group Participation ................................................................................................. 3
       Use of Appropriate Language ................................................................................. 3
       Name Tags or IDs .................................................................................................. 3
       Handouts ................................................................................................................ 3
       Breaks .................................................................................................................... 3
       Checklist ................................................................................................................. 4
       Supplies and Equipment Checklist ......................................................................... 4
Instructional Strategies .................................................................................................. 5
      Key Points to Remember When Leading an Interactive Learning Activity .............. 5
      Debriefing after an Interactive Group Learning Activity .......................................... 5
How To Read The Training Materials............................................................................. 7
     Table of Abbreviations/Symbols ............................................................................. 7
     Purpose of Session ................................................................................................ 8
     Training Team Staffing ........................................................................................... 8
Activity I Progress Reports by Clinic Staff on Force Field Analysis (10-30 Min.) ..... 9
Activity II Treatment Plans for Asthma (45 Min.) ......................................................... 10
Activity III Break (15 Min.) .............................................................................................. 11
Activity IV Discussion of Treatment Plan (30 Min.) .................................................... 12
Activity V Demonstration of Equipment and Teaching Technique—Guided
       Practice (60 Min.) .................................................................................................. 13
Activity VI Closing Remarks (5 Min.) ............................................................................ 15
Session 3: Handout 3-1 (Activity II) .............................................................................. 17
Session 3: Handout 3-2 (Activity II) .............................................................................. 23
Session 3: Handout 3-3 (Activity II) .............................................................................. 24



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Creating a Medical Home for Asthma                                                                                               i
Instructor’s Guide                                          Session 3
Session 3: Using Medications for the Prevention
of Asthma

Introduction to CMHA Training

   Instructional Strategies

   Debriefing after an Interactive Group Learning Activity

   Tips for Running the Session

   Checklist

Session 3: Using Medications for the Prevention of Asthma

   Progress Reports by Clinic Staff on Force Field Analysis

   Treatment Plans for Asthma

   Discussion of Treatment Plans

   Demonstration of Equipment and Teaching Technique—Guided Practice

   Closing Remarks




Creating a Medical Home for Asthma                                     ii
Instructor’s Guide                          Session 3
Preparing for the Sessions
Making Arrangements

Group Size
The number of participants for the training sessions should be small enough to allow for good
instructor-participant interaction, yet large enough to elicit a variety of feedback from the
attendees. A group of approximately 10-12 participants is the recommended size.
If you have to work with larger groups, be sure to elicit feedback and discussion from everyone
in the group so each person feels involved in the learning activity.
If additional trainers are available, it may be possible to divide the group in half and allow each
sub-group to work with a separate trainer. At the end of the session, the entire group can come
together and discuss the important concepts from each activity.

Facilities
Room - Because this training program involves a great deal of interactive learning, the room(s)
used should have movable furniture that allows participants to easily move in and out of large
and small group learning experiences.
Audio-Visual Equipment - Overhead projectors, flip charts, and other audio/visual aids are key
to the success of the training. Be sure to make arrangements for obtaining the necessary
equipment at least a week in advance of each session.
Refreshments – your plans for hospitality/breaks (e.g., refreshments, location of coffee pots,
where rest facilities are located) should be considered when selecting and setting up the room.
Also, be sure to ask whether food from outside is permitted or does the facility provides catering.
This may affect the cost of the space you are planning to use.
Location - Be sure to choose a facility that is accessible to all participants.


Key Points to Know

            How to arrange for audio-visual equipment
            How to operate audio-visual equipment
            Who to contact in maintenance for problems with facilities




Creating a Medical Home for Asthma                                                                    1
Instructor’s Guide                             Session 1
Audiovisual Equipment
As soon as you know where and when the session is scheduled, be sure to notify the people who
supply the equipment.
Identify in advance the individual who will accept the equipment when it arrives and who will be
responsible for storing it. Consider alternative options just in case the building is locked or if the
elevator is not running when the equipment needs to be moved from where it is stored to the
room in which it will be used.
Test the equipment to make sure it is in proper working order and that you know how to operate
it.
Decide ahead of time where the equipment will be placed and make sure there are enough
electrical outlets in appropriate places, and they are appropriate for the equipment you are
planning to use. For example, it may be wise to have a 3- pronged adaptor.
When working with sensitive equipment that is regularly transported to different sites, there is
always the chance that something will go wrong. It is always wise to have an alternate plan, just
in case the equipment you were expecting to use does not arrive or is inoperable.

Creating an Alternative Plan: Questions to Consider

       1.   Is there another source you can use to obtain similar equipment in an emergency—
            possibly a clinic in the building or another office?
       2.   Is it possible to move the session to a location where there is equipment available?
       3.   Can the session be rescheduled?
       4.   Other options generated at the training session can be listed below.




Creating a Medical Home for Asthma                                                                   2
Instructors’ Guide                             Session 1
Tips for Running the Session
Group Participation
The Creating a Medical Home for Asthma Program has been designed with activities that
encourage participation and interaction between health care clinic and organization staff. Some
of these activities may appear time consuming, and there will be the temptation to eliminate or
modify them. However, the activities and interactions are an important part of the program. The
activities are not only designed to convey information, but to develop skills in areas such as
communication, problem solving and networking. These skills, along with the enhanced
knowledge of asthma management and care, will serve staff well in working with patients.
Health care and policy issues regarding the delivery of care are likely to be different across each
health care organization. Therefore, the trainer should be prepared to identify clinic staff or
additional trainers who can answer questions throughout the sessions or as issues arise.

Use of Appropriate Language
Since there will be participants with diverse backgrounds and experiences—from clerical staff to
clinicians—it is essential that the instructor use language that can be understood by all attendees,
regardless of their educational level or clinic position. This also allows the participants to get
used to the idea that they too (especially the clinicians) will need to apply the same language
usage skills when communicating with patients.

Name Tags or IDs
Since multiple opportunities for communication and networking are woven throughout the
program, it is good to encourage the development and refinement of these skills whenever
possible. For this reason, the use of nametags or other form of identification that is clearly
visible is strongly recommended.

Handouts
Since people tend to read things as soon as they are distributed, handouts should be distributed
either before the session starts or be held until the time they are needed. By the end of the
session each participant should have received all handouts, including protocols. It is important
that you have enough legible copies for everyone.

Breaks
The break times have been scheduled throughout the sessions where they will be most useful, so
participants don’t miss material that is being covered by leaving the session at different times.
Absorbing new material is often difficult and adequate time is needed to process what has been
heard before more information can be delivered successfully. Therefore skipping breaks is not
recommended. They serve a vital purpose in reinforcing the tone of the session.
Session facilitators are encouraged to promote dialogue during the breaks about what has just
been heard. Interaction between staff is helpful in planning, implementation, anticipating


Creating a Medical Home for Asthma                                                                    3
Instructor’s Guide                            Session 3
problems and arriving at alternative solutions to address concerns, particularly, if training
involves staff from multiple sites.

Checklist
The following checklist can be used as a reminder to make sure you have the needed equipment
and supplies available for each session, as well as identify persons to provide assistance, as
needed.

However, be sure to review the materials needed for each session because there may be
additional resources that are required.

Supplies and Equipment Checklist
           Masking tape, or clear removable tape
           Felt tip markers
           Newsprint (paper on flip chart) and an easel
           Chalk
           Handouts, including agenda
           Attendance sheet (if desired)
           Audio-visual equipment, including screen—arrange at least 1 week in advance
           Extension cord and adaptor for electrical equipment (be sure you know where
            working outlets are)
           Refreshments
               What is appropriate
               Who will bring it
               Is there a coffee pot, extension cord, etc.
           Who is responsible for cleaning up afterwards




Creating a Medical Home for Asthma                                                               4
Instructor’s Guide                             Session 3
Instructional Strategies

Key Points to Remember When Leading an Interactive Learning
Activity
          Time: Be sure to keep track of the time. You can either do it yourself, or assign
           someone to be a silent timekeeper.
          Sequence: The activities within each session provide a series of information and
           learning experiences that have been designed to build on the participant’s knowledge
           and experience. The activities are also intended to provide new information and
           opportunities to try out new behaviors.
          Active Participation: Participants should have something to do throughout each
           session besides sitting and listening. If information is being given, participants
           should be encouraged to ―listen actively‖ and be aware of what key points they will
           be responsible for knowing.
              If a role-play or other activity is planned, each person should have a specific part
               to play, either as ―actor‖ or observer. It is critical that adequate time is allowed
               for discussing (i.e., processing/debriefing) each activity and how it is related to
               the learning experiences. The debriefing should take place immediately after the
               activity and focus on what the participants learned as a result.
              The discussion of the behaviors and feelings that came out of the activity is very
               important.

Debriefing after an Interactive Group Learning Activity

          Be sure to keep track of the time. You can either do it yourself or assign someone to
           be a timekeeper.
          Start the discussion by asking, ―What happened in the situation?‖
            Allow participants to answer first. If roles involve health care personnel and
               patients, debrief health care personnel first.
              After role-playing exercises, go around the room and make sure each ―actor‖ who
               wants to answer gets a chance. Refer to the actors by role name rather than their
               real name to keep the focus on the role play.
              Next, encourage observers to make their comments. Keep the discussion moving
               by calling on them to respond to specific questions on their observation forms.
          When the group seems ―talked out,‖ ask, ―What was learned?,‖ ―What should have
           been done?,‖ or, ―What could be done differently?‖ Again, call on ―actors‖ first and
           then observers.
          Conclude the discussion by asking for any other comments. If none are forthcoming,
           summarize and repeat what the group has learned. Say things like, ―The group seems
           to feel ...,‖ ―You say you learned....‖


Creating a Medical Home for Asthma                                                                    5
Instructor’s Guide                            Session 3
          Move on to the introduction of the next activity.


Note: It is important to remember that you are not responsible for coming up with all of the
answers to the problems discussed. Rather, the task is to help the participants develop their own
understanding from the experiences provided.




Creating a Medical Home for Asthma                                                                  6
Instructor’s Guide                           Session 3
How To Read The Training Materials
The CMHA training materials are designed to allow the facilitators or trainers to move quickly
and easily through each activity. In an effort to minimize the amount of information, symbols are
used to represent key points the facilitator should remember during each session.

Prior to the start of the sessions, you should become familiar with each symbol and how they are
used in the text. By understanding how these are integrated throughout the text you will reduce
the likelihood of unnecessary interruptions and promote continuous learning experiences for the
participants.

                             Table of Abbreviations/Symbols


                 PS        Preparation steps: things that can/should be done
                           before conducting an activity

                 TN        Trainer’s notes: things for the trainer to keep in mind
                           before conducting an activity

                Bold       Trainer’s script: suggested wording

                          Important note: action or message to be noted




Creating a Medical Home for Asthma                                                              7
Instructor’s Guide                          Session 3
Session 3: Using Medications for the Prevention
of Asthma

                               Agenda for Session 3 (165-185 Min.)
                          Using Medications for the Prevention of Asthma
             Activities                                         Time                 Method
    I        Progress Reports by Clinic Staff on             10-30 min.     Presentations by clinic
             Force Field Analysis                                           teams
   II        Treatment Plans for Asthma                        45 min.      Presentation
   III       Break                                             15 min.
   IV        Discussion of Treatment Plan                      30 min.      Discussion
   V         Demonstration of Equipment and                    60 min.      Demonstration & Role
             Teaching Technique—Guided Practice                             Play
   VI        Closing Remarks                                    5 min.


Purpose of Session
             To reinforce the importance of utilizing force field analysis as a tool for
              implementing change
             To describe and discuss in detail the rationale for and the content of the treatment
              plans
             To provide participants with an opportunity (1) to see the correct way to use each
              piece of equipment mentioned in the program and (2) to see effective methods for
              teaching its use to caregivers and children


Training Team Staffing
             Health educator
             Clinician(s)




Creating a Medical Home for Asthma                                                                    8
Instructor’s Guide                               Session 3
Activity I: Progress Reports by Clinic Staff on
Force Field Analysis (10-30 Min.)

 Purpose:                     To reinforce the importance of utilizing force field analysis as a
                              tool for implementing change
 Time needed:                 10-30 minutes
 Training team:               Health educator/facilitator
 Materials needed:            1.     Felt tip markers
                              2.     Flip chart on an easel
 Seating arrangements:        Usual arrangement for entire group



TN     Allow five minutes for each team to report on its progress. If a team feels that there was
       no progress, the five minutes can be used to identify the obstacles to progress and what
       could be done to modify or eliminate these obstacles.




Creating a Medical Home for Asthma                                                                  9
Instructor’s Guide                            Session 3
Activity II: Treatment Plans for Asthma (45 Min.)

Purpose:                      To describe and discuss in detail the rationale for and the content
                              of the treatment plans
Time needed:                  45 minutes
Training team:                Clinician(s)
Materials needed:             Trainer:
                                1. Overhead or LCD projector
                                2. Overhead or PowerPoint slides
                              Each person will need:
                                1. A copy of Handout 3-1 (Quick Reference: NAEPP Expert
                                   Panel Report – Guidelines for the Diagnosis and
                                   Management of Asthma—Update on Selected Topics 2002)
                                2. A copy of Handout 3-2 (Sample Asthma Action Plan)
                                3. A copy of Handout 3-3 (Recommended Treatment
                                   Protocols for Children with Asthma at Different Levels of
                                   Severity)
Seating arrangements:         Usual arrangement for entire group



TN     This is an in-depth presentation and detailed discussion of current treatment protocols for
       children with asthma based on the NHLBI guidelines. Make sure everyone present has a
       copy of Quick Reference: NAEPP Expert Panel Report–Guidelines for the Diagnosis and
       Management of Asthma–Updated on Selected Topics 2002 and blank copies of the
       treatment plans in their Program Handbook.

       The PowerPoint presentation entitled Treating Children with Asthma: Making the
       NHLBI Guidelines Work In Primary Care is the basis of this activity. The Power Point
       slides have extensive notes that contain suggested points to emphasize and references for
       the information presented in the slides.

       When you arrive at the slides that show different treatment options using the New York
       City Department of Health and Mental Hygiene’s Asthma Action Plan form, emphasize
       the different scenarios in the discussion. The treatment is determined by the severity
       assessment, but there are treatment options that the asthma specialist will comment on out
       of his or her own experience. It may also be helpful to provide examples of the clinic’s
       own treatment plans and the rationale for its own treatment protocol.




Creating a Medical Home for Asthma                                                              10
Instructor’s Guide                           Session 3
Activity III: Break (15 Min.)

During the break, you may want to prepare for the following:
Activity IV – Discussion of Treatment Plan
          Make sure that there will be several clinicians available




Creating a Medical Home for Asthma                                     11
Instructor’s Guide                           Session 3
Activity IV: Discussion of Treatment Plan
(30 Min.)

 Purpose:                       To address any questions and concerns participants might have
                                about the protocol

 Time needed:                   30 minutes
 Training team:                 Clinicians
 Materials needed:              Trainer:
                                   1. Overhead or LCD projector
                                   2. Overheads or PowerPoint slides, as needed (e.g., blank
                                           and completed samples of treatment plans)

                                Each person will need:
                                      A copy of Handout 3-1 (Recommended Treatment Protocols
                                     for Children with Asthma at Different Levels of Severity)
 Seating arrangements:          Usual arrangement for entire group



TN     Remind staff that the therapeutic choices provided in the treatment plans reflect the most
       optimal treatment based on the asthma guidelines.

       Ask for staff to express any questions and concerns they might have about the protocol.
       All clinicians on the training team should feel free to enter into this discussion and
       respond to the therapeutic strategy utilized in the protocol. Be prepared to come up with
       some leading questions to begin the discussion; for example:

       Which aspects of the treatment plans from the protocol are not entirely
       clear to you?

       When you talk about a treatment plan for a child with his or her caregiver,
       what are the first things that you say or point out?

           You can also ask about their experience in:
               Assessing patient severity at each visit
               Prescribing controllers for patients with persistent asthma
               Providing a written treatment plan to the family and teaching them how to follow
                it




Creating a Medical Home for Asthma                                                             12
Instructor’s Guide                             Session 3
Activity V: Demonstration of Equipment and
Teaching Technique—Guided Practice (60 Min.)

 Purpose:                     To provide participants with an opportunity (1) to see the correct
                              way to use each piece of equipment mentioned in the program and
                              (2) to see effective methods for teaching its use to caregivers and
                              children
 Time needed:                 60 minutes

 Training team:               Clinician(s)
 Materials needed:            Pulmo-aide, nebulizer and tubing, face mask, normal saline
                              solution, Albuterol for nebulizer solution, a vial of Intal for nebulizer
                              solution.
                              Demonstrator Metered Dose Inhaler.
                              Dry powder inhaler.
                              InspirEase with travel pack and replacement bags.
                              Aerochamber with face mask.

                              A sample of each of the asthma medications used in the clinic.
 Seating arrangements:        Chairs positioned so that each participant can see the
                              demonstration



TN     This demonstration should be done by someone who routinely teaches caregivers and
       children about how to use the equipment in the clinic.

      Ask for two volunteers to play the part of the caregiver and the child during the
       demonstration

       Demonstrate the use of the nebulizer, and MDI with both spacers.

       Include all steps you normally use in teaching, including an explanation of the advantages
       of using this method of taking medicine. Give the full treatment.

       If appropriate, hand out ―generic instructions‖ for MDI and nebulizer use. Several
       sources for these instructions can be found at:

               http://www.nhlbi.nih.gov/health/public/lung/asthma/asth_fs.pdf
               http://www.aaaai.org/patients/publicedmat/tips/inhaledmedications.stm
               http://www.pharmacyandyou.org/healthinfo/2001_inhaler.htm



Creating a Medical Home for Asthma                                                                    13
Instructor’s Guide                             Session 3
      As each demonstration is completed, say:

          When you finish demonstrating proper use to the family, give them the
           equipment and ask them to show you what they learned

          Reinforce the correct technique to the caregiver and child (this is the
           guided practice), and thank them for their participation

      At the end of each demonstration, ask for different volunteers to keep your audience
       involved.

       Have trainers stationed at different places around the room with the different pieces of
       equipment to answer questions and explain again how the equipment works. At the end
       of the guided practices, you can say:

       You have seen all the equipment and heard how it fits into the treatment
       plan. Take the next five minutes or so to go around and look at the
       equipment and ask any questions you may have. Please schedule your
       next team meeting with a member of the Training Team, to go over it again
       in your own clinic.

      After this, reconvene the group for the closing remarks.




Creating a Medical Home for Asthma                                                            14
Instructor’s Guide                          Session 3
Activity VI: Closing Remarks (5 Min.)

 Purpose:                       1.   To provide an overview of the activities in the current
                                     session
                                2.   To provide closure to current session
                                3.   To prepare participants for the activities for the upcoming
                                     session and remind them of any assignments
 Time needed:                   5 minutes
 Materials needed:              Trainer: None

                                Each person will need: None
 Seating arrangements:          Usual arrangement for entire group


TN     Whoever is doing this part should jot down notes throughout the session to include in the
       summary remarks. The closing remarks should take no more than five minutes, to
       provide closure and remind trainees of any assignments.

      Give a very brief review of what activities were done in this session and the reasons
       behind these activities.

       In today’s session, we have heard progress reports from the teams about
       what they have done for the force field analysis assignment. We have also
       covered in detail the rationale for and content of the various treatment
       plans. Again, if you have any questions or concerns about any aspect of
       these plans, please be sure to talk with one of our clinicians. Lastly, we
       gave you a demonstration of each piece of equipment used in our asthma
       program and reviewed the correct techniques for using them. Remember,
       it is also important to remember how the equipment fits into the treatment
       plan.


       For our next session, we will continue to hear the progress reports from
       the teams on force field analysis. That will be followed by a review of
       communication skills that all of us should use for teaching families about
       asthma.




Creating a Medical Home for Asthma                                                                 15
Instructor’s Guide                           Session 3
TN     Remind participants of date and time of next session and the materials they should bring
       with them.


       Emphasize that they should begin to apply the concepts learned in the training session
       today, and be prepared during the next session to discuss their experiences. Also, ask
       staff to review concepts covered in Program Handbook to prepare for the next session.




Creating a Medical Home for Asthma                                                              16
Instructor’s Guide                          Session 3
               Session 3: Handout 3-1 (Activity II)




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               Session 3: Handout 3-2: (Activity II)
                                           Sample




Creating a Medical Home for Asthma                     23
Instructor’s Guide                   Session 3
             Session 3: Handout 3-3 (Activity II)
                            Recommended Treatment Protocols for Children
                             with Asthma at Different Levels of Severity

            SAMPLE LONG TERM TREATMENT PLAN FOR MILD INTERMITTENT ASTHMA



Name                                                       Date                    Spacer



                                                                                               For cough
                       Baseline Plan and        At the FIRST       For rapidly worsening       or wheeze
    CLINICAL            When asthma is         sign of a cold             asthma                  with
                                                              b
   CONDITION             under control         or mild attack         (severe attack)           exercise
Peak Flow
(% personal best)         80% or above            50 to 80%               below 50%

MEDICATION                                                                                       2 puffs
                                                                          2-4 puffs           5-10 minutes
Reliever:                                                             every 20 minutes           before
Inhaled short-                2 puffs              2 puffs              for 3 doses
                                                                                    e           exercise
                                                            c,f
acting                      as needed            every 4 hr
              a
beta2-agonist
                                                                        then 2-4 puffs
Albuterol                                                                 every 4 hr


Corticosteroid                  0                      0                  Begin with
                                                                                     d
Tablet or Syrup                                                         1-2 mg/kg/day

                                                                         NOTIFY MD

Footnotes for clinicians only

a Use more than 2x/week may indicate need to initiate long term controller (anti-inflammatory) therapy.
  See Long Term Treatment Plan for Mild Persistent Asthma.
b If viral infections provoke severe attacks (exacerbations) consider short course of corticosteroid tablets
  or syrup at the first sign of a cold or viral illness; see dose next column.
c The need for beta2-agonist for more than 24-48 hrs indicates at least a moderate attack; consider
  short course of corticosteroid tablets or syrup.
d Maximum corticosteroid dose 60 mg/day; 3-11 day course.
e If there is not a good response, seek emergency care immediately. If there is a good response
  continue in this column and notify MD.
f. If beta2-agonist needs to be given for 24 hr or longer more often than every 6 weeks, initiate long term
   controller (anti-inflammatory) therapy. See Sample Long Term Treatment Plan for Mild Persistent
   Asthma.


Creating a Medical Home for Asthma                                                                       24
Instructor’s Guide                               Session 3
                    SAMPLE LONG TERM TREATMENT PLAN FOR MILD PERSISTENT ASTHMA


Name                                               Date       Date                Spacer Spacer



                                                                     For rapidly      When there
                                             At the FIRST            worsening           is no       For cough
                       Baseline Plan &       sign of a cold           asthma           cough or      or wheeze
     CLINICAL          When asthma is           Or mild               (severe         wheeze for        with
    CONDITION           under control            attack                attack)         2 months       exercise
Peak Flow                80% or above          50 to 80%             below 50%          over 80%
(% personal best)                                                                     for 2 months

MEDICATION                                                         2-4 puffs                          2 puffs
Reliever                                                         every 20 min                        5-10 min
Inhaled short-               2 puffs             2 puffs         for 3 doses
                                                                             e          2 puffs       before
                                                          c                                                   h
acting                     as needed           every 4 hr                              as needed     exercise
              a
beta2-agonist
                                                                 then 2-4 puffs
Albuterol                                                          every 4 hr

Controller
1) inhaled low dose         1-4 puffs           1-4 puffs             1-4 puffs            0
               b
corticosteroid               2x/day              2x/day                2x/day
   Beclomethasone
42 mcg or
              g
2) nonsteroid                   0                   0                    0              2 puffs
                                                                                                f
   Nedocromil                                                                          2-3x/day
Corticosteroid                  0                   0             Begin with               0
                                                                             d
Tablet or Syrup                                                 1-2 mg/kg/day

                                                                 NOTIFY MD

Footnotes for clinician only
a Daily or increasing use indicates need for more long term controller (anti-inflammatory) therapy.
b Equivalent drugs: fluticasone 44 (1-2 puffs, 2x/day), flunisolide 250 (1 puff, 2x/day), budesonide 200
  (inhalation 1x/day) or triamcinolone 100 (2-4 puffs, 2x/day).
c The need for beta2-agonist for more than 24-48 hrs indicates at least a moderate attack; consider
  short course of corticosteroid tablets or syrup.
d Maximum corticosteroid dose 60mg/day; 3-11 day course.
e If there is not a good response, seek emergency care immediately. If there is a good response,
  remain in this column and notify MD.
f   When free of symptoms for 4 to 6 months may try discontinuing controller medicines.
g Nonsteroids include cromolyn and nedocromil: In young children, these may be tried before inhaled
  corticosteroids. Antileukotriene agents may also be considered as an alternative: zafirlukast (20 mg
                                                                                                  -14 yrs,
  10 mg 1x/
h If it is difficult to take short acting beta2-agonists before exercise consider long-acting beta2-agonist
  (salmeterol) to protect against exercise induced bronchospasm for up to 8 hr.

Creating a Medical Home for Asthma                                                                            25
Instructor’s Guide                                 Session 3
                SAMPLE LONG TERM TREATMENT PLAN FOR MODERATE PERSISTENT ASTHMA

   Name                                           Date                            Spacer


 CLINICAL               Baseline Plan       At the FIRST             For rapidly      When there     For cough
 CONDITION                    &           sign of a cold or          worsening        is no cough    or wheeze
                        When asthma         mild asthma                asthma          or wheeze        with
                          is under              attack             (severe attack)        for 2       exercise
                           control                                                       months
 Peak Flow              Baseline-60 to        50 to 80%              below 50%          over 80%
 (% personal best)       80% Under                                                    for 2 months
                           control-
                        80% or above                                                                    2 puffs
                                                                                                     5-10 minutes
 MEDICATION                                                                                             before
                                                                                                                g
 Reliever:                                                         2-4 puffs                           exercise
 Inhaled short-                0                2 puffs        every 20 minutes              0
                                                         c                   e
 acting                                       every 4 hr         for 3 doses
               a
 beta2-agonist                                                  then 2-4 puffs
                                                                  every 4 hr
 Albuterol

 Controller:
                                                                                                 f
 1) inhaled medium         2-4 puffs           2-4 puffs              2-4 puffs            1 puff
 dose                       2x/day              2x/day                 2x/day              2x/day
                   b
    corticosteroid
    Beclomethasone
 84 mcg

 and
 2) Long-acting
               h
 beta2-agonist
    Salmeterol

 and
                    i
 3) Antileukotriene

 Corticosteroid                0                   0                 Begin with              0
                                                                                d
 Tablet or Syrup                                                   1-2 mg/kg/day
                                                                    NOTIFY MD

Footnotes for clinician only
a Daily or increasing use indicates the need for more long term controller (anti-inflammatory) therapy.
b Equivalent drugs: fluticasone 110 (1-2 puffs, 2x/day), flunisolide 250 (2 puffs, 2x/day), budesonide 200 (1
   inhalation 2x/day) or triamcinolone 100 (4-6 puffs, 2x/day). If night time symptoms not controlled, add
   long acting inhaled beta2-agonist 2x/day.
c The need for beta2-agonist for more than 24-48 hrs indicates at least a moderate attack; consider short
   course of corticosteroid tablets or syrup.
d Maximum corticosteroid dose 60 mg/day; 3-11 day course.
e If there is not a good response, seek emergency care immediately. If there is a good response continue
   in this column and notify MD.
f When free of symptoms for 4 months use low dose inhaled corticosteroid.
g If it is difficult to take short acting beta2-agonists before exercise consider long-acting beta2-agonist
   (salmeterol) to protect against exercise induced bronchospasm for up to 8 hr.
h. If needed, consider long-acting inhaled beta2-agonist (salmeterol 2 puffs, 2x/day) especially for night time
   symptoms.
 i Antileukotriene agents may be used as additive therapy: zafirlukast (20 mg 2x/day) or zileuton (600 mg
                                                                           -

   Creating a Medical Home for Asthma                                                                        26
   Instructor’s Guide                                  Session 3
                  SAMPLE LONG TERM TREATMENT PLAN FOR SEVERE PERSISTENT ASTHMA


Name                                             Date                     Spacer


CLINICAL                 Baseline Plan&           For rapidly          When there is        For cough or
CONDITION                When asthma is        worsening asthma        no cough or          wheeze with
                          under control         (severe attack)        wheeze for 2           exercise
                                                                         months
Peak Flow              Baseline-below 60%          below 50%             above 80%
(% personal best)        Under control-                                 for 2 months
                         80% or above

MEDICATION                                                                                     2 puffs
Reliever:                                                                                  5-10 min before
Inhaled short-acting                                2-4 puffs                                 exercise
              a
beta2-agonist                2-4 puffs          every 20 minutes          2-4 puffs
                                                              e
                            as needed             for 3 doses            as needed
Albuterol                                        then 2-4 puffs
                                                   every 4 hr

Controller:
1) Inhaled high dose         4-5 puffs              4-5 puffs             2-4 puffs
                  b                                                               f
   Corticosteroid             2x/day                 2x/day                2x/day
   Beclomethasone
84 mcg

and
2) Long-acting                2 puffs                2 puffs               2 puffs
beta2-agonist                 2x/day                 2x/day                2x/day
   Salmeterol

and
                   g
3) Antileukotriene
                                          d
                        0.25-2 mg/kg/day           2 mg/kg/day                0
Corticosteroid
Tablet or Syrup                                    NOTIFY MD
Footnotes for clinician only
a Daily or increasing use indicates need for more long-term controller (anti-inflammatory) therapy.
b Equivalent drugs: fluticasone 110 (2-3 puffs, 2x/day), flunisolide 250 (2-3 puffs, 2x/day), budesonide
  200 (1-2 inhalations 2x/day) or triamcinolone 100 (>6 puffs, 2x/day).
d Maximum corticosteroid dose 60 mg/day. With improvement gradually lower dose and if possible
  change to every other day schedule.
e If there is not a good response, seek emergency care immediately. If there is a good response continue
   in this column and notify MD.
f When free of symptoms for 4-6 months reduce inhaled corticosteroids to medium dose.
g. Antileukotriene agents may be used as additive therapy: zafirlukast (20 mg 2x/day) or zileuton (600 mg
                                                                       -14 yrs, 10 mg 1x




Creating a Medical Home for Asthma                                                                         27
Instructor’s Guide                               Session 3
              LONG TERM TREATMENT PLAN FOR MILD INTERMITTENT ASTHMA




Name                                             Date                Spacer




CLINICAL CONDITION                Baseline Plan     At the FIRST       For rapidly     For cough
                                        &           sign of a cold     worsening       or wheeze
                                 When asthma is           or             asthma           with
                                  under control      mild attack     (severe attack)    exercise
Peak Flow                         80% or above          50 to 80%      below 50%
(% personal best)

MEDICATION
Reliever:
Inhaled short-acting
beta2-agonist




Corticosteroid Tablet or Syrup




Creating a Medical Home for Asthma                                                            28
Instructor’s Guide                               Session 3
                  LONG TERM TREATMENT PLAN FOR MILD PERSISTENT ASTHMA




Name                                          Date                    Spacer




CLINICAL              Baseline Plan &   At the FIRST      For rapidly     When there     For cough
CONDITION              When asthma      sign of a cold    worsening       is no cough    or wheeze
                         is under       or mild attack     asthma          or wheeze        with
                          control                          (severe            for 2       exercise
                                                            attack)          months
Peak Flow              80% or above       50 to 80%       below 50%         over 80%
(% personal best)                                                         for 2 months

MEDICATION

Reliever
Inhaled short-
acting
beta2-agonist


Controller
1) inhaled low
dose corticosteroid

or

2) nonsteroid




Corticosteroid
Tablet or Syrup




Creating a Medical Home for Asthma                                                              29
Instructor’s Guide                            Session 3
         LONG TERM TREATMENT PLAN FOR MODERATE PERSISTENT ASTHMA




Name                                   Date                    Spacer


CLINICAL              Baseline Plan      At the FIRST     For rapidly    When there    For cough
CONDITION                   &            sign of a cold   worsening      is no cough   or wheeze
                     When asthma is     or mild asthma     asthma         or wheeze       with
                      under control          attack        (severe      for 2 months    exercise
                                                            attack)
Peak Flow             Baseline-60 to      50 to 80%       below 50%       over 80%
(% personal best)      80% Under                                        for 2 months
                         control-
                      80% or above

MEDICATION

Reliever:
Inhaled short-
acting
beta2-agonist



Controller:
1) inhaled medium
dose
   corticosteroid


        and
2) Long-acting
beta2-agonist


         and
3) Antileukotriene


Corticosteroid
Tablet or Syrup




Creating a Medical Home for Asthma                                                            30
Instructor’s Guide                            Session 3
           LONG TERM TREATMENT PLAN FOR SEVERE PERSISTENT ASTHMA




Name                                   Date                      Spacer



CLINICAL                    Baseline Plan        For rapidly      When there is   For cough or
CONDITION                         &           worsening asthma    no cough or     wheeze with
                           When asthma is      (severe attack)    wheeze for 2      exercise
                            under control                           months
Peak Flow                  Baseline-below        below 50%          above 80%
(% personal best)               60%                                for 2 months
                           Under control-
                           80% or above

MEDICATION
Reliever:
Inhaled short-acting
beta2-agonist




Controller:
1) Inhaled high dose
   Corticosteroid


and
2) Long-acting beta2-
agonist


and
3) Antileukotriene


Corticosteroid Tablet or
Syrup




Creating a Medical Home for Asthma                                                           31
Instructor’s Guide                             Session 3

				
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