Download About Asthma

HEALTHAMERICA PENNSYLVANIA
MANAGEMENT OF ASTHMA
PRACTICE RECOMMENDATIONS
INTRODUCTION
The following information was developed by the National Asthma Education and Prevention Program Expert
Panel Report II: Guidelines for the Diagnosis and Management of Asthma [The Expert Panel is a
multidisciplinary group of clinicians and scientists with an expertise in asthma management. The Panel includes
health professionals in the areas of general medicine, family practice, pediatrics, emergency medicine, allergy,
pulmonary medicine, nursing, pharmacy and health education]. HealthAmerica endorses the information contained in
these recommendations.
RECOMMENDATIONS
Patient History at time of initial diagnosis should include:
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Symptoms (cough, wheezing, shortness of breath, chest tightness, sputum production)
Pattern of symptoms (perennial, seasonal or both; continual, episodic, or both; onset, duration, frequency;
diurnal variations-especially nocturnal and on awakening in early morning)
Precipitating and/or aggravating factors
Development of disease and treatment (age of onset & diagnosis, history of early life injury to airways,
progress of disease, present management and response, need for oral corticosteroids, comorbid conditions).
Family history/Social history
Profile of typical exacerbation
Impact of asthma on patient and family
Assessment of patient's and family's perceptions of disease
Periodic Assessment and Monitoring
The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of a sthma
therapy are being achieved. The goals of asthma therapy include the following:
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Prevent chronic and troublesome symptoms (coughing or breathlessness in the night, early morning or after
exertion)
Maintain (near) "normal" pulmonary function
Maintain normal activity levels (including exercise and other physical activity)
Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or
hospitalizations
Provide optimal pharmacotherapy with minimal or no adverse effects
Meet patients' and families' expectations of and satisfaction with asthma care
The Expert Panel recommends ongoing monitoring in the following areas to determine whether the goals of
asthma therapy are being met:
HEALTHAMERICA PENNSYLVANIA
MANAGEMENT OF ASTHMA
PRACTICE RECOMMENDATIONS
INTRODUCTION
The following information was developed by the National Asthma Education and Prevention Program Expert
Panel Report II: Guidelines for the Diagnosis and Management of Asthma [The Expert Panel is a
multidisciplinary group of clinicians and scientists with an expertise in asthma management. The Panel includes
health professionals in the areas of general medicine, family practice, pediatrics, emergency medicine, allergy,
pulmonary medicine, nursing, pharmacy and health education]. HealthAmerica endorses the information contained in
these recommendations.
RECOMMENDATIONS
Patient History at time of initial diagnosis should include:
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
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Symptoms (cough, wheezing, shortness of breath, chest tightness, sputum production)
Pattern of symptoms (perennial, seasonal or both; continual, episodic, or both; onset, duration, frequency;
diurnal variations-especially nocturnal and on awakening in early morning)
Precipitating and/or aggravating factors
Development of disease and treatment (age of onset & diagnosis, history of early life injury to airways,
progress of disease, present management and response, need for oral corticosteroids, comorbid conditions).
Family history/Social history
Profile of typical exacerbation
Impact of asthma on patient and family
Assessment of patient's and family's perceptions of disease
Periodic Assessment and Monitoring
The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma
therapy are being achieved. The goals of asthma therapy include the following:






Prevent chronic and troublesome symptoms (coughing or breathlessness in the night, early morning or after
exertion)
Maintain (near) "normal" pulmonary function
Maintain normal activity levels (including exercise and other physical activity)
Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or
hospitalizations
Provide optimal pharmacotherapy with minimal or no adverse effects
Meet patients' and families' expectations of and satisfaction with asthma care
The Expert Panel recommends ongoing monitoring in the following areas to determine whether the goals of
asthma therapy are being met:
• Monitoring signs and symptoms of asthma: patients with asthma should be taught to recognize symptoms of
inadequate control and they should be assessed at the time of each health care visit. Assessment should
include the following:
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Monitoring pulmonary function:
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Daytime asthma symptoms
Nocturnal awakening as a result of asthma symptoms
Asthma symptoms early in the morning that are not improved 15 minutes after inhaling a short acting beta 2agonist
Spirometry: at the time of initial assessment, after treatment is initiated and symptoms and peak
expiratory flow (PEF) have stabilized and at least every 1-2 years to assess the maintenance of airway
function.
Peak flow monitoring: Used as a tool for ongoing monitoring, not diagnosing. Patients with moderate
to severe persistent asthma should learn how to monitor their PEF and have a peak flow at home. Long term
daily peak flow monitoring for patients with mild intermittent or mild persistent asthma is not required
unless the patient, family or physician finds it useful in guiding therapeutic decisions.
Monitoring quality of life/functional status: The following areas should be periodically assessed:
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Any missed work or school due to asthma
Any reduction in usual activities (either home/work/school or recreation/exercise)
Any disturbance in sleep due to asthma
Any change in caregiver's activities due to a child's asthma (for caregivers of children with asthma)
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Monitoring history of asthma exacerbations: It is important to evaluate the frequency, severity and causes of
exacerbation.
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Monitoring pharmacotherapy: The following factors should be monitored:
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Patient adherence to the regime
Inhaler technique
Level of usage of as-needed inhaled short-acting beta 2 -agonist
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Frequency of oral corticosteroid "burst" therapy
Changes in dosage of inhaled anti-inflammatory or other long-term control medications
Side effects of medications
Monitoring patient-provider communication and patient satisfaction: Two aspects of patient satisfaction should be
monitored:
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Satisfaction with asthma control
Satisfaction with the quality of care
Referral for consultation or care to a specialist in asthma care is recommended when:
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Patient has life-threatening asthma exacerbation
Patient is not meeting the goals of asthma therapy
• Signs and symptoms are atypical or there are problems in differential diagnosis
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Other conditions complicate asthma or its diagnosis
Additional diagnostic testing is indicated
Patient requires additional education and guidance on complications of therapy, problems with adherence, or
allergen avoidance
Patient is being considered for immunotherapy
Patient has severe persistent asthma
Patient requires continuous oral corticosteroid therapy or high-dose inhaled corticosteroids or has required more
that two bursts of oral corticosteroids in one year
Patient requires confirmation of a history that suggests that an occupational or environmental inhalant or ingested
substance is provoking or contributing to asthma
Patient is pregnant
Controlling Factors Contributing to Asthma Severity,
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It is essential to identify and reduce exposure to relevant allergens and irritants including inhalant
allergens, occupational exposures, non-allergic factors and other factors
Intranasal corticosteroids are recommended for the treatment of chronic rhinitis in patients with
persistent asthma
Treatment of sinusitis includes medical measures to promote drainage and the use of antibiotics when
complicating bacterial infection is present
Medical management of gastroesophageal reflux should be instituted for any patients with asthma complaining of
frequent heartburn or pyrosis, particularly those with frequent episodes of nocturnal asthma
Adult patients with asthma should be questioned regarding precipitation of bronchoconstriction by aspirin and other
nonsteroidal anti-inflammatory drugs
Patients who have asthma symptoms associated with eating processed potatoes, shrimp, or dried fruit or with
drinking beer or wine should avoid these products
Nonselective beta-blockers, including those in ophthalmological preparations, can cause asthma symptoms and
should be avoided by asthma patients
Annual influenza vaccinations are recommended for patients with persistent asthma
One lifetime Pneumococcal Vaccination, with possible revaccination after 65 years is recommended.
Pharmocologic Therapy
Pharmocologic therapy is used to prevent and control asthma symptoms, reduce the frequency and severity of
asthma exacerbations and reverse airflow obstruction. Asthma medications are categorized into two general classes:
long-term control medications and "quick relief' medications. Patients with persistent asthma require both classes of
medication.
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Long-term control medications
* Corticosteroids: Inhaled form is used for the long-term control of asthma. Systemic corticosteroids are
often used to gain prompt control of the disease when initiating long-term therapy and are the
medications of choice.
* Cromolyn sodium and nedocromil: Mild-moderate anti-inflammatory medications. May be used as initial
choice for long-term control therapy for children. Can also be used as preventive treatment prior to
exercise or unavoidable exposure to allergens.
• Long-acting beta 2 -agonists: Long-acting bronchodilator used concomitantly with anti
inflammatory medications for long-term control of symptoms, especially nocturnal symptoms. Also
prevents exercise induced bronchospasm.
 Methylxanthines: Sustained-release theophylline is a mild-moderate bronchodilator used principally as an
adjuvant to inhaled corticosteroids for prevention of nocturnal asthma symptoms. May have mild antiinflammatory effect.
 Leukotriene modifiers: May be used alone and with low-to-medium dose inhaled corticostoroids in mild
persistent asthma.
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Quick relief medications
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Short-acting beta 2 -agonists: Therapy of choice for relief of acute symptoms and prevention of
exercise-induced bronchospasm
Anticholinergics: Ipratropium bromide may provide some additive benefit to inhaled beta 2 
agonists in severe exacerbations. May be an alternative bronchodilator for patients who do not tolerate
inhaled short acting beta 2 -agonists.
 Systemic corticosteroids: Used for moderate to severe exacerbations to speed recovery and prevent
recurrence of exacerbations.
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Managing exacerbations of asthma: Early treatment of asthma exacerbation is the best strategy for
management. Important elements of early treatment include:
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Written action plan to guide patient self-management of exacerbation at home, especially for a patient with
moderate-to-severe persistent asthma
Recognition of early signs of worsening asthma
Appropriate intensification of therapy
Prompt communication between patient and physician regarding serious deterioration in symptoms
or peak flow
Inhaled beta 2 -agonists to provide prompt relief of airflow obstruction
Systemic corticosteroids, for moderate-to-severe exacerbations or for patients who fail to respond promptly
and completely to an inhaled beta 2 -agonist, to suppress and reverse airway
inflammation
Oxygen to relieve hypoxia for moderate-to-severe exacerbations
Monitoring response to therapy with serial measurements of lung function with spirometry or peak flow
meters for FEVI/PEF.
Patient Education
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Patient education should begin at the time of diagnosis and be integrated into every step of clinical
asthma care
 It is essential that education be provided by all members of the health care team.
 Patient education should include asthma self-management, tailoring the approach to meet the needs of
each patient
 The following should be taught/reinforced at every opportunity:
• Basic facts about asthma
* Roles of medications
 Skills: inhaler, spacer, holding chamber use, self-monitoring
 Environmental control measures
Asthma patients should not smoke or be exposed to environmental tobacco smoke. Tobacco
smoke is the most important environmental indoor irritant and is a major precipitant of
asthma symptoms in children and adults.
Asthma patients should avoid exertion or exercise outside to the extent possible when levels of
air pollution are high.
 When and how to take rescue action
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Jointly develop treatment goals
All patients should be provided with a written daily self-management plan and an action plan for exacerbations
Encourage adherence by promoting open communication, emphasizing goals and outcomes and encouraging family
involvement
HealthAmerica's Wellness and Health Education Programs, PLUS SERVICES, offers assistance and support groups
through the America Lung Association.
Footnote:
* A meter dose inhaler should be used with a spacer device when appropriate *
Osteoporosis evaluation should be done inappropriate patients.
REFERENCES:
1 Gilbert, Ileen A., MD, McFadden, E.R.,MD. Asthma. New England Journal of Medicine. 1992;327:19281937.
2. National Education Program, Expert Panel Report II. Guidelines for the Diagnosis and Management of
Asthma. Bethesda, MD: US Dept. of Health and Human Services; July 2002.
3. Shapiro, Gail G., MD. Childhood Asthma: Update. Pediatrics in Review. 1992;13,11: 403 -412.
4. The American Academy of Pediatrics, JCQIP Ambulatory Care Quality Improvement Program, 279 -92.
5. The American Academy of Family Physicians , The Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention. Quality Standards for Immunization. IDSA National Guideline
Clearinghouse March 1999
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The Expert Panel Report is a valuable resource for office practices. It contains numerous aids for providers and education
handouts for patients. The full report can be obtained from:
NHLBI Information Center
P.O. Box 30105
Bethesda, MD 20824-0105
or
http://www.nhlbi.nih.gov/nhlbi/lung/astlnna/prof/asthgdln.htm
APPENDICES:
l. Asthma Severity Classification
2. Flowchart for the management of asthma in infants and children 5 years of age and younger
3. Flowchart for the management of asthma inpatients older than five years of age
Original date 5/1997
First Revision 3/99
Second Revision 10/01
Third Revision 10/02
Asthma Health Management Team 10/14/02
UM/01 10/29/02
Asthma Health Management Team 10/15/04
UM/QI 10/26/04
Updated 6/27/05
UM/QI 6/28/05