Download 2010 National Institutes of Health (NIH) NAEPP 2007 Asthma

National Institutes of Health (NIH)
NAEPP 2007 Asthma Guideline
Expert Panel Report (EPR) ‐3
Susan K. Ross RN, AE‐C
MDH Asthma Program 651‐201‐5629 [email protected]
1
National Institutes of Health
National Asthma Education Prevention Program (NAEPP)
2007
Guidelines for the Diagnosis and
Management of Asthma (EPR-3)
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
National Asthma Education
and Prevention Program
2
What is Asthma?
“Asthma is a common chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation. This interaction can be highly variable among patients and within patients over time”.
3
EPR 3‐
EPR 3‐ Section 2, p 12.
Characteristics of Asthma
• Airway Inflammation • Airway Obstruction (reversible) • Hyperresponsiveness (irritability of airways)
4
Normal & Asthmatic Bronchiole
5
Why Do We Need Asthma Guidelines?
6
Asthma:
–
–
In 2008, it was estimated that 23.3 million Americans currently have asthma Is one of the most common chronic disorders in childhood, affecting an approx. 7.1 million children under 18 years (9.6%) In 2007, 3,447 deaths were attributed to asthma, 152 deaths were children under the age of 15 Is the third leading cause of hospitalization among children under the age of 15 Is one of the leading causes of school absenteeism In 2008 asthma accounted for approx. 14.4 million lost school days
The annual health care costs of asthma is approx. $20.7 billion dollars 1
–
2
–
6
–
3
4
–
5
From ALA website 11/2010 www.Lungusa.org
1 CDC: National Center for Health Statistics, National Health Interview Survey Raw Data, 2009
2 CDC. National Center for Health Statistics. Final Vital Statistics Report. Deaths: Final Data for 2007. April 17, 2009. Vol 58 No 19.
3 CDC. National Center for Chronic Disease Prevention and Health Promotion. Healthy Youth! Health Topics: Asthma. August 14, 2009
4 CDC: National Center for Health Statistics, National Health Interview Survey Raw Data, 2008.
5 NHLBI Chartbook, U.S. Department of Health and Human Services, National Institute of Health, 2009
6 CDC: National Center for Health Statistics, National Hospital Discharge Survey, 2006.
7
2007 ‐ Guidelines for the Diagnosis &
Management of Asthma
Expert Review Panel (EPR‐3)
8
Asthma Guidelines:
History & Context
Initial guidelines released in 1991 and updated in 1997
 Updated again in 2002 (EPR‐2) with a focus on several key questions about medications, monitoring and prevention

–
–
–
–
Long‐term management of asthma in children
Combination therapy
Antibiotic use
Written asthma action plans (AAP) and peak flow meters (PFM)
– Effects of early treatment on the progression of asthma
9
Old & New Asthma Guidelines:
What has not changed





Initial asthma therapy is determined by assessment of asthma severity
– Ideally, before the patient is on a long‐term controller
Stepping therapy up or down is based on how well asthma is controlled or not controlled
Inhaled corticosteroids (ICS) are the preferred first‐line therapy for asthma
Systemic steroids can still be used to treat asthma exacerbations
Peak flows and written asthma action plans are recommended for asthma self management
– Especially in moderate and severe persistent asthma, or for those with a history of severe exacerbations or poorly controlled asthma
10
Asthma Therapy Goals
“The goal of asthma therapy is to control
asthma so patients can live active, full lives
while minimizing their risk of asthma
exacerbations and other problems”
Dr. William Busse, MD., chairman of the NAEPP EPR ‐3
11
2007 ‐ Guidelines for the Diagnosis & Management of Asthma (EPR‐3)
–
–
–
–
–
–
(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 ongoing management issues
Summarizes 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
12
New Strategies of the EPR‐3
Assessment
Management
Severity
The intrinsic intensity of A clinical guide most useful
the disease process
for initiating controller
therapy
Control
The degree to which
symptoms are
minimized & goals are
met
(After therapy is initiated) a
clinical guide used to
maintain or adjust therapy
Responsiveness
The ease of which
prescribed therapy
achieves asthma
control
(Variable) frequent followup to step-up and stepdown therapy to achieve
the goal of control
13
Key Points: Definition, Pathophysiology &
Pathogenesis –
Asthma is a chronic inflammatory disorder of the airways
–
The immunohistopathologic features of asthma include inflammatory cell infiltration
–
Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity
–
In some patients, persistent changes in airway structure occur, including sub‐basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis (remodeling)
14
Key Points: cont..
–
Gene‐by‐environment interactions are important to the expression of asthma –
Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)‐mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma
–
Viral respiratory infections are one of the most important causes of asthma exacerbation and may also contribute to the development of asthma
EPR 3, Section 2: Page 11
15
Causes – We Don’t Know…Yet!
–
Asthma has dramatically risen worldwide over the past decades, particularly in developed countries, and experts are puzzled over the cause of this increase
–
Not all people with allergies have asthma, and not all cases of asthma can be explained by allergic response
–
Asthma is most likely caused by a convergence of factors that can include genes (probably several) and various environmental and biologic triggers – e.g., infections, dietary patterns, hormonal changes in women, and allergens 16
4 Components of Asthma Management Component 1: Measures of Asthma Assessment & Monitoring
Component 2: Education for a Partnership in Asthma Care
Component 3: Control of Environmental Factors & Comorbid Conditions that Affect Asthma
Component 4: Medications
17
Component 1
Measures of Asthma Assessment &
Monitoring
18
Key Points ‐
Overview: Measures of Asthma Assessment &
Monitoring
Assessment and monitoring are closely linked to the concepts of severity, control, and responsiveness to treatment:
– Severity ‐ intensity of the disease process. Severity is measured most easily and directly in a patient not receiving long‐term‐control therapy.
– Control ‐ degree to which asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met.
– Responsiveness ‐ the ease with which asthma control is achieved by therapy. 19
EPR ‐
EPR ‐3 , Pg. 36,
Key Points – cont. Domains Assess Severity and Control based on:

Impairment (Present): – Frequency and intensity of symptoms – Functional limitations (quality of life)

Risk (Future):
– Likelihood of asthma exacerbations or
– Progressive loss of lung function (reduced lung growth) – Risk of adverse effects from medication
EPR ‐
EPR ‐3, Pg. 38‐
3, Pg. 38‐80, 277‐
80, 277‐345
20
Key Points ‐ cont. Severity & Control
Are used as follows for managing asthma:


If the patient is not currently on a long‐term controller at the first visit:
– Assess asthma severity to determine the appropriate medication & treatment plan
Once therapy is initiated, the emphasis is changed to the assessment of asthma control
– The level of asthma control will guide decisions either to maintain or adjust therapy
21
Assessing Impairment (Present) Domain
 Assess by taking a careful, directed history and lung function measurement
 Assess Quality of Life using standardized questionnaires
– Asthma Control Test (ACT)
– Childhood Asthma Control Test
– Asthma Control Questionnaire
– Asthma Therapy Assessment Questionnaire (ATAQ) control index
 Some patients may perceive the severity of airflow obstruction poorly
22
Assessing Risk (Future)
Domain
– Of adverse events in the future, especially of exacerbations and of progressive, irreversible loss of pulmonary function—is more problematic (airway remodeling) – The test most used for assessing the risk of future adverse events is spirometry
23
Measures of Assessment &
Monitoring
Diagnosis
24
Key Points – Diagnosis of Asthma
To establish a diagnosis of asthma the clinician should determine that:
– Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present
– Airflow obstruction is at least partially reversible
– Alternative diagnoses are excluded
25
Key Points – Methods to Establish Diagnosis Recommended methods to establish the diagnosis are: – Detailed medical history
– Physical exam focusing on the upper respiratory tract, chest, and skin
– Spirometry to demonstrate obstruction and assess reversibility, including in children 5 years of age or older
– Additional studies to exclude alternate diagnoses
26
Key Indicators: Diagnosis of Asthma
Has/does the patient:
–
–
–
–
–
–
had an attack or recurrent attacks of wheezing?
have a troublesome cough at night?
wheeze or cough after exercise?
experience wheezing, chest tightness, or cough after exposure to airborne allergens or pollutants?
colds ‘go to the chest’ or take more than 10 days to clear up?
symptoms improved by appropriate asthma treatment?
27
Adapted from the GINA guidelines 2008
Characterization & Classification of Asthma
Severity
28
Key Points ‐ Initial Assessment: Severity


Once a diagnosis is established:
– Identify precipitating factors (triggers)
– Identify comorbidities that aggravate asthma
– Assess the patient’s knowledge and skills for self‐
management
– Classify severity using impairment and risk domains
Pulmonary function testing (spirometry) to assess severity
EPR ‐
EPR ‐3, Sec. 3, pg. 47
29
Assessment of Asthma Severity
Previous Guidelines



Frequency of daytime symptoms
Frequency of nighttime symptoms
Lung function
2007 Guidelines

Impairment
– Frequency of daytime /nighttime symptoms
– Quality of life assessments
– Frequency of SABA use
– Interference with normal activity
– Lung function (FEV1/FVC) 
Risk
– Exacerbations (frequency and severity)
30
NOT Currently Taking Controllers
C la ssifica tio n o f A sth m a S e v e rity
(0  4 y e a rs o f a g e )
C o m p o n e n ts o f
S e v e rity
Im p a irm e n t
R isk
P e rs iste n t
In te rm itte n t
M ild
M o d e ra te
S e v e re
S ym p to m s
 2 d a ys/w e e k
> 2 d a ys/w e e k
b u t n o t d a ily
D a ily
T h ro u g h o u t
th e d a y
N ig h ttim e
a w a ke n in g s
0
1  2 x /m o n th
3  4 x /m o n th
> 1 x/w e e k
S h o rt-a ctin g
b e ta 2 -a g o n ist u se
fo r sym p to m
co n tro l (n o t
p reven tio n o f E IB )
2 d a ys/w e e k
> 2 d a ys/w e e k
b u t n o t d a ily
D a ily
S e ve ra l tim e s
per day
In te rference w ith
n o rm a l a ctivity
None
M in o r lim ita tio n
S o m e lim ita tio n
E xtrem ely lim ited
E xa ce rb a tio n s
re q u irin g o ra l
syste m ic
co rtico ste ro ids
0 1 /ye a r
 2 e xa ce rb a tio n s in 6 m o n th s re q u irin g o ra l syste m ic
co rtico ste ro ids, o r 4 w h e e zin g e p iso d e s/1 y e a r la stin g
> 1 d a y A N D risk fa cto rs for p e rsiste n t a sth m a
C o n sid er se ve rity a n d in te rva l sin ce la st e xa ce rb a tio n .
Fre q u e n cy a n d se v e rity m a y flu ctu a te o v e r tim e .
E xa ce rb a tio n s o f a n y se ve rity m a y o ccu r in p a tie n ts in a n y se v e rity ca te g o ry.
R e c o m m e n d e d S te p fo r
In itia tin g T h e ra p y
(S e e fig u re 4  1 a fo r
tre a tm e n t s te p s .)
S te p 1
S te p 2
S te p 3 a n d co n sid e r sh o rt co u rse o f
o ra l syste m ic co rtico ste ro id s
In 2  6 w e e ks, d e p e n d in g o n se ve rity, e va lu a te le v e l o f a sth m a co n tro l th a t is
a ch ie ve d . If n o cle a r b e n e fit is o b se rve d in 4 6 w e eks, co n sid e r a d ju stin g
th e ra p y o r a lte rn a tiv e d ia g n o se s.
Level of severity is determined by both impairment and risk. Assess impairment by caregivers recall of previous 2‐4 weeks.
NOT Currently Taking Controllers
Classification of Asthm a Severity
(511 years of age)
Com ponents of
Severity
Persistent
Interm ittent
M ild
M oderate
Severe
2 days/week
>2 days/week but
not daily
Daily
Throughout
the day
Nighttim e
awakenings
2x/month
34x/month
>1x/week but
not nightly
Often 7x/week
Short-acting
beta 2 -agonist use for
sym ptom control (not
prevention of EIB)
2 days/week
>2 days/week
but not daily
Daily
Several times
per day
Interference with
norm al activity
None
Minor limitation
Some limitation
Extremely limited
Sym ptom s
Im pairm ent
• Normal FEV 1
between
exacerbations
Lung function
Risk
Exacerbations
requiring oral
systemic
corticosteroids
Recom m ended Step for
Initiating Therapy
(See figure 41b for
treatm ent steps.)
• FEV 1 >80%
predicted
• FEV 1 = >80%
predicted
• FEV 1 = 6080%
predicted
• FEV 1 <60%
predicted
• FEV 1 /FVC >85%
• FEV 1 /FVC >80%
• FEV 1 /FVC = 7580%
• FEV 1 /FVC <75%
01/year (see note)
2/year (see note)
Consider severity and interval since last exacerbation.
Frequency and severity may fluctuate over time for patients in any severity category.
Relative annual risk of exacerbations may be related to FEV 1 .
Step 1
Step 2
Step 3, mediumdose ICS option
Step 3, medium-dose
ICS option, or step 4
and consider short course of
oral systemic corticosteroids
In 26 weeks, evaluate level of asthma control that is achieved, and adjust therapy
accordingly.
NOT Currently Taking Controllers
Classification of Asthm a Severity
12 years of age
Com ponents of Severity
Interm ittent
M ild
M oderate
2 days/w eek
> 2 days/w eek but
not daily
Daily
Throughout the day
Nighttim e
aw akenings
2x/m onth
34x/m onth
> 1x/w eek but
not nightly
Often 7x/w eek
Short-acting
beta 2 -agonist use for
sym ptom control (not
prevention of EIB)
2 days/w eek
Daily
Several tim es
per day
Interference w ith
norm al activity
None
Sym ptom s
Im pairm ent
N orm al FEV 1 /FVC :
819 yr
85%
20 39 yr
80%
40 59 yr
75%
60 80 yr
70%
>2 days/w eek
but not daily, and
not m ore than
1x on any day
M inor lim itation
Som e lim itation
Severe
Extrem ely lim ited
• Norm al FEV 1
betw een
exacerbations
Lung function
R isk
Persistent
Exacerbations
requiring oral
system ic
corticosteroids
• FEV 1 > 80%
predicted
• FEV 1 > 80%
predicted
• FEV 1 > 60% but
< 80% predicted
• FEV 1 < 60%
predicted
• FEV 1 /FVC norm al
• FEV 1 /FVC norm al
• FEV 1 /FVC reduced
5%
• FEV 1 /FVC
reduced > 5%
01/year (see
note)
2/year (see note)
Consider severity and interval since last exacerbation.
Frequency and severity m ay fluctuate over tim e for patients in any severity category.
Relative annual risk of exacerbations m ay be related to FEV 1 .
R ecom m ended Step
for Initiating Treatm ent
(See figure 45 for treatm ent steps.)
Step 3
Step 1
Step 2
Step 4 or 5
and consider short course of
oral system ic corticosteroids
In 26 w eeks, evaluate level of asthm a control that is achieved and adjust therapy
accordingly.
Classifying Severity AFTER Control is Achieved – All Ages
Classification of Asthma Severity
Lowest level of treatment required to maintain control
Intermittent
Step 1
Persistent
Mild
Moderate
Severe
Step 2
Step 3 or 4
Step 5 or 6
(already on controller)
Periodic Assessment & Monitoring
Asthma Control
35
Key Points –
Asthma Control (Goals of Therapy)
Reducing impairment
– Prevent chronic & troublesome symptoms
– Prevent frequent use (< 2 days /wk) of inhaled SABA for symptoms
– Maintain (near) “normal” pulmonary function
– Maintain normal activity levels (including exercise and other physical activity and attendance at work or school)
– Meet patients’ and families’ expectations of and satisfaction with asthma care
36
EPR‐
EPR‐ 3, p. 50
Key Points – cont. Reducing Risk



– Prevent recurrent exacerbations of asthma and minimize the need for ER visits and hospitalizations
– Prevent progressive loss of lung function ‐ for children, prevent reduced lung growth
– Provide optimal pharmacotherapy with minimal or no adverse effects
Periodic assessments at 1‐6 month intervals
Patient self‐assessment (w/clinician)
Spirometry testing
EP‐
EP‐3 , sec. 3, p. 53
37
Key Points cont. ‐ Written AAP’s & PFM 

Provide to all patients a written AAP based on signs and symptoms and/or PEF
– Written AAPs are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations or poorly controlled asthma.
Whether PF monitoring, symptom monitoring (available data show similar benefits for each), or a combo of approaches is used, self‐ monitoring is important to the effective self‐
management of asthma.
EPR ‐
EPR ‐3 Sec. 3, P.53
38
Peak Flow Monitoring
Long‐term daily PF monitoring can be helpful to:
– Detect early changes in asthma control that require adjustments in treatment:
– Evaluate responses to changes in treatment
– Provide a quantitative measure of impairment
EPR‐
EPR‐3 , Sec. 3, P.54
39
Asthma Control = Asthma Goals


Definition of asthma control is the same as asthma goals reducing impairment and risk
Monitoring quality of life, any:
– work or school missed because of asthma?
– reduction in usual activities?
– disturbances in sleep due to asthma?
– Change in caregivers activities due to a child's asthma?
40
Responsiveness ‐
Questions for Assessing Asthma Control
Ask the patient:
–
–
–
–
–
Has your asthma awakened you at night or early morning?
Have you needed more quick‐relief medication (SABA) than usual?
Have you needed any urgent medical care for your asthma, such as unscheduled visits to your provider, an UC clinic, or the ER?
Are you participating in your usual and desired activities?
If you are measuring your peak flow, has it been below
your personal best?
41
Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.” 1995 Responsiveness ‐ Actions
Actions to consider:
–
–
–
–
Assess whether the medications are being taken as prescribed
Assess whether the medications are being inhaled with correct technique
Assess lung function with spirometry and compare to previous measurement
Adjust medications, as needed; either step up if control is inadequate or step down if control is maximized, to achieve the best control with the lowest dose of medication
42
Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.” 1995 Assessing Asthma Control in Children 0 ‐ 4 Years of Age
C o m p o n e n ts o f C o n tro l
I m p a irm e n t
C la s s ific a tio n o f A s th m a C o n tro l
(C h ild re n 0  4 y e a rs o f a g e )
W e ll
C o n tro lle d
N o t W e ll
C o n tro lle d
V e ry P o o rly
C o n tro lle d
S ym p to m s
2 d a ys/w ee k
> 2 d a ys/w ee k
T hro ug ho ut the d a y
N ig h ttim e aw ake n ing s
1 x /m o nth
> 1 x/m o n th
> 1 x/w ee k
In te rfe re n ce w ith
n o rm al activity
None
S o m e lim ita tio n
E xtrem e ly lim ite d
S h o rt-a ctin g
b e ta 2 -a g o n ist u se
fo r sym p to m co ntro l
(n o t p re ve n tio n
o f E IB )
 2 d a ys/w ee k
> 2 d a ys/w ee k
S e ve ra l tim e s p e r d a y
E xa ce rb a tio n s
re q u iring o ra l system ic
co rtico stero id s
0  1/ye ar
2  3/ye ar
> 3 /ye a r
R is k
T re a tm e nt-re la ted
a d ve rse e ffe cts
M e d ica tio n sid e e ffe cts ca n va ry in in te n sity fro m n o n e to ve ry
tro u b le so m e a n d w o rriso m e . T h e le ve l o f in te n sity d o e s no t
co rre la te to sp e cific le ve ls o f co n tro l b ut sho u ld b e co n sid ere d
in th e o ve ra ll a sse ssm e n t o f risk.
Assessing Asthma Control in Children 5 ‐ 11 Years of Age
C la s s ific a t io n o f A s t h m a C o n t r o l
( C h ild r e n 5  1 1 y e a r s o f a g e )
C o m p o n e n ts o f C o n tr o l
I m p a ir m e n t
W e ll C o n t r o lle d
N o t W e ll
C o n t r o lle d
V e r y P o o r ly
C o n t r o lle d
S y m p to m s
 2 d a y s /w e e k b u t
n o t m o re th a n
once on each day
> 2 d a y s /w e e k o r
m u ltip le tim e s o n
 2 d a y s /w e e k
T h ro u g h o u t th e d a y
N ig h ttim e
a w a k e n in g s
 1 x /m o n th
 2 x /m o n th
 2 x /w e e k
In te rfe re n c e w ith
n o rm a l a c tiv ity
None
S o m e lim ita tio n
E x tre m e ly lim ite d
S h o rt-a c tin g
b e ta 2 -a g o n is t u s e
fo r s y m p to m c o n tro l
(n o t p re v e n tio n o f E IB )
 2 d a y s /w e e k
> 2 d a y s /w e e k
S e v e ra l tim e s p e r d a y
L u n g fu n c tio n
 F E V 1 o r p e a k flo w
> 8 0 % p re d ic te d /
p e rso n a l b e s t
6 0  8 0 % p re d ic te d /
p e rso n a l b e s t
< 6 0 % p re d ic te d /
p e rso n a l b e s t
 F E V 1 /F V C
> 80%
7580%
< 75%
E x a c e rb a tio n s re q u irin g
o ra l s y s te m ic
c o rtic o s te ro id s
R is k
R e d u c tio n in lu n g g ro w th
T re a tm e n t-re la te d
a d v e rs e e ffe c ts
0  1 /y e a r
 2 / y e a r (s e e n o te )
C o n s id e r s e v e rity a n d in te rv a l s in c e la s t e x a c e rb a tio n
E v a lu a tio n re q u ire s lo n g -te rm fo llo w u p .
M e d ic a tio n s id e e ffe c ts c a n v a ry in in te n s ity fro m n o n e to v e ry
tro u b le s o m e a n d w o rris o m e . T h e le v e l o f in te n s ity d o e s n o t c o rre la te
to s p e c ific le v e ls o f c o n tro l b u t s h o u ld b e c o n s id e re d in th e o v e ra ll
a s s e s s m e n t o f ris k .
Assessing Asthma Control in Youths 12 Years of Age & Adults
C o m p o n e n ts o f C o n tr o l
S y m p to m s
N ig h ttim e a w a k e n in g
In te rfe re n ce w ith n o rm a l
a ctiv ity
I m p a irm e n t
S h o rt-a ctin g b e ta 2 -a g o n is t u s e
fo r s y m p to m co n tro l (n o t
p re v e n tio n o f E IB )
F E V 1 o r p e a k flo w
C la s s ific a tio n o f A s th m a C o n tr o l
(Y o u th s  1 2 y e a rs o f a g e a n d a d u lts )
W e ll-C o n tro lle d
Not
W e ll-C o n tro lle d
V e ry P o o rly
C o n tro lle d
 2 d a y s /w e e k
> 2 d a y s /w e e k
T h ro u g h o u t th e d a y
 2 x /m o n th
1  3 x /w e e k
 4 x /w e e k
None
S o m e lim ita tio n
E x tre m e ly lim ite d
 2 d a y s /w e e k
> 2 d a y s /w e e k
S e v e ra l tim e s p e r d a y
> 8 0 % p re d icte d /
p e rs o n a l b e s t
6 0  8 0 % p re d icte d /
p e rs o n a l b e s t
< 6 0 % p re d icte d /
p e rs o n a l b e s t
0
 0 .7 5 *
20
1–2
 1 .5
1619
3–4
N /A
15
V a lid a te d Q u e s tio n n a ire s
ATAQ
ACQ
ACT
E x a ce rb a tio n s
R is k
0  1 /y e a r
 2 /y e a r (s e e n o te )
C o n s id e r s e v e rity a n d in te rv a l s in ce la s t e x a c e rb a tio n
P ro g re s s iv e lo s s o f lu n g
fu n ctio n
E v a lu a tio n re q u ire s lo n g -te rm fo llo w u p ca re
T re a tm e n t-re la te d a d v e rs e
e ffe cts
M e d ica tio n sid e e ffe cts ca n v a ry in in te n s ity fro m n o n e to v e ry
tro u b le s o m e a n d w o rris o m e . T h e le v e l o f in te n s ity d o e s n o t co rre la te to
s p e cific le v e ls o f co n tro l b u t s h o u ld b e co n s id e re d in th e o v e ra ll
a s s e s s m e n t o f ris k .
Component 2
Education for a Partnership in Asthma Care
46
Key Points ‐ Education




Self management education is essential and should be integrated into all aspects of care; requires repetition and reinforcement
Provide all patients with a written asthma action plan that includes 2 aspects:
– Daily management
– How to recognize & handle worsening asthma symptoms
Regular review of the status of patients asthma control
– Teach and reinforce at every opportunity
Develop an active partnership with the patient and family
EPR –
EPR – 3, Section 3, Pg. 93
47
Key Points – Education cont.

Encourage adherence by:

Choosing a tx regimen that achieves outcomes and addresses preferences important to the patient
– Review the success of tx plan and make changes as needed
Tailor the plan to needs of each patient
Encourage community based interventions
Asthma education provided by trained health professionals should be reimbursed and considered an integral part of effective asthma care ! (AE‐C)
–


48
Key Educational Messages
–
–
–
–
–
–
–
–
–
Significance of diagnosis
Inflammation as the underlying cause Controllers vs. quick‐relievers
How to use medication delivery devices
Triggers, including 2nd hand smoke
Home monitoring/ self‐management
How/when to contact the provider
Need for continuous, on‐going interaction w/the clinician to step up/down therapy
Annual influenza vaccine 49
Other Educational Points of Care 





ER Department and hospital based Medication therapy management (Pharmacist)
Community based
Home based for caregivers including home based allergen/ environmental assessment
Computer based technology Case management for high‐risk patients
50
Maintaining the Partnership
Promote open communication w/patient and family by addressing at each visit:
–
–
–
–
–
–
Ask what concerns they have and what they want addressed during the visit
Review short – term goals agreed to at the initial visit
Review written AAP and steps to take – adjust as needed
Encourage parents to take a copy of AAP to the school or childcare setting or send a copy to the school nurse
Teach and reinforce key educational messages
Provide simple, brief, written materials that reinforce the actions and skills taught
51
Component 3
Control of Environmental Factors &
Comorbid Conditions that Affect Asthma
52
Key Points – Environmental Factors
All patients with asthma should:
–
–
–
–
–
–
Reduce, if possible, exposure to allergens & irritants they are sensitive too
Understand effective allergen avoidance is multifaceted and individual steps alone are ineffective
Avoid exertion outdoors when levels of air pollution are high
Avoid use of nonselective beta‐blockers
Avoid sulfite‐containing and other foods they are sensitive to
Avoid use of humidifiers (generally)
53
Key Points – Environmental Cont.
Clinicians should:
–
–
–
–
Evaluate a patient for other chronic co‐morbid conditions when asthma cannot be well controlled
Encourage their asthma patients to receive a yearly influenza vaccination (inactivated)
Consider allergen immunotherapy when appropriate
Ask about possible occupational exposures, particularly those who have new‐onset disease (work related asthma)
54
Component 4
Medications
55
Key Points ‐ Medications


2 general classes:
– Long‐term control medications
– Quick‐Relief medications
Controller medications:
– Corticosteroids – Long Acting Beta Agonists (LABA’s)
– Leukotriene modifiers (LTRA)
– Cromolyn & Nedocromil
– Methylxanthines: (Sustained‐release theophylline) 56
Key Points – Medications cont.

Quick‐ relief medications
– Short acting bronchodilators (SABA’s)
– Systemic corticosteroids
– Anticholinergics
57
Key Points: Safety of ICS’s
–
ICS’s are the most effective long‐term therapy available, are well tolerated & safe at recommended doses
–
The potential but small risk of adverse events from the use of ICS treatment is well balanced by their efficacy
–
The dose‐response curve for ICS treatment begins to flatten at low to medium doses
–
Most benefit is achieved with relatively low doses, whereas the risk of adverse effects increases with dose
58
Key Points: Reducing Potential Adverse Effects 




Spacers or valved holding chambers (VHCs) used with non‐breath‐
activated MDIs reduce local side effects
– There is little or no data on use of spacers with hydrofluoroalkane
(HFA) MDIs
Patients should rinse their mouths (rinse and spit) after (ICS) inhalation
Use the lowest dose of ICS that maintains asthma control: – Evaluate patient adherence and inhaler technique as well as environmental factors before increasing the dose of ICS
To achieve or maintain control of asthma, add a LABA to a low or
medium dose of ICS rather than using a higher dose of ICS Monitor linear growth in children
59
Key Points:
Safety of Long‐Acting Beta2‐Agonists (LABA’s)
– Adding a LABA to the tx of patients whose asthma is not well controlled on low‐ or medium‐dose ICS improves lung function, decreases symptoms, and reduces exacerbations and use of SABA for quick relief in most patients
– The FDA determined that a Black Box warning was warranted on all
preparations containing a LABA
– For patients who have asthma not sufficiently controlled with ICS alone, the option to increase the ICS dose should be given equal weight to the option of the addition of a LABA to ICS
– It is not currently recommended that LABA be used for treatment of acute symptoms or exacerbations
– LABAs are not to be used as monotherapy for long‐term control
60
FDA Recommendations for LABA’s
February 2010
–
–
–
Are contraindicated without the use of an asthma controller medication such as an ICS
Single‐ingredient LABAs should only be used in combination with an asthma controller medication; they should not be used alone
Should only be used long‐term in patients whose asthma cannot be adequately controlled on asthma controller medications
61
FDA Recommendations for LABA’s Cont.
–
–
–
Should be used for the shortest duration of time required to achieve control of asthma symptoms and discontinued, if possible, once asthma control is achieved
Patients should then be maintained on an asthma controller medication
Pediatric and adolescent patients who require the addition of a LABA to an ICS should use a combination product containing both an ICS and a LABA, to ensure compliance with both medications
62
Key Points: Safety of Short ‐Acting Beta2‐Agonists (SABA’s)
–
–
–
SABAs are the most effective medication for relieving acute bronchospasm Increasing use of SABA treatment or using SABA >2 days a week for symptom relief (not prevention of EIB) indicates inadequate control of asthma
Regularly scheduled, daily, chronic use of SABA is not
recommended
63
Section 4 Managing Asthma Long Term “The Stepwise Approach”
64
Key Points: Managing Asthma Long Term
The goal of therapy is to control asthma by:
–


Reducing impairment
– Reducing risk
A stepwise approach to medication therapy is recommended to gain and maintain asthma control
Monitoring and follow‐up is essential
65
Treatment: Principles of “Stepwise” Therapy “The goal of asthma therapy is to maintain long‐
term control of asthma with the least amount of medication and hence minimal risk for adverse effects”.
EPR ‐
EPR ‐3, Section 4, P. 284
66
Principles of Step Therapy to Maintain Control



Step up medication dose if symptoms are not controlled
If very poorly controlled, consider an increase by 2 steps, add oral corticosteroids, or both
Before increasing medication therapy, evaluate:
– Exposure to environmental triggers – Adherence to therapy
– For proper device technique
– Co‐morbidities
67
Follow‐up Appointments




Visits every 2‐6 weeks until asthma control is achieved
When control is achieved, follow‐up every 3‐6 months
Step‐down in therapy:
– When asthma is well‐controlled for at least 3 months
Patients may relapse with total discontinuation or reduction of inhaled corticosteroids
68
Assessing Control & Adjusting Therapy Children 0‐4 Years of Age
C la ssifica tio n o f A sth m a C o n tro l (0  4 y e a rs o f a g e )
C o m p o n e n ts o f C o n tro l
Im p a irm e n t
R isk
W e ll
C o n tro lle d
N o t W e ll
C o n tro lle d
V ery P o o rly C o n tro lle d
S ym ptom s
 2 d ays/w e e k
> 2 d ays/w e e k
T h ro u gh o u t th e day
N igh ttim e aw ak en in gs
 1 x/m on th
> 1 x/m on th
> 1 x/w eek
In te rfe re n ce w ith
n orm al activity
N on e
S om e lim itation
E xtre m e ly lim ite d
S h ort-actin g
b e ta 2 -agon ist u se
for sym ptom con trol
(n ot preve ntion of E IB )
 2 d ays/w e e k
> 2 d ays/w e e k
S e ve ral tim e s pe r day
Ex ace rb atio n s re qu irin g
oral syste m ic
corticoste roids
0  1 /ye ar
2  3 /ye ar
> 3 /ye ar
T re atm e n t-re la te d
adve rse e ffe cts
R e c o m m e n d e d A ctio n
fo r T re a tm e n t
(S e e fig u re 4  1 a fo r
tre a tm e n t ste p s.)
M e dication side e ffe cts can vary in in te n sity from n on e to ve ry tro u ble som e an d
w orrisom e . T h e le ve l of in te n sity doe s n ot corre la te to spe cific le v e ls of con trol
bu t sh ou ld be co n side re d in th e ove rall asse ssm e n t o f risk.
• M ain tain cu rre n t
tre atm e n t.
• R e gu la r follow u p
e ve ry 1  6
m on th s.
• C on side r ste p
dow n if w e ll
con trolle d fo r at
le ast 3 m on th s.
• S te p u p (1 ste p ) an d
• R e e valu ate in
2  6 w e e ks.
• If n o cle ar be n e fit in
4  6 w e e ks, con side r
alte rn a tive diag n ose s
or adju stin g th e rapy.
• For side e ffe cts,
con side r alte rn a tive
tre atm e n t o p tio n s.
• C on side r sh ort cou rse of
oral syste m ic
corticoste roids,
• S te p u p (1  2 ste ps), a n d
• R e e valu ate in 2 w e e ks.
• If n o cle ar be n e fit in 4  6
w e e ks, con side r alte rn ative
diagn ose s or adju stin g
th e rapy .
• For side e ffe cts, co n sid e r
alte rn a tive tre atm e n t
option s.
Stepwise Approach for Managing Asthma in Children 0-4 Years of Age
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult asthma specialist if step 3 care or higher is required.
Consider consultation at step 2
Step 6
Step up if
needed
Preferred
(first check
adherence,
environment
al control)
Step 5
Step 2
Preferred
Step 1
Preferred
SABA
PRN
Low dose
ICS
Alternative
Montelukast
or Cromolyn
Step 4
Preferred
Step 3
Preferred
High
Dose ICS
Preferred
Medium
Dose ICS
Medium
Dose ICS
AND
AND
Either:
Montelukast
Either:
High
Dose ICS
AND
Either:
Montelukast
or LABA
or LABA
Montelukast
or LABA
AND
Oral
corticosteroid
Patient Education and Environmental Control at Each Step
Quick-relief medication for ALL patients -SABA as needed for symptoms.
With VURI: SABA every 4-6 hours up to 24 hours.
Consider short course of corticosteroids with (or hx of) severe exacerbation
Assess
control
Step
down if
possible
(and asthma
is well
controlled at
least 3
months)
Assessing Control & Adjusting Therapy Children 5‐11 Years of Age
C la ssifica tio n o f A sth m a C o n tro l (5 1 1 y e a rs o f a g e )
C o m p o n e n ts o f C on tro l
W ell
C o n tro lled
N o t W ell
C o n tro lled
V ery P o o rly C o n tro lled
Sym ptom s
2 days/w eek but not
m ore than once on each
day
> 2 days/w eek or
m ultiple tim es on
2 days/w eek
T hroughout the day
N ighttim e
aw akenings
1x/m onth
2x/m onth
2x/w eek
Interference w ith norm al
activity
N one
Som e lim itation
Extrem ely lim ited
Short-acting
beta 2 -agonist use
for sym ptom control
(not prevention of EIB)
2 days/w eek
> 2 days/w eek
Several tim es per day
Im p a irm en t
Lung function
•
FEV 1 or peak flow
> 80% predicted/
personal best
6080% predicted/
personal best
< 60% predicted/
personal best
•
FEV 1 /FV C
> 80%
7580%
< 75%
R isk
R eduction in
lung grow th
T reatm ent-related
adverse effects
R eco m m en d ed A ctio n
fo r T rea tm en t
(S ee fig u re 4  1 b fo r
trea tm en t step s.)
2/year (see note)
01/year
Exacerbations requiring
oral system ic
corticosteroids
Consider severity and interval since last exacerbation
Evaluation requires long-term follow up.
M edication side effects can vary in intensity from none to very troublesom e and w orrisom e.
T he level of intensity does not correlate to specific levels of control but should be
considered in the overall assessm ent of risk.
•
•
•
M aintain current step.
R egular follow up
every 16 m onths.
Consider step dow n if
w ell controlled for at
least 3 m onths.
•
•
•
Step up at least
1 step and
R eevaluate in
26 w eeks.
For side effects:
consider alternative
treatm ent options.
•
•
•
•
Consider short course of oral
system ic corticosteroids,
Step up 12 steps, and
R eevaluate in 2 w eeks.
For side effects, consider
alternative treatm ent options.
Stepwise Approach for managing asthma in children 5-11 years of age
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
Step 5
Step 2
Preferred
Step 1
Low dose
ICS
Preferred
Alternative
SABA
PRN
LTRA,
Cromolyn
Nedocromil
or
Theophylline
Step 4
Preferred
Step 3
Preferred
Preferred
Medium
Dose ICS +
LABA
High Dose
ICS + LABA
Either
Low Dose
ICS + LABA,
LTRA, or
Theophylline
OR
Medium
Dose ICS
Alternative
Medium dose
ICS + either
LTRA, or
Theophylline
Step 6
Preferred
High Dose ICS
+ LABA
+ oral
corticosteroid
Alternative
Alternative
High dose ICS
+ either LTRA,
or
Theophylline
High dose ICS
+ either LTRA,
or Theophylline
+ oral
corticosteroid
Patient Education and Environmental Control at Each Step
Quick-relief medication for ALL patients
SABA as needed for symptoms.
Short course of oral corticosteroids maybe needed.
Step up if
needed
(first check
adherence,
environmen
tal control,
and
comorbid
conditions)
Assess
control
Step down
if possible
(and asthma
is well
controlled at
least 3
months)
Assessing Control & Adjusting Therapy in Youths > 12 Years of Age & Adults
C la ssifica tio n o f A sth m a C o n tro l
( 1 2 y e a rs o f a g e )
C o m p o n e n ts o f C o n tro l
W ell C o n tro lled
Im p a irm en t
Not
W ell C o n tro lled
V ery P o o rly
C o n tro lled
Sym ptom s
2 days/w eek
> 2 days/w eek
T hroughout the day
N ighttim e aw akenings
2x/m onth
13x/w eek
4x/w eek
Interference w ith norm al activity
N one
Som e lim itation
Extrem ely lim ited
Short-acting beta 2 -agonist use for
sym ptom control (not prevention of E IB)
2 days/w eek
> 2 days/w eek
Several tim es per day
FEV 1 or peak flow
> 80% predicted/
personal best
6080% predicted/
personal best
< 60% predicted/
personal best
0
0.75*
20
1–2
1.5
1619
3–4
N /A
15
V alidated questionnaires
ATAQ
ACQ
ACT
Exacerbations requiring oral system ic
corticosteroids
R isk
2/year (see note)
01/year
Consider severity and interval since last exacerbation
Progressive loss of lung function
Evaluation requires long-term follow up care
T reatm ent-related adverse effects
M edication side effects can vary in intensity from none to very troublesom e
and w orrisom e. T he level of intensity does not correlate to specific levels of
control but should be considered in the overall assessm ent of risk.
R eco m m en d ed A ctio n
fo r T rea tm en t
(see fig u re 4  5 fo r treatm en t step s)
• M aintain current step.
• R egular follow ups
every 16 m onths to
m aintain control.
• Consider step dow n if
w ell controlled for at
least 3 m onths.
• Step up 1 step and
• R eevaluate in
26 w eeks.
• For side effects,
consider alternative
treatm ent options.
• Consider short course of
oral system ic
corticosteroids,
• Step up 12 steps, and
• R eevaluate in 2 w eeks.
• For side effects,
consider alternative
treatm ent options.
Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
Step 6
Step 5
Step 4
Step 3
Preferred:
Low dose ICS
Low-dose ICS
+ LABA
OR – Medium
dose ICS
Alternative:
Cromolyn,
LTRA,
Nedocromil or
Theophylline
Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton
Step 2
Preferred:
Step 1
Preferred:
SABA
PRN
Preferred:
Medium Dose
ICS + LABA
Alternative:
Medium-dose
ICS + either
LTRA,
Theophylline,
or Zileuton
Preferred
High
Dose ICS +
LABA
AND
Consider
Omalizumab
for patients
who have
allergies
Preferred
High dose ICS
+ LABA + oral
corticosteroid
AND
Consider
Omalizumab
for patients
who have
allergies
Each Step: Patient Education and Environmental Control and management of comorbidities
Steps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
Step up if
needed
(first check
adherence,
environmental
control &
comorbid
conditions)
Assess
control
Step
down if
possible
(and asthma
is well
controlled at
least 3
months)
•Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 tx @ 20 minute
intervals prn. Short course of o systemic corticosteroids may be needed.
• Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate
control & the need to step up treatment.
Section 5
Managing Exacerbations of Asthma
75
Key Points –
Managing Exacerbations Early treatment of asthma exacerbations is the best strategy for management:
Patient education includes a written asthma action plan (AAP) to
guide patient self‐management of exacerbations
– especially for patients who have moderate or severe persistent asthma and any patient who has a history of severe exacerbations
 A peak‐flow‐based plan for patients who have difficulty perceiving airflow obstruction and worsening asthma is recommended

EPR ‐
EPR ‐3 Pg. 373
76
Key Points – cont.
–
–
–
–
Recognition of early signs of worsening asthma & taking prompt action
Appropriate intensification of therapy, often including a short course of oral corticosteroids
Removal or avoidance of the environmental factors contributing to the exacerbation
Prompt communication between patient and clinician about any serious deterioration in symptoms or peak flow, decreased responsiveness to SABAs, or decreased duration of effect
77
Exacerbations Defined ‐ RISK


Are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness?
— or some combination of these symptoms Are characterized by decreases in expiratory airflow that can be documented and quantified by spirometry or peak expiratory flow
– These objective measures more reliably indicate the severity of an exacerbation than does the severity of symptoms
78
Classifying Severity of Asthma Exacerbations in the UC or ER Setting
Severity
Mild
Symptoms &
Signs
Dyspnea only with
activity (assess
tachypnea in young
children)
Initial PEF
(or FEV1)
PEF 70 percent
predicted or personal
best



Usually cared for at home
Prompt relief with inhaled SABA
Possible short course of oral systemic
corticosteroids
PEF 4069 percent
predicted or personal
best



Usually requires office or ED visit
Relief from freq. inhaled SABA
Oral systemic corticosteroids; some
symptoms last 1–2 days after treatment
is begun
PEF <40 percent
predicted or personal
best

Usually requires ED visit and likely
hospitalization
Partial relief from frequent inhaled
SABA
PO systemic corticosteroids; some
symptoms last >3 days after treatment
is begun
Adjunctive therapies are helpful

Moderate
Severe
Dyspnea interferes with
or limits usual activity
Dyspnea at rest;
interferes with
conversation
Clinical Course



Subset: Life
threatening
Too dyspneic to speak;
perspiring
PEF <25 percent
predicted or personal
best




Requires ED/hospitalization; possible
ICU
Minimal or no relief w/ frequent inhaled
SABA
Intravenous corticosteroids
Adjunctive therapies are helpful
Managing Asthma Exacerbations at Home A s s e s s S e v e rity
 P a t ie n t s a t h ig h r is k f o r a fa ta l a t t a c k (s e e fig u r e 5 – 2 a ) r e q u ir e im m e d ia t e m e d ic a l a t te n t io n
a f t e r in it ia l t r e a t m e n t.
 S y m p t o m s a n d s i g n s s u g g e s t iv e o f a m o r e s e r i o u s e x a c e r b a t i o n s u c h a s m a r k e d b r e a t h le s s n e s s ,
i n a b i l it y t o s p e a k m o r e t h a n s h o r t p h r a s e s , u s e o f a c c e s s o r y m u s c le s , o r d r o w s i n e s s ( s e e
f i g u r e 5 – 3 ) s h o u l d r e s u l t in in i t ia l t r e a t m e n t w h i le im m e d i a t e l y c o n s u l t i n g w i t h a c l in ic i a n .
 L e s s s e v e r e s i g n s a n d s y m p t o m s c a n b e t r e a t e d i n i t i a ll y w i t h a s s e s s m e n t o f r e s p o n s e t o t h e r a p y
a n d f u r t h e r s t e p s a s l is t e d b e l o w .
 I f a v a i la b le , m e a s u r e P E F — v a l u e s o f 5 0 – 7 9 % p r e d i c t e d o r p e r s o n a l b e s t in d ic a t e t h e n e e d f o r
q u ic k - r e l i e f m e d ia t i o n . D e p e n d i n g o n t h e r e s p o n s e t o t r e a t m e n t , c o n t a c t w i t h a c l in i c i a n m a y a l s o
b e in d ic a t e d . V a l u e s b e lo w 5 0 % i n d i c a t e t h e n e e d f o r i m m e d i a t e m e d i c a l c a r e .
In itia l T r e a tm e n t
 In h a le d S A B A : u p to tw o tr e a tm e n ts 2 0 m in u te s a p a r t o f 2 – 6 p u ffs
b y m e t e r e d - d o s e i n h a le r ( M D I ) o r n e b u li z e r t r e a t m e n t s .
 N o t e : M e d i c a t i o n d e l i v e r y i s h ig h l y v a r i a b l e . C h il d r e n a n d
i n d i v id u a l s w h o h a v e e x a c e r b a t i o n s o f l e s s e r s e v e r i t y m a y n e e d
fe w e r p u ffs th a n s u g g e s te d a b o v e .
G ood Response
In c o m p le te R e s p o n s e
Poor Response
N o w h e e z in g o r d y s p n e a
( a s s e s s ta c h y p n e a in y o u n g
c h il d r e n ) .
P e r s is t e n t w h e e z i n g a n d
d y s p n e a (ta c h y p n e a ).
M a r k e d w h e e z in g a n d d y s p n e a .
P E F  8 0 % p r e d ic t e d o r
p e rs o n a l b e s t.
 C o n ta c t c lin ic ia n fo r
f o l lo w u p i n s t r u c t i o n s a n d
fu rth e r m a n a g e m e n t.
 M a y c o n t in u e i n h a l e d
S A B A e v e ry 3 – 4 h o u rs fo r
2 4 – 4 8 h o u rs .
 C o n s id e r s h o r t c o u r s e o f
o r a l s y s t e m ic
c o r t ic o s t e r o i d s .
P E F 5 0 – 7 9 % p r e d ic te d o r
p e rs o n a l b e s t.
 A d d o ra l s y s te m ic
c o r t ic o s t e r o i d .
 C o n tin u e in h a le d S A B A .
 C o n ta c t c lin ic ia n u r g e n tly
( th is d a y ) fo r fu r th e r
in s tru c tio n .
P E F < 5 0 % p r e d ic t e d o r
p e rs o n a l b e s t.
 A d d o ra l s y s te m ic
c o r t ic o s t e r o i d .
 R e p e a t i n h a le d S A B A
i m m e d ia t e l y .
 I f d is t r e s s i s s e v e r e a n d
n o n r e s p o n s i v e t o i n it i a l
tr e a tm e n t:
— C a ll y o u r d o c to r A N D
— PROCEED TO ED;
— C o n s id e r c a ll i n g 9 – 1 – 1
( a m b u la n c e tr a n s p o r t) .
 To ED.
What the EPR ‐3 Does NOT Recommend
– Drinking large volumes of liquids or breathing warm, moist air (e.g., the mist from a hot shower)
– Using over‐the‐counter products such as antihistamines or cold remedies
– Although pursed‐lip and other forms of controlled breathing may help to maintain calm during respiratory distress, these methods do not bring about improvement in lung function
EPR ‐
EPR ‐3 , P.384
81
Many Thanks To ‐
Colleagues who shared their power point presentations and/or provided feedback on the foundation for this presentation:
–
–
–
–
–
Dr. Gail M Brottman MD, Director, Pediatric Pulmonary Medicine, HCMC
Dr. Don Uden, Pharm. D., Professor, University of Minnesota, College of Pharmacy Dr. Barbara P. Yawn, MD, MSc, Director of Research, Olmsted Medical Clinic
Dr. Mamta Reddy, MD, Chief
Allergy/ Immunology, Bronx Lebanon Hospital Center, NY
Mary Bielski, RN, LSN, CNS, Nursing Service Manager, Minneapolis Public Schools
82
Minnesota Department of Health
Asthma Program
www.health.state.mn.us/asthma
83