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Module 5:
Treatment of Severe Asthma
an educational program of:
Updated: June 2011
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Module 5:
Treatment of Severe Asthma
Authors:
Jean Bousquet, France
Ronald Dahl, Denmark
Michael A. Kaliner, USA
Connie Katelaris, Australia
Contributer:
Richard Lockey, USA
Severe asthma
• A shift in focus from severity to
control
• How to control severe asthma
• Diagnosis and management of acute
severe asthma
Section 1:
Asthma Control
Lecture Objectives
Section 1 – Asthma Control
At the end of this section participants will be able
to:
• Diagnose severe asthma
• Assess whether asthma is controlled
• Outline appropriate treatment strategies for
optimal control of severe asthma
Definition of severe asthma
• Patients who need high dose inhaled CCS and longacting ß2 agonists and:
– are still uncontrolled
– experience frequent acute exacerbations
– and/or often require emergency treatment and/or
hospitalization
Diagnosis and
classification of asthma
Asthma severity is classified by:
• the presence of clinical features before treatment
is started
• and/or by the amount of daily medication
required for optimal treatment
GINA 2002
Classification of asthma:
GINA 1998
Current treatment step
Step 1
Step 2
Step 3
Step 4
Clinical features
No controller
<500 BDP
200–1000 BDP
+ LABA
>1000 BDP +
LABA + other
Step 1
Symptoms <1 x week
Intermittent
Mild
persistent
Moderate
persistent
Severe
persistent
Mild
persistent
Moderate
persistent
Severe
persistent
Severe
persistent
Moderate
persistent
Severe
persistent
Severe
persistent
Severe
persistent
Severe
persistent
Severe
persistent
Severe
persistent
Severe
persistent
Nocturnal symptoms ≤2x month
Lung function normal between episodes
Step 2
Symptoms >1 x week
Nocturnal symptoms <1 x week
Lung function normal between episodes
Step 3
Symptoms daily
Nocturnal symptoms ≥1 x week
FEV1 60–80% predicted
Step 4
Symptoms daily
Frequent nocturnal symptoms
FEV1 <60% predicted
Asthma management:
from severity to control
There has been a shift in the paradigm for
asthma treatment; previous
recommendations for stepwise
implementation of pharmacotherapy were
based on disease severity, the focus is now on
asthma control
GINA: goals of treatment 2006
"The aim of asthma management
should be
control of the disease"
GINA 2002
What is asthma control?
• To the patient
– no symptoms which interfere with normal lifestyle no
exacerbations, normal quality-of-life
– particularly, no cough
• To carers (parents)
– able to get to school, no night cough
• To the GP
– no unscheduled visits, few exacerbations, no admissions
(sometimes maintenance of PEF)
What is asthma control?
• To the respiratory physician
– no night symptoms
– maintenance of lung function (FEV1)
– few exacerbations, no admissions
• To regulatory authorities
– improvement in a.m. PEF, FEV1
– improvement in symptom scores and quality of life
– enhanced cost effectiveness analyses
A composite measure of control may
help to improve outcomes
• Currently, single clinical endpoints, such as lung function, are
often used to guide treatment
• Single endpoints may overestimate true asthma control1
• Other disease areas such as diabetes use a composite measure
(HbA1c, blood pressure and cholesterol targets)2-4
1. Clark et al. Eur Respir J 2002 2. European Diabetes Policy Group 1999. Diabet Med 1999 3. Diabetes UK.
Recommendations for the management of diabetes in primary care. 2nd ed. October 2000 4. Department of Health. NSF for
Diabetes: Standards 5. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the Management of
Asthma. February 2003. 6. National Heart, Lung, and Blood Institute, World Health Organization. 1998
How can we assess
control in practice?
We need simple tools that both healthcare providers
and patients can use
– Asthma Control Questionnaire (ACQ)
7-item questionnaire. Based upon day/night-time
symptoms, daily activities, rescue bronchodilator
Juniper et al ERJ 1999; 14: 902-907
How can we assess
control in practice ?
- Royal College of Physicians (RCP)
3 questions based upon day/night-time symptoms and daily activities.
- Asthma Control Test (ACT)
Validated instrument. 5 questions based upon day/night-time
symptoms, rescue bronchodilator use and daily activities.
Br Med J 1990;301:651-653
Nathan et al., J Allergy Clin Immun, 2004: 113(1): 59-65
Differences between scores
RCP
rules 2
ACQ
ACT
30 sec
Night time symptoms
yes
yes
yes
yes
yes
Day time symptoms
yes
yes
yes
yes
Exercise, activities
yes
yes
yes
yes
Rescue medications
(yes)
yes
yes
yes
1 mo
1 wk to 3
mo
yes
FEV1 or PEFR
Duration of survey
ACQ7
1 wk or
1 mo
1 wk to
1 yr
1 wk
Levels of asthma control
Characteristic
Controlled
(All of the following)
Partly controlled
(Any present in any week)
Daytime symptoms
None (2 or less/ week)
More than
twice/week
Limitations of activities
None
Any
Nocturnal symptoms/
awakening
None
Any
Need for rescue/ “reliever”
treatment
None (2 or less/ week)
More than
twice/week
Lung function
(PEF or FEV1)
Normal
< 80% predicted or personal best
(if known) on any day
Exacerbation
None
One or more/year
Uncontrolled
3 or more features
of partly controlled
asthma present in
any week
1 in any week
Asthma Management and Prevention Program
Goals of long-term management
• Achieve and maintain control of symptoms
• Maintain normal activity levels, including exercise
• Maintain pulmonary function as close to normal levels
as possible
• Prevent asthma exacerbations
• Avoid adverse effects from asthma medications
• Prevent asthma mortality
Severe asthma
• A shift in focus from severity to control
• How to control severe asthma
• Diagnosis and management of acute severe
asthma
Asthma Management and
Prevention Program
• Asthma can be effectively controlled in most patients
by intervening to suppress and reverse inflammation
as well as treating bronchoconstriction and related
symptoms
• Early intervention to stop exposure to the risk
factors that sensitized the airway may help improve
the control of asthma and reduce medication needs
Asthma Management and Prevention Program
Component 3: Assess, treat and
monitor asthma
•
Depending on level of asthma control, the patient
is assigned to one of five treatment steps
•
Treatment is adjusted in a continuous cycle driven
by changes in asthma control status. The cycle
involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
Management of asthma in adults
and adolescents (GINA 2006 adapted)
Assess asthma control
Controlled
Partially controlled
Uncontrolled
Exacerbation
Maintain
treatment
or
Step down
No controller
treatment
Controller
treatment
Step 2
Step up
Step up until
controlled
Treat as
exacerbation
Treating to achieve asthma control
Step 4 – Reliever medication plus two or more
controllers
• Selection of treatment at Step 4 depends on prior selections at
Steps 2 and 3
• Where possible, patients not controlled on Step 3 treatments
should be referred to a health professional with expertise in the
management of asthma
Treating to achieve asthma control
Step 4 – Reliever medication plus two or more controllers
• Medium- or high-dose inhaled glucocorticosteroid combined with
a long-acting inhaled β2-agonist (Evidence A)
• Medium- or high-dose inhaled glucocorticosteroid combined with
leukotriene modifiers (Evidence A)
• Low-dose sustained-release theophylline added to medium- or
high-dose inhaled glucocorticosteroid combined with a longacting inhaled β2-agonist (Evidence B)
Treating to achieve asthma control
Step 5 – Reliever medication plus additional
controller options
• Addition of oral glucocorticosteroids to other controller medications
may be effective (Evidence D) but is associated with severe side
effects (Evidence A)
• Addition of anti-IgE treatment to other controller medications
improves control of allergic asthma when control has not been
achieved on other medications (Evidence A)
Treating to maintain asthma control
• When control as been achieved, ongoing
monitoring is essential to:
- maintain control
- establish lowest step/dose of treatment
• Asthma control should be monitored by the
health care professional and by the patient
Treating to maintain asthma control
Stepping down treatment when asthma is controlled
• When controlled on medium- to high-dose
inhaled glucocorticosteroids: 50% dose
reduction at 3 month intervals (Evidence B)
• When controlled on low-dose inhaled
glucocorticosteroids: switch to once-daily
dosing (Evidence A)
Treating to maintain asthma control
Stepping down treatment when asthma is controlled
• When controlled on combination inhaled
glucocorticosteroids and long-acting inhaled β2-agonist,
reduce dose of inhaled glucocorticosteroid by 50% while
continuing the long-acting β2-agonist (Evidence B)
• If control is maintained, reduce to low-dose inhaled
glucocorticosteroids and stop long-acting β2-agonist
(Evidence D)
Treating to maintain asthma control
Stepping up treatment in response to loss of control
• Rapid-onset, short-acting or long-acting inhaled
β2-agonist bronchodilators provide temporary
relief.
• Need for repeated dosing over more than
one/two days signals need for possible increase
in controller therapy
Treating to maintain asthma control
Stepping up treatment in response to loss of control
• Use of a combination long-acting inhaled β2-agonist (e.g.,
salmeterol, formoterol) and an inhaled glucocorticosteroid
(e.g., fluticasone, budesonide) in a single inhaler both as a
controller and reliever is effective in maintaining a high level
of asthma control and reduces exacerbations (Evidence A)
• Doubling the dose of inhaled glucocorticosteroids is not
effective, and is not recommended (Evidence A)
Treating to maintain asthma control
• When control as been achieved, ongoing monitoring
is essential to:
- maintain control
- establish lowest step/dose of treatment
• Asthma control should be monitored by the health
care professional and by the patient
Guided self-management plans
GINA 2006 (adapted)
• Guided self management action
plans enable patients with
asthma to gain the knowledge,
confidence and skills to assume a
major role in the management of
their asthma, reducing asthma
morbidity in adults (Evidence A)
and children (Evidence A).
Monitoring asthma: peak flow
meters
Peak flow meters are useful to monitor
asthma and prevent exacerbations:
•
•
•
•
Inexpensive
Easy to use
Accurate
Provide “real life” measurements
at worst and best times of the day
• Provide objective measurement
of pulmonary function
• Detect early changes of asthma
worsening
Patient “self management” based on
peak flow measurement
If personal best peak flow measurements:
– Fall 10+%, double dose of inhaled CCS
– Fall 20+%, use short-acting bronchodilator Q4 -6 hour, plus
2-4 x inhaled CCS
– Call office, try to determine if infection is present
– Fall 40 - 50%, add oral CCS
– Fall greater than 50%, urgent visit to either
• Outpatient office
• Emergency room
Kaliner In: Current Review of Asthma. Current Medicine, 2003
Use of inhaled corticosteroids
Copyright permission for reproduction pending
Rabe et al. Eur Respir J 2000;
www.asthmainamerica.com;
Lai et al. J Allergy Clin Immunol 2003;
Data on file
Preventing exacerbations underlying causes and patient education
Evaluate patient for :
– Allergy
– Infection
– Compliance
– Inappropriate concomitant
medications
– Social factors
– Tobacco, drugs, irritants, fumes
– Psychiatric disorders
Initiate or review patient education and selfmanagement plan
Role of allergy in managing asthma
•
•
•
•
90% of asthmatics <16 years old are allergic
70% of asthmatics 16-30 are allergic
50% of adult asthmatics are allergic
Any asthmatic who wheezes 2 times/week needs an
allergy assessment
• Allergy avoidance and allergy vaccination are effective
treatments for asthma (Evidence A)
• Allergy treatment is both cost-effective and is the only
treatment capable of reducing asthma long-term
The main goal of the 10 year Finnish
Asthma Programme:
• To lessen the burden of asthma on
individuals and society
Finnish Asthma Programme:
Measures to achieve the goals
• Early diagnosis and active treatment
• Guided self-management as the primary form of treatment
• Reduction in respiratory irritants such as smoking and
environmental tobacco smoke
• Implementation of patient education and rehabilitation combined
with normal treatment, planned individually and timed
appropriately
• Increase in knowledge about asthma in key groups; and promotion
of scientific research
• Appointment of one doctor, one nurse and one pharmacist
responsible for asthma care in each clinic/region
Healthcare benefits from asthma
intervention
Asthma Indices
(base 100 in 1981)
350
300
Reimbursement asthma
Hospitalization days
Death rate
250
200
150
100
50
0
1981
1983
1985
1987
1989
Year
Haahtela et al, Thorax 1998
1991
1993
1995
Healthcare benefits from asthma
intervention
Finnish Asthma Programme (1994-2004)
60
% change 1993-2003
40
20
0
-20
-40
-60
-80
Haahtela et al, Thorax 2006
asthma
prevalence
hospital
disability
days
pension
total costs
cost per pt
per year
Summary
• Asthma management in 2007 is focused on control of
the individual patient’s asthma symptoms, a paradigm
shift from earlier recommendations of a step-wise
increase in therapy based on asthma severity;
• Patient self-management plans play an important role in
prevention of exacerbations;
• Successful asthma interventions lead to increased
medication costs but decreased costs for
hospitalization, and decreased death rates;
• Allergen exposure is an important contributory factor
in exacerbations of IgE-mediated asthma.
Section 2:
Acute Severe Asthma
Severe asthma
• A shift in focus from severity to control
• How to control severe asthma
• Diagnosis and management of acute
severe asthma
Lecture objectives: Section 2
At the end of this section participants will be able
to:
• Understand the risk factors for asthma
exacerbations
• Understand the pathophysiology of acute severe
asthma
• Identify the signs and symptoms of acute asthma
• Outline appropriate treatment strategies for
optimal control of acute asthma exacerbations
Frequency of hospital and emergency room
visits in moderate-severe asthmatics;
TENOR study
Copyright permission for reproduction pending
Rabe et al. Eur Respir J 2000;
www.asthmainamerica.com;
Lai et al. J Allergy Clin Immunol 2003;
Adachi et al. Arerugi 2002;
Data on file
Acute severe asthma monitoring
the cross-road of death
Slight
Moderate Severe
Slight
Moderate Severe
Normoventilation
Hyperventilation
Hypoventilation
Exhaustion
RHONCHI
Copyright permission for reproduction pending
Eur Respir J 1997; 10: 1359–1371
Bronchial Asthma
Spirometric
abnormalities
Gas exchange
abnormalities
Central airway
narrowing
Distal airway
narrowing
Bronchoconstriction
Airway Inflammation
Treatments must be directed towards these two components:
Smooth muscle spasm
Inflammation, edema, plugs
Features of a severe asthma
exacerbation
One or more present:
•
•
•
•
•
•
•
Use of accessory muscles of respiration
Pulsus paradoxicus >25 mm Hg
Pulse > 110 BPM
Inability to speak sentences
Respiratory rate >25 - 30 breaths/min
PEFR or FEV1 < 50% predicted
SaO2 <91- 92%
McFadden Am J Respir Crit Care Med 2003
Risk factors for fatal or near-fatal
asthma attacks
•
•
•
•
•
•
•
•
Previous episode of near-fatal asthma
Multiple prior ER visits or hospitalizations
Poor compliance with medical treatments
Adolescents or inner city asthmatics
(USA) African-Americans>Hispanics>Caucasians
Allergy to Alternaria
Recent use of oral corticosteroid (OCS)
Inadequate therapy:
– Excessive use of β-agonists
– No inhaled corticosteroid (ICS)
– Concomitant β-blockers
Ramirez and Lockey In: Asthma, American College of Physicians, 2002
•
•
•
•
•
•
•
•
•
•
Physical findings in severe asthma
exacerbations
Tachypnea
Tachycardia
Wheeze
Hyperinflation
Accessory muscle use
Pulsus paradoxicus
Diaphoresis (profuse sweating)
Cyanosis
Sweating
Obtundation (altered mental state)
Brenner, Tyndall and Crain In: Emergency Asthma. Marcel Dekker 1999
Causes of asthma exacerbations
•
•
•
•
Lower or upper respiratory infections
Cessation or reduction of medication
Concomitant medication, e.g. β-blocker
Allergen or pollutant exposure
Differential diagnosis
• COPD
•
•
•
•
•
Bronchitis
Bronchiectasis
Endobronchial diseases
Foreign bodies
Extra- or intra-thoracic
tracheal obstruction
• Carcinoid syndrome
Brenner, Tyndall, Crain In: Emergency Asthma. Marcel Dekker, 1999
• Cardiogenic pulmonary
edema
• Non-cardiogenic
pulmonary edema
• Pneumonia
• Pulmonary emboli
• Chemical pneumonitis
• Hyperventilation syndrome
Acute severe asthma – associations and
differential diagnoses
•
•
•
•
•
•
•
•
Hyperventilation syndrome
Vocal cord dysfunction
Vaso-vagal reaction
Anaphylactic reaction (urticaria, BP, pulse rate, etc)
Aspiration - foreign body – pneumonia
Pneumothorax
Cardiac failure
Lung emboli
Stages of asthma exacerbations
Stage 1:
Symptoms
• Somewhat short of breath
• Can lie down and sleep through the night
• Cannot perform full physical activities without
shortness of breath
Signs
• Some wheezes on examination
• Respiratory rate, 15 (normal <12)
• Pulse 100
• Peak flows and spirometry reduced by 10%
Stages of asthma exacerbations
Stage 2:
Symptoms
• Less able to do physical activity due to shortness of breath
• Dyspnea on walking stairs
• May wake up at night short of breath
• Uncomfortable on lying down
• Some use of accessory muscles of respiration
Signs
• Wheezing
• Respiratory rate 18
• Pulse 111
• Peak flows and spirometry reduced by 20+%
Stages of asthma exacerbations
Stage 3:
Symptoms
• Unable to perform physical activity without shortness of
breath
• Cannot lie down without dyspnea
• Speaks in short sentences
• Using accessory muscles
Signs
• Wheezing
• Respiratory rate 19 - 20
• Pulse 120
• Peak flows and spirometry reduced by 30+%
Stages of asthma exacerbations
Stage 4:
Symptoms
• Sitting bent forward
• Unable to ambulate without shortness of breath
• Single word sentences
• Mentally-oriented and alert
• Use of accessory muscles
Signs
• Wheezing less pronounced than anticipated
• Respiratory rate 20 - 25
• Pulse 125+
• Peak flows and spirometry reduced by 40+%
• SaO2 91- 92%
Stages of asthma exacerbations
Stage 5:
Symptoms
• Reduced consciousness
• Dyspnea
• Silent chest – no wheezing
Signs
• Fast, superficial respiration
• Respiratory rate >25
• Unable to perform peak flows
or spirometry
• Pulse 130 - 150+
• SAO2 <90
Severity of asthma as graded by %
predicted FEV1
FEV% predicted
• 70 - 100
• 60 - 69
• 50 - 59
• 35 - 49
• < 35
Severity
Mild
Moderate
Moderately severe
Severe
Very severe:
(life-threatening)
Acute severe asthma - clinical assessment
• Respiratory frequency: (count)
– Speech: sentences, single words
• Auxiliary respiratory muscle use
• Posture: sitting, can patient lie down?
• Airway patency: rhonchi, silent chest (PEF)
• Respiration: cyanosis (SaO2, blood gases)
• General appearance, effort of breathing: activity level
(pulse rate)
Acute severe asthma - monitoring
• Clinical condition
• PEF or FEV1
• PaO2 and PaCO2
ACUTE ASTHMA – MONITORING CHART
Name:
Birth date:
Date:
Time first seen:
Time
Pulse rate
History:
Respiratory
rate
Use of
accessory
muscles
PEF
Pulse
oximetry
(SaO2)
Cyanosis
Exhaustion
Oxygen
flow
Neck
_________
______ l/m
Abdomen
Arms
Neck
_________
______ l/m
Abdomen
Arms
Neck
_________
______ l/m
Abdomen
Arms
Treatment
Short Acting Beta
Agonist
Dose: ____________
Delivery:
Nebuliser/Spacer
Oral steroid: ________
Inhaled steroid: ______
Short Acting Beta
Agonist
Dose: ____________
Delivery:
Nebuliser/Spacer
Oral steroid: ________
Inhaled steroid: ______
Short Acting Beta
Agonist
Dose: ____________
Delivery:
Nebuliser/Spacer
Oral steroid: ________
Inhaled steroid: ______
Acute severe asthma
Admission and close monitoring in hospital unit:
• Clinical stage 4
• PEF or FEV1 < 30% of personal best
(if unknown < 30% predicted)
• PaCO2 > 6 kPa
• PaO2 < 8 kPa
• Poor response to initial treatment
Acute severe asthma treatment
Oxygen by nasal cannulae or mask
Inhaled broncodilator should be administered at
regular Intervals (Evidence A):
Nebulised ß2-agonist combined with anticholinergic each
20 mins in the first hour, then hourly as necessary
Systemic steroid should be utilised in all but the
Mildest Exacerbations (Evidence A):
Oral (50-75mg prednisolone) or i.v. corticosteroid (80 mg
Methylprednisolone); repeat after 12 hours; over the following days
40 mg prednisolone or equivalent is usually maintained
Start inhaled high dose steroid as soon as possible
Acute severe asthma treatment
Dangerous, or at least ineffective
Dangerous:Sedation
Ineffective:
Mucolytics
Physiotherapy
Antihistamines
Acute severe asthma treatment
Consider:
Infusion of Beta-2-agonist
Infusion of theophylline
Antibiotics – not all acute asthma exacerbations require
antibiotics
Fluids
Acute severe asthma –
treatment options
Standard treatment:
Oxygen
Inhaled beta-2-agonist +/- anticholinergic
Systemic corticosteroid
Additional options:
Systemic beta-2-agonist and/or theophylline, antibiotics, fluids
Nonstandard treatment:
Antileukotrienes; Magnesium sulphate; Heliox; Bi-pap
Extreme intervention:
Intubation and controlled hypoventilation/other strategy
Anesthesia-sedation; Bronchial lavage
Treatment of asthma exacerbations
oral corticosteroids
• Oral corticosteroids are the most powerful
medications available to reduce airway inflammation
• Use until attack has completely abated:
– PEFR and FEV1 at baseline levels
– Symptoms gone
• Taper to QOD and determine if patient can remain
well if corticosteroids are withdrawn completely
Acute severe asthma
• Treat the condition symptomatically
• Determine what caused the exacerbation:
–
–
–
–
–
inhalant allergen
food allergen
drug reaction (ASA, vaccination, etc)
infection
worsening of a chronic condition:
- poor therapy compliance
- treatment needs adjustment
Prevention of relapse and recurrence
of asthma exacerbation - definition
Relapse:
Reappearance of asthma symptoms that require
unscheduled care within 3 weeks of an asthma
exacerbation
Recurrence:
Reappearance of asthma symptoms that require
unscheduled care more than 3 weeks after the
asthma exacerbation
Prevention of relapse and recurrence
of asthma exacerbation
Patients treated for an asthma
exacerbation are at risk for
subsequent severe attacks:
(unscheduled doctor visits,
Emergency Department visits,
hospitalization, asthma death)
Proper asthma care can reduce
this risk:
a)
Pharmacological intervention
with ICS
b) Patient education – knowledge
and skills
c)
Self management plans and
follow up
Prospective multicenter study of relapse
after ED care of acute severe asthma
Relapse rate: 17%
Associations
OR
Multiple previous ED visits for asthma
1.3
Use of home nebulizer
Long duration of symptoms
Report of multiple triggers (per trigger)
2.2
2.5
1.1
Emerman C et.al. Chest 1999; 115: 919-27
Comparison of short course of Inhaled CS and Oral
CS for acute asthma exacerbation in primary care
413 patient in 47 general practices.
Treatments:
a) oral prednisolone 40mg daily for 16 days
b) inhaled FP 1000mcg x 2 daily for16 days
Outcome was failure:
Defined by symptoms and/or PEF
Levy ML et el. Thorax; 1996; 51: 1087-92
Comparison of short courses of OCS vs
ICS in the treatment of asthma
exacerbation in primary care
Copyright permission for reproduction pending
Levy ML, et al. Thorax 1996; 51:1087-1092
Viral respiratory infection and
asthma exacerbations
Studies using PCR techniques have shown that viral infection is a
common cause of asthma exacerbations.
Age
19-46y
9-11y
6m-12y
2m-16y
n
138
108
75
70
Setting
Outpatient
Outpatient
Hospitalized
ED
%viral
55
85
82
83
Reference
_______
Nicholson BMJ 1993
Johnston BMJ 1995
Freymoth JCVirol 1999
Rakes AJRCCM 1999
Antibiotics in asthma exacerbations
• Use antibiotics if any suspicion of bacterial
infection
• If antibiotics are prescribed, recommendation is
for broad spectrum macrolide antibiotics that
cover atypical bacteria (chlamydia, mycoplasma), eg,
azithromycin, clarithromycin, erythromycin, roxithromycin,
dirithromycin, amoxicillin + clavulan; moxifloxacin,
cefuroxim
Delays in seeking help for acute asthma - the
patient’s perspective
95 patients explained their reasons for
delaying seeking professional care:
•
•
•
•
•
•
•
Janson S. J Asthma 1998; 35: 427-35
Uncertainty
Disruption
Minimization
”Self-reliance”
Fear of steroids
To avoid ED
Economic reasons
74%
86%
90%
46%
31%
34%
5%
Acute severe asthma
IS A RESPIRATORY ATTACK!
• Treat, Monitor and Follow-up
• Consider improved prophylaxis:
- allergen avoidance
- allergen vaccination
- pharmacological treatment update
- stop smoking
- enhance compliance to recommendations by
teaching and monitoring
World Allergy Organization (WAO)
For more information on the World Allergy
Organization (WAO), please visit
www.worldallery.org or contact the:
WAO Secretariat
555 East Wells Street, Suite 1100
Milwaukee, WI 53202
United States
Tel: +1 414 276 1791
Fax: +1 414 276 3349
Email: [email protected]