Download L4_GINA asthma

2007 NHLBI
Guidelines for the
Diagnosis & Management
of Asthma
Expert Panel Report-3
www.nhlbi.nih.gov/guidelines/asthma
The 4 Components of Asthma Management
 Component 1: Measures of Asthma Assessment and Monitoring
 Component 2: Education for a Partnership in Asthma Care
 Component 3: Control of Environmental Factors and Comorbid
Conditions That Affect Asthma
 Component 4: Medications
The Goals of Asthma Therapy:
(Asthma Control)
EPR-3, p284
 Reducing impairment
 prevent chronic and troublesome symptoms
 require infrequent use (≤ 2 days a week) of inhaled SABA
for symptoms
 maintain (near) “normal” pulmonary function
 maintain normal activity levels
 meet patients’ and families’ satisfaction with care
 Reducing risk
 prevent recurrent exacerbations of asthma (ED/inpatient)
 prevent progressive loss of lung function
 provide optimal pharmacotherapy
NAEPP Draft Report, ERP 2007
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
CHILDREN 5 - 11 YEARS OF AGE
EPR-3, p73, 308
Classification of Asthma Severity
Components of
Severity
Impairment
Intermittent
Mild
Severe
Symptoms
<2 days/week
>2 days/week not daily
Daily
Nighttime
Awakenings
<2x/month
3-4x/month
>1x/week
SABA use for sx
control
<2 days/week
>2 days/week not daily
Daily
Several times daily
Interference with
normal activity
none
Minor limitation
Some limitation
Extremely limited
not nightly
•Normal FEV1 between
exacerbations
Lung Function
• FEV1 > 80%
• FEV1 >80%
•FEV1/FVC> 80%
• FEV1/FVC> 85%
Exacerbations
Risk
Persistent
Moderate
(consider
frequency and
severity)
0-2/year
•FEV1/FVC=75%
-80%
Often nightly
•FEV1 <60%
•FEV1/FVC <
75%
> 2 /year
Frequency and severity may vary over time for patients in any category
Relative annual risk of excaerbations may be related to FEV
Step 1
Recommended Step for
Initiating Treatment
• FEV1=60% 80%
Continuous
Step 2
Step3
medium- Step 3 or 4
dose ICS option
Consider short course of oral steroids
In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
YOUTHS > 12 YEARS AND ADULTS
EPR-3, p74, 344
Classification of Asthma Severity
Components of
Severity
Intermittent
Mild
Persistent
Moderate
Severe
Symptoms
<2 days/week
>2 days/week not daily
Daily
Nighttime
Awakenings
<2x/month
3-4x/month
>1x/week
Normal
FEV1/FVC
SABA use for sx
control
<2 days/week
>2 days/week not daily
Daily
Several times daily
8-19 yr 85%
Interference with
normal activity
none
Minor limitation
Some limitation
Extremely limited
Impairment
20-39 yr 80%
•Normal FEV1 between
exacerbations
40-59 yr 75%
60-80 yr 70%
not nightly
Lung Function
• FEV1 > 80%
• FEV1 >80%
•FEV1/FVC normal
•FEV1/FVC
reduced 5%
• FEV1/FVC normal
Exacerbations
Risk
(consider
frequency and
severity)
0-2/year
Often nightly
•FEV1 <60%
•FEV1/FVC
reduced> 5%
> 2 /year
Frequency and severity may vary over time for patients in any category
Relative annual risk of excaerbations may be related to FEV
Step 1
Recommended Step for
Initiating Treatment
• FEV1 >60%
but< 80%
Continuous
Step 2
Step 3
Step 4 or 5
Consider short course of oral steroids
In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
accordingly
Classifying Severity for Patients Currently Taking
Controller Medications
Classification of Asthma Severity
Lowest level
of treatment
required to
maintain
control
Intermittent
Persistent
Mild
Moderate
Severe
Step 2
Step 3 or 4
Step 5 or 6
Step 1
NAEPP Draft Report, ERP 2007
EPR-3, Page 72-74
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
CHILDREN 5 - 11 YEARS OF AGE
EPR-3, p76, 310
Classification of Asthma Control
Components of Control
Well Controlled
Symptoms
Nighttime awakenings
IMPAIRMENT
Interference with
normal activity
SABA use
FEV1or peak flow
FEV1/FV
RISK
Exacerbations
Progressive loss of lung
function
Rx-related adverse effects
Recommended Action
For Treatment
< 2 days/week
< 1/month
none
< 2 days/week
> 80% predicted/
personal best
> 80% predicted
0- 1 per year
Not Well
Controlled
> 2 days/week
Very Poorly
Controlled
Throughout the day
> 2 x/month
>2x/week
Some limitation
Extremely limited
> 2 days/week
Several times/day
60-80% predicted/
personal best
<60% predicted/
personal best
75-80% predicted
2 - 3 per year
<75% predicted
> 3 per year
Evaluation requires long-term follow up care
Consider in overall assessment of risk
•Maintain current step
•Step up 1 step
•Consider step down
if well controlled at
least 3 months
•Reevaluate in 2 - 6
weeks
•Consider oral
steroids
•Step up 1-2 weeks
and reevaluate in 2
weeks
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
YOUTHS > 12 YEARS OF AGE AND ADULTS
EPR-3, p77, 345
Classification of Asthma Control
Components of Control
Well Controlled
Symptoms
Nighttime awakenings
IMPAIRMENT
Interference with
normal activity
SABA use
FEV1or peak flow
Validated questionnaires
RISK
ATAQ/ACT
Exacerbations
Progressive loss of lung
function
Rx-related adverse effects
Recommended Action
For Treatment
< 2 days/week
< 2/month
none
Not Well
Controlled
> 2 days/week
1-3/week
Some limitation
< 2 days/week
> 80% predicted/
personal best
0/> 20
0- 1 per year
Very Poorly
Controlled
Throughout the day
> 4/week
Extremely limited
> 2 days/week
Several times/day
60-80% predicted/
personal best
<60% predicted/
personal best
1-2/16-19
3-4/< 15
2 - 3 per year
> 3 per year
Evaluation requires long-term follow up care
Consider in overall assessment of risk
•Maintain current step
•Step up 1 step
•Consider step down
if well controlled at
least 3 months
•Reevaluate in 2 - 6
weeks
•Consider oral
steroids
•Step up 1-2 weeks
and reevaluate in 2
weeks
Monitoring Asthma Control
EPR-3, Page 78
Ask the patient
 Has your asthma awakened you at night or early morning?
 Have you needed more rescue inhaler than usual?
 Have you needed urgent care for asthma? (office, ED, etc)
 Are you participating in your usual or desired activities?
 What are your triggers? (and how can we manage them?)
Actions to consider
 Assess whether medications are being taken as prescribed
 Assess whether inhalation technique is correct
 Assess spirometry and compare to previous measurements
 Adjust medications, as needed to achieve best control with
the lowest dose needed to maintain control
 Environmental mitigation strategy
NAEPP Draft Report, ERP 2007
STEPWISE APPROACH FOR MANAGING ASTHMA IN
EPR-3, p291-296
CHILDREN 0 - 4 YEARS OF AGE
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 3 or higher care is required
Consider consultation at step 2
Step 6
adherence,
environmental
control )
Step 5
Preferred:
High dose ICS
Step 4
Step 3
Step 2
Preferred:
Low-dose ICS
Step 1
Preferred:
SABA prn
Alternative:
LTRA
Cromolyn
Preferred:
Medium-dose
ICS
Preferred:
Medium-dose
ICS
AND
AND
either LTRA
Or LABA
AND
AND
either LTRA
Or LABA
Step up if
needed (check
Oral
Corticosteroid
either LTRA
Or LABA
Patient Education and Environmental Control at Each Step
Assess
Control
Step down
if possible
(asthma well
controlled
for 3
months)
STEPWISE APPROACH FOR MANAGING ASTHMA IN
EPR-3, p296-304
CHILDREN 5-11 YEARS OF AGE
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 or higher care is required
Consider consultation at step 3
Step 6
Step 5
Step 4
Step 3
Step 2
Step 1
Preferred:
SABA prn
Preferred:
Medium-dose
ICS
Preferred:
Low-dose ICS
OR
Alternative:
Low-dose ICS+
LTRA
either LABA,
Cromolyn
LTRA, or
Theophylline
Theophylline
Preferred:
Medium-dose
ICS+LABA
Preferred:
High dose ICS
+ LABA
Alternative:
High-dose ICS+
either LTRA
or Theophylline
Preferred:
High-dose ICS
+ LABA + oral
Corticosteroid
Alternative:
High-dose ICS
+either LTRA or
Theophylline
+ oral
corticosteroid
AND
Alternative:
Medium-dose
ICS+either
LTRA, or
Theophlline
AND
Consider
Consider
Olamizumab for Olamizumab for
patients with
patients with
allergies
allergies
Patient Education and Environmental Control at Each Step
Step up if
needed (check
adherence,
environmental
control and
comorbidities)
Assess
Control
Step down
if possible
(asthma well
controlled
for 3
months)
STEPWISE APPROACH FOR MANAGING ASTHMA IN
EPR-3, p333-343
YOUTHS > 12 YEARS AND ADULTS
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 or higher care is required
Consider consultation at step 3
Step 6
Step 5
Step 4
Step 3
Step 2
Step 1
Preferred:
SABA prn
Preferred:
Medium-dose
ICS
Preferred:
OR
Low-dose ICS
Low-dose
ICS+
Alternative:
either LABA,
LTRA
LTRA,
Cromolyn
Theophylline
Theophylline
Or Zileutin
Preferred:
Medium-dose
ICS+LABA
Alternative:
Medium-dose
ICS+either
LTRA,
Theophlline
Or Zileutin
Preferred:
High dose ICS
+ LABA
Preferred:
High-dose ICS
+ LABA + oral
Corticosteroid
AND
AND
Consider
Olamizumab
for
Consider
patients with
Olamizumab for
allergies
patients with
allergies
Patient Education and Environmental Control at Each Step
Step up if
needed (check
adherence,
environmental
control and
comorbidities)
Assess
Control
Step down
if possible
(asthma well
controlled
for 3
months)
EPR-3, Page 330
Recommended Action for Treatment
Based on Assessment of Control
Well
Not Well
Controlled
Controlled
Very Poorly
Controlled
Maintain current step
Step up 1 step and
reevaluate in 2-6
weeks
Consider short course
of oral corticosteroids
Consider step down if
well controlled for at
least 3 months
For side effects,
consider alternative
treatment options
Step up 1-2 steps and
reevaluate in 2 weeks
For side effects,
consider alternative
treatment options
Before stepping up check adherence and environmental control
NAEPP Draft Report, ERP 2007
Treating to Achieve Asthma Control
Step 1 – As-needed reliever medication
 Patients with occasional daytime symptoms of
short duration
 A rapid-acting inhaled β2-agonist is the
recommended reliever treatment (Evidence A)
 When symptoms are more frequent, and/or
worsen periodically, patients require regular
controller treatment (step 2 or higher)
© Global Initiative for Asthma
Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single
controller
 A low-dose inhaled glucocorticosteroid is
recommended as the initial controller
treatment for patients of all ages (Evidence A)
 Alternative controller medications include
leukotriene modifiers (Evidence A)
appropriate for patients unable/unwilling to
use inhaled glucocorticosteroids
© Global Initiative for Asthma
Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two
controllers
 For adults and adolescents, combine a low-dose
inhaled glucocorticosteroid with an inhaled longacting β2-agonist either in a combination inhaler
device or as separate components (Evidence A)
 Inhaled long-acting β2-agonist must not be used
as monotherapy
 For children, increase to a medium-dose inhaled
glucocorticosteroid (Evidence A)
© Global Initiative for Asthma
Treating to Achieve Asthma Control
Additional Step 3 Options for Adolescents and Adults
 Increase to medium-dose inhaled
glucocorticosteroid (Evidence A)
 Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
 Low-dose sustained-release theophylline
(Evidence B)
© Global Initiative for Asthma
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
© Global Initiative for 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 long-acting
inhaled β2-agonist (Evidence B)
© Global Initiative for Asthma
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)
© Global Initiative for Asthma
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)
© Global Initiative for Asthma
Treating to Maintain Asthma Control
 When control as been achieved,
ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
 Asthma control should be monitored
by the health care professional and
by the patient
© Global Initiative for Asthma
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)
© Global Initiative for Asthma
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 lowdose inhaled glucocorticosteroids and
stop long-acting β2-agonist (Evidence D)
© Global Initiative for Asthma
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
 Rapid-onset, short-acting or longacting 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
© Global Initiative for Asthma
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control
 Use of a combination rapid and long-acting
inhaled β2-agonist (e.g., formoterol) and an
inhaled glucocorticosteroid (e.g., budesonide)
in a single inhaler both as a controller and
reliever is effecting 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)
© Global Initiative for Asthma
Treatment Strategies
 Gain Control!!!
 Aggressive, intensive initial therapy to
suppress airway inflammation and gain prompt
control
 Maintain Control
 Frequent follow-up, clinically and
physiologically
 Therapeutic modifications depending on
severity and clinical course
 “Step down” long-term control medications to
maintain control with minimal side effects
Referral to an Asthma Specialist for
Consultation and Co-Management
 Patient has had a life-threatening asthma exacerbation
(hospitalization is a risk factor for mortality)
 Patient is not meeting the goals of therapy after 3-6 months
 Signs and symptoms are atypical; differential diagnosis ?
 Co-morbid conditions complicate asthma (GERD, VCD etc)
 Additional diagnostic studies are indicated (allergy skin testing,
pulmonary function studies, bronchoscopy)
 Patient requires additional education/guidance
 Patient has required more than two bursts of oral corticosteroids
in 1 year
 Patient requires “Step 4” care or higher (“Step 3” for children 0–4
years of age). Consider referral if patient requires step 3 care
(“Step 2” for children 0–4 years of age)
Expert Panel Report-3, Page 68
The Outpatient Asthma Visit
EPR-3, p121-139
 Assess “severity” and “control” (NAEPP Classification Criteria)
 Reduce current impairment
 Reduce future risk
 Address “Inflammation vs bronchoconstriction”
 Differentiate “controller vs rescue medication”
 Prescribe an inhaled steroid (for at least 4-6 weeks)
 Teach spacer device technique
 Write an Asthma Action Plan
 Daily management & recognizing early s/s of worsening
 Step-up “Yellow Zone” plan for home management
 Follow-up in 4-6 weeks: step-up/step-down & modify Action Plan
 School MAF/504b; Albuterol & spacer for school
 Annual Influenza vaccine, regardless of severity
The 4 Components of Asthma Management
 Component 1: Measures of Asthma Assessment and Monitoring
 Component 2: Education for a Partnership in Asthma Care
 Component 3: Control of Environmental Factors and Comorbid
Conditions That Affect Asthma
 Component 4: Medications
Component 2: Education for a Partnership in Asthma Care

Asthma Self-Management Education at Multiple Points of Care







clinic/office-based education
emergency department/ hospital-based education
education by pharmacists
education in school settings
community-based interventions
home-based interventions
Tools for Asthma Self-Management
 asthma action plans
 peak flow meters

Establish and Maintain a Partnership
 jointly develop treatment goals
 health literacy (read, count, measure, time, schedule)
 cultural sensitivity/ ethnic considerations

Provider Education




implementing guidelines
communication techniques
clinical decision support
systems-based interventions
EPR-3, P 93-164
EPR-3, p121-139
Key Educational Messages
 Significance of the diagnosis
 Inflammation as the underlying cause of symptoms
 Controllers versus quick-relievers
 How to use medication delivery devices
 Triggers, including second-hand tobacco smoke
 Home monitoring/ self-management
 How/ when to reach the provider
 The need for continuous on-going interaction with the
clinician to step-up and step-down therapy
 Annual Influenza vaccine (yearround reminder)
NAEPP Guidelines: every patient with persistent asthma
should have a written home management plan
EPR-3, p115-123
The 4 Components of Asthma Management
 Component 1: Measures of Asthma Assessment and Monitoring
 Component 2: Education for a Partnership in Asthma Care
 Component 3: Control of Environmental Factors and Comorbid
Conditions That Affect Asthma
 Component 4: Medications
EPR-3, P 165
EPR-3, Page 166
EPR-3, Page 166
Provide Specific Guidance
on Environmental Controls
 Dust mite interventions
 impermeable encasings for pillows/mattresses
 wash linens in hot water
 HEPA filtration
 Animal allergens
 keep outside/ out of bedroom
 similar interventions like for dust mites
 Roach control
 integrated pest management
 clean up food, spills, trash, leaks
 Mold and mildew interventions
 air conditioning
 avoid humidifiers
 repair pipes and leaks
 Second-hand smoke exposure
 Air Pollution
EPR-3, P167-177
The 4 Components of Asthma Management
 Component 1: Measures of Asthma Assessment and Monitoring
 Component 2: Education for a Partnership in Asthma Care
 Component 3: Control of Environmental Factors and Comorbid
Conditions That Affect Asthma
 Component 4: Medications
EPR-3, p177-184
Comorbid Conditions That Affect Asthma
 Allergic Bronchopulmonary Aspergillosis
 Gastroesophageal Reflux Disease
 Obesity
 Obstructive Sleep Apnea
 Rhinitis/Sinusitis
 Stress, Depression, and Psychosocial Factors
 Medications, sulfites, infections, hormones
The 4 Components of Asthma Management
 Component 1: Measures of Asthma Assessment and Monitoring
 Component 2: Education for a Partnership in Asthma Care
 Component 3: Control of Environmental Factors and Comorbid
Conditions That Affect Asthma
 Component 4: Medications
Guidelines for the
Diagnosis &
Management
of Asthma
NAEPP/NHLBI
Expert Panel Report-3
Case Scenarios
www.nhlbi.nih.gov/guidelines/asthma
Case # 1
A 3-year old male currently not on any
asthma medications has visited your
outpatient clinic 3 times in the past 6
months for acute wheezing, each episode
lasting 2-3 days. In between episodes, his
mother reports nighttime cough about 4
nights per month. This patient’s asthma
severity can be BEST classified as:
A. Mild Persistent Asthma (Step 2)
B. Moderate Persistent Asthma (Step 3)
C. Severe Persistent Asthma (Step 3)
D. I would not diagnose this child with asthma
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
CHILDREN 0-4 YEARS OF AGE
EPR-3, p72, 307
Classification of Asthma Severity
Components of
Severity
Impairment
Intermittent
Mild
<2 days/week
>2 days/week not daily
Nighttime
Awakenings
0
1-2x/month
SABA use for sx
control
<2 days/week
>2 days/week not daily
Daily
Several times daily
Interference with
normal activity
none
Minor limitation
Some limitation
Extremely limited
Exacerbations
(consider
frequency and
severity)
3-4x/month
Continuous
>1x/week
>2 exacerbations in 6 months requiring oral
steroids, or >4 wheezing episodes/ year
lasting >1 day AND risk factors for persistent
asthma
Frequency and severity of may fluctuate over time
Exacerbations of any severity may occur in patients in any category
Step 1
Recommended Step for
Initiating Treatment
Daily
Severe
Symptoms
0-1/year
Risk
Persistent
Moderate
Step 2
Step 3
Consider short course of oral steroids
In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
accordingly
Case # 1
A 3-year old male currently not on any
asthma medications has visited your
outpatient clinic 3 times in the past 6
months for acute wheezing, each episode
lasting 2-3 days. In between episodes, his
mother reports nighttime cough about 4
nights per month. This patient’s asthma
severity can be BEST classified as:
A. Mild Persistent Asthma (Step 2)
B. Moderate Persistent Asthma (Step 3)
C. Severe Persistent Asthma (Step 3)
D. I would not diagnose this child with asthma
Case # 2
A 7-year old male presents to your clinic in November
complaining of daily nocturnal cough for 2 months. He
denies symptoms of GE Reflux. He has visited the
emergency room twice in the past year where he
received albuterol with good symptomatic relief. The
BEST choice of treatment would be to:
A. Start fluticasone 44 mcg 2 puffs twice daily for
4-6 weeks and then reassess
B. Start fluticasone 110 mcg 2 puffs twice daily for
4-6 weeks and then reassess
C. Start a leukotriene modifier as you suspect his
symptoms are likely due to post-nasal drainage
from allergic rhinitis
D. I cannot feel confident at this time that this
patient should be treated with asthma
medications
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
CHILDREN 5 - 11 YEARS OF AGE
EPR-3, p73, 308
Classification of Asthma Severity
Components of
Severity
Impairment
Intermittent
Mild
Severe
Symptoms
<2 days/week
>2 days/week not daily
Daily
Nighttime
Awakenings
<2x/month
3-4x/month
>1x/week
SABA use for sx
control
<2 days/week
>2 days/week not daily
Daily
Several times daily
Interference with
normal activity
none
Minor limitation
Some limitation
Extremely limited
not nightly
•Normal FEV1 between
exacerbations
Lung Function
• FEV1 > 80%
• FEV1 >80%
•FEV1/FVC> 80%
• FEV1/FVC> 85%
Exacerbations
Risk
Persistent
Moderate
(consider
frequency and
severity)
0-2/year
•FEV1/FVC=75%
-80%
Often nightly
•FEV1 <60%
•FEV1/FVC <
75%
> 2 /year
Frequency and severity may vary over time for patients in any category
Relative annual risk of excaerbations may be related to FEV
Step 1
Recommended Step for
Initiating Treatment
• FEV1=60% 80%
Continuous
Step 2
Step3
medium- Step 3 or 4
dose ICS option
Consider short course of oral steroids
In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
STEPWISE APPROACH FOR MANAGING ASTHMA IN
EPR-3, p296-304
CHILDREN 5-11 YEARS OF AGE
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 or higher care is required
Consider consultation at step 3
Step 6
Preferred:
High dose ICS
+ LABA
Alternative:
High-dose ICS+
either LTRA
or Theophylline
Preferred:
High-dose ICS
+ LABA + oral
Corticosteroid
Alternative:
High-dose ICS
+either LTRA or
Theophylline
+ oral
corticosteroid
AND
AND
Step 5
Step 4
Step 3
Step 2
Step 1
Preferred:
SABA prn
Preferred:
Medium-dose
ICS
Preferred:
Low-dose ICS
OR
Alternative:
Low-dose ICS+
LTRA
either LABA,
Cromolyn
LTRA, or
Theophylline
Theophylline
Preferred:
Medium-dose
ICS+LABA
Alternative:
Medium-dose
ICS+either
LTRA, or
Theophlline
Consider
Consider
Olamizumab for
Olamizumab for
patients with
patients with
allergies
allergies
Patient Education and Environmental Control at Each Step
Step up if
needed (check
adherence,
environmental
control and
comorbidities)
Assess
Control
Step down
if possible
(asthma well
controlled
for 3
months)
Case # 2
A 7-year old male presents to your clinic in November
complaining of daily nocturnal cough for 2 months. He
denies symptoms of GE Reflux. He has visited the
emergency room 3 times in the past year where he
received albuterol with good symptomatic relief. The
BEST choice of treatment would be to:
A. Start fluticasone 44 mcg 2 puffs twice daily for
4-6 weeks and then reassess
B. Start fluticasone 110 mcg 2 puffs twice daily for
4-6 weeks and then reassess
C. Start a leukotriene modifier as you suspect his
symptoms are likely due to post-nasal drainage
from allergic rhinitis
D. I cannot feel confident at this time that this
patient should be treated with asthma
medications
Case # 3
A 7-year old female with asthma reports
nighttime awakenings about 2 times per
week and requires albuterol about 3 times
per week. She is currently taking
fluticasone 44 mcg 2 puffs twice daily. The
BEST next step in your step-up treatment
plan would be to:
A. Increase the dose of the inhaled steroid
B. Add a leukotriene modifier
C. Add a long-acting B-agonist
D. Encourage albuterol more frequently, every 4 hours
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
CHILDREN 5 - 11 YEARS OF AGE
EPR-3, p76, 310
Classification of Asthma Control
Components of Control
Well Controlled
Symptoms
Nighttime awakenings
IMPAIRMENT
Interference with
normal activity
SABA use
FEV1or peak flow
FEV1/FVC
RISK
Exacerbations
Progressive loss of lung
function
Rx-related adverse effects
Recommended Action
For Treatment
< 2 days/week
< 1/month
none
Not Well
Controlled
> 2 days/week
> 2 x/month
Some limitation
< 2 days/week
> 80% predicted/
personal best
Throughout the day
>2x/week
Extremely limited
> 2 days/week
Several times/day
60-80% predicted/
personal best
<60% predicted/
personal best
> 80% predicted
0- 1 per year
Very Poorly
Controlled
75-80% predicted
2 - 3 per year
<75% pre
> 3 per year
Evaluation requires long-term follow up care
Consider in overall assessment of risk
•Maintain current step
•Step up 1 step
•Consider step down
if well controlled at
least 3 months
•Reevaluate in 2 - 6
weeks
•Consider oral
steroids
•Step up 1-2 steps
and reevaluate in 2
weeks
Recommended Action for Treatment
Based on Assessment of Control
Well
Not Well
Controlled
Controlled
Very Poorly
Controlled
Maintain current step
Step up 1 step and
reevaluate in 2-6
weeks
Consider short course
of oral corticosteroids
Consider step down if
well controlled for at
least 3 months
For side effects,
consider alternative
treatment options
Step up 1-2 steps and
reevaluate in 2 weeks
For side effects,
consider alternative
treatment options
Before stepping up check adherence and environmental control
NAEPP Draft Report, ERP 2007
STEPWISE APPROACH FOR MANAGING ASTHMA IN
EPR-3, p296-304
CHILDREN 5-11 YEARS OF AGE
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 or higher care is required
Consider consultation at step 3
Step 6
Preferred:
High dose ICS
+ LABA
Alternative:
High-dose ICS+
either LTRA
or Theophylline
Preferred:
High-dose ICS
+ LABA + oral
Corticosteroid
Alternative:
High-dose ICS
+either LTRA or
Theophylline
+ oral
corticosteroid
AND
AND
Step 5
Step 4
Step 3
Step 2
Step 1
Preferred:
SABA prn
Preferred:
Medium-dose
ICS
Preferred:
Low-dose ICS
OR
Alternative:
Low-dose ICS+
LTRA
either LABA,
Cromolyn
LTRA, or
Theophylline
Theophylline
Preferred:
Medium-dose
ICS+LABA
Alternative:
Medium-dose
ICS+either
LTRA, or
Theophlline
Consider
Consider
Olamizumab for
Olamizumab for
patients with
patients with
allergies
allergies
Patient Education and Environmental Control at Each Step
Step up if
needed (check
adherence,
environmental
control and
comorbidities)
Assess
Control
Step down
if possible
(asthma well
controlled
for 3
months)
Case # 3
A 7-year old female with asthma reports
nighttime awakenings about 2 times per
week and requires albuterol about 3 times
per week. She is currently taking
fluticasone 44 mcg 2 puffs twice daily. The
BEST next step in your step-up treatment
plan would be to:
A. Increase the dose of the inhaled steroid
B. Add a leukotriene modifier
C. Add a long-acting B-agonist
D. Encourage albuterol more frequently, every 4 hours
Case # 4
A 13-year old girl presents to your office in May
and is currently taking fluticasone 110 mcg 2
puffs twice daily and montelukast 5 mg 1 tablet at
bedtime daily. She denies any report of daytime
or nighttime asthma symptoms for the past 4
months. Her asthma severity classification is:
A. Intermittent Asthma (Step 1)
B. Mild Persistent Asthma (Step 2)
C. Moderate Persistent Asthma (Step 3 or 4)
D. All medications should be immediately discontinued
Classifying Severity for Patients Currently Taking
Controller Medications
Classification of Asthma Severity
Lowest level
of treatment
required to
maintain
control
Intermittent
Persistent
Mild
Moderate
Severe
Step 2
Step 3 or 4
Step 5 or 6
Step 1
NAEPP Draft Report, ERP 2007
EPR-3, Page 72-74
Case # 4
A 13-year old girl presents to your office in May
and is currently taking fluticasone 110 mcg 2
puffs twice daily and montelukast 5 mg 1 tablet at
bedtime daily. She denies any report of daytime
or nighttime asthma symptoms for the past 4
months. Her asthma severity classification is:
A. Intermittent Asthma (Step 1)
B. Mild Persistent Asthma (Step 2)
C. Moderate Persistent Asthma (Step 3 or 4)
D. All medications should be immediately discontinued
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
YOUTHS > 12 YEARS OF AGE AND ADULTS
EPR-3, p77, 345
Classification of Asthma Control
Components of Control
Well Controlled
Symptoms
Nighttime awakenings
IMPAIRMENT
Interference with
normal activity
SABA use
FEV1or peak flow
Validated questionnaires
RISK
ATAQ/ACT
Exacerbations
Progressive loss of lung
function
Rx-related adverse effects
Recommended Action
For Treatment
< 2 days/week
< 2/month
none
Not Well
Controlled
> 2 days/week
1-3/week
Some limitation
< 2 days/week
> 80% predicted/
personal best
0/> 20
0- 1 per year
Very Poorly
Controlled
Throughout the day
> 4/week
Extremely limited
> 2 days/week
Several times/day
60-80% predicted/
personal best
<60% predicted/
personal best
1-2/16-19
3-4/< 15
2 - 3 per year
> 3 per year
Evaluation requires long-term follow up care
Consider in overall assessment of risk
•Maintain current step
•Step up 1 step
•Consider step down
if well controlled at
least 3 months
•Reevaluate in 2 - 6
weeks
•Consider oral
steroids
•Step up 1-2 weeks
and reevaluate in 2
weeks
Recommended Action for Treatment
Based on Assessment of Control
Well
Not Well
Controlled
Controlled
Very Poorly
Controlled
Maintain current step
Step up 1 step and
reevaluate in 2-6
weeks
Consider short course
of oral corticosteroids
Consider step down if
well controlled for at
least 3 months
For side effects,
consider alternative
treatment options
Step up 1-2 steps and
reevaluate in 2 weeks
For side effects,
consider alternative
treatment options
Before stepping up check adherence and environmental control
NAEPP Draft Report, ERP 2007
STEPWISE APPROACH FOR MANAGING ASTHMA IN
EPR-3, p333-343
YOUTHS > 12 YEARS AND ADULTS
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 or higher care is required
Consider consultation at step 3
Step up if
needed (check
Step 6
Step 5
Step 4
Step 3
Step 2
Step 1
Preferred:
SABA prn
Preferred:
Medium-dose
ICS
Preferred:
OR
Low-dose ICS
Low-dose
ICS+
Alternative:
either LABA,
LTRA
LTRA,
Cromolyn
Theophylline
Theophylline
Or Zileutin
Preferred:
Medium-dose
ICS+LABA
Alternative:
Medium-dose
ICS+either
LTRA,
Theophlline
Or Zileutin
Preferred:
High dose ICS
+ LABA
AND
Preferred:
High-dose ICS
+ LABA + oral
Corticosteroid
AND
Consider
Olamizumab for
Consider
patients with
Olamizumab for
allergies
patients with
allergies
Patient Education and Environmental Control at Each Step
adherence,
environmental
control and
comorbidities)
Assess
Control
Step down
if possible
(asthma well
controlled
for 3
months)
Case # 5
A 5-year old male with asthma reports nocturnal
cough 3 nights per week during October through
February, but only 3 nights per month during
March through September. This patient’s asthma
severity can be classified and treated as follows:
A. Moderate Persistent during winter only, Mild
Persistent remainder of the year
B. Moderate Persistent year-round in order to prevent
winter exacerbations
C. Mild Persistent year-round in order to prevent longterm decrease in lung function
D. This patient does not have asthma but is at highrisk for frequent upper respiratory tract infections
with the change of seasons
Summary of the
EPR-3, Page 36-38
New Strategies of the EPR-3
Assessment
Management
Severity
the intrinsic intensity of
the disease
a clinical guide most useful
for initiating controller
therapy
Control
the degree to which
symptoms are
minimized
(after therapy is initiated) a
clinical guide used to
maintain or adjust therapy
Responsiveness
the ease of which
(variable) frequent follow-up
prescribed therapy
to step-up and step-down
achieves asthma control therapy to achieve the goal
of control
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
CHILDREN 5 - 11 YEARS OF AGE
EPR-3, p73, 308
Classification of Asthma Severity
Components of
Severity
Impairment
Intermittent
Mild
Severe
Symptoms
<2 days/week
>2 days/week not daily
Daily
Nighttime
Awakenings
<2x/month
3-4x/month
>1x/week
SABA use for sx
control
<2 days/week
>2 days/week not daily
Daily
Several times daily
Interference with
normal activity
none
Minor limitation
Some limitation
Extremely limited
not nightly
•Normal FEV1 between
exacerbations
Lung Function
• FEV1 > 80%
• FEV1 >80%
•FEV1/FVC> 80%
• FEV1/FVC> 85%
Exacerbations
Risk
Persistent
Moderate
(consider
frequency and
severity)
0-2/year
•FEV1/FVC=75%
-80%
Often nightly
•FEV1 <60%
•FEV1/FVC <
75%
> 2 /year
Frequency and severity may vary over time for patients in any category
Relative annual risk of excaerbations may be related to FEV
Step 1
Recommended Step for
Initiating Treatment
• FEV1=60% 80%
Continuous
Step 2
Step3
medium- Step 3 or 4
dose ICS option
Consider short course of oral steroids
In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy
ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN
CHILDREN 5 - 11 YEARS OF AGE
EPR-3, p76, 310
Classification of Asthma Control
Components of Control
Well Controlled
Symptoms
Nighttime awakenings
IMPAIRMENT
Interference with
normal activity
SABA use
FEV1or peak flow
FEV1/FVC
RISK
Exacerbations
Progressive loss of lung
function
Rx-related adverse effects
Recommended Action
For Treatment
< 2 days/week
< 1/month
none
< 2 days/week
> 80% predicted/
personal best
Not Well
Controlled
> 2 days/week
Throughout the day
> 2 x/month
>2x/week
Some limitation
Extremely limited
> 2 days/week
Several times/day
60-80% predicted/
personal best
<60% predicted/
personal best
> 80% predicted
0- 1 per year
Very Poorly
Controlled
75-80% predicted
2 - 3 per year
<75% pre
> 3 per year
Evaluation requires long-term follow up care
Consider in overall assessment of risk
•Maintain current step
•Step up 1 step
•Consider step down
if well controlled at
least 3 months
•Reevaluate in 2 - 6
weeks
•Consider oral
steroids
•Step up 1-2 weeks
and reevaluate in 2
weeks
Case # 5
A 5-year old male with asthma reports nocturnal
cough 3 nights per week during October through
February, but only 3 nights per month during
March through September. This patient’s asthma
severity can be classified and treated as follows:
A. Moderate Persistent during winter only, Mild
Persistent remainder of the year
B. Moderate Persistent year-round in order to prevent
winter exacerbations
C. Mild Persistent year-round in order to prevent longterm decrease in lung function
D. This patient does not have asthma but is at highrisk for frequent upper respiratory tract infections
with the change of seasons
Case # 6
A spacer device can be equally as effective as,
and perhaps more effective than, a nebulizer
machine in the delivery of inhaled medication.
(circle one) TRUE or FALSE
Case # 6
A spacer device can be equally as effective as,
and perhaps more effective than, a nebulizer
machine in the delivery of inhaled medication.
(circle one) TRUE or FALSE
Case # 7
Referral to an asthma specialist for
consultation and co-management should
be sought when a patient:
A. Is hospitalized twice in the past year or once in
the past month
B. Requires more than two bursts of oral
corticosteroids in one year
C. Requires “Step 3” care or higher or is not
responding to a treatment plan that is appropriate
for patient with “Moderate Persistent Asthma”
D. All of the above
Case # 7
Referral to an asthma specialist for
consultation and co-management should
be sought when a patient:
A. Is hospitalized twice in the past year or once in
the past month
B. Requires more than two bursts of oral
corticosteroids in one year
C. Requires “Step 3” care or higher or is not
responding to a treatment plan that is appropriate
for patient with “Moderate Persistent Asthma”
D. All of the above