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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