Download PCCP Council on Asthma

PCCP Council on Asthma
Classification of Chronic Asthma Severity
on Treatment
Domains/Estimates
Intermittent
Persistent
Mild to
Moderate
Severe**
Daytime symptoms
Monthly
Weekly
Daily
Nocturnal
awakening
Less than
monthly
Monthly to
weekly
Nightly
Rescue 2 agonist
use
Less than weekly Weekly to daily
PEF or FEV1*
> 80 % predicted
60 to 80 % of
predicted
< 60 % of
predicted
Treatment needed
to control asthma
Occasional prn
2 only
Regular ICS +
LABA
combination
Combination
ICS + LABA +
OCS
Several times a
day
*Objective measures take precedence over subjective complaints. The higher severity level of any domain will be the basis of the final severity level.
**Patients who are high risk for asthma-related deaths are initially classified here
PCRADM 2004
PCCP Council on Asthma
Controller Medications








Inhaled glucocorticosteroids
Long-acting inhaled β2-agonists
Systemic glucocorticosteroids
Leukotriene modifiers
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(Sustained Release) Theophylline
Cromones
Long-acting oral β2-agonists
Anti-IgE
PCCP Council on Asthma
Reliever Medications
Rapid-acting inhaled β2-agonists
 Systemic glucocorticosteroids
(acute setting)
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 Anticholinergics
 Theophylline
 Short-acting oral β2-agonists

Assessing
Control
PCCP Council on Asthma
Levels of Asthma Control
Partly controlled
Characteristic
Controlled
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 of more/year
(Any present in any week)
Uncontrolled
3 or more
features
of partly
controlled
asthma
present in
any week
One in any week
GINA. 2007. Available at: http://www.ginaasthma.org
PCCP Council on Asthma
Controlled
Uncontrolled
Exacerbation
Reduce
Increasee
Partly Controlled
Reduce
Level of Control
Treatment Action
Treating to
achieve Control
Maintain and find lowest controlling step
Consider stepping up to gain control
Step up until controlled
Treat as exacerbation
Increase
Treatment Steps (in the order of increasing efficacy to attain control)
Step 1
Step 2
Step 3
Step 4
Step 5
Asthma Education / Environmental Control
As needed rapidacting ß2-agonist
As needed rapid-acting ß2-agonist
Select One
Select One
Add one or more
Add one or more
Low-dose
Low dose
ICS
ICS+LABA
Medium or highdose
Oral
glucocorticosteroid
(lowest dose)
Medium or high-dose
ICS
Leukotriene
modifier
Controller
Options
Leukotriene
modifier
Low-dose ICS plus
Leukotriene modifier
Low dose ICS plus
sustained release
theophylline
ICS+LABA
Sustained release
theophylline
Anti IgE treatment
GINA. 2007. Available at: http://www.ginaasthma.org.
PCCP Council on Asthma
Treatment Steps (in the order of increasing efficacy to attain control)
Increase
Step 1
Reduce
Step 2
Step 3
Step 4
Step 5
Asthma Education / Environmental Control
As needed rapidacting ß2-agonist
As needed rapid-acting ß2-agonist
Select One
Select One
Add one or more
Add one or more
Low-dose
Low dose
ICS
ICS+LABA
Medium or highdose
Oral
glucocorticosteroid
(lowest dose)
Medium or high-dose
ICS
Leukotriene
modifier
Controller
Options
Leukotriene
modifier
Low-dose ICS plus
Leukotriene modifier
Low dose ICS plus
sustained release
theophylline
ICS+LABA
Sustained release
theophylline
Anti IgE treatment
In the local setting, for the majority of
GINA. 2007. Available at: http://www.ginaasthma.org.
symptomatic patients, the consensus is to
start at step 3, with low doses of a fixeddose ICS+LABA combination inhaler.
PCCP Council on Asthma
Single inhaler maintenance and relief
therapy strategy

If a combination inhaler containing formoterol
and budesonide is selected, it may be used for
both rescue and maintenance.
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
This approach has been shown to result in :
 Reductions in exacerbations
 Improvements in asthma control in adults and
adolescents at relatively low doses of treatment
(Evidence A)
PCCP Council on Asthma
Treating to Achieve Asthma Control
Additional Step 3 Options for Adolescents
and Adults :
 Increase to medium-dose inhaled glucocorticosteroid (Evidence A)P
 Low-dose inhaled glucocorticosteroid
combined with leukotriene modifiers
(Evidence A)
 Low-dose sustained-release theophylline (Evidence B)
PCCP Council on Asthma
Treating to Achieve Asthma Control

Asthma control should be monitored by the
health care professional & by the patient.

Improvement begins within days of initiating
controller treatment but the full benefit may only
be evident after 3 to 4 months
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
When control as been achieved, ongoing
monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
PCCP Council on Asthma
Monitoring to
maintain
Control
Low-dose ICS
Decrease to
Once daily
dosing
Stepping Down Treatment
when Asthma is Controlled
Med to high-dose ICS
ICS-LABA
Reduce by 50 %
Every 3 months
Reduce ICS by 50 %
Maintain LABA dose
Decrease to
Once daily
dosing
Further reduce ICS dose or
Stop LABA and
continue ICS or
Decrease ICS-LABA
to Once daily dosing
PCCP Council on Asthma
Stepping Up Treatment in Response
to Loss of Control

Treatment has to be adjusted periodically in
response to worsening control which may be
recognized by the minor recurrence or worsening
of symptoms
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
Treatment options :
 Rapid-onset, short-acting or long-acting
bronchodilators : repeated dosing provides
temporary relief
 A four-fold or greater increase in inhaled glucocorticosteroids
PCCP Council on Asthma
Algorithmic Approach to
Asthma Assessment and Management
Patient with Asthma
presenting with
symptoms
In Acute
exacerbation ?
Yes
Classify and Treat based on
Severity Classification of
Asthma in Acute Exacerbation
No
Currently on
Controller
Medications?
Yes
Assess level of
control
Partly controlled?
Yes
Go 1 step
higher
No
Poorly or
uncontrolled?
No
Controller
medication naive
?
Yes
Classify according
to PCRADM
Chronic Severity
Classified as
Severe ?
No
Treat as
Mild-to-Moderate
Persistent Asthma
Yes
Yes
Go 2 steps
higher
Treat as Severe
Persistent
Asthma
PCCP Council on Asthma
Asthma Exacerbations

Episodes of progressive worsening of SOB, cough,
wheezing or chest tightness or some combination of
these symptoms

Significant decreases in PEFP or FEV1 which are more
reliable indicators of severity of airflow obstruction than
degree of symptoms

Range from mild to life-threatening deterioration usually
progresses over hours or days, or precipitously over
some minutes
PCCP Council on Asthma
Severity of Asthma Exacerbations
Breathless
Talks in
Alertness
Respiratory rate
Accessory
muscles &
suprasternal
retractions
Wheeze
Pulse/min
Pulsus paradoxus
PEF after initial
BD
% predicted or
% personal best
PaO2
and/or PaCO2
SaO2
Mild
Moderate
Severe
Walking
Talking
At rest
Sentences
Phrases
Words
May be agitated
Usually agitated
Usually agitated
Increased
Increased
Often > 30/min
Respiratory
arrest
imminent
Drowsy or
confused
Usually not
Usually
Usually
Paradoxical
thoracoabdominal
movement
Moderate, often only
end-expiratory
Loud
Usually loud
Absence of
wheeze
<100
100 - 120
> 120
Bradycardia
Absent
< 10 mmHg
May be present
10-25 mmHg
Often present
> 25 mmHg
Approx 60 – 80 %
< 60 % predicted or
personal best
(<100/min or response
lasts 2 hrs
Over 80 %
Normal
< 42 mmHg
< 42 mm Hg
< 60 mmHg
Possible cyanosis
> 42 mmHg
Possible resp failure
> 95 %
91 – 95 %
< 90 %
PCCP Council on Asthma
Features of Patients at high-risk for
Asthma-Related Death
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

Current use of or recent withdrawal from systemic
corticosteroids
ER visit for asthma in the past year
History of near-fatal asthma requiring intubation or
mechanical intubation
P
Not currently using inhaled steroids
Overdependence on rapid acting inhaled 2 agonists, esp. those
with more than one canister monthly
Psychiatric disease or psychosocial problems, incl. the use of
sedatives
Noncompliance with asthma medication plan
PCCP Council on Asthma
Management of Asthma Exacerbations

Primary therapies for exacerbations:
 Repetitive administration of rapid-acting
inhaled β2-agonist
 Early introduction of Psystemic
glucocorticosteroids
 Oxygen supplementation

Closely monitor response to treatment
with serial measures of lung function
PCCP Council on Asthma
Criteria for hospitalization
Inadequate response to therapy within 1-2 hours
 Persistent PEF <50% after 1 hour of treatment
 Presence of risk factors
 Prolonged symptoms prior to ER consult
P
 Inadequate access to medical
care and
medications
 Difficult home condition
 Difficulty in obtaining transport to hospital in
event of further deterioration

PCCP Council on Asthma
Asthma Exacerbations &
Hospitalization
• Despite appropriate therapy, ~ 10 to 25 % of ER
patients with acute asthma will require
hospitalization.
P
• Response to initial treatment
in the ER is a better
predictor of the need for hospitalization than is
severity on presentation
• FEV1 or PEF appears to be more useful in adults
for categorizing severity of exacerbation &
response to treatment.
PCCP Council on Asthma
Management of Acute Exacerbations : Hospital Setting
Initial Assessment :
History, PE, PEF or FEV1, SaO2
PEF or FEV1 ≥ 40 % predicted
•Oxygen to achieve SaO2 ≥ 90%
•Inhaled SABA by nebulizer or MDI
with valve holding chamber
up to 3 doses in 1st hour
PEF or FEV1  40 % predicted
•Oxygen to achieve SaO2 ≥ 90%
•High-dose inhaled SABA +
ipratropium by nebulizer or MDI with
valve holding chamber every 20 min
or continuously for 1 hour
Impending or actual respiratory
arrest
•Intubation and mechanical ventilation
with 100% O2
•Nebulized SABA and ipratropium
•Intravenous corticosteroids
•Consider adjunct therapies
Admit to hospital intensive care
Repeat Assessment:
PE, PEF, SaO2 , other tests as needed
Moderate Episode:
Severe Episode:
PEF or FEV1 =40 – 69 % predicted or personal best
PEF or FEV1 < 40 % predicted or personal best
• PE : Severe symptoms at rest, accessory muscle use, chest
retraction
• History : high-risk for asthma- related death
• No improvement after initial treatment
•Treatment :
•Oxygen
• NebulizedSABA + ipratropium hourly or continuous
• Oral systemic corticosteroids
• Consider adjunct therapies
• PE : Moderate symptoms
•Treatment :
•Inhaled SABA every 60 minutes
•Oral systemic corticosteroids
•Continue treatment 1-3 hrs provided there is
improvement ; make decision in < 4 hrs
PCCP Council on Asthma
Management of Acute Exacerbations : Hospital Setting
Moderate Episode
Good Response
Response sustained for 1 hr
after last treatment
No risk factors
• S/Sx : No distress, normal PE
• PEF > 70 % predicted or personal best
• SaO2 > 90 %
Severe Episode
Incomplete Response
within 1 hr &/or (+) risk factors
within 1 hr &/or (+) risk factors
• S/Sx : severe, drowsiness, confusion
•S/Sx : Mild to moderate
• PEF > 50 % but < 70 % predicted
or personal best
• SaO2 not improving
• PEF < 30 % predicted or personal best
• ABG : paCO2 > 45 mm Hg
paO2 < 60 mm Hg
Admit to ICU:
Discharge Home
• Continue inhaled SABA q 3-4 hrs
(or oral  2- agonist or theophylline)
• Continue oral steroids
• Patient education
Poor Response
Admit to Hospital
Improved
• PEF > 70 %
• Sustained on meds
Discharge Home
• Continue inh SABA + inh. anti-cholinergic
•
•
•
•
•
Not Improved
within 6 – 12 hrs
Admit to ICU
Consider SQ,IV, or IM  2- agonist
IV steroids
IV aminophylline
Continue oxygen
Possible intubation/ mechanical ventilation
PCCP Council on Asthma
Asthma Action Plan
Name:____________________________________________________Date of issue:___________________
My Dr.:___________________________________________________Tel #: _________________________
Clinic Address:___________________________________________________________________________
Chronic Asthma Severity
Mild, intermittent
Moderate, persistent
PEF: Personal best (done ___/___/___): _______liters/min
PEAK FLOW
STATUS
Mild, persistent
Severe, persistent
Predicted: ________liters/min
ACTION
GOOD CONTROL
(GREEN )
ZONE
Continue my present treatment:
Regular controller/s:___________________________
___________________________
As needed reliever: ___________________________
Visit my doctor on next appointment :_____________
60-80% of predicted or
personal best
From:______________
To: ______________
WARNING
(YELLOW)
ZONE
Add or double the dose of
controller drug :_____________________________
Take reliever regularly:________________________
As needed reliever; (inhaled):___________________
*If improved (back to green zone), continue
maintenance drugs for 3 days.
*If unimporved, visit my doctor as soon as possible.
Below 60 % pred or
personal best
Below: ____________
DANGER
(RED)
ZONE
Take Prednisone _____tablets every ________hrs
Take reliever regularly:________________________
+ as needed reliever (inhaled):__________________
*Once improved, follow the yellow or green zone
instructions
Call or see my doctor immediately
Below 50 % pred or
personal best
Below:____________
EMERGENCY
(RED)
ZONE
80 % of predicted or
personal best
Above:____________
GO DIRECTLY TO HOSPITALor call ambulance
Take Prednisone ___________ tablets now
or ____________________
TAke 2 puffs of inhaled reliever every 10-15 mins on the way
to hospital
Thank you for your attention!
P