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Clinical Guideline for the Diagnosis, Evaluation and Management of Adults and Children with Asthma

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Clinical Guideline for the Diagnosis, Evaluation and Management of Adults and Children with Asthma Clinical Guideline for the Diagnosis, Evaluation and Management of Adults and Children with Asthma Color Key n Four Components of Asthma Care n Classifying Asthma Severity, Assessing Asthma Control and the Stepwise Approach for Managing Asthma in Children Aged 0– 4 years n Classifying Asthma Severity, Assessing Asthma Control and the Stepwise Approach for Managing Asthma in Children Aged 5–11 years n Classifying Asthma Severity, Assessing Asthma Control and the Stepwise Approach for Managing Asthma in Children >12 Years of Age & Adults n Long-Term Control Medications: Estimated Comparative Daily Dosages n Long-Term Control Medications: Usual Dosages n Quick-Relief Medications Guidelines are intended to be flexible. They serve as recommendations, not rigid criteria. Guidelines should be followed in most cases, but depending on the patient, and the circumstances, guidelines may need to be tailored to fit individual needs. 4750 11/18 Contents Criteria that suggest the diagnosis of asthma . 3 Goal of Therapy: Control of Asthma . 3 Four Components of Asthma Care 1. Assessment and Monitoring of Asthma Severity and Control . 4 2. Education for a Partnership in Care . 5 3. Control of Environmental Factors and Co-morbid Conditions that Affect Asthma . 5 4. Medications . 6 Bibliography . 6 Classifying Asthma Severity & Initiating Treatment in Children 0– 4 Years of Age . 7 Assessing Asthma Control & Adjusting Therapy in Children 0– 4 Years of Age . 7 Stepwise Approach for Managing Asthma in Children 0– 4 Years of Age . 8 Classifying Asthma Severity & Initiating Treatment in Children 5–11 Years of Age . 9 Assessing Asthma Control & Adjusting Therapy in Children 5–11 Years of Age . 9 Stepwise Approach for Managing Asthma in Children 5–11 Years of Age . 10 Classifying Asthma Severity & Initiating Treatment in Youths >12 Years of Age & Adults . 11 Assessing Asthma Control & Adjusting Therapy in Youths >12 Years of Age & Adults . 11 Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults . 12 Medication Charts Long-Term Control Medications Estimated Comparative Daily Doses for Inhaled Corticosteroids . 13 Long-Term Control Medications Usual Doses for Long-Term Control Medications . 14 Quick-Relief Medications Usual Doses for Quick-Relief Medications . 15 Acknowledgements . 16 2 Criteria that suggest the Goal of Therapy: diagnosis of asthma: Control of Asthma Consider a diagnosis of asthma and perform spirometry if any Reduce Impairment of these indicators are presen t*: zPrevent chronic and troublesome symptoms (e.g., cough - zThe symptoms of dyspnea, cough and/or wheezing, ing or breathlessness in the daytime, in the night, or after especially nocturnal, difficulty breathing or chest tightness; exertion). zWith acute episodes: hyperinflation of thorax, decreased zRequire infrequent use (<2 days a week) of inhaled short- breath sounds, high pitched wheezing, and use of acting beta 2-agonist (SABA) for quick relief of symptoms accessory muscles; (not including prevention of exercise-induced bron - zSymptoms worsen during exercise or in presence of viral chospasm [EIB ]). infections, inhaled allergens, irritants, weather changes, zMaintain (near) normal pulmonary function. strong emotional response, stress, menstrual cycles; zMaintain normal activity levels (including exercise and z Reversible airflow obstruction: FEV 1>12% from baseline or other physical activity and attendance at school or work). increase in FEV >10% of predicted after inhalation of 1 zMeet patients’ and families’ expectations of and bronchodilator, if able to perform spirometry; satisfaction with asthma care. zAlternative diagnoses are excluded; see Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Reduce Risk Asthma – Summary Report 200 7. NIH Publication No 08- zPrevent recurrent exacerbations of asthma and minimize 5846, October 2007, page 12 (www.nhlbi.nih.gov/files/ the need for emergency department (ED) visits or docs/guidelines/asthsumm.pdf ). hospital izations. zPrevent loss of lung function; for children, prevent *Eczema, hay fever, and/or a family history of asthma or atopic reduced lung growth. diseases are often associated with asthma, but they are not key zProvide optimal pharmacotherapy with minimal or no indicators. adverse effects of therapy. 3 Four Components of Asthma Care 1. Assessment and Monitoring of Acute exacerbation asthma visit zDo not underestimate the severity of an exacerbation. Severe exacerba - Asthma Severity and Control tions can be life threatening and can occur in patients at any level of asthma severity or control. Assessment and monitoring of asthma are tied to the concepts of severity, zAssess severity and control and consider co-morbid conditions. For emer - control and responsiveness and the domains of impairment and risk. gency asthma exacerbations, see Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma – Summary Report 2007. For assessing asthma severity and asthma control by impairment NIH Publication No 08-5846, October 2007, page 53 and risk, see age-specific charts. (www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf ). zPerform spirometry for patients >5 years during periods of loss of asthma Components of Asthma Assessment control. zPrescribe appropriate pharmacological therapy based on assessment of Medical history and physical exam: severity and control (See age specific stepwise chart) . zProvide a rescue plan of systemic corticosteroids or other medications if zAssess and document asthma severity and control, including impairment needed for acute exacerbations at any step. and risk domains. zCheck patient’s inhaler, spacer/holding chamber, and peak flow technique. z > Spirometry recommended for patients 5 years: zReview symptom/peak flow monitoring. (1) at time of initial assessment; (2) after treatment has begun and zProvide education, emphasizing medication adherence and medication symptoms and peak expiratory flow (PEF) have stabilized; (3) during administration technique. periods of loss of asthma control and (4) at least every 1–2 years. zReview methods of reducing exposure to relevant allergens and irritants. zIdentify or review triggers and precipitating factors z (e.g. allergens, exercise, upper respiratory infection, tobacco smoke, Update and review written Asthma Action Plan. chemicals, weather, strong emotions). zMonitor closely until control is achieved. zAssess family, psychosocial, occupational history including stressors. zAssess medication use, including CAM*. At every visit, review Referrals beta-agonist use. zAssess for co-morbidities (rhinitis, sinusitis, GERD**, obesity, ABPA***, Asthma Specialist OSA****, stress or depression). Consider referral to asthma specialist zConduct physical exam focusing on upper and lower airways, nose such as an allergist or pulmonologist when: and skin. zPatient has had a life-threatening asthma exacerbation; zAssess impact of asthma on patient and family, patient and family zPatient is not meeting the goals of asthma therapy after 3– 6 months perception of disease, and knowledge and skills for self-management. of treatment. An earlier referral or consultation is appropriate if the * complementary alternative medication, * * gastroesophageal reflux disease, physician concludes that the patient is unresponsive to therapy; ** * allergic bronchopulmonary aspergillosis, *** * obstructive sleep apnea zSigns and symptoms are atypical, or there are problems in differential diagnosis; zOther conditions complicate asthma or its diagnosis, e.g., sinusitis, nasal polyps, ABPA, severe rhinitis, vocal cord dysfunction (VCD), GERD, Recommended Approach to Care Management chronic obstructive pulmonary disease (COPD); zAdditional diagnostic testing is indicated (e.g., allergy skin testing, Initial asthma visit rhinoscopy, complete pulmonary function studies, provocative challenge, bronchoscopy); zAssess severity using both the impairment and risk domains z (See Classifying Asthma Severity and Initiating Treatment in specific age charts). Patient requires additional education and guidance on complications of therapy, problems with adherence, or allergen avoidance; zPerform spirometry measurement (FEV , FVC, FEV /FVC) in all patients 1 1 z >5 years old before and after the patient inhales a SABA. Patient is being considered for immunotherapy; z zAssess skills for self-management, including medication administration Patient requires step 4 care or higher (step 3 for children 0 –4 years of age). technique. Consider referral if patient requires step 3 care (step 2 for children 0– 4 years of age) (See age specific stepwise charts) ; zPrescribe appropriate pharmacological therapy based on severity z assessment (See age-specific stepwise chart). Patient has required more than two bursts of oral corticosteroids in 1 year or has an exacerbation requiring hospitalization; zDevelop and review Asthma Action Plan and provide education. zPatient requires confirmation of a history that suggests that an occupation - zMonitor at least at 2– 6 week intervals until control is achieved. al or environmental inhalant or ingested substance is provoking or con - tributing to asthma. Depending on the complexities of diagnosis, treat - Chronic maintenance asthma visit ment, or the intervention required in the work environment, it may be appropriate in some cases for the specialist to manage the patient over a zAssess asthma control based on impairment and risk period of time or to co-manage with the primary care provider (PCP).
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