1. National Institutes of Health (NIH) NAEPP 2007 Asthma Guideline UPDATE
Susan K. Ross RN, AE-C
MDH Asthma Program

2. Guidelines for the Diagnosis and Management of Asthma (EPR-3)
National Institutes of Health National Asthma Education Prevention Program (NAEPP)
2007
Guidelines for the Diagnosis and Management of Asthma (EPR-3)
National Asthma Education and Prevention Program

3. School Nurses
“School nurses are an important component of the health care system for children and play a critical role in identifying solutions to the health problems faced by today’s children and families”.
The Journal of School Nursing, June 2007, Vol.23, Num. 3

4. What Is Asthma?
“Asthma is a common chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation. This interaction can be highly variable among patients and within patients over time”.
2007 NAEPP Guidelines, EPR 3- Section 2, p 12.

5. Characteristics of Asthma
Airway Inflammation
Airway Obstruction (reversible)
Hyperresponsiveness (irritability of airways)

6. Normal & Asthmatic Bronchiole
During an “asthma episode,” muscles around the airways tighten, linings of the airways (bronchioles) become inflamed, and mucus clogs the tiny airways, making breathing difficult.
The airways become overly responsive (twitchy) to environmental changes, sometimes resulting in wheezing, coughing, breathlessness, or tightness in the chest.
During an asthma episode a child may feel he/she can't inhale enough air, but actually, the child’s lungs are having trouble exhaling. Continued exposure and/or lack of treating the inflammation results in preventing O2/CO2 exchange.
Untreated, the inflammation can cause recurrent episodes of wheezing, coughing, breathlessness, and chest tightness, especially at night / early morning
Potentially, airway remodeling (a type of lung scarring which is permanent) can occur when asthma goes untreated.

7. Why Do We Need Asthma Guidelines?

8. Asthma: Accounts for 12.8 million lost school days annually 1 (2003)
67% of US children with asthma have had at least one attack in the past year 1 (2005)
Is the 3rd leading cause of hospitalizations among children under 15 2
Close to 1 in 11 (8.9%) children have asthma (2005)
6.5 million children under 18 have asthma 1
1 National Health Interview Survey; Asthma Prevalence, Health Care Use, and Mortality, , National Center for Health Statistics, CDC
2 National Hospital Discharge Survey, 2002; American Lung Association Asthma and Children Fact Sheet, August 2006

9. Current asthma prevalence (%)
Age
Current asthma prevalence (%)
Deaths per 1,000,000
0-4 yrs
6.2
2.0
5-10 yrs
9.3
2.3
11-17 yrs
10.0
3.3
Total
8.7
2.6
Data here is presented as current asthma prevalence by percent and deaths per million.
Adapted from Akinbami L. Advance Data 2006

10. 2 to 3 students WILL have asthma
This means..
In a class of 30 children, you can expect
2 to 3 students WILL have asthma
This number will vary depending on age and geographical location

11. “Children & Asthma In America” Survey - 2004
The Children and Asthma in America survey focused on children 4 to 18 years of age with asthma, which represents about 5.8 million children in the country based on figures from the 2002 National Health Interview Survey.
A survey of a national probability sample of 801 children 4 to 18 years of age who currently have asthma, conducted from February to May 2004.
The survey found that nearly 1 out of 10 (9.2%) American children 18 years of age and younger currently suffer from asthma.
The Children and Asthma in America survey concludes that a significant number of children with asthma do not have their condition under control, falling far short of national treatment goals.
Excerpts taken from “Children & Asthma in America”, 2004 Glaxo-SmithKline

12. 2007 - Guidelines For The Diagnosis & Management Of Asthma
Expert Review Panel (EPR-3)

13. Asthma Guidelines: History and Context
Initial guidelines released in 1991 and updated in 1997
Updated again in 2002 (EPR-2) with a focus on several key questions about medications, monitoring and prevention.
Long-term management of asthma in children
Combination therapy
Antibiotic use
Written asthma action plans (AAP) and peak flow meters (PFM)
Effects of early treatment on the progression of asthma

14. Old and New Asthma Guidelines: What Has NOT Changed
Initial asthma therapy is determined by assessment of asthma severity.
Ideally, before the patient is on a long-term controller.
Stepping therapy up or down is based on how well asthma is controlled or not controlled .
Inhaled corticosteroids (ICS) are the preferred first-line therapy for asthma.
Systemic steroids can still be used to treat asthma exacerbations.
Peak flows and written asthma action plans are recommended for asthma self management .
Especially in moderate and severe persistent asthma, or those with a history of severe exacerbations or poorly controlled asthma.

15. Asthma Therapy Goals
“The goal of asthma therapy is to control asthma so patients can live active, full lives while minimizing their risk of asthma exacerbations and other problems”
Dr. William Busse, MD., chairman of the NAEPP EPR -3
Read slide

16. 2007 - Guidelines For The Diagnosis & Management of Asthma (EPR-3)
(Almost) no new medications.
Restructuring into “severity” and “control” .
Domains of “impairment” and “risk”.
Six treatment steps (step-up/step-down).
More careful thought into ongoing management issues.
Summarizes extensively-validated scientific evidence that the guidelines, when followed, lead to a significant reduction in the frequency and severity of asthma symptoms and improve quality of life.

17. New Strategies of the EPR-3 Summary
EPR-3, Page 36-38

18. Key Points: Definition, Pathophysiology & Pathogenesis
Asthma is a chronic inflammatory disorder of the airways.
The immunohistopathologic features of asthma include inflammatory cell infiltration.
Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity.
In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis. (remodeling)
Section 2:
Immunohistopathologic – features are Neutrophils (especially in sudden onset, fatal asthma exacerbations, occupational asthma and patients who smoke)
Eosinophils, Lymphocytes, Mast cell activation, Epithelial cell injury.
Angiogenesis - the formation and development of blood vessels

19. Key Points: Continued..
Gene-by-environment interactions are important to the expression of asthma.
Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma.
Viral respiratory infections are one of the most important causes of asthma exacerbation and may also contribute to the development of asthma.
EPR 3, Section 2: Page 11

20. Key Differences from 1997 & 2002 Reports
The critical role of inflammation is validated - there is considerable variability in the pattern of inflammation indicating phenotypic differences that may influence treatment responses. (in other words – genetics)
Gene-by-environmental interactions are affect the development of asthma. Of the environmental factors, allergic reactions are important. Viral respiratory infections are key and have an expanding role in these processes.
The onset of asthma for most patients begins early in life with the pattern of disease persistence determined by early, recognizable risk factors including atopic disease, recurrent wheezing, and a parental history of asthma.
Current asthma treatment with anti-inflammatory therapy does not appear to prevent progression of the underlying disease severity.
EPR 3 – section 2, p. 12

21. Causes – We Don’t Know…Yet!
Asthma has dramatically risen worldwide over the past decades, particularly in developed countries, and experts are puzzled over the cause of this increase.
Not all people with allergies have asthma, and not all cases of asthma can be explained by allergic response.
Asthma is most likely caused by a convergence of factors that can include genes (probably several) and various environmental and biologic triggers (e.g., infections, dietary patterns, hormonal changes in women, and allergens).

22. The 4 Components Of Asthma Management - (Section 3)
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

23. Measures of Asthma Assessment & Monitoring
Component 1
Measures of Asthma Assessment & Monitoring

24. Key Points - Overview: Measures Of Asthma Assessment & Monitoring
Assessment and monitoring are closely linked to the concepts of severity, control, and responsiveness to treatment:
Severity - intensity of the disease process. Severity is measured most easily and directly in a patient not receiving long-term-control therapy.
Control - degree to which asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met.
Responsiveness - the ease with which asthma control is achieved by therapy.
EPR -3 , Pg. 36, Section 3, Component 1: Measures of Asthma Assessment and Monitoring

25. Key Points – Cont. 2 Severity & Control Are Assessed Based On 2 Domains
Impairment (Present):
Frequency and intensity of symptoms
Functional limitations (quality of life)
Risk (Future):
Likelihood of asthma exacerbations or
Progressive loss of lung function (reduced lung growth)
Risk of adverse effects from medication
EPR -3, Pg ,

26. Key Points - Cont. 3 Severity & Control are used as follows for managing asthma:
If the patient is not currently on a long-term controller at the first visit:
Assess asthma severity to determine the appropriate medication & treatment plan.
Once therapy is initiated, the emphasis is changed to the assessment of asthma control.
The level of asthma control will guide decisions either to maintain or adjust therapy.

27. Key Differences: Component 1 - Overview
The key elements of assessment and monitoring include the concepts of severity, control, and responsiveness to treatment:
Classifying severity for initiating therapy.
Assessing control for monitoring and adjusting therapy.
Asthma severity and control are defined under domains of impairment and risk.
The distinction between the domains of impairment and risk for assessing severity and control emphasizes the need to consider separately asthma’s effects on quality of life and functional capacity on an ongoing basis and the risks it presents for adverse events in the future, such as exacerbations and progressive loss of pulmonary function.

28. Assessing Impairment (Present) Domain
Assess by taking a careful, directed history and lung function measurement.
Assess Quality of Life using standardized questionnaires
Asthma Control Test (ACT)
Childhood Asthma Control Test
Asthma Control Questionnaire
Asthma Therapy Assessment Questionnaire (ATAQ) control index.
Some patients, appear to perceive the severity of airflow obstruction poorly.

29. Assessing Risk (Future) Domain
Of adverse events in the future, especially of exacerbations and of progressive, irreversible loss of pulmonary function—is more problematic (airway remodeling).
The test most used for assessing the risk of future adverse events is spirometry.

30. Measures of Assessment & Monitoring
Diagnosis

31. Key Points – Diagnosis of Asthma
To establish a diagnosis of asthma the clinician should determine that:
Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present.
Airflow obstruction is at least partially reversible.
Alternative diagnoses are excluded.
Recommended methods to establish the diagnosis are:
Detailed medical history.
Physical exam focusing on the upper respiratory tract, chest, and skin.
Spirometry to demonstrate obstruction and assess reversibility, including in children 5 years of age or older.
Additional studies to exclude alternate diagnoses.

32. Key Differences – Diagnosis
Discussions added on use of spirometry, especially in children and on criteria for reversibility.
Information added on vocal cord dysfunction and cough variant asthma as alternative diagnosis.
References added about conditions that complicate diagnosis and treatment EPR -3, Sec.3, Pg. 41

33. Key Indicators: Diagnosis of Asthma
Wheezing – high-pitched whistling sounds when breathing out.
History of (any):
Cough, worse particularly at night
Recurrent wheeze
Recurrent difficulty in breathing
Recurrent chest tightness
Symptoms occur or worsen in the presence of known triggers.
Symptoms occur or worsen at night awakening patient.

34. Characterization & Classification of Asthma
SEVERITY

35. Key Points - Initial Assessment: Severity
Once diagnosis is established:
Identify precipitating factors (triggers).
Identify comorbidities that aggravate asthma
Assess patient’s knowledge & skills for self-management.
Classify severity using impairment & risk domains.
Pulmonary function testing (spirometry) to assess severity EPR -3, Sec. 3, pg. 47
Now that the diagnosis has been made you need to determine other factors affecting the patient..what triggers are causing their symptoms and how do you eliminate/ avoid them.
What other diseases or symptoms does the patient have that may aggravate their asthma
How much does the patient or their parent know about asthma and what is their ability to successfully manage those symptoms?
The 2 areas of impairment and risk require asking questions of the patients symptoms and effects of medications
Order PFT’s/ spirometry if it has not been done already. A PFM is not an appropriate diagnostic tool btw – it is for home monitoring for the patient only.

36. Key Differences – Initial Assessment & Severity
Severity class for asthma changed mild intermittent to intermittent.
Severity class is defined in terms of 2 domains – impairment & risk .
New emphasis on using FEV1 /FVC is added to classify severity in children because it may be a more sensitive measure than FEV1.
EPR-3 Sec.3, Pg. 48
Class changed to emphasize that even patients who have intermittent asthma can have severe exacerbations. P.48
Domain & Risk to emphasize the need to consider separately asthma’s effects on quality of life and function on an ongoing basis and risks asthma presents for adverse events in the future such as exacerbations and progressive loss of pulmonary function.

37. Assessment of Asthma Severity
2007 Guidelines
Impairment
Frequency of daytime /nighttime symptoms
Quality of life assessments
Frequency of SABA use
Interference with normal activity
Lung function (FEV1/FVC)
Risk
Exacerbations (frequency and severity)
Previous Guidelines
Frequency of daytime symptoms
Frequency of nighttime symptoms
Lung function

38. Footnote: The patient’s step is determined by the most severe feature.
Classification of Asthma Severity: Clinical Features Before Treatment – 2002 “Old” Guidelines
Days With Nights With PEF or PEF
Symptoms Symptoms FEV Variability
Step Continuous Frequent 60% 30%
Severe
Persistent
Step Daily >1night/week 60%-<80% 30%
Moderate
Step >2/week, <1x/day >2 nights/month 80% %
Mild
Step 1 2 days/week 2/month 80% 20%
Intermittent
Footnote: The patient’s step is determined by the most severe feature.

39. NOT Currently Taking Controllers
Level of severity is determined by both impairment a & risk. Assess impairment by caregivers recall of previous 2-4 weeks.

40. NOT Currently Taking Controllers

41. NOT Currently Taking Controllers

42. Classifying Severity AFTER Control is Achieved – All Ages
Lowest level of treatment required to maintain control
Classification of Asthma Severity
Intermittent
Persistent
Step 1
Mild
Moderate
Severe
Step 2
Step 3
or 4
Step 5
or 6
(already on controller)

43. Periodic Assessment & Monitoring
Asthma Control

44. Key Points – Asthma Control (Goals of Therapy)
Reducing impairment
Prevent chronic & troublesome symptoms.
Prevent frequent use (< 2 days /wk) of inhaled SABA for symptoms.
Maintain (near) “normal” pulmonary function.
Maintain normal activity levels (including exercise & other physical activity & attendance at work or school).
Meet patients’ and families’ expectations of and satisfaction with asthma care.
EPR- 3, p. 50

45. Key Points – Cont. Reducing Risk
Prevent recurrent exacerbations of asthma and minimize the need for ER visits and hospitalizations.
Prevent progressive loss of lung function - for children, prevent reduced lung growth.
Provide optimal pharmacotherapy with minimal or no adverse effects.
Periodic assessments at 1-6 month intervals.
Patient self-assessment (w/clinician).
Spirometry testing.
NAEPP 2007 guidelines, sec. 3, p. 53

46. Key Points Cont. - Written AAP’s & PFM
Provide to all patients a written AAP based on signs and symptoms and/or PEF.
Written AAPs are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations or poorly controlled asthma”.
“Whether PF monitoring, symptoms monitoring (available data show similar benefits for each), or a combo of approaches is used, self- monitoring is important to the effective self-management of asthma” .
EPR -3 Sec. 3, P.53
This was repeated in Section 3, component 2: Education for a partnership page 115 and beyond

47. Peak Flow Monitoring Long-term daily PF monitoring can be helpful to:
Detect early changes in asthma control that require adjustments in treatment:
Evaluate responses to changes in treatment
Provide a quantitative measure of impairment
NAEPP 2007 guidelines Sec. 3, P.54

48. Key Differences – Assessing/ Monitoring Control
Periodic assessment of asthma control is emphasized.
A stronger distinction between classifying asthma severity and assessing asthma control.
EPR-3 clarifies the issue:
For initiating treatment, asthma severity should be classified, and the initial treatment should correspond to the appropriate severity category.
Once treatment is established, the emphasis is on assessing asthma control to determine if the goals for therapy have been met and if adjustments in therapy (step up or step down) would be appropriate.
EPR-3, Sec.3 Pg.54

49. Key Differences Cont.
Assessment of asthma control includes the two domains of impairment and risk.
Peak flow monitoring:
Assessing diurnal variation was deleted.
Patients are most likely to benefit from routine peak flow monitoring.
Evidence suggests equal benefits to either peak flow or symptom-based monitoring; the important issue continues to be having a monitoring plan in place.
Parameters for lung function, specifically FEV1/FVC, were added as measures of asthma control for children.

50. Asthma Control = Asthma Goals
Definition of asthma control is the same as asthma goals (slides #44 & 45) reducing impairment and risk.
Monitoring quality of life, any:
work or school missed because of asthma?
reduction in usual activities?
disturbances in sleep due to asthma?
Change in caregivers activities due to a child's asthma?
There are quality of life assessment tools listed (p.62)
The purpose of periodic assessment and ongoing monitoring is to determine whether the goals of asthma therapy are being achieved and asthma is controlled
The level of asthma control (well controlled, not well controlled, or poorly controlled) is the degree to which both dimensions of the manifestations of asthma—impairment and risk—are minimized by therapeutic intervention. The level of control at the time of followup assessment will determine clinical actions—that is, whether to maintain or adjust therapy
For initiating treatment, asthma severity should be classified, and the initial treatment should correspond to the appropriate category of severity. Once treatment is established, the emphasis is on assessing asthma control to determine if the goals for therapy have been met and if adjustments in therapy (step up or step down) would be appropriate. P.56

51. Questions for Assessing Asthma Control
Responsiveness -
Questions for Assessing Asthma Control
Ask the patient:
Has your asthma awakened you at night or early morning?
Have you needed more quick-relief medication (SABA) than usual?
Have you needed any urgent medical care for your asthma, such as unscheduled visits to your provider, an UC clinic, or the ER?
Are you participating in your usual and desired activities?
If you are measuring your peak flow, has it been below
your personal best?
Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.” 1995

52. Responsiveness - Actions
Actions to consider:
Assess whether the medications are being taken as prescribed.
Assess whether the medications are being inhaled with correct technique.
Assess lung function with spirometry and compare to previous measurement.
Adjust medications, as needed; either step up if control is inadequate or step down if control is maximized, to achieve the best control with the lowest dose of medication.
Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.” 1995

53. Figure 3–5a. Assessing Asthma Control In Children 0 - 4 Years of Age
Key: EIB, exercise-induced bronchospasm; ICU, intensive care unit
Notes:
The level of control is based on the most severe impairment or risk category. Assess impairment domain by caregiver’s recall of previous 2–4 weeks. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient’s asthma is better or worse since the last visit.
At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with persistent asthma.

54. Figure 3–5b. Assessing Asthma Control In Children 5 - 11 Years of Age
Key: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, intensive care unit
Notes:
The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient’s/caregiver’s recall of previous 2–4 weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient’s asthma is better or worse since the last visit.
At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not‑well-controlled asthma.

55. Figure 3–5c. Assessing Asthma Control In Youths 12 Years of Age & Adults
ACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma.
Key: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second. See figure 3–8 for full name and source of ATAQ, ACQ, ACT.
Notes:
The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient’s recall of previous 2–4 weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient’s asthma is better or worse since the last visit.
At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not‑well-controlled asthma.

56. Education For A Partnership In Asthma Care
Component 2
Education For A Partnership In Asthma Care

57. Key Points - Education
Self management education is essential and should be integrated into all aspects of care & requires repetition and reinforcement.
Provide all patients with a written asthma action plan that includes 2 aspects:
Daily management
How to recognize & handle worsening asthma symptoms
Regular review of the status of patients asthma control.
Teach & reinforce at every opportunity
Develop an active partnership with the patient and family.
EPR – 3, Section 3, Pg. 93

58. Key Points – Education Cont.
Encourage adherence by:
Choosing a tx regimen that achieves outcomes and addresses preferences important to the patient.
Review the success of tx plan and make changes as needed.
Tailor the plan to needs of each patient.
Encourage community based interventions.
Asthma education provided by trained health professionals should be reimbursed and considered an integral part of effective asthma care ! (AE-C)

59. Key Differences –- Patient Education
Emphasis on the many points of care & sites available to provide education including efficacy of self management education outside the office setting.
Greater emphasis on the 2 aspects of written AAP:
1) daily management
2) how to recognize & handle worsening symptoms including adjustment of medication dose.
New sections on impact of cultural and ethnic factors & health literacy that affect education.

60. Educational Interventions In The School Setting
Implementation of comprehensive, proven school-based asthma education programs should be provided to children who have asthma to learn asthma self-management skills and help provide an “asthma-friendly” learning environment.
EPR -3, Sec. 3, Pg. 107

61. Key Educational Messages
Significance of diagnosis
Inflammation as the underlying cause
Controllers vs. quick-relievers
How to use medication delivery devices
Triggers, including 2nd hand smoke
Home monitoring/ self-management
How/when to contact the provider
Need for continuous, on-going interaction w/the clinician to step up/down therapy
Annual influenza vaccine

62. Other Educational Points of Care
ER Department & hospital based
Pharmacist
Community based
Home based for caregivers including home based allergen/ environmental assessment
Computer based technology
Case management for high-risk patients

63. Maintaining The Partnership
Promote open communication w/patient & family by addressing at each visit:
Ask early in each visit what concerns they have and what they especially want addressed during the visit.
Review short – term goals agreed at initial visit.
Review written AAP & steps to take – adjust as needed.
Encourage parents to take a copy of the AAP to the school or childcare setting or send a copy to the school nurse!!
Teach & reinforce key educational messages.
Provide simple, brief, written materials that reinforce the actions and skills taught.

64. Component 3
Control Of Environmental Factors & Comorbid Conditions That Affect Asthma

66. Key Points – Environmental Factors
For patients w/persistent asthma, evaluate the role of allergens.
All patients w/ asthma should:
Reduce, if possible, exposure to allergens they are sensitized and exposed to.
Understand effective allergen avoidance is multifaceted and individual steps alone are ineffective.
Avoid exertion outdoors when levels of air pollution are high.
Avoid use of nonselective beta-blockers.
Avoid sulfite-containing and other foods they are sensitive to.
Consider allergen immunotherapy.

67. Key Points – Environmental Cont.
Evaluate a patient for other chronic comorbid conditions when asthma cannot be well controlled.
Consider inactivated influenza vaccination for patients w/ asthma.
Use of humidifiers are not generally recommended.
Employed asthmatics should be asked about possible occupational exposures, particularly those who have new-onset disease. (work related asthma)
There is insufficient evidence to recommend any specific environmental strategies to prevent the development of asthma.

68. Key Differences –Environmental
Reducing exposure to inhalant indoor allergens can improve asthma control, a multifaceted approach is required; single steps to reduce exposure are generally ineffective.
Formaldehyde and volatile organic compounds (VOCs) are potential risk factors for asthma.
Influenza vaccine does not appear to reduce the frequency or severity of asthma exacerbations during the influenza season.
Discussion is included on ABPA, obesity, OSA, and stress as chronic comorbid conditions, in addition to rhinitis, sinusitis, and gastroesophageal reflux, that may interfere with asthma management.

69. Component 4
Medications

70. Key Points - Medications
2 general classes:
Long-term control medications
Quick-Relief medications
Controller medications:
Corticosteroids
Long Acting Beta Agonists (LABA’s)
Leukotriene modifiers (LTRA)
Cromolyn & Nedocromil
Methylxanthines: (Sustained-release theophylline)
Medications for asthma are categorized into two general classes: long-term control medications
used to achieve and maintain control of persistent asthma and quick-relief medications used to
treat acute symptoms and exacerbations.
Long-term control medications (listed in alphabetical order) C
corticosteroids: Block late-phase reaction to allergen, reduce airway
hyperresponsiveness, and inhibit inflammatory cell migration and activation. They are the most potent and effective anti-inflammatory medication currently available (Evidence A). ICSs are used in the long-term control of asthma. Short courses of oral systemic
corticosteroids are often used to gain prompt control of the disease when initiating long-term therapy; long-term oral systemic corticosteroid is used for severe persistent asthma.
Cromolyn sodium and nedocromil: Stabilize mast cells and interfere with chloride channel function. They are used as alternative, but not preferred, medication for the treatment of mild persistent asthma (Evidence A). They can also be used as preventive
treatment prior to exercise or unavoidable exposure to known allergens.
Immunomodulators: Omalizumab (anti-IgE) is a monoclonal antibody that prevents binding of IgE to the high-affinity receptors on basophils and mast cells. Omalizumab is used as adjunctive therapy for patients 12 years of age who have allergies and severe
persistent asthma (Evidence B). Clinicians who administer omalizumab should be prepared and equipped to identify and treat anaphylaxis that may occur (see discussion in text).
Leukotriene modifiers: Include LTRAs and a 5-lipoxygenase inhibitor. Two LTRAs are available—montelukast (for patients >1 year of age) and zafirlukast (for patients 7 years of age). The 5-lipoxygenase pathway inhibitor zileuton is available for patients 12 years of age; liver function monitoring is essential. LTRAs are alternative, but not preferred, therapy for the treatment of mild persistent asthma (Step 2 care) (Evidence A). LTRAs can also be used as adjunctive therapy with ICSs, but for youths 12 years of age and adults they are not the preferred adjunctive therapy compared to the addition of LABAs (Evidence A). Zileuton can be used as alternative but not preferred adjunctive therapy in adults (Evidence D).
LABAs: Salmeterol and formoterol are bronchodilators that have a duration of bronchodilation of at least 12 hours after a single dose. LABAs are not to be used as monotherapy for long-term control of asthma (Evidence A).
— LABAs are used in combination with ICSs for long-term control and prevention of
symptoms in moderate or severe persistent asthma (step 3 care or higher in children 5 years of age and adults) (Evidence A for 12 years of age, Evidence B for 5–11 years
of age).
Of the adjunctive therapies available, LABA is the preferred therapy to combine with ICS
in youths 12 years of age and adults (Evidence A).
— In the opinion of the Expert Panel, the beneficial effects of LABA in combination therapy
for the great majority of patients who require more therapy than low-dose ICS alone to
control asthma (i.e., require step 3 care or higher) should be weighed against the
increased risk of severe exacerbations, although uncommon, associated with the daily
use of LABAs (see discussion in text). For patients 5 years of age who have moderate persistent asthma or asthma
inadequately controlled on low-dose ICS, the option to increase the ICS dose should
be given equal weight to the option of adding LABA. For patients 5 years of age who have severe persistent asthma or asthma
inadequately controlled on step 3 care, the combination of LABA and ICS is the
preferred therapy.
— LABA may be used before exercise to prevent EIB (Evidence A), but duration of action
does not exceed 5 hours with chronic regular use. Frequent and chronic use of LABA
for EIB is discouraged, because this use may disguise poorly controlled persistent
asthma (Evidence D).
— In the opinion of the Expert Panel, the use of LABA for the treatment of acute symptoms
or exacerbations is not currently recommended (Evidence D). Methylxanthines: Sustained-release theophylline is a mild to moderate bronchodilator
used as alternative, not preferred, adjunctive therapy with ICS (Evidence A). Theophylline
may have mild anti-inflammatory effects. Monitoring of serum theophylline concentration is
essential.
213
August 28, 2007
Section 3, Component 4: Medications
— Of the adjunctive therapies available, LABA is the preferred therapy to combine with ICS

71. Key Points – Medications Cont.
Quick- relief medications
Short acting bronchodilators (SABA’s)
Systemic corticosteroids
Anticholinergics
uick-relief medications (listed in alphabetical order) Anticholinergics: Inhibit muscarinic cholinergic receptors and reduce intrinsic vagal tone of
the airway. Ipratropium bromide provides additive benefit to SABA in moderate-to-severe
asthma exacerbations. May be used as an alternative bronchodilator for patients who do
not tolerate SABA (Evidence D). SABAs: Albuterol, levalbuterol, and pirbuterol are bronchodilators that relax smooth
muscle. Therapy of choice for relief of acute symptoms and prevention of EIB (Evidence A). Systemic corticosteroids: Although not short acting, oral systemic corticosteroids are
used for moderate and severe exacerbations as adjunct to SABAs to speed recovery and
prevent recurrence of exacerbations (Evidence A).

72. Key Differences - Medications
The most effective medications for long-term therapy are those shown to have anti-inflammatory effects.
New medications—immunomodulators—are available for long-term control of asthma.
New data on the safety of LABAs are discussed, and the position of LABA in therapy has been revised.
The estimated clinical comparability of different ICS preparations is updated.
The significant role of ICSs in asthma therapy continues to be supported.
EPR-3, pg. 215
This updated report (EPR—3: Full Report 2007) continues to emphasize that the most effective medications for long-term therapy are those shown to have anti-inflammatory effects. New medications—immunomodulators—are available for long-term control of asthma. New data on the safety of LABAs are discussed, and the position of LABA in therapy has been revised (see text). The most significant difference is that for youths 12 years of age and adults who have moderate persistent asthma or asthma inadequately controlled on low-dose ICS, the option of increasing the dose of medium-dose ICS should be given equal weight to the option of adding LABA to low-dose ICS. The estimated clinical comparability of different ICS preparations has been updated. (See Section 4, “Managing Asthma Long-Term,” figures 4–4b and 4–8b.) The significant role of ICSs in asthma therapy continues to be supported.

73. Key Points: Safety of ICS’s
ICS’s are the most effective long-term therapy available, are well tolerated & safe at recommended doses.
The potential but small risk of adverse events from the use of ICS treatment is well balanced by their efficacy.
The dose-response curve for ICS treatment begins to flatten at low to medium doses.
Most benefit is achieved with relatively low doses, whereas the risk of adverse effects increases with dose.

74. Key Points: Reducing Potential Adverse Effects
Spacers or valved holding chambers (VHCs) used with non-breath-activated MDIs reduce local side effects.
But there is no data on use of spacers with ultra fine particle hydrofluoroalkane (HFA) MDIs.
Advise patients to rinse their mouths (rinse and spit) after (ICS) inhalation.
Use the lowest dose of ICS that maintains asthma control:
Evaluate patient adherence and inhaler technique as well as environmental factors that may contribute to asthma severity before increasing the dose of ICS.
To achieve or maintain control of asthma, add a LABA to a low or medium dose of ICS rather than using a higher dose of ICS.
Monitor linear growth in children.
To reduce the potential for adverse effects, the following measures are recommended:
— Spacers or valved holding chambers (VHCs) used with non-breath-activated MDIs
reduce local side effects (Evidence A), but there are no data on use of spacers with ultra
fine particle hydrofluoroalkane (HFA) MDIs.
— Advise patients to rinse their mouths (rinse and spit) after inhalation (Evidence B).
— Use the lowest dose of ICS that maintains asthma control. Evaluate patient adherence
and inhaler technique as well as environmental factors that may contribute to asthma
severity before increasing the dose of ICS (Evidence B).
— To achieve or maintain control of asthma, consider adding a LABA to a low or medium
dose of ICS rather than using a higher dose of ICS (Evidence A).
— For children, monitor growth (Evidence A). See “Key Points: Inhaled Corticosteroids
and Linear Growth in Children.”

75. Key Points: Safety of Long-Acting Beta2-Agonists (LABA’s)
Adding a LABA to the tx of patients whose asthma is not well controlled on low- or medium-dose ICS improves lung function, decreases symptoms, and reduces exacerbations and use of SABA for quick relief in most patients.
The FDA determined that a Black Box warning was warranted on all preparations containing a LABA.
For patients who have asthma not sufficiently controlled with ICS alone, the option to increase the ICS dose should be given equal weight to the option of the addition of a LABA to ICS.
It is not currently recommended that LABA be used for treatment of acute symptoms or exacerbations.
LABAs are not to be used as monotherapy for long-term control.
The addition of LABA (salmeterol or formoterol) to the treatment of patients whose asthma is
not well controlled on low- or medium-dose ICS improves lung function, decreases
symptoms, and reduces exacerbations and use of SABA for quick relief in most patients
(EPRUpdate 2002; Greenstone et al. 2005; Masoli et al. 2005). A large clinical trial comparing daily treatment with salmeterol or placebo added to usual
asthma therapy (Nelson et al. 2006) resulted in an increased risk of asthma-related deaths
in patients treated with salmeterol (13 deaths out of 13,176 patients treated for 28 weeks
with salmeterol versus 3 deaths out of 13,179 patients with placebo). In addition, increased
numbers of severe asthma exacerbations were noted in the pivotal trials submitted to the
FDA for formoterol approval, particularly in the higher dose formoterol arms of the trials
(Mann et al. 2003). Thus the FDA determined that a Black Box warning was warranted on
all preparations containing a LABA. The Expert Panel recommends that the established, beneficial effects of LABA for the great
majority of patients whose asthma is not well controlled with ICS alone should be weighed
against the increased risk for severe exacerbations, although uncommon, associated with
the daily use of LABAs. Therefore, the Expert Panel has modified its previous recommendation (EPRUpdate
2002) and has now concluded that, for patients who have asthma not sufficiently controlled
with ICS alone, the option to increase the ICS dose should be given equal weight to the
option of the addition of a LABA to ICS. Daily use of LABA generally should not exceed 100 mcg salmeterol or 24 mcg formoterol. It is not currently recommended that LABA be used for treatment of acute symptoms or
exacerbations. LABAs are not to be used as monotherapy for long-term control. Patients should be
instructed not to stop ICS therapy while taking salmeterol or formoterol even though their
symptoms may significantly improve.

76. Key Points: Safety of SABA’s
SABAs are the most effective medication for relieving acute bronchospasm
Increasing use of SABA treatment or using SABA >2 days a week for symptom relief (not prevention of EIB) indicates inadequate control of asthma.
Regularly scheduled, daily, chronic use of SABA is not recommended.
SABAs are the most effective medication for relieving acute bronchospasm (Evidence A). Increasing use of SABA treatment or using SABA >2 days a week for symptom relief (not
prevention of EIB) generally indicates inadequate control of asthma and the need for
initiating or intensifying anti-inflammatory therapy (Evidence C). Regularly scheduled, daily, chronic use of SABA is not recommended

77. “The Stepwise Approach” 2007 NAEPP Guidelines, EPR-3, pg. 277
Section 4
Managing Asthma
Long Term
“The Stepwise Approach”
2007 NAEPP Guidelines, EPR-3, pg. 277

78. Key Differences - Managing Asthma Long Term
Recommendations for managing asthma in children –4 and 5–11 years of age are presented separately from youths ≥12 years of age and adults.
Treatment decisions for initiating long-term control therapy are based on classifying severity (considering both impairment and risk domains) and selecting a corresponding step for treatment.
Recommendations on when to initiate therapy in children 0–4 years of age have been revised.
Treatment decisions for adjusting therapy and maintaining control are based on assessing the level of asthma control.
EPR -3, Pg. 279
The goal for therapy is to control asthma by (Evidence A):Reducing impairmentPrevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the daytime, in the night, or after exertion)Require infrequent use (≤2 days a week) of SABA for quick relief of symptomsMaintain (near) normal pulmonary functionMaintain normal activity levels (including exercise and other physical activity and attendance at work or school)Meet patients’ and families’ expectations of and satisfaction with asthma careReducing riskPrevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizationsPrevent progressive loss of lung function; for youths, prevent reduced lung growthProvide optimal pharmacotherapy with minimal or no adverse effectsA stepwise approach to pharmacologic therapy is recommended to gain and maintain control of asthma in both the impairment and risk domains (Evidence A):The type, amount, and frequency of medication is determined by asthma severity for initiating therapy and by the level of asthma control for adjusting therapy (Evidence A).Step-down therapy is essential to identify the minimum medication necessary to maintain control (Evidence D).Monitoring and followup is essential (Evidence B).When initiating therapy, monitor at 2- to 6‑week intervals to ensure that asthma control is achieved (Evidence D).Regular followup contacts at 1- to 6-month intervals, depending on the level of control, are recommended to ensure that control is maintained and appropriate adjustments in therapy are made—step up if necessary and step down if possible. Consider 3-month intervals if a step down in therapy is anticipated (Evidence D).Because asthma is a chronic inflammatory disorder of the airways with recurrent exacerbations, persistent asthma is most effectively controlled with daily long-term control medication, specifically, anti-inflammatory therapy (Evidence A).ICSs are the preferred treatment option for initiating long-term control therapy (Evidence A).Selection of an alternative treatment option includes consideration of treatment effectiveness, the domain of particular relevance to the patient (impairment, risk, or both), the individual patient’s history of previous response to therapies, the ability of the patient and family to use the medication correctly, and anticipated patient’s and family’s adherence to the treatment regime (Evidence D).Therapeutic strategies should be considered in concert with clinician-patient partnership strategies; education of patients is essential for achieving optimal pharmacologic therapy (Evidence A).At each step, patients should be advised to avoid or control allergens (Evidence A), irritants, or comorbid conditions that make the patient’s asthma worse (Evidence B).A written asthma action plan detailing for the individual patient daily management (medications and environmental control strategies) and how to recognize and handle worsening asthma is recommended for all patients; written asthma action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B). The written asthma action plan can be either symptom or peak-flow based; evidence shows similar benefits for each (Evidence B).Referral to an asthma specialist for consultation or comanagement is recommended if there are difficulties achieving or maintaining control of asthma; if the patient requires step 4 care or higher; if immunotherapy or omalizumab are considered; or if the patient has had an exacerbation requiring hospitalization. Consider referral if the patient requires step 3 care (Evidence D).Special considerations for youths (EPR¾2 1997):Pulmonary function testing should use appropriate reference populations. Adolescents compare better to childhood than to adult predicted norms.Adolescents (and younger children as appropriate) should be directly involved in establishing goals for therapy and developing their asthma management plans.Active participation in physical activities, exercise, and sports should be promoted.A written asthma management plan should be prepared for the student’s school, including plans to ensure reliable, prompt access to medications. Either encourage parents to take a copy to the child’s school or obtain parental permission and send a copy to the school nurse or designee.

79. Key Differences – Cont.
Stepwise approach to managing asthma is expanded to include six steps of care. Previous guidelines had several progressive actions within step 3 - updated guidelines separate the actions into different steps.
Treatment options within the steps have been revised:
For patients not well controlled on low-dose ICS’s, increasing the dose of ICSs to medium dose is recommended before adding adjunctive therapy in the 0–4 years age group.
For children 5–11 years and youths 12 years and adults, increasing the dose of ICS to medium dose or adding adjunctive therapy to a low dose of ICS are considered as equal options.

80. Key Differences – Cont.
Evidence for the selection of adjunctive therapy is limited in children under 12 years.
Recommendations vary according to the assessment of impairment or risk.
Steps 5–6 for youths 12 years of age and adults include consideration of omalizumab.
Managing special situations expanded to include racial and ethnic disparities.

81. Treatment: Principles of “Stepwise” Therapy
The goal of asthma therapy is to maintain long-term control of asthma with the least amount of medication and hence minimal risk for adverse effects.
EPR -3, Section 4, Managing Asthma Long Term in Children 0–4 Years of Age and 5–11 Years of Age, P. 284
The distinction between assessing impairment and risk to make treatment decisions draws attention to the multifaceted nature of asthma and the need to consider all manifestations of the disease. Assessing both domains emphasizes the need to consider separately asthma’s effects on quality of life and functional capacity on an ongoing basis (i.e., at present) and the risks asthma presents for adverse events in the future, such as exacerbations or progressive reduction in lung growth. These domains may respond differentially to treatment. For example, a large study of children who had asthma revealed that 30 percent of the low-dose ICS treatment group, whose levels of impairment (symptoms, SABA use, lung function) improved, remained at risk of exacerbations requiring oral systemic corticosteroids (CAMP 2000)
Deciding which step of care is appropriate for a patient depends on whether long-term control therapy is being initiated for the first time or whether therapy is being adjusted (i.e., stepped up to regain control or stepped down, for patients who have maintained control for a sufficient length of time, to determine the minimal amount of medication required to maintain control and/or reduce the risk of side effects). The classification of asthma severity, which considers the severity of both impairment and risk domains, provides a guide for initiating therapy for patients who are not currently taking long-term control medications

82. Principles Of Step Therapy To Maintain Control
Step up if not controlled.
If very poorly controlled, consider increase by 2 steps, oral corticosteroids, or both.
Before increasing pharmacologic therapy, consider as targets for therapy.
Adverse environmental exposures
Poor adherence
Co-morbidities

83. Follow-Up Visits every 2-6 weeks until control achieved.
When control achieved, contact every 3-6 months.
Step-down in therapy:
With well-controlled asthma for at least 3 months.
Patients may relapse with total discontinuation or reduction of inhaled corticosteroids.

84. Assessing Control & Adjusting Therapy Children 0-4 Years of Age
Key: EIB, exercise-induced bronchospasm
Notes:
The stepwise approach is meant to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
The level of control is based on the most severe impairment or risk category. Assess impairment domain by caregiver’s recall of previous 2–4 weeks. Symptom assessment for longer periods should reflect a global assessment such as inquiring whether the patient’s asthma is better or worse since the last visit.
At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.
Before step up in therapy:
Review adherence to medications, inhaler technique, and environmental control.
If alternative treatment option was used in a step, discontinue it and use preferred treatment for that step.

85. Stepwise Approach for Managing Asthma in Children 0-4 Years of Age
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult asthma specialist if step 3 care or higher is required.
Consider consultation at step 2
Step up if needed
(first check adherence, environmental control)
Step 6
Preferred
High
Dose ICS
AND
Either:
Montelukast or LABA
Oral corticosteroid
Step 5
Preferred
High
Dose ICS
AND
Either:
Montelukast or LABA
Step 4
Preferred
Medium Dose ICS
AND
Either:
Montelukast or LABA
Step 3
Preferred
Medium Dose ICS
Assess control
Step 2
Preferred
Low dose ICS
Alternative Montelukast or Cromolyn
Step 1
Preferred
SABA PRN
Step down if possible
(and asthma is well controlled at least 3 months)
Patient Education and Environmental Control at Each Step
Quick-relief medication for ALL patients -SABA as needed for symptoms.
With VURI: SABA every 4-6 hours up to 24 hours.
Consider short course of corticosteroids with (or hx of) severe exacerbation

86. Assessing Control & Adjusting Therapy Children 5-11 Years of Age

87. Stepwise approach for managing asthma in children 5-11 years of age
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
Step up if needed
(first check adherence, environmental control, and comorbid conditions)
Preferred
High Dose ICS
+ LABA
+ oral corticosteroid
Alternative
High dose ICS + either LTRA, or Theophylline
Step 6
Preferred
High Dose ICS + LABA
Alternative
High dose ICS + either LTRA, or
Theophylline
Step 5
Preferred
Medium Dose ICS + LABA
Alternative
Medium dose ICS + either LTRA, or
Theophylline
Step 4
Preferred
Either
Low Dose ICS + LABA, LTRA, or Theophylline OR
Medium Dose ICS
Step 3
Preferred
Low dose ICS
Alternative
LTRA, Cromolyn
Nedocromil or
Theophylline
Step 2
Preferred
SABA PRN
Step 1
Assess control
Step down if possible
(and asthma is well controlled at least 3 months)
Patient Education and Environmental Control at Each Step
Quick-relief medication for ALL patients
SABA as needed for symptoms.
Short course of oral corticosteroids maybe needed.

88. Assessing Control & Adjusting Therapy In Youths > 12 Years of Age & Adults
*ACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma.
Key: EIB, exercise-induced bronchospasm; ICU, intensive care unit
Notes:
The stepwise approach is meant to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient’s recall of previous 2–4 weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient’s asthma is better or worse since the last visit.
At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.
Validated Questionnaires for the impairment domain (the questionnaires do not assess lung function or the risk domain)
ATAQ = Asthma Therapy Assessment Questionnaire© (See sample in “Component 1: Measures of Asthma Assessment and Monitoring.”)
ACQ = Asthma Control Questionnaire© (user package may be obtained at or
ACT = Asthma Control Test (See sample in “Component 1: Measures of Asthma Assessment and Monitoring.”)
Minimal Important Difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT.
Before step up in therapy:
Review adherence to medication, inhaler technique, environmental control, and comorbid conditions.
If an alternative treatment option was used in a step, discontinue and use the preferred treatment for that step.

89. Persistent Asthma: Daily Medication
Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult asthma specialist if step 4 care or higher is required.
Consider consultation at step 3
Step up if needed
(first check adherence, environmental control & comorbid conditions)
Step 6
Preferred
High dose ICS + LABA + oral corticosteroid
AND
Consider Omalizumab for patients who have allergies
Step 5
Preferred
High
Dose ICS + LABA
AND
Consider Omalizumab for patients who have allergies
Step 4
Preferred:
Medium Dose ICS + LABA
Alternative:
Medium-dose ICS + either LTRA, Theophylline, or Zileuton
Step 3
Preferred:
Low-dose ICS + LABA
OR – Medium dose ICS
Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton
Assess control
Step 2
Preferred:
Low dose ICS
Alternative: Cromolyn, LTRA, Nedocromil or Theophylline
Step 1
Preferred:
SABA PRN
Step down if possible
(and asthma is well controlled at least 3 months)
Each Step: Patient Education and Environmental Control and management of comorbidities
Steps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 20 minute intervals prn. Short course of o systemic corticosteroids may be needed.
Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control & the need to step up treatment.

90. Section 5 Managing Exacerbations of Asthma
2007 Asthma Guidelines, EPR – 3, Pg. 373

91. Key Points – Managing Exacerbations
Early treatment of asthma exacerbations is the best strategy for management.
Patient education includes a written asthma action plan to guide patient self‑management of exacerbations.
especially for patients who have moderate or severe persistent asthma and any patient who has a history of severe exacerbations.
A peak‑flow‑based plan for patients who have difficulty perceiving airflow obstruction and worsening asthma.
EPR -3 Pg. 373

92. Key Points – Cont.
Recognition of early signs of worsening asthma & taking prompt action.
Appropriate intensification of therapy, often including a short course of oral corticosteroids.
Removal of the environmental factors contributing to the exacerbation.
Prompt communication between patient and clinician about any serious deterioration in symptoms or peak flow, decreased responsiveness to SABAs, or decreased duration of effect.

93. Key Differences From 1997 & 2002 Expert Panel Reports
For the treatment of exacerbations, the current update:
Simplifies classification of severity of asthma exacerbations.
Adds levalbuterol as a SABA treatment for asthma exacerbations.
For home management of exacerbations, no longer recommends doubling the dose of ICSs.
For prehospital management (e.g., emergency transport), encourages standing orders for albuterol and—for prolonged transport—repeated treatments and protocols to allow consideration of ipratropium and oral corticosteroids.
For ED management, reduces dose and frequency of oral corticosteroids in severe exacerbations, adds consideration of magnesium sulfate or heliox for severe exacerbations, and adds consideration of initiating an ICS upon discharge.

94. Exacerbations Defined (Risk)
Are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness — or some combination of these symptoms.
Are characterized by decreases in expiratory airflow that can be documented and quantified by spirometry or Peak expiratory flow.
These objective measures more reliably indicate the severity of an exacerbation than does the severity of symptoms.
Individuals who have their asthma under control with ICSs will decrease the risk of exacerbations.
Patients in good control can still be vulnerable to exacerbations, for example, when they have clinical respiratory infections (Reddel et al. 1999).
variations during exacerbations, as compared with during poor asthma control, suggests differences in beta2-adrenoceptor function between these conditions. The decrease in responsiveness to SABA during some severe exacerbations may help to explain the benefit of ipratropium bromide and other “alternative” approaches to bronchodilation.

95. Classifying Severity of Asthma Exacerbations in the UC or ER Setting
Symptoms & Signs
Initial PEF (or FEV1)
Clinical Course
Mild
Dyspnea only with activity (assess tachypnea in young
children)
PEF 70 percent predicted or personal best
Usually cared for at home
Prompt relief with inhaled SABA
Possible short course of oral systemic corticosteroids
Moderate
Dyspnea interferes with or limits usual activity
PEF 4069 percent predicted or personal best
Usually requires office or ED visit
Relief from freq. inhaled SABA
Oral systemic corticosteroids; some symptoms last 1–2 days after treatment is begun
Severe
Dyspnea at rest; interferes with conversation
PEF <40 percent predicted or personal best
Usually requires ED visit and likely hospitalization
Partial relief from frequent inhaled SABA
PO systemic corticosteroids; some symptoms last >3 days after treatment is begun
Adjunctive therapies are helpful
Subset: Life threatening
Too dyspneic to speak; perspiring
PEF <25 percent predicted or personal best
Requires ED/hospitalization; possible ICU
Minimal or no relief w/ frequent inhaled SABA
Intravenous corticosteroids
P.375

96. Managing Asthma Exacerbations At Home

97. What The EPR -3 Does NOT Recommend
Drinking large volumes of liquids or breathing warm, moist air (e.g., the mist from a hot shower).
Using over-the-counter products such as antihistamines or cold remedies.
Although pursed-lip and other forms of controlled breathing may help to maintain calm during respiratory distress, these methods do not bring about improvement in lung function.
EPR -3 , P.384

98. Many Thanks To -
Colleagues who shared their power point presentations and/or provided feedback on this presentation:
Dr. Gail M Brottman MD, Director, Pediatric Pulmonary Medicine, HCMC
Dr. Don Uden, Pharm. D., Professor, University of Minnesota, College of Pharmacy
Dr. Barbara P. Yawn, MD, MSc, Director of Research, Olmsted Medical Clinic
Dr. Mamta Reddy, MD, Chief
Allergy/ Immunology, Bronx Lebanon Hospital Center, NY
Mary Bielski, RN, LSN, CNS, Nursing Service Manager, Minneapolis Public Schools

99. Minnesota Department of Health Asthma Program
MN Dept of Health thanks to a grant the Centers for Disease control- we are one of 6 states initially awarded both a planning and implementation grant. We’re currently in our 2nd year of the grant (5 year).