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1 National Institutes of Health (NIH) NAEPP 2007 Asthma Guideline UPDATE Susan K. Ross RN, AE-C MDH Asthma Program 651-201-5629

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Presentation on theme: "1 National Institutes of Health (NIH) NAEPP 2007 Asthma Guideline UPDATE Susan K. Ross RN, AE-C MDH Asthma Program 651-201-5629"— Presentation transcript:

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

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

3 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 todays children and families. 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 todays children and families. The Journal of School Nursing, June 2007, Vol.23, Num. 3 The Journal of School Nursing, June 2007, Vol.23, Num. 3

4 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. 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 NAEPP Guidelines, EPR 3- Section 2, p 12.

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

6 6 Normal & Asthmatic Bronchiole

7 7 Why Do We Need Asthma Guidelines?

8 8 Asthma: Accounts for 12.8 million lost school days annually 1 (2003) 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) 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 Is the 3rd leading cause of hospitalizations among children under 15 2 Close to 1 in 11 (8.9%) children have asthma 1 (2005) Close to 1 in 11 (8.9%) children have asthma 1 (2005) 6.5 million children under 18 have asthma 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 9 Asthma Prevalence Age Age Current asthma prevalence (%) Deaths per 1,000, yrs yrs yrs Total Adapted from Akinbami L. Advance Data 2006

10 10 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 11 Children & Asthma In America Survey Children & Asthma In America Survey 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. 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 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 The survey found that nearly 1 out of 10 (9.2%) American children 18 years of age and younger currently suffer from asthma. 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. 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 Guidelines For The Diagnosis & Management Of Asthma Expert Review Panel (EPR-3)

13 13 Asthma Guidelines: History and Context Initial guidelines released in 1991 and updated in 1997 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. 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 14 Old and New Asthma Guidelines: What Has NOT Changed Initial asthma therapy is determined by assessment of asthma severity. 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. 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. Inhaled corticosteroids (ICS) are the preferred first-line therapy for asthma. Systemic steroids can still be used to treat asthma exacerbations. Systemic steroids can still be used to treat asthma exacerbations. Peak flows and written asthma action plans are recommended for asthma self management. 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 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

16 Guidelines For The Diagnosis & Management of Asthma (EPR-3) (Almost) no new medications. (Almost) no new medications. Restructuring into severity and control. Restructuring into severity and control. Domains of impairment and risk. Domains of impairment and risk. Six treatment steps (step-up/step-down). Six treatment steps (step-up/step-down). More careful thought into ongoing management issues. 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. 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 17 New Strategies of the EPR-3 Summary EPR-3, Page 36-38

18 18 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) Key Points: Definition, Pathophysiology & Pathogenesis

19 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 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) 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. 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. 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. 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 21 Causes – We Dont 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. 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. 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). 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 22 The 4 Components Of Asthma Management - (Section 3) Component 1: Measures of Asthma Assessment and Monitoring Component 1: Measures of Asthma Assessment and Monitoring Component 2: Education for a Partnership in Asthma Care Component 2: Education for a Partnership in Asthma Care Component 3: Control of Environmental Factors and Comorbid Conditions That Affect Asthma Component 3: Control of Environmental Factors and Comorbid Conditions That Affect Asthma Component 4: Medications Component 4: Medications

23 23 Component 1 Measures of Asthma Assessment & Monitoring

24 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: 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 25 Key Points – Cont. 2 Severity & Control Are Assessed Based On 2 Domains Impairment (Present): Impairment (Present): – Frequency and intensity of symptoms – Functional limitations (quality of life) Risk (Future): Risk (Future): – Likelihood of asthma exacerbations or – Progressive loss of lung function (reduced lung growth) – Risk of adverse effects from medication EPR -3, Pg , EPR -3, Pg ,

26 26 Key Points - Cont. 3 S everity & Control are used as follows for managing asthma: If the patient is not currently on a long-term controller at the first visit: 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. 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 27 Key Differences: Component 1 - Overview The key elements of assessment and monitoring include the concepts of severity, control, and responsiveness to treatment: 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 asthmas 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. The distinction between the domains of impairment and risk for assessing severity and control emphasizes the need to consider separately asthmas 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 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 29 Assessing Risk (Future) Domain Of adverse events in the future, especially of exacerbations and of progressive, irreversible loss of pulmonary functionis more problematic (airway remodeling). Of adverse events in the future, especially of exacerbations and of progressive, irreversible loss of pulmonary functionis more problematic (airway remodeling). The test most used for assessing the risk of future adverse events is spirometry. The test most used for assessing the risk of future adverse events is spirometry.

30 30 Measures of Assessment & Monitoring Diagnosis

31 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. Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present. Airflow obstruction is at least partially reversible. Airflow obstruction is at least partially reversible. Alternative diagnoses are excluded. 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 32 Key Differences – Diagnosis Discussions added on use of spirometry, especially in children and on criteria for reversibility. 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. 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 References added about conditions that complicate diagnosis and treatment. EPR -3, Sec.3, Pg. 41

33 33 Key Indicators: Diagnosis of Asthma Wheezing – high-pitched whistling sounds when breathing out. Wheezing – high-pitched whistling sounds when breathing out. History of (any): 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 in the presence of known triggers. Symptoms occur or worsen at night awakening patient. Symptoms occur or worsen at night awakening patient.

34 34 Characterization & Classification of Asthma SEVERITY

35 35 Key Points - Initial Assessment: Severity Once diagnosis is established: Once diagnosis is established: –Identify precipitating factors (triggers). –Identify comorbidities that aggravate asthma –Assess patients knowledge & skills for self- management. –Classify severity using impairment & risk domains. Pulmonary function testing (spirometry) to assess severity. EPR -3, Sec. 3, pg. 47 Pulmonary function testing (spirometry) to assess severity. EPR -3, Sec. 3, pg. 47

36 36 Key Differences – Initial Assessment & Severity Severity class for asthma changed mild intermittent to intermittent. Severity class for asthma changed mild intermittent to intermittent. Severity class is defined in terms of 2 domains – impairment & risk. Severity class is defined in terms of 2 domains – impairment & risk. New emphasis on using FEV 1 /FVC is added to classify severity in children because it may be a more sensitive measure than FEV 1. New emphasis on using FEV 1 /FVC is added to classify severity in children because it may be a more sensitive measure than FEV 1. EPR-3 Sec.3, Pg. 48 EPR-3 Sec.3, Pg. 48

37 37 Assessment of Asthma Severity Previous Guidelines Frequency of daytime symptoms Frequency of daytime symptoms Frequency of nighttime symptoms Frequency of nighttime symptoms Lung function Lung function 2007 Guidelines 2007 Guidelines Impairment Impairment –Frequency of daytime /nighttime symptoms –Quality of life assessments –Frequency of SABA use –Interference with normal activity –Lung function (FEV 1 /FVC) Risk Risk –Exacerbations (frequency and severity)

38 Classification of Asthma Severity: Clinical Features Before Treatment – 2002 Old Guidelines Days With Nights With PEF or PEF Symptoms Symptoms FEV 1 Variability Step 4 Continuous Frequent 60% 30% SeverePersistent Step 3 Daily >1night/week 60%- 1night/week 60%-<80% 30%ModeratePersistent Step 2 >2/week, 2 nights/month 80% 20-30% MildPersistent Step 1 2 days/week 2/month 80% 20% MildIntermittent Footnote: The patients step is determined by the most severe feature. Footnote: The patients step is determined by the most severe feature.

39 NOT Currently Taking Controllers 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 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 IntermittentPersistent Step 1 MildModerateSevere Step 2 Step 3 or 4 Step 5 or 6 (already on controller)

43 43 Periodic Assessment & Monitoring Asthma Control

44 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 EPR- 3, p. 50

45 45 Key Points – Cont. Reducing Risk 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. Periodic assessments at 1-6 month intervals. Patient self-assessment (w/clinician). Patient self-assessment (w/clinician). Spirometry testing. Spirometry testing. NAEPP 2007 guidelines, sec. 3, p. 53

46 46 Key Points Cont. - Written AAPs & PFM Provide to all patients a written AAP based on signs and symptoms and/or PEF. 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. 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 EPR -3 Sec. 3, P.53

47 47 Peak Flow Monitoring Long-term daily PF monitoring can be helpful to : Long-term daily PF monitoring can be helpful to : Detect early changes in asthma control that require adjustments in treatment : 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 48 Key Differences – Assessing/ Monitoring Control Periodic assessment of asthma control is emphasized. Periodic assessment of asthma control is emphasized. A stronger distinction between classifying asthma severity and assessing asthma control. 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 EPR-3, Sec.3 Pg.54

49 49 Key Differences Cont. Assessment of asthma control includes the two domains of impairment and risk. Assessment of asthma control includes the two domains of impairment and risk. Peak flow monitoring: 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. Parameters for lung function, specifically FEV1/FVC, were added as measures of asthma control for children.

50 50 Asthma Control = Asthma Goals Definition of asthma control is the same as asthma goals (slides #44 & 45) reducing impairment and risk. Definition of asthma control is the same as asthma goals (slides #44 & 45) reducing impairment and risk. Monitoring quality of life, any: 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)

51 51 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 52 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 Responsiveness - Actions

53 Figure 3–5a. Assessing Asthma Control In Children Years of Age

54 Figure 3–5b. Assessing Asthma Control In Children Years of Age

55 Figure 3–5c. Assessing Asthma Control In Youths 12 Years of Age & Adults

56 56 Component 2 Education For A Partnership In Asthma Care

57 57 Key Points - Education Self management education is essential and should be integrated into all aspects of care & requires repetition and reinforcement. 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: 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. Regular review of the status of patients asthma control. –Teach & reinforce at every opportunity Develop an active partnership with the patient and family. Develop an active partnership with the patient and family. EPR – 3, Section 3, Pg. 93 EPR – 3, Section 3, Pg. 93

58 58 Key Points – Education Cont. Encourage adherence by: 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. Tailor the plan to needs of each patient. Encourage community based interventions. 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) Asthma education provided by trained health professionals should be reimbursed and considered an integral part of effective asthma care ! (AE-C)

59 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. 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: 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. New sections on impact of cultural and ethnic factors & health literacy that affect education.

60 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 61 Key Educational Messages Significance of diagnosis Significance of diagnosis Inflammation as the underlying cause Inflammation as the underlying cause Controllers vs. quick-relievers Controllers vs. quick-relievers How to use medication delivery devices How to use medication delivery devices Triggers, including 2 nd hand smoke Triggers, including 2 nd hand smoke Home monitoring/ self-management Home monitoring/ self-management How/when to contact the provider How/when to contact the provider Need for continuous, on-going interaction w/the clinician to step up/down therapy Need for continuous, on-going interaction w/the clinician to step up/down therapy Annual influenza vaccine Annual influenza vaccine

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

63 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. 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 short – term goals agreed at initial visit. Review written AAP & steps to take – adjust as needed. 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!! 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. Teach & reinforce key educational messages. Provide simple, brief, written materials that reinforce the actions and skills taught. Provide simple, brief, written materials that reinforce the actions and skills taught.

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

65 65

66 66 Key Points – Environmental Factors For patients w/persistent asthma, evaluate the role of allergens. For patients w/persistent asthma, evaluate the role of allergens. All patients w/ asthma should: 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 67 Key Points – Environmental Cont. Evaluate a patient for other chronic comorbid conditions when asthma cannot be well controlled. Evaluate a patient for other chronic comorbid conditions when asthma cannot be well controlled. Consider inactivated influenza vaccination for patients w/ asthma. Consider inactivated influenza vaccination for patients w/ asthma. Use of humidifiers are not generally recommended. 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) 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. There is insufficient evidence to recommend any specific environmental strategies to prevent the development of asthma.

68 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. 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. 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. 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. 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 69 Component 4 Medications

70 70 Key Points - Medications 2 general classes: 2 general classes: – Long-term control medications – Quick-Relief medications Controller medications: Controller medications: – Corticosteroids – Long Acting Beta Agonists (LABAs) – Leukotriene modifiers (LTRA) – Cromolyn & Nedocromil – Methylxanthines: ( Sustained-release theophylline)

71 71 Key Points – Medications Cont. Quick- relief medications Quick- relief medications – Short acting bronchodilators (SABAs) – Systemic corticosteroids – Anticholinergics

72 72 Key Differences - Medications The most effective medications for long-term therapy are those shown to have anti-inflammatory effects. The most effective medications for long-term therapy are those shown to have anti-inflammatory effects. New medicationsimmunomodulatorsare available for long-term control of asthma. New medicationsimmunomodulatorsare 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. 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 estimated clinical comparability of different ICS preparations is updated. The significant role of ICSs in asthma therapy continues to be supported. The significant role of ICSs in asthma therapy continues to be supported. EPR-3, pg. 215 EPR-3, pg. 215

73 73 Key Points: Safety of ICSs ICSs are the most effective long-term therapy available, are well tolerated & safe at recommended doses. ICSs 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 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. 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. Most benefit is achieved with relatively low doses, whereas the risk of adverse effects increases with dose.

74 74 Key Points: Reducing Potential Adverse Effects Spacers or valved holding chambers (VHCs) used with non- breath-activated MDIs reduce local side 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. Advise patients to rinse their mouths (rinse and spit) after (ICS) inhalation. Use the lowest dose of ICS that maintains asthma control: 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. 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. Monitor linear growth in children.

75 75 Key Points: Safety of Long-Acting Beta 2 -Agonists (LABAs) 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. 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. 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. 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. 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. LABAs are not to be used as monotherapy for long-term control.

76 76 Key Points: Safety of SABAs SABAs are the most effective medication for relieving acute bronchospasm 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. 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. Regularly scheduled, daily, chronic use of SABA is not recommended.

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

78 78 Key Differences - Managing Asthma Long Term 1.Recommendations for managing asthma in children 0–4 and 5–11 years of age are presented separately from youths 12 years of age and adults. 2.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. 3.Treatment decisions for adjusting therapy and maintaining control are based on assessing the level of asthma control. EPR -3, Pg. 279

79 79 Key Differences – Cont. 4. 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. 5. Treatment options within the steps have been revised: –For patients not well controlled on low-dose ICSs, 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 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. 6. Managing special situations expanded to include racial and ethnic disparities.

81 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

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

83 83 Follow-Up Visits every 2-6 weeks until control achieved. Visits every 2-6 weeks until control achieved. When control achieved, contact every 3-6 months. When control achieved, contact every 3-6 months. Step-down in therapy: 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

85 Intermittent Asthma Persistent Asthma: Daily Medication Consult asthma specialist if step 3 care or higher is required. Consider consultation at step 2 Step 1 Preferred SABA PRN Step 2 Preferred Low dose ICS Alternative Montelukast or Cromolyn Step 3 Preferred Medium Dose ICS Step 4 Preferred Medium Dose ICS AND Either: Montelukast or LABA Step 5 Preferred High Dose ICS AND Either: Montelukast or LABA Step 6 Preferred High Dose ICS AND Either: Montelukast or LABA AND Oral corticosteroid Patient Education and Environmental Control at Each Step Stepwise Approach for Managing Asthma in Children 0-4 Years of Age 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 Step down if possible (and asthma is well controlled at least 3 months) Assess control Step up if needed (first check adherence, environment al control)

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

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

88 Assessing Control & Adjusting Therapy In Youths > 12 Years of Age & Adults

89 Intermittent Asthma Persistent Asthma: Daily Medication Consult asthma specialist if step 4 care or higher is required. Consider consultation at step 3 Step 1 Preferred: SABA PRN Step 2 Preferred: Low dose ICS Alternative: Cromolyn, LTRA, Nedocromil or Theophylline Step 3 Preferred: Low-dose ICS + LABA OR – Medium dose ICS Alternative: Low-dose ICS + either LTRA, Theophylline, or Zileuton Step 4 Preferred: Medium Dose ICS + LABA Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton Step 5 Preferred High Dose ICS + LABA AND Consider Omalizumab for patients who have allergies Step 6 Preferred High dose ICS + LABA + oral corticosteroid AND Consider Omalizumab for patients who have allergies Each Step: Patient Education and Environmental Control and management of comorbidities Steps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults 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. Step down if possible (and asthma is well controlled at least 3 months) Assess control Step up if needed (first check adherence, environmental control & comorbid conditions)

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

91 91 Key Points – Managing Exacerbations Early treatment of asthma exacerbations is the best strategy for management. 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. 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. A peak flow based plan for patients who have difficulty perceiving airflow obstruction and worsening asthma. EPR -3 Pg. 373 EPR -3 Pg. 373

92 92 Key Points – Cont. Recognition of early signs of worsening asthma & taking prompt action. Recognition of early signs of worsening asthma & taking prompt action. Appropriate intensification of therapy, often including a short course of oral corticosteroids. Appropriate intensification of therapy, often including a short course of oral corticosteroids. Removal of the environmental factors contributing to the exacerbation. 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. 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 93 Key Differences From 1997 & 2002 Expert Panel Reports For the treatment of exacerbations, the current update: For the treatment of exacerbations, the current update: Simplifies classification of severity of asthma exacerbations. Simplifies classification of severity of asthma exacerbations. Adds levalbuterol as a SABA treatment for 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 home management of exacerbations, no longer recommends doubling the dose of ICSs. For prehospital management (e.g., emergency transport), encourages standing orders for albuterol andfor prolonged transportrepeated treatments and protocols to allow consideration of ipratropium and oral corticosteroids. For prehospital management (e.g., emergency transport), encourages standing orders for albuterol andfor prolonged transportrepeated 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. 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 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 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. 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.

95 Classifying Severity of Asthma Exacerbations in the UC or ER Setting Severity Severity Symptoms & Signs Initial PEF (or FEV 1 ) 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 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 Adjunctive therapies are helpful

96 Managing Asthma Exacerbations At Home

97 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). 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. 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. 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 EPR -3, P.384

98 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. Gail M Brottman MD, Director, Pediatric Pulmonary Medicine, HCMC Dr. Don Uden, Pharm. D., Professor, University of Minnesota, College of Pharmacy 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. Barbara P. Yawn, MD, MSc, Director of Research, Olmsted Medical Clinic Dr. Mamta Reddy, MD, Chief Dr. Mamta Reddy, MD, Chief Allergy/ Immunology, Bronx Lebanon Hospital Center, NY Allergy/ Immunology, Bronx Lebanon Hospital Center, NY Mary Bielski, RN, LSN, CNS, Nursing Service Manager, Minneapolis Public Schools Mary Bielski, RN, LSN, CNS, Nursing Service Manager, Minneapolis Public Schools

99 99 Minnesota Department of Health Asthma Program


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