National Institutes of Health (NIH)
NAEPP 2007 Asthma Guideline
UPDATE
Susan K. Ross RN, AE-C
MDH Asthma Program
651-201-5629
Susan.Ross@health.state.mn.us
1
National Institutes of Health
National Asthma Education Prevention Program
(NAEPP)
2007
Guidelines for the Diagnosis and Management
of Asthma (EPR-3)
http://www.nhlbi.nih.gov/guidelines/asthma/index.htm
National Asthma Education
and Prevention Program
2
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
3
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.
4
Characteristics of Asthma
• Airway Inflammation
• Airway Obstruction (reversible)
• Hyperresponsiveness (irritability of airways)
5
Normal & Asthmatic Bronchiole
6
Why Do We Need Asthma
Guidelines?
7
Asthma:

Accounts for 12.8 million lost school days annually


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 1

6.5 million children under 18 have asthma

(2003)
(2005)
1 National Health Interview Survey; Asthma Prevalence, Health Care Use, and Mortality, 2000-01, National Center for Health Statistics, CDC
2 National Hospital Discharge Survey, 2002; American Lung Association Asthma and Children Fact Sheet, August 2006
1
8
1
Asthma Prevalence
Age
Current asthma
prevalence (%)
Deaths per
1,000,000
2004-2005
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
Adapted from Akinbami L. Advance Data 2006
9
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
10
“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 www.asthmainamerica.com, “Children & Asthma in America”, 2004 Glaxo-SmithKline
11
2007 - Guidelines For The Diagnosis
& Management Of Asthma
Expert Review Panel (EPR-3)
12
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
13
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.
14
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
15
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.
16
New Strategies of the EPR-3
Summary
17
EPR-3, Page 36-38
Key Points: Definition,
Pathophysiology & Pathogenesis
 Asthma
airways.
is a chronic inflammatory disorder of the
 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)
18
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
19
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
20
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).
21
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
22
Component 1
Measures of Asthma
Assessment & Monitoring
23
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
24
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. 38-80, 277-345
25
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.
26
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.
27
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.
28
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.
29
Measures of Assessment &
Monitoring
Diagnosis
30
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.
31
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
32
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.
33
Characterization &
Classification of Asthma
SEVERITY
34
Key Points - Initial Assessment:
Severity


Once diagnosis is established:
– Identify precipitating factors (triggers).
– Identify comorbidities that aggravate asthma
– Assess patient’s knowledge & skills for selfmanagement.
– Classify severity using impairment & risk
domains.
Pulmonary function testing (spirometry) to
assess severity.
35
EPR -3,
Sec. 3, pg. 47
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
36
Assessment of Asthma Severity
Previous Guidelines
 Frequency of daytime
symptoms
 Frequency of nighttime
symptoms
 Lung function

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)
37
Classification of Asthma Severity: Clinical Features
Before Treatment – 2002 “Old” Guidelines
Days With
Symptoms
Step 4
Continuous
Nights With
Symptoms
Frequent
PEF or
FEV1
60%
PEF
Variability
30%
Severe
Persistent
Step 3
Daily
>1night/week
60%-<80%
30%
Moderate
Persistent
Step 2
>2/week, <1x/day
>2 nights/month
80%
20-30%
80%
20%
Mild
Persistent
2 days/week
Step 1
2/month
Mild
Intermittent
Footnote: The patient’s step is determined by the most severe feature.
NOT Currently Taking Controllers
Classification of Asthma Severity
(04 years of age)
Components of
Severity
Impairment
Risk
Persistent
Intermittent
Mild
Moderate
Severe
Symptoms
2 days/week
>2 days/week
but not daily
Daily
Throughout
the day
Nighttime
awakenings
0
12x/month
34x/month
>1x/week
Short-acting
beta2-agonist use
for symptom
control (not
prevention of EIB)
2 days/week
>2 days/week
but not daily
Daily
Several times
per day
Interference with
normal activity
None
Minor limitation
Some limitation
Extremely limited
Exacerbations
requiring oral
systemic
corticosteroids
01/year
2 exacerbations in 6 months requiring oral systemic
corticosteroids, or 4 wheezing episodes/1 year lasting
>1 day AND risk factors for persistent asthma
Consider severity and interval since last exacerbation.
Frequency and severity may fluctuate over time.
Exacerbations of any severity may occur in patients in any severity category.
Recommended Step for
Initiating Therapy
(See figure 41a for
treatment steps.)
Step 1
Step 2
Step 3 and consider short course of
oral systemic corticosteroids
In 26 weeks, depending on severity, evaluate level of asthma control that is
achieved. If no clear benefit is observed in 46 weeks, consider adjusting
therapy or alternative diagnoses.
Level of severity is determined by both impairment a & risk. Assess impairment by caregivers recall of previous 2-4 weeks.
NOT Currently Taking Controllers
Classification of Asthma Severity
(511 years of age)
Components of
Severity
Persistent
Intermittent
Mild
Moderate
Severe
2 days/week
>2 days/week but
not daily
Daily
Throughout
the day
Nighttime
awakenings
2x/month
34x/month
>1x/week but
not nightly
Often 7x/week
Short-acting
beta2-agonist use for
symptom control (not
prevention of EIB)
2 days/week
>2 days/week
but not daily
Daily
Several times
per day
Interference with
normal activity
None
Minor limitation
Some limitation
Extremely limited
Symptoms
Impairment
• Normal FEV1
between
exacerbations
Lung function
Risk
Exacerbations
requiring oral
systemic
corticosteroids
Recommended Step for
Initiating Therapy
(See figure 41b for
treatment steps.)
• FEV1 >80%
predicted
• FEV1 = >80%
predicted
• FEV1 = 6080%
predicted
• FEV1 <60%
predicted
• FEV1/FVC >85%
• FEV1/FVC >80%
• FEV1/FVC = 7580%
• FEV1/FVC <75%
01/year (see note)
2/year (see note)
Consider severity and interval since last exacerbation.
Frequency and severity may fluctuate over time for patients in any severity category.
Relative annual risk of exacerbations may be related to FEV1.
Step 1
Step 2
Step 3, mediumdose ICS option
Step 3, medium-dose
ICS option, or step 4
and consider short course of
oral systemic corticosteroids
In 26 weeks, evaluate level of asthma control that is achieved, and adjust therapy
accordingly.
NOT Currently Taking Controllers
Classification of Asthma Severity
12 years of age
Components of Severity
Intermittent
Mild
Moderate
2 days/week
>2 days/week but
not daily
Daily
Throughout the day
Nighttime
awakenings
2x/month
34x/month
>1x/week but
not nightly
Often 7x/week
Short-acting
beta2-agonist use for
symptom control (not
prevention of EIB)
2 days/week
Daily
Several times
per day
Interference with
normal activity
None
Symptoms
Impairment
Normal FEV1/FVC:
819 yr
85%
20 39 yr 80%
40 59 yr 75%
60 80 yr 70%
>2 days/week
but not daily, and
not more than
1x on any day
Minor limitation
Some limitation
Severe
Extremely limited
• Normal FEV1
between
exacerbations
Lung function
Risk
Persistent
Exacerbations
requiring oral
systemic
corticosteroids
• FEV1 >80%
predicted
• FEV1 >80%
predicted
• FEV1 >60% but
<80% predicted
• FEV1 <60%
predicted
• FEV1/FVC normal
• FEV1/FVC normal
• FEV1/FVC reduced
5%
• FEV1/FVC
reduced >5%
01/year (see
note)
2/year (see note)
Consider severity and interval since last exacerbation.
Frequency and severity may fluctuate over time for patients in any severity category.
Relative annual risk of exacerbations may be related to FEV1.
Recommended Step
for Initiating Treatment
(See figure 45 for treatment steps.)
Step 3
Step 1
Step 2
Step 4 or 5
and consider short course of
oral systemic corticosteroids
In 26 weeks, evaluate level of asthma control that is achieved and adjust therapy
accordingly.
Classifying Severity AFTER Control
is Achieved – All Ages
Classification of Asthma Severity
Lowest
level of
treatment Intermittent
required to
maintain
control
Step 1
Persistent
Mild
Moderate
Severe
Step
2
Step 3
or 4
Step 5
or 6
(already on controller)
Periodic Assessment &
Monitoring
Asthma Control
43
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
44
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
45
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.5346
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
47
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
48
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.
49
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)
50
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?
51
Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.” 1995
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
52
Figure 3–5a. Assessing Asthma Control In
Children 0 - 4 Years of Age
Components of Control
Impairment
Classification of Asthma Control
(Children 04 years of age)
Well
Controlled
Not Well
Controlled
Very Poorly
Controlled
Symptoms
2 days/week
>2 days/week
Throughout the day
Nighttime awakenings
1x/month
>1x/month
>1x/week
Interference with
normal activity
None
Some limitation
Extremely limited
Short-acting
beta2-agonist use
for symptom control
(not prevention
of EIB)
2 days/week
>2 days/week
Several times per day
Exacerbations
requiring oral systemic
corticosteroids
01/year
23/year
>3/year
Risk
Treatment-related
adverse effects
Medication side effects can vary in intensity from none to very
troublesome and worrisome. The level of intensity does not
correlate to specific levels of control but should be considered
in the overall assessment of risk.
Figure 3–5b. Assessing Asthma Control In
Children 5 - 11 Years of Age
Classification of Asthma Control
(Children 511 years of age)
Components of Control
Impairment
Well Controlled
Not Well
Controlled
Very Poorly
Controlled
Symptoms
2 days/week but
not more than
once on each day
>2 days/week or
multiple times on
2 days/week
Throughout the day
Nighttime
awakenings
1x/month
2x/month
2x/week
Interference with
normal activity
None
Some limitation
Extremely limited
Short-acting
beta2-agonist use
for symptom control
(not prevention of EIB)
2 days/week
>2 days/week
Several times per day
Lung function
 FEV1 or peak flow
>80% predicted/
personal best
6080% predicted/
personal best
<60% predicted/
personal best
 FEV1/FVC
>80%
7580%
<75%
Exacerbations requiring
oral systemic
corticosteroids
Risk
Reduction in lung growth
Treatment-related
adverse effects
01/year
2/year (see note)
Consider severity and interval since last exacerbation
Evaluation requires long-term followup.
Medication side effects can vary in intensity from none to very
troublesome and worrisome. The level of intensity does not correlate
to specific levels of control but should be considered in the overall
assessment of risk.
Figure 3–5c. Assessing Asthma Control In
Youths 12 Years of Age & Adults
Components of Control
Symptoms
Nighttime awakening
Interference with normal
activity
Impairment
Short-acting beta2-agonist use
for symptom control (not
prevention of EIB)
FEV1 or peak flow
Classification of Asthma Control
(Youths 12 years of age and adults)
Well-Controlled
Not
Well-Controlled
Very Poorly
Controlled
2 days/week
>2 days/week
Throughout the day
2x/month
13x/week
4x/week
None
Some limitation
Extremely limited
2 days/week
>2 days/week
Several times per day
>80% predicted/
personal best
6080% predicted/
personal best
<60% predicted/
personal best
0
0.75*
20
1–2
1.5
1619
3–4
N/A
15
Validated Questionnaires
ATAQ
ACQ
ACT
Exacerbations
Risk
01/year
2/year (see note)
Consider severity and interval since last exacerbation
Progressive loss of lung
function
Evaluation requires long-term followup care
Treatment-related adverse
effects
Medication side effects can vary in intensity from none to very
troublesome and worrisome. The level of intensity does not correlate to
specific levels of control but should be considered in the overall
assessment of risk.
Component 2
Education For A Partnership
In Asthma Care
56
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
57
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)
58
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.
59
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
60
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
61
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
62
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.
63
Component 3
Control Of Environmental
Factors & Comorbid Conditions
That Affect Asthma
64
65
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.
66
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.
67
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.
68
Component 4
Medications
69
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)
70
Key Points – Medications Cont.
 Quick- relief medications
– Short acting bronchodilators (SABA’s)
– Systemic corticosteroids
– Anticholinergics
71
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.
72
EPR-3, pg. 215
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.
73
Key Points:
Reducing Potential Adverse Effects
Spacers or valved holding chambers (VHCs) used with nonbreath-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.

74
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.
75
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.
76
Section 4
Managing Asthma
Long Term
“The Stepwise Approach”
2007 NAEPP Guidelines, EPR-3, pg. 277
77
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.
–
3.
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
78
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 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.
79
Key Differences – Cont.
–
–
–
6.
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.
80
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
81
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

82
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.
83
Assessing Control & Adjusting Therapy
Children 0-4 Years of Age
Classification of Asthma Control (04 years of age)
Components of Control
Impairment
Risk
Well
Controlled
Not Well
Controlled
Very Poorly Controlled
Symptoms
2 days/week
>2 days/week
Throughout the day
Nighttime awakenings
1x/month
>1x/month
>1x/week
Interference with
normal activity
None
Some limitation
Extremely limited
Short-acting
beta2-agonist use
for symptom control
(not prevention of EIB)
2 days/week
>2 days/week
Several times per day
Exacerbations requiring
oral systemic
corticosteroids
01/year
23/year
>3/year
Treatment-related
adverse effects
Recommended Action
for Treatment
(See figure 41a for
treatment steps.)
Medication side effects can vary in intensity from none to very troublesome and
worrisome. The level of intensity does not correlate to specific levels of control
but should be considered in the overall assessment of risk.
• Maintain current
treatment.
• Regular followup
every 16
months.
• Consider step
down if well
controlled for at
least 3 months.
• Step up (1 step) and
• Reevaluate in
26 weeks.
• If no clear benefit in
46 weeks, consider
alternative diagnoses
or adjusting therapy.
• For side effects,
consider alternative
treatment options.
• Consider short course of
oral systemic
corticosteroids,
• Step up (12 steps), and
• Reevaluate in 2 weeks.
• If no clear benefit in 46
weeks, consider alternative
diagnoses or adjusting
therapy.
• For side effects, consider
alternative treatment
options.
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 6
Step up if
needed
Preferred
(first check
adherence,
environment
al control)
Step 5
Step 4
Step 2
Preferred
Step 1
Preferred
SABA
PRN
Low dose
ICS
Alternative
Montelukast
or Cromolyn
Step 3
Preferred
Preferred
Medium
Dose ICS
Medium
Dose ICS
AND
Preferred
High
Dose ICS
AND
Either:
Montelukast
Either:
High
Dose ICS
AND
Either:
Montelukast
or LABA
or LABA
Montelukast
or LABA
AND
Oral
corticosteroid
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
Assess
control
Step
down if
possible
(and asthma
is well
controlled at
least 3
months)
Assessing Control & Adjusting Therapy
Children 5-11 Years of Age
Classification of Asthma Control (511 years of age)
Components of Control
Impairment
Well
Controlled
Not Well
Controlled
Very Poorly Controlled
Symptoms
2 days/week but not
more than once on each
day
>2 days/week or
multiple times on
2 days/week
Throughout the day
Nighttime
awakenings
1x/month
2x/month
2x/week
Interference with normal
activity
None
Some limitation
Extremely limited
Short-acting
beta2-agonist use
for symptom control
(not prevention of EIB)
2 days/week
>2 days/week
Several times per day
Lung function
• FEV1 or peak flow
>80% predicted/
personal best
6080% predicted/
personal best
<60% predicted/
personal best
• FEV1/FVC
>80%
7580%
<75%
Exacerbations requiring
oral systemic
corticosteroids
Risk
Reduction in
lung growth
Treatment-related
adverse effects
Recommended Action
for Treatment
(See figure 41b for
treatment steps.)
2/year (see note)
01/year
Consider severity and interval since last exacerbation
Evaluation requires long-term followup.
Medication side effects can vary in intensity from none to very troublesome and worrisome.
The level of intensity does not correlate to specific levels of control but should be
considered in the overall assessment of risk.
• Maintain current step.
• Regular followup
every 16 months.
• Consider step down if
well controlled for at
least 3 months.
• Step up at least
1 step and
• Reevaluate in
26 weeks.
• For side effects:
consider alternative
treatment options.
• Consider short course of oral
systemic corticosteroids,
• Step up 12 steps, and
• Reevaluate in 2 weeks.
• For side effects, consider
alternative treatment options.
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 5
Step 2
Preferred
Step 1
Low dose
ICS
Preferred
Alternative
SABA
PRN
LTRA,
Cromolyn
Nedocromil or
Theophylline
Step 4
Preferred
Step 3
Preferred
Preferred
Medium
Dose ICS +
LABA
High Dose
ICS + LABA
Either
Low Dose
ICS + LABA,
LTRA, or
Theophylline
OR
Medium
Dose ICS
Alternative
Medium dose
ICS + either
LTRA, or
Theophylline
Step 6
Preferred
High Dose ICS
+ LABA
+ oral
corticosteroid
Alternative
Alternative
High dose ICS
+ either LTRA,
or
Theophylline
High dose ICS +
either LTRA, or
Theophylline
+ oral
corticosteroid
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.
Step up if
needed
(first check
adherence,
environmen
tal control,
and
comorbid
conditions)
Assess
control
Step down
if possible
(and asthma
is well
controlled at
least 3
months)
Assessing Control & Adjusting Therapy
In Youths > 12 Years of Age & Adults
Classification of Asthma Control
(12 years of age)
Components of Control
Well Controlled
Impairment
Not
Well Controlled
Very Poorly
Controlled
Symptoms
2 days/week
>2 days/week
Throughout the day
Nighttime awakenings
2x/month
13x/week
4x/week
Interference with normal activity
None
Some limitation
Extremely limited
Short-acting beta2-agonist use for
symptom control (not prevention of EIB)
2 days/week
>2 days/week
Several times per day
FEV1 or peak flow
>80% predicted/
personal best
6080% predicted/
personal best
<60% predicted/
personal best
0
0.75*
20
1–2
1.5
1619
3–4
N/A
15
Validated questionnaires
ATAQ
ACQ
ACT
Exacerbations requiring oral systemic
corticosteroids
Risk
2/year (see note)
01/year
Consider severity and interval since last exacerbation
Progressive loss of lung function
Evaluation requires long-term followup care
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome
and worrisome. The level of intensity does not correlate to specific levels of
control but should be considered in the overall assessment of risk.
Recommended Action
for Treatment
(see figure 45 for treatment steps)
• Maintain current step.
• Regular followups
every 16 months to
maintain control.
• Consider step down if
well controlled for at
least 3 months.
• Step up 1 step and
• Reevaluate in
26 weeks.
• For side effects,
consider alternative
treatment options.
• Consider short course of
oral systemic
corticosteroids,
• Step up 12 steps, and
• Reevaluate in 2 weeks.
• For side effects,
consider alternative
treatment options.
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 6
Step 5
Step 4
Step 3
Preferred:
Low dose ICS
Low-dose ICS +
LABA
OR – Medium
dose ICS
Alternative:
Cromolyn,
LTRA,
Nedocromil or
Theophylline
Alternative:
Low-dose ICS +
either LTRA,
Theophylline, or
Zileuton
Step 2
Preferred:
Step 1
Preferred:
SABA
PRN
Preferred:
Medium Dose
ICS + LABA
Alternative:
Medium-dose
ICS + either
LTRA,
Theophylline,
or Zileuton
Preferred
High
Dose ICS +
LABA
AND
Consider
Omalizumab
for patients
who have
allergies
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
Step up if
needed
(first check
adherence,
environmental
control &
comorbid
conditions)
Assess
control
Step
down if
possible
(and asthma
is well
controlled at
least 3
months)
•Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 tx @ 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.
Section 5
Managing Exacerbations of
Asthma
2007 Asthma Guidelines, EPR – 3, Pg. 373
90
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
91
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.
92
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.
93
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.
94
Classifying Severity of Asthma Exacerbations in the UC or ER Setting
Severity
Mild
Moderate
Severe
Symptoms &
Signs
Dyspnea only with
activity (assess
tachypnea in young
children)
Dyspnea interferes
with or limits usual
activity
Dyspnea at rest;
interferes with
conversation
Initial PEF
(or FEV1)
Clinical Course
PEF 70 percent
predicted or personal
best



Usually cared for at home
Prompt relief with inhaled SABA
Possible short course of oral
systemic corticosteroids
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
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
Managing Asthma Exacerbations At Home
Assess Severity
Patients at high risk for a fatal attack (see figure 5–2a) require immediate medical attention
after initial treatment.
Symptoms and signs suggestive of a more serious exacerbation such as marked breathlessness,
inability to speak more than short phrases, use of accessory muscles, or drowsiness (see
figure 5–3) should result in initial treatment while immediately consulting with a clinician.
Less severe signs and symptoms can be treated initially with assessment of response to therapy
and further steps as listed below.
If available, measure PEF—values of 50–79% predicted or personal best indicate the need for
quick-relief mediation. Depending on the response to treatment, contact with a clinician may also
be indicated. Values below 50% indicate the need for immediate medical care.
Initial Treatment
 Inhaled SABA: up to two treatments 20 minutes apart of 2–6 puffs
by metered-dose inhaler (MDI) or nebulizer treatments.
 Note: Medication delivery is highly variable. Children and
individuals who have exacerbations of lesser severity may need
fewer puffs than suggested above.
Good Response
Incomplete Response
Poor Response
No wheezing or dyspnea
(assess tachypnea in young
children).
Persistent wheezing and
dyspnea (tachypnea).
Marked wheezing and dyspnea.
PEF 80% predicted or
personal best.
 Contact clinician for
followup instructions and
further management.
 May continue inhaled
SABA every 3–4 hours for
24–48 hours.
 Consider short course of
oral systemic
corticosteroids.
PEF 50–79% predicted or
personal best.
 Add oral systemic
corticosteroid.
 Continue inhaled SABA.
 Contact clinician urgently
(this day) for further
instruction.
PEF <50% predicted or
personal best.
 Add oral systemic
corticosteroid.
 Repeat inhaled SABA
immediately.
 If distress is severe and
nonresponsive to initial
treatment:
—Call your doctor AND
—PROCEED TO ED;
—Consider calling 9–1–1
(ambulance transport).
 To ED.
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
97
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
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Minnesota Department of Health
Asthma Program
www.health.state.mn.us/asthma
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