National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma

1
National Asthma Education and Prevention
ProgramExpert Panel Report 2Guidelines for
the Diagnosis and Management of Asthma
2
Second Expert Panel

• Multidisciplinary group of clinicians and
  scientists with expertise in asthma management
• Health professionals from internal medicine,
  family medicine, pediatrics, emergency medicine,
  allergy, pulmonary medicine, nursing, pharmacy,
  and health education

3
Charge to the Second Expert Panel

• Review and update the 1991 Expert Panel Report
• Prepare recommendations for health care providers
  working in diverse health care settings
• Address practical decisionmaking issues in the
  diagnosis and management of asthma
• Develop specific aids to facilitate implementation

4
Expert Panel Report 2Four Components ofAsthma
Management

• Measures of Assessment and Monitoring
• Control of Factors Contributing to Asthma
  Severity
• Pharmacologic Therapy
• Education for a Partnership in Asthma Care

5
Component 1 Measures of Assessment and
Monitoring

• Two aspects
• Initial assessment and diagnosis of asthma
• Periodic assessment and monitoring

6
Initial Assessment and Diagnosis of Asthma

• Determine that
• Patient has history or presence of episodic
  symptoms of airflow obstruction
• Airflow obstruction is at least partially
  reversible
• Alternative diagnoses are excluded

7
Initial Assessment andDiagnosis of Asthma
(continued)

• Methods for establishing diagnosis
• Detailed medical history
• Physical exam
• Spirometry to demonstrate reversibility

8
Initial Assessment andDiagnosis of Asthma
(continued)

• Does patient have history or presence of
• episodic symptoms of airflow obstruction?
• Wheeze, shortness of breath, chest tightness, or
  cough
• Asthma symptoms vary throughout the day
• Absence of symptoms at the time of the
  examination does not exclude the diagnosisof
  asthma

9
Initial Assessment andDiagnosis of Asthma
(continued)

• Are alternative diagnoses excluded?
• Vocal cord dysfunction, vascular rings, foreign
  bodies, other pulmonary diseases

10
Underdiagnosis of Asthma in Children

• The majority of people with asthma experience
  onset before age 5.
• Commonly misdiagnosed as
• Chronic bronchitis
• Wheezy bronchitis
• Recurrent croup
• Recurrent upper respiratory infection
• Recurrent pneumonia

11
Wheezing Infants When Is It Asthma?

• Patterns of wheezing in infants
• Those who develop asthma
• Those who do not develop asthma.
• Both groups generally benefit from a trial of
  treatment

12
Wheezing Infants When Is It Asthma? (continued)

• Risk factors for asthma
• Family history of asthma
• Atopy
• Perinatal exposure to aeroallergens and
  irritants(e.g., passive smoke)

13
General Guidelines for Referral to an Asthma
Specialist

• Based on the opinion of the Expert Panel,
• referral for consultation or care to a specialist
  in
• asthma care (usually, a fellowship-trained
• allergist or pulmonologist occasionally, other
• physicians with expertise in asthma
• management developed through additional
• training and experience) is recommended
• when

14
General Guidelines for Referral to an Asthma
Specialist (continued)

• Patient has had a life-threatening asthma
  exacerbation.
• Patient is not meeting the goals ofasthma
  therapy.
• Signs and symptoms are atypical.
• Other conditions complicate asthma.

15
General Guidelines for Referral to an Asthma
Specialist (continued)

• Patient requires continuous oral corticosteroid
  therapy or high-doseinhaled corticosteroids.
• Child ?5 and requires step 3 or 4 care. When
  child is ?5 and requires step 2 care, referral
  should be considered.

16
Periodic Assessment and Monitoring

• Teach all patients with asthma to recognize
  symptoms that indicate inadequateasthma control.
• Patients should be seen by a clinicianat least
  every 1 to 6 months.

17
Goals of Asthma Therapy

• Prevent chronic and troublesome symptoms
• Maintain (near-) normal pulmonary function
• Maintain normal activity levels (including
  exercise and other physical activity)

18
Goals of Asthma Therapy (continued)

• Prevent recurrent exacerbations and minimize the
  need for emergency department visits or
  hospitalizations
• Provide optimal pharmacotherapy with minimal or
  no adverse effects
• Meet patients and families expectations of, and
  satisfaction with, asthma care

19
Monitoring the Goals of Therapy

• Recognition of signs and symptoms
• Spirometry and peak flow
• Quality of life/functional status
• Patient self-monitoring and health care
  utilization
• Adherence, beta2-agonist use, oral corticosteroid
  bursts, side effects
• Satisfaction with asthma control and qualityof
  care

20
Monitoring Symptoms

• Symptom history should be based ona short (2 to
  4 weeks) recall period
• Symptom history should include
• Daytime asthma symptoms
• Nocturnal wakening as a result ofasthma symptoms
• Exercise-induced symptoms
• Exacerbations

21
Importance of Action Plan

• It is the opinion of the Expert Panel that all
  patients should be given a written action plan
  and be instructed to use it.

22
Monitoring History of Exacerbations

• Review patient self-monitoring records
• Ask about frequency, severity, and causes of
  exacerbations
• Ask about unscheduled, emergency, or hospital care

23
Monitoring Quality of Life/Functional Status

• Periodically assess
• Missed work or school due to asthma
• Reduction in usual activities due to asthma
• Sleep disturbances due to asthma
• Change in caregiver activities due tochilds
  asthma

24
Monitoring Pharmacotherapy

• Monitor
• Patient adherence to regimen
• Inhaler technique
• Frequency of inhaled short-actingbeta2-agonist
  use
• Frequency of oral corticosteroid burst therapy
• Side effects of medications

25
Component 2 Control of Factors Contributing
to Asthma Severity

• Assess exposure and sensitivity to
• Inhalant allergens
• Occupational exposures
• Irritants
• Indoor air (including tobacco smoke)
• Air pollution

26
Component 2Control of FactorsContributing to
Asthma Severity (continued)

• Assess contribution of other factors
• Rhinitis/sinusitis
• Gastroesophageal reflux
• Drugs (NSAIDs, beta-blockers)
• Viral respiratory infections
• Sulfite sensitivity

27
Approach to theIdentification and Control of
Inhalant Allergens

• Determine relevant exposures
• Assess sensitivity to
• Seasonal allergens by history
• Perennial allergens by history, and when
  necessary, skin or in vitro testing
• Assess significance of positive tests in context
  of medical history

28
Significant Inhalant Allergens Additional
Considerations

• Air conditioning allows windows to remain closed
  and reduces indoor humidity.
• Humidifiers and evaporative coolers arenot
  recommended.

29
Reduce Irritant Exposure

• Tobacco Smoke
• Advise patient and others in home who smoke to
  stop or to smoke outside
• Discuss ways to reduce exposure from day care,
  workplace, and other settings

30
Component 3 Pharmacologic Therapy

• Environmental risk factors (causes)
• INFLAMMATION
• Airway Airflow
• hyperresponsiveness limitation
• Precipitants
• Adapted with permission from Stephen T. Holgate,
  M.D., D.Sc. Symptoms
  
• Asthma is a chronic inflammatory disorder of the
  airways.
• A key principle of therapy is regulation of
  chronic airway inflammation.

31
(No Transcript)
32
Inhaled Medication Delivery Devices

• Metered-dose inhaler (MDI)
• Dry powder inhaler (DPI)
• Spacer/holding chamber
• Spacer/holding chamber and face mask
• Nebulizer

33
(No Transcript)
34
(No Transcript)
35
Transition to Non-CFC Inhalers

• Most currently available MDIs use
  chlorofluorocarbons(CFCs) as propellants.
• CFCs are being phased out globally to protectthe
  earths ozone layer.
• CFC MDIs have a temporary medical exemptionto
  the phaseout.
• Over the next several years, CFC MDIs will be
  gradually replaced by non-CFC alternatives.
• Non-CFC alternatives will include HFA MDIs,
  DPIs,and other new devices.

36
Overview ofAsthma Medications

• Daily Long-Term Control
• Corticosteroids (inhaled and systemic)
• Cromolyn/nedocromil
• Long-acting beta2-agonists
• Methylxanthines
• Leukotriene modifiers

37
Overview of Asthma Medications (continued)

• As-needed Quick Relief
• Short-acting beta2-agonists
• Anticholinergics
• Systemic corticosteroids

38
Inhaled Corticosteroids

• Most effective long-term-control therapy for
  persistent asthma
• Small risk for adverse events at recommended
  dosage
• Reduce potential for adverse events by
• Using spacer and rinsing mouth
• Using lowest dose possible
• Using in combination with long-acting
  beta2-agonists
• Monitoring growth in children

39
Inhaled Corticosteroids(continued)

• Benefit of daily use
• Fewer symptoms
• Fewer severe exacerbations
• Reduced use of quick-relief medicine
• Improved lung function
• Reduced airway inflammation

40
(No Transcript)
41
Inhaled Corticosteroids and Linear Growth in
Children

• Potential risks are well balanced by benefits.
• Growth rates in children are highly variable.
  Short-term evaluations may not be predictive of
  attaining final adult height.
• Poorly controlled asthma may delay growth.
• Children with asthma tend to have longerperiods
  of reduced growth rates prior to puberty (males gt
  females).

42
Inhaled Corticosteroids and Possible Effect
onLinear Growth

• Most studies show no effect with low-to-medium
  doses,but some short-term studies show growth
  delay.
• Potential risk appears to be dose dependent
• Medium doses may be associated with possible, but
  notpredictable, effect on linear growth. The
  clinical significancehas not yet been
  determined.
• High doses have greater potential for growth
  delay or suppression.
• For severe persistent asthma, high doses of
  inhaled corticosteroids have less risk than oral
  corticosteroids.

43
Inhaled Corticosteroids and Possible Effect
onLinear Growth (continued)

• Some caution is suggested while studies continue
• Monitor growth
• Use the lowest dose necessary to maintain
  control(step down therapy when possible)
• Administer with spacers/holding chambers
• Advise patients to rinse and spit following
  inhalation
• Consider adding a long-acting inhaled
  beta2-agonist to alow-to-medium dose of inhaled
  corticosteroids (vs. using a higher dose of the
  corticosteroid)

44
Estimated ComparativeDosages ofInhaled
Corticosteroids

• Preparations are not equivalent per puff or per
  microgram.
• Comparative doses are estimated.
• Few data directly compare preparations.
• Most important determinant of dosingis clinician
  judgment.
• Monitor patients clinical response to therapy.
• Adjust dose accordingly.

45
Long-Acting Beta2-Agonists

• Not a substitute for anti-inflammatory therapy
• Not appropriate for monotherapy
• Beneficial when added to inhaled corticosteroids
• Not for acute symptoms or exacerbations

46
Short-Acting Beta2-Agonists

• Most effective medication for relief of acute
  bronchospasm
• More than one canister per month suggests
  inadequate asthma control
• Regularly scheduled use is not generally
  recommended
• May lower effectiveness
• May increase airway hyperresponsiveness

47
Leukotriene Modifiers

• Mechanisms
• 5-LO inhibitors
• Cysteinyl leukotriene receptor antagonists
• Indications
• Long-term-control therapy in mildpersistent
  asthma
• Improve lung function
• Prevent need for short-acting beta2-agonists
• Prevent exacerbations
• Further experience and research needed

48
Stepwise Approach to Therapy Gaining Control
1. Start high and step down.


2.
Start at initial level of severity gradually
step up.
STEP 4
Severe Persistent
2
STEP 3
1
Moderate Persistent
STEP 2
Mild Persistent
STEP 1
Mild Intermittent
49
Stepwise Approach to Therapy for Adults and
Children gtAge 5 Maintaining Control

• Step down if possible
• Step up if necessary
• Patient education and environmental control at
  every step
• Recommend referral to specialist atStep 4
  consider referral at Step 3

STEP 4 Multiple long-term-control medications,
includeoral corticosteroids
STEP 3 gt 1 Long-term-control medications
STEP 2 1 Long-term-control medication
anti-inflammatory
STEP 1 Quick-relief medication PRN
50
Step 1 Treatment for Adults and Children gt5
Mild Intermittent

• Daily Long-Term Control
• Not needed
• Quick Relief
• Short-acting inhaledbeta2-agonist PRN
• Increasing use, or use more than 2x/week, may
  indicate need for long- term-control therapy
• Intensity of treatment depends on severity of
  exacerbation

STEP 1
51
Step 2 Treatment for Adults and Children gt5
Mild Persistent

• Daily Long-Term Control
• Anti-inflammatory
• Inhaled corticosteroid (low dose) or
• Cromolyn or nedocromil
• OR
• Sustained-release theophylline (to
  serum concentration 5-15
  mcg/mL) is an alternative but not preferred
• Leukotriene modifier may be considered

STEP 2
52
Step 3 Treatment for Adults andChildren gt5
Moderate Persistent

• Daily Long-Term Control
• Inhaled corticosteroid (medium dose)
• OR
• Inhaled corticosteroid (low-to-medium dose) AND
• Long-acting bronchodilator
  (long-acting beta2-agonist
• or sustained-release theophylline)
• IF NEEDED, increase to
• Inhaled corticosteroid (medium-to-high dose)
  andlong-acting bronchodilator
• Consider referral to a specialist

STEP 3
53
Step 4 Treatment for Adults andChildren gt5
Severe Persistent

• Daily Long-Term Control
• Inhaled corticosteroid (high dose) AND
• Long-acting bronchodilator
• Long-acting inhaledbeta2-agonist OR
• Sustained-release theophylline OR
• Long-acting beta2-agonist tablets AND
• Oral corticosteroid, long term
• Recommend referral to a specialist

STEP 4
54
Treatment for Infants and Young Children With
Viral Respiratory Infection

• Short-acting inhaled beta2-agonist q 4 to 6 hours
  up to 24 hours (longer with physician consult)
• Consider step up if repeated more than once every
  6 weeks
• Consider systemic corticosteroid if
• Current exacerbation is severe
• OR
• Patient has history of previous severe
  exacerbations

55
School-Age Children Special Considerations

• In addition to following adult management
  principles
• Give special consideration to school
  anddevelopmental issues
• Monitor growth in children receiving
  corticosteroids
• Consider use of cromolyn or nedocromil first
  forStep 2 care
• Encourage active participation in physical
  activity
• Provide written asthma management planfor home
  and school
• Involve children in developing plan

56
Managing Exercise-Induced Bronchospasm (EIB)

• Anticipate EIB in all patients
• Teachers and coaches need to be notified
• Diagnosis
• History of cough, shortness of breath, chest pain
  or tightness, wheezing, or endurance
  problemsduring exercise
• Conduct exercise challenge OR have
  patientundertake task that provoked the symptoms
• 15 decrease in PEF or FEV1 is compatible with EIB

57
Managing Exercise-Induced Bronchospasm (EIB)
(continued)

• Management Strategies
• Short-acting inhaled beta2-agonists used shortly
  before exercise last 2 to 3 hours
• Salmeterol may prevent EIB for 10 to 12 hours
• Cromolyn and nedcromil are also acceptable
• A lengthy warmup period before exercise may
  preclude medications for patients who can
  tolerate it
• Long-term-control therapy, if appropriate

58
Component 4 Education for aPartnership in
Asthma Care

• The goal of all patient education is to help
  patients take the actions needed to control their
  asthma.

59
Establish a Partnership

• Patient education should begin at diagnosis and
  be integrated into every step of medical care.
• Principal clinician should introduce key
  educational messages and negotiate agreements
  with patients.
• Other members of the health care team should
  reinforce and expand patient education.
• Team members should document in the patients
  record the key educational points, patient
  concerns, and actions the patient agrees to take.

60
Key Educational Messages for Asthma

• Basic Facts About Asthma
• Contrast normal and asthmatic airways
• Roles of Medications
• Long-term-control and quick-relief medications
• Skills
• Inhalers, spacers, symptom and peak flow
  monitoring, early warning signs of attack
• Relevant Environmental Control Measures
• When and How To Take Rescue Actions

61
Education for a Partnershipin Asthma CareKey
Patient Tasks

• Take daily medications for long-term control as
  prescribed
• Use metered-dose inhalers, spacers, and
  nebulizers correctly
• Identify and control factors that makeasthma
  worse

62
Jointly Develop Treatment Goals

• Determine the patients personaltreatment goals
• Share the general goals of asthma treatment with
  the patient and family
• Prevent troublesome symptoms, including nocturnal
  symptoms
• Maintain (near-) normal lung function
• Maintain normal activity levels (including
  exercise and other physical activity). Not miss
  work or school due to asthma symptoms

63
Jointly Develop Treatment Goals (continued)

• Prevent recurrent exacerbations of asthma and
  minimize the need for emergency department visits
  or hospitalizations
• Provide optimal pharmacotherapy with least amount
  of adverse effects
• Meet patients and families expectations of
• and satisfaction with asthma care
• Agree on the goals of treatment

64
Patient Education by Clinicians Initial Visit

• Assessment Questions
• Focus on concerns, quality of life,
  expectations, goals
• Information
• Teach what is asthma, treatments, when to seek
  medical advice
• Skills
• Teach correct inhaler/spacer use, signs and
  symptoms of asthma, signs of deterioration,
  action plan

65
Patient Education by CliniciansFirst Followup
Visit

• Assessment Questions
• Ask New concerns? medication use? problems?
• Information
• Teach Use of types of medications evaluation
  of progress in asthma control
• Skills
• Teach Use of action plan correct inhaler use
  consider peak flow monitoring

66
Education for a Partnership in Asthma Care
Increasing the Likelihood of Compliance

• Fit the daily medication regimen into the
  patients and familys daily routines.
• Identify and address obstacles and concerns.
• Ask for agreement/plans to act.

67
Education for a Partnership in Asthma Care
Increasing the Likelihood of Compliance
(continued)

• Encourage or enlist family involvement.
• Follow up. At each visit, review the performance
  of the agreed-upon actions.
• Assess the influence of the patients cultural
  beliefs and practices that might affect asthma
  care.