NOTES:

• The most important determinant of appropriate dosing is the clinician’s judgment of the patient’s response to therapy. The clinician must monitor the patient’s response on several clinical parameters and adjust the dose accordingly. The stepwise approach to therapy emphasizes that once control of asthma is achieved, the dose of medication should be carefully titrated to the minimum dose required to maintain control, thus reducing the potential for adverse effect.
• See figure 3-5c for an explanation of the rationale used for the comparative dosages. The reference point for the range in the dosages for children is data on the safety of inhaled corticosteroids in children, which, in general, suggest that the dose ranges are equivalent to beclomethasone dipropionate 200-400 mcg/day (low dose), 400-800 mcg/day (medium dose), and >800 mcg/day (high dose).
• Some dosages may be outside package labeling.
• Metered-dose inhaler (MDI) dosages are expressed as the actuater dose (the amount of drug leaving the actuater and delivered to the patient), which is the labeling required in the United States. This is different from the dosage expressed as the valve dose (the amount of drug leaving the valve, all of which is not available to the patient), which is used in many European countries and in some of the scientific literature. Dry powder inhaler (DPI) doses (e.g., Turbuhaler) are expressed as the amount of drug in the inhaler following activation.

Figure 3-5c

Data from in vitro and clinical trials suggest that the different inhaled corticosteroid preparations are not equivalent on a per puff or microgram basis. However, it is not entirely clear what implications these differences have for dosing recommendations in clinical practice because there are few data directly comparing the preparations. Relative dosing for clinical comparability is affected by differences in topical potency, clinical effects at different doses, delivery device, and bioavailability. The Expert Panel developed recommended dose ranges (see figure 3-5b) for different preparations based on available data and the following assumptions and cautions about estimating relative doses needed to achieve comparable clinical effect.

Relative topical potency using human skin blanching

• The standard test for determining relative topical anti-inflammatory potency is the topical vasoconstriction (MacKenzie skin blanching) test.
• The MacKenzie topical skin blanching test correlates with binding affinities and binding half-lives for human lung corticosteroid receptors (see table below) (Dahlberg et al. 1984; Högger and Rohdewald 1994).
• The relationship between relative topical anti-inflammatory effect and clinical comparability in asthma management is not certain. However, recent clinical trials suggest that different in vitro measures of anti-inflammatory effect correlate with clinical efficacy (Barnes and Pedersen 1993; Johnson 1996; Kamada et al. 1996; Ebden et al. 1986; Leblanc et al. 1994; Gustafsson et al. 1993; Lundback et al. 1993; Barnes et al. 1993; Fabbri et al. 1993; Langdon and Capsey 1994; Ayres et al. 1995; Rafferty et al. 1985; Bjorkander et al. 1982; Stiksa et al. 1982; Willey et al. 1982).

* Numbers are assigned in reference to dexamethasone, which has a value of "1" in the MacKenzie test.

Relative doses to achieve similar clinical effects:

• Clinical effects are evaluated by a number of outcome parameters (e.g., changes in spirometry, peak flow rates, symptom scores, quick-relief beta2-agonist use, frequency of exacerbations, airway responsiveness).
• The daily dose and duration of treatment may affect these outcome parameters differently (e.g., symptoms and peak flow may improve at lower doses and over a shorter treatment time than bronchial reactivity) (van Essen-Zandvliet et al. 1992; Haahtela et al. 1991)
• Delivery systems influence comparability. For example, the delivery device for budesonide (Turbuhaler) delivers approximately twice the amount of drug to the airway as the MDI, thus enhancing the clinical effect (Thorsson et al. 1994; Agertoft and Pedersen1993).
• Individual patients may respond differently to different preparations, as noted by clinical experience.

Clinical trials comparing effects in reducing symptoms and improving peak expiratory flow demonstrate:

• BDP and BUD achieved comparable effects at similar microgram doses by MDI (Bjorkander et al. 1982; Ebden et al. 1986; Rafferty et al. 1985).
• BDP achieved effects similar to twice the dose of TAA on a microgram basis.
• FP achieved effects similar to twice the dose of BDP and BUD via an MDI on a microgram basis (Gustaffson et al. 1993; Fabbri et al. 1993; Barnes et al. 1993; Dahl et al. 1993; Ayres et al. 1995).
• BUD by Turbuhaler achieved effects similar to twice the dose delivered by MDI, thus implying greater bronchial delivery by the delivery device (Thorsson et al. 1994; Agertoft and Pedersen 1993).

Bioavailability

Both the relative potency and the relative bioavailability (systemic availability) determine the potential for systemic activity of an inhaled corticosteroid preparation. As illustrated here, the bioavailability of an inhaled corticosteroid is dependent on the absorption of the dose delivered to the lungs and the oral bioavailability of the swallowed portion of the dose received.

Absorption of the dose delivered to the lungs:

• Approximately 10 to 30 percent of the dose from the MDI is delivered to the lungs. This amount varies among preparations and delivery devices.
• Nearly all of the amount delivered to the lungs is bioavailable.
• Oral bioavailability of the swallowed portion of the dose received:
• Approximately 80 percent of the dose from the MDI without a spacer/holding chamber is swallowed.

Absorption of the dose delivered to the lungs:

• Either a high first-pass liver metabolism or the use of a spacer/holding chamber with an MDI can decrease oral bioavailability, thus enhancing safety (Lipworth 1995).
• The approximate oral bioavailability of inhaled corticosteroids has been reported as: BDP 20%; FLU 21%; TAA 10.6%; BUD 11%; FP 1% (Chaplin et al. 1980; Check and Kaliner 1990; Clissold and Heel 1984; Davies 1993; Harding 1990; Heald et al. 1995; Martin et al. 1974; Mollman et al. 1985; Szefler 1991; Wurthwein and Rohdewald 1990).

Adapted from Barnes 1995

Although few clinical trials are available that compare systemic activity among preparations (Kamada et al. 1996), studies have found:

• As suggested by one cross-over comparison study, BDP, FLU, and TAA appear to have equivalent dose-dependent systemic activity, as measured by 24-hour urinary free cortisol excretion (McCubbin et al. 1995).
• Inconsistent results comparing BDP and BUD. Some show equivalent systemic activity (Kamada et al. 1996; Prahl 1991; Prahl et al. 1987); others show BUD having slightly less systemic activity than BDP (Barnes and Pedersen 1993; Pedersen and Fuglsang 1988; Bisgaard et al. 1988).
• FP had greater adrenal suppression at doses of 400 to 2,000 micrograms than BUD in equivalent microgram doses delivered by MDI and accompanied by mouth washing to prevent oral bioavailability (Clark et al. 1996). This confirms that there are differences in microgram potencies among preparations and that absorption through the lung can result in systemic activity.

Local Adverse Effects

Oral candidiasis (thrush) is one of the most common adverse effects of inhaled corticosteroids. Positive throat cultures of Candida can be identified in about 45 to 58 percent of patients, whereas clinical thrush is diagnosed in only 0 to 34 percent of patients (Rinehart et al. 1975; Toogood et al. 1980; Shaw and Edmunds 1986). With lower dosages of inhaled corticosteroids, candidiasis is uncommon (5 percent) (Rinehart et al. 1975), although it is more frequent in adults than in children. Prevention and treatment: Use a spacer/holding chamber to reduce the incidence of colonization and clinical thrush, rinse mouth with water after inhalation (Selroos and Halme 1991), and administer inhaled corticosteroids less frequently (bid vs. qid). Topical or oral antifungal agents should be used to treat active infections.

Dysphonia is reported in 5 to 50 percent of patients using inhaled corticosteroids and is associated with vocal stress and increasing dosages of inhaled corticosteroids (Toogood et al. 1980). Prevention and treatment: Use a spacer/holding chamber, temporarily reduce dosage, or rest for vocal stress.

Slower rates of inspiration and/or use of a spacer/holding chamber or pretreatment with an inhaled beta2 -agonist can reduce reflex cough and bronchospasm. There is no convincing evidence that the routine use of an inhaled beta2 -agonist prior to each dose of inhaled corticosteroids increases intrapulmonary delivery of the inhaled corticosteroid or reduces dosage requirement.

Systemic Adverse Effects

Key Points: Inhaled Corticosteroids and Linear Growth in Children

• The potential risks of inhaled corticosteroids are well balanced by their benefits.
• Growth rates are highly variable in children. Short-term evaluations may not be predictive of attaining final adult height.
• Poorly controlled asthma may delay growth in children.
• The potential for adverse effects on linear growth from inhaled corticosteroids appears to be dose dependent. In treating children with mild-to-moderate persistent asthma, medium-dose inhaled corticosteroid therapy may be associated with a possible, but not predictable, adverse effect on linear growth. The clinical significance of this potential systemic effect has yet to be determined. High doses of inhaled corticosteroids have greater potential for growth suppression.
• Use of high doses of inhaled corticosteroids with children with severe persistent asthma has significantly less potential for having an adverse effect on linear growth than oral systemic corticosteroids.
• A majority of studies of the use of inhaled corticosteroids by children have not demonstrated an effect on growth, but a few have identified growth delay. Some caution (e.g., monitoring growth, stepping down therapy when possible) is suggesting while this issue is studied further.

Linear Growth. The potential effects of inhaled corticosteroids on children’s growth are important because the drugs are more likely to be used for longer periods of time, although it is recognized that poorly controlled asthma itself may result in retarded linear growth. Growth in children with asthma who have not received any form of corticosteroid therapy may be influenced by concomitant atopy, asthma severity, and being male, among other factors (Kamada and Szefler 1995; Allen 1996). Indeed, childhood asthma appears to be associated with delayed maturation and a longer period of reduced growth prior to puberty. Although this could be viewed as growth suppression, these delays do not appear to compromise the attainment of final predicted adult heights (Balfour-Lynn 1986; Allen 1996).

Because of these numerous confounding factors, evaluating the effects of systemic or inhaled corticosteroids on growth in children with asthma has been challenging and has led to contradictory findings.

A few studies of children with asthma have identified some growth delay in those treated with inhaled corticosteroids, suggesting that some caution may be prudent until this important issue can be studied further. A 1-year controlled trial comparing children with mild-to-moderate asthma receiving either inhaled beclomethasone (400 mcg per day, administered without a spacer/holding chamber) or oral theophylline demonstrated slower growth in children receiving beclomethasone (Tinkelman et al. 1993). In a placebo-controlled, community-based 7-month study of 7- to 9-year-old children to determine the effect on growth during treatment with beclomethasone at 400 mcg/day, growth was significantly decreased in both males and females, and there was no evidence of catchup growth during a 5-month washout period (Doull et al. 1995). However, the results of this short-term study may not reflect effects on long-term growth.

A recent meta-analysis of the influence of inhaled beclomethasone in the attainment of expected adult height did not find any significant adverse effects regardless of dose, duration of asthma, or disease severity (Allen et al. 1994). An uncontrolled followup study (mean duration of 2.7 years, range of 1 to 5 years) of prepubertal children with moderate asthma found no effect of inhaled budesonide (800 mcg mean daily dose) on long-term growth (Ninan and Russell 1992). A majority of studies do not demonstrate a negative effect on growth with dosages of 400 to 800 mcg a day (Wolthers 1996; Kamada et al. 1996; Kamada and Szefler 1995; Barnes and Pederson 1993).

Bone Metabolism/Osteoporosis. The few published observations regarding the effect of inhaled corticosteroids on bone metabolism and osteoporosis are complicated by oral corticosteroid use and small patient populations (Jennings et al. 1991a, 1991b; Toogood et al. 1991). The effects of inhaled corticosteroid on markers of skeletal metabolism—serum osteocalcin, serum alkaline phosphatase, and urinary hydroxyproline:creatinine ratio—are equivocal (Hodsman et al. 1991; Jennings et al. 1991a; Ali et al. 1991). The clinical implications in terms of risk of osteoporosis and fracture after long-term use of inhaled corticosteroids are still unknown (Jennings et al. 1991b; Pouw et al. 1991). Although low and medium dosages of inhaled corticosteroids appear to have no major adverse effects on any clinically important measure of bone metabolism (Toogood et al. 1991, 1995), a dose-dependent, yet significant, reduction in bone mineral content of subjects with asthma has been associated with inhaled corticosteroid use (Packe et al. 1992; Puolijoki et al. 1992; Toogood et al. 1988). Elderly female patients may be more at risk due to preexisting osteoporosis, previous use of oral corticosteroids, a sedentary lifestyle, and the normal changes of estrogen in aging that affect calcium utilization. However, the risk of uncontrolled asthma, which may unnecessarily limit the patient’s mobility and activities, must be weighed against the limited risks of using inhaled corticosteroids. Prevention and treatment: Concurrent treatment with calcium supplements and vitamin D (and estrogen replacement where appropriate) is reasonable.

Disseminated Varicella. Although high doses of inhaled corticosteroids theoretically present risks similar to those of systemic corticosteroids, the reports of disseminated Varicella in patients receiving only inhaled corticosteroids are rare, causality is not clear, and there is no evidence that recommended doses of inhaled corticosteroids are immunosuppressive. Cases have been reported of children with severe persistent asthma on immunosuppressive doses of systemic corticosteroids developing fatal disseminated disease from Varicella infection (Kasper and Howe 1990; Silk et al. 1988). Other case reports indicate complications for patients with Strongyloides or tuberculosis who take high doses of systemic corticosteroids. Prevention and treatment: Children who require episodic therapy with systemic corticosteroids who have not had clinical Varicella should receive the Varicella vaccine. The vaccine should not be administered to patients who are receiving immunosuppressive doses of systemic corticosteroids (2 mg/kg or more of prednisone equivalent or 20 mg/day of prednisone for more than 1 month), unless this dosage is discontinued for at least 1 month. Children who have completed a short prednisone course may receive Varicella vaccine without delay (American Academy of Pediatrics 1995; CDC 1994). Children and adults on treatment with immunosuppressive doses of corticosteroids who have not been immunized against Varicella and are exposed to Varicella infection are candidates for zoster immunoglobulin and therapy with oral acyclovir. Should they develop clinical Varicella, intravenous acyclovir with or without zoster immunoglobulin should be given.

Dermal thinning and increased ease of skin bruising have been observed in elderly subjects treated with inhaled corticosteroids. The effect is dose dependent, but the threshold dose is variable (Capewell et al. 1990).

Hypothalamic Pituitary Axis (HPA) Function. The issue of inhaled corticosteroid effects on HPA function is complex and requires further study. Several studies indicate that low-to-medium doses of inhaled corticosteroids do not appear to have significant effects on HPA function (Doull et al. 1995; Goldstein and Konig 1983). However, some studies showed that, compared with placebo, both beclomethasone and budesonide reduced the 24-hour urinary cortisol excretion even in doses as low as 400 to 500 mcg daily (Tabachnik and Zadik 1991; Prahl 1991). At higher doses, there appears to be a dose-dependent effect on different measures of HPA function (Kamada et al. 1996; Brown et al. 1993). Fluticasone caused greater adrenal suppression at doses of 400 to 2,000 mcg than budesonide in equivalent doses (Clark et al. 1996; Boorsma et al. 1996). The clinical significance, if any, of these findings is not known.

Cataracts. Although cataracts are a documented adverse effect of systemic corticosteroids, there appears to be no association between inhaled corticosteroids and posterior subcapsular cataracts in adults (Toogood et al. 1993) or children (Simons et al. 1993; Rooklin et al. 1979).

Glucose Metabolism. In a study of children, inhaled corticosteroids at dosages from 400 to 1,000 mcg/day (budesonide) failed to affect fasting glucose or glycated hemoglobin (Turpeinen et al. 1991). At 1,000 mcg/day, a significantly greater rise in fasting serum insulin levels and glucose during a glucose tolerance test was noted, but results remained within normal limits.

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Guidelines for the Health Care Professionals to Instruct Patients Using Inhaled Medications

Correct Use of Inhalers and Spacers
Materials Needed:

• A metered dose inhaler
• A spacer or holding chamber
• Some dosages may be outside package labeling.
• Worksheet No. 12: Correct Use of a Metered Dose Inhaler (MDI)
• Worksheet No. 13: Spacers

Reminder: Identify and address the patient's or parent's concerns and expectations at every visit.

Step 1: Refer to Worksheet No. 12: Correct Use of a Metered Dose Inhaler (MDI) to discuss and then demonstrate the correct use of inhaled medicines.

• Describe the advantages and disadvantages of using inhaled medicines.
• Demonstrate to the patient how to use each inhaled medicine prescribed.
• Ask the patient to demonstrate to you the correct use of each inhaled medicine prescribed.
• Explain that if the patient is taking both bronchodilator and antiinflammatory medicines, the inhaled bronchodilators are usually taken first.
• If more than one inhaler is prescribed, label each in order of intended use.
• Give the patient Worksheet No. 12.

Step 2: Assess the patient's need for a spacer or holding chamber.
The following criteria indicate who may benefit from using a spacer or holding chamber:

• The young patient
• The patient with coordination problems
• The patient with particularly irritable airways

Step 3: Refer to Worksheet No. 13: Spacers to describe and then demonstrate the correct use of an inhaler with a spacer or holding chamber attached.

• Explain the purpose and advantages of using a spacer.
• Demonstrate to the patient the correct use of the metered dose inhaler with spacer or holding chamber attached.
• Ask the patient to demonstrate to you the correct use of the metered dose inhaler with the spacer attached.
• Emphasize the importance of closing the mouth around the mouthpiece when using a spacer or holding chamber to allow for maximum effectiveness of the medicine.
• Give the patient Worksheet No. 13.

Step 4: Tell the patient that his or her MDI technique will be reviewed periodically.

Correct Use of Nebulizer

Materials Needed

• A nebulizer (with a mouthpiece)
• Water
• Empty sample bottle of liquid beta2-agonist medicine with

Reminder Identify and address the patient's or parent's concerns and expectations at every visit.

Step 1: Assess the patient's need for a nebulizer.
The following criteria indicate who may benefit from using a nebulizer:

• The young patient (under age 5)
• The patient with coordination problems
• The patient with severe asthma

Step 2: Refer to Worksheet Supervise the use of nebulizers closely in order to avoid inappropriate doses and too frequent use.

• Describe the advantages and disadvantages of using a nebulizer.
• Emphasize the importance of correctly measuring the medicine and saline solution.
• Demonstrate to the patient how to use the nebulizer. Use an empty sample medicine bottle filled with water to show the patient how much medicine and saline solution to use.
• Ask the patient to demonstrate to you the correct use of the nebulizer.
• Explain the importance of proper cleaning of the nebulizer to prevent infection.
• Supervise the use of nebulizers closely in order to avoid inappropriate doses and too frequent use.

Step 3: Review the patient's weight periodically and adjust medicine dosages accordingly (children only).

Patient Worksheet 12

Using a metered dose inhaler is a good way to take asthma medicines. There are few side effects because the medicine goes right to the lungs and not to other parts of the body. It takes only 5 to 10 minutes for the medicine to have an effect compared to liquid asthma medicines, which can take 1 to 3 hours. Inhalers can be used by all asthma patients age 5 and older. A spacer or holding chamber attached to the inhaler can help make taking the medicine easier for even younger children. These devices are helpful to people having trouble using an inhaler. Worksheet No. 13 tells about spacers. The inhaler must be cleaned often to prevent buildup that will clog it and reduce how well it works.

• The guidelines that follow will help you use the inhaler the right way.
• Ask your doctor or nurse to show you how to use the inhaler.

Using the Inhaler

1. Remove the cap and hold the inhaler upright.
2. Shake the inhaler.
3. Tilt your head back slightly and breathe out.
4. Use the inhaler in any one of these ways. (A is the best way, but C is okay if you are having trouble with A or B.)

     A. Open mouth with inhaler 1 to 2 inches away
     B. Use spacer (Worksheet No. 13 tells how to use an inhaler with a spacer)
     C. In the mouth

5. Press down on the inhaler to release the medicine as you start to breathe in slowly.
6. Breathe in slowly for 3 to 5 seconds.
7. Hold your breath for 10 seconds to allow the medicine to reach deeply into your lungs.
8. Repeat puffs as prescribed. Waiting 1 minute between puffs may permit the second puff to go deeper into the lungs.

Note: Dry powder capsules are used differently. To use a dry powder inhaler, close your mouth tightly around the mouthpiece and inhale very fast.

Cleaning
1. Once a day clean the inhaler and cap by rinsing it in warm running water. Let it dry before you use it again. Have another inhaler to use while it is drying.
2. Twice a week wash the plastic mouthpiece with mild dishwashing soap and warm water. Rinse and dry well before putting it back.

Checking How Much Medicine Is Left in the Canister
1. If the canister is new, it is full.
2. An easy way to check the amount of medicine left in your metered dose inhaler is to place the canister in a container of water and observe the position it takes in the water. Note: This method does not work for all inhalers. Please ask your doctor if you can check your inhaler this way.

Patient Worksheet 13

Unless you use your inhaler the right way, much of the medicine may end up on your tongue, on the back of your throat, or in the air. Use of a spacer or holding chamber can help this problem.

A spacer or holding chamber is a device that attaches to a metered dose inhaler. It holds the medicine in its chamber long enough for you to inhale it in one or two slow deep breaths. The spacer makes it easy for you to use the medicines the right way (especially if your child is young or you have a hard time using just an inhaler). It helps you not cough when using an inhaler. A spacer will also help prevent you from getting a yeast infection in your mouth (thrush) when taking inhaled steroid medicines.

There are many models of spacers or holding chambers that you can purchase through your pharmacist or a medical supply company. Ask your doctor about the different models.

How To Use a Spacer
1. Attach the inhaler to the spacer or holding chamber as explained by your doctor or by using the directions that come with the product.
2. Shake well.
3. Press the button on the inhaler. This will put one puff of the medicine in the holding chamber.
4. Place the mouthpiece of the spacer in your mouth and inhale slowly. (A face mask may be helpful for a young child.)
5. Hold your breath for a few seconds and then exhale. Repeat steps 4 and 5 two more times.
6. If your doctor has prescribed two puffs, wait between puffs for the amount of time he or she has directed and repeat steps 2-5.

STEPWISE APPROACH FOR MANAGING ASTHMA IN ADULTS AND CHILDREN OLDER THAN 5 YEARS OF AGE

  Gaining Control of Asthma

  Maintaining Control of Asthma

  Pharmacologic Steps

  Intermittent Asthma

  Persistent Asthma

SPECIAL CONSIDERATIONS FOR MANAGING ASTHMA IN DIFFERENT AGE GROUPS

  Infants and Young Children (<5 years)

  School-age Children

  Older Adults

MANAGING SPECIAL SITUATIONS IN ASTHMA

  Seasonal Asthma

  Cough-Variant Asthma

  Exercise-Induced Bronchospasm

  Surgery and Asthma

  Stress and Asthma

Key Recommendations for Managing Asthma Long Term

  Persistent asthma is most effectively controlled with daily long-term-control medication, specifically, anti-inflammatory therapy.

  A stepwise approach to pharmacologic therapy is recommended to gain and maintain control of asthma:

  The amount and frequency of medication is dictated by asthma severity and directed toward suppression of airway inflammation.

  Therapy should be initiated at a higher level than the patient’s step of severity at the onset to establish prompt control and then   stepped down.

  Continual monitoring is essential to ensure that asthma control is achieved.

  Step-down therapy is essential to identify the minimum medication necessary to maintain control.

  Regular followup visits (at 1- to 6-month intervals) are essential to ensure that control is maintained and the appropriate step down   in therapy is considered. Therapeutic strategies should be considered in concert with clinician-patient partnership strategies;   education of patients is essential for achieving optimal pharmacologic therapy.

  At each step, patients should be advised to avoid or control allergens, irritants, or other factors that make the patient’s asthma   worse.

  Referral to an asthma specialist for consultation or co-management of the patient is recommended if there are difficulties achieving or   maintaining control of asthma or if the patient requires step 4 care (see Unit 1-Initial Assessment and Diagnosis). Referral may be   considered if the patient requires step 3 care. For infants and young children, referral is recommended if the patient requires step 3   or 4 care and should be considered if the patient requires step 2 care.

Step 4-1 care

(Preferred treatments are in bold print.)

NOTE:

• The stepwise approach presents general guidelines to assist clinical decision-making; it is not intended to be a specific prescription. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients.
• Gain control as quickly as possible; then decrease treatment to the least medication necessary to maintain control. Gaining control may be accomplished by either starting treatment at the step most appropriate to the initial severity of the condition or starting at a higher level of therapy (e.g., a course of systemic corticosteroids or higher dose of inhaled corticosteroids).
• A rescue course of systemic corticosteroids may be needed at any time and at any step.
• Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. This may be especially common with exacerbations provoked by respiratory infections. A short course of systemic corticosteroids is recommended.
• At each step, patients should control their environment to avoid or control factors that make their asthma worse (e.g., allergens, irritants); this requires specific diagnosis and education.

STEPWISE APPROACH FOR MANAGING ASTHMA IN ADULTS AND CHILDREN OLDER THAN 5 YEARS OF AGE

The aim of asthma therapy is to maintain control of asthma with the least amount of medication and hence minimal risk for adverse effects. Control of asthma is defined as:

   Preventing chronic and troublesome symptoms (e.g., coughing or breathlessness in the night, in the early morning, or after exertion)

   Maintaining (near) "normal" pulmonary function

   Maintaining normal activity levels (including exercise and other physical activity)

   Preventing recurrent exacerbations of asthma and minimizing the need for emergency department visits or hospitalizations

   Providing optimal pharmacotherapy with minimal or no adverse effects

   Meeting patients’ and families’ expectations of and satisfaction with asthma care

The stepwise approach to therapy, in which the dose and number of medications and frequency of administration are increased as necessary and decreased when possible, is used to achieve this control. This is illustrated in figures 3-4a and 3-4b. Figures 3-5a and 3-5d present usual medication dosages for therapy. Because asthma is a chronic inflammatory disorder of the airways with recurrent exacerbations, therapy for persistent asthma must emphasize efforts to suppress inflammation over the long term and prevent exacerbations. Recommendations in the stepwise approach to therapy are based on the Expert Panel’s review of the literature (see Unit 3-Medications) and the Expert Panel’s experience and opinion.

Figure 3-4a Classify Severity

Goals of Asthma Treatment

• Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the night, in the early morning, or after exertion)
• Maintain (near) "normal" pulmonary function
• Maintain normal activity levels (including exercise and other physical activity)
• Prevent recurrent exacerbations of asthma 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

* The presence of one of the features of severity is sufficient to place a patient in that category. An individual should be assigned to the most severe grade in which any feature occurs. The characteristics noted in this figure are general and may overlap because asthma is highly variable. Furthermore, an individual’s classification may change over time.

** Patients at any level of severity can have mild, moderate, or severe exacerbations. Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms.

Figure 3-4b Treatment

(Preferred treatments are in bold print.)

NOTE:

• The stepwise approach presents general guidelines to assist clinical decision-making; it is not intended to be a specific prescription. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients.
• Gain control as quickly as possible; then decrease treatment to the least medication necessary to maintain control. Gaining control may be accomplished by either starting treatment at the step most appropriate to the initial severity of the condition or starting at a higher level of therapy (e.g., a course of systemic corticosteroids or higher dose of inhaled corticosteroids).
• A rescue course of systemic corticosteroids may be needed at any time and at any step.
• Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms. This may be especially common with exacerbations provoked by respiratory infections. A short course of systemic corticosteroids is recommended.
• At each step, patients should control their environment to avoid or control factors that make their asthma worse (e.g., allergens, irritants); this requires specific diagnosis and education.

Figure 3-5a Usual Dosages for Long-Term-Control Medications

Factors Affecting Serum Theophylline Concentrations*

*This list is not all inclusive; for discussion of other factors, see package inserts

Figure 3-5d Usual Dosages for Quick-Relief Medications

Gaining Control of Asthma

The clinician must judge individual patient needs and circumstances to determine at what step to initiate therapy. There are two appropriate approaches to gaining control of asthma:

   Start treatment at the step appropriate to the severity of the patient’s disease at the time of evaluation and gradually step up if    control is not achieved.

OR

   At the onset, administer therapy at a level higher than the patient’s step of severity to gain rapid control. This can be accomplished    by either a short course of systemic corticosteroids (see figure 3-5a) along with inhaled corticosteroids or initiating a medium-to-   high dose of inhaled corticosteroids. Once control is gained, step down the therapy.

The two approaches are illustrated by the solid and broken lines in the diagram

The more aggressive approach of gaining prompt control with a higher level of therapy is preferred, in the opinion of the Expert Panel. At present, there are no studies directly comparing the two approaches—the traditional step-up care (low dose to high) vs. step-down care (initial high dose to low). However, there is evidence supporting a more aggressive initial approach. First, asthma symptoms and altered pulmonary function are related to the level of ongoing airway inflammation. Suppression of airway inflammation is more likely to occur with higher doses of corticosteroids. Furthermore, studies indicate that the dose of inhaled or systemic corticosteroids can be reduced and the clinical benefits sustained once the disease is controlled (Haahtela et al. 1994; Agertoft and Pedersen 1994). A preliminary observation in a retrospective study of children suggests that initiating inhaled corticosteroids early in the course of the disease results in better clinical benefit and less accumulated corticosteroid dose over the long term (Agertoft and Pedersen 1994). Therefore, it is conceivable that a more aggressive approach in initial therapy will more rapidly suppress airway inflammation, restore pulmonary function, and allow for eventual asthma control at lower doses of anti-inflammatory therapy.

Continual monitoring is essential to ensure that asthma control is achieved. Control is indicated by, for example, peak expiratory flow (PEF) values indicating less than 10 to 20 percent variability or PEF consistently greater than 80 percent of the patient’s personal best, minimal symptoms, minimal need for short-acting inhaled beta2 -agonist, absence of nighttime awakenings, and no activity limitations.

If control is not achieved with initial therapy (e.g., within 1 month), the pharmacologic management plan, and possibly the diagnosis, should be reevaluated (see Pharmacologic Steps).

Maintaining Control of Asthma

Once control is achieved and sustained for several weeks or months, a reduction in pharmacologic therapy—a step down—is appropriate and helpful to identify the minimum therapy for maintaining control. Reduction in therapy should be gradual because asthma can deteriorate at a highly variable rate and intensity.

In general, the last medication added to the medical regimen should be the first medication reduced. Although guidelines for the rate of reduction and intervals for evaluation have not been established, the opinion of the Expert Panel is that the dose of inhaled corticosteroids may be reduced about 25 percent every 2 to 3 months to the lowest dose possible required to maintain control. It is likely that most patients with persistent asthma will continue to benefit from daily medication to suppress underlying airway inflammation. Patients may relapse when inhaled corticosteroids are completely discontinued (Waalkens et al. 1993).

Regular followup visits (at 1- to 6-month intervals) are essential. Clinicians need to assess whether control of asthma has been maintained and if a step down in therapy is appropriate. Clinicians also need to monitor and review the daily self-management and action plans, the medications, and the patient’s self-management behaviors (e.g., inhaler and peak flow monitoring techniques, actions to control factors that aggravate their asthma) (see figure 4-2).

Figure 4-2 Delivery of Asthma Education by Caregivers During Patient Care Visits

   Recommendations for Initial Visit

   Recommendations for First Followup Visit

   RRecommendations for Second Followup Visit

   Recommendations for All Subsequent Visits

The Expert Panel recommends referral to an asthma specialist for consultation or co-management of the patient if: there are difficulties achieving or maintaining control of asthma; immunotherapy is being considered; the patient requires step 4 care (step 3 or 4 care for infants and young children); or the patient has had a life-threatening exacerbation (see Unit 1-Initial Assessment and Diagnosis). Referral may be considered if a patient requires step 3 care (or step 2 care for infants and young children).

Pharmacologic Steps

The following recommendations for pharmacologic therapy at different steps of asthma severity (see figures 3-4a and 3-4b) are intended to be general guidelines for making therapeutic decisions. They are not intended to be prescriptions for individual treatment. Specific therapy should be tailored to the needs and circumstances of individual patients. Pharmacologic therapy must be accompanied at every step by patient education and measures to control those factors that contribute to the severity of the asthma (see Unit 2 and Unit 4).

If optimal control of asthma is not achieved and sustained at any step of care (nocturnal symptoms, urgent care visits, or an increased need for short-acting beta2 -agonists are key indications that asthma is not optimally controlled), several actions may be considered:

  Patient adherence and technique in using medications correctly should be assessed.

  A temporary increase in anti-inflammatory therapy may be indicated to reestablish control. A deterioration of asthma may be   characterized by gradual reduction in PEF (approximately 20 percent), by failure of inhaled bronchodilators to produce a sustained   response, by a reduced tolerance to activities or exercise, and by the development of increasing nocturnal symptoms. To regain   control of asthma, a short course of oral prednisone (see figure 3-5a) is often effective. If asthma symptoms do not recur and   pulmonary functions remain normal, no additional therapy is necessary. However, if the prednisone burst does not control symptoms,   is effective only for a short period of time (e.g., less than 1 to 2 weeks), or is repeated frequently, the patient should be managed   according to the next higher step of care.

  Other factors that diminish control may need to be identified and addressed. These factors include the presence of a   coexisting condition (e.g., sinusitis), a new or increased exposure to allergens or irritants, patient or family barriers to adequate self-  management behaviors, or psychosocial problems. In some cases, alternative diagnoses may need to be considered, such as vocal   cord dysfunction.

  A step up to the next higher step of care may be necessary.

  Consultation with an asthma specialist may be indicated (see Unit 1-Initial Assessment and Diagnosis).

Intermittent Asthma

Step 1: Mild Intermittent Asthma

Short-acting inhaled beta2 -agonists taken as needed to treat symptoms are usually sufficient therapy for mild, intermittent asthma. If effective in relieving symptoms and normalizing pulmonary function, intermittent use of short-acting inhaled beta2 -agonists can continue to be used on an as-needed basis. If significant symptoms reoccur or beta2 -agonist is required for quick-relief treatment more than two times a week (with the exception of using beta2 -agonist for exacerbations caused by viral infections and for exercise-induced bronchospasm [EIB]), the patient should be moved to the next step of care.

Patients with intermittent asthma who experience EIB benefit from taking inhaled beta2 -agonists, cromolyn, or nedocromil shortly before exercise (see Exercise-Induced Bronchospasm). Cromolyn or nedocromil taken before unavoidable exposure to an aeroallergen known to exacerbate the patient’s asthma may be beneficial (Cockcroft and Murdock 1987)

The Expert Panel recommends the following actions for managing exacerbations due to viral respiratory infections, which are especially common in children. If the symptoms are mild, inhaled beta2 -agonist (every 4 to 6 hours for 24 hours, longer with a physician consult) may be sufficient to control symptoms and improve lung function. If this therapy needs to be repeated more frequently than every 6 weeks, a step up in long-term care is recommended. If the viral respiratory infection provokes a moderate-to-severe exacerbation, a short course of systemic corticosteroids should be considered. For those patients with a history of severe exacerbations with viral respiratory infections, systemic corticosteroids should be initiated at the first sign of the infection.

The Expert Panel recommends that a detailed written action plan be developed for those patients with intermittent asthma who have a history of severe exacerbations (see figures 4-4and 4-6). Intermittent asthma—infrequent exacerbations separated by periods of no symptoms and normal pulmonary function—is often mild. However, some patients with intermittent asthma experience sudden, severe, and life-threatening exacerbations. It is essential to treat these exacerbations accordingly. The patient’s action plan should include indicators of worsening asthma (specific symptoms and PEF measurements), as well as specific recommendations for using beta2 -agonist rescue therapy, early administration of systemic corticosteroids, and seeking medical care. Furthermore, periodic monitoring (see Unit 1-Periodic Assessment and Monitoring) of the patient is appropriate to evaluate whether the patient’s asthma is indeed intermittent or whether a step up in long-term therapy is warranted.

Figure 4-4 Asthma Daily Self-Management Plan (Examples)

ASTHMA SELF-MANAGEMENT PLAN FOR
___________________________ (Name)
YOUR TREATMENT GOALS

• Be free from severe symptoms day and night, including sleeping through the night
• Have the best possible lung function
• Be able to participate fully in any activities of your choice
• Not miss work or school because of asthma symptoms
• Not need emergency visits or hospitalizations for asthma
• Use asthma medications to control asthma with as few side effects as possible

YOUR DAILY MEDICATIONS

RECORD DAILY SELF-MONITORING ACTIONS in the asthma diary your doctor gives you.

Peak flow: At least every morning when you wake up, before taking your medication, measure your peak flow and record it in your diary. Bring these records to your next appointment with your doctor.

Symptoms: Note if you had asthma symptoms (shortness of breath, wheezing, chest tightness, or cough) and rate how severe they were during the day or night: mild, moderate, severe.

Use of your quick-relief inhaler (bronchodilator): Keep a record of the number of puffs you needed to use each day or night to control your symptoms.

Actual use of daily medications

Activity restriction

This plan is provided as an example to clinicians.

Figure 4-4. Asthma Daily Self-Management Plan (Example 2)

Long-Term Self-Management Plan for Persistent Asthma

Introduction: This long-term plan provides four benefits to the clinician and patient, who complete it together during an early visit and review it periodically. The chart (1) reflects the step-up/step-down concept of pharmacotherapy; (2) enables patient and clinician to negotiate which medicines will be used and how often; (3) combines symptoms and/or peak flow monitoring as the basis for patient’s adding or deleting medicines at home and self-adjusting doses; and (4) gives the patient a view of what the clinician recommends over the long-term—under what future circumstances the clinician intends that the regimen be increased or decreased.

Directions: The clinician writes the patient’s medicines in the first column. Based on the symptoms and peak flow specified in the top row, the clinician then writes the doses and frequency of administration for each medication. (Some clinicians may prefer to print standard recommendations on the form to save time.) See example below.

Figure 4-6 Promoting Open Communication to Encourage Patient Adherence

Friendly Manner:

   Show attentiveness (eye contact, attentive listening, etc.)

   Give encouragement with nonverbal communication (nodding agreement, smiling, etc.)

   Give verbal praise for effective management strategies

   Use interactive conversation (e.g., asking open-ended questions)

Reassuring Communication:

   Elicit patient’s underlying concerns about asthma

   Allay fears with specific reassuring information

Adapted from Clark et al. 1995.

Persistent Asthma

The Expert Panel recommends that patients with persistent asthma, either mild, moderate, or severe, receive daily long-term-control medication. The most effective long-term-control medications are those with anti-inflammatory effects, that is, those that diminish chronic airway inflammation and airway hyperresponsiveness. Evidence from clinical trials supports this recommendation (van Essen-Zandvliet et al. 1992; Kerstjens et al. 1992).

Step 2: Mild Persistent Asthma

The main characteristics of step 2 care are as follows:

   Step 2 care long-term-control medication is daily anti-inflammatory medication: either inhaled corticosteroids at a low     dose (see figure 3-5b), cromolyn, or nedocromil. For children, a trial of cromolyn or nedocromil is often the initial long-term    therapy due to the safety profiles of these medications.

   Sustained-release theophylline is an alternative, but not preferred, long-term-control medication. It is not preferred    because its modest clinical effectiveness (theophylline is primarily a bronchodilator and its anti-inflammatory activity demonstrated    thus far is modest) must be balanced against concerns about potential toxicity (see Unit 3-Medications). Theophylline remains a    therapeutic option for certain patients due to expense or need for tablet-form medication. Sustained-release theophylline is given to    achieve a serum concentration of between 5 and 15 mcg/mL. Periodic theophylline monitoring is necessary to maintain a    therapeutic—but not toxic—level.

   Zafirlukast or zileuton may also be considered an alternative long-term-control medication for patients older than 12     years of age, although their position in therapy is not yet fully established. Initial experience in clinical trials and possible    patient requirements for tablet-form medication make these new medications a therapeutic option. Further clinical experience and    additional data are needed to establish the role of zafirlukast and zileuton in stepwise therapy.

   Quick-relief medication must be available. Inhaled short-acting beta2 -agonists should be taken as needed to relieve     symptoms. The intensity of treatment will depend on the severity of the exacerbation (see Unit 3-Managing Exacerbations). Use of    inhaled short-acting beta2 -agonists on a daily basis, or increasing use, indicates the need for additional long-term-control therapy.

Step 3: Moderate Persistent Asthma

Consultation with an asthma specialist may be considered because the therapeutic options at this juncture pose a number of challenging risk/benefit outcomes. There are at least three options for initiating step 3 therapy.

Increase inhaled corticosteroids to medium dose. This strategy will benefit many patients. Adverse effects, although infrequent, may arise (see Unit 3-Medications).

OR

Add a long-acting bronchodilator to a low-to-medium dose of inhaled corticosteroids. The long-acting bronchodilator may be either a long-acting inhaled beta2 -agonist (e.g., salmeterol) (Greening et al. 1994; Woolcock et al. 1996) or sustained-release theophylline (Nassif et al. 1981); although not preferred, long-acting beta2 -agonist tablets may be considered. This approach has been shown to improve symptom control and may be especially beneficial in patients who have significant nocturnal symptoms. Improved asthma control has been demonstrated with an inhaled long-acting beta2 -agonist and a medium-dose inhaled corticosteroid compared to a doubled dose of inhaled corticosteroid (Woolcock et al. 1996), but the potential for incorrectly using long-acting inhaled beta2 -agonists as a quick-relief medication needs to be considered. The approach of adding theophylline has the potential for adverse reactions related to fluctuations in theophylline serum concentrations.

OR

Establish control with medium-dose inhaled corticosteroids, then lower the dose (but still within the medium-dose range) and add nedocromil. Nedocromil has a notable safety profile, and some studies (Lal et al. 1993; O’Hickey and Rees 1994; Svendsen and Jorgensen 1991) have shown that it has some, albeit modest, inhaled corticosteroid-sparing effects in adults. Other studies (e.g., Wong et al. 1993) did not demonstrate this. Therefore, this treatment option is not preferred. Furthermore, adding another inhaler into the patient’s medication schedule may affect patient adherence. It will also affect the total cost of care.

If the patient’s asthma is not optimally controlled with initial step 3 therapy, and medications are used correctly, additional step 3 therapy is recommended.

  Increase daily long-term-control medications to a high dose of inhaled corticosteroids

AND

  Add a long-acting bronchodilator, especially to control nocturnal symptoms. The long-acting bronchodilator can be either long-  acting inhaled beta2 -agonist or sustained- release theophylline. An evening dose of either bronchodilator may alleviate and prevent   nocturnal symptoms and thus improve adherence to the overall therapeutic regimen.

Step 4: Severe Persistent Asthma

Patients whose asthma is not controlled on high doses of inhaled corticosteroids and the addition of long-acting bronchodilators will also need oral systemic corticosteroids on a regularly scheduled, long-term basis. For patients who require long-term systemic corticosteroids:

  Use the lowest possible dose (single dose daily or on alternate days).

  Monitor patients closely for corticosteroid adverse side effects (see Unit 3-Medications).

  When control of asthma is achieved, make persistent attempts to reduce systemic corticosteroids. High doses of inhaled   corticosteroids are preferable to systemic corticosteroids because inhaled corticosteroids have fewer systemic effects.

  Consultation with an asthma specialist is recommended.

SPECIAL CONSIDERATIONS FOR MANAGING ASTHMA IN DIFFERENT AGE GROUPS

Infants and Young Children (5 Years of Age and Younger)

Key Recommendations for Managing Asthma in Infants and Young Children

  Diagnosing asthma in infants is often difficult, yet under-diagnosis and under-treatment are key problems in this age    group. Thus, a diagnostic trial of inhaled bronchodilators and anti-inflammatory medications may be helpful.

  In general, infants and young children consistently requiring symptomatic treatment more than two times per week should    be given daily anti-inflammatory therapy.

  When initiating daily anti-inflammatory therapy, a trial of cromolyn or nedocromil is often given due to the safety profile of    these medications.

  Response to therapy should be carefully monitored. Once control of asthma symptoms is established and sustained, a    careful step down in therapy should be attempted. If clear benefit is not observed, alternative therapies or diagnoses    should be considered.

Diagnosis

Several studies show that as many as 50 to 80 percent of children with asthma develop symptoms before their fifth birthday. Diagnosis can be difficult in this age group and has important implications. On the one hand, asthma in early childhood is frequently under-diagnosed (receiving such labels as chronic bronchitis, wheezy bronchitis, recurrent pneumonia, gastroesophageal reflux, and recurrent upper respiratory tract infections), and thus many infants and young children do not receive adequate therapy. On the other hand, not all wheeze and cough are caused by asthma, and caution is needed to avoid giving infants and young children inappropriately prolonged asthma therapy. Episodic or chronic wheeze, cough, and breathlessness also may be seen in other less common conditions, including cystic fibrosis, vascular ring, tracheomalacia, primary immunodeficiency, congenital heart disease, parasitic disease, and foreign body aspiration.

Among children 5 years of age and younger, the most common cause of asthma symptoms is viral respiratory infection. At present, the relative contributions of airway inflammation, bronchial smooth muscle abnormalities, or other structural factors in producing wheeze with acute viral upper respiratory infections are unknown. There appear to be two general patterns of illness in infants and children who have wheezing with acute viral upper respiratory infections: a remission of symptoms in the preschool years and persistence of asthma throughout childhood. There are no clear markers to predict the prognosis for an individual child; however, the factors more strongly associated with continuing asthma are allergy, a family history of allergy or asthma, and perinatal exposure to passive smoke and aero-allergens (Pullan and Hey 1982; Sporik et al. 1991; Martinez et al. 1995; Martinez 1995).

Diagnosis is complicated by the difficulty in obtaining objective measurements of lung function in this age group. Essential elements in the evaluation include the history, symptoms, physical examination, and assessment of quality of life. A therapeutic trial with medications listed in figure 3-5d will also aid in the diagnosis.

Treatment

Figure 3-6 illustrates the Expert Panel’s recommendations for a stepwise approach to managing acute and chronic asthma symptoms, regardless of the prognosis for the wheezing infant or young child.

Figure 3-6

It is the opinion of the Expert Panel that, in general, infants and young children consistently requiring symptomatic treatment more than two times per week should be given daily anti-inflammatory medication.

At present there are few studies of medications in children younger than 3 years of age. A therapeutic trial of anti-inflammatory medications should be monitored carefully. Treatment should be stopped if a clear beneficial effect is not obvious. Although only inhaled corticosteroids have been shown to be effective in long-term clinical studies with infants (Ilangovan et al. 1993; Gleeson and Price 1988; Bisgaard et al. 1990), cromolyn has demonstrated symptom control and reduced airway hyperresponsiveness in a number of pediatric studies (Geller-Bernstein and Sneh 1980; Hilman et al. 1987; Miraglia del Giudice et al. 1982; Shapiro and Konig 1985; Silverman et al. 1972; Bertelsen et al. 1986; Glass et al. 1981). Fewer studies are available on nedocromil, but benefit has been demonstrated (Brogden and Sorkin 1993). Sustained-release theophylline, an alternative long-term-control medication for older children, may have particular risks of adverse side effects in infants, who frequently have febrile illnesses which increase theophylline concentrations. Theophylline should be considered only if serum concentration levels will be carefully monitored.

In deciding when to initiate daily long-term-control therapy, the clinician must weigh the possible long-term effects of inadequately controlled asthma vs. the possible adverse effects of medications given over prolonged periods. A preliminary study suggests that appropriate control of childhood asthma may prevent more serious asthma or irreversible obstruction in later years (Agertoft and Pedersen 1994). There is evidence that anti-inflammatory treatment can reduce morbidity from wheezing in early childhood (Connett et al. 1993). Studies in older children suggest that the potential but small risk of delayed growth from the use of inhaled corticosteroids is balanced by their efficacy (see Unit 3-Medications). Furthermore, there are options (cromolyn and nedocromil) for initiating anti-inflammatory therapy.

Recommendations for treating infants and young children at different steps of care include:

The patient’s response to therapy should be monitored carefully. When benefits are sustained, a step down in therapy should be attempted. If there are no clear benefits, treatment should be stopped and alternative therapies or diagnoses should be considered.

Daily long-term-control therapy often begins with cromolyn or nedocromil.

When inhaled corticosteroids are introduced in step 2 care, doses may range from 100 to 400 mcg/day; this generally translates to a dose of 15 mcg/kg up to 400 mcg/day beclomethasone (Allen and Lemanske 1993). See figures 3-5b and 3-5c for discussion of equivalency among preparations.

When step 3 care is required, it is the opinion of the Expert Panel that control should be established promptly with higher doses of inhaled corticosteroid and then therapy should be stepped down after 2 to 3 months to maintain control (Pedersen and Hansen 1995). For some patients, control of asthma may be maintained by using a lower dose of inhaled corticosteroid (e.g., the minimum dose in the medium-dose range) along with the addition of either nedocromil or theophylline. Some, but not all, studies with nedocromil in adults have demonstrated its potential corticosteroid-sparing effect. There are no studies demonstrating this effect with cromolyn. Studies in infants and young children are necessary. Some clinicians prefer gradually increasing medication to establish control—for example, adding nedocromil or theophylline before increasing the dose of inhaled corticosteroid beyond low-dose therapy.

Exacerbations caused by viral respiratory infections may be intermittent yet severe. Consider systemic corticosteroids if the exacerbation is moderate to severe or at the onset of a viral respiratory infection if the patient has a history of severe exacerbations.

Consultation with an asthma specialist should be considered for infants and young children requiring step 2 care; consultation is recommended for those requiring step 3 or step 4 care.

Several delivery devices are available for infants and young children. The dose received may vary considerably among devices and age groups. (See figure 3-3 for a summary of therapeutic issues regarding aerosol delivery devices.) The child’s caregivers must be instructed in the proper use of appropriately sized face masks, spacers/holding chambers with face masks, and spacers/holding chambers for medication delivery to be effective and efficient. For children younger than 2 years of age, nebulizer therapy may be preferred for administering cromolyn and for high doses of beta2 -agonists during exacerbations. Children between 3 and 5 years may begin therapy with MDI and spacer/holding chamber alone, but if the desired therapeutic effects are not achieved, they may require a nebulizer or an MDI plus spacer/holding chamber and face mask.

School-Age Children (Older Than 5 Years of Age) and Adolescents

Key Recommendations for Managing Asthma in School-Age Children and Adolescents

  Pulmonary function testing should use appropriate reference populations. Adolescents compare better to childhood than    to adult predicted norms.

  When initiating daily anti-inflammatory therapy for mild-to-moderate persistent asthma, a trial of cromolyn or nedocromil    is often given.

  Adolescents (and younger children as appropriate) should be directly involved in establishing goals for therapy and    developing their asthma management plans.

  Active participation in physical activities, exercise, and sports should be promoted.

  A written asthma management plan should be prepared for the student’s school, including plans to ensure reliable, prompt    access to medications.

The pharmacologic management of school-age children and adolescents follows the same basic principles as those for adults, but the special circumstances of growth, school, and social development require special consideration.

Assessment

Pulmonary function testing should be performed using comparison data from an appropriate reference population (American Thoracic Society 1991). Adolescents generally compare better to childhood than to adult predicted norms. Testing in a laboratory or clinic specializing in children can result in higher pulmonary function values and more consistent data. Technicians who conduct pulmonary function testing for children should have special training in achieving the best possible effort from young patients.

Treatment

For children with mild or moderate persistent asthma, cromolyn or nedocromil are often effective anti-inflammatory therapies and have no known long-term systemic effects. However, for children with severe persistent asthma, and for many children with moderate persistent asthma, cromolyn and nedocromil do not provide adequate control and thus inhaled corticosteroids are necessary for long-term therapy (see figure 3-4b)

The Expert Panel recommends that adolescents (and younger children as appropriate) be directly involved in developing their asthma management plans. Adolescents may experience more difficulties than younger children in adhering to a medication plan because they may fail to recognize the danger of poorly controlled asthma (Strunk et al. 1985), they may not accept having a chronic illness, or they may view the plan as infringing upon their emerging independence and adulthood. In teaching adolescents the same asthma self-management techniques expected of adults, the clinician should address adolescent developmental issues such as building a positive self-image and confidence, increasing personal responsibility, and gaining problem solving skills. To accomplish this, it is often helpful to see the adolescent initially without parents present and to involve the adolescent directly in setting goals for therapy, developing an appropriate treatment plan, and reviewing the effectiveness of the plan at repeated visits. The parents can be brought in at the end of the visit to review the plan together and emphasize the parents’ important role in supporting the adolescent’s efforts.

School Issues

The clinician should prepare a written asthma management plan for the student’s school (see figure 4-7) that includes the following information: an action plan for handling exacerbations (including the clinician’s recommendation regarding self-administration of medication and plans to ensure prompt, reliable access to medications); recommendations for long-term-control medications and prevention of exercise-induced bronchospasm (EIB), if appropriate; and identification of those factors that make the student’s asthma worse so the school may help the student avoid exposure.

It is preferable to schedule daily, long-term medications so that they are not taken at school, even if this results in unequal dosing intervals throughout the day. However, in school districts that have more comprehensive school nurse coverage, children who would benefit from close supervision to promote adherence may be given medications at school. In this way, daily medication can be administered and patient education can be supplemented most days of the week.

Students with asthma often require medication during school to treat acute symptoms or to prevent EIB that may develop during physical education class, school recess, or organized sports. Reliable, prompt access to medication is essential, but it may be difficult because of school rules that preclude the child from carrying medications. The National Asthma Education and Prevention Program and several member organizations have adopted resolutions that endorse allowing students to carry and self-administer medications when the caregiver and parent consider this appropriate. It may be helpful for some children to have a compressor-driven nebulizer available at the school.

Sports

Physical activity at play or in organized sports is an essential part of a child’s life, and full participation in physical activities should be encouraged. Many children with asthma experience cough, wheeze, or excessive fatigue when they exercise. Treatment immediately prior to vigorous activity or exercise usually prevents EIB. If symptoms occur during usual play activities, a step up in long-term therapy is warranted. Poor endurance or EIB can be an indication of poorly controlled persistent asthma; appropriate use of long-term-control medication can reduce EIB (see Exercise-Induced Bronchospasm). Activity should be limited or curtailed only as a last resort.

Older Adults

Key Recommendations for Managing Asthma in Older Adults

  Chronic bronchitis/emphysema may coexist with asthma. A trial of systemic corticosteroids will determine the presence    of reversibility and the extent of therapeutic benefit.

  Asthma medications may aggravate coexisting medical conditions (e.g., cardiac disease, osteoporosis); adjustments in    the medication plan may need to be made.

  Be aware of increased potential for adverse drug/disease interaction (e.g., aspirin, beta-blockers).

  Review of patient technique in using medications and devices is essential.

Because of the high prevalence of other obstructive lung disease (e.g., chronic bronchitis, emphysema) among the elderly, it is important to determine the extent of reversible airflow obstruction. Careful evaluation is required because the precise cause of severe airflow obstruction can be difficult to identify in older patients with asthma. A 2- to 3-week trial of therapy with systemic corticosteroids can help detect the presence of significant reversibility of the airway disease. Long-term-control asthma medication can then be offered.

Asthma medications may have increased adverse effects in the elderly patient; adjustments in the medication plan may be necessary.

Airway response to bronchodilators may change with age, although this is not clearly established. Older patients, especially those with preexisting ischemic heart disease, may also be more sensitive to beta2 -agonist side effects, including tremor and tachycardia. Concomitant use of anticholinergics and beta2 -agonists may be beneficial to the older patient (Ullah et al. 1981; Barros and Rees 1990; Gross et al. 1989).

Theophylline clearance is reduced in the elderly patient (Nielsen-Kudsk et al. 1988), causing increased blood levels of theophylline. In addition, age is an independent risk factor for developing life-threatening events from iatrogenic chronic theophylline overdose (patients 75 years of age or older have a 16-fold greater risk of death from theophylline overdose than do 25-year-olds) (Shannon and Lovejoy 1990). The potential for drug interaction—especially with antibiotics and H -histamine antagonists such as cimetidine—is greater because of the increased use of medications in this age group. Theophylline and epinephrine may exacerbate underlying heart conditions.

Systemic corticosteroids can provoke confusion, agitation, and changes in glucose metabolism.

A dose-dependent reduction in bone mineral content may be associated with inhaled corticosteroid use, although low or medium doses appear to have no major adverse effect. Elderly patients may be more at risk due to preexisting osteoporosis, changes in estrogen levels that affect calcium utilization, and a sedentary lifestyle. However, the risk of not adequately controlling asthma may unnecessarily limit the patient’s mobility and activities. Concurrent treatment with calcium supplements and vitamin D, and estrogen replacement when appropriate, are recommended. At the present time, the optimal approach for identifying patients at risk for accelerated bone loss from high-dose corticosteroid therapy is to conduct bone densitometry when treatment begins and again 6 months later (NHLBI 1996), although the benefits of this approach have not yet been evaluated in clinical trials.

Medications employed for other diseases may exacerbate asthma; adjustments may need to be made. Nonsteroidal anti-inflammatory agents for treating arthritis, nonselective beta-blockers for treating hypertension, or beta-blockers found in some eye drops used to treat glaucoma may exacerbate asthma (Bailey et al. 1987). See Unit 2 for more details on drugs that can complicate asthma management.

For more information on asthma in older patients, see NAEPP Working Group Report: Considerations for Diagnosing and Managing Asthma in the Elderly (NHLBI 1996).

MANAGING SPECIAL SITUATIONS IN ASTHMA

Seasonal Asthma

Some patients experience asthma symptoms only in relationship to certain pollens and molds. Such seasonal asthma should be treated according to the stepwise approach to long-term management of asthma. If the patient has seasonal asthma on a predictable basis, daily, long-term anti-inflammatory therapy (inhaled corticosteroids, cromolyn, or nedocromil) should be initiated prior to the anticipated onset of symptoms and continued through the season.

Cough Variant Asthma

Cough variant asthma is seen especially in young children. Cough is the principal symptom; because this frequently occurs at night, examinations during the day may be normal. Monitoring of morning and afternoon PEF variability and/or therapeutic trials with anti-inflammatory or bronchodilator medication may be helpful in diagnosis. Once the diagnosis is established, treat according to the stepwise approach to long-term management of asthma.

Exercise-Induced Bronchospasm

Exercise-induced bronchospasm—which untreated can limit and disrupt otherwise normal lives—should be anticipated in all asthma patients. EIB is a bronchospastic event that is caused by a loss of heat, water, or both from the lung during exercise because of hyperventilation of air that is cooler and dryer than that of the respiratory tree (Anderson 1985; Godfrey 1986; McFadden and Gilbert 1994). EIB usually occurs during or minutes after vigorous activity, reaches its peak 5 to 10 minutes after stopping the activity, and usually resolves in another 20 to 30 minutes.

Exercise may be the only precipitant of asthma symptoms for some patients. These patients should be monitored regularly to ensure that they have no symptoms of asthma or reductions in PEF in the absence of exercise, because EIB is often a marker of inadequate asthma management and responds well to regular anti-inflammatory therapy.

Diagnosis

A history of cough, shortness of breath, chest pain or tightness, wheezing, or endurance problems during exercise suggests EIB. An exercise challenge can be used to establish the diagnosis. This can be performed in a formal laboratory setting or as a free-run challenge sufficiently strenuous to increase the baseline heart rate to 80 percent of maximum for 4 to 6 minutes. Alternatively, the patient may simply undertake the task that previously caused the symptoms. A 15 percent decrease in PEF or FEV (measurements taken before and after exercise at 5-minute intervals for 20 to 30 minutes) is compatible with EIB.

Management Strategies

One goal of management is to enable patients to participate in any activity they choose without experiencing asthma symptoms. EIB should not limit either participation or success in vigorous activities. Recommended treatments include:

  Beta2 -agonists will prevent EIB in more than 80 percent of patients.

    Short-acting inhaled beta2 -agonists used shortly before exercise (or as close to exercise as possible) may be helpful for 2 to 3     hours.

    Salmeterol has been shown to prevent EIB for 10 to 12 hours (Kemp et al. 1994).

  Cromolyn and nedocromil, taken shortly before exercise, are also acceptable for preventing EIB (Tullett et al. 1985; Woolley et al.   1990; Albazzaz et al. 1989; de Benedictis et al. 1995).

  A lengthy warmup period before exercise may benefit patients who can tolerate continuous exercise with minimal symptoms. The   warmup may preclude a need for repeated medications.

  Long-term-control therapy, if appropriate. There is evidence that appropriate long-term control of asthma with anti-inflammatory   medication will reduce airway responsiveness, and this is associated with a reduction in the frequency and severity of EIB (Vathenen   et al. 1991).

Teachers and coaches need to be notified that a child has EIB, should be able to participate in activities, and may need inhaled medication before activity. Individuals involved in competitive athletics need to be aware that their medication use should be disclosed and should adhere to standards set by the U.S. Olympic Committee (Nastasi et al. 1995). The U.S. Olympic Committee’s Drug Control Hotline is 1-800-233-0393.

Surgery and Asthma

Asthma patients are at risk for specific complications during and after surgery: acute bronchoconstriction triggered by intubation, hypoxemia and possible hypercapnia, impaired effectiveness of cough, atelectasis and respiratory infection (Kingston and Hirshman 1984), and latex exposure (Slater 1994; Sussman and Beezhold 1995). The likelihood of these complications depends on the severity of the patient’s airway hyperresponsiveness, airflow obstruction, mucus hyper-secretions, and latex sensitivity. Recommended actions include:

  Patients with asthma should have an evaluation before surgery that includes a review of symptoms, medication use   (particularly the use of systemic corticosteroids for longer than 2 weeks in the past 6 months), and measurement of pulmonary   function.

  If possible, attempts should be made to improve lung function (FEV1 or PEF) to their predicted values or their personal best   level. A short course of systemic corticosteroids may be necessary to optimize pulmonary function.

  For patients who have received systemic corticosteroids during the past 6 months, give 100 mg hydrocortisone every 8    hours intravenously during the surgical period and reduce dose rapidly within 24 hours following surgery.

Pregnancy and Asthma

Maintaining sufficient lung function and blood oxygenation to ensure adequate oxygen supply to the fetus is essential. Poorly controlled asthma during pregnancy can result in increased perinatal mortality, increased prematurity, and low birth weight (Nelson and Weber 1988). For most drugs used to treat asthma and rhinitis, with the exception of brompheniramine, epinephrine, and alpha-adrenergic compounds (other than pseudoephedrine), there is little to suggest an increased risk to the fetus (Schatz et al. 1988; Federal Register 1976; Briggs et al. 1986). Other classes of drugs with some possibility of risk to the fetus include decongestants (other than pseudoephedrine), antibiotics (tetracycline, sulfonamides, and ciprofloxacin), live virus vaccines, immunotherapy (if doses are increased), and iodides.

For more information on asthma and pregnancy, see Executive Summary: Management of Asthma During Pregnancy (NHLBI 1992).

Stress and Asthma

The role of stress and psychological factors in asthma is important but not fully defined. There is emerging evidence that stress can play an important role in precipitating exacerbations of asthma and possibly act as a risk factor for an increase in prevalence of asthma (Busse et al. 1995). The mechanisms involved in this process have yet to be fully established and may involve enhanced generation of pro-inflammatory cytokines (Friedman et al. 1994). Equally important are psychosocial factors that are associated with poor outcome (e.g., conflict between patients and family and the medical staff, inappropriate asthma self-care, depressive symptoms, behavioral problems, emotional problems, and disregard of perceived asthma symptoms) (Strunk et al. 1985; Strunk 1993; Brush and Mathé 1993).

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Key Points: Managing Exacerbations of Asthma

  Early treatment of asthma exacerbations is the best strategy for management. Important elements of early treatment include:

• A written action plan to guide patient self-management of exacerbations at home, especially for patients with moderate-to-severe persistent asthma and any patient with a history of severe exacerbations
• Recognition of early signs of worsening asthma
• Appropriate intensification of therapy
• Prompt communication between patient and clinician about any serious deterioration in symptoms or peak flow, decreased responsiveness to inhaled beta2-agonists, or decreased duration of effect

  Management of asthma exacerbations includes:

• Inhaled beta2-agonist to provide prompt relief of airflow obstruction
• Systemic corticosteroids, for moderate-to-severe exacerbations or for patients who fail to respond promptly and completely to an inhaled beta2-agonist, to suppress and reverse airway inflammation
• Oxygen to relieve hypoxemia for moderate-to-severe exacerbations
• Monitoring response to therapy with serial measurements of lung function

Asthma exacerbations are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness or some combination of these symptoms. Exacerbations are characterized by decreases in expiratory airflow that can be documented and quantified by simple measurement of lung function (spirometry or peak expiratory flow [PEF]). These objective measures more reliably indicate the severity of an exacerbation than does the severity of symptoms.

GENERAL CONSIDERATIONS

The Expert Panel recommends that clinicians consider the following general principles and goals for managing asthma exacerbations, based on the scientific literature and the opinion of the Panel.

  Early treatment is the best strategy for management of asthma exacerbations. Important elements of early treatment include:

• A written action plan (see figure 4-5) to guide patient self-management, especially for patients with moderate-to-severe persistent asthma and any patient with a history of severe exacerbations
• Recognition of early indicators of an exacerbation, including worsening FEV1 or PEF
• Prompt communication between patient and clinician about any serious deterioration in symptoms or peak flow, decreased responsiveness to inhaled beta2-agonist, or decreased duration of effect
• Appropriate intensification of therapy, often including a short course of systemic corticosteroids
• Removal of or withdrawal from allergic or irritant precipitants in the environment that may be contributing to the exacerbation

  Patients at high risk of asthma-related death require special attention — particularly intensive education, monitoring, and care.   They should be counseled to seek medical care early during an exacerbation and instructed about the availability of ambulance   services. Such patients include those with identifiable risk factors.

  Infants require special attention, especially due to their greater risk for respiratory failure.

Figure 4-5 Asthma Action Plan Examples

Example 1:

Name: ______________________________________ Date: __________________________

ASTHMA ACTION PLAN

It is important in managing asthma to keep track of your symptoms, medications, and peak expiratory flow (PEF). You can use the colors of a traffic light to help learn your asthma medications:

   A. Green means Go - use preventive (anti-inflammatory) medicine

   B. Yellow means Caution - use quick-relief (short-acting bronchodilator) medicine in addition to the preventive medicine.

   C. Red means STOP! - get help from a doctor.

Physician Signature __________________________ Patient’s/Family Member’s Signature ______________________________

Example 2:

ASTHMA ACTION PLAN

Adult Self-management Instructions for Asthma Action Plan

Date:___________________________

If you have questions, please call:

_________________________________________ Phone: ________________________________

Your home physician. Phone:___________________ After Hours Phone:_______________________

Physician signature: _____________________________ Date: ______________________

Patient/Family signature:_____________________________ Staff Signature: _________________________

TREATMENT GOALS

The principal goals for treating asthma exacerbations are:

  Correction of significant hypoxemia by administering supplemental oxygen. In rare instances, alveolar hypoventilation requires   mechanically assisted ventilation.

  Rapid reversal of airflow obstruction. This is best achieved by:

    Repetitive or continuous administration of an inhaled beta2-agonist (Brenner 1983b; Lipworth et al. 1988; McFadden 1989; Lin et al.     1993; Rudnitsky et al. 1993; Papo et al. 1993)

    AND

    Early in the course of treatment, administration of systemic corticosteroids to patients with moderate-to-severe exacerbations or to     patients who fail to respond promptly and completely to an inhaled beta2-agonist (Fanta et al. 1983; Littenberg and Gluck 1986;     Rowe et al. 1992; Scarfone et al. 1993; Connett et al. 1994)

  Reduction of the likelihood of recurrence of severe airflow obstruction by intensifying therapy. Often, a short course of   systemic corticosteroids is useful (Fanta et al. 1983; Littenberg and Gluck 1986; Rowe et al. 1992; Scarfone et al. 1993; Connett et   al. 1994).

Achieving these goals requires close monitoring by serial measurements of lung function to quantify the severity of airflow obstruction and its response to treatment. The improvement in FEV1 after 30 minutes of treatment correlates significantly with a broad range of indices of the severity of asthma exacerbations (Rodrigo and Rodrigo 1993), and repeated measurement of airflow in the emergency department can help reduce unnecessary admissions (Taylor 1994). Use PEF or FEV1 values to guide treatment decisions, along with the patient’s history, current symptoms, and physical findings. In using PEF expressed as a percentage of personal best, it is important to consider the impact 3c-3 of irreversible airflow obstruction. For a patient whose best PEF is 160 L/min, for example, a fall of 40 percent represents severe, potentially life-threatening obstruction.

HOME MANAGEMENT OF ASTHMA EXACERBATIONS

Beginning treatment at home avoids treatment delays, prevents exacerbations from becoming severe, and also adds to patients’ sense of control over their asthma. The degree of care provided in the home depends on the patients’ (or parents’) abilities and experience and on the availability of emergency care.

The Expert Panel recommends the following actions to prepare patients for home management of asthma exacerbations, based on scientific literature (see Unit 1-Periodic Assessment and Monitoring and Unit 4) and the opinion of the Panel.

  Teach all patients how to monitor symptoms to recognize early signs of deterioration (see Unit 1-Periodic Assessment and   Monitoring and Unit 4) and how to adjust their medications accordingly.

  Teach patients with moderate-to-severe persistent asthma and those with a history of severe exacerbations how to    monitor their peak flow to assess the severity of an exacerbation and the response to therapy (see Unit 1-Periodic Assessment   and Monitoring). In the absence of PEF measurement, severity can be judged only from the presence and intensity of signs and   symptoms, which correlate imperfectly with the severity of airflow obstruction. This is especially true in a subgroup of patients ("poor   perceivers") who do not sense airway narrowing until it is far advanced (Kikuchi et al. 1994).

  Give a written asthma action plan to be followed in the event of an exacerbation (see figure 4-5), especially to patients with   moderate-to-severe persistent asthma and any patient with a history of severe exacerbations. Children should also receive a plan   appropriate to the school setting . The plan should direct the patient to adjust medications in response to particular signs, symptoms,   and peak flow measurements and should state when to seek medical help. Review the plan with the patient and family. The clinician   should tailor the plan to the needs of individual patients. Patients at risk for asthma death require especially close monitoring.

  Teach patients to seek medical help early if (1) an asthma exacerbation is severe, (2) therapy does not give rapid,    sustained improvement, or (3) there is further deterioration.

  Advise patients with moderate-to-severe persistent asthma or a history of severe exacerbations to have the medication   (e.g., corticosteroid tablets or liquid) and equipment (e.g., peak flow meter, compressor-driven nebulizer for young children) for    treating exacerbations at home .

The Expert Panel recommends the following pharmacologic therapy, based on the scientific literature, for home management of exacerbations:

  Increase the frequency of inhaled beta2-agonist.

  Initiate or increase corticosteroid treatment under certain circumstances. For mild exacerbations in patients already taking an   inhaled corticosteroid, many experts prescribe doubling the dose until peak flow returns to predicted or personal best. Although this   practice has not been proved in a clinical trial, a few studies suggest its benefit (Lahdensuo et al. 1996; Wilson and Silverman 1990).   For moderate-to-severe exacerbations, and for mild exacerbations that persist despite an increased dose of inhaled corticosteroids, a   course of oral corticosteroids is necessary (Chapman et al. 1991; Fiel et al. 1983; Harris et al. 1987; Deshpande and McKenzie 1986;   Loren et al. 1980; Rowe et al. 1992).

  Continue more intensive treatment for several days. Recovery from an exacerbation is often gradual. Greater use of medication   should be continued until symptoms and PEF are stable, but patients should seek medical care rather than rely on bronchodilator   therapy in excessive doses or for prolonged periods.

The Expert Panel does not recommend the following home management techniques because there are no studies demonstrating effectiveness and it is the opinion of the Panel that these techniques may delay patients from obtaining necessary care.

  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, cold remedies, and bronchodilators. Over-the-counter metered-dose   inhalers may provide transient bronchodilation, but their use should not be permitted to delay seeking medical care.

The Expert Panel also notes that although pursed-lip and other forms of controlled breathing may help to maintain calm during respiratory distress, they do not bring about improvement in lung function.

PREHOSPITAL EMERGENCY MEDICINE/AMBULANCE MANAGEMENT OF ASTHMA EXACERBATIONS

The Expert Panel recommends that pre-hospital providers administer supplemental oxygen and inhaled short-acting bronchodilators to patients who have signs or symptoms of asthma. Pre-hospital administration of inhaled bronchodilators reduces airflow obstruction and relieves symptoms (Fergusson et al. 1995). Thus, advanced life support units should have available an inhaler plus spacer/holding chamber and/or nebulizer for beta2-agonist administration . If these are not available, subcutaneous epinephrine or terbutaline should be given for severe exacerbations (Sly et al. 1977; Smith et al. 1977).

Ambulance services should develop pre-hospital protocols for the treatment of acute asthma in children and adults. Pre-hospital providers should receive training in how to respond to the clinical signs and symptoms of severe airway obstruction and imminent respiratory failure.

EMERGENCY DEPARTMENT AND HOSPITAL MANAGEMENT OF ASTHMA EXACERBATIONS

Severe exacerbations of asthma are potentially life threatening. Care must be prompt. Effective initial therapies (i.e., a short-acting beta2-agonist and the means of giving it by aerosol and a source of supplemental oxygen) should be available in a caregiver’s office. However, serious exacerbations require close observation for deterioration, frequent treatment, and repetitive measurement of lung function. Therefore, most severe exacerbations of asthma require prompt transfer to an emergency department for a complete course of therapy (Brenner 1983a).

Assessment

The Expert Panel recommends that all clinicians treating asthma exacerbations be familiar with the characteristics of patients at risk for life-threatening deterioration. In the emergency department, treatment should be started as soon as an asthma exacerbation is recognized and an assessment of lung function is made.

While treatment is given, obtain a brief, focused history and physical examination pertinent to the exacerbation. Take a more detailed history and complete physical examination and perform laboratory studies only after initial therapy has been completed.

The objectives of functional assessment are to:

• Obtain objective information on the severity of airflow obstruction (FEV1 or PEF) and the patient’s response to treatment. In the emergency department, obtain FEV1 or PEF on presentation, after initial treatment, and at frequent intervals thereafter, depending on the patient’s response to therapy. Rarely, a patient’s airflow obstruction may be so severe as to prevent performance of a maximal expiratory maneuver. In the hospital, measure FEV1 or PEF before and 15 to 20 minutes after bronchodilator therapy during the acute phase of the exacerbation. Thereafter, measure FEV1 or PEF at least daily until discharge. Values < 30 percent of predicted that improve by < 10 percent after bronchodilator therapy or that fluctuate widely over 24 hours indicate a heightened risk of life-threatening deterioration.
• In patients with severe distress or with FEV1 or PEF < 50 percent of predicted, assess the adequacy of arterial oxygen saturation by pulse oximetry (Connett and Lenney 1993; Geelhoed et al. 1994).

Objectives of the brief history are to determine:

• Time of onset and cause of current exacerbation
• Severity of symptoms, especially compared with previous exacerbations
• All current medications and time of last dose
• Prior hospitalizations and emergency department visits for asthma, particularly within the past year
• Prior episodes of respiratory insufficiency due to asthma (loss of consciousness or intubation and mechanical ventilation)
• Other potentially complicating illness, especially other pulmonary or cardiac disease or diseases that may be aggravated by systemic corticosteroid therapy such as diabetes, peptic ulcer, hypertension, and psychosis

Objectives of the physical examination are to:

• Assess the severity of the exacerbation as indicated by the findings listed in figure 3-9.
• Assess overall patient status, including level of alertness, fluid status, and presence of cyanosis, respiratory distress, and wheezing. Wheezing can be an unreliable indicator of obstruction; in rare cases, extremely severe obstruction may be accompanied by a "silent chest" (Shim and Williams 1980).
• Identify complications (e.g., pneumonia, pneumothorax, or pneumomediastinum).
• Identify other diseases that may affect asthma (e.g., allergic rhinitis, rhinitis, sinusitis).
• Rule out upper airway obstruction. Both intrathoracic and extrathoracic central airway obstruction can cause severe dyspnea and may be diagnosed as asthma. Causes include epiglottitis, organic diseases of the larynx, vocal cord dysfunction, and extrinsic and intrinsic tracheal narrowing (see Unit 1- Initial Assessment and Diagnosis). Clues as to their presence include dysphonia, inspiratory stridor, monophonic wheezing loudest over the central airway, normal values for PO2, and unexpectedly complete resolution of airflow obstruction with intubation. When upper airway obstruction is suspected, obtain further evaluation by flow-volume curves and by referral for laryngoscopy (see Unit 1- Initial Assessment and Diagnosis).

The most important objective of laboratory studies is detection of actual or impending respiratory failure; other objectives include detection of theophylline toxicity and of conditions that complicate the treatment of asthma exacerbations. Do not permit these studies to delay initiation of treatment. For example,

• Consider arterial blood gas (ABG) measurement for evaluating arterial carbon dioxide tension (PCO2) in patients with suspected hypoventilation, with severe distress, or with FEV1 or PEF 30 percent of predicted after initial treatment. (NOTE: Respiratory drive is typically increased in asthma exacerbations, so a "normal" PCO2 of 40 mm indicates severe airflow obstruction and a heightened risk of respiratory failure.)
• Complete blood count (CBC) may be appropriate in patients with fever or purulent sputum; keep in mind that modest leukocytosis is common in asthma exacerbations and that corticosteroid treatment causes a further outpouring of polymorphonuclear leukocytes within 1 to 2 hours of administration.
• Measure serum theophylline concentration in patients taking theophylline prior to presentation.
• It may be prudent to measure serum electrolytes in patients who have been taking diuretics regularly and in patients with coexistent cardiovascular disease, because frequent beta2-agonist administration can cause transient decreases in serum potassium, magnesium, and phosphate.
• Chest radiography is not recommended for routine assessment but should be obtained in patients suspected of a complicating cardiopulmonary process, such as pneumothorax, pneumomediastinum, pneumonia, lobar atelectasis, or congestive heart failure.
• Electrocardiograms need not be routinely obtained, but a baseline electrocardiogram and continual monitoring of cardiac rhythm are appropriate in patients older than 50 years of age and in those with coexistent heart disease or chronic obstructive pulmonary disease. The electrocardiogram may show a pattern of right ventricular strain that reverses promptly with treatment of airflow obstruction.

Assessment considerations unique to children and infants are as follows:

• It is often difficult for caregivers and parents to determine the severity of the airway obstruction in infants and small children with asthma. However, using a combination of the subjective and objective parameters permits a fairly accurate assessment to guide initial therapy. Many of these parameters have not been systematically studied, so they serve only as general guides
• The differences in the anatomy and physiology of the lungs of infants place them at greater risk for respiratory failure. These differences include greater peripheral airway resistance, fewer collateral channels of ventilation, further extension of airway smooth muscle into the peripheral airways, less elastic recoil, and mechanical disadvantage of the diaphragm. Viral infections, particularly respiratory syncytial virus, are the most common cause of acute wheezing illness in infants. The edematous inflammatory response in the airways leads to air trapping and hyperinflation, atelectasis, increased respiratory rate, and wheezing. This sequence of changes can rapidly progress to respiratory failure. Close monitoring is critical.
• It is particularly important to monitor O2 saturation by pulse oximetry in infants because their ventilation/perfusion characteristics lead them to become hypoxemic more readily than adults. SaO2 should be normal for altitude (>95 percent at sea level). Decreased oxygen saturation is often an early sign of severe airway obstruction, and an SaO2 < 91 percent on room air is a good predictor of the need for hospitalization in small infants (Connett and Lenney 1993; Geelhoed et al. 1994).
• Capillary or ABG measurements should be performed in infants suspected of respiratory failure. PaCO2 is the best measurement of ventilation in infants, as it is in adults. Children with a normal PCO2 but in obvious respiratory distress are at high risk for respiratory failure.

Treatment

In the emergency department and hospital, tailor the intensity of treatment and surveillance to the severity of the exacerbation. The primary therapies—the administration of oxygen, inhaled beta2- agonist, and systemic corticosteroids—are constant, but the dose and frequency with which they are given and the frequency with which the patient’s response is assessed may vary. Thus, for patients presenting with a severe exacerbation, give inhaled beta2-agonist therapy at the higher dose either repeatedly (three treatments in the first hour) or continuously (by nebulization), give systemic corticosteroids immediately, and watch closely for signs of worsening airflow obstruction or fatigue. For patients with mild exacerbations, give inhaled beta2-agonist therapy and assess the patient’s response before deciding whether additional therapy is necessary. Give supplemental oxygen to patients with significant hypoxemia and to patients with FEV1 or PEF < 50 percent of predicted when arterial oxygen monitoring is not available.

The following recommendations are based on scientific evidence (key studies are cited) and the opinion of the Expert Panel:

Oxygen is recommended for most patients. Administer supplemental oxygen (by nasal cannulae or mask, whichever is best tolerated) to maintain an SaO2 >90 percent (>95 percent in pregnant women and in patients with coexistent heart disease). Monitor oxygen saturation until a clear response to bronchodilator therapy has occurred.

Inhaled short-acting beta2-agonists are recommended for all patients.

• The repetitive or continuous administration of inhaled short-acting beta2-agonists is the most effective means of reversing airflow obstruction (Lipworth et al. 1988; Lin et al. 1993; Rudnitsky et al. 1993)
• In the emergency department, three treatments of beta2-agonists spaced every 20 to 30 minutes can be given safely as initial therapy. Thereafter, the frequency of administration varies according to the improvement in airflow obstruction and associated symptoms and the occurrence of side effects. Continuous administration of beta2-agonists may be more effective in children and severely obstructed adults (Lin et al. 1993; Rudnitsky et al. 1993; Papo et al. 1993; Kelly and Murphy 1992).
• Because of the risk of cardiotoxicity, use only selective beta2-agonists (albuterol, terbutaline, pirbuterol, bitolterol) in high doses.
• Studies show that equivalent bronchodilation can be achieved by either high doses (6 to 12 puffs) of a beta2-agonist by MDI with a spacer/holding chamber under the supervision of trained personnel or by nebulizer therapy (Idris et al. 1993; Colacone et al. 1993; Kerem et al. 1993). However, nebulized therapy is more effective in patients who are unable to coordinate inhalation of medication from an MDI because of their age, agitation, or severity of the exacerbation.
• The onset of action for inhaled beta2-agonist is less than 5 minutes; repetitive administration produces incremental bronchodilation (Lipworth et al. 1988).
• Duration of action of bronchodilation from beta2-agonists in severe asthma exacerbations is not precisely known.

Anticholinergics may be considered. Adding high doses of ipratropium bromide (0.5 mg in adults, 0.25 mg in children) to an aerosolized solution of a selective beta2-agonist has been shown to cause additional bronchodilation, particularly in those with severe airflow obstruction (Schuh et al. 1995; Reisman et al. 1988; O’Driscoll et al. 1989; Kelly and Murphy 1991), although some studies did not demonstrate this effect (Karpel et al. 1996).

Systemic corticosteroids are recommended for most patients (for recommended doses, see figure 3-10).

• In the emergency department: Give systemic corticosteroids to patients who have moderate-to-severe exacerbations and patients who do not respond completely to initial beta2-agonist therapy. These medications appear to speed the resolution of airflow obstruction and reduce the rate of relapse (Fanta et al. 1983; Rowe et al. 1992; Scarfone et al. 1993; Connett et al. 1994; Chapman et al. 1991).
• -- Oral administration of prednisone has been shown to have effects equivalent to those of intravenous methylprednisolone (Harrison et al. 1986; Ratto et al. 1988) and, in the opinion of the Expert Panel, is usually preferred because it is less invasive.
• -- Give supplemental doses of oral corticosteroids to patients who take them regularly, even if the exacerbation is mild.
• -- In infants and children, it is especially important to give corticosteroids early in the course of an asthma exacerbation (Harris et al. 1987).
• In the hospital: Give systemic corticosteroids to patients admitted to the hospital, because they speed the resolution of asthma exacerbations (Connett et al. 1994; Rowe et al. 1992; Singh and Kumar 1993).

Methylxanthines are not generally recommended.

• In the emergency department: Theophylline/aminophylline is not recommended because it appears to provide no additional benefit to optimal inhaled beta2-agonist therapy and may increase adverse effects (Fanta et al. 1986; Rossing et al. 1980; Murphy et al. 1993; Rodrigo and Rodrigo 1994; Coleridge et al. 1993).
• In patients currently taking a theophylline-containing preparation, determine serum theophylline concentration to rule out theophylline toxicity.
• In the hospital: Therapy with oral or intravenous methylxanthines does not benefit children hospitalized with severe asthma (Strauss et al. 1994; Carter et al. 1993; DiGiulio et al. 1993). The addition of intravenous theophylline in hospitalized adults remains controversial (Huang et al. 1993; Self et al. 1990).

Antibiotics are not recommended for asthma treatment but may be necessary for comorbid conditions. Bacterial, chlamydia, and mycoplasma respiratory tract infections are thought to contribute only infrequently to exacerbations of asthma. The use of antibiotics is generally reserved for those patients with fever and purulent sputum (discolored because of polymorphonuclear leukocytes, not eosinophils) and for patients with evidence of pneumonia. When the presence of bacterial sinusitis is suspected, treat with antibiotics.

Aggressive hydration is not recommended for older children and adults but may be indicated for infants and young children. Intravenous or oral administration of large volumes of fluids does not play a role in the management of severe asthma exacerbations. However, infants and young children may become dehydrated as a result of increased respiratory rate and decreased oral intake. In these patients, make an assessment of fluid status (urine output, urine specific gravity, mucus membrane moisture, electrolytes) and provide appropriate corrections.

Chest physical therapy is not generally recommended. In general, chest physiotherapy is not beneficial and is unnecessarily stressful for the breathless asthma patient.

Mucolytics are not recommended. Avoid mucolytic agents (e.g., acetylcysteine, potassium iodide) because they may worsen cough or airflow obstruction.

Sedation is not recommended. Anxiolytic and hypnotic drugs are contraindicated in severely ill asthma patients because of their respiratory depressant effect.

Repeat Assessment

The Expert Panel recommends that repeat assessment of patients with severe exacerbations be made after the initial dose of inhaled bronchodilator and that repeat assessment of all patients be made after three doses of inhaled bronchodilator (60 to 90 minutes after initiating treatment). The response to initial treatment in the emergency department is a better predictor of the need for hospitalization than is the severity of an exacerbation on presentation (Rodrigo and Rodrigo 1993). The elements to be evaluated include the patient’s subjective response, physical findings, measurement of airflow, and measurement of ABG if the patient now meets the criteria described in the discussion of laboratory studies in the Assessment section.

Hospitalization

The decision to hospitalize a patient should be based on duration and severity of symptoms, severity of airflow obstruction, course and severity of prior exacerbations, medication use at the time of the exacerbation, access to medical care and medications, adequacy of support and home conditions, and presence of psychiatric illness. In general, the principles of care in the hospital resemble those for care in the emergency department and involve both treatment with oxygen, aerosolized bronchodilators, and systemic corticosteroids and frequent assessment, including clinical assessment of respiratory distress and fatigue and objective measurement of airflow (PEF or FEV1 ) and oxygen saturation.

Impending Respiratory Failure

Most patients respond well to therapy. However, a small minority will show signs of worsening ventilation, whether from worsening airflow obstruction, worsening respiratory muscle fatigue, or a combination of the two. Impending respiratory failure is suggested by any deterioration in mental clarity, worsening fatigue, and a PaCO2 of 42 mm Hg. The Expert Panel recommends that intubation not be delayed once it is deemed necessary. Because respiratory failure can progress rapidly and can be difficult to reverse, early recognition and treatment are critically important.

Because intubation of a severely ill asthma patient is difficult, additional treatments are sometimes attempted, such as intravenous administration of magnesium sulfate (Kuitert and Kletchko 1991; Skorodin et al. 1995; Tiffany et al. 1993; Green and Rothrock 1992) and substituting a mixture of helium and oxygen ("heliox") for oxygen-enriched air (Manthous et al. 1995; Gluck et al. 1990). Although limited observations suggest that these therapies may be effective, possibly among certain subgroups (Bloch et al. 1995), they have not yet been proven consistently effective. Intravenous administration of a beta2-agonist also falls into this category of unproven treatment. Recent studies suggest that albuterol is more effective and has fewer side effects when it is given by aerosol than when given intravenously (Salmeron et al. 1994), but the efficacy of adding an intravenous beta2-agonist to high-dose nebulized therapy has not been studied. Do not use intravenous isoproterenol in the treatment of asthma because of the danger of myocardial toxicity (Maguire et al. 1991).

The Expert Panel recommends the following actions regarding intubation:

• Patients presenting with apnea or coma should be intubated immediately. There are no other absolute indications for endotracheal intubation, but persistent or increasing hypercapnia, exhaustion, and depression of mental status strongly suggest the need for ventilatory support.
• Consultation with or co-management by caregivers expert in ventilator management is appropriate because mechanical ventilation of patients with severe refractory asthma is complicated and fraught with risk.
• Because intubation is difficult in asthma patients, it is best done semi-electively, before the crisis of respiratory arrest.
• Intubation should be performed in a controlled setting by a caregiver with extensive experience in intubation and airway management.
• It is preferable that patients with severe exacerbations who are slowly responsive to therapy be admitted to an intensive care unit where they can be monitored closely and intubated if it is indicated.
• Because intubation should not be delayed once it is deemed necessary, it may be performed in the emergency department or inpatient ward and the patient transferred to an intensive care unit appropriate to the patient’s age.
• Children intubated for asthma should be admitted to a pediatric intensive care unit or transferred to a facility that has such a unit.

Issues to consider at the time of intubation include the following:

• Close attention should be given to maintaining or replacing intravascular volume, because hypotension commonly accompanies the initiation of positive pressure ventilation.
• Once mechanical ventilation has been started, it is important to avoid high ventilator pressures and the associated risks of barotrauma.

"Permissive hypercapnia" or "controlled hypoventilation" is the recommended ventilator strategy to provide adequate oxygenation and ventilation while minimizing high airway pressures and barotrauma (Tuxen 1994; Darioli and Perret 1984; Menitove and Goldring 1983). It involves administration of as high an FiO2 as is necessary to maintain adequate arterial oxygenation, acceptance of hypercapnia, and treatment of respiratory acidosis with intravenous sodium bicarbonate. Adjustments are made to the tidal volume, ventilator rate, and I:E ratio to minimize airway pressures. Bronchodilators are continued, and even in ventilated patients, aerosol delivery is the route of choice (Dhand and Tobin 1996).

This ventilator strategy is not uniformly successful in critically ill asthma patients, and additional therapies are being evaluated. Their review is beyond the scope of this report.

Patient Discharge

Before discharge, provide patients with necessary medications and education in how to use them, instruction in self-assessment (e.g., by monitoring symptoms and peak flow), a followup appointment, and instruction in an action plan for managing recurrence of airflow obstruction.

From the Emergency Department

• Release of the patient from the emergency department depends on the patient’s response to treatment.
• In general, discharge is appropriate if FEV1 or PEF has returned to 70 percent of predicted or personal best and symptoms are minimal or absent. Patients with an incomplete response to therapy (FEV1 or PEF 50 but < 70 percent predicted or personal best) and with mild symptoms should be assessed individually for their suitability for discharge home.
• The Panel’s opinion is that patients with a rapid response should be observed for 30 to 60 minutes after the most recent dose of bronchodilator to ensure stability of response before discharge to home.
• Extended treatment and observation in a holding area, clinical decision unit, or overnight unit to determine the need for hospitalization may be appropriate provided there is sufficient monitoring and nursing care.

Prescribe sufficient medications for the patient to continue treatment after discharge. Patients given systemic corticosteroids should continue oral systemic corticosteroids for 3 to 10 days. The need for further corticosteroid therapy should be assessed at a followup visit. If the patient is receiving inhaled corticosteroids, it is not necessary to taper the dose gradually when the course is completed (O’Driscoll et al. 1993).

Emphasize the need for continual, regular care in an outpatient setting. Refer the patient to a followup medical appointment. A visit to the emergency department is often an indication of inadequate long-term management of asthma or inadequate plans for handling exacerbations. Notify the patient’s health care professional (or provide a referral to one if the patient does not name a source of asthma care), and instruct the patient to seek a followup medical appointment within 3 to 5 days. When possible, schedule such an appointment prior to the patient’s discharge. The followup visit should include a detailed review of the patients’ medications, inhaler and peak flow meter technique, and development of comprehensive daily management and action plans that will help prevent exacerbations and urgent care visits (see figure 4-5). Referral to an asthma specialist for consultation should be considered because this has been reported to reduce the rate of subsequent emergency department visits (Zeiger et al. 1991).

Review written discharge medications and, whenever possible, provide patient education on avoidance of asthma triggers and correct use of an inhaler.

Instruct the patient in a simple action plan for increasing medications or returning for care should asthma worsen.

Consider issuing a peak flow meter and providing patient education on how to measure and record daily PEF rates.

From the Hospital

Prior to discharge, adjust the patient’s medication to an oral and/or inhaled regimen. The optimal timing of this transition is not precisely established, but the general approach is to wait until the patient is minimally symptomatic from asthma and has little wheezing on chest examination. Usually this clinical status corresponds to a PEF or FEV1 of 70 percent of predicted or personal best. During the first 24 hours after this medication adjustment, observe the patient for possible deterioration.

Discharge medications should include a short-acting inhaled beta2-agonist and sufficient oral corticosteroid to complete the course of therapy or to continue therapy until the followup appointment. If the decision is made to start the patient on inhaled corticosteroids, they should be started before the course of oral corticosteroids is completed, because their onset of action is gradual (Kraan et al. 1988). Starting the inhaled corticosteroid therapy before discharge gives the patient additional time to learn and demonstrate appropriate technique.

Provide patient education:

• An exacerbation severe enough to require hospitalization may reflect a failure of the patient’s self-management plan. Hospitalized patients may be particularly receptive to information and advice about their illness; take the opportunity to review patient understanding of the causes of asthma exacerbations, the purposes and correct uses of treatment, and the actions to be taken for worsening symptoms or peak flow values.
• Educate patients about their discharge medications and the importance of a followup medical visit. Referral to an asthma specialist should be considered for patients with a history of life-threatening exacerbations or multiple hospitalizations (see Unit 1) (Mayo et al. 1990).
• Educate patients older than 5 years of age in the use of peak flow meters to monitor their lung function at home.
• Review or develop an action plan for management of recurrent symptoms or exacerbations. The plan should describe the signs, symptoms, and/or peak flow values that should prompt increases in self-medication, contact with a health care provider, or return for emergency care. The plan given at discharge from the emergency department may be quite simple (e.g., instructions for discharge medications and returning for care should asthma worsen). The plan developed for discharge from the hospital should be more complete. A detailed plan for comprehensive long-term management and handling exacerbations should be developed by the regular provider at a followup visit (see figure 4-5).

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Key Points

Patient education should begin at the time of diagnosis and be integrated into every step of clinical asthma care.

It is essential that education be provided by all members of the health care team. The principal clinician should introduce the key educational messages and negotiate agreements with patients; these messages should be reinforced and expanded by all members of the health care team.

Teach asthma self-management, tailoring the approach to the needs of each patient. Maintain a sensitivity to cultural beliefs and practices. Teach and reinforce at every opportunity:

• Basic facts about asthma
• Roles of medications
• Skills: inhaler/spacer/holding chamber use, self-monitoring
• Environmental control measures
• When and how to take rescue actions

Jointly develop treatment goals.

To encourage an active partnership, provide all patients with a written daily self-management plan and an action plan for exacerbations. Action plans are especially important for patients with moderate-to-persistent asthma and patients with a history of severe exacerbations. Provide appropriate patients with a daily asthma diary.

Encourage adherence by promoting open communication; individualizing, reviewing, and adjusting plans as needed; emphasizing goals and outcomes; and encouraging family involvement.

Patient education is an essential component of successful asthma management. Current management approaches require patients and families to effectively carry out complex pharmacologic regimens, institute environmental control strategies, detect and self-treat most asthma exacerbations, and communicate appropriately with health care providers. Patient education is the mechanism through which patients learn to successfully accomplish those tasks. It is also a powerful tool for helping patients gain the motivation, skill, and confidence to control their asthma (Feldman et al. 1987; Mellins 1989). Research shows that asthma education can be cost-effective and can reduce morbidity for both adults and children, especially among high-risk patients (Trautner et al. 1993; Bolton et al. 1991; Fireman et al. 1981; Hindi-Alexander and Cropp 1984; Lewis et al. 1984; Clark et al. 1986). This Unit covers strategies for enhancing the delivery of patient education and improving the likelihood that patients will follow clinical recommendations, as well as key messages to communicate to the patient. When references are not cited, recommendations are based on the opinion of the Expert Panel.

ESTABLISH A PARTNERSHIP

Patient education should begin at the time of diagnosis and be integrated into every step of medical care, in the context of medical appointments and other clinician-patient communication. When clinicians take the time to provide education, it sends a powerful message to patients and families about the importance of being knowledgeable self-management of asthma. Specific educational messages delivered in the context of a medical care appointment clearly communicate the importance of collaboration in the treatment of asthma (Mayo et al. 1990; Ignacio-Garcia and Gonzales-Santos 1995).

From the time of diagnosis, the clinician and other members of the health care team should begin to build a partnership with the patient and family. Building the partnership requires that clinicians promote open communication and ensure that patients have a basic and accurate foundation of knowledge about asthma, understand the treatment approach, and have the self-management skills necessary to monitor the disease objectively and take medication effectively (Evans et al. 1997).

When nurses, pharmacists, respiratory therapists, and other health care professionals are available to support and expand patient education (NHLBI 1995a, 1995b), a team approach should be used. The principal clinician should introduce the key educational messages (see figure 4-1) and negotiate agreements with patients (Mayo et al. 1990; Kotses et al. 1996). Different members of the health care team should reinforce and expand these messages during office visits and telephone calls or in more formal educational sessions.

Communication and coordination within the team are critical. Team members should document in the patient’s record the key educational points (see figure 4-1), patient concerns, and actions the patient agrees to take. This will enable all members of the team to be consistent and to reinforce the educational points and the progress being made.

Figure 4-1

Check off or document that the following key messages have been covered:

Basic Facts About Asthma

    The contrast between asthmatic and normal airways

    What happens to the airways in an asthma attack

Roles of Medications

    How medications work

• Long-term control: medications that prevent symptoms, often by reducing inflammation
• Quick relief: short-acting bronchodilator relaxes muscles around airways

    Stress the importance of long-term-control medications and not to expect quick relief from them.

Skills

    Inhaler use (patient demonstrate)

    Spacer/holding chamber use

    Symptom monitoring, peak flow monitoring, and recognizing early signs of deterioration

Environmental Control Measures

    Identifying and avoiding environmental precipitants or exposures

When and How To Take Rescue Actions

    Responding to changes in asthma severity (daily self-management plan and action plan)

Teach Asthma Self-Management

The Expert Panel recommends that clinicians teach patients and families the essential information, medication skills, self-monitoring techniques, and environmental control measures outlined in figure 4-2 (Bailey et al. 1990; Ignacio-Garcia and Gonzales-Santos 1995; Kotses et al. 1995, 1996; Wilson et al. 1993). These key points should be adapted to meet the individual patient’s needs. Clinicians should:

    Teach basic facts about asthma so that the patient and family understand the rationale for needed actions. Give a brief verbal     description of what asthma is and the intended role of each medication. Do not overwhelm the patient with too much information all     at once, but repeat the important messages at each visit. Ask the patient to bring all medications to each appointment for review.

    Teach the patient necessary medication skills, such as correct use of the inhaler (see figure 4-3) and spacer/holding      chamber and knowing when and how to take quick-relief medications.

    Teach self-monitoring skills: symptom monitoring, peak flow monitoring as appropriate (see Unit 1-Periodic Assessment and     Monitoring), and recognizing early signs of deterioration.

    Teach relevant environmental control/avoidance strategies (see figure 2-4). Teach how environmental precipitants or     exposures can make the patient’s asthma worse (e.g., allergens and irritants) at home, school, and work and how to recognize both     immediate and delayed reactions.

Jointly Develop Treatment Goals

Fundamental to building a partnership is for clinicians and patients to jointly develop and agree on both short- and long-term treatment goals. Such agreements can encourage active participation, enhance the partnership, and improve asthma management (Schulman 1979; Clark 1989; Clark et al. 1995). It is the opinion of the Expert Panel that clinicians should:

    Determine the patient’s personal treatment goals. Ask how asthma interferes with the patient’s life (e.g., inability to sleep     through the night, play a sport) and incorporate the responses into personal treatment goals. Asthma-specific quality-of-life     instruments (Juniper et al. 1992; Marks et al. 1993) may be useful.

    Share the general goals of asthma treatment with the patient and family. Tell patients, "Our goals are to have you:

• Be free from severe symptoms day and night, including sleeping through the night."
• Have the best possible lung function."
• Be able to participate fully in any activities of your choice."
• Not miss work or school because of asthma symptoms."
• Need fewer or no urgent care visits or hospitalizations for asthma."
• Use medications to control asthma with as few side effects as possible."
• Be satisfied with your asthma care."

    Agree on the goals of treatment. The clinicians, the patient, and when appropriate, the patient’s family should agree on the goals     of asthma management, which include both the patient’s personal goals and the general goals (see list above) suggested by the     clinicians.

Provide the Patient With Tools for Self-Management

It is the opinion of the Expert Panel that, at the first visit, clinicians should develop a written, individualized, daily self-management plan in consultation with the patient. Include the recommended doses and frequencies of daily medications and the daily self-management activities needed to achieve the agreed-on goals. Review and refine the plan at subsequent followup visits. List the treatment goals in the plan and explain how following the plan will help the patient reach those goals. Emphasizing the patient’s personal goals is essential to enhancing adherence. For example, ask, "Have you had any problems taking your bronchodilator immediately before playing basketball? Has it helped you stay in the game?"

Discuss the long-term benefits of following the written, daily self-management plan (Plaut 1996). For some patients, focusing on long-term treatment goals and discussing the "big picture" of asthma control and how medications can be adjusted over time may improve adherence (NHLBI 1995c).

Also at the first visit, jointly develop a written action plan to help the patient manage asthma exacerbations (see figure 4-5 for examples). This is especially important for patients with moderate-to-severe persistent asthma and patients with a history of severe exacerbations. Review and refine the plan at followup visits. The action plan directs the patient to adjust medicines at home in response to particular signs, symptoms, and peak flow measurements. It should also list the PEF levels and symptoms indicating the need for acute care and emergency telephone numbers for the caregiver, emergency department, rapid transportation, and family/friend for aid and support. A number of action plans have been published (Woolcock et al. 1988; Beasley et al. 1989; D’Souza et al. 1994; Charlton et al. 1990; Mellins and Evans, in press; NHLBI 1995d; NHLBI 1995e). Those tested in randomized clinical trials were effective in decreasing asthma exacerbations (Woolcock et al. 1988; Charlton et al. 1990). Clinicians should choose an action plan that suits their practice, patients, and style. The examples in figure 4-5 are not endorsed by the Expert Panel; rather, they are provided to demonstrate a range of possibilities and should be modified as appropriate.

It is the opinion of the Expert Panel that clinicians should provide an asthma diary to appropriate patients for self-monitoring symptoms, peak flow measurements, frequency of daily quick-relief inhaler medication use, and activity restriction.

Encourage Adherence

An important part of patient education is encouraging adherence.

• Use effective techniques to promote open communication. Research suggests that certain clinician behaviors are associated with patient adherence and/or satisfaction with care (Clark et al. 1995). Not all are appropriate for cultural subgroups, but the items listed in figure 4-6 are general guidelines.

• Early in each visit, elicit the patient’s concerns, perceptions, and unresolved questions about his or her asthma. A question such as "What worries you most about your asthma?," which cannot be answered yes or no, encourages patients and families to voice issues, personal beliefs, or concerns they may be apprehensive about discussing or may not think are of interest to the clinician. These potential barriers to adherence can be dealt with only if they are identified. By asking about and discussing such concerns, clinicians build trust and a sense of partnership with the patient. Most non-adherence originates in personal beliefs or concerns about asthma that have not been discussed with the clinician (Korsch et al. 1968; Janz et al. 1984). Until such fears and worries are identified and addressed, patients will not be able to adhere to the clinician’s recommendations (Korsch et al. 1968).

• Assess the patient’s and family’s perceptions of the severity level of the disease. Two questions may prove useful: "How severe do you think your asthma is?" and "How much danger do you believe you are in from your asthma?" When patients are identified who are overwhelmed by fear of death, put their fears in perspective by providing them with the results of objective assessments and expert opinion. A clearly written, detailed action plan that directs the patient how to respond to worsening asthma may be extremely helpful in reducing anxiety (figure 4-5). Patients’ perceptions about their disease severity and its threat to their well-being influence self-management behavior and use of the health care system (Janson-Bjerklie et al. 1992; Janz et al. 1984).

• Assess the patient’s and family’s level of social support. Ask, "Who among your family or friends can you turn to for help if your asthma worsens?" Counsel patients to identify an asthma "partner" among their family or friends who is willing to be educated and provide support. Include at least one of these individuals in followup appointments with the patient so that he or she can hear what is expected of the patient in following the self-management and action plans (Graham et al. 1990).

• Encourage or enlist family involvement. Ask patients to identify ways their family members can help them follow the plans. Ask the patient to share the plans with family members, elicit their input, and agree on actions they can help with. It may be helpful for children and parents to discuss this with a clinician present.

• Consider referral to a psychologist, social worker, psychiatrist, or other licensed professional when stress seems to unduly interfere with daily asthma management. As with other chronic diseases, emotional and social stress may be a confounding factor for many patients struggling with asthma control. Although stress does not cause asthma, it can play a role in precipitating asthma exacerbations (Busse et al. 1995) and can complicate an individual’s attempts at self-management. Referral to a local support group may be useful.

• Use methods to increase the chances that the patient will adhere to the written, daily self-management plan. For instance, adherence to the self-management plan is enhanced when the plan is simplified as much as possible, when the number of medications and frequency of daily doses are minimized, when the medication doses and frequency fit into the patient’s and family’s daily routine (Clark et al. 1995; Haynes et al. 1979; Eisen et al. 1990; Evans 1993; Meichenbaum and Turk 1987), and when the plan considers the patient’s ability to afford the medications (Hindi-Alexander and Throm 1987). Because nonadherence is difficult for clinicians to detect (Haynes et al. 1979; Charney et al. 1967; Mushlin and Appel 1977), it is prudent to explore potential barriers to adherence with every patient by asking what concerns they have about medicines (e.g., safety) or other aspects of treatment.

Tailor Education to the Needs of the Individual Patient

Assess cultural or ethnic beliefs or practices that may influence self-management activities and modify educational approaches, as needed. Cultural variables may affect patient understanding of and adherence to medical regimens (Pachter and Weller 1993; Kleinman et al. 1978). Open-ended questions such as "In your community, what does having asthma mean?" can elicit informative responses. The culturally sensitive clinician should attempt to find ways to incorporate harmless or potentially beneficial remedies with the pharmacologic plan. For example, a prevalent belief among the Latino population is that illnesses are either "hot" or "cold" (Risser and Mazur 1995). Asthma is viewed as a "cold" illness amenable to "hot" treatment. Suggesting that asthma medications be taken with hot tea or hot water incorporates this belief into the therapeutic regimen and helps build the therapeutic partnership. When harmful home remedies are being used, clinicians should discourage their use by suggesting a culturally acceptable alternative as a replacement or recommending a safer route of administration (Pachter et al. 1995). These and other strategies may be useful in working with ethnic minorities (NHLBI 1995c).

Every effort should be made to discuss asthma care, especially the self-management plan, in the patient’s native language so that educational messages are fully understood. Research suggests that lack of language concordance between the clinician and the patient affects adherence and appropriate use of health care services (Manson 1988). Language barriers also may complicate the assessment of cultural differences. If interpreters are used, they should be equally competent in both English and the patient’s language and knowledgeable about medical terms (Woloshin et al. 1995).

MAINTAIN THE PARTNERSHIP

As part of ongoing care, the clinician should continue to build the partnership by being a sympathetic coach and by helping the patient follow the self-management plan and take other needed actions. Educational efforts should be continuous, because it may take up to 6 months for the impact of education to be evident (Toelle et al. 1993). Furthermore, it is necessary to periodically review information and skills covered previously because patient self-management behavior is likely to decline over time (Reis et al. 1995).

In particular, it is essential that clinicians demonstrate, review, evaluate, and correct inhaler/spacer/holding chamber technique at each visit because these skills deteriorate rapidly (Keston et al. 1993). Written instructions are helpful, but insufficient (Nimmo et al. 1993; Wilson et al. 1993). Research suggests that patients tend to make specific mistakes in using inhalers that need to be corrected (Larsen et al. 1994; Dolovich et al. 1981; Kesten et al. 1993; Hanania et al. 1994). Patients especially need to be reminded to inhale slowly and to activate the inhaler only once for each breath (Rau et al. 1996).

Clinicians should continue to promote open communication with the patient and family by addressing the following elements in each followup visit:

• Continue asking patients early in each visit what concerns they have about their asthma and what they especially want addressed during the visit.
• Review the short-term goals agreed on in the initial visit. Assess how well they are being achieved (e.g., was the patient’s wish to engage in physical activity achieved?). Revise the goals as needed. Achievement of short-term goals should be discussed as indicators that the patient is moving toward long-term goals. Give positive verbal reinforcement for achievement of a goal and recognize the patient’s success in moving closer to full control of the disease.