GINA_smjernice Za Astmu

8/13/2019 GINA_smjernice Za Astmu

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TABLE OF CONTENTS

PREFACE .......................................................................................2

WHAT IS KNOWN ABOUT ASTHMA?...........................................4DIAGNOSING ASTHMA ..............................................................6

Figure 1. Is it Asthma? ........................................................6

CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL ...............8

Figure 2. Levels of Asthma Control.........................................8

FOUR COMPONENTS OF ASTHMA CARE .....................................9

Component 1. Develop Patient/Doctor Partnership..................9

Figure 3. Example of Contents of an Action Plan to MaintainAsthma Control....................................................10

Component 2. Identify and Reduce Exposure to Risk Factors..11

Figure 4. Strategies for Avoiding Common Allergens andPollutants ............................................................11

Component 3. Assess, Treat, and Monitor Asthma.................12Figure 5. Management Approach Based on Control..............14

Figure 6. Estimated Equipotent Doses of InhaledGlucocorticosteroids.............................................15

Figure 7. Questions for Monitoring Asthma Care ..................17

Component 4. Manage Exacerbations.....................................18

Figure 8. Severity of Asthma Exacerbations ..........................21

SPECIAL CONSIDERATIONS IN MANAGING ASTHMA..............22

Appendix A: Glossary of Asthma Medications - Controllers....23

Appendix B: Combination Medications for Asthma ................24

Appendix C: Glossary of Asthma Medications - Relievers......25


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PREFACE

Asthma is a major cause of chronic morbidity and mortality throughoutthe world and there is evidence that its prevalence has increasedconsiderably over the past 20 years, especially in children. The GlobalInitiative for Asthma was created to increase awareness of asthmaamong health professionals, public health authorities, and the generalpublic, and to improve prevention and management through a concerted

worldwide effort. The Initiative prepares scientific reports on asthma,encourages dissemination and implementation of the recommendations,and promotes international collaboration on asthma research.

The Global Initiative for Asthma offers a framework to achieve andmaintain asthma control for most patients that can be adapted to localhealth care systems and resources. Educational tools, such as laminatedcards, or computer-based learning programs can be prepared that aretailored to these systems and resources.

The Global Initiative for Asthma program publications include:

Global S"a"eg% fo A!"hma Managemen" and Pe$en"ion (2009).Scientific information and recommendations for asthma programs.

Global S"a"eg% fo A!"hma Managemen" and Pe$en"ionGINA Executive Summary. Eur Respir J 2008; 31: 1-36

Pocke" G#ide fo A!"hma Managemen" and Pe$en"ion fo Ad#l"!

and Childen Olde Than 5 Yea! (2009). Summary of patient careinformation for primary health care professionals.

P"cke% G&ide f"# A$%ha Ma!agee!% a!d P#e'e!%i"! i! Child#e!5 Yea#$ a!d Y"&!ge#(2009). Summary of patient care informationfor pediatricians and other health care professionals.

Wha" Yo# and Yo# Famil% Can Do Abo#" A!"hma. An informationbooklet for patients and their families.

"@ = =444.%'+a1&*a.,%.

This Pocket Guide has been developed from the G),a) S1a1#%6 $,A1&*a Ma+a%#*#+1 a+" P#3#+1',+ (Updated 2009). Technicaldiscussions of asthma, evidence levels, and specific citations from thescientific literature are included in that source document.

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Acknowledgements:

Grateful acknowledgement is given for unrestricted educational grants from

AstraZeneca, Boehringer Ingelheim, Chiesi Group, Cipla, GlaxoSmithKline,Meda Pharma, Merck Sharp & Dohme, Mitsubishi Tanabe, Novartis,Nycomed and PharmAxis. The generous contributions of these companiesassured that the GINA Committees could meet together and publicationscould be printed for wide distribution. However, the GINA Committee par-ticipants are solely responsible for the statements and conclusions in the pub-lications.

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WHAT IS KNOWNABOUT ASTHMA?

Unfortunatelyasthma is one of the most common chronic diseases,with an estimated 300 million individuals affected worldwide. Itsprevalence is increasing, especially among children.

Fortunatelyasthma can be effectively treated and most patients canachieve good control of their disease. When asthma is under control

patients can:

3 Avoid troublesome symptoms night and day3 Use little or no reliever medication3 Have productive, physically active lives3 Have (near) normal lung function3 Avoid serious attacks

Asthma causes recurring episodes ofwheezing, breathlessness,

chest tightness, and coughing, particularly at night or in the earlymorning.

Asthma is a chronic inflammatory disorder of the airways.Chronically inflamed airways are hyperresponsive; they becomeobstructed and airflow is limited (by bronchoconstriction, mucus plugs,and increased inflammation) when airways are exposed to variousrisk factors.

Common risk factors for asthma symptoms include exposure toallergens (such as those from house dust mites, animals with fur,cockroaches, pollens, and molds), occupational irritants, tobacco smoke,respiratory (viral) infections, exercise, strong emotional expressions,chemical irritants, and drugs (such as aspirin and beta blockers).

A stepwise approach to pharmacologic treatment to achieve andmaintain control of asthma should take into account the safety of

treatment, potential for adverse effects, and the cost of treatment requiredto achieve control.

Asthma attacks (or exacerbations) are episodic, but airway inflammationis chronically present.

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For many patients, controller medication must be taken daily toprevent symptoms, improve lung function, and prevent attacks.Reliever medications may occasionally be required to treat acute

symptoms such as wheezing, chest tightness, and cough. To reach and maintain asthma control requires the development of a

partnership between the person with asthma and his or her healthcare team.

Asthma is not a cause for shame. Olympic athletes, famous leaders,other celebrities, and ordinary people live successful lives with asthma.

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DIAGNOSINGASTHMA

Asthma can often be diagnosed on the basis of a patients symptomsand medical history(Figure 1).

Measurements of lung function provide an assessment of the severity,reversibility, and variability of airflow limitation, and help confirm thediagnosis of asthma.

Spirometryis the preferred method of measuring airflow limitation and

its reversibility to establish a diagnosis of asthma. An increase in FEV1 of 12% and 200 ml after administration of a

bronchodilator indicates reversible airflow limitation consistent withasthma. (However, most asthma patients will not exhibit reversibilityat each assessment, and repeated testing is advised.)

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Presence of any of these signs and symptoms should increase the suspicion of asthma:

n Wheezinghigh-pitched whistling sounds when breathing outespecially in children.

(A normal chest examination does not exclude asthma.)n History of any of the following:

Cough, worse particularly at night Recurrent wheeze Recurrent difficult breathing Recurrent chest tightness

n Symptoms occur or worsen at night, awakening the patient.

n Symptoms occur or worsen in a seasonal pattern.

n The patient also has eczema, hay fever, or a family history of asthma or atopicdiseases.

n Symptoms occur or worsen in the presence of: Animals with fur Aerosol chemicals Changes in temperature Domestic dust mites Drugs (aspirin, beta blockers) Exercise Pollen Respiratory (viral) infections Smoke

Strong emotional expressionn Symptoms respond to anti-asthma therapy.

n Patients colds go to the chest or take more than 10 days to clear up.

Figure 1. Is It Asthma?


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Peak expiratory flow (PEF) measurements can be an important aid inboth diagnosis and monitoring of asthma.

PEF measurements are ideally compared to the patients own previousbest measurements using his/her own peak flow meter.

An improvement of 60 L/min (or 20% of the pre-bronchodilator PEF)after inhalation of a bronchodilator, or diurnal variation in PEF ofmore than 20% (with twice-daily readings, more than 10%), suggestsa diagnosis of asthma.

Additional diagnostic tests: For patients with symptoms consistent with asthma, but normal lung

function, measurements of airway responsiveness to metha-choline, histamine, direct airway challenges such as inhaled mannitol,or exercise challenge may help establish a diagnosis of asthma.

Skin tests with allergens or measurement of specific IgE inserum: The presence of allergies increases the probability of adiagnosis of asthma, and can help to identify risk factors that causeasthma symptoms in individual patients.

Diagnostic Challenges

n Cough-variant asthma. Some patients with asthma have chroniccough (frequently occurring at night) as their principal, if not only,symptom. For these patients, documentation of lung function variability

and airway hyperresponsiveness are particularly important.n Exercise-induced bronchoconstriction. Physical activity is an

important cause of asthma symptoms for most asthma patients, andfor some (including many children) it is the only cause. Exercise testingwith an 8-minute running protocol can establish a firm diagnosis ofasthma.

n Children 5 Years and Younger. Not all young children whowheeze have asthma. In this age group, the diagnosis of asthma mustbe based largely on clinical judgment, and should be periodically

reviewed as the child grows (see the GINA P,!(#1 G'"# $, A1&*aMa+a%#*#+1 a+" P#3#+1',+ '+ C&')"#+ 5 Y#a a+" Y,+%#forfurther details).

nAsthma in the elderly. Diagnosis and treatment of asthma in theelderly are complicated by several factors, including poor perceptionof symptoms, acceptance of dyspnea as being normal for old age,and reduced expectations of mobility and activity. Distinguishingasthma from COPD is particularly difficult, and may require a trialof treatment.

n Occupational asthma. Asthma acquired in the workplace is a diagnosisthat is frequently missed. The diagnosis requires a defined history ofoccupational exposure to sensitizing agents; an absence of asthmasymptoms before beginning employment; and a documented relation-ship between symptoms and the workplace (improvement in symptomsaway from work and worsening of symptoms upon returning to work).

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8

CLASSIFICATION OF ASTHMABY LEVEL OF CONTROL

The g"al "f a$%ha ca#e i$ %" achie'e a!d ai!%ai! c"!%#"l of the clini-cal manifestations of the disease for prolonged periods. When asthma iscontrolled, patients can prevent most attacks, avoid troublesome symptomsday and night, and keep physically active.

The assessment of asthma control should include control of the clinical man-ifestations and control of the expected future risk to the patient such as

exacerbations, accelerated decline in lung function, and side-effects oftreatment. In general, the achievement of good clinical control of asthmaleads to reduced risk of exacerbations.

Fige 2 describes the clinical characteristics of controlled, partly con-trolled, and uncontrolled asthma.

Figure 2. Levels of Asthma Control

Characteristic Controlled(All of the following)

Partly Controlled(Any measure present in any week)

Uncontrolled

Daytime symptoms None (twice or less/week) More than twice/week Three or morefeatures ofpartly controlledasthma presentin any week

Limitations of activities None Any

Nocturnal symptoms/awakening

None Any

Need for reliever/rescue treatment

None (twice or less/week) More than twice/week

Lung function(PEF or FEV1)

Normal < 80% predicted or

personal best (if known)

* An exacerbation should prompt review of maintenance treatment to ensure that it is adequate.

B definition, an exacerbation in an week makes that an uncontrolled asthma week.

! Lung function testing is not reliable for children 5 ears and ounger.

Examples of validated measures for assessing clinical control of asthma include:

Asthma Control Test (ACT): www.asthmacontrol.com

Childhood Asthma Control test (C-Act) Asthma Control Questionnaire (ACQ): www.qoltech.co.uk/Asthma1.htm

Asthma Therapy Assessment Questionnaire (ATAQ):www.ataqinstrument.com

Asthma Control Scoring System

B. A$$e$$e!% "f F&%e Ri$k (risk of exacerbations, instability, rapid decline in lung function, side-effects)

Fea+e "a a+e a(c#aed #" #'c+eaed +#$ ( ad/e+e e/e' #' "e +e #'c%de:P((+ c%#'#ca% c('+(%, +e*e' eace+ba#(' #' )a ea+, e/e+ ad#(' ( c+##ca% ca+e (+ a"&a,%( FEV1, e)(+e ( c#!a+ee &($e, "#!" d(e &ed#ca#('.


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FOUR COMPONENTS OFASTHMA CARE

Four interrelated components of therapy are required to achieve and main-tain control of asthma

Component 1. Develop patient/doctor partnership

Component 2. Identify and reduce exposure to risk factorsComponent 3. Assess, treat, and monitor asthmaComponent 4. Manage asthma exacerbations

Component 1: Develop Patient/Doctor Partnership

The effective management of asthma requires the development of apartnership between the person with asthma and his or her health care team.

With your help, and the help of others on the health care team, patientscan learn to:

Avoid risk factors Take medications correctly Understand the difference between controller and reliever medications Monitor their status using symptoms and, if relevant, PEF Recognize signs that asthma is worsening and take action

Seek medical help as appropriate

Education should be an integral part of all interactions between healthcare professionals and patients. Using a variety of methodssuch asdiscussions (with a physician, nurse, outreach worker, counselor, or educa-tor), demonstrations, written materials, group classes, video or audio tapes,dramas, and patient support groupshelps reinforce educational messages.

Working together, you and your patient should prepare awrittenpersonal asthma action plan that is medically appropriate andpractical. A sample asthma plan is shown in Figure 3.

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Additional self-management plans can be found onseveral Websites, including:

444.a1&*a.,%.(444.+&)',1.!,*/a1&*a/'+"#.&1*)444.a1&*a+7.!,.+7

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Figure 3. Example of Contents of an Action Plan to Maintain Asthma Control

@= #@= %=:1. E 7

2. B= =, 7

HE %! IC#EA$E %#EA%ME%A @= A C=I


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Component 2: Identify and Reduce Exposure to RiskFactors

To improve control of asthma and reduce medication needs, patientsshould take steps to avoid the risk factors that cause their asthma symptoms(Figure 4). However, many asthma patients react to multiple factors thatare ubiquitous in the environment, and avoiding some of these factorscompletely is nearly impossible. Thus, medications to maintain asthmacontrol have an important role because patients are often less sensitive tothese risk factors when their asthma is under control.

Physical activity is a common cause of asthma symptoms but patients

should not avoid exercise. Symptoms can be prevented by taking arapid-acting inhaled 2-agonist before strenuous exercise (a leukotrienemodifier or cromone are alternatives).

Patients with moderate to severe asthma should be advised to receive aninfluenza vaccination every year, or at least when vaccination of thegeneral population is advised. Inactivated influenza vaccines are safe foradults and children over age 3.

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Avoidance measures that improve control of asthma and reduce medication needs: Tobacco smoke: Stay away from tobacco smoke. Patients and parents should

not smoke. Drugs, foods, and additives: Avoid if they are known to cause symptoms. Occupational sensitizers: Reduce or, preferably, avoid exposure to these agents.

Reasonable avoidance measures that can be recommended but have not been shown

to have clinical benefit: House dust mites: Wash bed linens and blankets weekly in hot water anddry in a hot dryer or the sun. Encase pillows and mattresses in air-tight covers.Replace carpets with hard flooring, especially in sleeping rooms. (If possible, usevacuum cleaner with filters. Use acaricides or tannic acid to kill mitesbut makesure the patient is not at home when the treatment occurs.)

Animals with fur: Use air filters. (Remove animals from the home, or at leastfrom the sleeping area. Wash the pet.)

Cockroaches: Clean the home thoroughly and often. Use pesticide spraybutmake sure the patient is not at home when spraying occurs.

Outdoor pollens and mold: Close windows and doors and remain indoorswhen pollen and mold counts are highest.

Indoor mold: Reduce dampness in the home; clean any damp areas frequently.

Figure 4. Strategies for Avoiding Common Allergens and Pollutants


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Component 3: Assess, Treat, and Monitor Asthma

The goal of asthma treatmentto achieve and maintain clinical control

can be reached in most patients through a continuous cycle that involves Assessing Asthma Control Treating to Achieve Control Monitoring to Maintain Control

Assessing Asthma Control

Each patient should be assessed to establish his or her current treatment

regimen, adherence to the current regimen, and level of asthma control.A simplified scheme for recognizing controlled, partly controlled, anduncontrolled asthma is provided in Figure 2.

Treating to Achieve Control

Each patient is assigned to one of five treatment steps. Figure 5 detailsthe treatments at each step for adults and children age 5 and over.

At each treatment step, reliever medication should be provided forquick relief of symptoms as needed. (However, be aware of how muchreliever medication the patient is usingregular or increased use indicatesthat asthma is not well controlled.)

At Steps 2 through 5, patients also require one or more regular controllermedications, which keep symptoms and attacks from starting. Inhaledglucocorticosteroids (Figure 6) are the most effective controller medications

currently available.

For most patients newly diagnosed with asthma or not yet on medication,treatment should be started at Step 2 (or if the patient is very symptomatic,at Step 3). If asthma is not controlled on the current treatment regimen,treatment should be stepped up until control is achieved.

Patients who do not reach an acceptable level of control at Step 4 canbe considered to have difficult-to-treat asthma. In these patients, acompromise may need to be reached focusing on achieving the best levelof control feasiblewith as little disruption of activities and as few dailysymptoms as possiblewhile minimizing the potential for adverse effectsfrom treatment. Referral to an asthma specialist may be helpful.

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A variety of controller (Appendix A and Appendix B) and reliever(Appendix C) medications for asthma are available. The recommendedtreatments are guidelines only. Local resources and individual patient

circumstances should determine the specific therapy prescribed for eachpatient.

Inhaled medications are preferred because they deliver drugs directly tothe airways where they are needed, resulting in potent therapeutic effectswith fewer systemic side effects. Inhaled medications for asthma are availableas pressurized metered-dose inhalers (pMDIs), breath-actuated MDIs, drypowder inhalers (DPIs), and nebulizers. Spacer (or valved holding-chamber)devices make inhalers easier to use and reduce systemic absorption and

side effects of inhaled glucocorticosteroids.

Teach patients (and parents) how to use inhaler devices. Different devicesneed different inhalation techniques.

Give demonstrations and illustrated instructions. Ask patients to show their technique at every visit. Information about use of various inhaler devices is found on the

GINA Website (www.ginasthma.org).


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Figure 5. Management Approach Based On ControlAdults and Children Older than 5 Years

Alternative reliever treatments include inhaled anticholinergics, short-acting oral 2-agonists,

some long-acting 2-agonists, and short-acting theophlline. Regular dosing with short and

long-acting 2-agonistis not advised unless accompanied b regular use of an inhaled

glucocorticosteroid.

Controlleroptions****ICS =inhaledglucocorti costeroids**=Re ceptorantagonisto rsynthesisinhibito rs***=P referredcontrollero ptionsareshowni nshadedboxes

TreatmentSteps

A sneededrapid-a cting2-agonistA s neededrapid-actin g2-agonistLow -doseICSpluslong-a cting2-agonistSelecto neLeukotrie nemodifie r**S electoneMedium-orhig h-doseICS

Medium-orhigh-d oseICSpluslong-ac ting2-agonist

Low-d oseICSplusleuko trienemodifierLow-d oseICSplussusta inedreleaseth eophylline

ToStep3treatme nt,selectoneormo reToStep 4treatment,ad deitherAsthmaeducationEnvironmentalcontrol

Low-dosein haledICS*O ralgluco corticosteroid(lowe stdose)An ti-IgEtre atmentLeukotrienemodifierSustainedrelea setheophylline

Controlled Mainta inandfindlowestc ontrollingstepPartlycontrolled C on sidersteppingupto gaincontrolUncontrolled S tepupuntilcon trolledExacerbation T reatasexacerb ation

TreatmentAc tionLevelofContr ol Reduce

Reduce I ncreaseIncrease

2Step1Step 3 Step 4Step 5Ste p

Controlleroptions***

* ICS = inhaled glucocorticosteroids

**= Receptor antagonist or synthesis inhibitors

*** = Preferred controller options are shown in shaded boxes

Treatment Steps

As needed rapid-

acting 2-agonistAs needed rapid-acting 2-agonist

Low-dose ICS plus

long-acting 2-agonist

Select one

Leukotriene

modifier**

Select one

Medium-or

high-dose ICS

Medium-or high-dose

ICS plus long-acting

2-agonist

Low-dose ICS plus

leukotriene modifier

Low-dose ICS plus

sustained release

theophylline

To Step 3 treatment,select one or more

To Step 4 treatment,add either

Asthma education

Environmental control

Low-dose inhaled

ICS*Oral glucocorticosteroid

(lowest dose)

Anti-IgE

treatment

Leukotriene

modifier

Sustained release

theophylline

Controlled Maintain and find lowest controlling step

Partly controlled Consider stepping up to gain control

Uncontrolled Step up until controlled

Exacerbation Treat as exacerbation

Treatment ActionLevel of Control

R

educe

Reduce Increase

Increase

2Step1Step 3Step 4Step 5Step


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Figure 6. Estimated Eqipotent Dail" Doses of InhaledGlcocorticosteroids for Adlts and Children Older than 5 Years#

Drg

200-500 >500-1000 >1000-2000B1/8;91?4->;:105800-1600B@*

80-160 >160-320 >320-1280C*

500-1000 >1000-2000 >2000F@

100-250 >250-500 >500-1000F8@?5/->;:1800-1200M@=*

400-1000 >1000-2000 >2000%=

Lo! Dose (g)4 M@ D D (g)4

4 C(&)a+#,(', ba,ed )(' e#cac daa.

6 Pa#e', c(',#de+ed (+ "#!" da#% d(,e, e1ce) (+ ,"(+ )e+#(d, ,"(%d be +ee++ed ( a,)ec#a%#, (+ a,,e,,&e' ( c(',#de+ a%e+'a#/e c(&b#'a#(', (c('+(%%e+,. Ma1#&& +ec(&&e'ded d(,e, a+e a+b#+a+ b 0#" )+(%('!ed ,e a+e a,,(c#-

aed 0#" #'c+ea,ed +#,$ ( ,,ec ,#de eec,.

* A))+(/ed (+ ('ce-da#% d(,#'! #' %d )a#e',.

Notes

The most important determinant of appropriate dosing is the clinicians judgment of thepatients response to therapy. The clinician must monitor the patients response in terms ofclinical control and adjust the dose accordingly. Once control of asthma is achieved, thedose of medication should be carefully titrated to the minimum dose required to maintaincontrol, thus reducing the potential for adverse effects.

Designation of low, medium, and high doses is provided from manufacturers recommen-dations where possible. Clear demonstration of dose-response relationships is seldom pro-vided or available. The principle is therefore to establish the minimum effective controllingdose in each patient, as higher doses may not be more effective and are likely to be asso-ciated with greater potential for adverse effects.

As CFC preparations are taken from the market, medication inserts for HFA preparationsshould be carefully reviewed by the clinician for the equivalent correct dosage.

H D D (g)4


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Monitoring to Maintain Control

Ongoing monitoring is essential to maintain control and establish the

lowest step and dose of treatment to minimize cost and maximize safety.Typically, patients should be seen one to three months after the initialvisit, and every three months thereafter. After an exacerbation, follow-upshould be offered within two weeks to one month.

At each visit, ask the questions listed in Figure 7.

A@ :

If asthma is not controlled on the current treatment regimen, step uptreatment. Generally, improvement should be seen within 1 month.But first review the patients medication technique, compliance, andavoidance of risk factors.

If asthma is partly controlled, consider stepping up treatment,depending on whether more effective options are available, safetyand cost of possible treatment options, and the patients satisfactionwith the level of control achieved.

If control is maintained for at least 3 months, step down with agradual, stepwise reduction in treatment. The goal is to decreasetreatment to the least medication necessary to maintain control.

Monitoring is still necessary even after control is achieved, as asthma isa variable disease; treatment has to be adjusted periodically in responseto loss of control as indicated by worsening symptoms or the developmentof an exacerbation.


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Figure 7. Questions for Monitoring Asthma Care

IS THE ASTHMA MANAGEMENT PLAN MEETING EXPECTED GOALS?

IS THE PATIENT USING INHALERS, SPACER, ORPEAK FLOW METERS CORRECTLY?

IS THE PATIENT TAKING THE MEDICATIONS AND AVOIDING RISKFACTORS ACCORDING TO THE ASTHMA MANAGEMENT PLAN?

Ask the patient:

Ha0 62/ a01&*a a4a(#+#" 62 a1

+'%&1?

Ha3# 62 +##"#" */# /#)'#3#/

*#"'!a1'+0 1&a+ 202a)?

Ha3# 62 +##"#" a+6 2/%#+1 *#"'!a)

!a/#?

Ha0 62/ #a( $)4 ##+ #)4 62/

#/0+a) #01?

A/# 62 a/1'!'a1'+% '+ 62/ 202a)&60'!a) a!1'3'1'#0?

Ask the patient:

P)#a0# 0&4 *# &4 62 1a(# 62/*#"'!'+#.

Action to consider:

Demonstrate correct technique.Have patient demonstrate back.

Ask the patient, for example:

S 1&a1 4# *a6 )a+ 1/a6, )#a0#1#)) *# &4 $1#+ 62 a!12a))6 1a(#1 *#"'!'+#.

W&a1 /)#*0 &a3# 62 &a" $))4-

'+% 1 *a+a%#*#+1 )a+ / 1a('+%62/ *#"'!a1'+?

D2/'+% 1 )a01 *+1&, &a3# 62 #3#/01#" 1a('+% 62/ *#"'!'+# #!a20#62 4#/# $##)'+% #11#/?

Ask the patient:

W&a1 !+!#/+0 *'%&1 62 &a3#a21 62/ a01&*a, *#"'!'+#0, /*a+a%#*#+1 )a+?

Action to consider:

Provide additional education to relieveconcerns and discussion to overcomebarriers.

Action to consider:

Adjust plan to be more practical.Problem solve with the patient to over-come barriers to following the plan.

Action to consider:

Adjust medications and managementplan as needed (step up or step down).But first, compliance should beassessed.

DOES THE PATIENT HAVE ANY CONCERNS?


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Component 4: Manage Exacerbations

Exacerbations of asthma (asthma attacks) are episodes of a progressive

increase in shortness of breath, cough, wheezing, or chest tightness, or acombination of these symptoms.

Do not underestimate the severity of an attack; severe asthmaattacks may be life threatening. Their treatment requires close supervision.

Patients at high risk of asthma-related death require closer attention andshould be encouraged to seek urgent care early in the course of their

exacerbations. These patients include those:

With a history of near-fatal asthma requiring intubation and mechanicalventilation

Who have had a hospitalization or emergency visit for asthma withinthe past year

Who are currently using or have recently stopped using oral gluco-corticosteroids

Who are not currently using inhaled glucocorticosteroids Who are overdependent on rapid-acting inhaled 2-agnoists, especially

those who use more than one canister of salbutamol (or equivalent)monthly

With a history of psychiatric disease or psychosocial problems, includingthe use of sedatives

With a history of noncompliance with an asthma medication plan

Patients should immediately seek medical care if:

The attack is severe (Figure 8):

- The patient is breathless at rest, is hunched forward, talks inwords rather than sentences (infant stops feeding), is agitated,drowsy, or confused, has bradycardia, or has a respiratory rategreater than 30 per minute

- Wheeze is loud or absent

- Pulse is greater than 120/min (greater than 160/min for infants)- PEF is less than 60 percent of predicted or personal best, even

after initial treatment- The patient is exhausted


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The response to the initial bronchodilator treatment is notprompt and sustained for at least 3 hours

There is no improvement within 2 to 6 hours after oral

glucocorticosteroid treatment is started There is further deterioration

Mild attacks, defined by a reduction in peak flow of less than 20%, nocturnalawakening, and increased use of rapid-acting 2-agonists, can usually betreated at home if the patient is prepared and has a personal asthmamanagement plan that includes action steps.

Moderate attacks may require, and severe attacks usually require, care ina clinic or hospital.

Asthma attacks require prompt treatment:

Inhaled rapid-acting 2-agonists in adequate doses are essential.

(Begin with 2 to 4 puffs every 20 minutes for the first hour; then mild

exacerbations will require 2 to 4 puffs every 3 to 4 hours, and moderateexacerbations 6 to 10 puffs every 1 to 2 hours.)

Oral glucocorticosteroids (0.5 to 1 mg of prednisolone/kg or equivalent

during a 24-hour period) introduced early in the course of a moderate or

severe attack help to reverse the inflammation and speed recovery.

Oxygen is given at health centers or hospitals if the patient is hypoxemic

(achieve O2 saturation of 95%).

Combination 2-agonist/anticholinergic therapy is associated with lowerhospitalization rates and greater improvement in PEF and FEV1.

Methylxanthines are not recommended if used in addition to high doses

of inhaled 2-agonists. However, theophylline can be used if inhaled

2-agonists are not available. If the patient is already taking theophylline

on a daily basis, serum concentration should be measured before adding

short-acting theophylline.

Therapies not recommended for treating asthma attacks include:

Sedatives (strictly avoid)

Mucolytic drugs (may worsen cough)


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Chest physical therapy/physiotherapy (may increase patient discomfort)

Hydration with large volumes of fluid for adults and older children (may

be necessary for younger children and infants)

Antibiotics (do not treat attacks but are indicated for patients who also

have pneumonia or bacterial infection such as sinusitis)

Epinephrine/adrenaline (may be indicated for acute treatment of

anaphylaxis and angioedema but is not indicated for asthma attacks)

Monitor response to treatment:

Evaluate symptoms and, as much as possible, peak flow. In the hospital, alsoassess oxygen saturation; consider arterial blood gas measurement inpatients with suspected hypoventilation, exhaustion, severe distress, or peakflow 30-50 percent predicted.

Follow up:

After the exacerbation is resolved, the factors that precipitated the

exacerbation should be identified and strategies for their future avoidanceimplemented, and the patients medication plan reviewed.


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Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.

*Note: The presence of several parameters, but not necessarily all, indicates the general classification of the exacerbation.Note: Kilopascals are also used internationally, conversion would be appropriate in this regard.

Parameter

Talks in

Alertness

Respiratory rate

Sentences

May be agitated

Increased

Phrases

Usually agitated

Increased

Words

Usually agitated

Often > 30/min

Drowsy or confused

Mild Moderate Severe Respiratoryarrest imminent

Breathless Walking

Can lie down

TalkingInfant - softer, shortercry; difficulty feeding

Prefer sitting

At restInfant stopsfeeding

Hunched forward

Normal rates of breathing in awake children:

Age Nomal a"e

< 2 months < 60/min2-12 months < 50/min1-5 years < 40/min6-8 years < 30/min

Guide to limits of normal pulse rate in children:

Infants 2-12 months -Normal rate 45 mm Hg;Possible respiratoryfailure (see text)

Over 80% Approx. 60-80% < 60% predicted orpersonal best(< 100 L/min adults)

orresponse lasts < 2 hrs

Absent< 10 mm Hg

May be present10-25 mm Hg

Often present> 25 mm Hg (adult)20-40 mm Hg (child)

Absence suggestsrespiratory musclefatigue

SaO2% (on air) > 95% 91-95% < 90%

Figure 8. Severity of Asthma Exacerbations*


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Special considerations are required in managing asthma in relation to:

n Pregnancy. During pregnancy the severity of asthma often changes, andpatients may require close follow-up and adjustment of medications. Pregnantpatients with asthma should be advised that the greater risk to their babylies with poorly controlled asthma, and the safety of most modern asthmatreatments should be stressed. Acute exacerbations should be treated

aggressively to avoid fetal hypoxia.n Surgery. Airway hyperresponsiveness, airflow limitation, and mucus hyper-

secretion predispose patients with asthma to intraoperative and postoperativerespiratory complications, particularly with thoracic and upper abdominalsurgeries. Lung function should be evaluated several days prior to surgery,and a brief course of glucocorticosteroids prescribed if FEV1 is less than80% of the patients personal best.

n Rhinitis, Sinusitis, and Nasal Polyps. Rhinitis and asthma often coexistin the same patient, and treatment of rhinitis may improve asthma symptoms.Both acute and chronic sinusitis can worsen asthma, and should be treated.Nasal polyps are associated with asthma and rhinitis, often with aspirinsensitivity and most frequently in adult patients. They are normally quiteresponsive to topical glucocorticosteroids.

n Occupational asthma. Pharmacologic therapy for occupational asthmais identical to therapy for other forms of asthma, but is not a substitute foradequate avoidance of the relevant exposure. Consultation with a specialist inasthma management or occupational medicine is advisable.

n Respiratory infections. Respiratory infections provoke wheezing andincreased asthma symptoms in many patients. Treatment of an infectious

exacerbation follows the same principles as treatment of other exacerbations.n Gastroesophageal reflux. Gastroesophageal reflux is nearly three timesas prevalent in patients with asthma compared to the general population.Medical management should be given for the relief of reflux symptoms,although this does not consistently improve asthma control.

nAspirin-induced asthma. Up to 28 percent of adults with asthma, butrarely children, suffer from asthma exacerbations in response to aspirinand other nonsteroidal anti-inflammatory drugs. The diagnosis can only beconfirmed by aspirin challenge, which must be conducted in a facility withcardiopulmonary resuscitation capabilities. Complete avoidance of the drugs

that cause symptoms is the standard management.nAnaphylaxis. Anaphylaxis is a potentially life-threatening condition that can

both mimic and complicate severe asthma. Prompt treatment is crucial andincludes oxygen, intramuscular epinephrine, injectable antihistamine,intravenous hydrocortisone, and intravenous fluid.

SPECIAL CONSIDERATIONSIN MANAGING ASTHMA


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Appendix A: Glossary of Asthma Medications - Controllers

Ta)# !,+1'+#"...

Glucocortico-

steroidsAdrenocorticoidsCorticosteroidsGlucocorticoids

Inhaled (ICS):BeclomethasoneBudesonideCiclesonideFlunisolideFluticasoneMometasoneTriamcinolone

Tablets or syrups:hydrocortisonemethylprednisoloneprednisoloneprednisone

Sodiumcromoglycatecromolyncromones

MDI 2 mg or 5 mg2-4 inhalations 3-4times daily. Nebulizer20 mg 3-4 times daily.

Minimal side effects. Coughmay occur upon inhalation. May take 4-6 weeks todetermine maximum effects.

Frequent daily dosingrequired.

Nedocromilcromones

Long-acting2-agonists

beta-adrenergissympathomimetics

LABAs

Inhaled:Formoterol (F)Salmeterol (Sm)

Sustained-releaseTablets:Salbutamol (S)Terbutaline (T)Aminophyllinemethylxanthinexanthine

Inhaled:DPI -F: 1 inhalation(12 g) bid.MDI- F: 2 puffs bid.

DPI-Sm: 1 inhalation(50 g) bid.MDI-Sm: 2 puffs bid.

Tablets:S: 4 mg q12h.T: 10mg q12h.

Starting dose 10mg/kg/day withusual 800 mgmaximum in

1-2 divided doses.

Inhaled: fewer, and lesssignificant, side effects thantablets. Have been associatedwith an increased risk of

severe exacerbations andasthma deaths when addedto usual therapy.

Tablets: may causetachycardia, anxiety, skeletalmuscle tremor, headache,hypokalemia.

Nausea and vomiting aremost common. Serious effectsoccurring at higher serum

concentrations includeseizures, tachycardia, andarrhythmias.

Inhaled: Salmeterol NOT tobe used to treat acute attacks.Should not use as mono-therapy for controller therapy.

Always use as adjunct toICS therapy. Formoterol hasonset similar to salbutamoland has been used as neededfor acute symptoms.

Tablets: As effective assustained-release theophylline.No data for use as adjunctivetherapy with inhaledglucocorticosteroids.

Theophylline level monitoring

is often required. Absorptionand metabolism may beaffected by many factors,including febrile illness.

MDI 2 mg/puff 2-4inhalations 2-4 timesdaily.

Cough may occur uponinhalation.

Some patients unable totolerate the taste.

Name andAlso Known As

Usual Doses Side Effects

Inhaled: Beginningdose dependent onasthma control thentitrated down over2-3 months to lowesteffective dose oncecontrol is achieved.

Tablets or syrups:For daily control uselowest effective dose5-40 mg of prednisoneequivalent in a.m. orqod.

For acute attacks40-60 mg daily in1 or 2 divided dosesfor adults or 1-2 mg/kgdaily in children.

Inhaled: High daily doses

may be associated with skinthinning and bruises, andrarely adrenal suppression.Local side effects are hoarse-ness and oropharyngealcandidiasis. Low to mediumdoses have produced minorgrowth delay or suppression(av. 1cm) in children. Attainmentof predicted adult height doesnot appear to be affected.

Tablets or syrups: Used

long term, may lead toosteoporosis, hypertension,diabetes, cataracts, adrenalsuppression, growth suppression,obesity, skin thinning or muscleweakness. Consider coexistingconditions that could beworsened by oral glucocortico-steroids, e.g. herpes virusinfections, Varicella,tuberculosis, hypertension,diabetes and osteoporosis

Inhaled: Potential but smallrisk of side effects is wellbalanced by efficacy. Valvedholding-chambers with MDIsand mouth washing with DPIsafter inhalation decrease oralCandidiasis. Preparations notequivalent on per puff or gbasis.

Tablet or syrup: Longterm use: alternate day a.m.dosing produces less toxicity.Short term: 3-10 day bursts

are effective for gainingprompt control.

Comments


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Appendix A: Glossary of Asthma Medications - Controllers (con"in#ed...)

Name andAlso Known As

Usual Doses Side Effects Comments

Antileukotrienes

Leukotriene modifiersMontelukast (M)Pranlukast (P)Zafirlukast (Z)Zileuton (Zi)

ImmunomodulatorsOmalizumabAnti-IgE

Adults: Doseadministered subcu-taneously every 2 or 4weeks dependent

on weight and IgEconcentration

Pain and bruising at injec-tion site (5-20%) and veryrarely anaphylaxis (0.1%).

Need to be stored underrefrigeration 2-8C andmaximum of 150 mgadministered per injection site.

Adults: M 10mg qhsP 450mg bidZ 20mg bid;Zi 600mg qid.

Children: M 5 mgqhs (6-14 y)M 4 mg qhs (2-5 y)Z 10mg bid (7-11 y).

No specific adverse effectsto date at recommendeddoses. Elevation of liverenzymes with Zafirlukastand Zileuton and limitedcase reports of reversiblehepatitis and hyperbiliru-binemia with Zileuton andhepatic failure with afirlukast

Antileukotrienes are mosteffective for patients withmild persistent asthma. Theyprovide additive benefit whenadded to ICSs though not aseffective as inhaled long-acting2-agonists.

Formulation Inhaler Devices Inhalations/day

Fluticasone

propionate/salmeterol

Fluticasonepropionate/salmeterol

DPI

pMDI(Suspension)

1 inhalation x 2

DosesAvailable( )1 ICS/LABA

100/501

250/50500/50

50/251

125/25250/25

TherapeuticUse

Maintenance

Maintenance

Budesonide/formoterol

Budesonide/formoterol

DPI

pMDI(Suspension)

80/4.52

160/4.5320/9.0

80/4.52

160/4.5

2 inhalations x 2

1-2 inhalations x 2

2 inhalations x 2

Maintenanceand Relief

Maintenance

Appendix B: Combination Medications For Asthma

ICS = #'"a%ed c(+#c(e+(#d; LABA = %('! ac#'! 2-a!('#; )MDI = )+e+#ed &ee+ed d(e #'"a%e+; DPI = d+ )(de+ #'"a%e+

Ne (+&%a#(' #%% be +e/#eed (+ #'c%#(' #' "e ab%e a "e a+e a))+(/ed. Sc" &ed#ca#(' &a be

b+(!" ( "e ae'#(' ( "e GINA Sc#e'ce C(&ee.

1 Ree+ ( &ee+ed d(e. F(+ add##('a% #'(+&a#(' ab( d(a!e a'd )+(dc a/a#%ab%e #' )ec##c

c('+#e, )%eae c('% www.gsk.com ( #'d a %#'$ ( (+ c('+ eb#e (+ c('ac (+ %(ca% c(&)a'

+e)+ee'a#/e (+ )+(dc a))+(/ed (+ e #' (+ c('+.

2

Ree+ ( de%#/e+ed d(e. F(+ add##('a% #'(+&a#(' ab( d(a!e a'd )+(dc a/a#%ab%e #' )ec##c

c('+#e, )%eae c('% www.astrazeneca.com( #'d a %#'$ ( (+ c('+ eb#e (+ c('ac (+

%(ca% c(&)a' +e)+ee'a#/e (+ )+(dc a))+(/ed (+ e #' (+ c('+.

3 Ree+ ( &ee+ed d(e. F(+ add##('a% #'(+&a#(' ab( d(a!e a'd )+(dc a/a#%ab%e #' )ec##c

c('+#e, )%eae c('% www.chiesigroup.com( #'d a %#'$ ( (+ c('+ eb#e (+ c('ac (+

%(ca% c(&)a' +e)+ee'a#/e (+ )+(dc a))+(/ed (+ e #' (+ c('+.

Beclomethasone/formoterol

1-2 inhalations x 2pMDI(Solution)

100/63 Maintenance


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Appendix C: Glossary of Asthma Medications - Relievers

Name and AlsoKnown As

Short-acting2-agonistsAdrenergics2-stimulantsSympathomimetics

Albuterol/salbutamolFenoterolLevalbuterolMetaproterenolPirbuterolTerbutaline

AnticholinergicsIpratropium

bromide (IB)Oxitropium

bromide

Short-actingtheophyllineAminophylline

Epinephrine/adrenalineinjection

IB-MDI 4-6 puffs q6h orq20 min in the emergencydepartment. Nebulizer500 g q20min x 3then q2-4hrs for adultsand 250-500 g forchildren.

7 mg/kg loadingdose over 20 minfollowed by 0.4

mg/kg/hr continuousinfusion.

1:1000 solution(1mg/mL) .01mg/kgup to 0.3-0.5 mg, cangive q20min x 3.

Minimal mouth dryness orbad taste in the mouth.

Nausea, vomiting, headache.At higher serum concentra-tions: seizures, tachycardia,

and arrhythmias.

Similar, but more significanteffects than selective 2-agonist.In addition: hypertension,fever, vomiting in children andhallucinations.

May provide additive effectsto 2-agonist but has sloweronset of action. Is an alternativefor patients with intolerancefor 2-agonists.

Theophylline level monitoringis required. Obtain serumlevels 12 and 24 hours into

infusion. Maintain between10-15 g/mL.

In general, not recommendedfor treating asthma attacks ifselective 2-agonists areavailable.

Differences in potencyexist but all productsare essentiallycomparable on a perpuff basis. For presymptomatic use andpretreatment beforeexercise 2 puffs MDIor 1 inhalation DPI.For asthma attacks4-8 puffs q2-4h, mayadminister q20min x 3with medical supervi-sion or the equivalent

of 5 mg salbutamolby nebulizer.

Inhaled: tachycardia,skeletal muscle tremor,headache, and irritability.At very high dose hyper-glycemia, hypokalemia.

Systemic administration asTablets or Syrup increasesthe risk of these side effects.

Drug of choice for acutebronchospasm. Inhaled routehas faster onset and is moreeffective than tablet or syrup.Increasing use, lack of expectedeffect, or use of > 1 canistera month indicate poor asthmacontrol; adjust long-termtherapy accordingly. Useof 2 canisters per month isassociated with an increasedrisk of a severe, life-threateningasthma attack.

Usual Doses Side Effects Comments


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NOTES


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NOTES


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The Global Initiative for Asthma is supported by educational grants from:

' GIA 444.%'+a1&*a.,%

444.%'+a1&*a.,%/a)'!a1',+.a

C

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