Key Components in Treating Asthma in Adults and Children Older than 5 Years: Diagnosis, Treatment and Referral

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1 Key Components in Treating Asthma in Adults and Children Older than 5 Years: Diagnosis, Treatment and Referral Initial Asthma Assessment Critical to accurately diagnose asthma by: Identifying the presence of characteristic symptoms (cough, chest tightness, shortness of breath, wheezing) Conducting spirometry at the time of the initial asthma assessment. Document obstructive ventilatory defect and/or post-bronchodilator reversibility ( % and > ml increase over baseline in the forced expiratory volume in the first second (FEV)) after puffs of a short-acting beta agonist (SABA). Ensuring that alternative diagnoses are excluded (COPD, vocal cord dysfunction, aspiration, and cystic fibrosis in children) At the initial asthma visit, it is important to identify asthma triggers (viruses, allergens, exercise, pollutants, etc). Categorize the patient s asthma into intermittent or persistent asthma (see below). For patients not previously on controller therapy, initiate therapy based on severity of asthma. If these various elements are discordant, the patient s asthma should be categorized at the level of most severe. See Figure. Severity 5- and Figure 4. Severity > Treatment The goals of treatment are to reduce impairment, i.e. minimize the day-to-day impact of asthma on lifestyle while minimizing rescue inhaler use and optimizing lung function and meeting patient/family expectations, and to reduce risk, i.e. minimize the likelihood of an asthma attack, thereby reducing resource usage (emergency/urgent care.) Other components of reducing risk include minimizing loss of lung function and always considering the possible adverse effects of medications. Initiate therapy based on severity of asthma (patients not previously on controller therapy). If these various elements are discordant, the patient s asthma should be categorized at the level of most severe. Intermittent (STEP Treatment) Intermittent asthma (for adults) is characterized by daytime asthma symptoms occurring two or fewer days per week; two or fewer nocturnal awakenings per month; the use of short-acting beta agonists to relieve symptoms fewer than two times a week; no interference with normal activities between exacerbations; the use of short-acting FEV measurements between exacerbations that are consistently within the normal range (ie, 8 percent of predicted normal); FEV/FVC ratio between exacerbations that is normal (based on ageadjusted values); and one or no exacerbations requiring systemic corticosteroids per year. In addition, the use of a SABA to prevent exercise-induced asthmatic symptoms does not count against the patient. Patients whose asthmatic symptoms can be predicted (eg, prior to exercise)

2 are encouraged to use a SABA approximately minutes prior to exposure in order to prevent the onset of symptoms. Step Treatment - Short acting beta agonist, taken as needed for relief of symptoms. See figure. Managing Asthma 5- and Figure 6. Managing Asthma >. Mild persistent (Step Treatment) - Mild persistent asthma is characterized by: symptoms more than twice weekly (although less than daily); three to four nocturnal awakenings per month due to asthma; use of SABA to relieve symptoms more than times a week (but not daily); minor interference with normal activities; FEV measurements within normal range ( 8 % of predicted normal); FEV/FVC ratio is normal (based on age-adjusted values); and two or more exacerbations requiring systemic corticosteroids per year. Step Treatment - The distinction between intermittent and mild persistent asthma is important since current guidelines call for initiation of daily long-term controller medication in those with mild persistent asthma. The preferred long-term controller for mild persistent asthma is low dose inhaled corticosteroids (ICS). See Figure. Managing Asthma 5- and Figure 6. Managing Asthma >. Regular use of ICS reduces the frequency of symptoms (and the need for SABA for symptom relief), improves the overall quality of life, and decreases the risk of serious exacerbations. Regular use of ICS has not been shown to prevent progressive loss of lung function over time. Moderate persistent (Step Treatment) - The presence of one or more of the following is considered an indication of moderate persistent asthma: daily symptoms of asthma; nocturnal awakenings more than once per week; daily need for SABA for symptom relief; some limitation in normal activity; FEV between 6 and 8 % of predicted; FEV/FVC reduced below normal (based on age-adjusted values); and two or more exacerbations requiring systemic corticosteroids per year. Step Treatment - The preferred therapies for moderate persistent asthma are either low-doses of an ICS plus a long-acting beta agonist (LABA), or medium doses of an ICS). See Figure. Managing Asthma 5- and Figure 6. Managing Asthma >. The former combination has proven more effective in controlling asthmatic symptoms than increasing the dose of ICSs, although it entails the potential risk of adverse outcomes that have been reported in association with LABAs. Severe Persistent (Step 4, 5 or 6 Treatment) The presence of one or more of the following is considered an indication of severe persistent asthma: symptoms of asthma throughout the day; nocturnal awakenings nightly; need for SABA for symptom relief several times per day; extreme limitation of normal activity; FEV < 6 % of predicted; FEV/FVC reduced below normal (based on age-adjusted values); and two or more exacerbations requiring systemic corticosteroids per year.

3 Step 4 or 5 Treatment - The preferred treatments for severe persistent asthma are medium (Step 4) to high (Step 5) doses of an ICS, in combination with a LABA. See Figure. Managing Asthma 5- and Figure 6. Managing Asthma >. In addition, for patients who are inadequately controlled on high-dose ICS and LABA, the anti-ige therapy omalizumab may be considered if there is objective evidence (allergy skin tests or in vitro measurements of allergen-specific IgE) of sensitivity to a perennial allergen and if the serum IgE level is within the established target range (referral to allergy section recommended). Step 6 Treatment - Addition of systemic corticosteroids on a daily or alternate-day basis. See Figure. Managing Asthma 5- and Figure 6. Managing Asthma >. For each treatment step: patient education, environmental control, and management of comorbid conditions are imperative. For treatment steps -4, subcutaneous allergen immunotherapy should be considered for those patients with one or more allergic triggers to their asthma. Patient Education Patient education is an essential component of asthma care in order to impart the skills essential to asthma control and to the improvement of outcomes. Education should include: basic asthma facts; the patient s current level of control and how to maintain or improve; the role of asthma medication; self-management skills; a written action plan with instructions on how to respond to signs and symptoms of worsening asthma; and information on how to control asthma triggers. Follow-up Asthma Visits Should occur every -6 months and include the following: Assessment for compliance and proper use of medications Assessment of quality of life (normal physical activity, exercise, work or school absenteeism) Questioning regarding any medication side effects Questioning regarding any interim exacerbations Assess for the contribution of other conditions that can mimic or worsen asthma (smoking, gastroesophageal reflux, post nasal drainage, vocal cord dysfunction etc.) Reinforce environmental control (remove pets, carpeting, visible mold, etc) Consider allergy testing, if not yet completed. Spirometry should be conducted every 6- months to follow lung function, and yearly influenza vaccinations should be given. Assess asthma control by monitoring: Night time symptoms Activity-limiting symptoms (See ACT and C-ACT)

4 Rescue inhaler usage (more than twice per week for symptom relief may indicate that a patient s asthma is not being well-controlled. The provider should limit the number of albuterol refills given by avoiding refill as needed ) Assessment of "control": Used to adjust therapy in returning patients or alter therapy in patients evaluated for the first time while already taking a long-term controller medication. Based on impairment over the past to 4 weeks (based on history or validated questionnaire, current FEV or peak flow, and estimates of risk, shown in Figure. Assessing Control 5- and Figure 5. Assessing Control >) The clinician should determine whether the patient's asthma is Well Controlled, Not Well Controlled, or Very Poorly Controlled. If the level of control does not fall into the Well Controlled classification, therapy should be stepped-up. If the asthma is well-controlled for a period of at least months, therapy can be continued or possibly stepped-down to minimize medication side-effects. See Figure. Managing Asthma 5- and Figure 6. Managing Asthma >. Therapy should be readjusted at each visit, because asthma is an inherently variable condition, and the management of asthma is a dynamic process that changes in accordance with the patient's needs over time. Referral Referral to both pulmonologists and allergists/immunologists for consultation or co-management is recommended when any of the following circumstances arise: Patient has experienced a life-threatening asthma exacerbation Patient has required hospitalization or more than two courses of systemic corticosteroids within a month period Adult or pediatric patient >5 years requiring step 4 care or higher Asthma is not controlled after to 6 months of active therapy and appropriate monitoring Patient appears unresponsive to therapy Diagnosis of asthma is uncertain Other conditions are present which complicate management (nasal polyposis, chronic sinusitis, severe rhinitis, allergic bronchopulmonary aspergillosis, COPD, vocal cord dysfunction, etc); Additional diagnostic tests are needed (skin testing for allergies, bronchoscopy, formal pulmonary function tests); Patient has one or more allergic triggers to their asthma (i.e. may be a candidate for allergen immunotherapy) Other possible indications for referral include; adult or pediatric patient > 5 years who requires step care or higher or a child < 5 years who requires step care or higher; there appear to be occupational triggers; patients with whom psychosocial or psychiatric problems are interfering with asthma management and with whom referral to other appropriate specialists may be required. 4

5 This information is meant to serve as a guideline and not a substitute for clinical judgment. Because standards change, it is advisable to keep abreast of revised recommendations. Figures for Asthma Guidelines. Classifying Asthma Severity and Initiating Therapy in Children 5-yo 5

6 . Assessing asthma control and adjusting therapy in children 5-yo. 6

7 . Stepwise approach for managing asthma long-term in children 5-yo Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. ICS, inhaled corticosteroid; LABA, inhaled long-acting beta-agonist, LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta-agonist 7

8 4. Classifying asthma severity and initiating treatment in youths years of age and adults Components of Severity Impairment Normal FEV /FVC: 8 9 yr 85% 9 yr 8% 4 59 yr 75% 6 8 yr 7% Risk Symptoms Nighttime awakenings Short-acting beta -agonist use for symptom control (not prevention of EIB) Interference with normal activity Lung function Exacerbations (consider frequency and severity) Intermittent days/week x/month days/week None Normal FEV between exacerbations FEV >8% predicted FEV /FVC normal /year Classification of Asthma Severity years of age > days/week but not >x/day Minor limitation >/year Mild > days/week but not daily 4x/month FEV >8% predicted FEV /FVC normal Persistent Moderate Daily >x/week but not nightly Daily Some limitation FEV >6% but <8% predicted FEV /FVC reduced 5% Severe Throughout the day Often 7x/week Several times per day Extremely limited FEV <6% predicted FEV /FVC reduced >5% Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category Lowest level of treatment required to maintain control (See figure 4 5 for treatment steps) Step Relative annual risk of exacerbations may be related to FEV Step Step or 4 Step 5 or 6 and consider short course of systemic oral corticosteroids In 6 weeks, evaluate level of asthma control that is achieved and adjust therapy accordingly. Key: FEV, forced expiratory volume in second; FVC, forced vital capacity; ICU, intensive care unit 8

9 5. Assessing asthma control and adjusting therapy in youths years of age and adults *ACQ values of.76.4 are indeterminate regarding well-controlled asthma. Key: EIB, exercise-induced bronchospasm; ICU, intensive care unit 9

10 6. Stepwise approach for managing asthma in youths years of age and adults Key: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting inhaled betaagonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta-agonist

11 . ACT TEST > y/o Asthma Control Test (ACT). In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? Score. During the past 4 weeks, how often have you had shortness of breath?. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning? 4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? 5. How would you rate your asthma control during the past 4 weeks? Asthma Control Test is a trademark of QualityMetric Incorporated. Patient Total Score

12 . C-ACT 4- y/o. Childhood Asthma Control Test Questions Completed by Child Age 4- Years. How is your asthma today? SCORE Very bad Bad Good Very Good. How much of a problem is your asthma when you run, exercise or play sports? It s a big problem, I can t do what I want to do. It s a problem and I don t like it. It s a little problem but it s okay. It s not a problem.. Do you cough because of your asthma? Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time. 4. Do you wake up during the night because of your asthma? Yes, all of the time. Yes, most of the time. Yes, some of the time. No, none of the time.

13 Childhood Asthma Control Test Questions Completed by Parent/Caregiver 5. During the last 4 weeks, on average, how many days per month did your child have any daytime asthma symptoms? 5 4 Not at all - days/mo 4- days/mo -8 days/mo 9-4 days/mo Everyday 6. During the last 4 weeks, on average, how many days per month did your child wheeze during the day because of asthma? 5 4 Not at all - days/mo 4- days/mo -8 days/mo 9-4 days/mo Everyday 7. During the last 4 weeks, on average, how many days per month did your child wake up during the night because of asthma? 5 4 Not at all - days/mo 4- days/mo -8 days/mo 9-4 days/mo Everyday TOTAL References Institute for Clinical Systems Improvement (ICSI). Asthma, Diagnosis and Management of (Guideline). July Retrieved from: https://www.icsi.org/guidelines more/search_results_- _browsing/?catalog_search_panel_query=&catalog_search_panel_label_ids%5b%5d=94 American Lung Association. Expert Panel Report : Guidelines for the Diagnosis and Management of Asthma (7) Retrieved from: Adopted: July 8, Quality Improvement Subcommittee Reviewed and approved by QI Subcommittee: April 9; March 8, ; June,, June,, August, Next Review Date: June 4

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