2007 NIH Asthma Guidelines Summary
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1 2007 NIH Asthma Guidelines Summary Summary of the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma National Institutes of Health (NIH) National Heart, Lung, and Blood Institute National Asthma Education and Prevention Program (NAEPP) This information is abstracted from the 2007 NAEPP Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. To access the complete report, go to
2 Goals of Asthma Control 1 Reduce impairment Prevent chronic and troublesome symptoms Require infrequent use of inhaled short-acting beta 2 -agonists (SABA) for quick relief of symptoms ( 2 days per week) Maintain (near) normal pulmonary function Maintain normal activity levels (including exercise and other physical activity and attendance at work or school) Meet patients and families expectations of and satisfaction with asthma care Reduce risk Prevent recurrent exacerbations and minimize the need for emergency department (ED) visits/hospitalizations Prevent progressive loss of lung function; for children, prevent reduced lung growth Provide optimal pharmacotherapy with minimal or no adverse effects Guidelines include separate but related concepts of severity, control, and responsiveness to treatment Severity The intrinsic intensity of the disease process Measured most easily and directly in a patient not receiving long-term control therapy Assessed to guide clinical decisions on appropriate medications and interventions Control The degree to which the manifestations of asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met Guide decisions to maintain or adjust therapy Responsiveness The ease with which asthma control is achieved by therapy Assess asthma severity to initiate therapy During a patient s initial presentation, if the patient is not currently taking long-term control medication, assess asthma severity to guide clinical decisions for initiating the appropriate medication and other therapeutic interventions Assess asthma control to monitor and adjust therapy Once therapy is initiated, the emphasis for clinical management is changed to the assessment of asthma control. Use the level of asthma control to guide decisions either to maintain or to adjust therapy 2
3 Patients 12 Years of Age Assessing Severity: Patients 12 Years of Age * Classifying Asthma Severity and Initiating Treatment in Patients > 12 Years of Age 1 Assessing severity and initiating treatment for patients who are not currently taking long-term control medications Components of Severity Short-acting beta 2 -agonist use for symptom control (not prevention of EIB) Interference with normal activity Lung function Exacerbations requiring oral systemic corticosteroids Recommended Step for Initiating Therapy <_2x/month Normal FEV 1 between exacerbations FEV 1 >80% predicted FEV 1 /FVC normal Classification of Asthma Severity (> 12 Years of Age) Persistent Mild Moderate but not daily 3-4x/month but not daily, and not more than 1x on any day Minor limitation FEV 1 >80% predicted FEV 1 /FVC normal >1x/week but not nightly FEV 1 >60% but <80% predicted FEV 1 /FVC reduced 5% Severe FEV 1 <60% predicted FEV 1 /FVC reduced >5% >_2 per year Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV 1. Step 3 Step 4 or 5 and consider short course of oral systemic corticosteroids In 2-6 weeks, evaluate level of asthma control that is achieved, and adjust therapy accordingly. *Normal FEV 1 /FVC: 8-19 yr: 85% yr: 80% yr: 75% yr: 70% Often 7x/week Assessing Control: Patients 12 Years of Age Assessing Asthma Control and Adjusting Therapy in Patients > 12 Years of Age 1 Components of Control Interference with normal activity Short-acting beta 2 -agonist use for symptom control (not prevention of EIB) FEV 1 or peak flow Validated questionnaires ATAQ ACQ ACT Exacerbations requiring oral systemic corticosteroids Progressive loss of lung function Treatment-related adverse effects Recommended Action for Treatment Well Controlled <_2x/month >80% predicted/personal best 60%-80% predicted/personal best <60% predicted/personal best 0 <_0.75 >_20 Classification of Asthma Control (> 12 Years of Age) Not Well Controlled 1-3x/week 1-2 >_ >_2 per year Evaluation requires long-term follow-up care. Maintain current step. Regular follow-ups every 1-6 Step up 1 step and months to maintain control. Reevaluate in 2-6 weeks. Consider step down if well controlled for at least 3 months. Very Poorly Controlled >_4x/week 3-4 N/A <_15 Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. ACQ values are indeterminate regarding well-controlled asthma. ACT = Asthma Control Test. Asthma Control Test is a trademark of QualityMetric Incorporated. Consider short course of oral systemic corticosteroids, Step up 1-2 steps, and Reevaluate in 2 weeks. 3
4 Patients 12 Years of Age Assessing Treatment Options: Patients 12 Years of Age Stepwise Approach for Managing Asthma in Patients > 12 Years of Age 1 Asthma Persistent Asthma: Medication Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3. SABA PRN Cromolyn, LTRA, nedocromil, or theophylline Step 3 OR LTRA, theophylline, or zileuton Step 4 LTRA, theophylline, or zileuton Step 5 AND Consider omalizumab for patients who have allergies Each step: Patient education, environmental control, and management of comorbidities Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma. Step 6 + oral corticosteroid AND Consider omalizumab for patients who have allergies Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed. Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment. Step up if needed (first, check adherence, environmental control, and comorbid conditions) Assess control Step down if possible (and asthma is well controlled at least 3 months) 4
5 Patients 5-11 Years of Age Assessing Severity: Children 5-11 Years of Age Classifying Asthma Severity and Initiating Treatment in Children 5-11 Years of Age 1 Assessing severity and initiating treatment in children who are not currently taking long-term control medication Classification of Asthma Severity (5-11 Years of Age) Components Persistent of Severity Mild Moderate Severe Short-acting beta 2 -agonist use for symptom control (not prevention of EIB) Interference with normal activity Lung function Exacerbations requiring oral systemic corticosteroids Recommended Step for Initiating Therapy <_2x/month Normal FEV 1 between exacerbations FEV 1 >80% predicted FEV 1 /FVC >85% but not daily 3-4x/month but not daily Minor limitation FEV 1 = >80% predicted FEV 1 /FVC >80% >1x/week but not nightly FEV 1 = 60%-80% FEV predicted 1 <60% predicted FEV 1 /FVC <75% FEV 1 /FVC = 75%-80% >_2 per year Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV 1. Step 3, medium-dose option Often 7x/week Step 3, medium-dose option, or Step 4 and consider short course of oral systemic corticosteroids In 2-6 weeks, evaluate level of asthma control that is achieved, and adjust therapy accordingly. Assessing Control: Children 5-11 Years of Age Assessing Asthma Control and Adjusting Therapy in Children 5-11 Years of Age 1 Components of Control Interference with normal activity Short-acting beta 2 -agonist use for symptom control (not prevention of EIB) Lung function FEV 1 or peak flow FEV 1 /FVC Exacerbations requiring oral systemic corticosteroids Reduction in lung growth Treatment-related adverse effects Recommended Action for Treatment Classification of Asthma Control (5-11 Years of Age) Well Controlled Not Well Controlled Very Poorly Controlled but not more than once on each day or multiple times on <_1x/month >_2x/month >_2x/week >80% predicted/personal best >80% >_2 per year Evaluation requires long-term follow-up care. Maintain current step. Regular follow-up every 1-6 months. Consider step down if well controlled for at least 3 months. 60%-80% predicted personal best 75%-80% Step up 1 step and Reevaluate in 2-6 weeks. <60% predicted/personal best <75% predicted Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Consider short course of oral systemic corticosteroids, Step up 1-2 steps, and Reevaluate in 2 weeks. 5
6 Patients 5-11 Years of Age (continued) Assessing Treatment Options: Children 5-11 Years of Age Stepwise Approach for Managing Asthma in Children 5-11 Years of Age 1 Asthma Persistent Asthma: Medication Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3. SABA PRN Cromolyn, LTRA, nedocromil, or theophylline Step 3 EITHER LABA, LTRA, or theophylline OR Step 4 LTRA or theophylline Step 5 LTRA or theophylline Each step: Patient education, environmental control, and management of comorbidities Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma. Step 6 + oral systemic corticosteroid LTRA or theophylline + oral systemic corticosteroid Step up if needed (first, check adherence, inhaler technique, environmental control, and comorbid conditions) Assess control Step down if possible (and asthma is well controlled at least 3 months) Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed. Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment. 6
7 Patients 0-4 Years of Age Assessing Severity: Children 0-4 Years of Age Classifying Asthma Severity and Initiating Treatment in Children 0-4 Years of Age 1 Assessing severity and initiating treatment in children who are not currently taking long-term control medications Components of Severity Short-acting beta 2 -agonist use for symptom control (not prevention of EIB) Interference with normal activity Exacerbations requiring oral systemic corticosteroids Recommended Step for Initiating Therapy 0 Classification of Asthma Severity (0-4 Years of Age) Persistent Mild Moderate but not daily 1-2x/month but not daily Minor limitation >_2 exacerbations in 6 months requiring oral systemic corticosteroids, or >_4 wheezing episodes/1 year lasting >1 day AND risk factors for persistent asthma. Frequency and severity may fluctuate over time. Exacerbations of any severity may occur in patients in any severity category. 3-4x/month Severe >1x/week Step 3 and consider short course of oral systemic corticosteroids In 2-6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is observed in 4-6 weeks, consider adjusting therapy or alternative diagnoses. Assessing Control: Children 0-4 Years of Age Assessing Asthma Control and Adjusting Therapy in Children 0-4 Years of Age 1 Components of Control Interference with normal activity Short-acting beta 2 -agonist use for symptom control (not prevention of EIB) Exacerbations requiring oral systemic corticosteroids Treatment-related adverse effects Classification of Asthma Control (0-4 Years of Age) Well Controlled Not Well Controlled Very Poorly Controlled <_1x/month >1x/month >1x/week 2-3 per year >3 per year Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Recommended Action for Treatment Maintain current treatment. Regular follow-up every 1-6 months. Consider step down if well controlled for at least 3 months. Step up 1 step and Reevaluate in 2-6 weeks. If no clear benefit in 4-6 weeks, consider alternative diagnoses or adjusting therapy. Consider short course of oral systemic corticosteroids, Step up 1-2 steps, and Reevaluate in 2 weeks. If no clear benefit in 4-6 weeks, consider alternative diagnoses or adjusting therapy. 7
8 Patients 0-4 Years of Age (continued) Assessing Treatment Options: Children 0-4 Years of Age Stepwise Approach for Managing Asthma in Children 0-4 Years of Age 1 Asthma SABA PRN Persistent Asthma: Medication Consult with asthma specialist if Step 3 care or higher is required. Consider consultation at. Cromolyn or montelukast Step 3 Patient education and environmental control at each step Step 4 LABA or montelukast Step 5 LABA or montelukast Step 6 LABA or montelukast Oral systemic corticosteroid Step up if needed (first, check adherence, inhaler technique, and environmental control) Assess control Step down if possible (and asthma is well controlled at least 3 months) Quick-Relief Medication for All Patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms. With viral respiratory infection: SABA q 4-6 hours up to 24 hours (longer with physician consult). Consider short course of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severe exacerbations. Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on initiating daily long-term control therapy. Reference: 1. National Heart, Lung, and Blood Institute. Expert panel report 3: guidelines for the diagnosis and management of asthma: full report NIH publication Accessed February 28, 2008.
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