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PCCP Council on Asthma. Classification of Chronic Asthma Severity on Treatment. *Objective measures take precedence over subjective complaints. The higher severity level of any domain will be the basis of the final severity level. - PowerPoint PPT Presentation
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Classification of Chronic Asthma Classification of Chronic Asthma Severity on TreatmentSeverity on Treatment
Domains/Estimates
Intermittent Persistent
Mild to Moderate
Severe**
Daytime symptoms
Monthly Weekly Daily
Nocturnal awakening
Less than monthly
Monthly to weekly
Nightly
Rescue 2
agonist useLess than
weeklyWeekly to
dailySeveral
times a day
PEF or FEV1* > 80 % predicted
60 to 80 % of predicted
< 60 % of predicted
Treatment needed to control asthma
Occasional prn
2 only
Regular ICS + LABA
combination
Combination ICS + LABA +
OCS
PCCP Council on Asthma
PCRADM 2004
*Objective measures take precedence over subjective complaints. The higher severity level of any domain will be the basis of the final severity level. **Patients who are high risk for asthma-related deaths are initially classified here
P
Controller MedicationsController MedicationsInhaled glucocorticosteroidsLong-acting inhaled β2-agonistsSystemic glucocorticosteroidsLeukotriene modifiers (Sustained Release) TheophyllineCromonesLong-acting oral β2-agonistsAnti-IgE
PCCP Council on Asthma
P
Reliever MedicationsReliever MedicationsRapid-acting inhaled β2-agonistsSystemic glucocorticosteroids (acute setting)
AnticholinergicsTheophyllineShort-acting oral β2-agonists
PCCP Council on Asthma
Characteristic
ControlledPartly controlled(Any present in any
week)
Uncontrolled
Daytime symptoms
None (2 or less / week)
More than twice / week
3 or more features of partly
controlled asthma
present in any week
Limitations of activities
None Any
Nocturnal symptoms / awakening
None Any
Need for rescue /
“reliever” treatment
None (2 or less / week)
More than twice / week
Lung function (PEF or FEV1)
Normal< 80% predicted or
personal best (if known) on any day
Exacerbation None One of more/yearOne in any
week
Assessing
Control
Levels of Asthma Levels of Asthma ControlControl
PCCP Council on Asthma
GINA. 2007. Available at: http://www.ginaasthma.org
Treatment ActionLevel of Control
Treatment Steps (in the order of increasing efficacy to attain control)
Controlled Maintain and find lowest controlling step
Partly Controlled Consider stepping up to gain control
Uncontrolled Step up until controlled
Exacerbation Treat as exacerbation
Incre
asee
Red
uce
Step 2 Step 3 Step 4 Step 5Step 1
Asthma Education / Environmental ControlAs needed
rapid-acting ß2-agonist
As needed rapid-acting ß2-agonist
Controller Options
Select One Select One Add one or more
Add one or more
Low-dose
ICSLow dose
ICS+LABAMedium or high-dose
ICS+LABA
Oral glucocorticosteroid (lowest
dose)
Leukotriene modifier
Medium or high-dose ICS
Leukotriene modifier
Anti IgE treatment
Low-dose ICS plus Leukotriene
modifier Sustained release
theophyllineLow dose ICS plus sustained release
theophylline
ReduceReduce IncreaseIncrease
Treating toachieve Control
GINA. 2007. Available at: http://www.ginaasthma.org.
PCCP Council on Asthma
Treatment Steps (in the order of increasing efficacy to attain control)
Step 2 Step 3 Step 4 Step 5Step 1
Asthma Education / Environmental ControlAs needed
rapid-acting ß2-agonist
As needed rapid-acting ß2-agonist
Controller Options
Select One Select One Add one or more
Add one or more
Low-dose
ICSLow dose
ICS+LABAMedium or high-dose
ICS+LABA
Oral glucocorticosteroid (lowest
dose)
Leukotriene modifier
Medium or high-dose ICS
Leukotriene modifier
Anti IgE treatment
Low-dose ICS plus Leukotriene
modifier Sustained release
theophyllineLow dose ICS
plus sustained release
theophylline
GINA. 2007. Available at: http://www.ginaasthma.org.
Increase Reduce
In the local setting, for the majority of symptomatic patients, the consensus is to start at step 3, with low doses of a fixed-dose ICS+LABA combination inhaler.
PCCP Council on Asthma
P
Single inhaler maintenance and Single inhaler maintenance and relief therapy strategyrelief therapy strategy
If a combination inhaler containing formoterol and budesonide is selected, it may be used for both rescue and maintenance.
This approach has been shown to result in : Reductions in exacerbations Improvements in asthma control in adults and
adolescents at relatively low doses of treatment (Evidence A)
PCCP Council on Asthma
P
Additional Step 3 Options for Adolescents and Adults :
Increase to medium-dose inhaled gluco-corticosteroid (Evidence A)
Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline (Evidence B)
Treating to Achieve Asthma Treating to Achieve Asthma ControlControl
PCCP Council on Asthma
P
Asthma control should be monitored by the health care professional & by the patient.
Improvement begins within days of initiating controller treatment but the full benefit may only be evident after 3 to 4 months
When control as been achieved, ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
Treating to Achieve Asthma Treating to Achieve Asthma ControlControl
PCCP Council on Asthma
Stepping Down Treatment when Asthma is Controlled
Reduce by 50 %
Every 3 months
Monitoring to
maintain Control
Med to high-dose ICS
Low-dose ICS
Decrease to Once daily
dosing
Decrease to Once daily
dosing
ICS-LABA
Reduce ICS by 50 %
Maintain LABA dose
Further reduce ICS dose or
Stop LABA and continue ICS or
Decrease ICS-LABAto Once daily dosing
PCCP Council on Asthma
P
Stepping Up Treatment in Stepping Up Treatment in Response to Loss of ControlResponse to Loss of Control
Treatment has to be adjusted periodically in response to worsening control which may be recognized by the minor recurrence or worsening of symptoms
Treatment options : Rapid-onset, short-acting or long-acting
bronchodilators : repeated dosing provides temporary relief
A four-fold or greater increase in inhaled gluco-corticosteroids
PCCP Council on Asthma
No
Classify and Treat based on Severity Classification of
Asthma in Acute Exacerbation
YesIn Acute exacerbatio
n ?
Patient with Asthma
presenting with symptoms
No
No
Yes
Go 2 steps higher
Go 1 step higher
Assess level of control
Partly controlled?
YesCurrently onController
Medications?
Classify according to
PCRADM Chronic Severity
Controller medication
naive ?
Treat as Severe
Persistent Asthma
Yes
Treat as Mild-to-ModeratePersistent Asthma
No
Algorithmic Approach to Asthma Assessment and Management
YesPoorly or
uncontrolled?
Yes Classified as Severe
?
PCCP Council on Asthma
P
Asthma ExacerbationsAsthma ExacerbationsEpisodes of progressive worsening of SOB,
cough, wheezing or chest tightness or some combination of these symptoms
Significant decreases in PEF or FEV1 which are more reliable indicators of severity of airflow obstruction than degree of symptoms
Range from mild to life-threatening deterioration usually progresses over hours or days, or precipitously over some minutes
PCCP Council on Asthma
Severity of Asthma ExacerbationsSeverity of Asthma Exacerbations
Mild Moderate SevereRespiratory
arrest imminent
Breathless Walking Talking At rest
Talks in Sentences Phrases Words
Alertness May be agitatedUsually agitated
Usually agitatedDrowsy or confused
Respiratory rate
Increased Increased Often > 30/min
Accessory muscles & suprasternal retractions
Usually not Usually Usually
Paradoxical thoraco-
abdominal movement
WheezeModerate, often
only end-expiratory
Loud Usually loudAbsence of
wheeze
Pulse/min <100 100 - 120 > 120 Bradycardia
Pulsus paradoxus
Absent < 10 mmHg
May be present
10-25 mmHg
Often present> 25 mmHg
PEF after initial BD % predicted or % personal best
Over 80 %Approx 60 – 80
%
< 60 % predicted or personal best(<100/min or
response lasts 2 hrs
PaO2
and/or PaCO2
Normal
< 42 mmHg < 42 mm Hg
< 60 mmHg Possible cyanosis
> 42 mmHgPossible resp failure
SaO2 > 95 % 91 – 95 % < 90 %
PCCP Council on Asthma
P
Features of Patients at high-risk Features of Patients at high-risk for for Asthma-Related DeathAsthma-Related Death Current use of or recent withdrawal from systemic
corticosteroids ER visit for asthma in the past year History of near-fatal asthma requiring intubation
or mechanical intubation Not currently using inhaled steroids Overdependence on rapid acting inhaled 2
agonists, esp. those with more than one canister monthly
Psychiatric disease or psychosocial problems, incl. the use of sedatives
Noncompliance with asthma medication plan
PCCP Council on Asthma
P
Management of Asthma Management of Asthma ExacerbationsExacerbations Primary therapies for exacerbations:
Repetitive administration of rapid-acting inhaled β2-agonist
Early introduction of systemic glucocorticosteroids
Oxygen supplementation
Closely monitor response to treatment with serial measures of lung function
PCCP Council on Asthma
P
Criteria for Criteria for hospitalizationhospitalization Inadequate response to therapy within 1-
2 hoursPersistent PEF <50% after 1 hour of
treatmentPresence of risk factorsProlonged symptoms prior to ER consult Inadequate access to medical care and
medicationsDifficult home conditionDifficulty in obtaining transport to
hospital in event of further deterioration
PCCP Council on Asthma
P
Asthma Exacerbations & Asthma Exacerbations & HospitalizationHospitalization• Despite appropriate therapy, ~ 10 to 25
% of ER patients with acute asthma will require hospitalization.
• Response to initial treatment in the ER is a better predictor of the need for hospitalization than is severity on presentation
• FEV1 or PEF appears to be more useful in adults for categorizing severity of exacerbation & response to treatment.
PCCP Council on Asthma
Initial Assessment : History, PE, PEF or FEV1, SaO2
Repeat Assessment:PE, PEF, SaO2 , other tests as needed
Moderate Episode: PEF or FEV1 =40 – 69 % predicted or personal best
• PE : Moderate symptoms •Treatment :
•Inhaled SABA every 60 minutes •Oral systemic corticosteroids•Continue treatment 1-3 hrs provided there is improvement ; make decision in < 4 hrs
Severe Episode:PEF or FEV1 < 40 % predicted or personal best
• PE : Severe symptoms at rest, accessory muscle use, chest retraction• History : high-risk for asthma- related death• No improvement after initial treatment•Treatment :
•Oxygen• NebulizedSABA + ipratropium hourly or continuous • Oral systemic corticosteroids• Consider adjunct therapies
Management of Acute Exacerbations : Hospital Setting
PEF or FEV1 ≥ 40 % predicted•Oxygen to achieve SaO2 ≥ 90%•Inhaled SABA by nebulizer or MDI with valve holding chamber up to 3 doses in 1st hour
PEF or FEV1 40 % predicted•Oxygen to achieve SaO2 ≥ 90%•High-dose inhaled SABA + ipratropium by nebulizer or MDI with valve holding chamber every 20 min or continuously for 1 hour
Impending or actual respiratoryarrest
•Intubation and mechanical ventilation with 100% O2
•Nebulized SABA and ipratropium •Intravenous corticosteroids•Consider adjunct therapies
Admit to hospital intensive care
PCCP Council on Asthma
Moderate Episode Severe Episode
Good Response Response sustained for 1 hr
after last treatment No risk factors
• S/Sx : No distress, normal PE• PEF > 70 % predicted or personal best• SaO2 > 90 %
Incomplete Responsewithin 1 hr &/or (+) risk factors
•S/Sx : Mild to moderate• PEF > 50 % but < 70 % predicted or personal best• SaO2 not improving
Poor Responsewithin 1 hr &/or (+) risk factors
• S/Sx : severe, drowsiness, confusion• PEF < 30 % predicted or personal best• ABG : paCO2 > 45 mm Hg paO2 < 60 mm Hg
Discharge Home• Continue inhaled SABA q 3-4 hrs (or oral 2- agonist or theophylline)• Continue oral steroids• Patient education
Admit to Hospital
Improved• PEF > 70 %• Sustained on meds
Discharge Home
Not Improved within 6 – 12 hrs
Admit to ICU
Admit to ICU:• Continue inh SABA + inh. anti-cholinergic• Consider SQ,IV, or IM 2- agonist• IV steroids• IV aminophylline• Continue oxygen• Possible intubation/ mechanical ventilation
Management of Acute Exacerbations : Hospital Setting
PCCP Council on Asthma
Asthma Action PlanName:____________________________________________________Date of issue:___________________My Dr.:___________________________________________________Tel #: _________________________Clinic Address:___________________________________________________________________________
Chronic Asthma Severity Mild, intermittent Mild, persistent Moderate, persistent Severe, persistent
PEF: Personal best (done ___/___/___): _______liters/min Predicted: ________liters/min
PEAK FLOW STATUS ACTION80 % of predicted or personal bestAbove:____________
GOOD CONTROL(GREEN )
ZONE
Continue my present treatment:Regular controller/s:___________________________
___________________________As needed reliever: ___________________________Visit my doctor on next appointment :_____________
60-80% of predicted or personal bestFrom:______________To: ______________
WARNING(YELLOW)
ZONE
Add or double the dose of controller drug :_____________________________Take reliever regularly:________________________As needed reliever; (inhaled):___________________*If improved (back to green zone), continue maintenance drugs for 3 days.*If unimporved, visit my doctor as soon as possible.
Below 60 % pred or personal bestBelow: ____________
DANGER(RED)ZONE
Take Prednisone _____tablets every ________hrsTake reliever regularly:________________________+ as needed reliever (inhaled):__________________*Once improved, follow the yellow or green zone instructionsCall or see my doctor immediately
Below 50 % pred or personal bestBelow:____________
EMERGENCY(RED)ZONE
GO DIRECTLY TO HOSPITALor call ambulanceTake Prednisone ___________ tablets now or ____________________TAke 2 puffs of inhaled reliever every 10-15 mins on the way to hospital
PCCP Council on Asthma
P
Thank you for your attention!