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Guidelines for the Diagnosis and Management of Asthma in Children and Adolescents Clinical Practice Guideline

MedStar Health

“These guidelines are provided to assist physicians and other clinicians in making decisions regarding the care of their patients. They are not a substitute for individual judgment brought to each clinical situation by the patient’s primary care provider in collaboration with the patient. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but should be used with the clear understanding that continued research may result in new knowledge and recommendations.”

MedStar Health, MedStar Prompt Care, and MedStar Family Choice accept and endorse the following clinical guidelines:

National Heart, Lung, and Blood Institute Expert Panel on Asthma, Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma – Full Report, 2007 http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines

and:

Global Initiative for Asthma: GINA 2019 https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf

These guidelines provide guidance for selecting treatment based on a patient's individual needs and level of asthma control. The guidelines focus on four components of asthma care: 1. measures to assess and monitor asthma: 2. patient education: 3. control of environmental factors and other conditions that can worsen asthma; and 4. medications.

These guidelines emphasize that while asthma can be controlled; the condition can change over time and differs among individuals and by age groups. Thus, it is important to monitor regularly the patient's level of asthma control so that treatment can be adjusted as needed. The stepwise asthma management charts specify treatment for three age groups: 0-4 years, 5-11 years, and 12 years and older.

The Key Components for Asthma Control 1. Reduce impairment Prevent chronic and troublesome symptoms (e.g. coughing or breathlessness in the night, in the

early morning, or after exertion). Reduce Short Acting Beta Agonist (SABA) to < 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. Use a written asthma management plan

2. Reduce Risk Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations Prevent progressive loss of lung function; for children, prevent reduced lung growth Provide optimal pharmacotherapy with minimal or no adverse effects

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- Use an inhaled corticosteroid for persistent asthma symptoms to prevent further exacerbations

- Leukotriene Receptor Antagonist (montelukast) can be useful as a controller for mild asthma that is triggered by allergy and as an adjunct agent.

- Combination LABA/ICS therapy is useful for moderate to severe asthmatics not controlled with a single agent.

- Use a spacer holding chamber with an inhaler

Decision support tool and order set is available in MedConnect (Cerner) in the ad hoc or order sets. Order set title is AMB Peds asthma Ad hoc title is AMB Peds asthma NEW GUIDELINE Changes in the 2019 GINA guidelines: The 2019 GINA guidelines have several significant changes in management from prior guidelines. After deliberation with pediatric pulmonologists, pediatric allergists and pediatricians, this MedStar Pediatric Ambulatory Committee has decided to follow the local standard of care and the NHLBI guidelines and not recommend all of the changes included in the 2019 GINA guideline. (1.) Specifically, the use of an ICS/LABA as a rescue agent instead of albuterol alone is NOT recommended by our committee. (2.) The use of an ICS for all asthmatics (6 years and older) regardless of Intermittent or Persistent asthma diagnosis will NOT be recommended by our committee. We will continue to recommend the NHLBI guidelines as well as the other recommendations of the GINA guidelines that are the local standards of care. Appendices - Age Based Guidelines for Asthma Management and Medication Use from NHLBI and GINA: Step Wise Management and Severity Classification - pages 2-11 Step Wise Approach For Managing Asthma In Children 0-4 Years Of Age (NHLBI, Figure 4-1a, 4-2a, 4-3a) Step Wise Approach For Managing Asthma In Children 5-11 Years Of Age (NHLBI, Figure 4-1b, 4-2b, 4-3b) Step Wise Approach For Managing Asthma In Youths > 12 And Adults (NHLBI, Figure 4-5, 4-6, 4-7) Medication Management (pages 13-23) Medication Dosages (NHLBI, Figure 4-4a, 4-4b, 4-4c, 4-8a, 4-8b, 4-8c) Product Updates Table Product Availability Table (updated by Medstar Pediatric Work Group, August 2017)

References

1. Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. (2007). National Institutes of Health publication number 08-4051. http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines

2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2019.

https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf Clinical Guidelines are reviewed every two years by a committee of experts in the field. Updates to guidelines occur more frequently as needed when new scientific evidence or national standards are published.

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Product Updates: Page Item Guideline Availability Current Availability 14 Figure 4-4B Budesonide DPI 90, 180, or 200

mcg/inhalation Budesonide DPI 90 or 180 inhalation

15 Figure 4-4c Albuterol CFC No longer available 15 Figure 4-4c Pirbuterol CFC Autohaler No longer available 16 Figure 4-4c Key: CFC, chlorofluorocarbon CFC products no longer available 21 Figure 4-8a Cromolyn MDI No longer available 21 Figure 4-8a Nedocromil MDI No longer available 19 Figure 4-8b Budesonide DPI 90, 180, or 200

mcg/inhalation Budesonide DPI 90 or 180 inhalation

19 Figure 4-8b Mometasone DPI 200 mcg/inhalation 200 mcg / 400 mcg / >400 mcg

Mometasone DPI 110 or 220 mcg/inhaler 220 mcg/440 mcg/ >440 mcg

19 Figure 4-8b Triamcinolone acetonide No longer available 21 Figure 4-8c Albuterol CFC No longer available 21 Figure 4-8c Pibuterol CFC Autohaler No longer available

Available products not included in guideline tables

Medication Dosage Form(s) Age Restrictions Fluticasone/salmeterol HFA 45/21, 115/21, 230/21

Respiclick 44/14, 113/14, 232/14 Use in ≥ 5 years of age

Mometasone/formoterol HFA 100/5, 200/5 Use in ≥ 12 years of age Tiotropium Respimat 1.25, 2.5 Use in ≥ 6 years of age Mometasone HFA 200, 400 Use in ≥ 12 years of age Albuterol ProAir® HFA 90 mcg Use in ≥ 4 years of age

Ventolin® HFA 90 mcg Proventil® HFA 90 mcg ProAir® Respiclick 90 mcg

Initial Approval Date and Reviews: Effective 1997, 7/15 (by Adult

Committee), 08/15 (by Pediatric Committee), 7/17- Decision to Separate

Adult and Pediatric Guideline, 8/17

Most Recent Revision and Approval Date: 8/19

Next Scheduled Review Date: 8/21

Condition: Asthma