## National Asthma Education and Prevention Program Expert Panel Report 3 

# Guidelines for the 

# Diagnosis and Management of Asthma SUMMARY REPORT 2007

## National Asthma Education and Prevention Program Expert Panel Report 3 

# Guidelines for the 

# Diagnosis and Management of Asthma S UMMARY REPORT 2007

NIH Publication Number 08-5846 October 2007

# Contents

Acknowledgments iii Preface ix Introduction 1 Asthma Definition and Implications for Treatment 9 Definition and Pathophysiology 9 Causes of Asthma 10 Implications for Treatment 10 

### Diagnosis of Asthma 11 Managing Asthma Long Term 15 Four Components of Asthma Care 15 Component 1: Assessing and Monitoring Asthma Severity and Asthma Control 15 Component 2: Education for a Partnership in Care 18 Component 3: Control of Environmental Factors and Comorbid Conditions That Affect Asthma 23 Allergens and Irritants 23 Co morb id Co nditions 25 Component 4: Medications 28 General Mechanisms and Role in Therapy 28 De liver y Devices for Inhaled Medications 29 S afet y I ssues for Inhaled Corticosteroids and Long-Acting Beta 2 

### -Agonists 29 Inhaled Corticosteroids 29 Inhaled Corticosteroids and Linear Growth in Children 30 Long-Acting Beta 2 

### -Agonists 30 Step wise Approach for Managing Asthma 30 Principles of the Stepwise Approach 30 Stepwise Treatment Recommendations for Different Ages 34 Steps for Children 0–4 Years of Age 34 Steps for Children 5–11 Years of Age 35 Steps for Youths >12 Years of Age and Adults 37 M anag ing Special S ituations 38 Exercise-Induced Bronchospasm 38 Pregnancy 38 Surgery 39 Disparities 39 

### Managing Exacerbations 53 Classifying Severity 53 Home M anagement 53 Management in the Urgent or Emergency Care and Hospital Settings 54 

### For More Information back cover

i Contents

### List of Boxes and Figures Figure 1. Summary of Recommended Key Clinical Activities for the Diagnosis and Management of Asthma 4 Figure 2. The Interplay and Interaction Between Airway Inflammation and the Clinical Symptoms and Pathophysiology of Asthma 9 Figure 3. Suggested Items for Medical History* 13 Figure 4. Sample Patient Self-Assessment Sheet for Followup Visits* 17 Figure 5. Asthma Action Plan—Adult 20 Figure 6. Sample Asthma Action Plan—Child 21 Figure 7. Delivery of Asthma Education by Clinicians During Patient Care Visits 22 Figure 8. Asthma Education Resources 24 Figure 9. How To Control Things That Make Your Asthma Worse 26 Figure 10. Aerosol Delivery Devices 31 Figure 11. Classifying Asthma Severity and Initiating Therapy in Children 40 Figure 12. Assessing Asthma Control and Adjusting Therapy in Children 41 Figure 13. Stepwise Approach for Managing Asthma Long Term in Children, 0–4 Years of Age and 5–11 Years of Age 42 Figure 14. Classifying Asthma Severity and Initiating Treatment in Youths ≥ 12 Years of Age and Adults 43 Figure 15. Assessing Asthma Control and Adjusting Therapy in Youths ≥ 12 Years of Age and Adults 44 Figure 16. Stepwise Approach for Managing Asthma in Youths ≥ 12 Years of Age and Adults 45 Figure 17. Usual Dosages for Long-term control Medications* 46 Figure 18. Estimated Comparative Daily Dosages for Inhaled Corticosteroids 49 Figure 19. Usual Dosages for Quick-Relief Medications* 50 Figure 20. Classify ing Severity of Asthma Exacerbations in the Urgent or Emergency Care Setting 54 Figure 21. Management of Asthma Exacerbations: Emergency Department and H ospital-Base d C are 55 Figure 22. Dosages of Drugs for Asthma Exacerbations 56 Figure 23a. Emergency Department—Asthma Discharge Plan 59 Figure 23b. Emergency Department—Asthma Discharge Plan: How to Use Your Metered-Dose Inhaler 60

ii Guidelines for the Diagnosis and Management of Asthma

### National Asthma Education and Prevention Program Coordinating Committee Agency for Healthcare Research and Quality Denise Dougher t y, Ph.D. Allergy & Asthma Network Mothers of Asthmatics Nancy Sander American Academy of Allergy, Asthma, and Immunology Michael Schatz, M.D., M.S. American Academy of Family Physicians K

ur tis S. Elward, M.D., M.P.H., F.A.A.F.P. American Academy of Pediatrics Gar y S. Rachelefsky, M.D.
A merican Academy of Physician Assistants Tera Crisalida, P.A.-C., M.P.A.S.
A merican Associatio n for Respiratory Care Thomas J. Kallstrom, R.R.T., F.A.A.R.C., AE-C American College of Allergy, Asthma, and I mmunology W illiam Storms, M.D. American College of Chest Physicians John Mitchell, M.D., F.A.C.P. American College of Emergency Physicians Richard M. Nowak, M.D., M.B.A., F.A.C.E.P. American Lung Association Noreen M. Clark, Ph.D.
A mer ican Me dical Association Paul V. Williams, M.D.
American Nurses Association Karen Huss, D.N.Sc., R.N., A.P.R.N.B.C., F.A.A.N., F

.A.A.A.A.I.
Amer ican Phar macists Association Dennis M. Williams, Pharm.D. American Public Health Association Pamela J. Luna, Dr.P.H., M.Ed. American School Health Association Lani S. M. Wheeler, M.D., F.A.A.P., F.A.S.H.A. American Society of Health-System Pharmacists Kathryn V. Blake, Pharm.D. American Thoracic Society Stephen C. Lazarus, M.D. Asthma and Allergy Foundation of America Mo Mayrides Council of Stat e and Territorial Epidemiologists Sarah Lyon-Callo, M.A., M.S. National Association of School Nurses Donna Mazyck, R.N., M.S., N.C.S.N. National Black Nurses Association, Inc. Susan B. Clark, R.N., M.N.
N atio nal Center for Chronic Disease Prevention, Ce nter s f o r Disease Control and Prevention (CDC) Sarah Merkle, M.P.H. National Center for Environmental Health, CDC Paul M. Garbe, M.D.
Nat ional Center for Health Statistics, CDC Lara Akinbami, M.D. National Institute for Occupational Safety and Health, CDC Margaret Filios, S.M., R.N. National Heart, Lung, and Blood Institute National Institutes of Health (NIH) Elizabeth Nabel, M.D.
N at ional Heart, Lung, and Blood Institute NIH, Ad Hoc Committee on Minority Populations Ruth I. Quartey, Ph.D.
Natio nal I nstit ute of Allergy and Infectious Diseases (NIAID), NIH Peter J. Gergen, M.D., M.P.H.

iii Acknowledgements 

# Acknowledgements

### National Institute of Environmental Health Sciences, NIH Charles A. Wells, Ph.D. National Medical Association Michael Lenoir, M.D. National Respiratory Training Center Pamela Steele, M.S.N., C.P.N.P., AE-C Society for Academic Emergency Medicine Rita Cydulka, M.D., M.S. Society for Public Health Education Judith C. Taylor-Fishwick, M.Sc., AE-C U.S. Department of Education Dana Carr U.S. Environmental Protection Agency Indoor Environments Division Da vid Rowson, M.S. U.S. Environmental Protection Agency Office of Research and Development Hillel S. Koren, Ph.D.
U .S. F ood and Drug Administration Rober t J. Meyer, M.D.

Thir d Expert P anel on the Management of Asthma William W

. Busse, M.D., Chair Uni v ersit y o f Wisconsin Medical School M adison, Wisconsin
H omer A. Boushey, M.D. University of California–San Francisco San Francisco, California
C arlos A. Camargo, Jr., M.D., Dr.P.H. Massachusetts General Hospital B oston, Massachusetts
Dav id Ev ans, Ph.D., A.E.-C, Columbia University New York, New York Michael B. Foggs, M.D. Advocate Health Centers C hicago, Illinois Susan L. Janson, D.N.Sc., R.N., A.N.P., F.A.A.N. University of California–San Francisco San Francisco, California H. William Kelly, Pharm.D. University of New Mexico Health Sciences Center Albuquerque, New Mexico Robert F. Lemanske, M.D. University of Wisconsin Hospital and Clinics Madison, Wisconsin Fernando D. Martinez, M.D. University of Arizona Medical Center Tucson, Arizona Robert J. Meyer, M.D. U.S. Food and Drug Administration Silver Spring, Maryland Harold S. Nelson, M.D. National Jewish Medical and Research Center Denver, Colorado Thomas A. E. Platts-Mills, M.D., Ph.D. U niversity of Virginia School of Medicine Charlottesville, Virginia Michael Schatz, M.D., M.S. Kaiser-Permanente–San Diego San Diego, California Gail Shapiro, M.D.* University of Washington Seattle, Washington Stuart Stoloff, M.D. U niver sity of Nevada School of Medicine Carson City, Nevada Stanley J. Szefler, M.D. National Jewish Medical and Research Center Denver, Colorado
Sc ott T . Weiss, M.D., M.S. Brigham and Women’s Hospital B oston, Massachusetts Barbara P. Yawn, M.D., M.Sc. Olmstead Medical Center Roc hester, Minnesota

iv Guidelines for the Diagnosis and Management of Asthma

### Development of the guidelines was funded by the NHLBI, NIH. Expert Panel members completed financial disclosure forms, and the Expert Panel members disclosed relevant financial interests to eachother prior to their discussions. Expert Panel members participated as volunteers and were compensated only for travel expenses related to the Expert Panel meetings. Financial disclosure information covering the 3-year period during which the guidelines were developed is provided for each Expert Panel member below. Dr. Busse has served on the Speakers’ Bureaus of GlaxoSmithKline, Merck, Novartis, and Pfizer; and on the Advisory Boards of Altana, Centocor, Dynavax, Genentech/Novartis, GlaxoSmithKline, Isis, Merck,Pfizer, Schering, and Wyeth. He has received funding/grant support for research projects from Astellas, Centocor, Dynavax, GlaxoSmithKline, Novartis, and Wyeth. Dr. Busse also has research support from the NIH. Dr. Boushe y has served as a consultant for Altana, Pr ote in D esig n Lab , and Sumitomo. He has received honoraria from Boehringer-Ingelheim, Genentech, Merck, Novartis, and Sanofi Aventis, and funding/- grant support for research projects from the NIH. Dr. Camarg o has served on the Speakers’ Bureaus of AstraZeneca, GlaxoSmithKline, Merck, and Schering Plough; and as a consultant for AstraZeneca, Critical Therapeutics, Dey Laboratories, GlaxoSmithKline, Me dImmune, Merck, Novartis, Praxair, Respironics, Schering Plough, Sepracor, and TEVA. He has received funding/grant support for research projectsfrom a variety of Government agencies and not-forprofit foundations, as well as AstraZeneca, Dey Laboratories, GlaxoSmithKline, MedImmune, Merck, Novartis, and Respiromics.
Dr. Evans has received funding/grant support for research projects from the NHLBI. Dr. Foggs has served on the Speakers’ Bureaus of GlaxoSmithKline, Mer ck, Pfizer, Sepracor, and UCB Pharma; on the Advisory Boards of Alcon, Altana, AstraZeneca, Critical Therapeutics, Genentech, GlaxoSmithKline, and IVAX, and as consultant for Merck and Sepracor. He has received funding/grant support for research projects from GlaxoSmithKline. Dr. Janson has served on the Advisory Board of Altana, and as a consultant for Merck. She has received funding/grant support for research projects from the NHLBI. Dr. Kelly has served on the Speakers’ Bureaus of AstraZeneca and GlaxoSmithKline; and on the MAP Pharmaceuticals Advisory Boards of AstraZeneca, Merck, Novartis, and Sepracor. Dr. Lemanske has served on the Speakers’ Bureaus of GlaxoSmithKline and Merck, and as a consultant for AstraZeneca, Aventis, GlaxoSmithKline, Merck, and Novartis. He has received honoraria from Altana, and funding/grant support for research projects from the NHLBI and NIAID.
Dr . Martinez has served on the Advisory Board of Merck and as a consultant for Genentech, GlaxoSmithKline, and Pfizer. He has received honoraria from Merck.
Dr . Meyer has no relevant financial interests. Dr. Nelson has served on the Speakers’ Bureaus of A straZeneca, Glax oSmithKline, Pfizer, and Schering Plough; and as a consultant for Air Pharma, Altana Phar ma US, Astellas, AstraZeneca, Curalogic, De y Lab oratories, Dynavax Technologies, Genentech/Novartis, GlaxoSmithKline, Inflazyme Pharmaceuticals, MediciNova, Protein Design Laboratories, Sanofi-Aventis, Schering Plough, and Wyeth Pharmaceuticals. He has received funding/grant support for research projects from Altana, Astellas, AstraZeneca, Behringer, Critical Therapeutics, Dey Laboratories, Epigenesis, Genentech, GlaxoSmithKline, IVAX, Medicinova, Nov artis, Sanofi-Aventis, Schering Plough, Sepracor, TEVA, and Wyeth. Dr. Platts-Mills has served on the Advisory Committee of Indoor Biotechnologies. He has received funding/grant support for a research project from Pharmacia Diagnostics. Dr. Schatz has served on the Speakers’ Bureaus of A straZeneca, Genentech, GlaxoSmithKline, and Merck; and as a consultant for GlaxoSmithKline on an unbranded asthma initiative. He has received funding/gr ant s upp ort for research projects from GlaxoSmithKline, Merck, and Sanofi-Aventis.

v Acknowledgements * The NAEPP would like to acknowledge the contributions of Dr. Gail Shapiro, who served on the NAEPP Expert Panels from 1991
unt il he r d eath in August 2006. She had a passion for improving asthmacare and an unwavering commitment to develop evidence-based recommendations that would offer practical guidance for clinicians and patients to work together to achieve asthma control.

### Dr. Shapiro* served on the Speakers’ Bureaus of AstraZeneca, Genentech, GlaxoSmithKline, IVAX Laboratories, Key Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Schering Corporation, UCB Pharma, and 3M; and as a consultant for Altana, AstraZeneca, Dey Laboratories, Genentech/Novartis, GlaxoSmithKline, ICOS, IVAX Laboratories, Merck, Sanofi-Aventis, and Sepracor. She received funding/grant support for research projects from Abbott, AstraZeneca, Boehringer Ingelheim, Bristol-Myers-Squibb, Dey Laboratories, Fujisawa Pharmaceuticals, Genentech, GlaxoSmithKline, Immunex, Key, Lederle, Lilly Research, MedPointe Pharmaceuticals, Medtronic Emergency Response Systems, Merck, Novartis, Pfizer, Pharmaxis, Purdue Frederick, Sanofi-Aventis, Schering, Sepracor, 3M Pharmaceuticals, UCB Pharma, and Upjohn Laboratories. Dr. Stoloff has served on the Speakers’ Bureaus

o f Alcon, Altana, AstraZeneca, Genentech, GlaxoSmithKline, Novartis, Pfizer, Sanofi Aventis, and Schering; and as a consultant for Alcon, Altana, AstraZeneca, Dey, Genentech, GlaxoSmithKline, Merck, Novart is, Pfizer, Sanofi Aventis, and Schering.
Dr. Sz efler has served on the Advisory Boards of Altana, AstraZeneca, Genentech, GlaxoSmithKline, Merck, Novartis, and Sanofi Aventis; and as a consultant for Altana, AstraZeneca, Genentech, GlaxoSmithKline, Merck, Novartis, and Sanofi Aventis. He has received funding/grant support for a research project from Ross. Dr. Weiss has served on the Advisory Board of Genentech, and as a consultant for Genentech and GlaxoSmithKline. He has received funding/grant support for research projects from GlaxoSmithKline.
Dr . Yawn has served on the Advisory Boards of A ltana, AstraZeneca, Merck, Sanofi Aventis, and Schering Plough. She has received honoraria from Pfize r and Sc her ing Plough, and funding/grant support for research projects from the Agency for Healthcare Research and Quality, the CDC, the NHLBI, Merck, and Sc he ring Plough. C onsultant Reviewer s Financial disclosure infor mation covering a 12 mon t h period prior to the review of the guidelines is provided below for each consultant. Andrea J. Apter, M.D., M.Sc. University of Pennsylvania Medical Center Philadelphia, Pennsylvania Noreen M. Clark, Ph.D. University of Michigan School of Public Health Ann Arbor, Michigan Anne Fuhlbrigge, M.D., M.S. Brigham and Women’s Hospital Boston, Massachusetts Elliott Israel, M.D. Brigham and Women’s Hospital B oston, Massachusetts Meyer Kattan, M.D. Mount Sinai Medical Center New York, New York Jerry A. Krishnan. M.D., Ph.D. The Johns Hopkins School of Medicine Baltimore, Maryland J ames T. Li, M.D., Ph.D., F.A.A.A.A.I. Mayo Clinic Rochester, Minnesota
De nnis R. Ownby, M.D. Medical College of Georgia A

ugusta, Georgia Gary S. Rachelefsky, M.D. University of California–Los Angeles, School of M edicine Los Angeles, California
Br ian H. R owe, M.D., M.Sc., C.C.F.P. (E.M.), F.C.C.P. University of Alberta Hospital Edmonton, Alberta, Canada
E. R and Su therland, M.D., M.P.H. National Jewish Medical and Research Center Denver, Colorado Sandra R. Wilson, Ph.D. P alo Alto Medical Foundation P alo Alto, California Robert A. Wood, M.D. The Johns Hopkins School of Medicine Baltimore, Maryland

vi Guidelines for the Diagnosis and Management of Asthma

### Robert Zeiger, M.D. Kaiser Permanente Medical Center San Diego, California

Dr. Apter owns stock in Johnson & Johnson. She has received funding/grant support for research projects from the NHLBI. Dr. Clark has no relevant financial interest. Dr. Fulhlbrigge has served on the Speakers’ Bureau of GlaxoSmithKline, the Advisory Boards of GlaxoSmithKline and Merck, the Data Systems Monitoring Board for a clinical trial sponsored by Sepracor, and as a consultant for GlaxoSmithKline. She has received honoraria from GlaxoSmithKline and Merck, and funding/grant support for a research project from Boehringer Ingelheim.
Dr . Israel has served on the Speakers’ Bureau of Genentech and Merck, and as a consultant for A sthmatx, Crit ical T herapeutics, Genentech, Merck, Novart is Phar mac euticals, Protein Design Labs, Schering-Plough Company, and Wyeth. He has received funding/grant support for research projects from Asthmatx, Boehringer Ingelheim, Centocor, Genentech, GlaxoSmithKline, and Merck. Dr. Kattan has served on the Speakers’ Bureau of A straZeneca. Dr. Krishnan has received funding/grant support for a research project from Hill-Rom, Inc. Dr. Li has received funding/grant support for

r esear ch projects from the American Lung Association, GlaxoSmithKline, Pharming, and ZLB B ehring. Dr. Ownby has no relevant financial interest. Dr. Rachelefsky has served on the Speakers’ Bureaus of AstraZeneca, GlaxoSmithKline, IVAX, Medpointe, Merck, and Schering Plough. He has received honoraria from AstraZeneca, GlaxoSmithKline, IVA X, Medpointe, Merck, and Schering Plough. Dr. Rowe has served on the Advisory Boards of Abbott, AstraZeneca, Boehringer Ingelheim, and GlaxoSmithKline. He has received honoraria from A bbott, AstraZeneca, Boehringer Ingelheim, and Glax oSmithKline. H e has received funding/ grant support for research projects from Abbott, A straZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Trudell. Dr. Sutherland has served on the Speakers’ Bureau of Novartis/Genentech and the Advisory Board of Dey Laboratories. He has received honoraria from IVAX and funding/grant support for research projects from GlaxoSmithKline and the NIH. Dr. Wilson has served as a consultant for the Department of Urology, University of California, San Francisco (UCSF); Asthmatx, Inc.; and the Stanford UCSF Evidence-Based Practice Center. She has received funding/grant support for research projects from the NHLBI and from a subcontract to Stanford University from Blue Shield Foundation. Dr. Wood has served on the Speakers’ Bureaus of Dey Laboratories, GlaxoSmithKline, and Merck; on the Advisory Board of Dey Laboratories; and as a consultant to Dey Laboratories. He has received honoraria from Dey Laboratories, GlaxoSmithKline, and Merck, and funding/grant support for a research project from Genentech.
Dr. Ze iger has served on the Data Monitoring Board of Genentech, Advisory Board of GlaxoSmithKline, and as a consultant for Aerocrine, AstraZeneca, and Genentech. He has received honoraria from AstraZeneca and funding/grant support for a research project from Sanofi-Aventis.

National Heart, Lung , and Blood Institute Robinso n (R ob) Fulwood, Ph.D., M.S.P.H. Branch Chief, Enhanc ed Dissemination and Utilization Branch Division for the Application of Research Discoveries James P. Kiley, Ph.D. D irector Di vision of Lung Diseases Gregory J. Morosco, Ph.D., M.P.H. Associate Director for Prevention, Education, and Co ntrol Director Division for the Application of Research Discoveries Diana K. Schmidt, M.P.H. C oordinator Nat ional Asthma Education and Prevention Program Virginia S. Taggart, M.P.H. Program Director Division of Lung Diseases

vii Acknowledgements

### A merican Institutes for Research Heather Banks, M.A., M.A.T. Senior Editor
P att i Louthian Senior Desktop Publisher Karen L. Soeken, Ph.D. Methodologist Mary Tierney, M.D. Project Manager

viii Guidelines for the Diagnosis and Management of Asthmaix Preface 

# Preface

The Expert Panel Report 3 (EPR—3) Summary Report 2007: Guidelines for the Diagnosis and Management of Asthma was developed by an expert panel commissioned by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee (CC), coordinated by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. Using the 1997 EPR—2 guidelines and the 2002 update on selected topics as the framework, the expert panel organized the literature review and updated recommendations for managing asthma long term and for managing exacerbations around four essential components of asthma care, namely:

assessme nt and mo nitoring, patie nt e ducation,

c ontrol of factors contributing to asthma severity, and p harma cologic treatment. Subtopics were developed fo r eac h o f these four broad categories. The EPR—3 Full Report and the EPR—3 Summary Report 2007 have been developed under the excellent leade rship of Dr. William Busse, Panel Chair. The NHLBI is grateful for the tremendous dedication of time and outstanding work of all the members of the expert panel, and for the advice from an expert consultant group in developing this report. Sincere appreciation is also extended to the NAEPP CC and the Guidelines Implementation Panel as well as other stakeholder groups (professional societies, voluntary health, government, consumer/patient advocacy organizations, and industry) for their invaluable comments during the public review period that helped to enhance the scientific credibility and practical utility of this document. Ultimately, the broad change in clinical practice depends on the influence of local primary care physicians and other health professionals who not only provide state-of-the-art care to their patients, bu t also co mmunicat e to the ir peers the importance of doing the same. The NHLBI and its partners will fo rg e new initiatives based on these guidelines to stimulat e a d option of the recommendations at all levels, but particularly with primary care clinicians at the community level. We ask for the assistance of every reader in reaching our ultimate goal: improving asthma care and the quality of life for every asthma pat ient with asthma

Gregory Morosco, Ph.D., M.P.H. James Kiley, Ph.D. Director Director Division for the Application of Research Discoveries Division of Lung Diseases National Heart, Lung, and Blood Institute National Heart, Lung, and Blood Institutex Guidelines for the Diagnosis and Management of Asthma

### More than 22 million Americans have asthma, and it is one of the most common chronic diseases of childhood, affecting an estimated 6 million children. The burden of asthma affects the patients, their families, and society in terms of lost work and school, lessened quality of life, and avoidable emergency department (ED) visits, hospitalizations, and deaths. Improved scientific understanding of asthma has led to significant improvements in asthma care, and the National Asthma Education and Prevention Program (NAEPP) has been dedicated to translating these research findings into clinical practice through pub licatio n and dissemination of clinical practice guidelines. The first NAEPP guidelines were published in 1991, and updates were made in 1997, 2002, and now with the current report. Important gains have been made in reducing morbidity and mortality rates due to asthma; however, challenges

re main. T he NAEPP hopes that the “Expert Panel Repor t 3: Guid elines for the Diagnosis and Management of Asthma—Full Report 2007” (EPR—3 : Full Report 2007) will support the efforts of those who already incorporate best practices and will help enlist even greater numbers of primary care clinicians, asthma specialists, health care systems and providers, and communities to join together in making quality asthma care available to all people who have asthma. The goal, simply stated, is to help people with asthma control their asthma so that they can be active all day and sleep well at night. This EPR—3: Summary Report 2007 presents the key recommendations from the EPR—3: Full Report 2007 (See www.nhlbi.nih.gov/guidelines/asthma/ asthg dln. htm). Detailed recommendations, the levels of scientific evidence upon which they are based, citations from the published scientific literature, discussion of the Expert Panel’s rationale for the

reco mmendations, and d escr iption of methods used t o develop the report are included in that resource do cume nt. Because EPR—3: Full Report 2007 is an updat e o f previous NAEPP guidelines, highlights of major changes in the update are presented below, and figure 1 presents a summary of recommended key clinical activities.

1 Introduction 

# Introduction2 Guidelines for the Diagnosis and Management of Asthma 

## HIGHLIGHTS OF MAJOR CHANGES IN EPR—3: FULL REPORT 2007
The following are highlights of major changes. Many recommendations were updated or expanded b ased on new evidence. See EPR—3: Full Report 2007 for key differences at the beginning of each section and for a full discussion.
New focus on monitoring asthma control as the goal for asthma therapy and distinguishing between classifying asthma severity and monitoring asthma control.
■ Severity: the intrinsic intensity of the disease process. Assess asthma severity to initiate therapy.
■ Control: the degree to which the manifestations of asthma are minimized by therapeutic interventions and the

goals of therapy are met. Assess and monitor asthma control to adjust therapy.
New focus on impairment and risk as the two key domains of severity and control, and multiple measures for assessment. The domains represent different manifestations of asthma, they may not correlate with each other, and they may respond differentially to trea tment.
■ Impairment: frequency and intensity of symptoms and functional limitations the patient is experiencing currently

or has recently experienced.
■ Risk: the likelihood of either asthma exacerbations, progressive decline in lung function (or, for children, lung

growth), or risk of adverse effects from medication.
Modifications in the stepwise approach to managing asthma long term.
■ Treatment recommendations are presented for three age groups (0–4 years of age, 5–11 years of age, and

youths ≥ 12 years of age and adults). The course of the disease ma y change over time; the relevance of dif ferent measures of impairment or risk and the potential short- and long-term impact of medications may be age related; and varied levels of scientific evidence are available for these three a ge groups. ■ The stepwise approach expands to six steps to simplify the actions within each step. Previous guidelines had

several progressive actions within different steps; these are now separated into different steps.
■ Medica tions have been repositioned within the six steps of care.

— Inhaled corticosteroids (ICSs) continue as preferred long-term control therapy for all ages.

— Combination of long-acting beta 2 -agonist (LABA) and ICS is presented as an equally preferred option, with increasing the dose of ICS in step 3 care, in patients 5 years of age or older. This approach balances the esta blished beneficial effects of combination therapy in older children and adults with the increased risk for severe exacerbations, although uncommon, associated with daily use of LABA.

— Omalizuma b is recommended for consideration for youths ≥ 12 years of age who have allergies or for adults who require step 5 or 6 care (severe asthma). Clinicians who administer omalizumab should be prepared and equipped to identify and treat anaphylaxis that may occur.3 Introduction New emphasis on multifaceted approaches to patient education and to the control of environmental factors or comorbid conditions that affect asthma.
■ Patient education for a partnership is encouraged in expanded settings.

— Patient education should occur at all points of care: clinic settings (offering separate self-management programs as well as integrating education into every patient visit), Emergency Departments (EDs) and hospitals, pharmacies, schools and other community settings, and patients’ homes.

— Provider education should encourage clinician and health care systems support of the partnership (e.g., through interactive continuing medical education, communication skills training, clinical pathways, and information system supports for clinical decisionmaking.
■ Environmental control includes several strategies:

— Multifaceted approaches to reduce exposures are necessary; single interventions are generally ineffective.

— Consideration of subcutaneous immunotherapy for patients who have allergies at steps 2–4 of care (mild or moderate persistent asthma) when there is a clear relationship between symptoms and exposure to an allergen to which the patient is sensitive. Clinicians should be prepared to treat anaphylaxis that may occur.

— Potential benefits to asthma control by treating comorbid conditions that affect asthma.
Modifications to treatment strategies for managing asthma exacerbations. These changes:
■ Simplify the classification of severity of exacerbations. For the urgent or emergency care setting: <40 percent

predicted forced expira tor y volume in 1 second (FEV 1 ) or peak expira tor y f low (PEF) indicates severe exacerba tion and potential benefit from use of adjunctive therapies; ≥ 70 percent predicted FEV 1 or PEF is a goal for discharge from the emergency care setting.
■ Encoura ge development of prehospital protocols for emergency medical services to allow administration of

albuterol, oxygen, and, with medical oversight, anticholinergics and oral systemic corticosteroids.
■ Modify recommendations on medications:

— Add levalbuterol. — Add magnesium sulfate or heliox for severe exacerbations unresponsive to initial treatments.

— Emphasize use of oral corticosteroids. Doubling the dose of ICS for home management is not effective.

— Emphasize tha t anticholinergics are used in emergency care, not hospital care. — Add consideration of initiating ICS at discharge.4 Guidelines for the Diagnosis and Management of Asthma 

### Figure 1. SUMMARY OF RECOMMENDED KEY CLINICAL ACTIVITIES FOR THE DIAGNOSIS AND MANAGEMENT OF ASTHMA

C linical Issue Key Clinical Activities Action Steps DIAGNOSIS Establish asthma diagnosis.

MANAGING ASTHMA LONG TERM

Assessment and Monitoring Four Components of Care Assess asthma severity to initiate therapy.

Assess asthma control to monitor and adjust therapy.

Schedule followup care. Use severity classification chart, assessing both domains of impairment and risk, to determine initial treatment. Use asthma control chart, assessing both domains of impairment and risk, to determine if therapy should be maintained or adjusted (step up if necessary, step down if possible). Use multiple measures of impairment and risk: different measures assess dif ferent manifestations of asthma; the y ma y not correlate with each other; and they may respond differently to therapy. Obtain lung function measures by spirometry at least every 1–2 years, more frequently for not-well-controlled asthma. Asthma is highly variable over time, and periodic monitoring is essential. In general, consider scheduling patients at 2- to 6-week intervals while gaining control; at 1–6 month intervals, depending on step of care required or duration of control, to monitor if sufficient control is maintained; at 3-month intervals if a step down in therapy is anticipated. Assess asthma control, medication technique, written asthma action plan, pa tient adherence and concerns at every visit. Use medical history and physical examination to determine that symptoms of r ecurrent episodes of airflow obstruction are present. U se spirometry in all patients ≥ 5 years of age to determine that airway obstruction is at least partially reversible. Consider alternative causes of airway obstruction. Goal of asthma therapy is asthma control:

■ Reduce impairment (prevent chronic symptoms, require infrequent use of short-acting beta 2 -agonist (SABA), maintain (near) normal lung function and normal activity levels).

■ Reduce risk (prevent exacerbations, minimize need for emergency care or hospitalization, prevent loss of lung function, or for children, prevent reduced lung growth, have minimal or no adverse effects of therapy).

Education Provide self-management education. Teach and reinforce:

■ Self-monitoring to assess level of asthma control and signs of worsening asthma (either symptom or peak flow monitoring shows similar benefits f or most patients). Peak flow monitoring may be particularly helpful for patients who have difficulty perceiving symptoms, a history of severe exacerbations, or moderate or severe asthma.

■ Using written asthma action plan (review differences between long-term control and quick-relief medication).

■ Taking medication correctly (inhaler technique and use of devices).

■ Avoiding environmental factors that worsen asthma. Tailor education to literacy level of patient. Appreciate the potential role of a patient’ s cultural beliefs and practices in asthma management.5 Introduction 

### Figure 1. SUMMARY OF RECOMMENDED KEY CLINICAL ACTIVITIES FOR THE DIAGNOSIS AND MANAGEMENT OF ASTHMA (continued)
C linical Issue Key Clinical Activities Action Steps

Education (continued Develop a written asthma action plan in partnership with patient. Integrate education into all points of care where health professionals interact with patients. Agree on treatment goals and address patient concerns. Provide instructions for (1) daily management (long-term control medication, if appropriate, and environmental control measures) and (2) managing worsening asthma (how to adjust medication, and know when to seek medical care).
I nvolve all members of the health care team in providing/reinforcing education, including physicians, nurses, pharmacists, respiratory therapists, and asthma educators.Encourage education at all points of care: clinics (offering separate selfmanagement education programs as well as incorporating education into every patient visit), Emergency Departments and hospitals, pharmacies, schools and other community settings, and patients’ homes. Use a variety of educational strategies and methods.

Control Environmental Factors and Comorbid conditions

Medications Recommend measures to control exposures to allergens and pollutants or irritants tha t make and asthma worse.

Treat comorbid conditions.

Select medication and delivery devices to meet patient’s needs and circumstances. Determine exposures, history of symptoms in presence of exposures, and sensitivities (In patients who have persistent asthma, use skin or in vitro testing to assess sensitivity to perennial indoor allergens.). Advise patients on ways to reduce exposure to those allergens and pollutants,or irritants to which the patient is sensitive. Multifaceted approaches are beneficial; single steps alone are generally ineffective. Advise all patients and pregnant women to avoid exposure to tobacco smoke. Consider allergen immunotherapy, by specifically trained personnel, for patients who have persistent asthma and when there is clear evidence of a relationship between symptoms and exposure to an allergen to which the patient is sensitive. Consider especially: allergic bronchopulmonary aspergillosis; gastroesophageal reflux, obesity, obstructive sleep apnea, rhinitis and sinusitis, and stress or depression. Recognition and treatment of these conditions may improve asthma control. Consider inactivated influenza vaccine for all patients over 6 months of age. Use stepwise approach (See below.) to identify appropriate treatment options. Inhaled corticosteroids (ICSs) are the most effective long-term control therapy. When choosing among treatment options, consider domain of relevance to the patient (impairment, risk, or both), patient’s history of response to the medication, and patient’s willingness and ability to use the medication. Four Components of Care (continued)6 Guidelines for the Diagnosis and Management of Asthma 

### Figure 1. SUMMARY OF RECOMMENDED KEY CLINICAL ACTIVITIES FOR THE DIAGNOSIS AND MANAGEMENT OF ASTHMA (continued) Clinical Issue Key Clinical Activities Action Steps

General Principles for All Age Groups Incorporate four components of care.

Initiate therapy based on asthma severity.

Adjust therapy based on asthma control. Include medications, patient education, environmental control measures, and management of comorbidities at each step. Monitor asthma control regularly (See above, assessment and monitoring.). For patients not taking long-term control therapy, select treatment step based on severity (See figures on stepwise approach for different age groups.). Patients who have persistent asthma require daily long-term control medication. Once therapy is initiated, monitor the level of asthma control and adjust therapy accordingly: step up if necessary and step down if possible to identify the minimum amount of medication required to maintain asthma control. Refer to an asthma specialist for consultation or comanagment if there are difficulties achieving or maintaining control; step 4 care or higher is required (step 3 care or higher for children 0–4 years of age); immunotherapy or omalizumab is considered; or additional testing is indicated; or if the patient required 2 bursts of oral systemic corticosticosteroids in the past year or a hospitalization. Stepwise Approach

Young children may be at high risk for severe exacerbations, yet have low levels of impairment between exacerbations. Initiate daily long-term control therapy f or:

■ Children who had ≥ 4 episodes of wheezing the past year that lasted >1 da y and affected sleep AND who have a positive asthma risk profile, either (1) one of the following: parental history of asthma, physician dia gnosis of atopic derma titis, or evidence of sensitization to aeroallergens OR (2) two of the following: sensitization to foods, ≥ 4 percent blood eosinophilia, or wheezing apart from colds. Consider initiating dail y long-term control therap y f or:

■ Children who consistentl y require SABA treatment >2 days per week

for >4 weeks.

■ Children who have two exacerbations requiring oral systemic corticosteroids within 6 months. If no clear and positive response occurs within 4–6 weeks and the patient’s/caregiver’s medication technique and adherence are satisfactory, stop the treatment and consider alternative therapies or diagnoses. If clear benefit is sustained for at least 3 months, consider step down to evaluate the continued need for daily therapy. Children this age have high ra tes of spontaneous remission of symptoms. Ages 0–4 Years Consider daily long-term control therapy.

Monitor response closely, and adjust treatment.7 Introduction 

### Figure 1. SUMMARY OF RECOMMENDED KEY CLINICAL ACTIVITIES FOR THE DIAGNOSIS AND MANAGEMENT OF ASTHMA (continued)
C linical Issue Key Clinical Activities Action Steps Stepwise Approach (continued)
A ddress child’s concerns, preferences, and school schedule in selecting treatments. Encourage students to take a copy of written asthma action plan to school/ afterschool activities. Trea t exercise-induced bronchospasm (EIB) (See below .) Step up daily therapy if the child has poor endurance or symptoms during normal play activities. Treatment will not alter underlying progression of the disease, but a step up in therapy may be required to maintain asthma control. Address youth’s concerns, preferences, and school schedule in selecting treatment. Encourage students to take a copy of written asthma action plan to school/afterschool activities. Treat EIB. Step up daily therapy if the child has poor endurance or symptoms during normal daily activities. Esta blish reversibility with a short course of oral systemic corticosteroids.

Consider, for example: calcium and vitamin D supplements for patients who take ICS and have risk factors for osteoporosis; increased sensitivity to side effects of bronchodilators with increasing age; increased drug interactions with theophylline; medications for arthritis (NSAIDs), hypertension, or glaucoma (beta blockers) may exacerbate asthma. Ages 5–11 Years Involve child in developing a written a sthma action plan.

Promote physical activity.

Monitor for disease progression and loss of lung growth.
Involve youths in developing written asthma action plan.

Promote physical activity.

Assess possible benefit of treatment in older pa tients. Adjust medications to address coexisting medical conditions common among older pa tients.

T rea tment strategies to prevent EIB include:

■ Long-term control thera p y.

■ Pretreatment before exercise with SABA, leukotriene receptor antagonists (L

TRAs), cromolyn or nedocromil; frequent or chronic use of long acting beta 2 -agonist (LABA) for pretreatment is discouraged, as it may disguise poorly controlled persistent asthma.

■ Warmup period or a mask or scarf over the mouth for cold-induced EIB. Exercise-Induced Bronchospasm (EIB) Prevent EIB

Monitor asthma control during all prenatal visits; asthma worsens in one-third of women during pregnancy and improves in one-third; medications should be adjusted accordingly. It is safer to be treated with asthma medications than to have poorly controlled asthma. Maintaining lung function is important to ensure oxygen supply to the fetus. Albuterol is the preferred SABA. ICS is the preferred long-term control medication (Budesonide is preferred because more data are available on this medica tion during pregnancy .). Pregnancy Maintain asthma control through pregnancy.

Assess asthma control prior to surgery. If lung function is not well controlled, provide medications to improve lung function. A short course of oral systemic corticosteroids may be necessary. For patients receiving oral systemic corticosteroids during 6 months prior to surgery, and for selected patients on high dose ICS, give 100 mg hydrocortisone ever y 8 hours intravenously during the surgical period, and reduce the dose rapidly within 24 hours after surgery. Surgery Reduce risks for complications during and after surger y. Ages 12 and Older8 Guidelines for the Diagnosis and Management of Asthma 

### Figure 1. SUMMARY OF RECOMMENDED KEY CLINICAL ACTIVITIES FOR THE DIAGNOSIS AND MANAGEMENT OF ASTHMA (continued)
C linical Issue Key Clinical Activities Action Steps Managing Exacerbations Include assessment and monitoring, patient education, environmental control, and medications.
I nstruct patients how to:

■ Recognize early signs, symptoms, peak expiratory flow (PEF) measures that indicate worsening asthma.

■ Adjust medications (increase SABA and, in some cases, add oral systemic corticosteroids) and remove or withdraw from environmental factors contributing to the exacerbation.

■ Monitor response and seek medical care if there is serious deterioration or lack of response to trea tment. Home Management Incorporate four components of care.

D evelop a written asthma action plan.

Treatment strategies include:

■ Assessing initial severity by lung function measures (for ages ≥ 5 years) and symptom and functional assessment

■ Supplemental oxygen

■ Repetitive or continuous SABA

■ Oral systemic corticosteroids

■ Monitoring response with serial assessment of lung function measures, pulse oximetry, and symptoms

■ Considering adjunctive treatments magnesium sulfate or heliox in severe exacerbations (e.g., forced expiratory volume in 1 second (FEV 1 ) or PEF <40 percent predicted) unresponsive to initial trea tment

■ Providing a t discharge:

— Medications: SABA, oral systemic corticosteroids; consider initia ting ICS

— Referral to followup care — An emergency department asthma discharge plan

— Review of inhaler technique and, whenever possible, environmental control measures Management in the Urgent or Emergency Care Setting Assess severity. Treat to relieve hypoxemia and airflow obstruction; reduce airway inflammation. Monitor response. Discharge with medication and pa tient education

### Definition and Pathophysiology Asthma is a complex disorder characterized by variable and recurring symp t oms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation. The interaction of these features determines the clinical manifestations and severity of asthma (See figure 2,

“ The Interplay and Interaction Between Airway Inflammation and the Clinical Symptoms and Pathophysiology of Asthma.”) and the response to treatment. The working definition of asthma is as follows: Asthma is a chronic inflammatory disorder of the airways in w hic h man y c el ls and ce llular elements p la y a role: in particular, mast cells, eosinophils, neutrophils (especially in sudden onset, fatal exacerbations, occupational asthma, and p at ients who smoke), T lymphocytes, macrophages,and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of coughing (particularly at night or early in the morning), wheezing, breathlessness, and chest tightness. These episodes are usually associated

w ith widespread but variable airflow obstruction that is

o ften reversible either spontaneously or with treatment. Airflow limitation is caused by a variety of changes in the air way, all in influenced by airway inflamation:

■ 

### Bronchoconstriction—bronchial smooth muscle

contraction that quickly narrows the airways in response to exposure to a variety of stimuli, including allergens or irritants.

■ 

### Airway hyperresponsiveness—an exaggerated

bronchoconstrictor response to stimuli.

■ 

### Airway edema—as the disease becomes more

persistent and inflammation becomes more progressive, edema, mucus hypersecretion, and formation of inspissated mucus plugs further limit airflow.
Re modeling of airways may occur. Reversibility of airflo w limitation may be incomplete in some patients. Persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis. Recent studies provide insights on different phenotypes of asthma that exist. Different manifestations of asthma may have specific and varying patterns of inflammat ion (e.g., varying intensity, cellular mediator pattern, and therapeutic response). Further studies will determine if different treatment approaches benefit the different patterns of inflammation.

9 Asthma Definition and Implications for Treatment 

### Figur e 2. THE INTERPLAY AND INTERACTION BETWEEN AIRWAY INFLAMMATION AND THE CLINICAL SYMPTOMS AND PATHOPHYSIOLOGY OF ASTHMA

Inflammation

Airway Hyperresponsiveness

Clinical Symptoms Airway Obstruction 

# Asthma Definition and Implications for Treatment

### C auses of Asthma The development of asthma appears to involve the interplay be tw een host factors (particularly genetics) and environmental exposures that occur at a crucial time in the development of the immune system. A definitive cause of the inflammatory process leading to asthma has not yet been established.

■ 

### Innate immunity. Numerous factors may affect the

balance between Th1-type and Th2- type cytokine responses in early life and increase the likelihood that the immune response will downregulate the Th1 immune response that fights infection and instead will be dominated by Th2 cells, leading to the expression of allergic diseases and asthma. This is known as the “hygiene hypothesis,” which postulates that certain infections early in life,

e xpos ure to other children (e.g., presence of older sibling s and earl y e nrollment in childcare, which have greater likelihood of exposure to respiratory infection), less frequent use of antibiotics, and “country living” is associated with a Th1 response and lower incidence of asthma, whereas the absence of these factors is associated with a per siste nt Th2 r esp onse and higher rates of asthma. Interventions to prevent the onset of this process (e.g., with probiotics) are under study, bu t no recommendations can yet be made.

■ 

### Genetics. A sthma has an inheritable component,

bu t the ge net ics inv ol ved remain complex. As the linkage of genetic factors to different asthma phenotypes becomes clearer, treatment approaches

ma y b ecome directed to specific patient phenotypes and genotypes.

■ 

### Environmental factors.

— Two major factors are the most important in the development, persistence, and possibly the severity of asthma: airborne allergens (particularly sensitization and exposure to house-d ust mit e and A lternaria) and viral respiratory infections (including respiratory syncytial virus [RSV] and rhinovirus). — Other environmental factors are under study: tobacco smoke (exposure in utero is associated with an increased risk of wheezing, but it is not certain this is linked to subsequent development of asthma), air pollution (ozone and particular matter) and diet (obesity or low intake of antioxidants and omega-3 fatty acids). The association of these factors with the onset of asthma has not been clearly defined. A number of clinical trials have investigated dietary and environmental manipulations, but these trials have not been sufficiently long term or conclusive to permit recommendations. Implications for Treatment Knowledge of the importance of inflammation to the

ce ntral featur es o f asthma continues to expand and underscores inflammation as a primary target of treatment. Studies indicate that current therapeutic approaches are effective in controlling symptoms, reducing airflow limitation, and preventing

e xacer bations, but currently available treatments do not appear t o p revent the progression of asthma in children. As various phenotypes of asthma are defined and inflammatory and genetic factors become more appare nt, new therapeutic approaches may be developed that will allow even greater specificity to tailor treatment to the individual patient’s needs and circumstances.

10 Guidelines for the Diagnosis and Management of Asthma

### To establish a diagnosis of asthma, the clinician should determine that symptoms of recurrent episodes of airflow obstruction or airway hyperresponsiveness are present; airflow obstruction is at least partially reversible; and alternative diagnoses are excluded. ■ 

### Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present.

■ 

### Airflow obstruction is at least partially reversible,

measured by spirometry. Reversibility is determined by an increase in FEV 1 

### of >200 mL and ≥ 12 percent from baseline measure after inhalation of short-acting beta 2 

### -agonist (SABA). Some studies indicate that an increase of ≥ 10 percent of the predicted FEV 1 

### after inhalation of a SABA may have higher likelihood of separating patients

w

ho have asthma from those who have chronic obstructive pulmonary disease (COPD).

■ 

### Alternativ e diag noses are excluded. See discussion

below. Recommended methods to establish the diagnosis
are:

■ 

### Detailed medical history. See figure 3, “Suggested

Items for Me dical History,” for questions to include.

■ 

### Phy sical examinat ion ma y r ev eal finding s that increase the probability o f asthma, but the absenc e o f these finding s does not rule out asthma, because the disease is variable and signs may be absent between episodes. The examination focuses on:

— up per respiratory tract (increased nasal

secre tion, mucosal swelling, and/or nasal polyp; — chest (sounds of wheezing during normal breathing or prolonged phase of forced exhalation, hyperexpansion of the thorax, use of accessory muscles, appearance of hunched shoulders, chest deformity); and — skin (atopic dermatitis, eczema).

■ 

### Spirometry can demonstrate obstruction and assess

reve rsibility in patients ≥ 5 year s of age. Patients’ perceptions of airflow obstruction are highly

v ariable. Spir o me try is an essential objective measure to establish the diagnosis of asthma,

11 Diagnosis of Asthma 

## KEY SYMPTOM INDICATORS FOR CONSIDERING A DIAGNOSIS OF ASTHMA
The presence of multiple key indicators increases the proba bility of asthma, but spirometry is needed to establish a diagnosis.

■ Wheezing—high-pitched whistling sounds when breathing out—especially in children. A lack of wheezing and a normal chest examination do not exclude asthma.

■ History of any of the following:

— Cough (worse particularly at night)

— Recurrent wheeze

— Recurrent difficulty in breathing

— Recurrent chest tightness

■ Symptoms occur or worsen in the presence of:

— Exercise

— Viral infection

— Inhalant allergens (e.g., animals with fur or hair, house-dust mites, mold, pollen)

— Irritants (tobacco or wood smoke, airborne chemicals)

— Changes in wea ther

— Strong emotional expression (laughing or crying hard)

— Stress

— Menstrual cycles

■ Symptoms occur or worsen a t night, awakening the patient. 

# Diagnosis of Asthma12 Guidelines for the Diagnosis and Management of Asthma 

### because the medical history and physical examination are not reliable means of excluding other diagnoses or of assessing lung status. Spirometry is generally recommended, rather than measurements by a peak flow meter, due to wide variability in peak flow meters and reference values. Peak flow meters are designed for monitoring, not as diagnostic tools.
A diff erential diagnosis of asthma should be consider e d. Recurrent episodes of cough and wheezing most often ar e d ue to asthma in both children and adults; however, other significant causes of airway obstruction leading to wheeze must be considered both in the initial diagnosis and if there is no clear response to initial therapy.

■ 

### A dditional studies are not routinely necessary

but may be useful when considering alternative diagnoses.

— A dditional pulmonary function studies will he lp if ther e are q uest ions ab out COPD (diffusing capacity), a restrictive defect (measures of lung volumes), or VCD (evaluation of inspiratory flow-volume loops).

— Broncho provocation w ith me thacholine, histamine, c old air, o r e xercise challeng e may be useful when asthma is suspected and spirometry is normal or near normal. For saf ety reasons, bronchoprovocation should be carried out only by a trained individual. A positive test is diagnostic for airway hyperre sponsiveness, which is a characteristic feature of asthma but can also be present in other conditions. Thus, a positive test is consistent with asthma, but a negative test may be more helpful to rule out asthma.

— Chest x ray may be needed to exclude other diagnoses.

— Biomarker s o f inflammation ar e curre ntly being evaluated f or their usefulness in the diagnosis and assessment of asthma. Biomarkers include total and differential cell count and mediator assays in sputum, blood, urine, and exhaled air.

■ 

### Common diagnostic challenges include the

f ollowing:

— Coug h v ar iant asthma. Coug h can b e the principal—or only—manif estat ion of asthma, especially in young children. 

## DIFFERENTIAL DIAGNOSTIC POSSIBILITIES FOR ASTHMA
Infants and Children Upper airway diseases

■ Allergic rhinitis and sinusitis Obstructions involving large airways

■ Foreign body in trachea or bronchus

■ Vocal cord dysfunction (VCD)

■ Vascular rings or laryngeal webs

■ Laryngotracheomalacia, tracheal stenosis, or bronchostenosis

■ Enlarged lymph nodes or tumor Obstructions involving small airways

■ Viral bronchiolitis or obliterative bronchiolitis

■ Cystic fibrosis

■ Bronchopulmonary dysplasia

■ Heart disease Other causes

■ Recurrent cough not due to asthma

■ Aspiration from swallowing mechanism dysfunction or gastroesophageal reflux
Adults

■ Chronic obstructive pulmonary disease (COPD) (e.g., chronic bronchitis or emphysema)

■ Congestive heart failure

■ Pulmonary embolism

■ Mechanical obstruction of the airways (benign and malignant tumors)

■ Pulmonar y infiltra tion with eosinophilia

■ Cough secondar y to drugs (e.g., angiotensinconverting enzyme [ACE] inhibitors)

■ Vocal cord dysfunction (VCD)13 Diagnosis of Asthma 

### FIGURE 3. SUGGESTED ITEMS FOR MEDICAL HISTORY*

1. Symptoms C ough Wheezing Shortness of breath Chest tightness Sputum production 2. Pattern of symptoms Perennial, seasonal, or both Continual, episodic, or both Onset, duration, frequency (number of da ys or nights, per week or month) Diurnal varia tions, especially nocturnal and on awakening in early morning 3. Precipitating and/or aggravating factors

Viral respira tor y infections Environmental allergens, indoor (e.g., mold, house-dust mite, cockroach, animal dander or secretor y products) and outdoor (e.g., pollen) Characteristics of home including a ge, location, cooling and heating system, wood-burning stove, humidifier, carpeting over concrete, presence of molds or mildew, presense of pets with fur or hair, characteristics of rooms where patient spends time (e.g., bedroom and living room with attention to bedding, floor covering, stuffed furniture) Smoking (patient and others in home or daycare) Exercise Occupa tional chemicals or allergens Environmental change (e.g., moving to new home; going on vaca tion; and/or alterations in workplace, work processes, or materials used) Irritants (e.g., tobacco smoke, strong odors, air pollutants, occupa tional chemicals, dusts and particulates, vapors, gases, and aerosols) Emotions (e.g., fear, anger, frustration, hard crying or laughing) Stress (e.g., fear, anger, frustration) Drugs (e.g., aspirin; and other nonsteroidal anti-inf lammator y drugs, beta-blockers including eye drops, others) Food, f ood additives, and preservatives (e.g., sulfites) Changes in wea ther, exposure to cold air Endocrine factors (e.g., menses, pregnancy, thyroid disease) Comorbid conditions (e.g. sinusitis, rhinitis, gastroesophageal ref lux disease (GERD) 4. Development of disease and treatment

Age of onset and diagnosis History of early-life injury to airways (e.g., bronchopulmonar y dysplasia, pneumonia, parental smoking) Progression of disease (better or worse) Present management and response, including plans for mana ging exacerbations Frequency of using short-acting beta 2 -agonist (SABA) N eed for oral corticosteroids and frequency of use 5. Family history History of asthma, allergy, sinusitis, rhinitis, eczema, or nasal polyps in close relatives 6. Social history Daycare, workplace, and school characteristics that may interfere with adherence Social factors that interfere with adherence, such as substance abuse Social support/social networks Level of education completed Employment 7. History of exacerbations Usual prodromal signs and symptoms Ra pidity of onset Duration Frequency Severity (need for urgent care, hospitaliza tion, intensive care unit (ICU) admission.) Life-threa tening exacerbations (e.g., intubation, intensive care unit admission) Number and severity of exacerba tions in the past year

. Usual patterns and management (wha t works?) 8. Impact of asthma on patient and f amily Episodes of unscheduled care (emergency department (ED), urgent care, hospitalization) Number of days missed from school/work Limita tion of activity, especially sports and strenuous work History of nocturnal a wakening Ef fect on growth, development, behavior, school or work performance, and lifestyle Impact on family routines, activities, or dynamics Economic impact 9. Assessment of patient’s and family’s perceptions of disease Patient’s, parent’s, and spouse’s or partner’s knowledge of asthma and belief in the chronicity of asthma and in the efficacy of trea tmentPatient’s perception and beliefs regarding use and longterm effects of medications Ability of patient and parents, spouse, or partner to cope with disease Level of famil y support and pa tient’s and parents’, spouse’s, or partner’ s capacity to recognize severity of an exacerbation Economic resources Sociocultural beliefs A detailed medical history of the new patient who is known or thought to have asthma should address the following items

* This list does not represent a standardized assessment or diagnostic instrument. The validity and reliability of this list have not been assessed.

### Monitoring of PEF or bronchoprovocation maybe helpful. Diagnosis is confirmed by a positive response to asthma medications.

— VCD can mimic asthma, but it is a distinct disorder. V CD may coexist with asthma. Asthma medications typically do little, if any thing, to relieve VCD symptoms. Variable flattening of the inspiratory flow loop on spirometry is strongly suggestive of VCD. Diagnosis of VCD is from indirect or direct vocal cord visualization during an episode, during which the abnormal adduction can be documented. VCD should be considered in difficult-to-treat, atypical asthma patients and in elite athletes who have exercise-related breathlessness unresponsive to asthma medication.

— Gastroesophageal reflux disease (GERD),
o bstructiv e sle ep apnea (OSA), and allergic bronchopulmonary aspergillosis (ABPA) may coe xist with asthma and complicate diagnosis. Se e the sec t io n on “Comorbid Conditions,” for further discussion.

— Children ages 0–4 years. Diagnosis in infants and young children is chal le nging and is

co mplicate d by the difficult y in obtaining objective measurements of lung function in this age group. Caution is needed to avoid giving young children inappropriate pr olo nged asthma therapy. However, it is important to avoid underdiagnosing asthma, and thereby missing the opportunity to treat a child, by using such labels as “wheezy bronchitis,” “recurrent pneumonia,” or “reactive airway disease” (RAD). The chronic airway inflammatory response and structural changes that are characteristic of asthma can de velop in the preschool years, and appropriate asthma tr eatme nt will reduce morbidity.

■ 

### Consider referral to an asthma specialist if signs

and symptoms are atypical, if there are problems with a differe nt ial diag nosis, or if additional testing is indicated.

14 Guidelines for the Diagnosis and Management of Asthma

### Achieving and maintaining asthma control requires four components of care: assessment and monitoring,education for a partnership in care, control of environmental factors and comorbid conditions that affect asthma, and medications. A stepwise approach to asthma management incorporates these four

co mponents, emp hasizing that pharmacologic therapy is initiated based on asthma severity and adjusted (stepped up or down) based on the level of asthma control. Special considerations of therapeutic options within the stepwise approach may be necessary for situations such as exercise-induced bronchospasm (EIB), surgery, and pregnancy. F our Components of Asthma Care Compone nt 1: A ssessing and Monitoring Asthma Severity and Asthma Control The functions of assessment and monitoring are closely linked t o the c oncepts of severity, control, and responsiveness to treatment: ■ 

### Severity: the intrinsic intensity of the disease process. Se verity is most easily and directly measured in a patient who is not receiving long-term control the rapy. Severity can also be measured, once asthma control is achieved, by the step of care (i.e., the amount of medication) required to maintain co ntrol.

■ 

### Control: the degree to which the manifestations of

asthma are minimized by therap eutic intervention and the goals of therapy are met.

■ 

### Responsiveness: the ease with which asthma

co nt rol is achieved b y therapy.
A sthma severity and asthma control inc l ude the domains of current impairment and future risk.

■ 

### Impairment: frequency and intensity of symptoms

and funct io nal limitat io ns the pat ie nt is curre ntly experiencing o r has recently experienced.

15 Managing Asthma Long Term 

# Managing Asthma Long Term

GOAL OF THERAPY: CONTROL OF ASTHMA Reduce Impairment

■ Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness in the daytime, in the night, or after exertion).

■ Require infrequent use ( ≤ 2 days a week) of inhaled SABA for quick relief of symptoms (not including prevention of exercise-induced bronchospasm [EIB]).

■ Maintain (near) normal pulmonary function.

■ Maintain normal activity levels (including exercise and other physical activity and attendance at school or work).

■ Meet patients’ and families’ expectations of and satisfaction with asthma care. Reduce Risk

■ Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitaliza tions.

■ Prevent loss of lung function; for children, prevent reduced lung growth.

■ Provide optimal pharmacotherapy with minimal or no adverse effects of therapy.■ 

### Risk: the likelihood of either asthma exacerbations, progressiv e decline in lung function (or, for children, reduced lung growth), or risk of adverse effects from medication. This distinction emphasizes the multifaceted nature of asthma and the need to consider separately asthma’s current, ongoing effects on the present quality of life and functional capacity and the future risk of adverse events. The two domains may respond differentially to treatment. For example, evidence demonstrates that some patients can have adequate control of symptoms and minimal day-to-day impairment, but still be at significant risk of exacerbations; these patients should be treated accordingly.
T he specific measures used to assess severity and control are similar: symptoms, use of SABAs for quick relief of symptoms, limitations to normal activities due to asthma, pulmonary function, and exacerbations. Multiple measures are important, because different

measur es assess diff er ent manifestations of the disease and ma y not c orre lat e with each other. The concepts of severity and control are used as f ollows fo r manag ing asthma:

■ 

### A ssess sever it y to initiate therapy. Se e sectio n on “Stepwise A pproach for Managing Asthma” for figures on classifying asthma severity and initiating the rapy in different age groups. During a patient’s initial presentation, if the patient is not currently taking long-term control medication, asthma severity is assessed to guide clinical decisions for initiating the appropriate medication and other therapeutic interventions.

■ 

### Assess control to adjust therapy. See section on “Stepwise Ap proach for Managing Asthma” for figures on assessing asthma control and adjusting therap y in different age groups. Once therapy is initiated, the emphasis for clinical management thereafter is changed to the assessment of asthma

co ntrol. T he level of asthma control will guide decisions either to maintain or to adjust therapy (i.e., step up if necessary, step down if possible).

■ 

### For assessing a patient’s overall asthma severity,

once the most optimal asthma control is achieved and maintaine d, o r for population-based evaluations or clinical r esear ch, asthma severity can be inferre d by correlating the level of severity with the lowest level of treatment required to maintain control. However, the emphasis for clinical management is to assess asthma severity prior to initiating therapy and then to assess asthma control for monitoring and adjusting therapy. For the initial assessment to characterize the patient’s asthma and guid e d ecisions for init iat ing therapy, use inf or mat ion from the diagnostic evaluation to:

■ 

### Classify asthma severity.

■ 

### Identify precipitating factors for episodic symptoms (e.g., exposur e at home, work, daycare, or school to inhalant allergens or irritants).

■ 

### Identify comorbid conditions that may impede

asthma management (e.g., sinusit is, rhinitis, GERD, OSA, o besity, stress, or depression).

■ 

### Assess the patient’s knowledge and skills for

self-manag e ment. Fo r periodic monitoring of asthma control to guide decisions fo r maintaining o r adjusting therapy:

■ 

### Instruct patients to monitor their asthma control in

an o ng oing manner. All patients should be taught ho w to r e cognize inadequate asthma control. — Either symptom or peak flow monitoring is approp r iate for most patients; evidence suggests the benefits are similar. — Consider daily peak-flow monitoring for patients who have moderate or severe persistent asthma, patients who have a history of severe

e xa cerbations, and patients who poorly perceive airway obstruction or worsening asthma.

■ 

### Monitor asthma control periodically in clinical

v isits, be cause asthma is hig hl y v ar iable over time and the rapy may need to be adjusted (stepped up if necessary, stepped down if possible). The fr eq ue ncy o f monit o ring is a matter of c linical j udgment. In general:

16 Guidelines for the Diagnosis and Management of Asthma Lowest level of treatment required to maintain

c ontrol (See “Stepwise Approach for Managing Asthma” for treatment steps.) Classification of Asthma Severity When Asthma Is Well Controlled
Persistent Intermittent Mild Moderate Severe Step 1 Step 2 Step 3 Step 5 or or Step 4 Step 617 Managing Asthma Long Term 

### FIGURE 4. SAMPLE PATIENT SELF-ASSESSMENT SHEET FOR FOLLOWUP VISITS*

Name:___________________________________ Date:________________________



## Your Asthma Control How many days in the past week have you had chest tightness, cough, shortness of breath, or wheezing (whistling in your chest)? _____ 0 _____ 1 _____ 2 _____ 3 _____ 4 _____ 5 _____ 6 _____ 7 How many nights in the past week have you had chest tightness, cough, shortness of breath, or wheezing (whistling in your chest)? _____ 0 _____ 1 _____ 2 _____ 3 _____ 4 _____ 5 _____ 6 _____ 7 Do you perform peak flow readings at home? ______ yes ______ no If yes, did you bring your peak flow chart? ______ yes ______ no How man y da ys in the past week has asthma restricted your physical activity? _____ 0 _____ 1 _____ 2 _____ 3 _____ 4 _____ 5 _____ 6 _____ 7 Ha ve you had an y asthma attacks since your last visit? ______ yes ______ no Have you had any unscheduled visits to a doctor, including to the emergency department, since your last visit? ______ yes ______ no How well controlled is your asthma, in your opinion? ____ very well controlled ____ somewhat controlled ____ not well controlled Average number of puffs per day of quick-relief medication (short acting beta 2 

### -agonist) ____________________ 

## T

aking your medicine What problems have you had taking your medicine or following your asthma action plan? Please ask the doctor or nurse to review how you take your medicine.



## Your questions
Wha t questions or concerns would you like to discuss with the doctor? How satisfied are you with your asthma care?____ very satisfied ____ somewhat satisfied ____ not satisfied

* These questions are examples and do not represent a standardized assessment instrument. Other examples of asthma control questions: Asthma Control Questionnaire (Juniper); Asthma Therap y Assessment Questionnaire (V olmer); Asthma Control Test (Nathan); Asthma Control Score (Boulet)18 Guidelines for the Diagnosis and Management of Asthma 

### — Schedule visits at 2- to 6-week intervals for patients who are just starting therapy or who require a step up in therapy to achieve or regain asthma control. — Schedule visits at 1- to 6-month intervals, after asthma control is achieved, to monitor whether asthma control is maintained. The interval will depend on factors such as the duration of asthma control or the level of treatment required. — Consider scheduling visits at 3-month intervals if a step down in therapy is anticipated.

■ 

### Assess asthma control, medication technique,

the written asthma action plan, adherence, and patient concerns at every patient visit. See figure 4 for a sample patient self-assessme nt o f overall asthma control and asthma care.

■ 

### U se spir o me tr y to obtain objective measures of lung func t ion.

— Perform spirometry at the following times:
• A t the initial assessme nt. • After treatment is initiated and symptoms

and PEF have stabilized.
• D ur ing periods of progressive or prolonged

loss of asthma control. • At least every 1–2 years; more frequently

depending on response to therapy.

— Low FEV 1 

### indicat es current obstruction (impairment) and risk for future exacerbations (risk). For children, FEV 1 

### /forced vital capacity (FVC) appears to be a more sensitive measure of severity and control in the impairment d omain. FEV 1 

### is a useful measure of risk for exacerbations, although it is emphasized that even children who have normal lung function experience exacerbations.

■ 

### Minimally invasive markers (called biomarkers)

s uc h as fractionated exhaled nitr ic oxide (FeNO) and sputum eosinophils may be useful, but bio markers require further evaluation before they can be recommended as clinical tools for routine management. Component 2: Education for a Partnership in Care
A par tnership between the clinician and the person who has asthma (and the caregi v

er, for children) is required for effective asthma management. By working together, an appropriate treatment can be selected, and the patient can learn self-management skills necessary to control asthma. Self-management education improves patient outcomes (e.g., reduced urgent care visits, hospitalizations, and limitations on activities as well as improved health status, quality of life, and perceived control of asthma) and can be cost-effective. Self-management education is an integral component of effective asthma care and should be treated as such by health care providers as well as by health care policies and r eimbursements.



## KEY EDUCATIONAL MESSAGES: TEACH AND REINFORCE AT EVERY OPPORTUNITY

Basic Facts About Asthma
■ The contrast between airways of a person who has and a person who does not have asthma; the role of inflammation. ■ What ha ppens to the airwa ys during an asthma attack. Role of Medications: Understanding the Difference Between:
■ Long-term control medications: prevent symptoms, often by reducing inf lammation. Must be taken daily . Do not expect them to give quick relief. ■ Quick-relief medications: SABAs relax airwa y muscles to provide prompt relief of symptoms. Do not expect them to provide long-term asthma control. Using SABA >2 days a week indicates the need for starting or increasing longterm control medica tions. Patient Skills
■ T aking medications correctly — Inhaler technique (demonstrate to the patient and ha ve the patient return the demonstration).

— Use of devices, as prescribed (e.g., valved holding chamber (VHC) or spacer
, nebulizer). ■ Identifying and a voiding environmental exposures tha t

worsen the patient’s asthma; e.g., allergens, irritants, tobacco smoke. ■ Self-monitoring

— Assess level of asthma control. — Monitor symptoms and, if prescribed, PEF measures.

— Recognize early signs and symptoms of worsening asthma. ■ Using a written asthma action plan to know when and how to:

— Take daily actions to control asthma.

— Adjust medication in response to signs of worsening asthma. ■ Seeking medical care as a ppropriate.19 Managing Asthma Long Term 

### Develop an active partnership with the patient and family by:

■ 

### Establishing open communications that consider

cultural and ethnic factors, as well as language and health care literacy needs, of each patient and family.

■ 

### Identifying and addressing patient and family

concerns about asthma and asthma treatment.

■ 

### Developing treatment goals and selecting

medications together with the patient and family, allowing full participation in treatment decision making.

■ 

### Encouraging self-monitoring and self-management

by reviewing at each opportunity the patient’s reports of asthma symptoms and response to treatment. Provide to all patients a written asthma action plan that includes instructio ns f or both daily management (long-term control medication, if ap propr iate, and env ir onmental control measures) and a ct io ns t o manag e w o rsening asthma (what signs, symptoms, and PEF measurements (if used) indicate

w

orsening asthma; what medications to take in

r esp o nse; what signs and symptoms indicate the need for immediate medical care). Written asthma action plans are particularly recommended for patients who have moderate or severe persistent asthma (i.e.,

r equiring treatment at step 4, 5, or 6), a history of

se ve re exacerbations, or poorly controlled asthma. See figures 5 and 6 for samples of written asthma action plans.
I nt egrate asthma self-management education into all aspects of asthma car e. Asthma self management requires repetition and reinforcement. It should:

■ 

### Be gin at the time of diagnosis and continue through

followup care. See figure 7, “Delivery of Asthma Educatio n b y Clinicians During Patient Care Visits,” for a sample of how to incorporate teaching into routine clinic visits.

■ 

### Involve all members of the health care team, including

physicians, nurses, pharmacists, respiratory therapists, and asthma educators, as well as other health professionals who come in contact with asthma pat ie nts and their families.

■ 

### Oc cur at al l p oints of care where health care professionals interact with patients who have asthma. The stro ng est evidence supports self-management education in the clinic setting. Evidence also supports education provided in patients' homes,pharmacies, targeted education in EDs and hospitals, and selected programs in schools and other community sites. Proven community programs should be considered because of their potential to reach large numbers of people who have asthma and encourage “asthma-friendly” support from their families and community environments.

■ 

### Use a variety of educational strategies to reach

people who have varying levels of health literacy or learning styles. Individual instruction, group programs, written materials (at a 5th grade readinglevel or below), video- or audiotapes, and computer and Internet programs all provide effective educational opportunities. See figure 8, “Asthma Education Resources,” for a sample of available

resources.

■ 

### Incorporate individualized case/care management

by trained health care professionals for patients who hav e p oorly controlled asthma and have

re curre nt visits t o the emergency department or hospital. This will provide tailored self-management education and skills training. Encourage patients' adherence to the written asthma act io n plan by:

■ 

### Choosing treatment that achieves outcomes and

addresses preferences that are important to the patient, and reminding patients that adherence will help them achieve the outcomes they want.

■ 

### Review ing with the patient at each visit the success

of the treatment plan to achieve asthma control and make adjustments as needed.

■ 

### Reviewing patients' concerns about their asthma

o r t reatment at every visit. Inquire about any difficulties e ncountered in adhering to the written asthma action plan.

■ 

### Assessing the patient's and family's level of social

support, and encouraging family involvement.

■ 

### Tailoring the self-management approach to the

needs and literacy levels of the patient, and maintaining sensitivity to cultural beliefs and

e thno cultural practices. Encourag e he alth care provide r and he alth care system support of the therapeutic partnership by:

■ 

### Incorporating effective clinician education strategies,20 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 5. SAMPLE ASTHMA ACTION PLAN—ADULT

Ada pted and reprinted with permission from the Reg ional Asthma Management and Prevention (RAMP) Initiative, a program of the Public Health Institute, to include terms used in the EPR—3: Full Report 2007.
Source: http://www.calasthma.org/uploads/resources/actionplanpdf.pdf; San Francisco Bay Area Regional Asthma Management Plan, http://www.rampasthma.org21 Managing Asthma Long Term 

### FIGURE 6. SAMPLE ASTHMA ACTION PLAN—CHILD

Adapted and reprinted with permission from “The Asthma Action Plan” developed by a committee facilitated by the Regional Asthma Management and Prevention (RAMP) Initiative, a program of the Public Health Institute. Source: http://www.calasthma.org/uploads/resources/actionplanpdf.pdf; San Francisco Bay Area Regional Asthma Management Plan, http://www.rampasthma.org22 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 7. DELIVERY OF ASTHMA EDUCATION BY CLINICIANS DURING PATIENT CARE VISITS

A ssessment Questions Information Skills

Focus on:

■ Expectations of visit

■ Asthma control

■ Patients’ goals of treatment

■ M edications

■ Quality of life Ask relevant questions “What worries you most about your asthma?”

“ What do you want to accomplish at this visit?” “What do you want to be able to do that you can’t do

now because of your asthma?” “Wha t do you expect from trea tment?” “What medicines have you tried?” “What other questions do you have for me today?” “Are there things in your environment that make your

asthma worse?” Recommendations for Initial Visit Teach in simple language:

■ What is asthma? Asthma is a chronic lung disease.

The airways are very sensitive. They become inflamed and narrow; breathing becomes difficult.

■ T he definition of asthma control: few daytime symptoms, no nighttime awakenings due to asthma, able to engage in normal activities, normal lung function.

■ Asthma treatments: two types of medicines are n eeded: — Long-term control: medications that prevent symptoms, often by reducing inflammation. — Quick relief: short-acting bronchodilator relaxes muscles around airways.

■ Bring all medications to every appointment.

■ When to seek medical advice. Provide appropriate telephone number. Teach or review and demonstrate:

■ I nhaler and spacer or valved holding chamber ( VHC) use. Check performance.

■ Self-monitoring skills that are tied to a written asthma action plan: — Recognize intensity and frequency of asthma s ymptoms. — Review the signs of deterioration and the need to reevaluate therapy:

s Waking at night or early morning with asthma

s Increased medication use

s Decreased activity tolerance

■ Use of a written asthma action plan (See figures 5 and 6.) that includes instructions for daily management and for recognizing and handling worsening asthma.

Focus on:

■ Expectations of visit

■ Asthma control

■ Patient’s goals of treatment

■ Medications

■ Patient’s treatment preferences

■ Quality of life Ask relev ant questions from previous visit and also ask: “Wha t medica tions are you taking?” “How and when are you taking them?” “Wha t problems have you had using your

medications?” “Please show me how you use your inhaled

medications.” Recommendations for First Followup Visit (2 to 4 Weeks or Sooner as Needed) Teach in simple language:

■ Use of two types of medications.

■ Remind patient to bring all medications and the peak flow meter, if using, to every appointment for review.

■ Self/assessment of asthma control using symptoms and/or peak flow as a guide. Teach or review and demonstrate:

■ Use of written asthma action plan. Review and adjust as needed.

■ Peak flow monitoring if indicated

■ Correct inhaler and spacer or VHC technique.

Focus on:

■ Expecta tions of visit

■ Asthma control

■ Patients’ goals of treatment

■ Medications

■ Quality of life Ask relev ant questions from previous visits and also ask: “Have you noticed anything in your home, work, or

school tha t makes your asthma worse?” “Describe f or me how you know when to call your

doctor or go to the hospital for asthma care.” “What questions do you have about the asthma

action plan?” “Can we make it easier?” “Are your medica tions causing you an y problems?” “Ha ve you noticed anything in your environment that

makes your asthma worse?” “Ha ve you missed an y of your medications?” Recommendations for Second Followup Visit Teach in simple language:

■ Self-assessment of asthma control, using symptoms and/or peak flow as a guide.

■ Relevant environmental control/avoidance strategies:

— How to identify home, work, or school exposures tha t can cause or worsen asthma — How to control house-dust mites, animal exposures if applicable — How to avoid cigarette smoke (active and passive)

■ Review all medications. Teach or review and demonstrate:

■ Inhaler/spacer or VHC technique.

■ Peak flow monitoring technique.

■ Use of written asthma action plan. Review and adjust as needed.

■ Confirm that patient knows what to do if asthma gets worse23 Managing Asthma Long Term 

### such as interactive formats, practice-based case studies, and multidimensional teaching ap proaches that reinforce guideline-based care.

■ 

### Providing communication skills training to

clinicians to enhance competence in caring for all patients, especially multicultural populations.

■ 

### U sing sy st ems approaches, such as clinical pathways

and clinical information system prompts, to improve the quality of asthma care and to support clinical care decisionmaking.
Co mponent 3: Control of Environmental Factors and Co mo rbid Condit io ns That Affect Asthma If patients who have asthma are exposed to irritants or inhalant allergens to w hic h they are sensitive, their asthma symptoms may increase and precipitate an asthma exacerbation. Substantially reducing exposure to these factors may reduce inflammation, symptoms, and need for medication. Several comorbid conditions can imp ed e asthma management. Recognition and treatment of these conditions may improve asthma

co nt r ol. See questions in figure 3, “Suggested Items for Medical History,” above, for questions related to environmental exposures and comorbid conditions. Allergens and Irritants
E

valuate the pot e ntial role of allergens (particularly inhalant allergens) and irritants.

■ 

### Ide ntify allergen and pollutants or irritant

exposures. The most important allergens for both children and adults appear to be those that are inhaled.

■ 

### For patients who have persistent asthma, use skin

testing or in vitro testing to assess sensitivity to perennial indoor allergens. Assess the significance of positive tests in the context of the person’s hist ory of symptoms when exposed to the allergen. Advise patients who have asthma to reduce exposure t o allerge ns and p ollutants or irritants to which they are sensitive.

■ 

### Se e figure 9, “How To Control Things That

M ak e Y our Asthma Worse,” for a sample patient information sheet.

■ 

### Effective allergen avoidance requires a multifaceted,

comprehensive approach; single steps alone are generally ineffective. Multifaceted allergen-control education programs provided in the home setting can help patients reduce exposures to cockroach, d ust-mite, and rodent allergens and, consequently, improve asthma control.

■ 

### Advise patients who have severe persistent asthma,

nasal p ol y ps, o r a hist o ry of sensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs)about their risk of severe and even fatal exacerbations from using these drugs.

■ 

### I ndoor air-cleaning devices (high-efficiency

par t iculate air [HEPA] and electrostatic precipitating filters), cannot substitute for more effective d ust-mit e and cockroach control measures because 

### FIGURE 7. DELIVERY OF ASTHMA EDUCATION BY CLINICIANS DURING PATIENT CARE VISITS (continued)
Assessment Questions Information Skills

F ocus on:
■ Expectations of visit

■ Asthma control

■ Patients’ goals of treatment

■ Medications

■ Q uality of life Ask relevant questions from previous visits and also ask: “How have you tried to control things that make

y our asthma worse?” “Please show me how you use your inhaled

medica tion.” Recommendations for All Subsequent Visits
T each in simple language:

■ Review and reinforce all:

— Educational messages — Environmental control strategies at home, work, or school

— Medications — Self-assessment of asthma control, using symptoms and/or peak flow as a guide Teach or review and demonstrate:

■ I nhaler/spacer or VHC technique.

■ P eak flow monitoring technique, if appropriate.

■ Use of written asthma action plan. Review and adjust as needed.

■ Confirm that patient knows what to do if asthma g ets worse.

Sources: Adapted from Guevara et al. 2003; Janson et al. 2003; Powell and Gibson 2003; Wilson et al. 1993.24 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 8. ASTHMA EDUCATION RESOURCES Allergy & Asthma Network Mothers of Asthmatics 1–800–878–4403 2751 Prosperity Avenue, Suite 150 1–703–641–9595 Fairfax, VA 22030 www.brea therville.org American Academy of Allergy, Asthma and Immunology 1–414–272–6071 555 East Wells Street, Suite 100 Milwaukee, WI 53202-3823 www .aaaai.org American Association For Respirator y Care 1–972–243–2272 9125 North MacArthur Boulevard, Suite 100 Irving, TX 75063 www.aarc.org American College of Allergy , Asthma, and Immunology 1–800–842–7777 85 W est Algonquin Road 1–847–427–1200 Suite 550 Arlington Heights, IL 60005 www.Acaai.Org American Lung Association 1–800–586–4872 61 Broadwa y New Y ork, NY 10006 www.lungusa.org Association of Asthma Educators 1–888–988–7747 1215 Anthony A venue Columbia, SC 29201 www.asthmaeducators.org Asthma and Allerg y Foundation of America 1–800–727–8462 1233 20th Street, NW., Suite 402 Washington, DC 20036 www .aafa.org Centers for Disease Control and Prevention 1–800–311–3435 1600 Clifton Road Atlanta, GA 30333 Food Allerg y & Anaphylaxis Network 1–800–929–4040 11781 Lee Jackson Highwa y, Suite 160 Fairfax, VA 22033 www .f oodallergy.org National Heart, Lung, and Blood Institute Information Center 1–301–592–8573 P

.O. Box 30105 Bethesda, MD 20824-0105 www.nhlbi.nih.gov National Jewish Medical and Research Center (Lung Line) 1–800–222–Lung 1400 Jackson Street Denver , CO 80206 www .njc.org U.S. Environmental Protection Agency 1–800–490–9198 National Center for Environmental Publications P

.O. Box 42419 Cincinna ti, OH 45242-0419 www.airnow.gov25 Managing Asthma Long Term 

### t hese particles do not remain airborne. The devices can reduce airborne dog and cat allergens, mold spores, and particulate tobacco smoke; however, most studies do not show an effect on symptoms or lung function.

■ 

### Use of humidifiers or evaporative (swamp) coolers

is not generally recommended in homes of patients who are sensitive to dust mites or mold. Consider subcutaneous allergen immunotherapy for patients who have pe r sistent asthma when there is clear evidence of a relationship between symptoms and exposure to an allergen to which the patient is sensitive. Evidence is strongest for use of subcutane o us imm unothe rapy for single allergens, particularly house dust mites, animal dander, and pollen. The role of allergy in asthma is greater in children than in adults. If use of allergen immunotherapy is elected, it should b e administered only in a physician’s office where facilities and trained personnel are available to treat any life-threatening reaction that can, but

r ar el y d o es, o ccur. Consider inactivated influenza vaccination for pat ients who have asthma. This v a ccine is safe for administration to c hi ldren over 6 months of age and ad ults, and the Ad visory Committee on Immunization Pract ic es o f the Centers for Disease Control andPrevention (CDC) recommends vaccination for perso ns who have asthma because they are considered to b e at r isk f o r complications from influenza. However, the vaccine should not be given with the expectation that it will reduce either the frequency or severity of asthma exacerbations during the influenza season. Dietary factors have an inconclusive role in asthma. F o od allergenies are rarely an aggravating factor in asthma. A n except io n is that sulfites in foods (e.g., shrimp , dried fruit, processed potatoes, beer, and wine) can precipitate asthma symptoms in people who

ar e sensit iv e to these food items. Furthermore, individuals who have both food allergy and asthma are at increased risk for fatal anaphlylactic reactions t o the f oo d t o w hic h the y ar e sensitized. Comorbid Conditions
I d entify and treat comorbid conditions that may impe de asthma management. I f these conditions are treated appropriately, asthma control may improve.

■ 

### Allergic Bronchopulmonar y

Aspergillosis (ABPA) may be considered in patients who have asthma and a history of pulmonar y infilt rates, i mmunoglobulin E (IgE) sensitization to Aspergillus, and/or are corticosteroid dependent. Diagnostic criteria include: positive immediate skin test and elevated serum IgE and/or IgG to Aspergillus, total serum IgE >417 IU (1,000 ng/mL), and central bronchiectasis. Treatment is prednisone, initially 0.5 mg per kilogram with gradual tapering. Azole antifungal agents as adjunctive therapy may also be helpful.

■ 

### Gastroesophageal Reflux (GERD) treatment may

benefit patients who hav e asthma and complain of frequent heartburn or pyrosis, particularly those who have frequent nighttime asthma symptoms. Even in the absence of suggestive GERD symptoms, consider evaluation for GERD in patients who ha ve poorly controlled asthma, especially withnighttime symptoms. Treatment includes: avoiding heavy meals, fried foods, caffeine, and alcohol; avoiding food and drink within 3 hours of retiring;

e lev ating the head of the bed on 6- to 8-inch blocks; using proton pump inhibitor medication.

■ 

### Obese or overweight patients who have asthma

ma y be advised that weight loss, in addition to imp ro ving overall health, might also improve asthma control.

■ 

### Obstructiv e S lee p Apnea (OSA) ma y b e c onsidered in patients who have not wel l controlled asthma, part icularly those who are overweight or obese. Tr eatme nt for OSA is nasal continuous positive air

wa y pressure (CPAP). However, this treatment may disr upt the sleep of asthma patients who do not also have OSA. Accurate diagnosis is important.

■ 

### Rhinitis or sinusitis symptoms or diagnosis should

b e evaluated in patients w ho have asthma, because the interrelationship of the upper and lower airwa y s uggests that therapy for the upper airway will improve asthma control. Treatment of allerg ic r hinit is includes intranasal corticosteroids, antihistamine therapy, and the consideration of immunotherapy. Treatment of sinusitis includes intr anasal cort icoste roids and antibiotics. Evidence is inconclusive regarding the effect on asthma of sinus surgery in patients who have chronic

r hinosinusitis.

■ 

### St ress and depression should b e c onsidered in

patie nts who ha ve asthma that is not well controlled. Additional education to improve self-manageme nt and coping skills may be helpful.26 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 9. HOW TO CONTROL THINGS THAT MAKE YOUR ASTHMA WORSE

You can help prevent asthma episodes by staying away from things that make your asthma worse. This guide suggests many ways to help you do this. You need to find out what makes your asthma worse. Some things that make asthma worse for some people are not a problem for others. You do not need to do all of the things listed in this guide. Look at the things listed below. Put a check next to the ones that you know make your asthma worse, particularly if you are allergic to these things. Then, decide with your doctor what steps you will take. Start with the things in your bedroom that bother your asthma. Try something simple first.

Tobacco Smoke
■ If you smoke, ask your doctor for ways to help you quit. Ask family members to quit smoking, too. ■ Do not allow smoking in your home, car or around you. ■ Be sure no one smokes at a child’s daycare center or school. Dust Mites Many people who have asthma are allergic to dust mites. Dust mites are like tiny “bugs” you cannot see that live in cloth or carpet. Things tha t will help the most: ■ Encase your mattress in a special dust-mite proof cover.* ■ Encase your pillow in a special dust-mite proof cover* or wash the pillow each week in hot water. Water must be hotter than 130 °F to kill the mites. Cooler water used with detergent and bleach can also be effective. ■ Wash the sheets and blankets on your bed each week in hot water. Other things that can help: ■ Reduce indoor humidity to or below 60 percent, ideall y 30–50 percent. Dehumidifiers or central air conditioners can do this. ■ Tr y not to sleep or lie on cloth-covered cushions or furniture. ■ Remove carpets from your bedroom and those laid on concrete, if you can. ■ Keep stuffed toys out of the bed, or wash the toys weekly in hot water or in cooler water with detergent and bleach. Placing toys weekly in a dr yer or freezer may help. Prolonged exposure to dry heat or freezing can kill mites but does not remove allergen.

*T

o find out where to get products mentioned in this guide, call: Asthma and Allergy Foundation of America (800–727–8462) Allerg y & Asthma Network Mothers of Asthmatics (800–878–4403) American Academy of Allergy, Asthma, and Immunology (800–822–2762) National Jewish Medical and Research Center (Lung Line) (800–222–5864) American College of Allergy, Asthma, and Immunology (800–842–7777)27 Managing Asthma Long Term Animal Dander Some people are allergic to the flakes of skin or dried saliva from animals. The best thing to do: ■ Keep pets with fur or hair out of your home. If you can’t keep the pet outdoors, then: ■ Keep the pet out of your bedroom, and keep the bedroom door closed. ■ Remove carpets and furniture covered with cloth from your home. If that is not possible, keep the pet out of the rooms where these are.

Cockroach Many people with asthma are allergic to the dried droppings and remains of cockroaches.
■ Keep all food out of your bedroom. ■ Keep food and garbage in closed containers (Never leave food out). ■ Use poison baits, powders, gels, or paste (f or example, boric acid). You can also use traps. ■ If a spray is used to kill roaches, stay out of the room until the odor goes away.

Vacuum Cleaning
■ T ry to get someone else to vacuum for you once or twice a week, if you can. Stay out of rooms while they are being vacuumed and for a short while afterward. ■ If you vacuum, use a dust mask (from a hardware store), a central cleaner with the collecting bag outside the home, or a vacuum cleaner with a HEPA filter or a double-layered bag.*

Indoor Mold
■ Fix leaking faucets, pipes, or other sources of water. ■ Clean moldy surfaces. ■ Dehumidify basements if possible. Pollen and Outdoor Mold During your allergy season (when pollen or mold spore counts are high): ■ Try to keep your windows closed. ■ If possible, stay indoors with windows closed during the midday and afternoon, if you can. Pollen and some mold spore counts are highest at that time. ■ Ask your doctor whether you need to take or increase anti-inflammatory medicine before your allergy season starts. Smoke, Strong Odors, and Sprays
■ If possible, do not use a wood-burning stove, kerosene heater, fireplace, unvented gas stove, or heater. ■ Try to stay away from strong odors and sprays, such as perfume, talcum powder, hair spray, paints, new carpet, or particle board.

Exercise or Sports
■ Y ou should be able to be active without symptoms. See your doctor if you have asthma symptoms when you are active—such as when you exercise, do sports, play, or work hard. ■ Ask your doctor about taking medicine before you exercise to prevent symptoms. ■ Warm up for a period before you exercise. ■ Check the air quality index and try not to work or play hard outside when the air pollution or pollen levels (if you are allergic to the pollen) are high.

Other Things That Can Make Asthma Worse
■ Sulfites in foods: Do not drink beer or wine or eat shrimp, dried fruit, or processed potatoes if they cause asthma symptoms. ■ Cold air: Cover your nose and mouth with a scarf on cold or windy days. ■ Other medicines: Tell your doctor about all the medicines you may take. Include cold medicines, aspirin, and even eye drops.

Key: HEPA, high-efficiency particulate air

### C omponent 4: Medications Medications for asthma are categorized into two general classes: lo ng-term control medication and quick-relief medication. Selection of medications includes consideration of the general mechanisms and role of the medication in therapy, delivery devices, and safety. General Mechanisms and Role in Therapy
Lo ng-term co nt rol medications are used daily to achieve and maintain control of persistent asthma. The most effective are those that attenuate the underlying inflammation characteristic of asthma. Long-term control medications include the following (listed in alphabetical order):

■ 

### Corticosteroids are anti-inflammatory medications

that reduce airway h yperresponsiveness, inhibit inflammator y cell migration and activation, and block late phase reaction to allergen. Inhaled Corticosteriods (ICSs) are the most consistently

e ff ective long-term control medication at all steps of car e for persistent asthma, and ICSs improve asthma control more effectively in both children and adults than leukotriene receptor antagonists (LTRAs) or any other single, long-term control medicat ion do. ICSs reduce impairment and risk of e xa cerbations, but ICSs do not appear to alter the progr essio n or underlying severity of the disease in children. Short courses of oral systemiccorticosteroids are often used to gain prompt control of asthma. Oral systemic corticosteroids are used long term to treat patients who require step 6

car e (for severe persistent asthma).

■ 

### Cromolyn sodium and nedocromil stabilize mast

cells and interf ere with chloride channel function. They are used as alternative, but not preferred,

me dication for patients requiring step 2 care (for mild p e rsistent asthma). They also can be used as preventive treatment before exercise or unavoidable

e xposur e to known allergens.

■ 

### I mmunomo d ulators. Omalizumab (ant i-I gE) is a

monoclonal antibo dy that prevents binding of IgE to the high-affinity receptors on basophils and mast cells. Omalizumab is used as adjunctive therapy for patients 12 years of age who have sensitivity to relevant allergens (e.g., dust mite, cockroach, cat, or d og) and who require step 5 or 6 care (for severe pe rsistent asthma). Clinicians who administer omalizumab should be prepared and equipped to id e nt ify and treat anaphylaxis that may occur. ■ 

### Leukotriene modifiers interfere with the pathway of leukotrie ne mediators, which are released frommast cells, eosinophils, and basophils. These medications include LTRAs (montelukast and zafirlukast) and a 5-lipoxygenase inhibitor (zileuton). LTRAs are alternative, but not preferred, therapy for the treatment of patients who require step 2 care (for mild persistent asthma). LTRAs also can be used as adjunctive therapy with ICSs, but for youths 12 years of age and adults, they are not preferred adjunctive therapy compared to the addition of LABAs. LTRAs can attenuate EIB. Zileuton can be used as alternative, but not preferred, adjunctive therapy in adults; liver function monitoring is essential.

■ 

### LABAs (salmeterol and formoterol) are

inhaled bronchodilat ors that have a duration of bronchodilation of at least 12 hours after a single dose. — LABAs are not to be used as monotherapy for long-t er m control of asthma. — LABAs are used in combination with ICSs for long-term control and prevention of symptoms in moderate or severe persistent asthma (Step 3 care or higher in children ≥ 5 years of age and ad ults and St e p 4 care or higher in children 0–4 years of age, although few data are available for 0–4-year-olds.). — Of the adjunctive therapies available, LABA is the preferred therapy to combine with ICS in youths ≥ 12 years of age and adults. — A LABA may be used before exercise to prevent EIB, but duration of action does not exceed 5 hours with chronic, regular use. Frequent

o r chronic use before exercise is discouraged, because this may disguise poorly controlled per sistent asthma. See also the section “SafetyIssues for Inhaled Corticosteroids and LongActing Beta 2 

### -Agonists.”

■ 

### Methylxanthines. Sustained-release theophylline

is a mild to moderat e bronchodilator used as alternative, not preferred, therapy for step 2 care (for mild persistent asthma) or as adjunctive therapy

w ith ICS in patients ≥ 5 years of age. Theophylline

ma y have mild anti-inflammatory effects. Monitoring of serum theophylline concentration is essential.

28 Guidelines for the Diagnosis and Management of Asthma29 Managing Asthma Long Term 

### Quick-relief medications are used to treat acute symptoms and exacerbations. They include the following (listed in alphabetical order):

■ 

### Anticholinergics inhibit muscarinic cholinergic

recepto rs and reduce intrinsic vagal tone of the airway. Ipratropium bromide provides additive benefit to SABA in moderate or severe exacerbations in the emergency care setting, not the hospital setting. Ipratropium bromide may be used as an alternative bronchodilator for patients who do not tolerate SABA, although it has not been compared to SABAs.

■ 

### SABAs —albuterol, levalbuterol, and pirbuterol—are

bronchodilato rs that relax smooth muscle. They are the treatment of choice for relief of acute symptoms and prevention of EIB. Increasing use of SABA t reatment or the use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate asthma control and the need for initiating or intensifying anti-inflammatory therapy. Regularly scheduled, daily, chronic use of SAB A is not r eco mmended.

■ 

### Systemic corticosteroids. Although not shortacting, or al systemic corticosteroids are used for moderate and severe exacerbations in addition to SABA to speed recovery and to prevent recurrence of

e xa cer bations. Complementary and alternative medications (CAMs) and inte rventio ns g enerally have insufficient evidence to permit recommendations. Because as much as one-third of the U .S. population uses complementary alternative healing methods, it is important to discuss their use with patients.

■ 

### Ask patients about all the medications and

interventions they are using. Some cultural b eliefs and pra c tices may be of no harm and can be integrated into the recommended asthma manag e me nt strategies, but it is important to advise patients that alternative healing methods are not substitutes for recommended therapeutic approaches. Clinical trials on safety and efficacy are limited, and their scientific basis has not been established.

■ 

### Evidence is insufficient to recommend or not

recommend most CAMs or treatments for asthma. T hese include chiropractic therapy, homeopathy and he r bal medicine, and breathing

o r r e laxatio n techniques. Acupuncture is not recommended for the treatment of asthma. ■ 

### Patients who use herbal treatments for asthma should be cautioned about the potential for harmful ingredients and f o r interactions with recommended asthma medications. Delivery Devices for Inhaled Medications Patients should be instr uct ed in the use of inhaled medications, and patients’ technique should be reviewed at every patient visit. The major advantages of d elivering drugs directly into the lungs via inhalation are that higher concentrations can be delivered more effectively to the airways and that systemic side effects are lessened. Inhaled medications, or aerosols, are available in a variety of devices that differ in the technique required. See figure 10, “Aerosol Delivery Devices,” for a summary of issues to consider f or different devices.Safety Issues for Inhaled Corticosteroids and LongA cting Beta 2 

### -Agonists Inhaled Corticosteroids

■ 

### ICSs are the p referr ed long-term control therapy in

children of all ages and adults. In general, ICSs are

w ell tolerated and safe at the recommended dosages.

■ 

### Most benefits of ICS for patients who have mild or

mo der at e asthma o c cur at the low- to medium-dose ranges. Data suggest higher doses may further

r educe the risk of exacerbations. Furthermore, highe r doses are beneficial for patients who have more severe asthma. The risk of adverse effects increases with the dose.

■ 

### High doses of ICS administered for prolonged

periods of time (e.g., >1 year) have significantly less potential than oral systemic corticosteroids for ha ving adverse effects. High doses of ICS used for pr olonged periods of time (e.g., >1 year), particularly in combination with frequent courses of oral cort icosteroids, may be associated with risk of posterior subcapsular cataracts or reduced bone density. Slit-lamp eye exam and bone densitometry may be considered. For adult patients, consider supplements of calcium and vitamin D, particularlyin perimenopausal women. For children, ageappropriate dietary intake of calcium and vitamin D should be reviewed with parents or caregivers.

■ 

### To reduce the potential for adverse effects, the

following measures are recommended. — Adv ise pat ie nts to use spacers or VHCs with nonbreath-activated metered-dose inhalers

### (MDIs) to reduce local side effects. There are no clinical data on use of spacers with ultrafine particle hydrofluoroalkane (HFA) MDIs. — Advise patients to rinse the mouth (rinse and spit) after inhalation. — Use the lowest dose of ICS that maintains asthma control. Evaluate the patient’s inhalertechnique and adherence, as well as environmental control measures, before increasing the dose. — Consider adding a LABA, or alternative adjunctive therapy, to a low or medium dose of ICS rather than using a higher dose of ICS to maintain asthma control. Inhaled Corticosteroids and Linear Growth in Children

■ 

### The potential risks of ICSs are well balanced by

the ir benefits.

■ 

### Poorl y controlled asthma may delay growth. Children who have asthma tend to have longer periods of reduced growth rates before puberty.

■ 

### Gro wth rates are highly variable in children.

Short-ter m evaluation may not be predictive of final adult height attained.

■ 

### The potential for adverse effects on linear growth

from ICS appear to be dose dependent. In tr eatme nt of children who have mild or moderate persistent asthma, low-to medium-dose ICS therapy may be associated with a possible, but not predictable, adverse effect on linear growth (app roximately 1 cm). The effect on growth velocity appears to occur in the first several

mo nths of treatment and is generally small and not progressive. The clinical significance of this p ote ntial systemic effect has yet to be determined.

■ 

### I n ge ner al, the efficacy of ICSs is sufficient to out

weigh any concerns about growth or other systemic effects. However, ICSs should be titrated to as low a dose as needed to maintain good control of the child’s asthma, and children receiving ICSs should be monitored for changes in growth by using a stadiometer. Long-Ac t ing Beta2-Agonists

■ 

### T he a dditio n of LABA (salmeterol or formoterol)

to the treatment of patients who require more than low-d ose ICS alone to co nt rol asthma improves lung function, decreases symptoms, reduces exacerbations and use of SABA for quick relief in most patients to a greater extent than doubling the dose of ICSs.

■ 

### A large clinical trial comparing daily treatment

with salmeterol or placebo added to usual asthmatherapy resulted in an increased risk of asthmarelated deaths in patients treated with salmeterol (13 deaths among 13,176 patients treated for 28 weeks with salmeterol versus 3 deaths among 13,179 patients treated with placebo). In addition, increased numbers of severe asthma exacerbations were noted in the pivotal trials submitted to the U.S. Food and Drug Administration (FDA) for formoterol approval, particularly in the arms of the trials with higher dose formoterol. Thus, the FDA determined that a Black Box warning was warranted on all preparations containing a LABA.

■ 

### The established beneficial effects of LABA for

the great majority of patients who require more therap y than lo w-d ose ICS alone to control asthma (i.e., requir e step 3 care or higher) should be weighed against the increased risk for severe exacerbations, although uncommon, associated with the daily use o f LABAs.

■ 

### Dail y use of L AB A generally should not exceed 100 mcg salmeterol or 24 mcg formoterol.

■ 

### I t is not currently recommended that LABA be

used for treatment of acute symptoms or exacerbations.

■ 

### LABA s are not to be used as monotherapy for longterm control. Patients should be instructed not to stop ICS therapy while taking LABA, even though their symptoms may significantly improve.

Stepwise Appr oach for Managing Asthma
Pr inciples of The Ste pwise Appro ac hA stepwise approach to managing asthma is recommended to gain and maintain c o ntrol of asthma in both the impairment and risk domains. These domains may respond differentially to treatment.
For c hildren, see:

Figur e 11, “C lassify ing Asthma Severity and Initiating Therapy in Children”

30 Guidelines for the Diagnosis and Management of Asthma31 Managing Asthma Long Term 

### FIGURE 10. AEROSOL DELIVERY DEVICES Device/Drugs Population Optimal Technique* Metered-dose inhaler (MDI)

Beta 2 -agonists
Corticosteroids C romolyn sodium Anticholinergics

Breath-actuated MDI

Beta 2 -agonist ≥ 5 years old (<5 with spacer or v alved holding chamber (VHC) or m ask)

≥ 5 years old Actuation during a slow (30 L/min or 3–5 seconds) deep inhalation, followed by 10-second breathhold.Under laboratory conditions, openm outh technique (holding MDI 2 inches away from open mouth) enhances delivery to the lung. This technique, however, has not been shown to enhance clinical benefitconsistently compared to closedmouth technique (inserting MDI mouthpiece between lips and teeth).
Tight seal around mouthpiece and slightly more rapid inhalation than standard MDI (see above) followed by 10-second breathhold. Slow inhalation and coordination of actuation during inhalation m ay be difficult, particularly in young children and elderly. Patients may incorrectly stop inhalation at actuation. Deposition o f 50–80 percent of actuated dose in oropharynx. Mouth washing and spitting is effective in reducing the amount of drug swallowed and absorbed systemically. Lung delivery under ideal conditions varies significantly between MDIs due to differences in formulation (suspension versus solution), propellant (chlorofluorocarbon [CFC] versus hydrofluoralkane [HFA]), and valve design. For example, inhaled corticosteroid (ICS) delivery varies from 5–50 percent.

May be particularly useful for patients unable to coordinate inhalation and actuation. May also be useful for elderly patients. Patients may incorrectly stop inhalation at actuation. Cannot be used with currently available spacer/valved holding chamber (VHC) devices. Therapeutic Issues

Dry powder inhaler (DPI)

Beta 2 -agonists
Corticosteroids Anticholinergics ≥ 4 years old Rapid (60 L/min or 1–2 seconds), deep inhalation. Minimally effective inspirator y flow is device dependent. Most children <4 years of age may not generate sufficient inspiratory flow to activate the inhaler. Dose is lost if patient exhales through device after actuating. Delivery may be greater or lesser than MDI, depending on device and technique. Delivery is more flow dependent in devices with highest internal resistance. Rapid inhalation promotes greater deposition in larger central airways. Mouth washing and spitting is effective in reducing amount of drug swallowed and a bsorbed.

Spacer or valved holding chamber (VHC) ≥ 4 years old

<4 years old VHC with face mask Slow (30 L/min or 3–5 seconds) deep inhalation, followed by 10-second breathhold immediately following actuation. Actuate only once into spacer/VHC per inhalation. If face mask is used, it should have a tight fit and allow 3–5 inhala tions per actuation. Rinse plastic VHCs once a month with low concentration of liquid household dishwashing detergent (1:5,000 or 1–2 drops per cup of water) and let drip dry. Indica ted for patients who have difficulty performing adequa te MDI technique. May be bulky. Simple tubes do not obviate coordinating actuation and inhala tion. The VHCs are preferred. Face mask allows MDIs to be used with small children. However, use of a face mask reduces delivery to lungs by 50 percent. The VHC improves lung delivery and response in patients who have poor MDI technique. The effect of a spacer or VHC on output from an MDI depends on both the MDI and device type; thus data from one combination should not be extrapolated to all others. Spacers and/or VHCs decrease oropharyngeal deposition and thus decrease risk of topical side effects (e.g., thrush). Spacers will also reduce the potential systemic a vaila bility of ICSs with higher oral absorption. However, spacer/VHCs may increase systemic availability of ICSs that are poorly absorbed orally by enhancing delivery to lungs. No clinical data are available on use of spacers or VHCs with ultrafine-particle-generated HFA MDIs. Use anti-sta tic VHCs or rinse plastic non-anti-static VHCs with dilute household detergents to enhance delivery to lungs and efficacy. This effect is less pronounced for albuterol MDIs with HF

A propellant than for albuterol MDIs with CFC propellant. As effective as nebulizer for delivering SABAs and anticholinergics in mild- to moderate-exacerbations; data in severe exacerbations are limited.

### Figure 12, “Assessing Asthma Control and Adjusting Therapy in Children” Figure 13, “Stepwise Approach for Managing Asthma Long Term in Children, 0–4 Years of Age and 5–11 Y ear s o f Age”
Fo r ad ults, see:

Figur e 14, “Classifying Asthma Severity and I nitiat ing Treatment in Youths 12 Years of Age and Adults” Figur e 15, “Assessing Asthma Control and Adjusting Therapy in Youths ≥ 12 Years of Age and A dults” Figure 16, “Stepwise Approach for Managing Asthma in Youths ≥ 12 Years of Age and Adults”
For me dicat ion dosages, see:

Figure 17, “Usual Dosages for Long-Term Control Medications” Figure 18, “Estimated Comparative Daily Dosages for Inhaled Corticosteroids” Figur e 19, “Usual Dosages for Quick-Relief Me dications”

■ 

### The stepwise approach incorporates all four

components of care: assessment of severity to initiat e ther ap y or assessment of control to monitor and adjust therapy; patient education; environmental control measures, and management of comorbid conditions at every step; and selection of medication. ■ 

### The type, amount, and scheduling of medication is determined by the level of asthma severity or asthma control. — Therapy is increased (stepped up) as necessary and de crease d (stepped down) when possible. — Because asthma is a c hro nic inflammato ry disorder, persistent asthma is most effectively controlled with daily long-term control medicatio n directed toward suppressing inflammation. ICSs are the most consistently

e ffective anti-inflammatory therapy for all age g roups, at all steps of care for persistent asthma. — Selection among alternative treatment options is based on consideration of treatment effectiveness for the domain of particular

re le vance to the patient (impairment, risk, or both), the individual patient’s history of previous response to therapies (sensitivity and responsiveness to different asthma medications can vary among patients), and the willingness and ability of the patient and family to use the medication.

■ 

### Once asthma control is achieved, monitoring and

followup are essential, because asthma often varies over time. A step up in therapy may be needed, or a step down may be possible, to identify the minimum medication necessary to maintain

co ntrol.

32 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 10. AEROSOL DELIVERY DEVICES (continued) Device/Drugs Population Optimal Technique* Therapeutic Issues
Nebulizer

Beta 2 -agonists
Corticosteroids C romolyn sodium Anticholinergics Patients of any age who cannot use MDI with VHC and face m ask. Slow tidal breathing with occasional deep breaths. Tightly fitting face mask for those unable to use m outhpiece. Using the “blow by” technique (i.e., holding the mask or open tube near the infant’s nose and mouth) is not appropriate. Less dependent on patient’s coordination and cooperation.
D elivery method of choice for cromolyn sodium in young children. May be expensive; time consuming; bulky; output is dependent on device and operating parameters (fill volume, driving gas flow); internebulizer and intranebulizer output variances are significant. Use of a face mask reduces delivery to lungs by 50 percent. N ebulizers are as effective as MDIs plus VHCs for delivering bronchodilators in the ED for mild to moderate exacerbations; data in severe exacerbations are limited. Choice of delivery system isdependent on resources, availability, and clinical judgment of the clinician caring for the patient. Potential for bacterial infections if not cleaned properly.

Key: ED, emergency department; SABAs, inhaled short-acting beta 2 -agonists *See figures in component 2—Education for a Partnership in Asthma Care for description of MDI and DPI techniques.33 Managing Asthma Long Term 

### T he stepwise approach and recommended treatments are meant to assist, not replace, the clinical decisionmaking necessary to determine the most appropriate treatment to meet the individual patient’s needs and circumstances. Referral to an asthma specialist for consultation orcomanagement is recommended if there are difficulties achieving or maintaining control of asthma, if the patient required >2 bursts of oral systemic corticosteriods in 1 year or has an exacerbation requiring hospitalization, if step 4 care or higher is required (step 3 care or higher for children 0–4 years of age), if immunotherapy or omalizumab is considered, or if additional testing is indicated.

To achieve control of asthma, the following sequence of activities is recommended:

■ 

### Fo r patients who are not already taking long-term

control medications, assess asthma severity and initiate therapy according to the level of severity.

■ 

### For patients who are already taking long-term

control medications, assess asthma control and ste p up therapy if the patient’s asthma is not well controlled on current therapy. Before stepping up, review the patient’s adherence to medications, inhaler technique, and environmental control

measures.

■ 

### Evaluate asthma control in 2–6 weeks (depending

on level of initial severity or control). — In general, classify the level of asthma control by the most severe indicator of impairment or risk. — The risk domain is usually more strongly associated with morbidity in young children than the impairment domain because young children are often symptom free between

e xacerbations. — If office spirometry suggests worse control than other measures of impairment, consider fixed obstruction and reassess the other measures. If fixed obstruction does not explain the lack of control, step up therapy, because low FEV 1 

### is a predictor of exacerbations. — If the history of exacerbations suggests poorer control than does assessment of impairment, reassess impairment measures, and consider a s tep up in therapy. Review plans for handling exacerbations and include the use of oral systemic corticosteroids, especially for patients who have a history of severe exacerbations.

■ 

### If asthma control is not achieved with the above

actions: — Review the patient’s adherence to medications, inhaler technique, environmental control measures (or whether there are new exposures), and management of comorbid conditions. — If adherence and environment control measures are adequate, then step up one step (if not well controlled ) or two steps (if very poorly controlled). — If an alternative treatment was used initially, discontinue its use and use the preferred treatment option before stepping up therapy.— A short course of oral systemic corticostero ids may be co nsid ered to gain more rapid control for patients whose asthma fre quently interrupts sleep or normal daily activities or who are experiencing an exacerbation at the time of assessment. — If lack of control persists, consider alternative diag noses before stepping up further. — If the patient experiences side effects, consider different treatment options.To maintain control of asthma, regular followup contact is esse ntial because asthma oft e n varies over time.

■ 

### Schedule patient contact at 1- to 6-month intervals;

the interval will depend on such factors as the level or duration of asthma control and the level of treatment required.

■ 

### Consider a step down in therapy once asthma is

well controlled for at least 3 months. A step down is necessary to identify the minimum therapy required to maintain good control. A reduction in ther ap y should be gradual and must be closely monitored. Studies are limited in guiding therapy red uction. I n general, the dose of ICS may be reduced 25 percent to 50 percent every 3 months to the lowest possible dose.

■ 

### C onsider seasonal periods of daily long-term

control therapy for patients who have asthma

### symptoms only in relation to certain seasons (e.g., seasonal pollens, allergens, or viral respiratory infections) and who have intermittent asthma the rest of the year. This approach has not been rigorously evaluated; close monitoring for 2–6 weeks after therapy is discontinued is essential to assure sustained asthma control.

Stepwise Treatment Recommendations for Diff erent Ag es R ecommendations for treatments in the different steps are prese nt ed in three different age groups (0–4 years, 5–11 years, and 12 years and older) because the course of the disease may change over time, the relevance of measures of impairment or risk and the potential short- and long-term impact of medications may be age related, and varied levels of scientific evidence are available for the different ages. Steps for Children 0–4 Years of Age
Se e figure 13, for rec ommended t r eatments in the different steps and figures 17–19 for recommended

me dication dosages. In addition to the generalprinciples of the stepwise approach, special considerations for this age group include initiating therapy, selecting among treatment options, and monitoring response to therapy. The init iatio n o f daily long-term c ontrol therapy in children ages 0–4 years is recommended as follows:

■ 

### It is recommended for reducing impairment and

risk of exacerbations in infants and young children who had four or more episodes of wheezing in the past year that lasted more than 1 day and affected sle ep AND who have a positive asthma predictive inde x (either (1) one of the following: a parental history of asthma, a physician’s diagnosis of ato pic dermatitis, or evidence of sensitization to aeroallergens; OR (2) two of the following: evidence of sensitization to foods, >4 percent peripheral blood eosinophilia, or wheezing apart from colds).

■ 

### It should be considered for reducing impairment

in infants and young children who consistently require symptomatic treatment >2 days per week for a period of more than 4 weeks.

■ 

### It should be considered for reducing risk in infants

and young c hildre n who have two exacerbations requiring systemic corticosteroids within 6 months. ■ 

### It may be considered for use only during periods, or seasons, of previously documented risk (e.g., during seasons of viral respiratory infections). The decision about when to start long-term daily therapy is difficult. The chronic airway inflammatory response in asthma can develop in the preschool years; for example, between 50–80 percent of children who have asthma developed symptoms before their fifth birthday. Adequate treatment will reduce theburden of illness, and underdiagnosis and undertreatment are key problems in this age group. Not all wheeze and cough are caused by asthma, however, and caution is needed to avoid giving inappropriate, prolonged therapy. Initiating long-term control therapy will depend on consideration of issues regarding diagnosis and prognosis.

— Viral respiratory infections are the most common cause of asthma symptoms in this age gr oup, and many children who wheeze with respiratory infections respond well to asthma therapy even though the diagnosis of asthma is not clearly established. For children who haveexacerbations with viral infections, exacerbations are often severe (requiring emergency

car e or hospitalizat ion), y et the child has no significant symptoms in between these exacerbations. These children have a low level of impairment but a high level of risk. — Most young children who wheeze with viral respiratory infection experience a remission of symptoms by 6 years of age, perhaps due to growing airway size. — However, two-thirds of children who have fr equent wheezing AND also have a positive asthma predictive index (see above) are likely to have asthma throughout childhood. Early identification of these children allows appropriate treatment with environmental control

measur es and me dicatio n to reduce morbidity. Select medications with the following considerations f or young childre n:

■ 

### A sthma treatment for young children, especially

infants, has not been studied adequately. Most recommendations are based on limited data and extrapolations from studies in older children and adults. Preferred treatment options are based on

34 Guidelines for the Diagnosis and Management of Asthma

### individual drug efficacy studies in this age group; comparator trials are not available.

■ 

### The following long-term control medications are

FDA approved for the following ages in young children: ICS budesonide nebulizer solution (1–8 years of age); ICS fluticasone dry power inhaler (DPI) (>4 years of age); LABA salmeterol DPI, alone or in combination with ICS (>4 years of age); LTRA montelukast (chewable tablets, 2–6 years of age; granules, down to 1 year old).

■ 

### Several delivery devices are available, and the doses

received may vary considerably among devices and age groups. In general, children <4 years of age will have less difficulty with a face mask and either (1) a nebulizer or (2) an MDI with a VHC. (See figur e 10 above.)

■ 

### ICSs are the preferred long-term control medication

for initiating therapy. The benefits of ICSs out weigh any concerns about potential risks of a small, nonpro gressive reduction in growth velocity or other possible adverse effects. ICSs, as with all medications, should be titrated to as low a dose as needed to maintain control.

■ 

### Fo r c hildr en whose asthma is not well controlled

on lo w-d ose ICS, few studies are available on stepup therapy in this age group, and the studies have mixed findings. Some data on children ≤ 4 years old and younger show dose-dependent improvements in the domains of impairment and risk of exacerbation from taking ICS. Data from studies on LABA combined with ICS have only small numbers of 4-year-old children, and these data show improvement in the impairment but not risk domain. Adding a noncorticosteroid long-term control medication to medium-dose ICS may be considered before increasing the dose of ICS to high dose to avoid potential risk of side effects with high doses of medication. Monitor response to therapy closely, because tre atme nt of y oung children is oft e n in the form of a therapeutic trial.

■ 

### If a clear and beneficial response is not obvious

within 4–6 weeks and the patient’s/family’s medicat ion technique and adherence are satisfactory, tr eatment should be stopped. Alternative therapies or alternative diagnoses should be considered. ■ 

### If a clear and beneficial response is sustained forat least 3 months, consider a step down to evaluate the need for continued daily long-term control therapy. Children in this age group have high rates

o f spontaneous r e mission of symptoms. Steps for Children 5–11 Years of Age See figure 13, “Stepwise Approach for Managing Asthma Long Term in C hildren, 0–4 Years of Age and 5–11 Years of Age,” for recommended treatments indifferent steps and figures 17, 18, and 19 for recommended medication dosages. Special considerations for this age group include the following: Promote active participation in physical activities,
ex

ercise, and spo r ts because physical activity is an essential part of a child’s life. Treatment immediately befor e v igorous activity usually prevents EIB (see section on “Exercise-Induced Bronchospasm”). However, if the child has poor endurance or has sy mptoms during usual play activities, a step up in the r ap y is war ranted. Directly involve children ≥ 10 y ears of ag e (and y

ounger children as appropriate) in developing the ir written asthma action plans and reviewing the ir adhere nce. T his inv ol v ement may help address deve lo p me ntal iss ues of emerging independence bybuilding the children’s confidence, increasing personal responsibility, and gaining problem-solving skills. Encourag e parents to take a co p y of the written asthma action plan to the student’s school, or childcare or extended care setting, or camp. Consider the following when selecting treatment options:

■ 

### ICSs are the preferred long-term control therapy.

The benefits of ICSs outweigh any concerns about potential risks of a small, nonprogressive reduction in growth velocity or other possible adverse effects. ICSs, as with all medications, should be titrated to as low a dose as needed to maintain control.High-quality evidence demonstrates the effectiveness of ICS in children 5–11 years of age, and comparator studies demonstrate improved control with ICS on a range of asthma outcomes compared to other long-term control medications.

■ 

### Step up treatment options for children whose asthma is not well controlled on low-dose ICS have not been adequately studied or compared in this age group. The selection will depend on the domain

35 Managing Asthma Long Term36 Guidelines for the Diagnosis and Management of Asthma 

### SAMPLE RECORD FOR MONITORING THE RISK DOMAIN IN CHILDREN: RISK OF ASTHMA PROGRESSION (INCREASED EXACERBATIONS OR NEED FOR DAILY MEDICATION, OR LOSS OF LUNG FUNCTION), AND POTENTIAL ADVERSE EFFECTS OF CORTICOSTEROID THERAPY

Patient name:

Date

I CS dail y dose*
LTRA
LABA Theophylline
Other

FEV 1 , forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroid; LABA, long-acting beta 2 agonist; LTRA, leukotriene receptor antagonist *Consider ophthalmologic exam and bone density measurement in children using high doses of ICS or multiple courses of oral corticosteroids. Long-term control medication

Significant exacerbations

Long-term control medication

Potential risk of adverse corticosteroid effects (as indicated by corticosteroid dose and duration of treatment) Exacerba tions (number/month) Oral systemic corticosteroids (number/year)* Hospitaliza tion (number/year)

Prebronchodilator FEV 1 /FVC
Prebronchodilator FEV 1 percent predicted
Postbronchodilator FEV 1 percent predicted Percent bronchodilator reversibility

Height, cm
Percentile Plots of growth velocity

### of particular relevance (impairment, risk, or both) and clinician–patient preference. — For the impairment domain: • Children who have low lung function and >2

days per week impairment may be better served by adding a LABA to a low dose of ICS (based on studies in older children and adults). • Increasing the dose of ICS to medium dose can

improve symptoms and lung function in those children who have greater levels of impairment (based on studies in children). • One study in children suggests some benefit in

the impairment domain with adding LTRA. — For the risk domain: • Studies have not demonstrated that adding

LABA or LTRA reduces exacerbations in children. Adding L AB A has the potential risk of rare life-threate ning or fatal exacerbations. • Studies in older children and adults show that

increasing the dose of ICS can reduce the risk of

e xac erbations, but this may require up to a fourfold increase in the d ose. T his dose may increase the potential risk of systemic effects, although the risk is small within the medium-dose range.

■ 

### The need for step 4 care usually involves children

who have a lo w le vel of lung function contributing to their impairment. The combination of ICS and LABA is preferred, on the basis of studies in older children and adults.

■ 

### Before maintenance dose of oral corticosteroids is

initiated in step 6, consider a 2-week course of oral

co rticosteroids to confirm clinical reversibility, measured by spirometry, and the possibility of an effective response to therapy. If the response is poor,

a car e ful r ev iew for other pulmonary conditions or comorbid conditions should be conducted to ensure that the primary diagnosis is severe asthma.
Mo nit or asthma progression. De clines in lung function o r r epeat ed periods of worsening asthma impairment may indicate a progressive worsening of the underlying severity of asthma. Although there is no indicat io n that treatment alters the progression of the underlying disease in children, adjustments in tr eatme nt may be necessary to maintain asthma control. Steps for Youths 12 Years of Age and Adults See figure 16, “Stepwise Approach for Managing A sthma in Youths 12 Year s o f Age and Adults,” for recommended treatment options in different steps and figures 18 and 19, for recommended medication dosages for youths 12 years of age and adults. Special considerations for this age group include the following: For youths:

■ 

### Involve adolescents in the development of their

written asthma action plans and reviewing their adherence.

■ 

### Encourage students to take a copy of their plan

to school, after school programs, and camps.

■ 

### Encourage adolescents to be physically active.
Fo r older adults:

■ 

### Consider a short course of oral systemic

corticosteroids to establish reversibility and the extent of possible benefit from asthma treatment. C hro nic bronchitis and emphysema may coexist with asthma.

■ 

### Adj ust me dicatio ns as nec essar y to address

coexisting medical conditions. For example, consider calcium and vitamin D supplements for patie nts who take ICS and have risk factors for osteoporosis. Consider increased sensitivity to side effects of bronchodilators, especially tremor and tachycardia with increasing age, and increased possibilities for drug interactions with theophylline. Consider also that NSAIDs prescribed for arthritis and the beta-blockers prescribed for hypertension or glaucoma may exacerbate asthma.

■ 

### Revie w the patient’s technique and adherence

in using medications, and make necessary adjustments. Physical or cognitive impairments may make proper technique difficult. Consider the following when selecting treatment options:

■ 

### Recommended treatment for step 3 weighs the

high-q uality evidence demonstrating the benefits of adding L AB A to low-dose ICS against the potential risk of rare life-threatening or fatal exacerbations with the use of L AB A. The selection will dependon the domain of particular relevance (impairment, risk, or both) and clinician–patient preference.

37 Managing Asthma Long Term

### — Adding LABA more consistently results in improvements in the impairment domain compared to increasing the dose of ICS. — If the risk domain is of particular concern, then a balance of potential risks needs to be considered.• Adding LABA to low-dose ICS reduces the frequency of exacerbations to a greater extent than doubling the dose of ICS, but adding LABA has the potential risk of rare life-threatening or fatal exacerbations. • Increasing the dose of ICS can significantly reduce

the risk of exacerbations, but this benefit may require up to a fourfold increase in the ICS dose. This dose may increase the potential risk of systemic effects, although the risk is small within the medium-dose range.

■ 

### Comparator studies demonstrate significantly

greater improvements with adding LABA to ICS compared to other adjunctive therapies.

■ 

### C linicians who a dministe r omalizumab are a dvised

to be prepared and equipped for the identification and treatment of anaphylaxis that may occur, to

o bser ve patients for an appropriate period of time following each omalizumab injection (the optimal length of the observation is not established), and to educate patients about the risks of anaphylaxis and ho w to recognize and treat it if it occurs (e.g., using pr escr iption auto injectors for emergency self treatment, and seeking immediate medical care).

Managing Special Situations
P at ients who have asthma may encounter situations that will r e quire adjustments to their asthma manageme nt t o k eep their asthma under control, such as EIB, pregnancy, and surgery.

Exercise-Induced Bronchospasm EIB should be anticipated in all asthma pat ie nts. A history of cough, shortness of breath, chest pain or t ig htness, wheezing, or endurance problems during exercises suggests EIB. An exercise challenge, in w hic h a 15 percent decr ease in P EF or FEV 1 

### (measure d before and after exercise at 5-minute intervals for 20–30 minutes) will establish the diagnosis. An important dimension of adequate asthma control is a patient’s ability to participate in any activity he or she chooses without experiencing asthma symptoms. EIB should not limit either participation or success in vigorous activities. Recommended treatments for EIB include:

■ 

### Long-term control therapy, if appropriate.

Frequent or severe EIB may indicate the need to initiate or step up lo ng-t erm control medications.

■ 

### Pretreatment before exercise:

— Inhaled beta 2 

### -agonists will prevent EIB for more than 80 percent of patients. SABA used shortly before exercise may be helpful for 2–3 hours. LABA can be protective up to 12 hours, but there is some shortening of the duration of protection when LABA is used on a daily basis.Frequent or chronic use of LABA as pretreatment for EIB is discouraged, as it may disguise poorly controlled persistent asthma.
— L TRAs, w ith an onset of action generally hours afte r a dministration, can attenuate EIB in up to 50 percent of patients. — Cromolyn or nedocromil taken shortly before exercise is an alternative treatment, but it is not as e ffectiv e as SAB As. — A warmup period before exercise may reduce the degree of EIB. — A mask or scarf over the mouth may attenuate cold-induced EIB. Pregnancy
M aintaining asthma control d ur ing pregnancy is impo rtant for the health and well-being of both the mother and her baby. Maintaining lung function is important to ensure oxyg e n supply to the fetus. Uncontrolled asthma increases the risk of perinatal mortality, preeclampsia, preterm birth, and low-birth-weight infants. It is safer for pregnant women to be treated with asthma medications than to have asthma symptoms and exacerbations.

■ 

### Monitor the level of asthma control and lung

functio n during prenatal visits. T he c ourse of asthma improve s in one-third of women and

wor se ns for one-third of women during pregnancy. Mo nthl y e v aluations of asthma will allow the opportunity to step up therapy if necessary and to st e p d ow n the r apy if possible.

38 Guidelines for the Diagnosis and Management of Asthma■ 

### Albuterol is the preferred SABA. The most data related to safe ty during human pregnancy are available for abuterol.

■ 

### ICSs are the preferred long-term control

medication. Budesonide is the preferred ICS because more data are available on using budesonide in pregnant wo m en than are available on other ICSs, and the data are reassuring. However, no data indicate that the other ICS preparations are unsafe during pregnancy. Surgery
P atients who hav e asthma ar e at risk for complications during and after surgery. These complications include acut e b ronchoconstriction triggered by intubation, hypoxemia and possible hypercapnia, impaired effectiveness of cough, atelectasis, and respiratory infection, and, if a history of sensitivity is present, reactions to latex exposure or some anesthe tic agents. The following actions are recommended to reduce the r isk of complicatio ns during surgery:

■ 

### B efore surgery, review the level of asthma control,

medicatio n use (especially oral systemic corticosteroids within the past 6 months), and pulmonary function.

■ 

### P rovide medications before surgery to improve

lung function if lung function is not well controlled. A short course of oral systemic corti costeroids may be necessary.

■ 

### For patients receiving oral systemic corticosteroids

during the 6 months prior to surgery and for selected patients on long-term high-dose ICS, give 100 mg hydrocortisone every 8 hours intravenously d ur ing the surgical period, and reduce the dose rapidly within 24 hours after surgery. Disparities Multiple factors contribute to the higher rates of p oorly c o ntrolled asthma and asthma deaths among Blacks and Latinos compared to Whites. These fa ctors include socioeconomic disparities in access toquality medical care, underprescription and underutilization of long-term control medication, cultural beliefs and practices about asthma management, and perhaps biological and pathophysiological differences that affect the underlying severity of asthma and

r espo nse to tr eatment. Heightene d a wareness of disparit ies and cultur al barriers, improving access to quality care, and improving communication strategies between clinicians and ethnic or racial minority patients regarding use of asthma medications may improve asthma outcomes.

39 Managing Asthma Long Term40 Guidelines for the Diagnosis and Management of AsthmaFIGURE11.CLASSIFYING ASTHMA SEVERITY AND INITIATING THERAPY IN CHILDRENKey:FEV1, forcedexpiratory volumein 1 second; FVC,forced vital capacity;ICS, inhaled corticosteroids; ICU,intensive care unit; N/A,not applicableNotes:■Levelof severity is determined byboth impairment and risk. Assessimpairment domain by caregiver’srecall of previous 2–4 weeks.Assign severity to the most severecategory in which any featureoccurs.■Frequencyand severity of exacerbations may fluctuate over time forpatients in any severity category.At present,there are inadequatedata to correspond frequenciesof exacerbations with differentlevels of asthma severity.In general,more frequent and severe exacerbations (e.g., requiring urgent,unscheduled care,hospitalization,or ICU admission) indicate greaterunderlying disease severity.Fortreatment purposes,patients with≥2exacerbations described above maybe considered the same as patientswho have persistent asthma,even inthe absence of impairment levelsconsistent with persistent asthma.41 Managing Asthma Long TermFIGURE12.ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDRENKey: EIB,exercise-inducedbronchospasm,FEV1, forcedexpiratoryvolume in 1 second; FVC,forced vitalcapacity; ICU, intensive care unit;N/A,not applicableNotes:■Thelevel of control is based on themost severe impairment or riskcategory.Assess impairmentdomain by patient’s or caregiver’srecall of previous 2–4 weeks.Symptom assessment for longerperiods should reflect a globalassessment, such as whetherthe patient’s asthma is better orworse since the last visit.■Atpresent,there are inadequatedata to correspond frequencies ofexacerbations with different levels ofasthma control.In general,morefrequent and intense exacerbations(e.g., requiring urgent,unscheduledcare, hospitalization, or ICUadmission) indicate poorerdisease control.42 Guidelines for the Diagnosis and Management of Asthma**FIGURE 13. STEPWISE APPROACH FOR MANAGING ASTHMA LONG TERM IN CHILDREN, 0–4 YEARS OF AGE AND 5–11 YEARS OF AGE** Oral corticosteriodsICSLABA orMontelukast43 Managing Asthma Long TermFIGURE14.CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS 12 YEARS OF AGE AND ADULTSAssessingseverity and initiating treatment for patients who are not currently takinglong-term control medicationsKey: EIB,exercise-inducedbronchospasm, FEV1,forced expiratoryvolume in 1 second; FVC,forced vitalcapacity; ICU, intensive care unitNotes:•Thestepwise approach is meant toassist, not replace, the clinicaldecisionmaking required to meetindividual patient needs.•Levelof severity is determined byassessment of both impairment andrisk. Assess impairment domain bypatient’s/caregiver’s recall ofprevious 2–4 weeks and spirometry.Assign severity to the most severecategory in which any featureoccurs.•Atpresent,there are inadequatedata to correspond frequencies ofexacerbations with different levelsof asthma severity.In general,morefrequent and intense exacerbations(e.g., requiring urgent,unscheduledcare, hospitalization, or ICUadmission) indicate greaterunderlying disease severity.Fortreatment purposes,patients whohad≥2 exacerbations requiring oralsystemic corticosteroids in the pastyear may be considered the sameas patients who have persistentasthma,even in the absence ofimpairment levels consistent withpersistent asthma.44 Guidelines for the Diagnosis and Management of AsthmaFIGURE15.ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS≥12YEARS OF AGE AND ADULTS*ACQvalues of 0.76–1.4 are indeterminate regardingwell-controlled asthma.Key: EIB, exercise-induced bronchospasm; ICU, intensive careunitNotes:•Thestepwise approach is meant to assist, not replace,the clinical decisionmaking required to meet individualpatient needs.•Thelevel of control is based on the most severe impair-ment or risk category.Assess impairment domain bypatient’s recall of previous 2–4 weeks and byspirometry/or peak flow measures.Symptom assessmentfor longer periods should reflect a global assessment, suchas inquiring whether the patient’s asthma is better orworse since the last visit.•Atpresent,there are inadequate data to correspond fre-quencies of exacerbations with different levels of asthmacontrol.In general,more frequent and intenseexacerbations (e.g., requiring urgent, unscheduled care,hospitalization, or ICU admission) indicate poorer diseasecontrol.For treatment purposes,patients who had≥2exacerbations requiring oral systemic corticosteroids in thepast year may be considered the same as patients whohave not-well-controlled asthma,even in the absence ofimpairment levels consistent with not-well-controlled asthma.ATAQ = AsthmaTherapy Assessment Questionnaire©ACQ= Asthma Control Questionnaire©ACT= Asthma ControlTestTMMinimal ImportantDifference:1.0 for theATAQ; 0.5 for the ACQ; notdetermined for theACT.Beforestep up in therapy:—Review adherence to medication, inhaler technique,environmental control, and comorbid conditions.— If an alternative treatment option was used in a step,discontinue and use the preferred treatment for that step.45 Managing Asthma Long TermFIGURE16.STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS≥12YEARS OF AGE AND ADULTSKey:Alphabeticalorder is used when more than onetreatment option is listed within either preferred oralternative therapy.ICS, inhaledcorticosteroid; LABA,longacting inhaled beta2-agonist;LTRA,leukotriene receptorantagonist; SABA, inhaled short-acting beta2-agonistNotes:•Thestepwise approach is meant to assist, not replace,theclinical decisionmaking required to meet individual patientneeds.•Ifalternative treatment is used and response is inadequate,discontinue it and use the preferred treatment beforestepping up.•Zileutonis a less desirable alternative due to limitedstudies as adjunctive therapy and the need to monitorliver function.Theophylline requires monitoring of serumconcentration levels.•Instep 6,before oral corticosteroids are introduced,a trialof high-dose ICS + LABA + either LTRA,theophylline,orzileuton may be considered, although this approach hasnot been studied in clinical trials.•Step1,2,and 3 preferred therapies are based on EvidenceA; step 3 alternative therapy is based on EvidenceA forLTRA, Evidence B for theophylline,and Evidence D forzileuton.Step 4 preferred therapy is based on Evidence B,and alternative therapy is based on Evidence B for LTRAand theophylline and Evidence D zileuton. Step 5preferred therapy is based on Evidence B. Step 6 preferredtherapy is based on (EPR—2 1997) and Evidence B foromalizumab.•Immunotherapyfor steps 2–4 is based on Evidence B forhouse-dust mites,animal danders,and pollens; evidence isweak or lacking for molds and cockroaches. Evidence isstrongest for immunotherapy with single allergens.The roleof allergy in asthma is greater in children than in adults.•Clinicianswho administer immunotherapy or omalizumabshould be prepared and equipped to identify and treatanaphylaxis that may occur.46 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 17. USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS*

Medication 0 –4 Years of Age

Methylprednisolone

2, 4, 8, 16, 32 mg tablets

Prednisolone

5 mg tablets, 5 mg/5 cc, 15 mg/5 cc

Prednisone

1, 2.5, 5, 10, 20, 50 mg tablets; 5 mg/cc, 5 mg/5 cc 0.25–2 mg/kg daily in single d ose in a.m. or qod as needed for control Short-course “burst”: 1–2mg/kg/day, maximum 6 0 mg/day for 3–10 days 5–11 Years of Age

0.25–2 mg/kg dail y in single d ose in a.m. or qod as needed for control Short-course “burst”: 1–2 mg/kg/day, maximum 60 mg/day for 3–10 days ≥ 12 Years of Age and Adults

7.5–60 mg daily in a single dose i n a.m. or qod as needed for control Short-course “burst”: to achieve control, 40–60 mg per day as single or 2 divided doses for 3–10 days ■ S hort-term use: reversibleabnormalities in glucose metabolism, increased appetite, fluid retention, weight gain, mood alteration, hypertension, peptic ulcer, and rarely aseptic necrosis.

■ Long-term use: adrenal axis suppression, growth suppression, dermal thinning, hypertension, diabetes, Cushing’s syndrome, ca taracts, muscle weakness, and—in rare instances —impaired immune function.

■ Consideration should be given to coexisting conditions that couldbe worsened by systemic corticosteroids, such as herpes virus infections, varicella, tuberculosis,hypertension, peptic ulcer, diabetes mellitus, osteoporosis, and Strongyloides Potential Adverse Effects Inhaled Corticosteroids (See Figure 18, “Estimated Comparative Daily Dosages for ICSs.”)

Key: DPI, dry powder inhaler; EIB, exercise-induced broncospasm; HFA, hydrofluoroalkane; ICS, inhaled corticosteroids; IgE, immunoglobulin E; MDI, metered-dose inhaler; NA, not available (either not approved, no data available, or safety and efficacy not established for this age group); SABA, short-acting beta 2 -agonist

* Note: Dosages are provided for those products that have been approved by the U.S. Food and Drug Administration or have sufficient clinical trial safety and efficacy data in the appropriate age ranges to support their use. Comments (not all inclusive)

■ F or long-term treatment of severe persistent asthma, administer single dose in a.m. either daily or on alternate days (alternate-day therapy may produce less adrenal suppression).

■ Short courses or “bursts” are effective for establishing control when initiating therapy or during a period of gradual deterioration.

■ There is no evidence that tapering the dose following improvement in symptom control and pulmonary function prevents relapse.

■ Children receiving the lower dose (1 mg/kg/day) experience fewer behavioral side effects, and it appears to be equally ef ficacious.

■ For patients unable to tolerate the liquid preparations, dexamethasone syrup at 0.4 mg/kg/day may be an alterna tive. Studies are limited, however, and the longer duration of activity increases the risk of adrenal suppression. Oral Systemic Corticosteroids (Apply to all three corticosteriods.)

Salmeterol

DPI 50 mcg/ blister Formoterol

DPI 12 mcg/ single-use capsule NA

NA 1 blister q 12 hours

1 ca psule q 12 hours 1 blister q 12 hours

1 capsule q 12 hours ■ Tachycardia, skeletal muscle tremor, hypokalemia, prolongation of QTc interval in overdose.

■ A diminished bronchoprotective ef fect may occur within 1 week of chronic thera py. Clinical signif

icance has not been established.

■ Potential risk of uncommon, severe, life-threa tening or fa talexacerbation; see text for additional discussion regarding safety of LABAs. ■ Should not be used for acute symptom relief or exacerbations. Use only with ICSs.

■ Decreased duration of protection against EIB may occur with redgular use.

■ Most children <4 years of age cannot provide sufficient inspiratory flow for adequa te lung deliver y.
■ Do not blow into inhaler after dose is activated.

■ Each capsule is for single use only; additional doses should not be administered for at least 12 hours.

■ Capsules should be used only with the inhaler and should not be taken orally. Inhaled Long-Acting Beta 2 -Agonists (LABAs) (Apply to both LABAs.)47 Managing Asthma Long Term 

### FIGURE 17. USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS* (continued)

Medication 0–4 Years of Age

F luticasone/Salmeterol

DPI 1 00 mcg/50 mcg, 250 mcg/50 mcg, or 500 mcg/ 50 mcg
HFA 45 mcg/21 mcg 115 mcg/21 mcg 230 mcg/21 mcg NA 5–11 Years of Age

1 inhala tion bid, dose depends on level of severity or control ≥ 12 Years of Age and Adults

1 inhalation bid; dose depends on level of severity or control ■ See notes for ICS and LABA. Potential Adverse Effects Comments (not all inclusive)

■ There have been no clinical trials in children <4 years of age.

■ Most children <4 years of age cannot p rovide sufficient inspiratory flow for adequate lung delivery.

■ Do not blow into inhaler after dose is activated.

■ 100/50 DPI or 45/21 HFA for patients who have asthma not controlled on low- to medium-dose ICS

■ 250/50 DPI or 115/21 HFA for patients who have asthma not controlled on medium to high dose ICS. Combined Medication

Budesonide/ Formoterol

HFA MDI 80 mcg/4.5 mcg 160mcg/4.5 mcg NA 2 puffs bid, dose depends on level of severity or control 2 puffs bid; dose depends on level of severity or control ■ See notes for ICS and LABA.

Cromolyn

MDI 0.8 mg/puff

Nebulizer 20 mg/ampule

Nedocromil

MDI 1.75 mg/puff NA

1 ampule qid NA <2 years of age

NA <6 years of age 2 puffs qid

1 ampule qid

2 puffs qid 2 puffs qid

1 ampule qid

2 puffs qid ■ Cough and irritation.

■ 15–20 percent of pa tients complain of an unpleasant taste from nedocromil.

■ Safety is the primary advantage of these Cromolyn/Nedocromil

■ One dose of cromolyn before exercise or allergen exposure provides effective prophylaxis for 1–2 hours. Not as effective as inhaled beta 2 -agonists for EIB as SABA.

■ 4- to 6-week trial of cromolyn or nedocromil may be needed to determine maximum benefit.

■ Dose by MDI may be inadequate to affect hyperresponsiveness.

■ Once control is achieved, the frequency of dosing may be reduced. ■ There have been no clinical trials in children <4 years of age.

■ Currently approved for use in youths ≥ 12 years of age. Dose for children 5–12 years of age based on clinical trials using DPI with slightly different deliver y characteristics.

■ 80/4.5 f or patients who have asthma not controlled on low- to medium-dose ICS.

■ 160/4.5 for patients who have asthma not controlled on medium- to high-dose ICS.48 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 17. USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS* (continued)

Medication 0–4 Years o f Age 5–11 Years of Age ≥ 12 Years of Age and Adults Potential Adverse Effects Comments (not all inclusive)

O malizumab (Anti IgE)

S ubcutaneous injection, 150 mg/ 1.2 mL following reconstitution with 1 .4 mL sterile water for injection NA NA 150–375 mg SC q 2–4 weeks, d epending on body weight and pretreatment serum IgE level ■ P ain and bruising of injection sites in 5–20 percent of patients.

■ Anaphylaxis has been reported in 0.2% of treated patients.

■ M alignant neoplasms were reported in 0.5 percent of patients compared to 0.2 percent receiving placebo; relationship to drug is unclear. ■ D o not administer more than 150 mg per injection site.

■ Monitor patients following injections; be prepared and equipped to identify and treat anaphylaxis that may occur.

■ W hether patients will develop significant antibody titers to the drug with long-term administration is unknown.

Leukotriene Receptor Antagonists (LTRAs)

Montelukast

4 mg or 5 mg chewa ble ta blet 4 mg granule packets 10 mg tablet

Zafirlukast

10 mg ta blet 20 mg tablet 4 mg qhs (1–5 years of age)

NA 5 mg qhs (6–14 years of age)

10 mg bid (7–11 years of a ge) 10 mg qhs

40 mg daily (20 mg ta blet bid) ■ No specific adverse effects have been identified.

■ Rare cases of Churg-Strauss have occurred, but the association is unclear

.

■ Postmarketing surveillance has reported cases of reversible hepa titis and, rarel y, irreversible hepatic failure resulting in death and liver transplanta tion. Leukotriene Modifiers

■ Montelukast exhibits a flat dose-response curve. Doses >10 mg will not produce a g rea ter response in adults.

■ No more efficacious than placebo in infants ages 6–24 months.

■ As long-term thera p y may a ttenuate exercise-induced bronchospasm in some patients, but less effective than ICS therapy.

■ For zafirlukast, administration with meals decreases bioavailability; take at least 1 hour before or 2 hours after meals.

■ Zarfirlukast is a microsomal P450 enzyme inhibitor that can inhibit the metabolism of warfarin. Doses of these drugs should be monitored accordingl y.
■ Monitor hepatic enzymes (ALT). Warn patients to discontinue use if they experience signs and symptoms of liver dysfunction. Immunomodulators

5-Lipoxygenase Inhibitor Zileuton

600 mg ta blet NA NA 2,400 mg daily (give tablets qid) ■ Elevation of liver enzymes has been reported. Limited case reports of reversible hepatitis and hyperbilirubinemia. ■ For zileuton, monitor hepatic enzymes (ALT).

■ Zileuton is a microsomal P450 enzyme inhibitor that can inhibit the meta bolism of warfarin and theophylline. Doses of these drugs should be monitored accordingly.

Theophylline

Liquids, sustainedrelease ta blets, and ca psules Starting dose 10 mg/kg/da y; usual maximum:

■ <1 year of age: 0.2 (age in weeks) + 5 = mg/kg/day

■ ≥ 1 year of a ge: 16 mg/kg/day Starting dose 10 mg/kg/da y; usual maximum: 16 mg/kg/day Starting dose 10 mg/kg/day up to 300 mg maximum; usual maximum: 800 mg/day ■ Dose-related acute toxicities include tachycardia, nausea and vomiting, tachyarrhythmias (SVT),central nervous system stimulation, headache, seizures, hematemesis, hyperglycemia, and hypokalemia.

■ Adverse effects at usual thera peutic doses include insomnia, gastric upset, aggravation of ulcer or reflux, increase in hyperactivity in some children, difficulty in urination in elderly males who have prosta tism. Methylxanthines

■ Adjust dosage to achieve serum concentration of 5–15 mcg/mL at steady state (at least 48 hours on same dosage).

■ Due to wide interpatient variability in theophylline metabolic clearance, routine serum theophylline level monitoring is essential.

■ Pa tients should be told to discontinue if they experience toxicity.

■ V arious factors (diet, f ood, febrile illness, age, smoking, and other medications) can affect serum concentrations. See EPR—3 Full Report 2007 and package inserts for details.49 Managing Asthma Long Term 

### FIGURE 18. ESTIMATED COMPARATIVE DAILY DOSAGES FOR INHALED CORTICOSTEROIDS

Beclomethasone HFA 40 or 80 mcg/puff Budesonide DPI 90, 180, or 200 mcg/inhala tion Budesonide Inhaled Inhalation suspension f or nebulization Flunisolide 250 mcg/puff Flunisolide HFA 80 mcg/puff Fluticasone HF

A/MDI: 44, 110, or 220 mcg/puff DPI: 50, 100, or 250 mcg/inhala tion Mometasone DPI 200 mcg/inhala tion Triamcinolone acetonide 75 mcg/puff NA

NA

0.25–0.5 mg

NA

NA

176 mcg

NA

NA

NA 80–160 mcg

180–400 mcg

0.5 mg

500–750 mcg

160 mcg

88–176 mcg
100–200 mcg

NA

300–600 mcg 80–240 mcg

180–600 mcg

NA

500–1,000 mcg

320 mcg

88–264 mcg
100–300 mcg

200 mcg

300–750 mcg NA

NA

>0.5–1.0 mg

NA

NA

>176–352 mcg

NA

NA

NA

Key: DPI, dr y power inhaler; HF A, hydrofluoroalkane; MDI, metered-dose inhaler; NA, not available (either not approved, no data available, or safety and efficacy not established for this age group) >160–320 mcg

>400–800 mcg

1.0 mg

1,000– 1,250 mcg 320 mcg

>176–352 mcg
>200–400 mcg

NA

>600–900 mcg >240–480 mcg

>600– 1,200 mcg

NA

>1,000– 2,000 mcg >320–640 mcg

>264–440 mcg
>300–500 mcg

400 mcg

>750– 1,500 mcg NA

NA

>1.0 mg

NA

NA

>352 mcg

NA

NA

NA >320 mcg

>800 mcg

2.0 mg

>1,250 mcg

≥ 640 mcg

>352 mcg
>400 mcg

NA

>900 mcg Drug

>480 mcg

>1,200 mcg

NA

>2,000 mcg

>640 mcg

>440 mcg
>500 mcg

>400 mcg

>1,500 mcg

Therapeutic Issues:

■ The most important determinant of appropriate dosing is the clinician’s judgment of the patient’s response to therapy. The clinician must monitor the patient’s response on several clinical parameters and adjust the dose accordingly. Once control of asthma is achieved, the dose should be carefully titrated to the minimum dose required to maintain control.

■ Prepara tions are not interchangeable on a mcg or per puff basis. This figure presents estimated comparable dail y doses. See EPR—3 Full Report 2007 for full discussion.

■ Some doses may be outside package labeling, especially in the high-dose range. Budesonide nebulizer suspension is the only inhaled corticosteroid (ICS) with FDA-approved labeling for children <4 years of age.

■ For children <4 years of age: The safety and efficacy of ICSs in children <1 year has not been established. Children <4 years of age generally require delivery of ICS (budesonideand fluticasone HFA) through a face mask that should fit snugly over nose and mouth and avoid nebulizing in the eyes. Wash face after each treatment to prevent local corticosteroid side ef fects. For budesonide, the dose may be administered 1–3 times daily. Budesonide suspension is compatible with albuterol, ipratropium, and levalbuterol nebulizer solutions in the same nebulizer. Use only jet nebulizers, as ultrasonic nebulizers are ineffective for suspensions. For fluticasone HFA, the dose should be divided 2 times daily; the low dose for children <4 years of age is higher than for children 5–11 years of age due to lower dose delivered with face mask and data on efficacy in young children.

Poten tial Adverse E ff ec ts of Inhaled Corticoster oids:

■ Cough, dysphonia, oral thrush (candidiasis).

■ Spacer or valved holding chamber with non-breath-actuated MDIs and mouthwashing and spitting after inhalation decrease local side effects.

■ A number of the ICSs, including fluticasone, budesonide, and mometasone, are metabolized in the gastrointestinal tract and liver by CYP 3A4 isoenzymes. Potent inhibitors of CYP 3A4, such as ritonavir and ketoconazole, have the potential for increasing systemic concentrations of these ICSs by increasing oral availability and decreasing systemic clearance. Some cases of clinically significant Cushing syndrome and secondary adrenal insufficiency have been reported.

■ In high doses, systemic effects may occur, although studies are not conclusive, and clinical significance of these effects has not been established (e.g., adrenal suppression, osteoporosis, skin thinning, and easy bruising). In low-to-medium doses, suppression of growth velocity has been observed in children, but this effect may be transient, and the clinical significance has not been esta blished. Child 0–4 Years of Age Child 5–11 Years of Age ≥ 12 Years of Age and

Adults Low Daily Dose

Child 0–4 Years of Age Child 5–11 Y ears of Age ≥ 12 Y ears of Age and

Adults Medium Daily Dose

Child 0–4 Years of Age Child 5–11 Years of Age ≥ 12 Years of Age and

Adults High Daily Dose50 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 19. USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS*

Medication <5 Years o f Age

MDI Albuterol CFC

90 mcg/puff, 200 puffs/canister

Albuterol HFA

90 mcg/puff, 200 puffs/canister

Levalbuterol HFA

45 mcg/puf f, 200 puf fs/canister

Pirbuterol CFC Autohaler

200 mcg/puf f, 400 puf fs/canister 1–2 puffs 5 minutes before exercise

2 puffs every 4–6 hours, as needed for symptoms
NA <4 years of age

NA 5 –11 Y ears of Age

2 puffs 5 minutes before exercise

2 puffs every 4–6 hours, as needed for symptoms

NA ≥ 12 Years of Age and Adults

2 puffs 5 minutes before exercise

2 puffs every 4–6 hours, as needed f or symptoms ■ T achycardia, skeletal muscle tremor, hypokalemia, increased lactic acid, headache, hyperglycemia. Inhaled route, in general, causes few systemic adverse effects. Patientswith preexisting cardiovascular disease, especially the elderly, may have adverse cardiovascular reactions with inhaled therapy. Potential Adverse Effects Comments (not all inclusive)

■ D rugs of choice for acute bronchospasm.

■ Differences in potencies exist, but all products are essentially comparable on a puff per puff basis.

■ An increasing use or lack of expected effect indicates diminished control of asthma.

■ Not recommended for long-term daily treatment. Regular use exceeding 2 days/week for symptom control (not prevention of EIB) indicates the need for additional long-term control thera py.
■ May double usual dose for mild exacerbations.

■ For levalbuterol, prime the inhaler by releasing 4 actuations prior to use.

■ For HFA: periodically clean HFA actuator, as drug may plug orifice.

■ For autohaler: children <4 years of a ge ma y not generate sufficient inspiratory flow to activate an auto-inhaler.

■ Nonselective agents (i.e., epinephrine,isoproterenol, metaproterenol) are not recommended due to their potential for excessive cardiac stimulation, especially in high doses. I nhaled Short-Acting Beta 2 - Agonists

Key: CFC, chlorofluorocarbon; ED, emergency department; EIB, exercise-induced bronchospasm; HFA, hydrofluoroalkane; IM, intramuscular; MDI, metered-dose inhaler; NA, not available (either not approved, no data available, or safety and efficacy not established for this age group); PEF, peak expiratory flor; SABA, short-acting beta 2 -agonist *Dosages are provided for those products that have been approved by the U.S. Food and Drug Administration (FDA) or have sufficient clinical trial safety and efficacy data in the appropriate age ranges to support their use. Nebulizer solution
Albuterol

0.63 mg/3 mL 1.25 mg/3 mL 2.5 mg/3 mL 5 mg/mL (0.5%)

Levalbuterol (R-albuterol)

0.31 mg/3 mL 0.63 mg/3 mL 1.25 mg/0.5 mL 1.25 mg/3 mL 0.63–2.5 mg in 3 cc of saline q 4–6 hours, as needed

0.31–1.25 mg in 3 cc q 4–6 hours, asneeded for symptoms 1.25–5 mg in 3 cc of saline q 4–8 hours, as needed

0.31–0.63 mg, q 8 hours, as needed for symptoms 1.25–5 mg in 3 cc of saline q 4–8 hours, as needed

0.63 mg– 1.25 mg q 8 hours, as needed f or symptoms (Same as with MDI)

(Same as with MDI) ■ Ma y mix with cromolyn solution, budesonide inhalant suspension, or ipratropium solution for nebulization. May double dose for severe exacerbations.

■ Does not have FDA-approved labeling for children <6 years of age.

■ Compa tible with budesonide inhalant suspension. The product is a sterile-filled preservative-free unit dose vial. Dose applies to Albuterol. D ose applies to A lbuter ol

/and L evalbuterol. D ose applies t o all four S

ABAs A pply to all four (SABAs)51 Managing Asthma Long Term 

### FIGURE 19. USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS* (continued)

Medication <5 Years of Age 5 –11 Years of Age ≥ 12 Years of Age and Adults Potential Adverse Effects Comments (not all inclusive)

Ipratropium HFA
MDI

1 7 mcg/puff, 200 puffs/canister
N

ebulizer solution 0.25 mg/mL (0.025%) Ipra tropium with

albuterol
MDI

18 mcg/puff of ipra tropium bromide and 90 mcg/puff of albuterol 200 puf fs/canister Nebulizer solution

0.5 mg/3 mL ipra tropium bromide and 2.5 mg/3 mL albuterol NA

NA

NA

NA NA

NA

NA

NA 2–3 puffs q 6 hours

0.25 mg q 6 hours

2–3 puf fs q 6 hours

3 mL q 4–6 hours ■ Drying of mouth and r espiratory secretions, increased wheezing in some individuals, blurred vision if sprayed in eyes. If used in the ED, produces less cardiac stimulation than SABAs. ■ Multiple doses in the emergency department (not hospital) setting provide additive benefit t o SABA.

■ Treatment of choice for bronchospasm due to beta-blocker medication.

■ Does not block EIB.

■ Reverses only cholinergically mediated bronchospasm; does not modify reaction to antigen.

■ May be an alternative for patients who do not tolerate SABA.

■ Has not proven to be efficacious as long-term control therapy for asthma.

■ Contains EDTA to prevent discoloration of the solution. This additive does not induce bronchospasm. Anticholinergics

Methylprednisolone

2, 4, 6, 8, 16, 32 mg tablets

Prednisolone

5 mg tablets, 5 mg/5 cc, 15 mg/5 cc

Prednisone

1, 2.5, 5, 10, 20, 50 mg tablets; 5 mg/cc, 5 mg/5 cc Short course “burst:” 1–2 mg/kg/ day, maximum 60 mg/day, for 3–10 days Short course “burst”: 1-2 mg/ kg/ day maximum 60 mg/day for 3–10 days Short course “burst”: 40–60 mg/day as single or 2 divided doses for 3–10 days ■ Short-term use: reversible abnormalities in glucose metabolism, increased appetite, fluid retention, weight gain, facial flushing,mood alteration, hypertension, peptic ulcer, and rarel y aseptic necrosis.

■ Consideration should begiven to coexisting conditions that could be worsened by systemic corticosteroids, such as herpes virus infections, varicella, tuberculosis, hypertension, peptic ulcer, diabetes mellitus, osteoporosis, and Strongyloides

. (Applies to the first three corticosteroids.)

■ Short courses or “bursts” are effective for establishing control when initiating therapy or during a period of gradual deterioration. Action may begin within an hour

. ■ The burst should be continued until pa tient achieves 80 percent PEF personal best or symptoms resolve. This usually requires 3–10 days but may require longer. There is no evidence that tapering the dose following improvement prevents relapse in asthma exacerbations.

■ Other systemic corticosteroids such as hydrocortisone and dexamethasone g iven in equipotent daily doses are likely to be as effective as prednisolone. Systemic Corticosteroids Dosages apply to first three corticosteroids.52 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 19. USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS* (continued)

Medication <5 Years o f Age 5–11 Years o f Age ≥ 12 Years of Age and Adults Potential Adverse Effects Comments (not all inclusive)

Repository injection (Methylprednisolone a cetate)

40 mg/mL 80 mg/mL 7.5 mg/kg IM once 240 mg IM once 240 mg IM once ■ M ay be used in place of a short burst of oral steroids in patients who are vomiting or if adherence is a problem. Systemic Corticosteroids (continued)

### Asthma exacerbations are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness, or some combination of these symptoms. Exacerbations are characterized by decreases in expiratory airflow; objective measures of lung function (spirometry or PEF) are more reliable indicators of severity than symptoms are. Individuals whose asthma is well controlled with ICSs have decreased risk of exacerbations. However, these patients can still be vulnerable to exacerbations, for example, when they have viral respiratory infections. Effec tive management of exacerbations incorporates the same four components of asthma management used in managing asthma long term: assessment and mo nitoring, patie nt ed ucation, environmental control, and medications. Classifying Severity Do not under estimat e the sever ity of an exace r bation. Severe exacerbations can be life threatening and can occur in patients at any level of asthma
se verity—i.e., intermittent, or mild, moderate, or severe persistent asthma. See figure 20, “Classifying Severity of Asthma Exacerbations in the Urgent or Emergency Care Setting.” Patients at high risk of asthma-related death require special attention

— particularly intensive education,

mo nitoring, and care. Such patients should beadvised to seek medical care early during an exacerbation. Risk factors for asthma-related death include:

■ 

### Previous severe exacerbation (e.g., intubation or

ICU a dmissio n for asthma)

■ 

### Two or more hospitalizations or >3 ED visits in the

past year

■ 

### U se of >2 canisters of SABA per month

■ 

### Difficulty perceiving airway obstruction or the

severity of worsening asthma

■ 

### Lo w so cioec onomic status or inner-city residence ■ 

### Illicit drug use

■ 

### Major psychosocial problems or psychiatric disease

■ 

### Comorbidities, such as cardiovascular disease or

other chronic lung disease Home Management
Ear ly treatment by the patient at home is the best strategy f or managing asthma exacerbations. Patients should be instructed how to:

■ 

### Use a written asthma action plan that notes when

and how to treat signs of an exacer bation. A peak flow-base d plan may be part icularl y useful for patients who have difficulty perceiving airflow obstruction or have a history of severe

e xacerbations.

■ 

### Recogniz e early indicators of an exacerbation, including worsening PEF.

■ 

### Adj ust their medications b y increasing SABA and,

in some cases, adding a shor t course of oral systemic corticosteroids. Doubling the dose of ICSs is not effective.

■ 

### Remove or withdraw from allergens or irritants in

the env ironment that may contribute to the

e xacerbation.

■ 

### Monitor response to treatment and promptly

communicate with the clinician about any serious deter ioration in sy mp to ms o r PEF or about de c reased responsiveness to SABA treatment, including decreased duration of effect. The f ollow ing home manage me nt techniques are not rec o mmended because no studies demonstrate their effect i veness and they may delay patients from obtaining necessary care: drinking large volumes of liquids; b reathing warm, moist air; or using over-thecounter products, such as antihistamines or cold

re medies. P ursed-lip and other forms of breathing may help to maintain calm, but these methods do not improve lung function. 

# Managing Exacerbations

53 Managing Exacerbations54 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 20. CLASSIFYING SEVERITY OF ASTHMA EXACERBATIONS IN THE URGENT OR EMERGENCY CARE SETTING

Symptoms and Signs

Mild

Moderate

Severe

Subset: Life threatening Dyspnea only with activity (assess tachypnea in young children) Initial PEF (or FEV1)

PEF ≥ 70 percent predicted or personal best Clinical Course

■ Usually cared for at home

■ Prompt relief with inhaled SABA

■ Possible short course of oral systemic corticosteroids

■ Usually requires office or ED visit

■ Relief from frequent inhaled SABA

■ Oral systemic corticosteroids; some symptoms last for 1–2 days after treatment is begun

■ Usually requires ED visit and likely hospitalization

■ Partial relief from frequent inhaled SABA

■ Oral systemic corticosteroids; some symptoms last for >3 days after treatment is begun

■ Adjunctive therapies are helpful

■ Requires ED/hospitalization; possible ICU

■ Minimal or no relief from

frequent inhaled SABA

■ Intra venous corticosteroids

■ Adjunctive therapies are helpful

Key: ED, emergency department; FEV 1 , forced expiratory volume in 1 second; ICU, intensive care unit; PEF, peak expiratory flow; SABA, short-acting beta 2 -agonist Note: Patients are instructed to use quick-relief medications if symptoms occur or if PEF drops below 80 percent predicted or personal best. If PEF is 50–79 percent, the patient should monitor response to quick-relief medication carefully and consider contacting a clinician. If PEF is below 50 percent, immediate medical care is usually required. In the urgent or emergency care setting, the following parameters describe the severity and likely clinical course of an exacerbation.

Dyspnea interferes with or limits usual activity PEF 40–69 percent predictedor personal best

PEF <40 percent predicted or personal best

PEF <25 percent predicted or personal best Dyspnea at rest; interferes with conversation

T oo dyspneic to speak; perspiring



### Management in the Urgent or Emergency Care and Hospital Settings Emergency medical services providers should have prehospital protov ols that al low administration of SABA, supplemental oxygen, and (with appropriate

me dical oversight) anticholinergics and oral systemiccorticosteriods to patients who have signs or symptoms of an asthma exacerbation.
Tr eatme nt strategies for managing moderate or severe exacerbations in the urgent or emergency care setting

ar e d escribe d be lo w. Also see figure 21 for a detailed sequence of recommended actions for monitoring and treatment and figure 22 for dosages of drugs for asthma exacerbations. ■ 

### Administer supplemental oxygen to correct significant hypoxemia in mo derate or severe exacerbations.

■ 

### Administer repetitive or continuous administration of SABA to reverse airflow obstruction rapidly.

■ 

### Administer oral systemic corticosteroids to

decrease airway inflammatio n in moderate or

sever e exacerbations or for patients who fail to respond promptly and completely to SABA tr eatment.

■ 

### Monito r r espo nse to therapy with serial

assessments.

— For children:55 Managing Exacerbations 

### FIGURE 21. MANAGEMENT OF ASTHMA EXACERBATIONS: EMERGENCY DEPARTMENT AND HOSPITAL-BASED CARE

Key: FEV 1 , forced expiratory volume in 1 second; ICS, inhaled corticosteroid; MDI, metered-dose inhaler; PCO2, partial pressure carbon dioxide; PEF, peak expiratory flow; SABA, short-acting beta 2 -agonist; SaO2, oxygen saturation56 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 22. DOSAGES OF DRUGS FOR ASTHMA EXACERBATIONS

Medication Child Dose* Adult Dose

Albuterol Nebulizer solution (0.63 mg/3 mL, 1 .25 mg/3 mL, 2.5 mg/3 mL, 5.0 mg/mL)
MDI (90 mcg/puff)

Bitolterol

Nebulizer solution (2 mg/mL)
MDI (370 mcg/puf f)
Levalbuterol (R-albuterol) Nebulizer solution (0.63 mg/3 mL, 1.25 mg/0.5 mL 1.25 mg/3 mL)
MDI (45 mcg/puf f) 0 .15 mg/kg (minimum dose 2.5 mg) every 20 minutes for 3 doses then 0.15–0.3 mg/kg up to 10 mg every 1–4 hours as needed, or 0 .5 mg/kg/hour by continuous n ebulization. 4–8 puffs every 20 minutes for 3 doses,then every 1–4 hours inhalation maneuver as needed. Use VHC; add mask in children <4 years.

See albuterol dose; thought to be half as potent as albuterol on mg basis. See albuterol MDI dose.

0.075 mg/kg (minimum dose 1.25 mg) every 20 minutes for 3 doses, then 0.075–0.15 mg/kg up to 5 mg ever y 1–4 hours as needed. See albuterol MDI dose 2 .5–5 mg every 20 minutes for 3 doses, then 2.5–10 mg every 1–4 hours as needed, or 10–15 mg/hour c ontinuously.

4–8 puffs every 20 minutes up to 4 hours, then every 1–4 hours as needed.

See albuterol dose.

See albuterol MDI dose.

1.25–2.5 mg ever y 20 minutes for 3 doses, then 1.25–5 mg ever y 1–4 hours as needed. See albuterol MDI dose. Only selective beta 2 agonists are recommended. For optimal delivery, dilute aerosols to minimum of 3 mL at gas flow of 6–8 L/min. Use large volume nebulizers for continuous administration. May mix with ipratropium nebulizer solution.

In mild-to-moderate exacerbations, MDI plus VHC is as effective as nebulized therapy with appropriate administration technique and coaching by trained personnel.

Has not been studied in severe asthma exacerbations. Do not mix with other drugs.

Has not been studied in severe asthma exacerba tions.

Levalbuterol administered in one-half the mg dose of albuterol provides comparable efficacy and safety. Has not been evaluated by continuous nebulization. Comments (not all inclusive) D osage

Inhaled Short-Acting Beta 2 -Agonists (SABA)

Epinephrine 1:1,000 (1 mg/mL)
T erbutaline (1 mg/mL) 0.01 mg/kg up to 0.3–0.5 mg every 20 minutes for 3 doses sq. 0.01 mg/kg every 20 minutes f or 3 doses then every 2–6 hours as needed sq. 0.3–0.5 mg every 20 minutes for 3 doses sq. 0.25 mg every 20 minutes for 3 doses sq. No proven advantage of systemic therapy over aerosol.

No proven advantage of systemic therapy over aerosol. Systemic (Injected) Beta 2 -Agonists

Ipra tropium bromide

Nebulizer solution (0.25 mg/mL)

MDI (18 mcg/puff) 0.25– 0. 5 mg every 20 minutes for 3 doses, then as needed

4–8 puffs every 20 minutes as needed up to 3 hours 0.5 mg ever y 20 minutes f or 3 doses, then as needed

8 puffs every 20 minutes as needed up to 3 hours Ma y mix in same nebulizer with albuterol. Should not be used as first-line therapy; should be added to SABA therapy for severe exacerbations. The addition of ipratropium has not been shown to provide further benefit once the patient is hospitalized. Should use with VHC and face mask for children <4 years. Studies have examined ipratropium bromide MDI for up to 3 hours. Anticholinergics Pirbuterol MDI (200 mcg/puff) See albuterol MDI dose; thought to be half as potent as albuterol on a mg basis. See albuterol MDI dose. Has not been studied in severe asthma exacerba tions

### • No single measure is best for assessing severity or predicting hospital admission. • Lung function measures (FEV 1 

### or PEF) may be

use ful for children ≥ 5 years of age, but these

measur es may not be obtainable during an exacerbation. • Pulse oximetry may be useful for assessing the

init ial sever it y; a repeated measure of pulse oximetry of <92–94 percent after 1 hour is predictive of the need for hospitalization. • Signs and symptoms scores may be helpful.

Children who have signs and symptoms after 1–2 hour s of initial treatment and who continue to meet the criteria for a moderate or severe

e xace rbation have a >84 percent chance of requiring hospitalization. — For adults: • Repeated lung function measures (FEV 1 

### or PEF) at 1 hour and beyond are the strongest single predictor of hospitalization. Such measures may not be helpful, or easily obtained, during severe exacerbations. • Pulse oximetry is indicated for patients who are

in severe distress, have FEV 1 

### o r PEF <40 pe rcent predicted, or are unable to perform lung function measures. Only repeat assessments after initial treatment, not a single assessment upon admission, are useful for predicting the need for hospitalization. • Signs and symptoms scores at 1 hour after

init ial treatments improve the ability to predict need for hospitalization. The presence of drowsiness is a useful predictor of impending

r espirator y failure and is reason to consider immediate transfer to a facility equipped to offer ventilatory support.

57 Managing Exacerbations 

### FIGURE 22. DOSAGES OF DRUGS FOR ASTHMA EXACERBATIONS (continued)

Medication Child Dose* Adult Dose Comments (not all inclusive) D osage

Ipratropium with albuterol

Nebulizer solution (Each 3 mL vial c ontains 0.5 mg ipratropium bromide and 2.5 mg albuterol.)
MDI

(Each puff contains 18 mcg ipratropium bromide and 90 mcg of albuterol.) 1.5 -3 mL every 20 minutes for 3 doses, then as needed

4–8 puffs ever y 20 minutes as needed up to 3 hours 3 mL ever y 20 minutes for 3 doses, then as needed

8 puffs every 20 minutes as needed up to 3 hours May be used for up to 3 hours in the initial management of severe exacerbations. The addition o f ipratropium to albuterol has not been shown to provide further benefit once the patient is hospitalized.

Should use with VHC and face mask for children <4 years. A nticholinergics (continued)

Prednisone
Methylprednisolone Prednisolone 1 -2 mg/kg in 2 divided doses (maximum = 60 mg/day) until PEF is 70 percent of predicted or personal best 40–80 mg/day in 1 or 2 divided doses until PEF reaches 70 percent of predicted or personal best For outpatient “burst,” use 40–60 mg in single or 2 divided doses for total of 5–10 da ys in adults (children: 1–2 mg/ kg/da y maximum 60 mg/day f or 3–10 da ys). Systemic Corticosteroids (Apply to all three corticosteriods.)

* Children ≤ 12 years of age Key: ED, emergency department; MDI, metered-dose inhaler; PEF, peak expiratory flow, VHC, valved holding chamber
Notes:

• There is no known advantage for higher doses of corticosteroids in severe asthma exacerbations, nor is there any advantage for intravenous administration over oral therapy

provided gastrointestinal transit time or absorption is not impaired.

• The total course of systemic corticosteroids for an asthma exacerbation requiring an ED visit of hospitalization may last from 3 to 10 days. For corticosteroid courses of less than

1 week, there is no need to taper the dose. For slightly longer courses (e.g., up to 10 days), there probably is no need to taper, especially if patients are concurrently taking ICSs.

• ICSs can be started at any point in the treatment of an asthma exacerbation.■ 

### Consider adjunctive treatments, such as intravenous magnesium sulfate or heliox, in
severe exac e rbations, if patients are unresponsive to the initial treatments listed above (e.g., FEV 1 

### or PEF <40 percent predicted or personal best after initial treatments).

■ 

### Provide the following to prevent relapse of the

exacerbation and recurrence of another exacerbatio n:

— Referral to followup asthma care within 1–4 weeks. In addition, encourage the patient to contact (e.g., by telephone) his/her asthma care provider during the first 3–5 days after discharge. A followup visit is essential to review the patient’s written asthma action plan, adherence, and environmental control and to consider a step up in therapy. If appropriate, consider referral to an asthma self-management education program. — An ED asthma disc harg e plan. See figure 23a, b “Emergency Department—Asthma Discharge Plan.”

— Review of inhaler technique whenever possible. — Consideration of initiating ICS.

■ 

### Treatment s that are not recommended in the

emergency care or hospital setting include: methy lxanthines, antobiotics (ex c ept as needed for comorbid conditions), aggressive hydration, chest physical therapy, mucolytics, or sedation. Inhaled ipratropium bromide is a helpful adjunctive the rapy in the emergency care setting, but does not provide additional benefit after a patient is hospitalized for a severe exacerbation.

58 Guidelines for the Diagnosis and Management of Asthma59 Managing Exacerbations 

### FIGURE 23a. EMERGENCY DEPARTMENT—ASTHMA DISCHARGE PLAN

Reprinted by permission from Carlos Camargo, M.D., Principal Investigator of Agency for Health Care Research and Quality. Grant No. R13H31094. Source: Camargo CA Jr, Emond SD, Boulet L, Gibson PG, Kolbe J, Wagner CW, Brenner BE. Emergency Department Asthma Discharge Plan. Developed at "Asthma Education in the Adult Emergency Department: A Multidisciplinary Consensus Conference," New York Academ y of Medicine, New York, NY; 2001 April 1–5. Boston, MA: Massachusetts General Hospital, 2001. 2 pp.60 Guidelines for the Diagnosis and Management of Asthma 

### FIGURE 23b. EMERGENCY DEPARTMENT—ASTHMA DISCHARGE PLAN: HOW TO USE YOUR METERED-DOSE INHALER

Clean your inhaler as needed, and know when to replace your inhaler. For instructions, read the package insert or talk to your doctor, other health care provider, or pharmacist. U sing an inhaler seems simple, but most patients do not use it the right way. When you use your inhaler the wrong way, less medicine gets to your lungs. For the next few days, read these steps aloud as you do them or ask someone to read them to you. Ask your doctor, nurse, other health care provider, or pharmacist to check how well you are using your inhaler. Use your inhaler in one of the three ways pictured below (A or B are best, but C can be used if you have trouble with A and B). (Your doctor may give you other types of inhalers.) 

## Steps for Using Your Inhaler

A. Hold inhaler 1 to 2 inches in front of your mouth (a bout the width of two fingers). C. Put the inhaler in your mouth. Do not use f or steroids. B. Use a spacer/holding

chamber. These come in man y shapes and can be useful to any patient. Getting ready 1. Take off the cap and shake the inhaler. 2. Breathe out all the way. 3. Hold your inhaler the way your doctor said (A, B, or C below). Breathe in slowly 4. As you start breathing in slowly through your mouth, press down on the inhaler one time. (If you use a holding chamber, first press down on the inhaler. Within5 seconds, beg in to brea the in slowl y.) 5. Keep breathing in slowly, as deeply as you can. Hold your breath 6. Hold your breath as you count to 10 slowly, if you can. 7. For inhaled quick-relief medicine (short-acting beta 2 agonists), wait about 15–30 seconds between puffs. There is no need to wait between puffs for other medicines.

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