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National Institutes of Health (NIH) NAEPP 2007 Asthma Guideline UPDATE. Susan K. Ross RN, AE-C MDH Asthma Program 651-201-5629 [email protected] http://www.nhlbi.nih.gov/guidelines/asthma/index.htm.

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National institutes of health nih naepp 2007 asthma guideline update l.jpg

National Institutes of Health (NIH) NAEPP 2007 Asthma GuidelineUPDATE

Susan K. Ross RN, AE-C

MDH Asthma Program

651-201-5629

[email protected]


Http www nhlbi nih gov guidelines asthma index htm l.jpg

http://www.nhlbi.nih.gov/guidelines/asthma/index.htm

National Institutes of HealthNational Asthma Education Prevention Program(NAEPP)

2007

Guidelines for the Diagnosis and Management of Asthma (EPR-3)

National Asthma Education and Prevention Program


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School Nurses

“School nurses are an important component of the health care system for children and play a critical role in identifying solutions to the health problems faced by today’s children and families”.

The Journal of School Nursing, June 2007, Vol.23, Num. 3


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What Is Asthma?

“Asthma is a common chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation. This interaction can be highly variable among patients and within patients over time”.

2007 NAEPP Guidelines, EPR 3- Section 2, p 12.


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Airway Inflammation

Airway Obstruction (reversible)

Hyperresponsiveness (irritability of airways)

Characteristics of Asthma




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Asthma:

  • Accounts for 12.8 million lost school days annually 1(2003)

  • 67% of US children with asthma have had at least one attack in the past year 1(2005)

  • Is the 3rd leading cause of hospitalizations among children under 15 2

  • Close to 1 in 11 (8.9%) children have asthma 1 (2005)

  • 6.5 million children under 18 have asthma 1

    1 National Health Interview Survey; Asthma Prevalence, Health Care Use, and Mortality, 2000-01, National Center for Health Statistics, CDC

    2 National Hospital Discharge Survey, 2002; American Lung Association Asthma and Children Fact Sheet, August 2006


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Asthma Prevalence

Adapted from Akinbami L. Advance Data 2006


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This means..

In a class of 30 children, you can expect

2 to 3 students WILL have asthma

This number will vary depending on age and geographical location


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“Children & Asthma In America” Survey - 2004

  • The Children and Asthma in America survey focused on children 4 to 18 years of age with asthma, which represents about 5.8 million children in the country based on figures from the 2002 National Health Interview Survey.

  • A survey of a national probability sample of 801 children 4 to 18 years of age who currently have asthma, conducted from February to May 2004.

  • The survey found that nearly 1 out of 10 (9.2%) American children 18 years of age and younger currently suffer from asthma.

  • The Children and Asthma in America survey concludes that a significant number of children with asthma do not have their condition under control, falling far short of national treatment goals.

    Excerpts taken from www.asthmainamerica.com, “Children & Asthma in America”, 2004 Glaxo-SmithKline



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Asthma Guidelines: History and Context

  • Initial guidelines released in 1991 and updated in 1997

  • Updated again in 2002 (EPR-2) with a focus on several key questions about medications, monitoring and prevention.

    • Long-term management of asthma in children

    • Combination therapy

    • Antibiotic use

    • Written asthma action plans (AAP) and peak flow meters (PFM)

    • Effects of early treatment on the progression of asthma


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Old and New Asthma Guidelines:What Has NOT Changed

  • Initial asthma therapy is determined by assessment of asthma severity.

    • Ideally, before the patient is on a long-term controller.

  • Stepping therapy up or down is based on how well asthma is controlled or not controlled .

  • Inhaled corticosteroids (ICS) are the preferred first-line therapy for asthma.

  • Systemic steroids can still be used to treat asthma exacerbations.

  • Peak flows and written asthma action plans are recommended for asthma self management .

    • Especially in moderate and severe persistent asthma, or those with a history of severe exacerbations or poorly controlled asthma.


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Asthma Therapy Goals

“The goal of asthma therapy is to control asthma so patients can live active, full lives while minimizing their risk of asthma exacerbations and other problems”

Dr. William Busse, MD., chairman of the NAEPP EPR -3


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2007 - Guidelines For The Diagnosis & Management of Asthma (EPR-3)

  • (Almost) no new medications.

  • Restructuring into “severity” and “control” .

  • Domains of “impairment” and “risk”.

  • Six treatment steps (step-up/step-down).

  • More careful thought into ongoing management issues.

  • Summarizes extensively-validated scientific evidence that the guidelines, when followed, lead to a significant reduction in the frequency and severity of asthma symptoms and improve quality of life.


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New Strategies of the EPR-3 (EPR-3)Summary

EPR-3, Page 36-38


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Key Points: Definition, Pathophysiology & Pathogenesis (EPR-3)

  • Asthma is a chronic inflammatory disorder of the airways.

  • The immunohistopathologic features of asthma include inflammatory cell infiltration.

  • Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity.

  • In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis. (remodeling)


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Key Points: Continued.. (EPR-3)

  • Gene-by-environment interactions are important to the expression of asthma.

  • Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma.

  • Viral respiratory infections are one of the most important causes of asthma exacerbation and may also contribute to the development of asthma.

    EPR 3, Section 2: Page 11


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Key (EPR-3)Differences from 1997 & 2002 Reports

  • The critical role of inflammation is validated - there is considerable variability in the pattern of inflammation indicating phenotypic differences that may influence treatment responses. (in other words – genetics)

  • Gene-by-environmental interactions are affect the development of asthma. Of the environmental factors, allergic reactions are important. Viral respiratory infections are key and have an expanding role in these processes.

  • The onset of asthma for most patients begins early in life with the pattern of disease persistence determined by early, recognizable risk factors including atopic disease, recurrent wheezing, and a parental history of asthma.

  • Current asthma treatment with anti-inflammatory therapy does not appear to prevent progression of the underlying disease severity.

    EPR 3 – section 2, p. 12


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Causes – We Don’t Know…Yet! (EPR-3)

  • Asthma has dramatically risen worldwide over the past decades, particularly in developed countries, and experts are puzzled over the cause of this increase.

  • Not all people with allergies have asthma, and not all cases of asthma can be explained by allergic response.

  • Asthma is most likely caused by a convergence of factors that can include genes (probably several) and various environmental and biologic triggers (e.g., infections, dietary patterns, hormonal changes in women, and allergens).


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The 4 Components Of Asthma Management - (Section 3) (EPR-3)

  • Component 1: Measures of Asthma Assessment and Monitoring

  • Component 2: Education for a Partnership in Asthma Care

  • Component 3: Control of Environmental Factors and Comorbid Conditions That Affect Asthma

  • Component 4: Medications


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Component 1 (EPR-3)

Measures of Asthma Assessment & Monitoring


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Key Points - (EPR-3)Overview: Measures Of Asthma Assessment & Monitoring

Assessment and monitoring are closely linked to the concepts of severity, control, and responsiveness to treatment:

  • Severity - intensity of the disease process. Severity is measured most easily and directly in a patient not receiving long-term-control therapy.

  • Control - degree to which asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met.

  • Responsiveness - the ease with which asthma control is achieved by therapy.

    EPR -3 , Pg. 36, Section 3, Component 1: Measures of Asthma Assessment and Monitoring


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Key Points – (EPR-3)Cont. 2Severity & Control Are Assessed Based On 2 Domains

  • Impairment (Present):

    • Frequency and intensity of symptoms

    • Functional limitations (quality of life)

  • Risk (Future):

    • Likelihood of asthma exacerbations or

    • Progressive loss of lung function (reduced lung growth)

    • Risk of adverse effects from medication

      EPR -3, Pg. 38-80, 277-345


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Key Points - (EPR-3)Cont. 3Severity & Control are used as follows for managing asthma:

  • If the patient is not currently on a long-term controller at the first visit:

    • Assess asthma severity to determine the appropriate medication & treatment plan.

  • Once therapy is initiated, the emphasis is changed to the assessment of asthma control.

    • The level of asthma control will guide decisions either to maintain or adjust therapy.


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Key (EPR-3)Differences: Component 1 - Overview

  • The key elements of assessment and monitoring include the concepts of severity, control, and responsiveness to treatment:

    • Classifying severity for initiating therapy.

    • Assessing control for monitoring and adjusting therapy.

    • Asthma severity and control are defined under domains of impairment and risk.

  • The distinction between the domains of impairment and risk for assessing severity and control emphasizes the need to consider separately asthma’s effects on quality of life and functional capacity on an ongoing basis and the risks it presents for adverse events in the future, such as exacerbations and progressive loss of pulmonary function.


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Assessing Impairment (EPR-3)(Present) Domain

  • Assess by taking a careful, directed history and lung function measurement.

  • Assess Quality of Life using standardized questionnaires

    • Asthma Control Test (ACT)

    • Childhood Asthma Control Test

    • Asthma Control Questionnaire

    • Asthma Therapy Assessment Questionnaire (ATAQ) control index.

  • Some patients, appear to perceive the severity of airflow obstruction poorly.


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Assessing Risk (Future) (EPR-3)Domain

  • Of adverse events in the future, especially of exacerbations and of progressive, irreversible loss of pulmonary function—is more problematic (airway remodeling).

  • The test most used for assessing the risk of future adverse events is spirometry.



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Key Points – Diagnosis of Asthma (EPR-3)

To establish a diagnosis of asthma the clinician should determine that:

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

  • Airflow obstruction is at least partially reversible.

  • Alternative diagnoses are excluded.

    Recommended methods to establish the diagnosis are:

  • Detailed medical history.

  • Physical exam focusing on the upper respiratory tract, chest, and skin.

  • Spirometry to demonstrate obstruction and assess reversibility, including in children 5 years of age or older.

  • Additional studies to exclude alternate diagnoses.


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Key (EPR-3)Differences – Diagnosis

  • Discussions added on use of spirometry, especially in children and on criteria for reversibility.

  • Information added on vocal cord dysfunction and cough variant asthma as alternative diagnosis.

  • References added about conditions that complicate diagnosis and treatment. EPR -3, Sec.3, Pg. 41


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Key Indicators: (EPR-3)Diagnosis of Asthma

  • Wheezing – high-pitched whistling sounds when breathing out.

  • History of (any):

    • Cough, worse particularly at night

    • Recurrent wheeze

    • Recurrent difficulty in breathing

    • Recurrent chest tightness

  • Symptoms occur or worsen in the presence of known triggers.

  • Symptoms occur or worsen at night awakening patient.



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Key Points - Initial Assessment: Severity (EPR-3)

  • Once diagnosis is established:

    • Identify precipitating factors (triggers).

    • Identify comorbidities that aggravate asthma

    • Assess patient’s knowledge & skills for self-management.

    • Classify severity using impairment & risk domains.

  • Pulmonary function testing (spirometry) to assess severity. EPR -3, Sec. 3, pg. 47


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Key (EPR-3)Differences – Initial Assessment & Severity

  • Severity class for asthma changed mildintermittent to intermittent.

  • Severity class is defined in terms of 2 domains – impairment & risk .

  • New emphasis on using FEV1 /FVC is added to classify severity in children because it may be a more sensitive measure than FEV1.

    EPR-3 Sec.3, Pg. 48


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Previous Guidelines (EPR-3)

Frequency of daytime symptoms

Frequency of nighttime symptoms

Lung function

2007 Guidelines

Impairment

Frequency of daytime /nighttime symptoms

Quality of life assessments

Frequency of SABA use

Interference with normal activity

Lung function (FEV1/FVC)

Risk

Exacerbations (frequency and severity)

Assessment of Asthma Severity


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Classification of Asthma Severity: Clinical Features Before Treatment – 2002 “Old” Guidelines

Days With Nights With PEF or PEF

Symptoms Symptoms FEV1 Variability

Step 4Continuous Frequent 60% 30%

Severe

Persistent

Step 3Daily >1night/week 60%-<80% 30%

Moderate

Persistent

Step 2>2/week, <1x/day >2 nights/month 80% 20-30%

Mild

Persistent

Step 12 days/week 2/month 80% 20%

Mild

Intermittent

Footnote: The patient’s step is determined by the most severe feature.


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NOT Currently Taking Controllers Treatment – 2002 “Old” Guidelines

Level of severity is determined by both impairment a & risk. Assess impairment by caregivers recall of previous 2-4 weeks.


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NOT Currently Taking Controllers Treatment – 2002 “Old” Guidelines


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NOT Currently Taking Controllers Treatment – 2002 “Old” Guidelines


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Classifying Severity AFTER Control Treatment – 2002 “Old” Guidelines is Achieved – All Ages

(already on controller)


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Periodic Assessment & Monitoring Treatment – 2002 “Old” Guidelines

Asthma Control


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Key Points – Treatment – 2002 “Old” GuidelinesAsthma Control (Goals of Therapy)

Reducing impairment

  • Prevent chronic & troublesome symptoms.

  • Prevent frequent use (< 2 days /wk) of inhaled SABA for symptoms.

  • Maintain (near) “normal” pulmonary function.

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

  • Meet patients’ and families’ expectations of and satisfaction with asthma care.

EPR- 3, p. 50


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Key Points – Cont. Treatment – 2002 “Old” Guidelines

Reducing Risk

  • Prevent recurrent exacerbations of asthma and minimize the need for ER visits and hospitalizations.

  • Prevent progressive loss of lung function - for children, prevent reduced lung growth.

  • Provide optimal pharmacotherapy with minimal or no adverse effects.

  • Periodic assessments at 1-6 month intervals.

  • Patient self-assessment (w/clinician).

  • Spirometry testing.

    NAEPP 2007 guidelines, sec. 3, p. 53


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    Key Points Cont. - Written AAP’s & PFM Treatment – 2002 “Old” Guidelines

    • Provide to all patients a written AAP based on signs and symptoms and/or PEF.

      • Written AAPs are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations or poorly controlled asthma”.

    • “Whether PF monitoring, symptoms monitoring (available data show similar benefits for each), or a combo of approaches is used, self- monitoring is important to the effective self-management of asthma” .

      EPR -3 Sec. 3, P.53


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    Peak Flow Monitoring Treatment – 2002 “Old” Guidelines

    Long-term daily PF monitoring can be helpful to:

    Detect early changes in asthma control that require adjustments in treatment:

    • Evaluate responses to changes in treatment

    • Provide a quantitative measure of impairment

      NAEPP 2007 guidelines Sec. 3, P.54


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    Key Treatment – 2002 “Old” GuidelinesDifferences – Assessing/ Monitoring Control

    • Periodic assessment of asthma control is emphasized.

    • A stronger distinction between classifying asthma severity and assessing asthma control.

      EPR-3 clarifies the issue:

      • For initiating treatment, asthma severity should be classified, and the initial treatment should correspond to the appropriate severity category.

      • Once treatment is established, the emphasis is on assessing asthma control to determine if the goals for therapy have been met and if adjustments in therapy (step up or step down) would be appropriate.

        EPR-3, Sec.3 Pg.54


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    Key Treatment – 2002 “Old” GuidelinesDifferences Cont.

    • Assessment of asthma control includes the two domains of impairment and risk.

    • Peak flow monitoring:

      • Assessing diurnal variation was deleted.

      • Patients are most likely to benefit from routine peak flow monitoring.

      • Evidence suggests equal benefits to either peak flow or symptom-based monitoring; the important issue continues to be having a monitoring plan in place.

    • Parameters for lung function, specifically FEV1/FVC, were added as measures of asthma control for children.


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    Asthma Control = Asthma Goals Treatment – 2002 “Old” Guidelines

    • Definition of asthma control is the same as asthma goals(slides #44 & 45) reducing impairment and risk.

    • Monitoring quality of life, any:

      • work or school missed because of asthma?

      • reduction in usual activities?

      • disturbances in sleep due to asthma?

      • Change in caregivers activities due to a child's asthma?

        There are quality of life assessment tools listed (p.62)


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    Ask the patient: Treatment – 2002 “Old” Guidelines

    Has your asthma awakened you at night or early morning?

    Have you needed more quick-relief medication (SABA) than usual?

    Have you needed any urgent medical care for your asthma, such as unscheduled visits to your provider, an UC clinic, or the ER?

    Are you participating in your usual and desired activities?

    If you are measuring your peak flow, has it been below

    your personal best?

    Responsiveness -

    Questions for Assessing Asthma Control

    Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.” 1995


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    Responsiveness - Actions Treatment – 2002 “Old” Guidelines

    • Actions to consider:

    • Assess whether the medications are being taken as prescribed.

    • Assess whether the medications are being inhaled with correct technique.

    • Assess lung function with spirometry and compare to previous measurement.

    • Adjust medications, as needed; either step up if control is inadequate or step down if control is maximized, to achieve the best control with the lowest dose of medication.

    Adapted from Global Initiative for Asthma: Pocket Guide for Asthma Management & Prevention.” 1995




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    Figure 3–5c. Assessing Asthma Control In Youths  11 Years of Age12 Years of Age & Adults


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    Component 2 11 Years of Age

    Education For A Partnership In Asthma Care


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    Key Points - Education 11 Years of Age

    • Self management education is essential and should be integrated into all aspects of care & requires repetition and reinforcement.

    • Provide all patients with a written asthma action plan that includes 2 aspects:

      • Daily management

      • How to recognize & handle worsening asthma symptoms

    • Regular review of the status of patients asthma control.

      • Teach & reinforce at every opportunity

    • Develop an active partnership with the patient and family.

      EPR – 3, Section 3, Pg. 93


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    Key Points – Education Cont. 11 Years of Age

    • Encourage adherence by:

      • Choosing a tx regimen that achieves outcomes and addresses preferences important to the patient.

      • Review the success of tx plan and make changes as needed.

    • Tailor the plan to needs of each patient.

    • Encourage community based interventions.

    • Asthma education provided by trained health professionals should be reimbursed and considered an integral part of effective asthma care ! (AE-C)


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    Key 11 Years of AgeDifferences –- Patient Education

    • Emphasis on the many points of care & sites available to provide education including efficacy of self management education outside the office setting.

    • Greater emphasis on the 2 aspects of written AAP:

      1) daily management

      2) how to recognize & handle worsening symptoms including adjustment of medication dose.

    • New sections on impact of cultural and ethnic factors & health literacy that affect education.


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    Educational Interventions In The School Setting 11 Years of Age

    • Implementation of comprehensive, proven school-based asthma education programs should be provided to children who have asthma to learn asthma self-management skills and help provide an “asthma-friendly” learning environment.

      EPR -3, Sec. 3, Pg. 107


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    Key Educational Messages 11 Years of Age

    • Significance of diagnosis

    • Inflammation as the underlying cause

    • Controllers vs. quick-relievers

    • How to use medication delivery devices

    • Triggers, including 2nd hand smoke

    • Home monitoring/ self-management

    • How/when to contact the provider

    • Need for continuous, on-going interaction w/the clinician to step up/down therapy

    • Annual influenza vaccine


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    Other Educational Points of Care 11 Years of Age

    • ER Department & hospital based

    • Pharmacist

    • Community based

    • Home based for caregivers including home based allergen/ environmental assessment

    • Computer based technology

    • Case management for high-risk patients


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    Maintaining The Partnership 11 Years of Age

    Promote open communication w/patient & family by addressing at each visit:

    • Ask early in each visit what concerns they have and what they especially want addressed during the visit.

    • Review short – term goals agreed at initial visit.

    • Review written AAP & steps to take – adjust as needed.

    • Encourage parents to take a copy of the AAP to the school or childcare setting or send a copy to the school nurse!!

    • Teach & reinforce key educational messages.

    • Provide simple, brief, written materials that reinforce the actions and skills taught.


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    Component 3 11 Years of Age

    Control Of Environmental Factors & Comorbid Conditions That Affect Asthma


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    Key Points – Environmental Factors 11 Years of Age

    For patients w/persistent asthma, evaluate the role of allergens.

    All patients w/ asthma should:

    • Reduce, if possible, exposure to allergens they are sensitized and exposed to.

    • Understand effective allergen avoidance is multifaceted and individual steps alone are ineffective.

    • Avoid exertion outdoors when levels of air pollution are high.

    • Avoid use of nonselective beta-blockers.

    • Avoid sulfite-containing and other foods they are sensitive to.

    • Consider allergen immunotherapy.


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    Key Points – Environmental Cont. 11 Years of Age

    • Evaluate a patient for other chronic comorbid conditions when asthma cannot be well controlled.

    • Consider inactivated influenza vaccination for patients w/ asthma.

    • Use of humidifiers are not generally recommended.

    • Employed asthmatics should be asked about possible occupational exposures, particularly those who have new-onset disease. (work related asthma)

    • There is insufficient evidence to recommend any specific environmental strategies to prevent the development of asthma.


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    Key 11 Years of AgeDifferences –Environmental

    • Reducing exposure to inhalant indoor allergens can improve asthma control, a multifaceted approach is required; single steps to reduce exposure are generally ineffective.

    • Formaldehyde and volatile organic compounds (VOCs) are potential risk factors for asthma.

    • Influenza vaccine does not appear to reduce the frequency or severity of asthma exacerbations during the influenza season.

    • Discussion is included on ABPA, obesity, OSA, and stress as chronic comorbid conditions, in addition to rhinitis, sinusitis, and gastroesophageal reflux, that may interfere with asthma management.


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    Component 4 11 Years of Age

    Medications


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    Key Points - Medications 11 Years of Age

    • 2 general classes:

      • Long-term control medications

      • Quick-Relief medications

    • Controller medications:

      • Corticosteroids

      • Long Acting Beta Agonists (LABA’s)

      • Leukotriene modifiers (LTRA)

      • Cromolyn & Nedocromil

      • Methylxanthines: (Sustained-release theophylline)


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    Key Points – Medications Cont. 11 Years of Age

    • Quick- relief medications

      • Short acting bronchodilators (SABA’s)

      • Systemic corticosteroids

      • Anticholinergics


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    Key 11 Years of AgeDifferences - Medications

    • The most effective medications for long-term therapy are those shown to have anti-inflammatory effects.

    • New medications—immunomodulators—are available for long-term control of asthma.

    • New data on the safety of LABAs are discussed, and the position of LABA in therapy has been revised.

    • The estimated clinical comparability of different ICS preparations is updated.

    • The significant role of ICSs in asthma therapy continues to be supported.

      EPR-3, pg. 215


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    Key Points: Safety of ICS’s 11 Years of Age

    • ICS’s are the most effective long-term therapy available, are well tolerated & safe at recommended doses.

    • The potential but small risk of adverse events from the use of ICS treatment is well balanced by their efficacy.

    • The dose-response curve for ICS treatment begins to flatten at low to medium doses.

    • Most benefit is achieved with relatively low doses, whereas the risk of adverse effects increases with dose.


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    Key Points: 11 Years of AgeReducing Potential Adverse Effects

    • Spacers or valved holding chambers (VHCs) used with non-breath-activated MDIs reduce local side effects.

      • But there is no data on use of spacers with ultra fine particle hydrofluoroalkane (HFA) MDIs.

    • Advise patients to rinse their mouths (rinse and spit) after (ICS) inhalation.

    • Use the lowest dose of ICS that maintains asthma control:

      • Evaluate patient adherence and inhaler technique as well as environmental factors that may contribute to asthma severity before increasing the dose of ICS.

    • To achieve or maintain control of asthma, add a LABA to a low or medium dose of ICS rather than using a higher dose of ICS.

    • Monitor linear growth in children.


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    Key Points: 11 Years of AgeSafety of Long-Acting Beta2-Agonists (LABA’s)

    • Adding a LABA to the tx of patients whose asthma is not well controlled on low- or medium-dose ICS improves lung function, decreases symptoms, and reduces exacerbations and use of SABA for quick relief in most patients.

    • The FDA determined that a Black Box warning was warranted on all preparations containing a LABA.

    • For patients who have asthma not sufficiently controlled with ICS alone, the option to increase the ICS dose should be given equal weight to the option of the addition of a LABA to ICS.

    • It is not currently recommended that LABA be used for treatment of acute symptoms or exacerbations.

    • LABAs are not to be used as monotherapy for long-term control.


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    Key Points: Safety of SABA’s 11 Years of Age

    • SABAs are the most effective medication for relieving acute bronchospasm

    • Increasing use of SABA treatment or using SABA >2 days a week for symptom relief (not prevention of EIB) indicates inadequate control of asthma.

    • Regularly scheduled, daily, chronic use of SABA is not recommended.


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    Section 4 11 Years of Age

    Managing Asthma

    Long Term

    “The Stepwise Approach”

    2007 NAEPP Guidelines, EPR-3, pg. 277


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    Key 11 Years of AgeDifferences -Managing Asthma Long Term

    • Recommendations for managing asthma in children 0–4 and 5–11 years of age are presented separately from youths ≥12 years of age and adults.

    • Treatment decisions for initiating long-term control therapy are based on classifying severity (considering both impairment and risk domains) and selecting a corresponding step for treatment.

      • Recommendations on when to initiate therapy in children 0–4 years of age have been revised.

    • Treatment decisions for adjusting therapy and maintaining control are based on assessing the level of asthma control.

      EPR -3, Pg. 279


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    Key 11 Years of AgeDifferences – Cont.

    • Stepwise approach to managing asthma is expanded to include sixsteps of care. Previous guidelines had several progressive actions within step 3 - updated guidelines separate the actions into different steps.

    • Treatment options within the steps have been revised:

      • For patients not well controlled on low-dose ICS’s, increasing the dose of ICSs to medium dose is recommended before adding adjunctive therapy in the 0–4 years age group.

      • For children 5–11 years and youths 12 years and adults, increasing the dose of ICS to medium dose or adding adjunctive therapy to a low dose of ICS are considered as equal options.


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    Key 11 Years of AgeDifferences – Cont.

    • Evidence for the selection of adjunctive therapy is limited in children under 12 years.

    • Recommendations vary according to the assessment of impairment or risk.

    • Steps 5–6 for youths 12 years of age and adults include consideration of omalizumab.

  • Managing special situations expanded to include racial and ethnic disparities.


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    The goal of asthma therapy is to maintain long-term control of asthma with the least amount of medication and hence minimal risk for adverse effects.

    EPR -3, Section 4, Managing Asthma Long Term in Children 0–4 Years of Age and 5–11 Years of Age, P. 284

    Treatment: Principles of “Stepwise” Therapy


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    Principles Of Step Therapy To Maintain Control control of asthma with the least amount of medication and hence minimal risk for adverse effects.

    • Step up if not controlled.

    • If very poorly controlled, consider increase by 2 steps, oral corticosteroids, or both.

    • Before increasing pharmacologic therapy, consider as targets for therapy.

      • Adverse environmental exposures

      • Poor adherence

      • Co-morbidities


    Slide83 l.jpg

    Follow-Up control of asthma with the least amount of medication and hence minimal risk for adverse effects.

    • Visits every 2-6 weeks until control achieved.

    • When control achieved, contact every 3-6 months.

    • Step-down in therapy:

      • With well-controlled asthma for at least 3 months.

      • Patients may relapse with total discontinuation or reduction of inhaled corticosteroids.


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    Assessing Control & Adjusting Therapy control of asthma with the least amount of medication and hence minimal risk for adverse effects.Children 0-4 Years of Age


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    Step up if needed control of asthma with the least amount of medication and hence minimal risk for adverse effects.

    (first check adherence, environmental control)

    Step down if possible

    (and asthma is well controlled at least 3months)

    Stepwise Approach for Managing Asthma in Children 0-4 Years of Age

    Intermittent

    Asthma

    Persistent Asthma: Daily Medication

    Consult asthma specialist if step 3 care or higher is required.

    Consider consultation at step 2

    Step 6

    Preferred

    High

    Dose ICS

    AND

    Either:

    Montelukast or LABA

    AND

    Oralcorticosteroid

    Step 5

    Preferred

    High

    Dose ICS

    AND

    Either:

    Montelukast or LABA

    Step 4

    Preferred

    Medium Dose ICS

    AND

    Either:

    Montelukast or LABA

    Step 3

    Preferred

    Medium Dose ICS

    Assess control

    Step 2

    Preferred

    Low dose ICS

    AlternativeMontelukast or Cromolyn

    Step 1

    Preferred

    SABA PRN

    Patient Education and Environmental Control at Each Step

    Quick-relief medication for ALL patients -SABA as needed for symptoms.

    With VURI: SABA every 4-6 hours up to 24 hours.

    Consider short course of corticosteroids with (or hx of) severe exacerbation


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    Assessing Control & Adjusting Therapy control of asthma with the least amount of medication and hence minimal risk for adverse effects.Children 5-11 Years of Age


    Slide87 l.jpg

    Step 6 control of asthma with the least amount of medication and hence minimal risk for adverse effects.

    Step 5

    Preferred

    High Dose ICS

    + LABA

    + oral corticosteroid

    Alternative

    High dose ICS + either LTRA, or Theophylline

    + oral corticosteroid

    Step up if needed

    (first check adherence, environmental control, and comorbid conditions)

    Preferred

    High Dose ICS + LABA

    Alternative

    High dose ICS + either LTRA, or

    Theophylline

    Step 4

    Step 3

    Preferred

    Medium Dose ICS + LABA

    Alternative

    Medium dose ICS + either LTRA, or

    Theophylline

    Step 2

    Preferred

    Either

    Low Dose ICS + LABA, LTRA, or Theophylline

    OR

    Medium Dose ICS

    Preferred

    Low dose ICS

    Alternative

    LTRA, Cromolyn

    Nedocromil or

    Theophylline

    Step 1

    Preferred

    SABA PRN

    Step down if possible

    (and asthma is well controlled at least 3 months)

    Stepwise approach for managing asthma in children 5-11 years of age

    Intermittent

    Asthma

    Persistent Asthma: Daily Medication

    Consult asthma specialist if step 4 care or higher is required.

    Consider consultation at step 3

    Assess control

    Patient Education and Environmental Control at Each Step

    Quick-relief medication for ALL patients

    SABA as needed for symptoms.

    Short course of oral corticosteroids maybe needed.


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    Assessing Control & Adjusting Therapy control of asthma with the least amount of medication and hence minimal risk for adverse effects. In Youths > 12 Years of Age & Adults


    Slide89 l.jpg

    Step up if needed control of asthma with the least amount of medication and hence minimal risk for adverse effects.

    (first check adherence, environmental control & comorbid conditions)

    Step down if possible

    (and asthma is well controlled at least 3months)

    Stepwise Approach for Managing Asthma in Youths >12 Years of Age & Adults

    Intermittent

    Asthma

    Persistent Asthma: Daily Medication

    Consult asthma specialist if step 4 care or higher is required.

    Consider consultation at step 3

    Step 6

    Preferred

    High dose ICS + LABA + oral corticosteroid

    AND

    Consider Omalizumab for patients who have allergies

    Step 5

    Preferred

    High

    Dose ICS + LABA

    AND

    Consider Omalizumab for patients who have allergies

    Step 4

    Preferred:

    Medium Dose ICS + LABA

    Alternative:

    Medium-dose ICS + either LTRA, Theophylline, or Zileuton

    Step 3

    Preferred:

    Low-dose ICS + LABA

    OR – Medium dose ICS

    Alternative: Low-dose ICS +either LTRA, Theophylline, or Zileuton

    Assess control

    Step 2

    Preferred:

    Low dose ICS

    Alternative: Cromolyn, LTRA, Nedocromil or Theophylline

    Step 1

    Preferred:

    SABA PRN

    Each Step: Patient Education and Environmental Control and management of comorbidities

    Steps 2 – 4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma

    • Quick-relief medication for ALL patients -SABA as needed for symptoms: up to 3 tx @ 20 minute intervals prn. Short course of o systemic corticosteroids may be needed.

    • Use of SABA >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control & the need to step up treatment.


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    Section 5 control of asthma with the least amount of medication and hence minimal risk for adverse effects.

    Managing Exacerbations of Asthma

    2007 Asthma Guidelines, EPR – 3, Pg. 373


    Key points managing exacerbations l.jpg
    Key Points – control of asthma with the least amount of medication and hence minimal risk for adverse effects.Managing Exacerbations

    Early treatment of asthma exacerbations is the best strategy for management.

    • Patient education includes a written asthma action plan to guide patient self‑management of exacerbations.

      • especially for patients who have moderate or severe persistent asthma and any patient who has a history of severe exacerbations.

    • A peak‑flow‑based plan for patients who have difficulty perceiving airflow obstruction and worsening asthma.

      EPR -3 Pg. 373


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    Key Points – Cont. control of asthma with the least amount of medication and hence minimal risk for adverse effects.

    • Recognition of early signs of worsening asthma & taking prompt action.

    • Appropriate intensification of therapy, often including a short course of oral corticosteroids.

    • Removal of the environmental factors contributing to the exacerbation.

    • Prompt communication between patient and clinician about any serious deterioration in symptoms or peak flow, decreased responsiveness to SABAs, or decreased duration of effect.


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    Key Differences From 1997 & 2002 Expert Panel Reports control of asthma with the least amount of medication and hence minimal risk for adverse effects.

    For the treatment of exacerbations, the current update:

    • Simplifies classification of severity of asthma exacerbations.

    • Adds levalbuterol as a SABA treatment for asthma exacerbations.

    • For home management of exacerbations, no longer recommendsdoubling the dose of ICSs.

    • For prehospital management (e.g., emergency transport), encourages standing orders for albuterol and—for prolonged transport—repeated treatments and protocols to allow consideration of ipratropium and oral corticosteroids.

    • For ED management, reduces dose and frequency of oral corticosteroids in severe exacerbations, adds consideration of magnesium sulfate or heliox for severe exacerbations, and adds consideration of initiating an ICS upon discharge.


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    Exacerbations Defined control of asthma with the least amount of medication and hence minimal risk for adverse effects.(Risk)

    • Are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness — or some combination of these symptoms.

    • Are characterized by decreases in expiratory airflow that can be documented and quantified by spirometry or Peak expiratory flow.

      • These objective measures more reliably indicate the severity of an exacerbation than does the severity of symptoms.




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    What The EPR -3 SettingDoes NOT Recommend

    • Drinking large volumes of liquids or breathing warm, moist air (e.g., the mist from a hot shower).

    • Using over-the-counter products such as antihistamines or cold remedies.

    • Although pursed-lip and other forms of controlled breathing may help to maintain calm during respiratory distress, these methods do not bring about improvement in lung function.

      EPR -3 , P.384


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    Many Thanks To - Setting

    Colleagues who shared their power point presentations and/or provided feedback on this presentation:

    • Dr. Gail M Brottman MD, Director, Pediatric Pulmonary Medicine, HCMC

    • Dr. Don Uden, Pharm. D., Professor, University of Minnesota, College of Pharmacy

    • Dr. Barbara P. Yawn, MD, MSc, Director of Research, Olmsted Medical Clinic

    • Dr. Mamta Reddy, MD, Chief

      Allergy/ Immunology, Bronx Lebanon Hospital Center, NY

    • Mary Bielski, RN, LSN, CNS, Nursing Service Manager, Minneapolis Public Schools


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    Minnesota Department of Health SettingAsthma Program

    www.health.state.mn.us/asthma


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