Dr.

C Caliri

Pediatrics
?
Selection from:
Guidelines for the Diagnosis and ?
Management of Asthma -- Part 2 - 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 hospitalizations.

 Prevent loss of lung function; for children, prevent reduced

lung growth.

 Provide optimal pharmacotherapy with minimal or no adverse

effects of therapy.

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 components, emphasizing 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.
Four Components of Asthma Care
Component 1: Assessing and Monitoring Asthma Severity and
Asthma Control
The functions of assessment and monitoring are closely linked to the
concepts of severity, control, and responsiveness to treatment:
 Severity: the intrinsic intensity of the disease process. Severity
is most easily and directly measured in a patient who is not
receiving long-term control therapy. Severity can also be
measured, once asthma control is achieved, by the step of care
(i.e., the amount of medication) required to maintain control.

 Control: the degree to which the manifestations of asthma are

minimized by therapeutic intervention and the goals of therapy
are met.

 Responsiveness: the ease with which asthma control is

achieved by therapy.
Asthma severity and asthma control include the domains of
current impairment and future risk.
 Impairment: frequency and intensity of symptoms and
functional limitations the patient is currently experiencing or
has recently experienced.

 Risk: the likelihood of either asthma exacerbations,

progressive 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.
The 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
measures assess different manifestations of the disease and may not
correlate with each other.
The concepts of severity and control are used as follows for
managing asthma:
 Assess severity to initiate therapy. See section on "Stepwise
Approach for Managing Asthma" for figures on classifying
asthma severity and initiating therapy 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

Approach for Managing Asthma" for figures on assessing
asthma control and adjusting therapy in different age groups.
Once therapy is initiated, the emphasis for clinical management
thereafter is changed to the assessment of asthma control. The
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 maintained, or
for population-based evaluations or clinical research, asthma
severity can be inferred by correlating the level of severity with
the lowest level of treatment required to maintain control.
Lowest level of treatment required to maintain control

(See "Stepwise Approach for Managing Asthma" for treatment steps.)

Classification of Asthma Severity When Asthma Is Well
Controlled

Intermittent
Persistent

Mild
Moderate
Severe

Step 1
Step 2
Step 3 or Step 4
 Step 5 or Step 6

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
guide decisions for initiating therapy, use information from the
diagnostic evaluation to:
 Classify asthma severity.

 Identify precipitating factors for episodic symptoms (e.g.,

exposure at home, work, daycare, or school to inhalant
allergens or irritants).

 Identify comorbid conditions that may impede asthma

management (e.g., sinusitis, rhinitis, GERD, OSA, obesity,
stress, or depression).

 Assess the patient's knowledge and skills for self-

management.
For periodic monitoring of asthma control to guide decisions for
maintaining or adjusting therapy:
 Instruct patients to monitor their asthma control in an
ongoing manner. All patients should be taught how to
recognize inadequate asthma control.

o Either symptom or peak flow monitoring is appropriate

for most patients; evidence suggests the benefits are
similar.

o Consider daily peak-flow monitoring for patients who

have moderate or severe persistent asthma, patients who
have a history of severe exacerbations, and patients
who poorly perceive airway obstruction or worsening
asthma.

 Monitor asthma control periodically in clinical visits,

because asthma is highly variable over time and therapy may
need to be adjusted (stepped up if necessary, stepped down if
possible). The frequency of monitoring is a matter of
clinical judgment. In general:

o 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.

o 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.

o 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-
assessment of overall asthma control and asthma care.

 Use spirometry to obtain objective measures of lung

function.

o Perform spirometry at the following times:

 At the initial assessment.

 After treatment is initiated and symptoms and

PEF have stabilized.

 During periods of progressive or prolonged loss

of asthma control.

 At least every 1–2 years; more frequently

depending on response to therapy.

o Low FEV1 indicates current obstruction (impairment)

and risk for future exacerbations (risk). For children,
FEV1/forced vital capacity (FVC) appears to be a more
sensitive measure of severity and control in the
impairment domain. FEV1 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) such as

fractionated exhaled nitric 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 partnership between the clinician and the person who has asthma
(and the caregiver, 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 reimbursements.
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 happens to the airways during an asthma attack.

Role of Medications: Understanding the Difference Between:
 Long-term control medications: prevent symptoms, often by
reducing inflammation. Must be taken daily. Do not expect
them to give quick relief.

 Quick-relief medications: SABAs relax airway 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 long-term
control medications.
Patient Skills
 Taking medications correctly

o Inhaler technique (demonstrate to the patient and have

the patient return the demonstration).

o Use of devices, as prescribed (e.g., valved holding

chamber (VHC) or spacer, nebulizer).

 Identifying and avoiding environmental exposures that worsen

the patient's asthma; e.g., allergens, irritants, tobacco smoke.

 Self-monitoring

o Assess level of asthma control.

 o Monitor symptoms and, if prescribed, PEF measures.

o Recognize early signs and symptoms of worsening

asthma.

 Using a written asthma action plan to know when and how to:

o Take daily actions to control asthma.

o Adjust medication in response to signs of worsening

asthma.

 Seeking medical care as appropriate.

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
instructions for both daily management (long-term control
medication, if appropriate, and environmental control measures)
and actions to manage worsening asthma (what signs, symptoms,
and PEF measurements (if used) indicate worsening asthma; what
medications to take in response; 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., requiring treatment at step 4, 5, or 6), a
history of severe exacerbations, or poorly controlled asthma. See
figures 5 and 6 for samples of written asthma action plans.

Integrate asthma self-management education into all aspects of

asthma care. Asthma self management requires repetition and
reinforcement. It should:
  Begin at the time of diagnosis and continue through followup
care. See figure 7, "Delivery of Asthma Education by
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 patients and their families.

 Occur at all points of care where health care professionals

interact with patients who have asthma. The strongest 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 reading level 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 have poorly
controlled asthma and have recurrent visits to the emergency
department or hospital. This will provide tailored self-
management education and skills training.
Encourage patients' adherence to the written asthma action 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.

 Reviewing 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 or treatment at

 every visit. Inquire about any difficulties encountered 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 ethnocultural practices.
Encourage health care provider and health care system support of
the therapeutic partnership by:
 Incorporating effective clinician education strategies, such as
interactive formats, practice-based case studies, and
multidimensional teaching approaches that reinforce guideline-
based care.

 Providing communication skills training to clinicians to

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

 Using systems approaches, such as clinical pathways and

clinical information system prompts, to improve the quality of
asthma care and to support clinical care decisionmaking.
Component 3: Control of Environmental Factors and Comorbid
Conditions That Affect Asthma
If patients who have asthma are exposed to irritants or inhalant
allergens to which 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
impede asthma management. Recognition and treatment of these
conditions may improve asthma control. See questions in figure 3,
"Suggested Items for Medical History," for questions related to
environmental exposures and comorbid conditions.
Allergens and Irritants
Evaluate the potential role of allergens (particularly inhalant
allergens) and irritants.
 Identify 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 history of symptoms when exposed to the allergen.
Advise patients who have asthma to reduce exposure to allergens
and pollutants or irritants to which they are sensitive.
 See figure 9, "How To Control Things That Make Your
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, dust-mite, and rodent allergens and,
consequently, improve asthma control.

 Advise patients who have severe persistent asthma, nasal

polyps, or a history of sensitivity to aspirin or nonsteroidal
anti-inflammatory drugs (NSAIDs) about their risk of severe
and even fatal exacerbations from using these drugs.

 Indoor air-cleaning devices (high-efficiency particulate air

[HEPA] and electrostatic precipitating filters), cannot
substitute for more effective dust-mite and cockroach control
measures because these 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 persistent 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
subcutaneous immunotherapy 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 be administered only in a physician's office where
facilities and trained personnel are available to treat any life-
threatening reaction that can, but rarely does, occur.
Consider inactivated influenza vaccination for patients who have
asthma. This vaccine is safe for administration to children over 6
months of age and adults, and the Advisory Committee on
Immunization Practices of the Centers for Disease Control and
Prevention (CDC) recommends vaccination for persons who have
asthma because they are considered to be at risk for 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. Food
allergenies are rarely an aggravating factor in asthma. An exception is
that sulfites in foods (e.g., shrimp, dried fruit, processed potatoes,
beer, and wine) can precipitate asthma symptoms in people who are
sensitive to these food items. Furthermore, individuals who have both
food allergy and asthma are at increased risk for fatal anaphlylactic
reactions to the food to which they are sensitized.
Comorbid Conditions
Identify and treat comorbid conditions that may impede asthma
management. If these conditions are treated appropriately, asthma
control may improve.
 Allergic Bronchopulmonary Aspergillosis (ABPA) may be
considered in patients who have asthma and a history of
pulmonary infiltrates, immunoglobulin 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 have 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 have
poorly controlled asthma, especially with nighttime symptoms.
Treatment includes: avoiding heavy meals, fried foods,
caffeine, and alcohol; avoiding food and drink within 3 hours
of retiring; elevating the head of the bed on 6- to 8-inch blocks;
using proton pump inhibitor medication.

 Obese or overweight patients who have asthma may be

advised that weight loss, in addition to improving overall
health, might also improve asthma control.

 Obstructive Sleep Apnea (OSA) may be considered in

patients who have not well controlled asthma, particularly
those who are overweight or obese. Treatment for OSA is nasal
continuous positive air way pressure (CPAP). However, this
 treatment may disrupt the sleep of asthma patients who do not
also have OSA. Accurate diagnosis is important.

 Rhinitis or sinusitis symptoms or diagnosis should be

evaluated in patients who have asthma, because the
interrelationship of the upper and lower airway suggests that
therapy for the upper airway will improve asthma control.
Treatment of allergic rhinitis includes intranasal
corticosteroids, antihistamine therapy, and the consideration of
immunotherapy. Treatment of sinusitis includes intranasal
corticosteroids and antibiotics. Evidence is inconclusive
regarding the effect on asthma of sinus surgery in patients who
have chronic rhinosinusitis.

 Stress and depression should be considered in patients who

have asthma that is not well controlled. Additional education to
improve self-management and coping skills may be helpful.
Editor's Note: Fourth Component discussed separately in Part 3:
Medications.