Classification of Chronic Asthma Severity on Treatment

1. PCCP Council on Asthma Classification of Chronic Asthma Severity on Treatment *Objective measures take precedence over subjective complaints. The higher severity level of any domain will be the basis of the final severity level. **Patients who are high risk for asthma-related deaths are initially classified here PCRADM 2004

2. PCCP Council on Asthma Controller Medications • Inhaled glucocorticosteroids • Long-acting inhaled β2-agonists • Systemic glucocorticosteroids • Leukotriene modifiers • (Sustained Release) Theophylline • Cromones • Long-acting oral β2-agonists • Anti-IgE

3. PCCP Council on Asthma Reliever Medications • Rapid-acting inhaled β2-agonists • Systemic glucocorticosteroids (acute setting) • Anticholinergics • Theophylline • Short-acting oral β2-agonists

4. PCCP Council on Asthma Assessing Control Levels of Asthma Control GINA. 2007. Available at: http://www.ginaasthma.org

5. PCCP Council on Asthma Level of Control Treatment Action Reduce Treating to achieve Control Increasee Reduce Increase Treatment Steps (in the order of increasing efficacy to attain control) Step 1 Step 2 Step 3 Step 4 Step 5 GINA. 2007. Available at: http://www.ginaasthma.org.

6. PCCP Council on Asthma Treatment Steps (in the order of increasing efficacy to attain control) Increase Reduce Step 1 Step 2 Step 3 Step 4 Step 5 In the local setting, for the majority of symptomatic patients, the consensus is to start at step 3, with low doses of a fixed-dose ICS+LABA combination inhaler. GINA. 2007. Available at: http://www.ginaasthma.org.

7. PCCP Council on Asthma Single inhaler maintenance and relief therapy strategy • If a combination inhaler containing formoterol and budesonide is selected, it may be used for both rescue and maintenance. • This approach has been shown to result in : • Reductions in exacerbations • Improvements in asthma control in adults and adolescents at relatively low doses of treatment (Evidence A)

8. PCCP Council on Asthma Treating to Achieve Asthma Control • Additional Step 3 Options for Adolescents and Adults : • Increase to medium-dose inhaled gluco-corticosteroid (Evidence A) • Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A) • Low-dose sustained-release theophylline (Evidence B)

9. PCCP Council on Asthma Treating to Achieve Asthma Control • Asthma control should be monitored by the health care professional & by the patient. • Improvement begins within days of initiating controller treatment but the full benefit may only be evident after 3 to 4 months • When control as been achieved, ongoing monitoring is essential to: • - maintain control • - establish lowest step/dose treatment

10. PCCP Council on Asthma Stepping Down Treatment when Asthma is Controlled Monitoring to maintain Control Low-dose ICS Med to high-dose ICS ICS-LABA Reduce by 50 % Every 3 months Reduce ICS by 50 % Maintain LABA dose Decrease to Once daily dosing Decrease to Once daily dosing Further reduce ICS dose or Stop LABA and continue ICS or Decrease ICS-LABA to Once daily dosing

11. PCCP Council on Asthma Stepping Up Treatment in Response to Loss of Control • Treatment has to be adjusted periodically in response to worsening control which may be recognized by the minor recurrence or worsening of symptoms • Treatment options : • Rapid-onset, short-acting or long-acting bronchodilators : repeated dosing provides temporary relief • A four-fold or greater increase in inhaled gluco-corticosteroids

12. PCCP Council on Asthma Algorithmic Approach to Asthma Assessment and Management Patient with Asthma presenting with symptoms Yes Classify and Treat based on Severity Classification of Asthma in Acute Exacerbation In Acute exacerbation ? No Partly controlled? Currently on Controller Medications? Yes Assess level of control Yes Go 1 step higher No Poorly or uncontrolled? Yes Go 2 steps higher No Classify according to PCRADM Chronic Severity Classified as Severe ? Yes Yes Treat as Severe Persistent Asthma Controller medication naive ? No Treat as Mild-to-Moderate Persistent Asthma

13. PCCP Council on Asthma Asthma Exacerbations • Episodes of progressive worsening of SOB, cough, wheezing or chest tightness or some combination of these symptoms • Significant decreases in PEF or FEV1 which are more reliable indicators of severity of airflow obstruction than degree of symptoms • Range from mild to life-threatening deterioration usually progresses over hours or days, or precipitously over some minutes

14. PCCP Council on Asthma Severity of Asthma Exacerbations

15. PCCP Council on Asthma Features of Patients at high-risk for Asthma-Related Death • Current use of or recent withdrawal from systemic corticosteroids • ER visit for asthma in the past year • History of near-fatal asthma requiring intubation or mechanical intubation • Not currently using inhaled steroids • Overdependence on rapid acting inhaled 2 agonists, esp. those with more than one canister monthly • Psychiatric disease or psychosocial problems, incl. the use of sedatives • Noncompliance with asthma medication plan

16. PCCP Council on Asthma Management of Asthma Exacerbations • Primary therapies for exacerbations: • Repetitive administration of rapid-acting inhaled β2-agonist • Early introduction of systemic glucocorticosteroids • Oxygen supplementation • Closely monitor response to treatment with serial measures of lung function

17. PCCP Council on Asthma Criteria for hospitalization • Inadequate response to therapy within 1-2 hours • Persistent PEF <50% after 1 hour of treatment • Presence of risk factors • Prolonged symptoms prior to ER consult • Inadequate access to medical care and medications • Difficult home condition • Difficulty in obtaining transport to hospital in event of further deterioration

18. PCCP Council on Asthma Asthma Exacerbations & Hospitalization • Despite appropriate therapy, ~ 10 to 25 % of ER patients with acute asthma will require hospitalization. • Response to initial treatment in the ER is a better predictor of the need for hospitalization than is severity on presentation • FEV1 or PEF appears to be more useful in adults for categorizing severity of exacerbation & response to treatment.

19. PCCP Council on Asthma Management of Acute Exacerbations : Hospital Setting Initial Assessment : History, PE, PEF or FEV1, SaO2 • PEF or FEV1 ≥ 40 % predicted • Oxygen to achieve SaO2 ≥ 90% • Inhaled SABA by nebulizer or MDI with valve holding chamber • up to 3 doses in 1st hour • PEF or FEV1  40 % predicted • Oxygen to achieve SaO2 ≥ 90% • High-dose inhaled SABA + ipratropium by nebulizer or MDI with valve holding chamber every 20 min or continuously for 1 hour • Impending or actual respiratory • arrest • Intubation and mechanical ventilation with 100% O2 • Nebulized SABA and ipratropium • Intravenous corticosteroids • Consider adjunct therapies Admit to hospital intensive care Repeat Assessment: PE, PEF, SaO2 , other tests as needed • Moderate Episode: • PEF or FEV1 =40 – 69 % predicted or personal best • PE : Moderate symptoms • Treatment : • Inhaled SABA every 60 minutes • Oral systemic corticosteroids • Continue treatment 1-3 hrs provided there is improvement ; make decision in < 4 hrs • Severe Episode: • PEF or FEV1 < 40 % predicted or personal best • PE : Severe symptoms at rest, accessory muscle use, chest retraction • History : high-risk for asthma- related death • No improvement after initial treatment • Treatment : • Oxygen • NebulizedSABA + ipratropium hourly or continuous • Oral systemic corticosteroids • Consider adjunct therapies

20. PCCP Council on Asthma Management of Acute Exacerbations : Hospital Setting Moderate Episode Severe Episode • Good Response • Response sustained for 1 hr • after last treatment • No risk factors • S/Sx : No distress, normal PE • PEF > 70 % predicted or personal best • SaO2 > 90 % • Incomplete Response • within 1 hr &/or (+) risk factors • S/Sx : Mild to moderate • PEF > 50 % but < 70 % predicted • or personal best • SaO2 not improving • Poor Response • within 1 hr &/or (+) risk factors • S/Sx : severe, drowsiness, confusion • PEF < 30 % predicted or personal best • ABG : paCO2 > 45 mm Hg • paO2 < 60 mm Hg • Admit to ICU: • Continue inh SABA + inh. anti-cholinergic • Consider SQ,IV, or IM 2- agonist • IV steroids • IV aminophylline • Continue oxygen • Possible intubation/ mechanical ventilation • Discharge Home • Continue inhaled SABA q 3-4 hrs • (or oral 2- agonist or theophylline) • Continue oral steroids • Patient education Admit to Hospital • Improved • PEF > 70 % • Sustained on meds Not Improved within 6 – 12 hrs Discharge Home Admit to ICU

21. PCCP Council on Asthma Asthma Action Plan • Name:____________________________________________________Date of issue:___________________ • My Dr.:___________________________________________________Tel #: _________________________ • Clinic Address:___________________________________________________________________________ • Chronic Asthma Severity Mild, intermittent Mild, persistent • Moderate, persistent Severe, persistent • PEF: Personal best (done ___/___/___): _______liters/min Predicted: ________liters/min PEAK FLOW STATUS ACTION Continue my present treatment: Regular controller/s:___________________________ ___________________________ As needed reliever: ___________________________ Visit my doctor on next appointment :_____________ 80 % of predicted or personal best Above:____________ GOOD CONTROL (GREEN ) ZONE Add or double the dose of controller drug :_____________________________ Take reliever regularly:________________________ As needed reliever; (inhaled):___________________ *If improved (back to green zone), continue maintenance drugs for 3 days. *If unimporved, visit my doctor as soon as possible. 60-80% of predicted or personal best From:______________ To: ______________ WARNING (YELLOW) ZONE Take Prednisone _____tablets every ________hrs Take reliever regularly:________________________ + as needed reliever (inhaled):__________________ *Once improved, follow the yellow or green zone instructions Call or see my doctor immediately Below 60 % pred or personal best Below: ____________ DANGER (RED) ZONE GO DIRECTLY TO HOSPITALor call ambulance Take Prednisone ___________ tablets now or ____________________ TAke 2 puffs of inhaled reliever every 10-15 mins on the way to hospital EMERGENCY (RED) ZONE Below 50 % pred or personal best Below:____________

22. Thank you for your attention!