Asthma - Treatment & Management

Page Contents

• Overview
• Primary Care Roles
• Pearls And Alerts
• Practice Guidelines
• Systems
• Resources

Overview

• Preventing chronic and troublesome symptoms (e.g., cough, breathlessness);
• Decreasing symptoms enough that only infrequent use (2 days a week or less) of inhaled SABA for quick relief is required;
• Maintaining (near) normal pulmonary function;
• Maintaining normal activity levels, including exercise and school/work attendance;
• Meeting families' and patients' expectations of and satisfaction with, asthma care.
  

• Preventing recurrent exacerbations of asthma and minimizing the need for ED visits or hospitalizations;
• Preventing loss of lung function (maximizing lung growth in children);
• Providing optimal pharmacotherapy with minimal or no adverse effects.

Primary Care Roles

1. Treating the patient for their current level of severity (for new patients) and control (for patients already on asthma medications), as well as for their risk for exacerbation.
2. Arranging follow-up depending on their current level of severity and control. Frequency will depend on many factors including severity of asthma and risk of exacerbations, familiarity of the family with asthma and medications used to treat it, etc. After an initial diagnosis or an exacerbation, consider a return visit in two weeks to assess response to treatment and ability of the family to accurately assess and adequately respond to symptoms.
3. Teaching the patient and family self-monitoring of their asthma. See the Patient self-assessment record (2007 NHLBI Guidelines) ( 54 KB) for an easy to fill out form for symptom monitoring.
4. Developing and sharing an asthma action plan.

   Sample plans:	Asthma action plan, child, English ()
   	Asthma action plan, Spanish ()
   	Asthma action plan, adult, English, Spanish, and Chinese ()

5. Education, and perhaps referral, regarding environmental control. Patients who are sensitive to allergens and pollutants or irritants should be advised to decrease their exposure to these substances, including cockroach, dust-mite, rodent, and house pet allergens. Other topics include exposure to aspirin or nonsteroidal anti-inflammatory drugs, use of indoor air-cleaning devices, and decreased use of humidifiers and/or evaporative coolers. See Environmental modifications for asthma (2007 NHLBI Guidelines) ( 69 KB) . Although allergy and asthma share many of the same mechanisms and the treatment of allergy is important in the treatment of many children with asthma, clear relationships between persistent asthma symptoms and particular allergens should exist before allergy testing and treatment.
6. Ongoing education regarding the disease and treatment. See Educational goals for asthma (2007 NHLBI Guidelines) ( 97 KB) for more information.
7. Consider inactivated influenza vaccination for all children with asthma.
8. Evaluate and treat comorbid conditions such as gastro-esophageal reflux disease (GERD), obesity, sinusitis, stress and depression, and obstructive sleep apnea.
9. Local asthma resources should be discussed with families, e.g., asthma camps and parent organizations. (see Services)
10. Educate the family that secondhand smoking can exacerbate asthma. Family members can be referred to Keeping Your Natural Beauty: A Smoker's Guide to Quitting, Quit Smoking (CDC), and I Quit! What to do when you're sick of smoking () for stopping smoking resources.

Pearls And Alerts

Bronchospasm that occurs with exercise in a child that does not otherwise have symptoms of asthma may respond to the use of inhaled beta2-agonists before exercise. See the Special Situations section of the guidelines, page 363 ([National: 2007]) and Exercise induced bronchospasm.

Practice Guidelines

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007.
National Institutes of Health: National Heart, Lung, and Blood Institute; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm. Accessed on 3/31/08.

Systems

Respiratory

Initiating Treatment: At the initial visit in children who have not yet received treatment for asthma, the child's asthma should be classified by severity (based on the most severe symptoms) and by risk for exacerbation (see Initial Assessment page or the Tools below). Once severity and risk are classified, these parameters guide the level of treatment at which to begin. Treatment of a child with an established diagnosis of asthma is based on the level of control (See below). The following Tools are simplified from the 2007 NHLBI Guidelines [National: 2007]. For the original, more detailed tables from the Guidelines, see the end of this section.

Tools for classifying Severity & Risk:	downloadable version: Asthma severity/risk grid, 0-4 yrs ( 74 KB)
	downloadable: Asthma severity/risk grid, 5-11 yrs ( 82 KB)
	downloadable: Asthma severity/risk grid, 12 yrs & up ( 76 KB)

Ongoing treatment: The link to the Asthma Control Test, a validated test for asthma symptoms in children with an established diagnosis of asthma as well as quick checklists for determining asthma control for children with ongoing asthma adapted from the tables in the Guidelines [National: 2007] are provided immediately following. The child is classified by their current asthma control (based on the most severe symptoms) and risk in order to guide any needed adjustments in management or therapy using the asthma treatment stepwise tables. Full tables from the Guidelines are provided at the end of this section.

Tools for classifying Control:	Asthma Control Test
	downloadable version: Asthma control/risk grid, 0-4 yrs ( 79 KB)
	downloadable: Asthma control/risk grid, 5-11 yrs ( 79 KB)
	downloadable: Asthma control/risk grid, 12 yrs & up ( 77 KB)

In a child with asthma who has been in excellent control with little risk for three months or more, a step-down from one treatment level to another may be considered.
In a child with poorly controlled asthma who has had frequent exacerbations and is using an inhaled SABA more than twice a week, a step up to the next treatment level should be considered. Before stepping up, adherence to medication, knowledge of inhaler technique, and control of comorbid and environmental cofactors should be reviewed. These and more in depth recommendations are also available for various classifications of asthma control on the Checklist for asthma control above and the Asthma treatment tables from the Guidelines, below.

Original tables for assessing asthma severity (for the new patient) and control (for ongoing care) and stepwise treatment from the Guidelines ([National: 2007]) are available as pdf files below.

• Initiating treatment table - children (2007 Guidelines, NHBLI) ( 575 KB)
• Initiating treatment table - youths and adults (2007 Guidelines, NHLBI) ( 617 KB)
• Ongoing management table - children (2007 Guidelines, NHLBI) ( 707 KB)
• Ongoing management table - youths and adults (2007 Guidelines, NHLBI) ( 996 KB)
• Stepwise treatment table - children (2007 Guidelines, NHLBI) ( 212 KB)
• Stepwise treatment table - youths and adults (2007 Guidelines, NHLBI) ( 887 KB)
  
  

Additional information regarding dosages and medications is available through the tables below. These medication tables are also from [National: 2007].

• Usual dosages for long-term asthma medications (2007 Guidelines, NHLBI) ( 210 KB)
• Inhaled corticosteroids - usual dosages (2007 Guidelines, NHLBI) ( 123 KB)
• Quick relief meds for asthma - usual dosages (2007 Guidelines, NHLBI) ( 128 KB)
  
  

Subspecialist Collaborations and Other Resources

A referral for specialty consultation and/or management should be considered if control has been erratic.

Pediatric Pulmonology (see Services below for relevant providers)

An asthma specialist might be helpful if symptoms are atypical or if additional testing, such as a challenge, are needed for diagnosis. Also consider referral for specialty consultation and/or management when: two or more bursts of oral steroids are needed within 6 months, an exacerbation requires hospitalization, care is at the step 4 level or higher, immuno-therapy is being considered, or additional testing is needed.

Pediatric Allergy (see Services below for relevant providers)

Consider referral for subcutaneous allergen immunotherapy if there is an obvious relationship between persistent asthma symptoms and sensitivity to a particular allergen, and for asthma management in refractory cases as described above.

Resources

Authors

Page Bibliography

National Asthma Education and Prevention Program Expert Panel.
Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma - Summary Report 2007.
National Institutes of Health: National Heart, Lung, and Blood Institute; (2007) http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm. Accessed on 3/31/08.