Management of Asthma in Adults and Children in the Primary Care Setting PRACTICE GUIDELINE

Transcription

1 Management of Asthma in Adults and Children in the Primary Care Setting PRACTICE GUIDELINE Practice Guidelines: Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Purpose: To improve asthma management in children and adults. Key Points: Asthma is under diagnosed throughout the world. In 2003, approximately 20 million Americans had asthma and the condition accounted for an estimated 12.8 million lost school days in children and 24.5 lost work days in adults. Close to 39% of the asthma discharges in 2002 were for those under 15, however only 21% of US population was less than 15 years of age. Asthma in all age groups may present only as repeated coughing, especially at night, with exercise and with viral illnesses, but these are particularly common patterns of presentation of asthma in children. The four key components for long-term control of asthma include: Assess and Monitor assess and document asthma severity, identify triggers, conduct medical history and physical exam, assess medication use. Schedule a medical appointment for asthma at least every six months. Pharmacological Therapy use stepwise approach to gaining control as quickly as possible and provide a rescue plan for acute exacerbations. Control Factors that Contribute to Severity asthma exacerbation may be caused by a variety of triggers including allergens, pollutants, foods, and drugs. Patient Education education is an essential part of the overall management of asthma. Education includes the development of an asthma action plan. Disparities in Asthma Care: In the elderly, the diagnosis of asthma is often not made or is missed. It is now becoming increasing recognized that undiagnosed asthma is a frequent cause of treatable respiratory symptoms. The presence of a recurrent nocturnal cough in an otherwise healthy child should raise asthma as a probable diagnosis. Some children with asthma present only with exercise-induced symptoms. In this group, or when in doubt over the presence of mild asthma in a child, exercise testing is helpful. Workers who are exposed to inhalant chemicals or allergens in the workplace can develop asthma and maybe misdiagnosed as having bronchitis or chronic obstructive disease. Low income and minority populations experience higher rates of hospital admissions and emergency room visits due to asthma. More boys develop asthma during childhood; the prevalence of asthma in girls surpasses boys during adolescence. Among year olds, the prevalence of women is nearly twice as high as in men. Reference: Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics 2002, Executive Summary of the NAEPP Expert Panel Report ; Pocket Guide for Asthma Management and Prevention: Updated 2005, Global Initiative for Asthma (GINA), National Heart, Lung and Blood Institute (NHLBI); Clinical Guideline for the Diagnosis, Evaluation, and Management of Adults and Children with Asthma 2005 developed by the New York State Consensus Asthma Guideline Expert Panel; Global Strategy for Asthma Management and Prevention, National Guideline Clearinghouse ( Trends in Asthma Morbidity and Mortality (May 2005), Research and Program Services, Epidemiology & Statistics Unit, American Lung Association; Asthma Among Adults in New York State, : Prevalence and Health Behavior, Spring 2004, Vol. 11, No. 1. Distributed to: Primary Care Physicians, including Internists, General Practice Physicians, Family Practice Physicians, Pediatricians, Obstetricians/Gynecologists, Allergists, Pulmonologists, Immunologists and Rheumatologists. Developed by: Norman Lindenmuth, MD (Chairperson), Internal Medicine - Excellus BlueCross BlueShield; Eulalia Cheng, MD, Pediatric Pulmonology; Valerie Newman, MD, Internal Medicine; Scott Roth, MD, Allergy and Immunology; Michael Sheehan, MD, Allergy and Immunology; Joseph Stankitis, MD, Internal Medicine Monroe Plan; Andrew Holt, MD, Pediatrics; Wendy Knight, RN, MSN; Lisa Smith, FNP; Robert Holzhauer, MD, Allergy and Immunology; Approved: Quality Management Committee - August 4, 2006 Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patient, the setting, the circumstances, or other factors, guidelines can and should be tailored to fit individual needs. Page 1 of 2

2 GRADING SYSTEM Grades of Recommendations: A = Good evidence to support the recommendation that the condition or intervention be specifically considered in a clinical practice guideline. B = Fair evidence to support the recommendation that the condition or intervention be specifically considered in a clinical practice guideline. C = Poor evidence regarding inclusion or exclusion of a condition or intervention in a clinical practice guideline, but recommendation made on other grounds. D = Fair evidence to support the recommendation that the condition or intervention be specifically excluded from consideration in a clinical practice guideline. E = Good evidence to support the recommendation that the condition or intervention be specifically excluded from consideration in a clinical practice guideline. Quality of Published Evidence: For Grade A: I Evidence from at least one properly randomized controlled trial. For Grade B: II 1 II 2 II 3 Evidence from well-designed controlled trials without randomization. Evidence from well-designed cohort or case-control analytic studies, preferably from more than one center or research group Evidence from comparisons between times or places with or without the intervention. Dramatic results in uncontrolled experiments could also be included here. For Grade C: III Opinions of respected authorities, based on clinical experience, descriptive studies or reports of expert committees. Guidelines are intended to be flexible. They serve as reference points or recommendations, not rigid criteria. Guidelines should be followed in most cases, but there is an understanding that, depending on the patients, the setting, the circumstances, or other factors, care can and should be tailored to fit individual needs. Approved 8/06. Next scheduled update by 8/08.

3 Clinical Guideline for the Diagnosis, Evaluation, and Management of Adults and Children with Asthma Criteria that suggest the diagnosis of Asthma: The symptoms of dyspnea, cough and/or wheezing, especially with nocturnal symptoms; With acute episodes: hyperinflation of thorax, decrease of breath sounds, higher pitched wheezing, and use of accessory muscles; Reversible airflow obstruction of 12 to 15 % or greater (of FEV 1 ) if able to perform spirometry, (usually > 6 years of age), or a significant clinical improvement after a short acting bronchodilator such as albuterol; Alternative diagnoses are excluded. Good Control of Asthma means: Minimal (or no) chronic symptoms, including nocturnal symptoms; Minimal (or no) exacerbations; No emergency visits or hospitalizations; Minimal (or no) need for p.r.n. (as needed) beta 2 -agonist, e.g. generally < 2x per week (for severe asthmatics once daily or less is acceptable); No limitations on activities, including exercise; No school or work missed; PEF circadian variation of less than 20 %; (Near) normal PEF (> 80 % of personal best); Minimal (or no) adverse effects from medications. 4 Key Components for Long-Term Control of Asthma Stepwise Classification & Therapy Recommendations Long-Term-Control Medications Estimated Comparative Daily Dosages Long-Term-Control Medications Usual Dosages Quick-Relief Medications Usual Dosages Developed by the New York State Consensus Asthma Guideline Expert Panel, and endorsed by the New York State Department of Health, New York City Department of Health and Mental Hygiene, New York State Health Plan Association, New York State Coalition of Prepaid Health Services Plans, Empire Blue Cross Blue Shield, Medical Society of the State of New York, New York State Academy of Family Physicians, New York Chapter American College of Physicians, American Academy of Pediatrics, District II, New York State oracic Society, and the American Lung Association of New York. Funded in part by the Centers for Disease Control and Prevention. Page 1 of 6 l 1/06

4 Four Key Components for Long-Term Control of Asthma Assessment and Monitoring Components of medical history and physical exam: Assess and document asthma severity (see Stepwise charts); Identify triggers and precipitating factors (e.g. allergens, exercise, upper respiratory infection, tobacco smoke, weather); Family, psychosocial and occupational history, including stressors. Medication use, including complementary alternative medications. At every patient visit review beta 2 -agonist use. Physical exam focusing on upper and lower airways and skin. Recommended Approach to Care Management Initial asthma visit Conduct medical history and physical exam. Assess severity; develop and review written Asthma Action Plan (see section 4). Perform spirometry measurements (FEV 1, FVC, FEV 1 /FVC) before and after the patient inhales a short-acting inhaled bronchodilator (usually can be done by children > 6 years of age). Provide education (see section 4). Chronic maintenance asthma visit Conduct focused medical history and physical exam. Assess severity; update and review written Asthma Action Plan. Schedule a medical appointment for asthma at least every six months and prior to predicted seasonal exacerbations. See patients with frequent exacerbations or symptoms at least every three months. Provide/recommend influenza vaccine annually. Perform spirometry measurements at least every 1 to 2 years when asthma is stable, more often when asthma is unstable, or at other times when clinically indicated by a change in the patient s condition (usually can be done by children > 6 years of age). Discuss information on reducing exposure to relevant allergens or irritants. Provide education, emphasizing medication adherence and medication administration technique. Acute exacerbation asthma visit Conduct focused medical history and physical exam. Assess severity; update and review written Asthma Action Plan. Check patient s inhaler, spacer/holding chamber, and peak flow technique. Provide education. Review symptom/peak flow monitoring. Review medication adherence and assess barriers, including financial. Discuss information on reducing exposure to relevant allergens or irritants. Referrals Asthma Specialist Consider consultation with an asthma specialist, such as an allergist or pulmonologist, when: there is difficulty in diagnosing asthma; the patient has a diagnosis of asthma, is currently under appropriate management, and has experienced any of the following: multiple hospitalizations with a diagnosis of asthma; multiple asthma related emergency department/urgent visits within one year; substantial interference exists with quality of life; prolonged or frequent bursts of oral steroids; life threatening asthma exacerbation e.g. ICU admission, intubation; unresponsive to prescribed therapy or has not achieved expected goals (e.g. continued need for beta 2 -agonist use > 1 canister per month); moderate to severe persistent asthma. Behavioral Health Specialist Refer patients with significant psychiatric, psychosocial, or family stressors, which adversely affects their asthma control, to a behavioral health professional for treatment. Health Plan and Community Agencies Contact individual health plan, local health department, or community agency for availability of: Case management, including one-to-one comprehensive asthma education. Asthma classes/support groups. Smoking cessation classes. Assistance with durable medical equipment and medical supplies, such as peak flow meters, spacers/holding chambers, nebulizers and compressors. Home environmental assessment and remediation when possible. Occupational Lung Disease Notify the New York State Department of Health Occupational Lung Disease Registry at of patients suspected of having occupational asthma/lung disease. Services may include education and workplace evaluations. Pharmacological Therapy Stepwise Approach to Asthma Management Gain control as quickly as possible; then decrease treatment to the least medication necessary to maintain control. The preferred approach is to start with more intensive therapy in order to more rapidly suppress airway inflammation and thus gain prompt control. Provide a rescue plan of systemic corticosteroids or other medications if needed for acute exacerbations at any step. Reinforce to all persistent asthmatics that daily inhaled corticosteroids are the preferred first line treatment that results in improved asthma control. For pregnant patients with asthma refer to Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment Page 2 of 6 l 1/06

5 Four Key Components for Long-Term Control of Asthma Update 2004 at asthma/astpreg.htm. See Long-Term-Control and Quick-Relief charts for medications and usual dosages. Check for availability and the health plan/insurance formulary when applicable. Control of Factors Contributing to Asthma Severity Environmental Control Measures For the patient s environments (e.g, home, workplace, child-care, school) the medical practitioner should: Assess the patient s exposure to and clinical significance of: irritants (e.g., smoke, chemicals) and allergens (e.g., animal dander, dust mites, cockroaches, mold, pollen, chemicals) and consider allergen testing. Provide information to the patient on: reducing exposure to relevant allergens and irritants, and preventing infections. For example: tobacco smoke exposure Assess for smoking or exposure to second hand smoke. Routinely advise and encourage patients/family to quit smoking. Advise no smoking indoors or in automobiles. Initiate and/or refer to smoking cessation interventions and counseling and consider pharmacotherapy for patients and household members. Inform patients that smoking cessation information and free Stop Smoking Kits are available through the New York State Smokers Quitline. The toll free number is , or visit the website at Co-Morbidity Management Manage, if present: rhinitis/sinusitis, GERD, respiratory tract infections, and obesity. Patient Education Effective partnerships between practitioners and patients produce better patient outcomes through the use of evidence-based techniques that emphasize patient responsibility, empowerment, collaborative goal setting and problem solving skills. Consider educational level and cultural background when providing asthma education. Health plans and community agencies may be able to support patient education as well as home remediation. Asthma Education Includes: Basic Facts About Asthma: what is asthma; basic pathophysiology; what happens during an attack; early warning signs and symptoms; physical activity and asthma. Roles of Medication and Techniques for Using Medication Devices: how medications work; two types of medicationsquick-relief and controller; importance of long-term controller medications; skill training on inhaler, spacer/holding chamber, nebulizer and peak flow technique. Environmental Control Measures at home, school, and work: identification and remediation of environmental and/or occupational triggers or exposure. Self Management Plan: what is chronic disease; patient responsibility in managing asthma; use of patient self management tools. Written Asthma Action Plan A written Asthma Action Plan based on peak flow and/or symptom monitoring developed jointly with the patient, assists in managing asthma exacerbations. Update the Asthma Action Plan at least every six months. A written Asthma Action Plan should include: Recommended doses and frequencies of daily controller medications and quick-relief medications. Information on what to do in case of an exacerbation (worsening symptoms and/or noctural awakenings). How to adjust medicines at home in response to particular signs, symptoms, and/or peak flow measurements. A list of Peak Expiratory Flow (PEF) levels and symptoms indicating the need for acute care. When and how to activate the EMS (Emergency Medical System) including emergency telephone numbers for the physician, and rapid transportation. A copy of a patient s written Asthma Action Plan should be: Carried with the patient. In the patient s medical record. Provided to the patient s family. Provided to the patient s school/daycare. Provided to other contacts of the patient as needed. Free Asthma Related Materials Free Asthma related materials, including asthma guideline tool and Asthma Action Plans (English and Spanish) are available at Click on Diseases and Conditions, click on Asthma, click on Asthma Action Plan and Informational Material ( diseases/asthma/brochures.htm). Bibliography Guidelines for the Diagnosis and Management of Asthma, Expert Panel Report 2. NIH Publication No , April Guidelines for the Diagnosis and Management of Asthma, Update on Selected Topics 2002, NAEPP Expert Panel Report. NIH Publication No , June Asthma and Pregnancy Update NAEPP Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment Update NIH Publication No Bethesda, MD: U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute, Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2001; 50(No. RR-4): page Guidelines are intended to be flexible. ey serve as recommendations, not rigid criteria. Guidelines should be followed in most cases, but depending on the patient, and the circumstances, guidelines may need to be tailored to fit individual needs. Page 3 of 6 l 1/06

6 Stepwise Approach for Managing Acute or Chronic Asthma Infants and Young Children (5 Years of Age and Younger) Classify Severity: Clinical Features Before Treatment or Adequate Control Medications Required to Maintain Long-Term Control Recommendations Symptoms/Day Symptoms/ Night Exercise Tolerance Daily Medications Education/Recommendations Intermittent Asthma Persistent Asthma Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent 2 days/week 2 nights/month > 2/week but < 1x/day Excellent exercise tolerance Exercise symptoms No daily medication needed. Preferred treatment: Low-dose inhaled corticosteroids (with nebulizer or MDI with holding chamber with or without face mask or DPI). > 2 nights/month Alternative treatment (listed alphabetically): Cromolyn (nebulizer is preferred or MDI with holding chamber) OR leukotriene receptor antagonist. Daily Frequent exercise symptoms Preferred treatment: Low-dose inhaled corticosteroids and long-acting inhaled beta 2 -agonists OR Medium-dose inhaled corticosteroids. Alternative treatment: Low-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline. > 1 night/week If needed (particularly in patients with recurring severe exacerbations): Preferred treatment: Medium-dose inhaled corticosteroids and long-acting beta 2 -agonists. Alternative treatment: Medium-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline. Continual Frequent Exercise severely limited Preferred treatment: High-dose inhaled corticosteroids AND Long-acting inhaled beta 2 -agonists AND, if needed Corticosteroid tablets or syrup long term (see chart for medication usual dosages). (Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.) For all levels of severity: Teach basic facts about asthma. Identify triggers and discuss avoidance measures. Discuss goals of optimal control. Teach inhaler/spacer/nebulizer techniques. Discuss role of medication and assess for use of complementary alternative medications. Develop and review written Asthma Action Plan with parent(s). Discuss management related to exercise. Emphasis on when to call for advice/ appointment. Provide/recommend influenza vaccine annually. Discuss smoking cessation with parent(s) if environmental tobacco smoke exposure is a risk factor. Home environmental assessment. Address questions related to long-term steroid use and emphasize maintenance during periods of wellness. Monitor for corticosteroid systemic effects. Consider specialist consultation for patients under age three who require Step 2 care Specialist consultation for patients requiring Step 3 or 4 care. Quick Relief All Patients Short-acting bronchodilator: 2 puffs short-acting inhaled beta 2 -agonists q 4 to 6 hours as needed for symptoms. The guidelines have indicated for severe exacerbations as many as 2 to 10 puffs as often as q 2 to 4 hours may be necessary. Intensity of treatment will depend on severity of exacerbation; up to 3 treatments at 20-minute intervals either by inhaler or by nebulizer as necessary. A course of systemic corticosteroids may also be needed. Use of short-acting beta 2 agonists > 2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term control therapy. Adults and Children Older Than 5 Years of Age Classify Severity: Clinical Features Before Treatment or Adequate Control Medications Required to Maintain Long-Term Control Recommendations Symptoms/Day Symptoms/ Night PEF or FEV 1 Daily Medications Education/Recommendations PEF Variability Intermittent Asthma Persistent Asthma Mild Intermittent Mild Persistent Moderate Persistent Severe Persistent 2 days/week 80 % 2 nights/month > 2/week but < 1x/day < 20 % 80 % No daily medication needed. Severe exacerbations may occur, separated by long periods of normal lung function and no symptoms. A course of systemic corticosteroids is recommended. Preferred treatment: Low-dose inhaled corticosteroids > 2 nights/month % Alternative treatment (listed alphabetically): Cromolyn, leukotriene modifier, nedocromil, OR sustained release theophylline to serum concentration of 5-15 mcg/ml. Daily > 60 % - < 80 % Preferred treatment: Low-to-medium dose inhaled corticosteroids and long-acting inhaled beta 2 -agonists. Alternative treatment (listed alphabetically): Increase inhaled corticosteroids within medium-dose range OR Low-to-medium dose inhaled corticosteroids and either leukotriene modifier or theophyline. > 1 night/week > 30 % If needed (particularly in patients with recurring severe exacerbations): Preferred treatment: Increase inhaled corticosteroids within medium-dose range and add long-acting inhaled beta 2 -agonists. Alternative treatment: Increase inhaled corticosteroids within medium-dose range and add either leukotriene modifier or theophyline. Continual 60 % Preferred treatment: High-dose inhaled corticosteroids AND Long-acting inhaled beta 2 -agonists For all levels of severity: Teach basic facts about asthma. Identify triggers and discuss avoidance measures. Discuss goals of optimal control. Teach inhaler/spacer/nebulizer techniques. Discuss role of medication and assess for use of complementary alternative medications. Develop and review written Asthma Action Plan (with parent(s) as appropriate). Discuss management related to exercise. Emphasis on when to call for advice/ appointment. Provide/recommend influenza vaccine annually. Discuss smoking cessation (with parent(s) as appropriate) if environmental tobacco smoke exposure is a risk factor. Home environmental assessment. Teach Peak Flow meter use. Address questions related to long-term steroid use and maintenance during periods of wellness. Monitor for corticosteroid systemic effects. Specialist consultation for patients requiring Step 3 or 4 care. Frequent > 30 % AND, if needed Corticosteroid tablets or syrup long term (see chart for medication usual dosages). (Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.) Quick Relief All Patients Short - acting bronchodilator: 2 puffs short - acting inhaled beta 2 -agonists q 4 to 6 hours as needed for symptoms. The guidelines have indicated for severe exacerbations as many as 2 to 10 puffs as often as q 2 to 4 hours may be necessary. Intensity of treatment will depend on severity of exacerbation; up to 3 treatments at 20-minute intervals either by inhaler or by nebulizer as necessary. A course of systemic corticosteroids may also be needed. Use of short-acting beta 2 agonists > 2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term control therapy. Page 4 of 6 l 1/06

7 Usual Dosages for Long-Term Control Medications Inhaled Corticosteroids: preferred first line therapy Estimated Comparative Daily Dosages Low Daily Dose Medium Daily Dose High Daily Dose Drug/Frequency Adult Child * Adult Child * Adult Child * Beclomethasone HFA/bid 40 or 80 mcg/puff Budesonide DPI/qd to bid 200 mcg/inhalation Inhalation suspension for nebulization (child dose) Flunisolide/bid 250 mcg/puff Fluticasone/bid MDI: 44, 110, or 220 mcg/puff DPI: 50, 100, or 250 mcg/inhalation Triamcinolone Acetonide/bid to qid 100 mcg/puff mcg mcg mcg mcg > 480 mcg > 320 mcg mcg mcg 0.5 mg 600-1,200 mcg mcg 1.0 mg > 1,200 mcg > 800 mcg 2.0 mg 500-1,000 mcg mcg 1,000-2,000 mcg 1,000-1,250 mcg > 2,000 mcg > 1,250 mcg mcg mcg mcg mcg mcg mcg mcg mcg > 660 mcg > 600 mcg > 440 mcg > 400 mcg 400-1,000 mcg mcg 1,000-2,000 mcg 800-1,200 mcg > 2,000 mcg > 1,200 mcg Other Long-Term Control Medications Medication Dosage Form Adult Dose Child dose * Mometasone Furoate inhalation powder/ qd to bid Combined Medication 220 mcg/inhalation 1 to 2 inhalations 1 to 2 inhalations Fluticasone/Salmeterol DPI 100, 250, or 500 mcg/50 mcg 1 inhalation bid; dose depends on severity of asthma Cromolyn and Nedocromil Cromolyn Nedocromil MDI 1 mg/puff Nebulizer 20 mg/ampule MDI 1.75 mg/puff 2-4 puffs tid-qid 1 ampule tid-qid 2-4 puffs bid-qid 1 inhalation bid; dose depends on severity of asthma 1-2 puffs tid-qid 1 ampule tid-qid 1-2 puffs bid-qid Leukotriene Modifiers Montelukast Zafirlukast 4 or 5 mg chewable tablet 10 mg tablet 10 or 20 mg tablet 10 mg qhs 40 mg daily (20 mg tablet bid) 4 mg oral granules qhs (12 mos-5 yrs) 4 mg chewable tablet qhs (2-5 yrs) 5 mg chewable tablet qhs (6-14 yrs) 10 mg qhs (> 14 yrs) 20 mg daily (7-11 yrs) (10 mg tablet bid) Zileuton 300 or 600 mg tablet 2,400 mg daily (give tablets qid) Long-Acting Inhaled Beta 2 -Agonists (Should not be used for symptom relief or for exacerbations. Generally used with inhaled corticosteroids). Formoterol Salmeterol DPI 12 mcg/single-use capsule DPI 50 mcg/blister 1 capsule q 12 hours 1 blister q 12 hours Methylxanthines (Serum monitoring is important [serum concentration of 5-15 mcg/ml at steady state]). Theophylline Liquids, sustained-release tablets, and capsules Starting dose 10 mg/kg/day up to 300 mg max; usual max 800 mg/day 1 capsule q 12 hours 1 blister q 12 hours Starting dose 10 mg/kg/day; usual max: < 1 year of age: 0.2 (age in weeks) + 5 = mg/kg/day 1 year of age: 16 mg/kg/day Systemic Corticosteroids Methylprednisolone Prednisolone Prednisone 2, 4, 8, 16, 32 mg tablets 5 mg tablets 5 mg/5 cc 15 mg/5 cc 1, 2.5, 5, 10, 20, 50 mg tablets 5 mg/cc, 5 mg/5 cc mg daily in a single dose in a.m. or qod as needed for control (applies to all three corticosteroids) Short-course burst to achieve control: mg per day as single or 2 divided doses for 3-10 days (applies to all three corticosteroids) mg/kg daily in single dose in a.m. or qod as needed for control (applies to all three corticosteroids) Short-course burst : 1-2 mg/kg/day, maximum 60 mg/day for 3-10 days (applies to all three corticosteroids) Anti-IgE Omalizumab is an injectable drug used in the treatment of allergic asthma. It is used for people with moderate to severe persistent asthma who are inadequately controlled with Step Therapy, including: inhaled corticosteroids, long acting inhaled beta 2-agonists, leukotriene receptor antagonist, theophylline, etc. Treatment should be administered in conjuction with ongoing specialty treatment. See package insert for dosage and administration details. * Children 12 years of age (Please refer to package insert for age appropriateness and drug interactions) Above list not all inclusive. Check for availability and health plan/insurance formulary when applicable. Use of a spacer/holding chamber is recommended with the use of a metered-dose inhaler (MDI). Page 5 of 6 l 1/06

8 Usual Dosages for Quick-Relief Medications Medication Dosage Form Adult Dose Child Dose * Short Acting Inhaled Beta 2 -Agonists Albuterol Albuterol HFA 90 mcg/puff, 200 puffs 90 mcg/puff, 200 puffs Treatment of acute episodes 2 puffs q 4-6 hours as needed Exercise-induced brochospasm prevention: 2-4 puffs 5-15 minutes prior to exercise Treatment of acute episodes 2 puffs q 4-6 hours as needed Exercise-induced brochospasm prevention: 2-4 puffs 5-15 minutes prior to exercise Pirbuterol 200 mcg/puff, 400 puffs 2 puffs q 4-6 hours as needed 2 puffs q 4-6 hours as needed Albuterol Levalbuterol (R-albuterol) Nebulizer solution 5 mg/ml (0.5%) 2.5 mg/ml 1.25 mg/3 ml 0.63 mg/3 ml Nebulizer solution 0.31 mg/3 ml 0.63 mg/3 ml 1.25 mg/3 ml mg in 3 cc of saline q 4-8 hours 0.05 mg/kg (min mg, max. 2.5 mg) in 3 cc of saline q 4-6 hours 0.63 mg mg q 4-8 hours mg/kg (min mg, max mg) q 4-8 hours The guidelines have indicated for severe exacerbations as many as 2-10 puffs as often as q 2-4 hours may be necessary. Anticholinergics - alternatives if patients do not tolerate Beta 2 -Agonists: Ipratropium Ipratropium with albuterol MDI 18 mcg/puff, 200 puffs Nebulizer solution 0.25 mg/ml (0.025%) MDI 18 mcg/puff of ipratropium bromide and 90 mcg/puff of Albuterol. 200 puffs/canister Systemic Corticosteroids Nebulizer solution 0.5 mg/3 ml ipratropium bromide and 2.5 mg/3 ml Albuterol 2-3 puffs q 6 hours 1-2 puffs q 6 hours 0.25 mg q 6 hours mg q 6 hours 2-3 puffs q 6 hours 1-2 puffs q 8 hours 3 ml q 4-6 hours ml q 8 hours Methylprednisolone 2, 4, 8, 16, 32 mg tablets Short course burst : mg/day as single or 2 divided doses, for 3-10 days (applies to first three corticosteroids) Prednisolone Prednisone (Methylprednisolone acetate) 5 mg tablets, 5 mg/5 cc, 15 mg/5 cc 1, 2.5, 5, 10, 20, 50 mg tablets; 5 mg/cc, 5 mg/5 cc Repository injection 40 mg/ml 80 mg/ml 240 mg IM once 7.5 mg/kg IM once Short course burst : 1-2 mg/kg/day, maximum 60 mg/day, for 3-10 days (applies to first three corticosteroids) * Children 12 years of age (Please refer to package insert for age appropriateness and drug interactions) Above list not all inclusive. Check for availability and health plan/insurance formulary when applicable. For emergency asthma exacerbations: see the Guidelines for the Diagnosis and Management of Asthma, Expert Panel Report 2 NIH Publication No , April 1997 Use of a spacer/holding chamber is recommended with the use of a metered-dose inhaler (MDI). Guidelines are intended to be flexible. ey serve as recommendations, not rigid criteria. Guidelines should be followed in most cases, but depending on the patient, and the circumstances, guidelines may need to be tailored to fit individual needs. Page 6 of 6 l 1/06

9 Asthma Action Plan English Directions to the Provider: The purpose of this Asthma Action Plan is to help families become proactive and anticipatory with respect to asthma exacerbations and their control. The Asthma Action Plan should be used as an education and communication tool between the provider and the patient and his or her family. The patient/family should be able to demonstrate an understanding of the plan and the appropriate use of medicines. This form has been designed for the primary care provider to use with families who need a relatively simple asthma management regimen. Once a family has become more informed about asthma, a plan can be developed with additional flexibility in treatment. Families should be given additional educational materials about asthma, peak flow monitoring, and environmental control. A spacer should be prescribed for all patients using an MDI. Give the top two copies of the form to the family, with instructions to give one copy to the child s school or day care. Keep one copy for your records. Children over the age of six may be given peak flow meters to monitor their asthma. Parents of children under the age of six should use symptoms to determine the child s zone. Zone Instructions: The Personal Best peak flow should be determined when the child is symptom-free. A diary can be used to determine personal best, and usually are part of the peak flow meter package. A peak flow reading should be taken at all asthma visits and personal best should be redetermined regularly. Because peak flow meters vary in recording peak flow, instruct your patients to bring their peak flow meter to every visit. Green: List all daily medicines. Fill in actual numbers, not percentages, for peak flow readings. Green zone is 100% 80% of personal best, or when no symptoms are present. Yellow: Add medicines to be taken in the yellow zone and instruct the patient to continue with green zone medicines. Yellow zone is 80% 50% of personal best, or when the listed symptoms are present. Include how long to continue taking these medicines and when to contact the provider. Red: List any medicines to be taken while waiting to speak to the provider or preparing to go to the emergency room. Red zone is 50% or below personal best, or when the listed symptoms are present. Peak Flow Chart: Personal Best 100% Yellow 80% Red 50% Personal Best 100% Yellow 80% Red 50% Tear off before giving to patient 4850

10 Asthma Action Plan Name Date Doctor Medical Record # Doctor s Office Phone #: Day Night/Weekend Emergency Contact Doctor s Signature The Colors of a traffic light will help you use your asthma medicines. Green means Go Zone! Use preventive medicine. Yellow Means Caution Zone! Add quick-relief medicine. Red means Danger Zone! Get help from a doctor. Personal Best Peak Flow GO You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work and play Use these daily preventive anti-inflammatory medicines: For asthma with exercise, take: CAUTION You have any of these: First signs of a cold Exposure to known trigger Cough Mild wheeze Tight chest Coughing at night Continue with green zone medicine and add: CALL YOUR PRIMARY CARE PROVIDER. DANGER Your asthma is getting worse fast: Medicine is not helping Breathing is hard and fast Nose opens wide Ribs show Can t talk well Peak flow reading below Take these medicines and call your doctor now. GET HELP FROM A DOCTOR NOW! Do not be afraid of causing a fuss. Your doctor will want to see you right away. It s important! If you cannot contact your doctor, go directly to the emergency room. DO NOT WAIT. Make an appointment with your primary care provider within two days of an ER visit or hospitalization. State of New York, George E. Pataki, Governor Department of Health, Antonia C. Novello, M.D., M.P.H., Dr.P.H., Commissioner COPY FOR PATIENT 4850

11 Asthma Action Plan Name Date Doctor Medical Record # Doctor s Office Phone #: Day Night/Weekend Emergency Contact Doctor s Signature The Colors of a traffic light will help you use your asthma medicines. Green means Go Zone! Use preventive medicine. Yellow Means Caution Zone! Add quick-relief medicine. Red means Danger Zone! Get help from a doctor. Personal Best Peak Flow GO You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work and play Use these daily preventive anti-inflammatory medicines: For asthma with exercise, take: CAUTION You have any of these: First signs of a cold Exposure to known trigger Cough Mild wheeze Tight chest Coughing at night Continue with green zone medicine and add: CALL YOUR PRIMARY CARE PROVIDER. DANGER Your asthma is getting worse fast: Medicine is not helping Breathing is hard and fast Nose opens wide Ribs show Can t talk well Peak flow reading below Take these medicines and call your doctor now. GET HELP FROM A DOCTOR NOW! Do not be afraid of causing a fuss. Your doctor will want to see you right away. It s important! If you cannot contact your doctor, go directly to the emergency room. DO NOT WAIT. Make an appointment with your primary care provider within two days of an ER visit or hospitalization. State of New York, George E. Pataki, Governor Department of Health, Antonia C. Novello, M.D., M.P.H., Dr.P.H., Commissioner COPY FOR FAMILY/SCHOOL/DAY CARE 4850

12 Asthma Action Plan Name Date Doctor Medical Record # Doctor s Office Phone #: Day Night/Weekend Emergency Contact Doctor s Signature The Colors of a traffic light will help you use your asthma medicines. Green means Go Zone! Use preventive medicine. Yellow Means Caution Zone! Add quick-relief medicine. Red means Danger Zone! Get help from a doctor. Personal Best Peak Flow GO You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work and play Use these daily preventive anti-inflammatory medicines: For asthma with exercise, take: CAUTION You have any of these: First signs of a cold Exposure to known trigger Cough Mild wheeze Tight chest Coughing at night Continue with green zone medicine and add: CALL YOUR PRIMARY CARE PROVIDER. DANGER Your asthma is getting worse fast: Medicine is not helping Breathing is hard and fast Nose opens wide Ribs show Can t talk well Peak flow reading below Take these medicines and call your doctor now. GET HELP FROM A DOCTOR NOW! Do not be afraid of causing a fuss. Your doctor will want to see you right away. It s important! If you cannot contact your doctor, go directly to the emergency room. DO NOT WAIT. Make an appointment with your primary care provider within two days of an ER visit or hospitalization. State of New York, George E. Pataki, Governor Department of Health, Antonia C. Novello, M.D., M.P.H., Dr.P.H., Commissioner COPY FOR PROVIDER 4850

13 Asthma Action Plan Spanish Directions to the Provider: The purpose of this Asthma Action Plan is to help families become proactive and anticipatory with respect to asthma exacerbations and their control. The Asthma Action Plan should be used as an education and communication tool between the provider and the patient and his or her family. The patient/family should be able to demonstrate an understanding of the plan and the appropriate use of medicines. This form has been designed for the primary care provider to use with families who need a relatively simple asthma management regimen. Once a family has become more informed about asthma, a plan can be developed with additional flexibility in treatment. Families should be given additional educational materials about asthma, peak flow monitoring, and environmental control. A spacer should be prescribed for all patients using an MDI. Give the top two copies of the form to the family, with instructions to give one copy to the child s school or day care. Keep one copy for your records. Children over the age of six may be given peak flow meters to monitor their asthma. Parents of children under the age of six should use symptoms to determine the child s zone. Zone Instructions: The Personal Best peak flow should be determined when the child is symptom-free. A diary can be used to determine personal best, and usually are part of the peak flow meter package. A peak flow reading should be taken at all asthma visits and personal best should be redetermined regularly. Because peak flow meters vary in recording peak flow, instruct your patients to bring their peak flow meter to every visit. Green: List all daily medicines. Fill in actual numbers, not percentages, for peak flow readings. Green zone is 100% 80% of personal best, or when no symptoms are present. Yellow: Add medicines to be taken in the yellow zone and instruct the patient to continue with green zone medicines. Yellow zone is 80% 50% of personal best, or when the listed symptoms are present. Include how long to continue taking these medicines and when to contact the provider. Red: List any medicines to be taken while waiting to speak to the provider or preparing to go to the emergency room. Red zone is 50% or below personal best, or when the listed symptoms are present. Peak Flow Chart: Personal Best 100% Yellow 80% Red 50% Personal Best 100% Yellow 80% Red 50% Tear off before giving to patient 4851

14 Asthma Action Plan Name Date Doctor Medical Record # Doctor s Office Phone #: Day Night/Weekend Emergency Contact Doctor s Signature The Colors of a traffic light will help you use your asthma medicines. Green means Go Zone! Use preventive medicine. Yellow Means Caution Zone! Add quick-relief medicine. Red means Danger Zone! Get help from a doctor. Personal Best Peak Flow GO You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work and play Use these daily preventive anti-inflammatory medicines: For asthma with exercise, take: CAUTION You have any of these: First signs of a cold Exposure to known trigger Cough Mild wheeze Tight chest Coughing at night Continue with green zone medicine and add: CALL YOUR PRIMARY CARE PROVIDER. DANGER Your asthma is getting worse fast: Medicine is not helping Breathing is hard and fast Nose opens wide Ribs show Can t talk well Peak flow reading below Take these medicines and call your doctor now. GET HELP FROM A DOCTOR NOW! Do not be afraid of causing a fuss. Your doctor will want to see you right away. It s important! If you cannot contact your doctor, go directly to the emergency room. DO NOT WAIT. Make an appointment with your primary care provider within two days of an ER visit or hospitalization. State of New York, George E. Pataki, Governor Department of Health, Antonia C. Novello, M.D., M.P.H., Dr.P.H., Commissioner COPY FOR PROVIDER 4851

15 Asthma Action Plan Name Date Doctor Medical Record # Doctor s Office Phone #: Day Night/Weekend Emergency Contact Doctor s Signature The Colors of a traffic light will help you use your asthma medicines. Green means Go Zone! Use preventive medicine. Yellow Means Caution Zone! Add quick-relief medicine. Red means Danger Zone! Get help from a doctor. Personal Best Peak Flow GO You have all of these: Breathing is good No cough or wheeze Sleep through the night Can work and play Use these daily preventive anti-inflammatory medicines: For asthma with exercise, take: CAUTION You have any of these: First signs of a cold Exposure to known trigger Cough Mild wheeze Tight chest Coughing at night Continue with green zone medicine and add: CALL YOUR PRIMARY CARE PROVIDER. DANGER Your asthma is getting worse fast: Medicine is not helping Breathing is hard and fast Nose opens wide Ribs show Can t talk well Take these medicines and call your doctor now. Peak flow reading below State of New York, George E. Pataki, Governor Department of Health, Antonia C. Novello, M.D., M.P.H., Dr.P.H., Commissioner GET HELP FROM A DOCTOR NOW! Do not be afraid of causing a fuss. Your doctor will want to see you right away. It s important! If you cannot contact your doctor, go directly to the emergency room. DO NOT WAIT. Make an appointment with your primary care provider within two days of an ER visit or hospitalization. COPY FOR FAMILY/SCHOOL/DAY CARE 4851

16 Plan de Acción para el Asma Nombre Médico Médico Día # En case de emergencia # Firma del Médico Fecha # Récord médico Noche/Fin de semana Los colores de un semáforo le ayudarán a usar sus medicinas para el asma. Verde representa la Zona de Proceder! Use medicinas preventivas. Amarillo representa la Zona de Precaución! Añada medicinas para alivio rápido. Rojo significa la Zona de Peligro! Busque inmediatamente ayuda de un médico. Su meor marca en el mejor de capacidad pulmonar PROCEDER Usted tiene todos estos: Respira bien No hay tos ni adeo con silbido Dueme toda la noche Puede trabajar y jugar Medida máxima de a Use estas medicinas ant-inflamatorias preventivas diariamente. MEDICINA CUÁNTO CUÁNTAS VECES/CUÁNDO Para el asma cuando practica ejercicio, tome: PRECAUCIÓN Usted tiene cualquiera de estos: Las primeras señales de un resfriado Se ha expuesto a algo que provoca el asma Tos Silbido leve Pecho apretado Tos por la noche Medida máxima de a Continúe con su medicina de zona verde, y AÑADA: MEDICINA CUÁNTO CUÁNTAS VECES/CUÁNDO LLAME A SU PROVEEDOR DE ATENCIÓN PRIMARIA. PELIGRO Su asma empeora rápidamente: Las medicinas no ayudan Sus respiratión es fuerte y rápido La naríz se abre ampliamente Puede ver sus costillas No puede hablar bien Alcance el máximo leer de flujo abajo Tome estas medicinas y llame a su médico immediatamente. MEDICINA CUÁNTO CUÁNTAS VECES/CUÁNDO OBTENGA AYUDA DE UN MÉDICO AHORA MISMO! No tenga miedo de causar un alboroto. Su médico querrá verle inmediatamente. Es importante! Si no se puede poner en contacto con su médico, vaya directamente a la sala de emergencia. NO ESPERE. Haga una cita con su médico dentro de dos días a partir de una visita a la sala de emergencia o de una hospitalizatión. State of New York, George E. Pataki, Governor Department of Health, Antonia C. Novello, M.D., M.P.H., Dr.P.H., Commissioner COPIA PARA EL PACIENTE 4851

17 Asthma and Your Child Don't Let Asthma Knock the Wind Out of Your Child! WHAT IS ASTHMA? Asthma is a disease that causes severe attacks of wheezing and coughing. One of every 10 American children has asthma. Although asthma cannot always be prevented, it can be controlled with the right medicine and information. WHAT CAUSES ASTHMA? We don't always know what causes asthma. The causes of asthma are different from one person to another. The most common causes are: Smoke, mainly tobacco smoke Animal dander ( small particles from fur, hair, feathers or skin) Mold Dust mites (microscopic animals that live in dust) Cockroaches and their droppings Viruses Sulfites (chemicals used for some soft drinks and processed foods to keep them fresh) Pollen WHAT ARE SOME SIGNS OF ASTHMA? If your child has any of the following problems, he or she may have asthma: Wheezing o Begins suddenly o May be worse at night or in early morning o May get worse when exposed to cold air o May get worse during exercise Coughing Chest tightness Chest pain Shortness of breath Excess mucus ARE THERE ANY OTHER SYMPTOMS THAT MAY MEAN MY CHILD HAS ASTHMA? Some other symptoms that are sometimes linked with asthma may include: Stuffy or runny nose Sinus problems Nasal polyps (growths inside the nose) CAN ASTHMA BE PREVENTED? No matter how hard you try, asthma may not be prevented. However, you can limit your child's exposure to things that may trigger asthma, especially in the first years of life. You should: Make sure your home is kept smoke-free. Keep pets out of your child's bedroom and out of the house if sensitivity has developed.

18 Asthma and Your Child Breastfeed as long as possible. Breast milk contains antibodies that can delay or even prevent allergies. Keep your child's bedroom as dust-free as possible. Read all food labels to avoid things to which your child may be allergic. CAN ASTHMA BE TREATED AND CONTROLLED? Yes! The answers to the following questions can help your doctor to better treat your child's asthma: Do asthma attacks occur only in certain seasons or are they year-round? Does your child have sudden attacks or do they start out mild and get worse over time? How often does your child have an asthma attack? How long do the attacks last? (minutes, hours, days) Do asthma attacks occur at certain times of the day? ( morning, evening) Do asthma attacks occur only in certain places? (home, school) THINK POSITIVE! The good news is that with the right treatment, children with asthma can live with almost no limits on their activities. A good doctor will help you find your child's asthma triggers. Then, he or she will explain how the right medicine can help prevent asthma attacks and how to limit your child's exposure to germs and other asthma triggers. Finding the right doctor and treatment plan can take time, but it is time well spent. Your efforts will help your child to be as healthy and as active as his or her asthma-free friends. FINDING HELP AND SUPPORT To learn more about asthma, please contact the following agencies: The American College of Allergy, Asthma, and Immunology , Asthma and Allergy Network/Mothers of Asthmatics , National Jewish Center's Lung Line Support for Asthmatic Youth American Lung Association , Adopted from: New York State Department of Health: Information for a Healthy New York, Asthma Information Revised October ( Questions or comments: asthma@health.state.ny.us

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