asthma clinical guide

8/7/2019 Asthma Clinical Guide

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Building Healthy Lifestyles

Chronic Respiratory

AsthmaClinical Guide

Building

Lifestyles

Healthy1-866-506-6654

388-6654


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Asthma

Building Healthy LifestylesChinook Health Region 2

We would like to acknowledge the contribution of the following groups:

Chronic Respiratory Interdisciplinary Working Group

Chronic Disease Physician Advisory Group

Chronic Disease Clinical Leadership Group

Specialist Consultants

Chronic Respiratory Clinical Champions

CHR Asthma Program Committee

Utilizing the Chronic Care model, these groups developed the Asthma Clinical Guide as a decision-support tool for improved functional and clinical outcomes. is Guide supports primary care

interdisciplinary team-based practice with a strong focus on self-management.

Please use and reproduce with acknowledgement to the Chinook Health Region.

Chronic Disease Management and Prevention Network:An Alberta Health Capacity Building Initiative

Chinook Health RegionLethbridge, Alberta

April 2006


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Table of Contents

1. Diagnosis

a. Definition ............................................................................................................5b. Risk Factors .........................................................................................................5c. Screening .............................................................................................................6d. Signs and Symptoms ............................................................................................6e. Testing and Evaluation ........................................................................................6f. Further Testing ....................................................................................................7g. Algorithm ............................................................................................................8

2. Classification/Type/Staginga. Stages/Types of Disease ........................................................................................11

3. Patient Care Flow Sheet for Health Teams

a. Patient Care Flow Sheet ......................................................................................13b. Key Clinical Summary .........................................................................................14

4. Management Strategies for Health Teamsa. Goals of Management ..........................................................................................15b. Key Clinical Targets .............................................................................................15c. Non-Pharmacologic Strategies .............................................................................15d. Pharmacologic Strategies......................................................................................16

5. Management Strategies for Patients/Clientsa. Self-Care Support Information/Handouts/Tools .................................................21b. Patient/Client Checklist for Evidence-Based Care ................................................25

6. Referral to Specialists/Specialty Programa. Indications for Referral to Medical Specialists ......................................................27b. Indications for Referral to Specialty Programs ......................................................27c. Local Contacts .....................................................................................................27

7. Referencesa. Evidence ..............................................................................................................29b. On-line Resources ...............................................................................................29c. Supplementary Handouts Available .....................................................................29


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1. Diagnosis

BUILDING HEALTHY LIFESTYLESCHRONIC RESPIRATORY-ASTHMA

Unless clinical practice guidelines are followed, the danger of bothunder- and over-diagnosis exists. e interpretation and availabilityof tests to assess variable airway obstruction is inconsistent. Becauseof the variable nature of the disease over time, the tests for airwayobstruction and hyper-responsiveness may not reveal a problem evenwhen asthma exists.

1. Diagnosis

a. Definitions:

Asthma: is characterized by paroxysmal or persistent symptomssuch as dyspnea, wheezing, chest tightness, sputum production andcough associated with variable airflow limitation and airway hyper-responsiveness to endogenous or exogenous stimuli.

Exercise Induced Bronchospasm (EIB): is a reversible airwayobstruction that occurs during or after strenuous physical exertion.Solitary EIB is not asthma and it is important to distinguish if exerciseinduced symptoms are the result of poorly controlled asthma.

EIB versus Asthma

A therapeutic trial is a practical way to confirm EIB. e clienttakes B-2 agonists, 15 minutes prior to exercise; the EIB diagnosis isconfirmed if the medications prevent or diminish symptoms. echallenge is to distinguish whether or not the patient has asthma

with an exercise exacerbation or has solitary EIB. Because treatmentis different for these two conditions, it is important to evaluatethe patient for asthma using patient history, physical exam andpulmonary function tests (spirometry).

Occupational Asthma (OA) is asthma induced by exposure to aspecific agent in the workplace; is the most common occupationallung disease in developed countries. OA has been estimated to cause5 15 % of adult onset asthma.

An occupational cause should be suspected for all new cases ofasthma in adults

Temporal associations are not sufficient to diagnose work-related

asthma and objective tests are required to confirm the diagnosis.Workers with asthma symptoms should not be told to leave theirjob until diagnosis is proven because part of the diagnostic work-up of OA may involve a return trial to work.

Referral to a medical specialist for evaluation of OA

Irritant-induced Asthma is caused by single or multiple exposuresto high concentrations of an irritant vapour, fume or smoke in peoplewho have no previous diagnosis or history of asthma symptoms. Teterm Reactive airways dysfunction syndrome or RADS is used

when the condition is caused by a single exposure.

Reactive Airways Disease (RADS) is poorly defined, confusing andshould not be used in lieu of possible or probable Asthma.

b. Risk Factors

Major risk factors:i. Personal history of atopy, especially atopic dermatitisii. Parental history of asthma or eczemaiii. ree or more episodes of wheeze during the first three years

of life

Minor risk factors:i. Eosinophiliaii. Wheezing without colds

iii. Allergic rhinitisiv. Environmental tobacco smoke (ETS)

OCCUPATIONAL ASTHMA (OA)

Highest risk occupations and asthma-producing substances

OCCUPATION ASTHMA-PRODUCINGSUBSTANCES

Adhesive handlers Chemicals such as acrylate

Animal handlers, vets, researcher Animal proteins

Bakers, Millers Cereal Grains

Carpet makers Gums

Electronic workers Soldering resin

Forest workers, Carpenters,Cabinet makers

Wood dust

Hairdressers Chemicals such as persulfate

Healthcare professionals Latex and chemicals such asglutaraldehyde

Janitors, Cleaning staff Chemicals such as chloramine-T

Pharmaceutical workers Drugs, enzymes

Seafood processors Seafood

Shellac handlers Chemicals such as amines

Solderers, Refiners Metals

Spray painters, Insulationinstallers, Plastic & Foamindustry workers

Chemicals such as diisocyanates

Textile workers Dyes

Users of plastics, epoxy resins Chemicals such as anhydrides


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1. Diagnosis

c. Screening

ere is currently no organized approach to screening for asthma inCanada.

d. Signs and Symptoms

Asthma

Coughing

Wheezing

Chest tightness

Shortness of breath

Trouble sleeping because of breathing difficulty

Reduced physical activity due to breathing difficulty

EIB:

Coughing, wheezing, shortness of breath and chest tightness

immediately following 6 to 8 minutes of strenuous exercise.ese symptoms may occur during or after exercise.

e. Testing and Evaluation

Evaluation and diagnosis of asthma in clients able to performlung function tests (Usually 6 years of age and older):

ere is no one definitive test that can be used to diagnose asthma,requiring the bringing together of many sources of information inorder to reach such a diagnosis. At the present time, diagnosingasthma is based on the following:

the presence of typical symptoms of asthma and an improvement

in these symptoms with asthma medication evidence of variable airflow limitation and/or obstruction

in some circumstances, evidence of hyper-responsiveness of theairways using a provocation challenge test

Steps in primary care setting to accurately diagnosis asthma, suspectasthma based on symptoms, physical exam and patient history.Next, confirm diagnosis through lung function tests showingvariable airflow obstruction and/or response to trial of asthmamedications.

orough history: covering symptoms and pattern of symptomsas well as what triggers the symptoms. Personal history of atopy

(eczema, hay fever, hives, allergic rhinitis, allergies) and familyhistory of atopy or asthma in close relatives.

Physical exam: should focus on upper respiratory airway(nasopharynx) and lower respiratory airway (chest) as well asthe skin. Physical exam may help confirm the diagnosis ofasthma, but does not generally provide the diagnosis. Physicalexam alone tends to underestimate the severity of an asthmaexacerbation. Co-morbid conditions such as rhinitis, sinusitis,post nasal drip or Gastroesphageal Reflux Disease (GERD) thatmimic or worsen asthma symptoms should be evaluated andaddressed.

Findings with asthma that may be present are: use of accessory muscles of respiration tracheal tug indrawing hyperinflation of the chest decreased air entry

prolonged expiration wheezing wheeze with forced expiration silent chest

Lung function tests (2 types): Objective measurements areneeded to confirm the diagnosis of asthma and to assess itsseverity accurately in all symptomatic patients.

i. Spirometry (preferred method)- A 12% (at least 180 mL in adults) or greater improvement in

Forced Expiratory Volume (FEV)1.0 15 minutes (10 minutesis more practical and used in the LRH PFT lab) after use ofan inhaled short-acting beta-2 agonist will confirm diagnosis

of asthma*- A 20% (at least 250mL in adults) or greater improvement in

FEV1.0 after 10-14 days of inhaled glucocorticosteriods oringested prednisone, when symptoms are stable will confirmdiagnosis of asthma

- A 20% (at least 250 mL in adults) or greater spontaneousvariability in FEV1.0 over time is considered significant and

will confirm the diagnosis of asthma

ii. Peak Expiratory Flow or PEF (used when spirometry isunavailable or home monitoring is required to diagnose)

- Variable airflow obstruction can be documented by homemeasured PEF that shows a 20% or greater diurnal variability

over a period of several weeks. is can confirm thediagnosis of asthma.

- A 20% or greater improvement in PEF, 15 minutes (10minutes is more practical) after the administration of a shortacting beta-2 agonist may be used to confirm asthma in aphysicians office when spirometry is not available.

- Both these methods are not as reliable as spirometry.

erapeutic trial of asthma medications, which should includeInhaled Corticosteroids (ICSs) daily and short-acting B-2 agonistas needed for a period of 2-4 weeks may be helpful in confirmingthe diagnosis of asthma.

Evaluation and diagnosis of asthma in clients unable to performlung function tests (Usually less than 6 years of age):

NOTE: ere are no age criteria for the diagnosis of asthmaas it can be diagnosed at any age. However, caution should beused when diagnosing asthma in clients less than one year ofage. Persistent respiratory symptoms in infants and children may

warrant a referral to a specialist.

e diagnosis rests on careful and sometimes repeated historytaking and physical examination as stated above

*Please note- in children age 6-17 only a 12% improvement in FEV 1.0 isrequired after bronchodilator.


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1. Diagnosis

Factors particularly useful in establishing a diagnosis in youngpatients: severe episodes of wheezing wheezing after 1 year of age more than 3 episodes of wheezing in a given year family history of asthma/atopy

personal history of asthma/atopy maternal smoking clinical benefits from acute bronchodilator therapy clinical evidence of improvement after anti-inflammatory

treatment chronic cough (especially nocturnal or associated with

exercise) wheezing when viral etiology is unlikely

e likelihood of a diagnosis of asthma increases with the numberof these factors present.

Clinical Index for the Diagnosis of Asthma

Stringent Index: 3 or more episodes of wheeze during the first3 years of life with either one of the major riskfactors: parental history of asthma or eczema, or2 of 3 minor risk factors; eosinophilia, wheezing

without colds, allergic rhinitis

Loose Index: any wheezing during the first 3 years of life plus 1major or 2 minor risk factors

Clinical Clues to Alternate Diagnosis

Not asthma: poor response to therapy after ensuring compliancewith trigger avoidance strategies, proper inhaler use and compliance

with medical treatment. No history of atopy. Cystic fibrosis: malabsorption, finger clubbing, nasal polyps

Pertussis: paroxysmal cough, ill contacts

Rhinitis/Sinusitis: no wheeze, throat clearing

Gastroesophageal Reflux (GER): previous regurgitation, nighttime

Congenital malformation: age under one year

Foreign Body: sudden onset without Upper Respiratory Infection(URI), focal findings

f. Further Testing

Referral to a medical specialist for bronchoprovocation testing tohelp confirm or rule out asthma.

Appropriate allergy assessment is warranted in patients withasthma and must be interpreted in light of patients history.

Allergen exposure is a risk factor for severe, acute asthma,especially if the patient is exposed to high concentrations ofthe specific allergen. erefore, allergens to which a personis sensitized should be identified through allergy testing.Once identified, steps should be taken to eliminate or at leastsubstantially reduce allergen exposure.


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1. Diagnosis

g. Algorithms

Approach to Asthma Diagnosis in Clients Able to Perform Spirometry Tests

Reliably (usually 6 years of age or greater) in the Primary Care Setting

Suspect asthma based on symptoms, patient history & physical exam

Confirm diagnosis of asthma with Pre & Post Spirometry Testing

Is there a >12% improvement in Forced ExpiratoryVolume FEV1.0 (of at least 180ml in adults 18+) 10 YES

minutes after short-acting bronchodilator*

Asthma diagnosis confirmedInitiate treatment & asthma education(Referral to asthma educator)

Does pre & post spirometry test meet the following criteria to be considered normal FEV1.0/FVC ratio > 0.7 FVC > 80% of predicted value FEV1.0 > 80% of predicted value

NO

If FVC is < 80% predicted andFEV1.0/FVC ratio is > 0.7

Post bronchodilator FEV1.0/FVCratio is < 0.7bronchodilator FEV1.0 is < 80%predicted

If post bronchodilatorFEV1.0/FVC ratio is < 0.7

Consider diagnosis of restrictivelung defect not consistent with adiagnosis of asthma - referral to aspecialist may be warranted

Diagnosis of COPD can beconfirmed alone or co-existing withasthma

Consider diagnosis of irreversibleobstructive lung defect

Is client currently symptomatic

YES NO

and post

Initiate proper COPD treatment

Initiate proper asthma therapy ofinhaled corticosteroids and short-acting bronchodilators for one monththen follow up and reassess

Repeat spirometry if and whensymptoms recur to confirmdiagnosis of asthma or dismissdiagnosis of asthma

YES NO

Clinical benefits after proper asthmatherapy?

Asthma diagnosis may be confirmedConsider re-test with spirometryInitiate treatment and asthmaeducation (referral to an asthmaeducator)

Referral to a specialist for bronchoprovocation testing to help confirm / rule out diagnosis of asthand investigate other conditions that mimic asthma (i.e. Gastroesophageal Reflux Disease (GEvocal cord dysfunction)

Notes:

FVC is forced vital capacity, FEV1.0 is forcedexpiratory volume in 1 second.

Normal predicted values in spirometry are availablefor people 5 years of age and older. No normalpredicted values exist for children younger than 5

years of age. Some children as young as 5 can givereliable spirometry testing. Therefore, this may needto be decided by the person performing the test.

*

NO YES

In children age 6 - 17 only a 12% improvement in

FEV1.0 10 minutes after a short-acting bronchodilator

is required to confirm a diagnosis of asthma.


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1. Diagnosis

Approach to Asthma Diagnosis in Clients Able to Perform Peak Expiratory Flow TestsReliably (usually 6 years of age or greater) in the Primary Care Setting


Spirometry is not available

(Spirometry is the preferred method according to the CPGs)

Confirm Diagnosis of asthma with Peak Expiratory Flows (PEF)

YES NO YES

Is client currently symptomatic

YES

YES NO

Note: PEF is less reliable than spirometry for confirming the diagnosis of asthmaTo calculate a 20% improvement in PEF following administration of a short-acting B-2 agonist:

1. Obtain a peak flow reading prior to medication, e.g. 400 lpm2. Multiply that number by 1.2 to give value needed to confirm a 20% improvement in PEF (400 x 1.2 = 480).3. Give B-2agonist, wait 10 minutes then repeat PEF; this value must be > 480 lpm to show a 20% improvement in

PEF and confirm diagnosis of asthmaTo calculate diurnal variation of PEF:

1. Client is to measure peak flows in the am and pm of each day for 2-4 weeks and record the best value of 3 triesin a diary

2. Once this data has been recorded, calculate the diurnal variation of each day by using the following formula:Highest PEF Lowest PEF (on the same day) x 100

Highest PEFFor example: Day 1 Day 2 Day 3

PEF am pm am pm am pm400 500 400 450 350 500

500 400 x 100 450 400 x 100 500 350 x 100500 450 500

= 20% diurnal variation = 11.1% diurnal variation = 30% diurnal variation Children as young as 5 years of age may be able to properly perform PEF. There are no predicted values for childrenunder 5 years of age for peak flow.

>20% improvement in PEF 10 minutes afteradministration of short-acting B-2 agonist

>20% or greater diurnal variability in PEFover a period of several weeks

Asthma diagnosis confirmedInitiate treatment and asthma education

(referral to an asthma educator)

Asthma diagnosis confirmedInitiate treatment and asthma education

(referral to an asthma educator)

Initiate proper asthma therapy of inhaledcorticosteroids and short-acting bronchodilatorsfor one month then follow up and reassess

Repeat PEF if and when symptoms recur

Clinical benefits after proper asthma therapy

Asthma diagnosis may be confirmedConsider retesting with spirometryInitiate treatment and asthmaeducationConsider a referral to an asthmaeducator

Consider a referral to have pre & post spirometry done or referral to aspecialist for bronchoprovocation test to help confirm / rule outasthma diagnosis and investigate other conditions that mimic asthma(i.e. Gastroesophageal Reflux Disease (GERD), vocal corddysfunction).


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Asthma


1. Diagnosis

Approach to Asthma Diagnosis in Clients Unable to Perform Reliable

Pulmonary Function Tests (less than 6 years of age) in the Primary Care Setting


First, determine the presence of airway sensitivity by inquiring about symptoms such as cough,wheeze, limited physical activity, chest tightness and shortness of breath.

Second, look for evidence of inherited ability to react to stimuli - is there a family history of atopyand a personal history of eczema or atopy.

Third, establish that there is no underlying lung disease - look for anything else that could becausing cough.

Therapeutic trial of asthma medications to confirm diagnosis of asthma in preschool children

OR

Reassess response to asthma therapy in child Did Beta-2 agonist provide relief from wheeze, chest tightness and SOB? Did cough subside after one month of inhaled corticosteroids? Did cough subside after 5 days of oral prednisone?

YES NO

NOTE- there is no age criteria for the diagnosis of asthma as it can be diagnosed at any age. However,caution should be used when diagnosing asthma in children less than one year of age. Persistentrespiratory symptoms in infants and children may warrant a referral to a specialist.

Asthma diagnosis may be confirmedespecially if symptoms recur whenmedications are stoppedInitiate treatment and asthma educationReferral to an asthma educator

Consider an alternate diagnosisConsider a referral to a Pediatrician

Beta-2 agonists for relief of symptoms such as wheeze, chest tightness and shortness of breath (SOB)

AND

Inhaled Corticosteroid for coughing for a period of one month

Oral prednisone for therapeutic trial for coughing, 1mg/kg per day up to a maximum of 50 mg x 5 days

CAUTION: ensure child is not incubating varicella virus. A comprehensive varicella history should bedone


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2. Classification/Type/Staging


Determining the Severity of Asthma

Assessment of asthma severity will help physician determineappropriate level of therapy required, as well as when a client

should be referred to a specialist.

e severity of asthma can be evaluated in two ways:

1. Before or without treatment which takes into accountsymptoms, physiological indicators of airway disease (lungfunction tests) and morbidity.

2. With treatment or when controlled asthma amount ofmedication required to maintain control.

e primary measure of asthma severity in the treated patientshould be the minimum therapy required to achieve acceptablecontrol.


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Asthma severity before or without proper treatment

Event or measurement Mild Moderate Severe

FEV1.0 or PEF, % of predicted >80% 60 79%


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Asthma Patient Care Flow Sheet Patient Name

Comorbid Conditions PHN

Year of Diagnosis

DATE: _________ _________ _________ ________ _________ _________

REVIEW ITEMSNeeds reliever medication 4 times/week(may use 1 dose/day for exercise)

Physical activity limited by symptoms (in past 3 months)(Sx: coughing, wheezing or chest tightness)

Symptoms wake patient at night 1 times/week

Symptoms 4 days/week

Any urgent visits for asthma since last regular appointment

Absence from work/school because of asthma

(in last 3 months)

lortnoCamhtsA

*Client must answer all with NO to have Control , if Yes to one or more questions asthma is not controlled reassess

Smoker or secondhand smoke in the home/vehicles. If yesaddress smoking (ask, advise, assist, arrange 4As)

Identified asthma triggers:

Have steps been taken to reduce exposure to asthma triggers

ecnadiovAreggirT

A client that is not reducing exposure to allergens and asthma triggers will be difficult to control. Referral to asthma program

Does client have a written asthma action plan

* If not, provide a written CHR asthma action plan

Client understands how to use the asthma action plan

Is controller medication used regularly?Controller medications:

Reliever Medications:

Economic Concerns (cost of meds):

ecnailpmoC

Have patient demonstrate how they use their inhaler device(s)

*Ensure Proper Inhaler Technique

Sx of GERD, Rhinitis, Sinusitis

Asthma meds that may affect other diseases

(Prednisone use, test blood glucose)

Sx of depression, anxiety

ISIV

ECIFFO

RALUGER

AMHTSA

ROF

ST

seitidibromo

C * If any comorbidities exist with asthma, treat appropriately as these may affect proper asthma control

Perform Pre & Post Spirometry testing yearly & prnstseT

Height and weight (especially for pediatrics)BMD for osteoporosis (If on ICSs and has risk factors)

Review asthma action plan, try to reduce medication required

while maintaining asthma control

Referrals: Asthma educatorfor education & evaluation

for initial education & follow up as needed

Medical Specialist as needed

YLLAUNNA

tnemeganaM

Vaccinations: Annual Influenza vaccine

Pneumoccocal vaccine if > 65 years

Immunizations up to date

Revised as of May 9, 2005 developed by the BHL/chronic respiratory/ Chinook Health Region

3. Chronic Disease Patient Care Flow Sheet

3. Chronic Disease Patient Care Flowsheet


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3. Patient Care Flow Sheet

Asthma Continuum of Care Reliever (Rescue) medications Salbutamol (Ventolin) MDI 100 mcg per dose 1 or 2 inhalations as needed Salbutamol (Ventolin) Diskus 200 mcg per dose

Adults & children 6 and older, 1 inhalation as needed

Terbutaline (Bricanyl) Turbuhaler 0.5 mg per dose

Adults & children 6 and older, 1 inhalation as needed

Salbutamol (Airomir) MDI 100 mcg per dose 1 to 2 inhalations as needed

Inhaled Corticosteriods (Preventer/controller medications)ICSs should be introduced as the initial maintenance treatment for asthma,even in subjects who have very mild asthma and use their relievermedication less than 3 times/week. Refer to chart on left for proposeddoses for ICSs Fluticasone (Flovent) MDI 50, 125 & 250 mcg per dose

BID dosing most effective Fluticasone (Flovent) Diskus 50, 100, 250, 500 mcg per dose BID dosing most effective Budesonide (Pulmicort) Turbuhaler 100, 200 & 400 mcg per dose BID dosing most effective

Daily Long Term Inhaled Steroid Agents and Doses Beclomethasone (Q-var) MDI 50 & 100 mcg per dose BID dosing most effective

Add on Therapy if requiredIf asthma is not controlled by low doses of ICSs, additional therapyshould be considered:FIRST OPTION Add long-acting beta2 agonist to existing therapy ofICSs and short-acting beta 2 agonists, or replace ICSs with a combinationmedication. Salmeterol (Serevent) MDI 25 mcg per dose Adults 1 or 2 inhalations BID

Children 4 years of age and older 1 or 2 inhalations BID Salmeterol (Serevent) Diskus 50 mcg per dose

Adults 1 inhalation BIDNote: children will auto scale their inhaled medication dose, (take Children 6 years of age and older 1 inhalation BIDsmaller inspiratory volumes which results in less dose reaching the Formoterol (Oxeze) Turbuhaler 6 or 12 mcg per doselower airways) the same dose can be used for all asthma medications Adults 1 inhalation of 6 or 12 mcg BID (max 48 mcg per day)at all ages. Children 6-16 1 inhalation of 6 or 12 mcg BID (max 24 mcg day)FP= Fluticasone propionate (GSK Canada Inc)

ORBUD= Budesonide (AstraZeneca Canada Inc) Advair (Serevent 50 mcg/Flovent 100, 250 & 500 mcg per dose) DiskusBDP= Beclomethosone dipropionate (3M Pharmaceuticals Canada) Adults and children 12 and older, 1 inhalation BID

Children 6-11 years of age, 1 inhalation BID Advair (Serevent 25 mcg/Flovent 125 & 250 per dose) MDI

Adults and children 12 and older, 1 or 2 inhalations BID Children 4 years of age and older, 1 or 2 inhalations BID

Symbicort (Oxeze 6 mcg/Pulmicort 100 & 200 mcg per dose) Turbuhaler Adults and children 12 years of age and older, 1 or 2 inhalations BID

Children 6 to 11 years of age, 1 or 2 inhalations BIDSECOND OPTION- Increase the inhaled corticosteriods (ICSs) to amoderate dosage as per chart or add in a leukotriene receptor antagonist. Montelukast (Singulair) 4, 5 & 10 mg chewable tablet Adults and children 15 years of age and older one 10 mg tablet daily

at bedtime Children 6 to 14 years of age one 5 mg tablet daily at bedtime Children 2 to 5 years of age one 4 mg tablet daily in the evening

Zarfirlukast (Accolate) 20 mg tablet

Adults and children 12 years of age and older two 20 mg tablets daily

THIRD OPTION consider theophylline, severe asthma may requireadditional treatment with Prednisone. If required to maintain control, referto the CPS for dosing requirements & refer to medical specialist.

Prednisone for acute exacerbations of asthma, use the followingdosages:

For ages 12 and over: 50 mg po daily for 3-10 days

For ages under 12: 1mg/kg po daily for 3-10 days (maximum dose: 2

mg/kg po daily)No Prednisone dose tapering required if less than 2 weeks

Treatment options from the Canadian Asthma Consensus Guidelines update 2003, medications updated as of January 12, 2006

Mcg/day (all ages)

Low Medium HighProduct

BUD TurbuhalerPulmicort

FP pMDI and spacerFlovent

FP DiskusBDP pMDI (HFA)

Q-varBUD wet nebulization

< 400

< 250

< 250< 250

< 1000

401 800

251 500

251 500251 500

1001- 2000

> 800

> 500

> 500> 500

> 2000

Asthma Severity based on treatment needed to obtain control Asthma Severity Symptoms Treatment required

Very mild Mild-infrequent None, or inhaled short-acting B-2 agonist rarely

Mild Well-controlled Short-acting B-2 agonist(occasionally) and low doseinhaled steroids

Moderate Well-controlled Short-acting B-2 agonist andlow to moderate doses ofinhaled steroids with orwithout add on therapy

Severe Well-controlled Short-acting B-2 agonist andhigh doses on inhaledsteroids and add on therapy

Very severe May be Short-acting B-2 agonist andcontrolled or not high doses of inhaledwell-controlled steroids and add on therapy

and oral steroids


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4. Management Strategies for Health Teams

a. Goals of Management

To maintain acceptable asthma control use nonpharmacologic andpharmacologic strategies. Asthma control is defined under KeyClinical Targets.

b. Key Clinical Targets

Criteria for asthma control

Parameter Frequency or value

Daytime symptoms less than 4 days/week

Night-time symptoms less than 1 night/week

Physical activity Normal

Exacerbations Mild, infrequent

Absence from work/school None

Need for short-acting beta-2 agonist Less than 4 doses/week*

FEV1.0 or PEF > 85% of personal bestIdeally 90%

PEF diurnal variation < 15% of diurnal variation

*May use 1 dose/day for prevention of exercise-induced symptoms

To be considered controlled asthma, all the above criteria mustbe met. If they are not met, it is then considered uncontrolledasthma.

Control can be achieved in uncontrolled asthma through patient

education, trigger avoidance and medications.

c. Non-Pharmacologic Strategies for Asthma

Environmental Control:

Elimination of exposure to environmental tobacco smoke (ETS)

Identification of asthma triggers and implement triggeravoidance strategies

Allergy testing to identify allergens to which a person issensitized; once these allergens are identified, steps shouldbe taken to eliminate or at least substantially reduce allergenexposure

Current recommendations for protecting against developmentof allergy and asthma in subsequent pregnancies and subsequentchildren:1. Elimination of exposure to ETS (includes during pregnancy)2. Promotion of exclusive breast feeding for at least 4 months3. For families with biparental atopy, maternal asthma or both,

it appears that there is substantive data to recommend againsthe presence of a cat or dog in the home

IMPORTANT! Medication should not be substituted forenvironmental control and trigger avoidance strategies.

Asthma Action Plan:

Devise a written action plan for the management ofexacerbations that includes medication adjustment in responseto changes in severity or frequency of symptoms, the need forsymptom relief medication or changes in PEF. Provide the

written document or ask an asthma educator to do so. Pleaserefer to Section 5, subsection a for a copy of the CHR Asthma

Action Plan.

Education and Follow-up:

Education is an essential component of asthma therapy and shouldbe offered to all patients. Educational interventions may be ofparticular benefit to patients with high asthma-related morbidity or

severe asthma and at the time of emergency department visits andadmissions to hospital.

All patients should self-monitor their asthma using symptoms orPEF or both

Ensure regular follow-up (every 6 months). Asthma controlcriteria should be assessed at each visit. Measurement ofpulmonary function, preferably spirometry, should be doneregularly in adults and children 6 years of age and older. Review

written action plan and medication required with an aim toreduce amount of medication while maintaining asthma control.

Smoking Cessation:

Smoking cessation interventions (4A model) should be offeredto patients who smoke, or parents of children with asthma whosmoke.

Influenza vaccination:

All patients with asthma should be encouraged to have an annuainfluenza vaccination, as well as any family members living withpatient (parents & siblings).



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Immunotherapy in Adults:

Immunotherapy is generally not recommended in the treatmentof asthma

Immunotherapy should not be used in place of avoidance ofenvironmental allergens

Immunotherapy with clinically relevant allergens may beconsidered if disease activity is inadequately controlled byavoidance of allergens and pharmacotherapy

Immunotherapy should be avoided while asthma is poorlycontrolled

Well-controlled asthma is not a contraindication forimmunotherapy for allergic rhinoconjunctivitis or insect venomhypersensitivity

Immunotherapy must be administered only by trained personnelin centres where there is medical supervision and resuscitativeequipment (for both children & adults)

Immunotherapy in Children: Although debate about the value of immunotherapy continues,

meta-analysis and review of immunotherapy support thepotential value of immunotherapy in childhood; earlyimmunotherapy may prevent development of asthma in childrensensitized to house dust mite allergen

Physicians should consider injection immunotherapy usingappropriate allergens for the treatment of allergic asthma only

when allergic component is well documented

Physicians should not recommend the use of injectionimmunotherapy in place of avoidance of environmental allergens

Physicians may consider injection immunotherapy in addition toappropriate environmental control and pharmacotherapy whenasthma control remains inadequate

Immunotherapy is not recommended when asthma is unstable

d. Pharmacologic Strategies for Asthma

First Line erapy:

Reliever medications rescue

Salbutamol (Ventolin) MDI 100 mcg per dose 1 or 2 inhalations as needed

Salbutamol (Ventolin) Diskus 200 mcg per dose Adults 1 inhalation as needed Children 6 years and older 1 inhalation as needed

Terbutaline (Bricanyl) Turbuhaler 0.5 mg per dose Adults 1 inhalation as needed Children 6 years and older 1 inhalation as needed

Salbutamol (Airomir) MDI 100 mcg per dose 1 to 2 inhalations as needed

AND

Inhaled Corticosteroids (ICSs) low dose maintenance

Regular use of low dose ICSs is currently the recommendedtreatment for persons with asthma of all ages, even for thosewith intermittent asthma symptoms

Physicians should recommend that children with frequentsymptoms, severe asthma exacerbations or both receive regular,not intermittent, treatment with ICSs

e use of intermittent treatment as a strategy for managementof intermittent asthma in childhood is not validated and requiresfurther research especially in very young children

For patients who cannot or will not use ICSs, leukotrienereceptor antagonists (LTRAs) should be the primary treatmentchoice, although they are less effective than low dose ICSs Fluticasone (Flovent) MDI 50, 125 & 250 mcg per dose

BID dosing most effective

Fluticasone (Flovent) Diskus 50, 100, 250, 500 mcg per dose BID dosing most effective

Budesonide (Pulmicort) Turbuhaler 100, 200 & 400 mcg perdose BID dosing most effective

Beclomethasone (Q-var) MDI 50 & 100 mcg per dose BID dosing most effective


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Dose equivalencies for inhaled corticosteroids - ICSs (All ages)

Product

Low

Daily Dose (mcg/day)Moderate

High

BUD turbuhaler < 400 401 - 800 > 800

FP pMDI and spacer < 250 251 - 500 > 500FP Diskus < 250 251 - 500 > 500

BDP pMDI (HFA) < 250 251 - 500 > 500

BUD wet nebulization < 1000 1001 - 2000 > 2000

BDP= Beclomethasone dipropionate (Q-var)BUD= Budesonide (Pulmicort)FP= Fluticasone propionate (Flovent)* Note: Children will auto-scale their inhaled medication dose, (take proportionately smaller inspiratory volumes compared to adults, whichresults in less of the dispensed dose of inhaled medication reaching the lungs). e same dose can be used for all medications at all ages.

Add on erapy as Required:

If after reassessment of compliance with treatment, triggeravoidance strategies, inhaler technique and co-morbidities,asthma is not controlled by low dose ICSs, additional therapyshould be considered:

FIRST OPTION Add long-acting beta-2 agonist to existingtherapy of ICSs and short-acting beta-2 agonist, or replace ICSs

with a combination medication.

Salmeterol (Serevent) MDI 25 mcg per dose Adults 1 or 2 inhalations BID

Children 4 years of age and older 1 or 2 inhalations BID Salmeterol (Serevent) Diskus 50 mcg per dose Adults 1 inhalation BID Children 6 years of age and older 1 inhalation BID

Formoterol (Oxeze) Turbuhaler 6 or 12 mcg per dose Adults 1 inhalation of 6 or 12 mcg BID (max 48 mcg per

day) Children 6-16 1 inhalation of 6 or 12 mcg BID (max 24

mcg day)

OR

Advair (Serevent 50 mcg/Flovent 100, 250 & 500 mcg per dose)

Diskus Adults and children 12 and older, 1 inhalation BID Children 6-11 years of age, 1 inhalation BID

Advair (Serevent 25 mcg/Flovent 125 & 250 per dose) MDI Adults and children 12 and older, 1 or 2 inhalations BID Children 4 years of age and older, 1 or 2 inhalations BID

Symbicort (Oxeze 6 mcg/Pulmicort 100 & 200 mcg per dose)Turbuhaler Adults and children 12 years of age and older, 1 or 2

inhalations BID Children 6 to 11 years of age, 1 or 2 inhalations BID

SECOND OPTION- Increase the inhaled corticosteroids (ICSs)to a moderate dosage as per chart or add in a leukotriene receptorantagonist (LTRAs)

Montelukast (Singulair) 4, 5 & 10 mg chewable tablet Adults and children 15 years of age and older one 10 mg

tablet daily at bedtime Children 6 to 14 years of age one 5 mg tablet daily at

bedtime Children 2 to 5 years of age one 4 mg tablet daily in the

evening

Zarfirlukast (Accolate) 20 mg tablet

Adults and children 12 years of age and older two 20 mgtablets daily

THIRD OPTION Consider theophylline; severe asthma mayrequire additional treatment with prednisone. If required tomaintain control, refer to the CPS for dosing requirements andrefer to a medical specialist.

Prednisone:

For acute exacerbations of asthma, use the following dosages:


For ages under 12: 1mg/kg po daily for 3-10 days (maximumdose: 2 mg/kg po daily)

No Prednisone dose tapering required if less than 2 weeks


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Management of Acute Asthma Exacerbations (excluding ER andacute care facilities)

Acute asthma exacerbation is defined as deterioration of asthmacontrol that is not responding to B-2 agonist rescue treatment inthe usual manner or a sustained worsening of asthma symptomsleading to increased use of B-2 agonists as well as increased use ofmaintenance medications and/or supplementation with additionalmedicine. e following are loose criteria that can define an acuteasthma exacerbation:

Bronchodilator use 4 times/week (excluding 1 dose/day forexercise)

Nocturnal awakenings due to asthma 2 times/week

Daytime asthma symptoms 4 days/week

Recent absence from work or school due to asthma

Recent unscheduled physician visit due to asthma

Spirometry testing shows FEV1.0 < 80% of predicted normal

PEF tests fall below 80% of personal best value, or predictedvalue if personal best is not known

Studies have shown that the major cause (80%) of asthmaexacerbations is viral upper respiratory infections. With viralupper respiratory infections the inflammatory response tends tobe more neutrophilic than eosinophilic. Inhaled corticosteroidsmay not be effective during neutrophilic inflammatory responsesseen with viral upper respiratory infections.

Non-Pharmacologic Strategies:

Avoid contact with environmental tobacco smoke

Continue to avoid personal asthma triggers

Refer to personalized written asthma action plan as to how totemporarily modify asthma medications

Pharmacologic Strategies:

Prevention of asthma exacerbations needs to be the primarytarget of asthma treatment and ICSs. is can be accomplishedthrough regular use of ICSs as maintenance treatment forasthma.

Previous asthma guidelines have recommended the use of anaction plan to manage asthma exacerbations. Many of theseplans advocate a doubling of the dose of maintenance ICS as

one of the first steps in the management of worsening asthma.However, there are no randomized controlled trials to supportdoubling the dose of ICS on identification of exacerbations ofasthma.

2 recent studies (adult & pediatric populations) have providedevidence that early or impending asthma exacerbations arenot always effectively treated by doubling the dose of inhaledcorticosteroids at the first sign of an exacerbation. ese resultsapply to those patients with asthma who regularly use theirpreventer or controller medication as maintenance therapy when

well.

ere is some evidence for the potential benefit of a moresubstantial increase in the dose of ICS such as tripling orquadrupling the regular maintenance dose at the first sign of anasthma exacerbation.

e standard of care is that ICS dose should be increased duringan asthma exacerbation, but there is not enough good evidence

to make a generic recommendation as what dose to increase theICS from the maintenance dose during the exacerbation.

rough the COPD & Asthma Network of Alberta (CANA),as well as consulting local CHR specialists we have summarizedcurrent clinical practices utilized by both pediatric and adultrespiratory specialists throughout Alberta in managing acuteasthma exacerbations: If the client is on high doses of ICS for maintenance

(or maximum daily dosage for that client as decided byphysician), the clinical practice is to double the maintenancedose of ICS or maintain the current dose of ICS and add ina long-acting beta agonist (LABA) or leukotriene receptor

antagonist (LTRA) for a period of approximately 2 weeks. If client is on low to moderate doses of ICS for maintenance,

the clinical practice is to increase to the full dose of thespecific ICS for approximately 2 weeks, then return tomaintenance dose.

Full dose:

Fluticasone (Flovent) 500 1000 mcg/dayBeclamethasone (Q-Var) 400 800 mcg/dayBudesonide (Pulmicort) 800 1600 mcg/day

e clinical practice of many respiratory specialists is toincrease the dose of ICS at the first sign of an exacerbation

and whether the dose is doubled or quadrupled depends onthe clients maintenance dose as well as personal history ofexacerbations. ose who become ill quickly upon exposureto triggers treat more aggressively than those who generallymanage trigger exposure without significant incident.

If the asthma exacerbation is not responding to increaseddoses of ICS and add on therapy, a short course of oralprednisone should be considered. Recommended doses:


For ages under 12: 1mg/kg po daily for 3-10 days(maximum dose: 2 mg/kg po daily)

No Prednisone dose tapering required if less than 2 weeks

Te above evidence is based on the opinions of those who have writtenand reviewed the asthma guidelines, based on their experience,knowledge of the relevant literature and discussion with their peers.


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Special Considerations:

Asthma in the Elderly

Diagnosis

A diagnosis of asthma should be more widely considered inelderly patients with dyspnea, wheezing or nocturnal cough.

Asthma may be difficult to diagnosis in the elderly because ofmisconceptions about its prevalence and also because olderpatients have diseases and disorders that mask the classic featuresof asthma.

Treatment

In the elderly patient with asthma, it is particularly important totake a careful medication history. Use of self-prescribed ASA hasbecome common and may go unrecognized. ASA and NSAIDSare commonly prescribed in the elderly and may cause late-on-set asthma. Oral and topical B-adrenergic blocking agents andother anti-arrhythmic agents, including verapamil and others

with acknowledged B-blocker potential, can exacerbate or causeasthma in those who are predisposed to the disease. Wheneverpossible, medications that might induce or aggravate asthmashould be withdrawn.

Special care should be taken to allow elderly patients with asthmato choose an inhaler device with which they are both comfortableand competent.

Measures should be taken to prevent osteoporosis in elderlypatients with asthma who require prolonged treatment with oralcorticosteroids.

Elderly patients with asthma require careful follow-up becausethey have an increased risk for exacerbations, which may be

related to impaired perception of their disease severity.

Asthma in Pregnancy

Asthma is present in 4 7 % of pregnant women and is therespiratory disorder that most frequently complicates pregnancy.

e course of asthma during pregnancy is variable and asthmacontrol may remain unchanged or become worse or improveand return to the pre-pregnancy state within 3 months afterparturition.

Overall, asthma control improves significantly in the last 4 weeksof pregnancy.

Asthmatic, pregnant women have been variably reported tohave an increased risk of pregnancy-induced hypertension, pre-eclampsia, caesarean section, placenta previa and antepartum orpostpartum hemorrhage.

Recommendations

Do not stop asthma therapy during pregnancy. Poorly controlledasthma may affect maternal comfort, safety and pregnancyoutcome for both mother and child. Several well designedstudies have shown fewer adverse infant and maternal outcomesthan those without therapy.

Physicians should discuss medication choices and the rationalefor treatment plan; they should emphasize that the treatmentprogram is considered to entail less risk than the uncontrolledillness that could result in its absence.

e use of systemic glucocorticosteriods for severe asthma,especially for prolonged periods, may be associated with a greater

risk of pre-eclampsia, antepartum or postpartum hemorrhage,low birth weight, preterm birth and hyperbilirubinemia.

Patients requiring systemic glucocorticosteroid therapy should beconsidered to be in a higher risk pregnancy.

Treatment

Avoidance of allergic and non-allergic triggering factors shouldbe the first form of therapy for asthma during pregnancy.

Treatment should take the same approach as the non-pregnantpatient and may include inhaled B-2 agonists, inhaledcorticosteroids, ipratropium bromide, cromolyn and systemicsteroids. eophylline may increase nausea and reflux and is less

desirable. ere is significantly less information about the effectsof long-acting B-2 agonists and leukotriene inhibitors and thereis less clinical experience with these drugs than with other classesof drugs. ese drugs should be used only for patients whoseasthma cannot be controlled using the more studied therapies.

For drugs with a longer history of usage, there tends to be moredata to support a lack of adverse effects. Use of most commonasthma medications (B-2 agonists, theophylline, cromolyn,inhaled glucocorticosteroids) during pregnancy has not beenshown to be associated with increased perinatal risks includingcongenital malformations.

Although no asthma medications can be considered proven

safe for use during pregnancy, the ones listed above are usedto prevent the potential direct and indirect consequences ofuncontrolled asthma.

e patient must be aware of the risks and benefits ofappropriate asthma control and must give her informed consentto the therapeutic approach recommended during pregnancy.



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Inhalation Devices for drug delivery In Asthma

Metered Dose Inhalers (MDIs)

Metered Dose Inhalers can be used with any age group. A spacer orchamber should be used with children and elderly adults. A spacershould also be used if patient is receiving inhaled corticosteroids.

Under one year of age - a valved spacer and face mask should beused with MDI. (orange infant aerochamber with face mask)

From 2 to 6 years of age - a valved spacer and face mask shouldbe used with MDI. (yellow pediatric aerochamber with facemask)

More than 6 years of age - a valved spacer with a mouthpieceshould be used, rather than a face mask. (blue aerochamber)

Try to use a valved spacer with mouthpiece in children at theearliest age it becomes feasible. is will eliminate breathingthrough the nose and maximize the chance of increased airwaydeposition in the lungs. It has been clearly shown in children

that breathing through a mask via the nose decreases lungdeposition by up to 67% compared with breathing through amouthpiece using a jet nebulizer.

Dry Powder Inhalers (DPIs)

Dry Powder Inhalers can be used by most patients by the time theyreach 5 years of age. Spacer devices are not required with thesedevices. e two devices in Canada are the Turbuhaler and theDiskus inhaler.

MDIs vs Nebulizers:

Wet nebulizers for home use are rarely indicated in the

management of asthma at any age. e wet nebulizer device iscumbersome and expensive and for the amount of medicationdelivered the most costly of all methods.

ree meta-analyses of studies in children and adults evaluatingMDI and wet nebulization indicate that the use of MDI witha chamber or spacer is associated with a more rapid onset ofbronchodilation, shorter duration of emergency departmenttreatment, fewer side effects and greater patient preference. Morerapid and profound bronchodilation is achieved when sufficientdoses are given with an MDI plus spacer than when conventionaldoses are administered with a wet nebulizer.

Note: Proper inhaler technique must be taught to client. Referralto an asthma education program can ensure this is done. ere aredevices available to measure inspiratory flow rate to ensure patientcan adequately use a DPI.



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5. Management Strategies for Patients / Clients


ASTHMA ACTION PLANPatient Name:

(Last and First) _______________________________

Date of Birth: _________________________________

GREEN ZONE

YOUR ASTHMA IS IN GOOD CONTROL IF:

You do not wheeze, cough, feel tight or have

trouble breathing with your usual activities,

with exercise, or at night.

You require your reliever medicine less than

three times per week

Your peak flow is

between ________ and ________

(80% to 100% of personal best)

Action:

Avoid your personal asthma triggersAvoid tobacco smoke exposureYearly flu immunization

Watch for asthma symptoms

If you have symptoms with exercise take

___________ 15 minutes beforehand and remember

to warm up and cool down with exercise

Check your peak flow _______ per day

Controller(s): ____________________________

____________________________

Reliever(s): ____________________________

____________________________

Other Actions: ____________________________

YELLOW ZONE

YOUR ASTHMA CONTROL IS DECREASING IF:

You wheeze, cough, feel tight or have

trouble breathing with your usual activities,

with exercise or at night

You develop cold symptoms

You require your reliever medicine more than

three times per week

Your peak flow is

between ________ and ________

(60% to 80% of personal best)

Action:

Avoid your personal asthma triggers

Avoid tobacco smoke exposure


if not already doing so

Controller(s): ____________________________

____________________________

Reliever(s): ____________________________

____________________________

Other Actions: ____________________________

____________________________

Seek medical attention if your asthma control isnot improving within 2 or 3 days

ORANGE ZONE

YOUR ASTHMA IS OUT OF CONTROL IF:

You wheeze, cough, feel tight or have

trouble breathing even at rest

Your symptoms are interrupting your sleep

You require your reliever medicine more than

four times in twenty four hours

Your peak flow is below _________

(60% of personal best)

Action:

Avoid your personal asthma triggers

Avoid tobacco smoke exposure


if not already doing so

Controller(s): ____________________________

____________________________

Reliever(s): ____________________________

____________________________

Other Actions: ____________________________

____________________________

Seek medical attention if your asthma control isnot improving within 12-24 hours

RED ZONE

YOU ARE IN THE DANGER ZONE IF:

You are getting little relief to no relief in 20

to 30 minutes after your reliever medicine

You are struggling to breathe or having

trouble walking or talking

Your lips or fingernails are turning blue

Action:

Call 911 or go to the nearest emergency department

immediately

You can repeat your reliever medicine every ____

minutes times ____ doses while assistance is being

arranged

Prepared by:

______________________________M.D./RT/CAE Date: ____________

Physician Signature:____________________________________________

FC-532-01/06 adapted with permission: Alberta Lung Association White: Chart Canary: Patient Pink: Physician

Appointments:

Personal best or predicted peak flow _______

Update yearly and as needed


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YOU HAVE JUST BEEN TOLD THAT YOU ORYOUR CHILD HAS ASTHMA, NOW WHAT?

WHAT IS ASTHMA?

Asthma is an inflammatory disease of the small airways in the

lungs that results in recurring episodes of difficult breathing due tothe airways becoming more narrow (smaller) than normal. eseepisodes may occur quite often or may come and go intermittently.

Asthma ranges from very mild to severe.

WHAT ARE THE SYMPTOMS OF ASTHMA?

When the small airways in lungs begin to narrow, people withasthma usually notice some or all of the following problems:

Coughing

Wheezing

Chest tightness

Shortness of breath

Reduced ability to exercise

WHAT CAUSES AN ASTHMA EPISODE?(See diagram on back of this page)

First, a trigger is inhaled into the lungs and irritates the smallairways in the lungs.

Once the small airways are irritated, the insides of the airwaysbecome red, swollen and narrower than normal. If nothing isdone about the swelling it can get worse and people tend todevelop more asthma symptoms.

Due to the swelling, the small airways in the lungs become quitetwitchy. is causes the muscles on the outside of the airwayto tighten and narrow the airways even more. Breathing becomesmuch harder than normal at this point and could lead to aserious asthma episode.

Asthma episodes, like asthma itself, can range from mild tosevere. Severe asthma episodes can be life threatening and canresult in a hospital stay or even death. erefore, prevention ofepisodes is very important.

Common asthma triggers are smoke, colds, animal dander, dust,pollen, cold air and exercise. Please note that exercise shouldnot be avoided. If you or your child develops asthma symptoms

with exercise, it may be a sign that your or your childs asthmais poorly controlled. Contact a healthcare professional to learnhow to improve asthma control. Triggers vary from person toperson. Each person should learn about their own triggers andtry to prepare for them and avoid them when possible.

IS ASTHMA A LIFELONG CONDITION?

As a general rule, asthma diagnosed in childhood is a lifelong

condition. Asthma symptoms may diminish in adolescence, butcan often return in adulthood. People with the following factorsare most likely to have asthma that persists into adulthood:

A parent with asthma

A history of eczema (scaly red rashes on the skin)

Allergies or hay fever; allergic rhinitis (inflammation of the liningin the nose)

THE GOOD NEWS FOR PEOPLE WITH ASTHMA:

Researchers are constantly seeking a cure. In the meantime,asthma can be controlled. If asthma is well controlled, there isa low risk for a serious asthma episode and a person can be asactive as they like.

To control asthma you need to avoid contact with things thattrigger your asthma and use your asthma medications regularly asdirected by your doctor.

ere are people with well-controlled asthma who are OLYMPICATHLETES!

WHO WILL HELP YOU TO MANAGE YOUR ASTHMA?

Your family doctor will diagnose and help manage your or yourchilds asthma and should provide you with a written asthmaaction plan.

Your pharmacist can also provide helpful information aboutasthma and asthma medications.

Te Chinook Asthma Program is where you will meet withasthma educators who can perform breathing tests to make sureyour lungs are working at their best as well as provide you withinformation about asthma and asthma medications. e asthmaeducators will work with your doctor to develop a writtenasthma plan and ensure you have the tools and confidence to feelat ease managing your or your childs asthma.

To contact an asthma educator in your community, contact theBuilding Healthy Lifestyles toll-free number at 1-866-506-6654or 388-6654.


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What is asthma?

As the swelling in the airway increases,

the lining of the airway becomes very

sensitive and small muscles around it

start to twitch and tighten.

3 Inflammation ofairway and mucous

6 Emergency room visit

2 Something startsinflammation

5 Muscles aroundairway tighten

1 Normal airway =normal function

houu

wheeze


Reprinted with permission from theAsthma Society of Canada

www.asthma.cawww.asthma-kids.ca


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Client Checklist for Asthma

What to expect at each office visit with your family physician:

Assess asthma control:

Discuss frequency of asthma symptoms

Amount of rescue medication required (blue inhaler usage)

Review triggers and trigger avoidance strategies

Demonstrate use of inhaler device

Make or review a written asthma action plan

Discuss roles and use of asthma medications

Aim to reduce asthma medication dosage while maintaining proper control of asthma

Discuss any other concerns about asthma with your doctor

Tests & Measurements that should be done or discussed on a yearly basis,or as recommended by your family physician:

Lung function testing (spirometry)

Height and weight measurements

Screening for osteoporosis if on inhaled corticosteroids for asthma and you have the following risk factors:

Age > 60 years Postmenopausal state without hormone replacement therapy

Male impotence or infertility

Previous fractures with minor trauma

Family history of fractures (parental)

Past or current chronic glucocorticoid therapy

Smoking or alcoholism

Physical inactivity

Referral to an Asthma educator for education & evaluation

Vaccinations

Annual influenza vaccine

Ensure immunizations are up to date


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6. Indications for a Referral to Medical Specialist or Specialty Program

6. Indications for a Referral to Medical Specialist or Specialty Program

a. and b. Indications for Referral to MedicalSpecialists and Specialty Programs

e following circumstances warrant a referral to an appropriate

specialist:

ere is doubt about the diagnosis of asthma

Factors, including aeroallergens and occupational exposures,could be involved and have not been properly evaluated; orsuspected occupational asthma

Asthma is severe according to severity rating criteria

ere is an apparent discrepancy between the severity ofsymptoms and success of treatment

ere has been a need for emergency treatment or hospitaladmission

Any persistent respiratory symptoms in infants (under 1 year ofage) and young children (age 1-6)

Normal spirometry tests and/or peak flows, but client requiresexcessive medication for symptom control or fails to respondto therapy after the clinician has confirmed compliance withtreatment and proper inhaler device technique

c. Local Contacts

In the CHR the primary care physicians would refer their adultpatients to see Dr. Wilde. Once the specialist has seen the client,they will book additional tests as they see fit.

Dr. E. Wilde, Specialist Internal & Respiratory Medicinephone 320-0633

In the CHR the primary care physicians would refer their pediatricpatients to see the following pediatricians:

Dr. K. Chan, Telephone 328-8101Dr. M. Harilal, Telephone 320-2236Dr. J. Holland, Telephone 320-7825

Or

e primary care physician could refer pediatric clients to theLethbridge Pediatric Asthma Clinic. A pediatrician will assess and

make recommendations for each child who attends the clinic. eprimary care physician would complete a referral form and fax it tothe Building Healthy Lifestyles Program.

Telephone: 388-6654 or 1-866-506-6654Fax: 317-0435

Key contacts in the CHR for Asthma:

Adult Specialists

Dr. Eric Wilde, Telephone 320-0633Pediatric Specialists

Dr. K. Chan, Telephone 328-8101Dr. M. Harilal, Telephone 320-2236Dr. J. Holland, Telephone 320-7825

Lethbridge Educators

Pediatric Asthma clinic, Telephone 388-6180 Adult Asthma Clinic, Telephone 388-6180

Rural Educators

Taber Asthma program, Telephone 223-3525Cardston Telephone 653-4411Magrath Telephone 758-4411Pincher Creek, Telephone 627-1234Crowsnest Pass, Telephone 562-2831Fort Macleod, Telephone 553-5311Raymond, Telephone 752-4561Milk River, Telephone 647-3500Picture Butte, Telephone 732-4762

By contacting Building Healthy Lifestyles 388-6654 or1-866-506-6654 an appointment can be booked for the patientand BHL will notify the appropriate asthma educator.

Clinical Guides are available on-line at:

www.chinookprimarycarenetwork.ab.ca/extranet/resources/guides.php


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7. References

a. Evidence1. Becker, Allan, MD; Berube, Denis, MD; Montgomery, Mark, MD; Sears, Malcolm, MD; Spier, Sheldon, MD; on behalf of

the Canadian Pediatric Asthma Consensus Guidelines 2003 (updated to December 2004) Supplement to CMAJ 2005; 173(6 suppl): S1-S56

2. Boulet,Louis-Philippe, MD; Becker, Allan, MD; Berube, Denis, MD; Beveridge,Robert, MD; Ernst, Pierre MD; on behalfof the Canadian Asthma Consensus group. Canadian Asthma Consensus Report 1999. Supplement to CMAJ 1999; 161(11 suppl)

3. British Columbia Guidelines & Protocols Advisory Committee, Diagnosis and Management of Asthma July 1, 2003

4. FitzGerald JM, Becker A, Sears MR, et al. Doubling the dose of budesonide versus maintenance treatment in asthmaexacerbations. orax 2004;59:550-6

5. Green RH, Brightling CE, McKenna S, et al. Asthma exacerbations and sputum eosinophil counts: a randomised controlledtrial. Lancet 2002; 360:1715-21

6. Harrison TW, Oborne J, Newton S, et al. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations:randomised controlled trial. Lancet 2004;363:271-5

7. Jarjour NN, Gern JE, Kelly EA, et al. e effect of an experimental rhinovirus 16 infection on bronchial lavage neutrophils.J Allergy Clin Immunol 2000;105:1169-77

8. Johnston SL, Pattemore PK, Sanderson G, et al. Community study of role of viral infections in exacerbations of asthma in9-11 year old children. BMJ 1995;310:1225-9

9. Lemiere,C; Bai,T; Balter, M, et al, on behalf of the Canadian Adult Consensus group of the Canadian oracic Society.Adult Asthma Consensus guidelines update 2003. Can Respir J 2004; 11 (Suppl A); 9A 18A

10. Respiratory Division, Cardio-Respiratory diseases and diabetes bureau, laboratory centre for disease control, Health Canada.e national asthma control task force. e prevention and management of asthma in Canada 2000

b. On-line Resources1. Canadian Lung Association www.lung.ca

2. Canadian oracic Society www.lung.ca/cts/3. COPD & Asthma Network of Alberta (CANA) www.canahome.org

4. Family Physicians Airways Group of Canada www.fpagc.com

5. Canadian Network for Asthma Care (CNAC) www.cnac.net

6. Child Asthma Network iCan www.calgaryhealthregion.ca/ican/

7. National Institute of Health www.nhlbi.nih.gov

8. Canadian Society of Allergy & Clinical Immunology www.csaci.medical.org

9. Global Initiative for Asthma www.ginaasthma.com

10. Calgary Allergy Network www.calgaryallergy.ca

11. American Academy of Allergy, Asthma & Immunology www.aaaai.org

12. Asthma Society of Canada www.asthma.ca

Available CHR Resources Winning with Asthma www.chr.ab.ca

asthma clinical guide

Documents