asthma nhlbi guidelines - cmetracker.netcmetracker.net/eh/files/eventmaterials/18087/asthma.pdf ·...
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ASTHMANHLBI GUIDELINES
Stephen Kurachek, MD
CRCCS
Children’s Hospitals and Clinics of MinnesotaChildren s Hospitals and Clinics of Minnesota
Gillette Children’s Specialty Hospital
CentraCare Health System
Essentia Health
Today’s Topics
• NHLBI Guidelines
• Assessment and control
• Inhaled corticosteroids
• Guidelines by age group
• Scenarios
• Allergen and irritant control
• Asthma Action Plan – self‐management
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http://www.nhlbi.nih.gov/health/prof/lung/asthma/naci/asthma‐info/asthma‐guidelines.htm
PRIORITY MESSAGES EPR‐3
ASSESS SEVERITY
MONITOR CONTROL
INHALED CORTICOSTEROIDS
ASTHMA ACTION PLANS
MONITOR FOLLOW‐UP
CONTROL ALLERGENS AND IRRITANTS
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ASSESS INITIAL SEVERITY EPR‐3
Current Impairment
Future Risk
COMPONENTSOF
SEVERITY
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ASSESSING CONTROL EPR‐3
No coughing or wheezing
No shortness of breath
No night awakenings
NO AD HOC MD VISITS
Oral steroid requirements
Pulmonary function testing
No activity limitation
No school absences
No provider work / activity loss
COMPONENTS OFCONTROL
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GENERIC STEROID
PROPRIETORY DOSING AVAILABLE
DOSEEQUIVALENCY
AGE RELEASE
NOTES
BeclomethasoneHFA
QVAR 40, 80 mcg/puff 1.00 > 5 yrs Small particle size. Good lung deposition. Pro‐drug activated in
INHALEDCORTICOSTEROIDS
p gthe lung.
budesonide DPI PulmicortFlexhaler
90, 180 mcg/act 1.25 > 6 yrs
budesonideinhaled
PulmicortRespules
0.25, 0.5,1mg/2ml
0.5 > 1 yrs
ciclesonide MDI Alvesco 80, 160 mcg/spray
1.5 > 12 yrs Small particle size. Once daily dosing. Pro‐drug activated in the lung. Highly protein bound in systemic circulation. Less adverse effects.
fluticasoneHFA/MDI
Flovent HFA 44, 110, 220 mcg/puff
2.0 > 4 yrs
fluticasone DPI Flovent Diskus 50, 100, 250 mcg/blister
2.0 > 4 yrs
mometasone DPI Asmanex 110, 220 mcg/act
1.5 > 4yrs Once daily dosing. Highly protein bound.
GENERIC MEDS
PROPRIETORY DOSING AVAILABLE DOSEEQUIVALENCY
AGE RELEASE
NOTES
/
CORTICOSTEROIDS+
LABA
fluticasone / salmeterol
Advair DiskusDPI
100, 250, 500mcg + 50mcg blister
2.00 > 4 yrs Only dual med inhaler approved for children < 12 years of age.
fluticasone / salmeterol
Advair HFA 45, 115, 230mcg + 21mcg spray
2.00 > 12 yrs
budesonide / formoterol
Symbicort HFA 80, 160mcg + 4.5mcgspray
1.25 > 12 yrs Small particle size. Good lung deposition. Pro‐drug activated in the lung.
mometasone/ fomoterol
Dulera 100, 200mcg + 5mcg/spray
1.5 > 12 yrs Small particle size. Pro‐drug activated in the lung. Highly protein bound in systemic circulation. Less adverse effects.
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STEPWISE THERAPY 0 – 4 YEARS
high doseSTEP 5
STEP 6
ASSESS:
o severity
o control
REVIEW:
❶ adherence❷ home❸ irritants
❺ stress❻ GERD
❼ sinusitis
❽ function
SABA prn
low dose ICS or
l k
medium dose ICS
medium dose ICS
+LABA ormontelukast
high dose ICS+
LABA ormontelukast
high dose ICS+
LABA or+
ORALSTEROIDS
STEP 1
STEP 2
STEP 3
STEP 4
STEP 5o control
o triggers
❸ irritants❹ allergies
SABA, prn montelukast
Intermittent PERSISTENT
“ASTHMATOLOGIST”
med
med dose +
LABA or
high dose +
LABA ormontelu‐
kast
high dose +
LABA ororalSTEP 2
STEP 3
STEP 4
STEP 5
STEP 6ICS THERAPY 0 – 4 YEARS
SABA
low dosedose
LABA ormontelu‐
kast
kaststeroids
STEP 1
STEP 2
INHALEDCORTICOSTEROID
Pulmicort(budesonide)
Flovent HFA
(mg) 0.25 – 0.5 0.5 – > 1.0 > 1.0 0.5 1.0
(mc ) 176 176 352 176 352 > 352 >352Flovent HFA(fluticasone)
Advair Diskus(fluticasone + salmeterol)
(mcg) 176 176 – 352 176 – 352 > 352 >352
(mcg) 100 – 200 200 200
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CASE PRESENTATION
2 yr old male
o 2 ED visits for “recurrent pneumonia” characterized by nasal
drainage, cough, wheeze, and SOB.drainage, cough, wheeze, and SOB.
o 1 hospitalization for asthma event characterized by nasal
drainage, prominent cough, tachypnea, retractions, wheeze,
and SOB. Diagnosed with asthma.
o No personal history of eczema, atopy, recurrent croup, or
sinusitis. No family history asthma, eczema, or atopy.sinusitis. No family history asthma, eczema, or atopy.
o “Perfect” in between events: no background cough, cough
with activity or laughter.
PLAN ?
STEPWISE THERAPY 5 – 11 YEARS
high dose
ICS +STEP 5
STEP 6ASSESS:
o severity
o control
REVIEW:
❶ adherence❷ home❸ irritants
❺ stress❻ GERD
❼ sinusitis
❽ function❾ PFTs
SABA, prn
low dose ICS
OR
low dose ICS+LABA or LTRA ortheo
OR
med dose
ICS + LABA
ORmed dose ICS +
high dose
ICS +LABA ormontelukast
ORhigh dose ICS + LTRA or
ICS +LABA +ORALSTEROIDS
ORhigh dose ICS +LTRA ortheo +
STEP 1
STEP 2
STEP 3
STEP 4
o control
o triggers
❸ irritants❹ allergies
, pOR
LTRA orcromolynortheo
ORmedium dose ICS
ICSLTRA or theo
theotheo +ORALSTEROIDS
Intermittent PERSISTENT
“ASTHMATOLOGIST”
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med
med dose +
LABA or
high dose +
LABA ormontelu‐
kast
high dose +
LABA ororalSTEP 2
STEP 3
STEP 4
STEP 5
STEP 6
ICS THERAPY 5 – 11 YEARS
low dosedose
LABA ormontelu‐
kast
kaststeroids
STEP 1
STEP 2INHALED
CORTICOSTEROID
Pulmicort NEBDPI
Flovent HFADPI
(mg) 0.25 – .5 0.5 0.5 – 1 > 1 > 1 (mcg) 180 ‐ 400 400 ‐ 800 400 – 800 > 800 >800
(mcg) 88 – 176 176 – 352 176 – 352 > 352 > 352100 – 200 200 ‐ 400 200 – 400 > 400 > 400DPI
QVAR
Advair DPIHFA
100 200 200 ‐ 400 200 400 > 400 > 400
(mcg) 80 – 160 160 – 320 160 – 320 > 320 > 320
(mcg) 200 – 500 > 500 > 50090 – 230 > 230 > 230
CASE PRESENTATION
6 yr old female
o Multiple ED visits for wheezing treated with albuterol nebs
sometimes “a shot of something” or Orapred.sometimes a shot of something or Orapred.
o Wheezing events occur with colds, weather change, and
while staying at the grandparents who have two cats.
o The home is “spotless”. No pets, rodents, cockroaches, or
smokers. The basement is musty.
o Child always coughs with activity and tends to take moreo Child always coughs with activity and tends to take more
rest periods than her siblings and neighborhood peers. Uses
albuterol MDI 2 – 3 times per day.
o Daily symptoms change little with QVAR 40, 2puffs, twice daily.
PLAN ?
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STEPWISE THERAPY > 12 YEARS
high dose
d al inh +STEP 5
STEP 6ASSESS:
o severity
o control
REVIEW:
❶ adherence❷ home❸ irritants
❺ stress❻ GERD
❼ sinusitis
❽ function❾ PFTs
SABA, prn
low dose ICS
OR
low dose dual inh
ORmedium dose ICS
med dose dual inh
ORmed dose ICS + LTRA or
high dose dual inhor high dost ICS +LTRA
ANDCONSIDER
dual inh +ORALSTEROIDS
ANDCONSIDER
XolairSTEP 1
STEP 2
STEP 3
STEP 4
o control
o triggers
❸ irritants❹ allergies
, pOR
LTRA orcromolynortheo
dose ICStheo
Xolair
Intermittent PERSISTENT
“ASTHMATOLOGIST”
low dose med dose
med dose dual or medICS + LTRA
high dose dual or highICS + LTRA
high dose dual+ LTRA
+ oral
steroids
STEP 2 STEP 3
STEP 4
STEP 5
STEP 6ICS THERAPY > 12 YEARS
INHALEDCORTICOSTEROID ICS + LTRACORTICOSTEROID
Pulmicort DPIFlovent HFA
DPI QVAR
AlvescoAsmanex
180 – 600 600 – 1,200 600 – 1,200 > 1,200 >1,20088 – 264 264 – 440 264 – 440 > 440 > 440 100 – 200 200 – 400 200 – 400 > 400 > 40080 – 160 160 – 320 160 – 320 > 320 > 32080 – 160 160 – 320 160 – 320 320 320110 220 220 – 440 440 440
Advair DPI 200 – 500 1,000 1,000HFA 180 – 460 460 – 920 920
Symbicort 320 640 640Dulera 400 800 800
Indications for Zolair
o > 12 years of ageo moderate to severe asthmao symptoms uncontrolledo + skin testo IgE: 30 – 700 IU/ml
DUAL DRUGINHALERS
med dose dual
high dose dual
high dose dual
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CASE PRESENTATION
17 yr old male
o Multiple ED visits and hospitalizations for asthma. 1 PICU stay.
Night awakenings weekly. Albuterol inhaler under pillow.
o Eczema, allergic rhinitis, and occasional sinusitis. Sits out of gym. Has
never played sports and has an elevator pass at school.
o Mother died from asthma. Other family members with atopy
and asthma. Young man lives with his cousin. Apt OK by history.
o Access a problem. Compliance a problem. PFTs never normal. Claims
to feel fine whether FEV1 is 60% or 40%.
o On Dulera 100, 2 puffs, twice daily; Singulair 10mg, nightly. Claims
nebulizer does not work.
PLAN ?
CONTROL: allergens and irritants
ASSESS EVERY VISIT EPR‐3
change in environmentchange in environmentcigarette smoke exposurewood burningremodelingdust mite controlcockroach controlnew pets
new observationscold aircleaningresponse to colds
h hwater damage (mold)other homes
weather changeseasonal symptomsfood reactionsexerciseschool feedback
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ASTHMAASTHMACONTROLPLAN
ASTHMA CONTROL PLAN
Asthma Severity Asthma Control
TRIGGERSALLERGIES
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ASTHMAASTHMACONTROLPLAN
ASTHMA CONTROL PLAN
FOLLOW YOUR INSTINCTS !
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MONITOR FOLLOW‐UP
• office visits
• office phone calls
• liaison with the school or day care
• public health nurse visit
• home assessment
• pharmacy review
• home/school audio‐video link?
SUMMARY
ASSESS SEVERITY
MONITOR CONTROL
INHALED CORTICOSTEROIDS
ASTHMA ACTION PLANS
MONITOR FOLLOW‐UP
CONTROL ALLERGENS AND IRRITANTS