Classification of Chronic Asthma Severity on Treatment Domains/EstimatesIntermittentPersistent Mild to Moderate Severe** Daytime symptoms MonthlyWeeklyDaily Nocturnal awakening Less than monthly Monthly to weekly Nightly Rescue  2 agonist use Less than weeklyWeekly to dailySeveral times a day PEF or FEV1*> 80 % predicted 60 to 80 % of predicted < 60 % of predicted Treatment needed to control asthma Occasional prn  2 only Regular ICS + LABA combination Combination ICS + LABA + OCS PCCP Council on Asthma PCRADM 2004 *Objective measures take precedence over subjective complaints. The higher severity level of any domain will be the basis of the final severity level. **Patients who are high risk for asthma-related deaths are initially classified here

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

P Reliever Medications Rapid-acting inhaled β 2-agonists Systemic glucocorticosteroids (acute setting) Anticholinergics Theophylline Short-acting oral β 2-agonists PCCP Council on Asthma

Characteristic Controlled Partly controlled (Any present in any week) Uncontrolled Daytime symptoms None (2 or less / week) More than twice / week 3 or more features of partly controlled asthma present in any week Limitations of activities NoneAny Nocturnal symptoms / awakening NoneAny Need for rescue / “reliever” treatment None (2 or less / week) More than twice / week Lung function (PEF or FEV 1 ) Normal < 80% predicted or personal best (if known) on any day ExacerbationNoneOne of more/yearOne in any week Assessing Control Levels of Asthma Control PCCP Council on Asthma GINA Available at:

Controlled Partly controlled Uncontrolled Exacerbation LEVEL OF CONTROL Maintain and find lowest controlling step Consider stepping up to gain control Step up until controlled Treat as exacerbation TREATMENT ACTION TREATMENT STEPS STEP 1 STEP 2 STEP 3 STEP 4 STEP 5 Reduce Increase Reduce PCCP Council on Asthma

Treatment Action Level of Control Treatment Steps (in the order of increasing efficacy to attain control) ControlledMaintain and find lowest controlling step Partly ControlledConsider stepping up to gain control UncontrolledStep up until controlled ExacerbationTreat as exacerbation Increase e Reduce Step 2 Step 3Step 4Step 5 Step 1 Asthma Education / Environmental Control As needed rapid- acting ß 2 -agonist Controller Options Select One Add one or more Low-dose ICS Low dose ICS+LABA Medium or high- dose ICS+LABA Oral glucocorticosteroid (lowest dose) Leukotriene modifier Medium or high-dose ICS Leukotriene modifier Anti IgE treatment Low-dose ICS plus Leukotriene modifier Sustained release theophylline Low dose ICS plus sustained release theophylline Reduce Increase Treating to achieve Control GINA Available at: PCCP Council on Asthma

Treatment Steps (in the order of increasing efficacy to attain control) Step 2 Step 3Step 4Step 5 Step 1 Asthma Education / Environmental Control As needed rapid- acting ß 2 -agonist Controller Options Select One Add one or more Low-dose ICS Low dose ICS+LABA Medium or high- dose ICS+LABA Oral glucocorticosteroid (lowest dose) Leukotriene modifier Medium or high-dose ICS Leukotriene modifier Anti IgE treatment Low-dose ICS plus Leukotriene modifier Sustained release theophylline Low dose ICS plus sustained release theophylline GINA Available at: IncreaseReduce In the local setting, for the majority of symptomatic patients, the consensus is to start at step 3, with low doses of a fixed- dose ICS+LABA combination inhaler. PCCP Council on Asthma

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

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

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

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

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

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

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

Severity of Asthma Exacerbations MildModerateSevere Respiratory arrest imminent BreathlessWalkingTalkingAt rest Talks inSentencesPhrasesWords AlertnessMay be agitatedUsually agitated Drowsy or confused Respiratory rateIncreased Often > 30/min Accessory muscles & suprasternal retractions Usually notUsually Paradoxical thoraco- abdominal movement Wheeze Moderate, often only end-expiratory LoudUsually loud Absence of wheeze Pulse/min< > 120Bradycardia Pulsus paradoxus Absent < 10 mmHg May be present mmHg Often present > 25 mmHg PEF after initial BD % predicted or % personal best Over 80 %Approx 60 – 80 % < 60 % predicted or personal best (<100/min or response lasts 2 hrs PaO 2 and/or PaCO 2 Normal < 42 mmHg < 60 mmHg Possible cyanosis > 42 mmHg Possible resp failure SaO 2 > 95 %91 – 95 %< 90 % PCCP Council on Asthma

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

P Management of Asthma Exacerbations  Primary therapies for exacerbations:  Repetitive administration of rapid-acting inhaled β 2 -agonist  Early introduction of systemic glucocorticosteroids  Oxygen supplementation  Closely monitor response to treatment with serial measures of lung function PCCP Council on Asthma

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

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

Initial Assessment : History, PE, PEF or FEV1, SaO 2 Repeat Assessment: PE, PEF, SaO 2, other tests as needed Moderate Episode: PEF or FEV1 =40 – 69 % predicted or personal best PE : Moderate symptoms Treatment : Inhaled SABA every 60 minutes Oral systemic corticosteroids Continue treatment 1-3 hrs provided there is improvement ; make decision in < 4 hrs Severe Episode: PEF or FEV1 < 40 % predicted or personal best PE : Severe symptoms at rest, accessory muscle use, chest retraction History : high-risk for asthma- related death No improvement after initial treatment Treatment : Oxygen NebulizedSABA + ipratropium hourly or continuous Oral systemic corticosteroids Consider adjunct therapies Management of Acute Exacerbations : Hospital Setting PEF or FEV1 ≥ 40 % predicted Oxygen to achieve SaO 2 ≥ 90% Inhaled SABA by nebulizer or MDI with valve holding chamber up to 3 doses in 1 st hour PEF or FEV1  40 % predicted Oxygen to achieve SaO 2 ≥ 90% High-dose inhaled SABA + ipratropium by nebulizer or MDI with valve holding chamber every 20 min or continuously for 1 hour Impending or actual respiratory arrest Intubation and mechanical ventilation with 100% O 2 Nebulized SABA and ipratropium Intravenous corticosteroids Consider adjunct therapies Admit to hospital intensive care PCCP Council on Asthma

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

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

P Thank you for your attention!