STEP APPROACH TO ASTHMA THERAPY and ROUTINE SURVEILLANCE OF ASTHMATICS


Step Approach to Asthma Therapy
Routine Surveillance of Asthmatics

STEP APPROACH TO ASTHMA THERAPY

A system for establishing a rational regimen of controller and quick relief medications for long-term use, adjusted according to clinical status of the patient

  1. Initiating therapy: two strategies
  1. Start therapy at the step c/w severity of pt's disease and step up if disease isn't controlled
  2. "Get control": start therapy at one step higher than the pt's level of severity, and after control is achieved, step down therapy (e.g. oral steroids to start with then inhaled steroids) to "the least medication necessary to maintain control." The last medication added should be the first medication reduced when stepping down. This is favored by the NAEPP though no trials comparing the 2 approaches as of 1997.
  3. In either case, re-evaluate management plan if control not achieved within 1mo or so
  1. Nocturnal sx, unscheduled visits, increase need for short-acting inhaled beta-agonists
  1. If optimal control is not achieved at any step of care, several things to try:
  1. Assess pt adherence/technique in using meds
  2. Evaluate possibility of comorbid conditions, irritant/allergen exposure, or psychosocial problems interfering with adherence to tx as possible causes of failure to respond; consider environmental controls
  3. Consider alternative dx's to asthma, e.g. vocal cord dysfunction
  4. May try incrasing doses or adding another agent in a given "step" before going to the next "step"
  5. Bump to next level of care if these don't work
  6. Consider referral
  1. See below for details on routine surveillance
  2. If control sustained for 3mos or more, can consider gradual step down in tx; last med added should be first one reduced. Can reduce dose of inhaled steroids about 25% every 2-3mos to find lowest dose required to maintain control
  3. In pts with h/o mod-to-severe exacerbations, consider giving steroids to keep at home to use in the event of an exacerbations
  4. Note: in clinical classification below, presence of one of the features of severity is sufficient to place a pt in that category; should assign pt to most severe grade in which any feature occurs. Pts at any level can have mild, mod, or severe exacerbations and require systemic steroids for them.
  5. STEP 1: "Intermittent asthma"
  1. Clinical features
  1. Sx 2 or fewer times/wk
  2. No sx and nl PEFR between exacerbations
  3. Exacerbations brief , i.e. few hours to few days
  4. Nighttime sx 2 or fewer times/mo
  5. FEV1 or PEFR 80% of predicted or better
  6. PEFR variability < 20%
  1. Recommended tx approach
  1. Quick relief with short-acting bronchodilators (MDI or nebs; consider oral if child) PRN
  2. Use of inhaled short-acting bronchodilator, salmeterol, or mast-cell stabilizer (cromolyn or nedocromil) before exposure to known precipitants, e.g. exercise or inhaled allergens
  3. No chronic meds
  4. For exacerbations: increased use of bronchodilators or, if severe or past h/o severe exacerbations, systemic steroids
  1. Step up if:
  1. Using quick-relief meds > 2x/wk (other than use for exacerbations caused by viral illness less often than Q6wks or for exercise-induced bronchospasm)
  2. Nocturnal sx > 2x/mo
  3. FEV1 or PEFR is < 80% of personal best
  1. STEP 2: "Mild persistent asthma"
  1. Clinical features
  1. Sx > 2x/wk but < 1x/d
  2. May be limited in activity during exacerbations
  3. Nighttime sx > 2x/mo
  4. FEV1 or PEFR 80% of predicted or better
  5. PEFR variability 20-30%
  1. Recommended tx approach
  1. Daily maintenance therapy with any of the following
  1. Low-dose inhaled corticosteroids (probably first-line; in kids, can use with a spacer and face mask)
  2. Cromolyn (available in nebs; better for kids b/c of difficulty with MDI's) or nedocromil (MDI only); either would be TID-QID. Either of these may be preferable to inhaled steroids given better safety profile
  3. Leukotriene modulators (not in kids < 12yo; "their position in therapy is not fully established")
  4. Sustained-release theophylline ("not preferred because its modest clinical effectiveness must be balanced against concerns about potential toxicity"; advantage is cost)

However, may not be necessary:
In a study in 225 adults with mild persistent asthma randomzied to inhaled budesonide 200mcg BID, zafirlukast 20mg PO BID, or placebo, over 1y, there were no sig. differences in morning PEFR, use of systemic corticosteroids, asthma symptom scores, or quality of life scores (NEJM 352:1519, 2005--AFP)

  1. Quick-relief with short-acting bronchodilators PRN
  1. Step up if needing short-acting bronchodilators > 3-4x/d (to higher dose inhaled steroid or added long-acting inhaled beta-agonist or theo)
  1. STEP 3: "Moderate persistent asthma"
  1. Clinical features
  1. Daily sx
  2. Daily use of inhaled short-acting beta-agonists
  3. Exacerbations > 2x/wk
  4. Exacerbations limit activity
  5. Nighttime sx 1x/wk or more
  6. FEV1 or PEFR 61-79% of predicted
  7. PEFR variability > 30%
  1. Recommended tx approach: same as step 2 except higher doses
  1. Medium-dose inhaled steroid (with spacer/face mask in kids) vs.
  2. Low-dose inhaled steroid plus another long-acting agent, viz:
  1. Long-acting bronchodilator (salmeterol, sustained-release theophylline)
  2. Cromolyn or nedocromil
  3. Leukotriene modulating agents
  1. Quick-relief w/short-acting inhaled beta-agonists PRN
  2. Same criteria for step-up as for Step 2; initial response to treatment failure would be increase to high dose of inhaled steroids & add long-acting inhaled beta-agonist or theo if haven't already done so.
  1. STEP 4: "Severe persistent asthma"
  1. Clinical features
  1. Continual sx
  2. Limited physical activity
  3. Frequent exacerbations
  4. Frequent nighttime sx
  5. FEV1 or PEFR 60% of predicted or worse
  6. PEFR variability > 30%
  1. Recommended treatment approach
  1. Maintenance therapy with either of the following:
  1. High-dose inhaled corticosteroids (probably first-line; use spacer/face mask in kids)
  2. Leukotriene modulators
  1. Quick relief with short-acting bronchodilators PRN
  2. Re-assess tx if using short-acting inhaled bronchodilators > 3-4x/d
  3. If need a step up, consider adding:
  1. Long-acting beta-agonist (might do well to add before maxing out dose of inhaled steroids)
  2. Sustained-release theophylline
  3. Might consider adding leukotriene modulators to inhaled steroids though little data available
  4. May be able to reduce need for chronic steroids with inhaled cromolyn or nedocromil
  5. Chronic oral steroids as a last resort, try to maintain lowest possible dose QOD; monitor for side effects; try to reduce or eliminate as quickly as possible after achieving control.

ROUTINE SURVEILLANCE OF ASTHMATICS

Once asthma is stabilized, should have regularly scheduled visits (Q1-6mos) to assess the status of these aspects of the disease:

  1. Quality of life/functional status
  1. Missing school/work
  2. Limitations in activities
  3. Change in caregiver activities due to child's asthma
  1. Monitor pharmacotherapy
  1. Understanding of and compliance with prescribed regimen
  2. MDI technique
  3. Pt-initiated changes in meds
  4. Side effects
  1. Signs/sx self-monitored by patient (note that people do poorly at recalling sx > 2-4 wks back)
  1. Daytime asthma sz (wz, cough, chest tightness, dyspnea)
  2. Nocturnal awakening due to asthma sx
  3. Early am sx not improved 15min after inhaled short-acting beta-agonist
  4. Need for use of inhaled short-acting beta-antagonists
  5. History of recent exacerbations requiring unscheduled care
  6. Can use daily diary (see figure) and/or periodic self-assessment form to be filled out by pt and/or parent for followup visits; should include these items:
  1. Symptoms as above
  2. PEF is measured
  3. Med use
  4. Restrictions in activity
  5. Impression of degree of control and overall satisfaction with care
  1. PEFR monitoring  (note-benefit of regular monitoring of PEFR in office or at home in predicting exacerbations has been questioned)
  1. Recc'd for any pt with h/o severe exacerbations or those who seem not to be able to perceive their asthma status well
  2. Check PEF in the office at time of initial assessment, after tx initiated and sx stabilized, and at least Q1-2y
  3. Compare PEF's to pt's personal best PEF
  1. Establish personal best by checking 2-4x/d over 2-3 weeks after stabilizing sx; may need oral steroids to establish personal best
  2. Re-assess periodically, esp. in kids (Q6mo) b/c will change with growth
  1. Home PEFR monitoring
  1. Recc'd for pts with mod-severe persistent asthma or any pt who has had a severe exacerbation nocturnal sx
    1. In such pts, reduces urgent visits more than written management plan alone (see below) (Chest 112:1534, 1997--JW; AFP)
  2. Appears to be no benefit for pts with mild intermittent or mild persistent asthma
  3. With periodic checks can detect early changes in status that require alteration in tx
  4. Always use the same meter; instruct pts to bring their into the office each visit
  5. Also to evaluate changes in chronic maintenance therapy and tx of exaerbations
  6. Also to identify relationship between PEF and exposure to precipitants
  7. If checking daily, do so in am before taking any bronchodilators
  8. "Traffic light" system for pt ed:
  1. Green = 80-100% of personal best [no action required]
  2. Yellow = 50-79% [get seen vs. increase frequency of monitoring, still before using bronchodilators]
  3. Red = < 50%
  4. PEF < 80% of personal best "indicates a need for additional medication"; < 50% = "a severe asthma exacerbation"
  1. Spirometry on occasion to check on accuracy of PEF meter, or when need more precise info (e.g. when assessing response to a step down in Rx) or when PEF results seem to be unreliable
  2. Is the pt in the correct "step" level of care? (see above re: things to think about if asthma not under good control)
  3. Written Asthma Management Plan
  1. A written plan recc'd in guideline for pts with mod-severe asthma or h/o severe exacerbations
  2. For kids/adolescents, copy should go to school
  3. Education as above
  4. Plan for self-monitoring, including PEF
  5. Medication self-management, including exacerbation plan, e.g.
    1. Doubling doose of inhaled steroids if note increase in asthma sx or PEFR < 70% personal best
    2. Starting oral steroids if inhaled bronchodilator provides relief for < 2h of PEFR < 50% personal best
    3. Seek urgent tx if inhaled bronchodilator provides relief for < 30min, difficulty speaking, or or PEFR < 30% personal best
  6. How to recognize incipient exacerbations
  7. List of known precipitants to avoid
  8. Include message to call if unable to comply
  9. Plan for followup care
  10. Long-term goals
  11. Bring all meds to each visit (& PEF meter, if using one)
  12. #'s to call for ?'s/probs
  1. Patient education
  1. Pathophysiology: diff. Between asthmatic & nl airways; what happens during an attack
  2. Rationale of pharmacotherapy, esp. diff. between controller and quick-relief meds
  3. How to use MDI's, spacers, nebulizer, etc.
  4. Instruction in monitoring asthma signs/sx including PEF, nighttime sx, increased med. usage, decreased exercise tolerance
  5. How to recognize and avoid asthma triggers
  6. What to do when exacerbation begins
  7. If exercising, should avoid when air pollution/allergens are high
  8. Bring all meds to each visit
  9. Ask about pt's personal tx goals, concerns, and beliefs at each visit