Asthma Management Guide For Children 5 and Older

Prepared by Armando Sarmiento, RN, DNP-c University of Hawaii at Hilo

Doctor of Nursing Practice Program

IntroductionA significant number of the underserved, uninsured, and

underinsured population in Nevada seek care in nonprofit health care clinics such as the First Person Care Clinic (FPCC). Despite serving all sectors regardless of their ability to pay, they strive to provide efficient,

quality, and affordable healthcare by maintaining continuity of care through a holistic, compassionate, and accessible approach. In addition, they take pride in providing services using evidence-based healthcare.

Services available aim to promote wellness through screening- and identification of chronic-illness, and dental, mental health, and pediatric

programs. Providing evidence-based care to treat pediatric asthma patients can properly address the growing needs of the clinic. As a result,

this document was created to guide the providers and staff of the First Person Care Clinic in the management of asthma in children age 5 and

older.

ContentsDiagnosisDiagnosis of Asthma 4Key Symptom Indicators 5Physical Examination 6Classification of Severity 7Differential Diagnosis 8Management - InitialStepwise Approach Age 5-11 9Stepwise Approach Age 12 and Older 10Education - Initial and First visit 11Education - Second Followup and Subsequent visits 12Recommended Followup and Testing Intervals 13Management - Long-termGoals of Treatment 14Assessing Control and Adjusting Therapy Age 5-11 15Stepwise Approach Age 5-11 16Assessing Control and Adjusting Therapy Age 12 and Older 17Stepwise Approach Age 12 and Older 18Asthma Therapy Assessment Questionnaire (ATAQ) 19Asthma Control Test (ACT) 20Asthma Control Questionnaire (ACQ) 21Management - Acute ExacerbationsGoals of Treatment 22Classification of Severity 23Prevention, Assessment, Interventions 24Special SituationsExercise Induced Bronchospasm (EIB) 26Surgery and Asthma 27Pregnancy and Asthma 28Medications - Usual Dosages Age 5-11Long-Term - Systemic Corticosteroids, Long-acting Beta2-Agonists (LABAs) 29Long-Term - Combined Medication, Leukotriene Receptor Antagonists, Methylxanthines (LTRAs) 30Quick-Relief - Inhaled Short-Acting Beta2-agonists 31Quick-Relief - Anticholinergics, Systemic corticosteroids 32Medications - Usual Dosages Age 12 and OlderLong-Term - Systemic Corticosteroids, Inhaled LABAs, Combined Medication 33Long-Term - Cromolyn and Nedocromil, LTRAs, 5-Lipoxygenase Inhibitor, Methylxanthines, Immunomodulators 34Quick-Relief - Inhaled SABAs 35Quick-Relief - Anticholinergics, Systemic Corticosteroids 36Medication - Glossary 36-41Delivery Devices 42-44HandoutsAsthma Action Plan - English 45Asthma Action Plan - Spanish 46

Diagnosis of AsthmaTo establish a diagnosis of asthma, the clinician should determine that symptoms of recurrent episodes of airflow obstruction or airway hyperresponsiveness are present; airflow obstruction is at least partially reversible; and alternative diagnoses are excluded.

Recommended methods to establish diagnosis

Detailed medical history

Physical examination

Spirometry

Key Symptom Indicators

Indicator * Presence of multiple key indicators increases the probability of asthma.

Wheezing High-pitched which whistling when breathing out, especially in children

History of any of the following:

Cough (worse particularly at night) Recurrent wheeze

Recurrent difficulty when breathing Recurrent chest tightness

Symptoms that occur or worsen in the presence of:

ExerciseViral infection

Inhalant allergensIrritants

Changes in weatherStrong emotional expressions

Stress Menstrual Cycles

Symptoms that: Occur or worsen at night, awakening the patient

Physical Assessment Assessment Finding

Upper Respiratory TractIncreased nasal secretion

Mucosal swelling Nasal polyp

Chest

Sounds of wheezing during normal breathing or prolonged phase of forced

exhalation Hyper-expansion of the thorax

Use of accessory muscles Appearance of hunched shoulders

Chest deformity

Skin Atopic dermatitis Eczema

Physical Examination

✴ Findings may increase the probability of asthma

Age 5-11 Intermittent Mild Persistent

Moderate Persistent

Severe Persistent

FEV1 (predicted)or

Peak Flow (personal best)

>80% >80% 60-80% <60%

FEV1/FVC >85% >80% 75-80% <75%

Recommended Step for Initiating Therapy Step 1 Step 2

Step 3 Medand consider

OCS

Step 3 Medand consider

OCS

Classification of Severity and Initiating Therapy

Age 5-11

Age 12+ Intermittent Mild Persistent

Moderate Persistent

Severe Persistent

FEV1 (predicted)or

Peak Flow (personal best)

>80% >80% >60%<80% <60%

FEV1/FVC Normal Normal Reduced5%

Reduced >5%

Recommended Step for Initiating

TherapyStep 1 Step 2

Step 3 Medand consider

OCS

Step 4 or 5and

consider OCS

Age 12 and OlderNormal

FEV1/FVC

8-19 yr 85%

20-39 yr 80%

40-59 yr 75%

60-80 yr 70%

Differential Diagnoses

AdultsChronic obstructive pulmonary disease (COPD)

Congestive heart failure

Pulmonary embolism

Mechanical obstruction of the airways (benign and malignant tumors)

Pulmonary infiltration with eosinophilia

Cough secondary to drugs (e.g., angiotensin converting enzyme [ACE] inhibitors)

Vocal cord dysfunction

Infants and Children

Upper airway disease Allergic rhinitis and sinusitis

Obstructions involving large airways

Foreign body in trachea or bronchus; vocal cord dysfunction (VCD); vascular rings or laryngeal webs;

laryngotracheomalacia, tracheal stenosis, or bronchostenosis; enlarged lymph nodes

Obstructions involving small airways

Viral bronchitis or obliterative bronchiolitis; cystic fibrosis; bronchopulmonary dysplasia; heart disease

Other CausesRecurrent cough not due to asthma; aspiration from

swallowing mechanism dysfunction or gastroesophageal reflux

Stepwise Approach for Managing Asthma, Age 5-11

Stepwise Approach for Managing Asthma, Age 12+

Recommended Education Topics - Initial, First follow-up

Recommended Education Topics - Second Follow-up,

Subsequent

Intervals

Phase Interval

Initial 2 to 6 weeks

Step Up 2 to 6 weeks

Regain Control 2 to 6 weeks

Step Down 3 months

Control Achieved 1 to 6 months

For Follow-Up Care

Perform Testing During Following Times

Initial Assessment

After treatment is initiated and symptoms and PEF have stabilized

During periods of progressive or prolonged asthma control

At least every 1-2 years; more frequently in response to therapy

For PFT/Spirometry

Long-Term Management Goals of

Therapy

Long-Term Management Age 5-11

Assessing Asthma Control and Adjusting Therapy

Stepwise Approach for Managing Asthma, Age 5-11

Long-Term Management Age 12 and older

Assessing Asthma Control and Adjusting Therapy

Stepwise Approach for Managing Asthma, Age 12 and Older

Asthma Therapy Assessment Questionnaire

(ATAQ) Pediatric/Adolescent

Asthma TherapyAssessment

Questionnaire

Patient Name:___________________________________________________

ID Number:_____________________________________________________

Physician Name:________________________________ Date:____________

Please have the parent or guardian complete this questionnaire.

INSTRUCTIONS: Check 1 answer to each question and enter point value (0 or 1) on line

Add numbers in the light blue area and enter total SCORE here. TOTAL ____Add numbers in the dark blue area and enter total SCORE here. TOTAL ____If either SCORE is 1 or greater, discuss questionnaire with your doctor.

ControlIssues

OtherIssues1. In the past 4 weeks, did your child:

a) Have wheezing or difficulty breathing when exercising? ■ Yes (1) ■ No (0) ■ Unsure (1) ____b) Have wheezing during the day when not exercising? ■ Yes (1) ■ No (0) ■ Unsure (1) ____c) Wake up at night with wheezing or difficulty breathing? ■ Yes (1) ■ No (0) ■ Unsure (1) ____d) Miss days of school because of his/her asthma? ■ Yes (1) ■ No (0) ■ Unsure (1) ____e) Miss any daily activities (such as playing, going to a friend’s house,

or any family activity) because of asthma? ■ Yes (1) ■ No (0) ■ Unsure (1) ____

2. Does your child use an inhaler or a nebulizer for quick relieffrom asthma symptoms?* ■ Yes ■ No ■ Unsure (If Yes) In the past 4 weeks, what was the greatest number of timesin 1 day your child used this inhaler/nebulizer?0 ■ (0) 5 to 6 ■ (1)1 to 2 ■ (0) More than 6 ■ (1)3 to 4 ■ (1)* Enter score ____

3. Has your child ever had a prescription for an asthma medicine that is NOT used for quick relief but is used to control his/her asthma? ■ Yes ■ No ■ Unsure (If Yes or Unsure) What best describes how your child takes this medicine now?Takes it every day ■ (0) Only takes it when he/she has symptoms ■ (1)Takes it some days, but not other days ■ (1) Never takes it ■ (1)Used to take it, but now does not ■ (1) Enter score ____

4. Are you dissatisfied with any part of your child’s currentasthma treatment? ■ Yes (1) ■ No (0) ■ Unsure (1) ____

5. Do you believe that:a) Your child’s asthma was well controlled in the past 4 weeks? ■ Yes (0) ■ No (1) ■ Unsure (1) ____b) Your child is able to take his/her asthma medicine(s) as directed? ■ Yes (0) ■ No (1) ■ Unsure (1) ____c) Your child’s medicine(s) is useful for controlling his/her asthma? ■ Yes (0) ■ No (1) ■ Unsure (1) ____

6. During this office visit, would you like the doctor to discuss:a) Different types of drugs available to control asthma? ■ (1)b) Your child’s asthma treatment options? ■ (1)c) How your child prefers to take his/her asthma medicine(s)? ■ (1)d) Other issues? ■ (1)

Enter score ____

Copyright ©2006 Merck & Co., Inc. All rights reserved. 20605031(3)-10/06-SNG-MCM Printed in USA. Minimum 10% Recycled Paper

*This reflects a lower threshold to identify potential control problems than was used in the ATAQ validation studies. This modification was designed to encourage patients and providers to discuss how asthma medications are being used.

Asthma Control Test

ASTHMA CONTROL TEST™

Know your scoreThe Asthma Control Test™ provides a numerical score to help you and your healthcare provider determine if your asthma symptoms are well controlled.

Take this test if you are 12 years or older. Share the score with your healthcare provider.

Step 1: Write the number of each answer in the score box provided.

Step 2: Add up each score box for the total.

Step 3: Take the completed test to your healthcare provider to talk about your score.

If your score is 19 or less, your asthma symptoms may not be as well controlled as they could be. No matter what the score, bring this test to your healthcare provider to talk about the results.

Name: Today’s Date:

2. During the past 4 weeks, how often have you had shortness of breath?

More than Once a day [1]

Once a day [2]

3 to 6 times a week [3]

Once or twice a week [4]

Not at all [5]

3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

4 or more nights a week [1]

2 to 3 nights a week [2]

Once a week [3]

Once or twice [4]

Not at all [5]

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?

3 or more times per day [1]

1 or 2 times per day [2]

2 or 3 times per week [3]

Once a week or less [4]

Not at all [5]

5. How would you rate your asthma control during the past 4 weeks?

Not Controlled at All [1]

Poorly Controlled [2]

Somewhat Controlled [3]

Well Controlled [4]

Completely Controlled [5]

1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?

All of the time [1]

Most of the time [2]

Some of the time [3]

A little of the time [4]

None of the time [5]

SCORE

If your score is 19 or less, your asthma symptoms may not be as well controlled as they could be. No matter what your score is, share the results with your healthcare provider.

TOTAL:

Copyright 2002, by QualityMetric Incorporated.Asthma Control Test is a trademark of QualityMetric Incorporated.

This material was developed by GSK.

©2014 GSK group of companies.All rights reserved. Produced in USA. 80108R0 December 2014

Asthma Control Questionnaire

(ACQ)

Goals

Correction of significant hypoxemia

Rapid reversal of airflow obstruction

Reduction of likelihood of relapse of exacerbation or recurrence of future obstruction by intensifying therapy

Careful assessment and monitoring

Acute Exacerbations Goals of Treatment

Classification of Severity of Asthma Exacerbations

Management of Acute Exacerbations in Children

Assessment

Serial measurements of lung function

Pulse oximetry

Signs and symptoms scores

Intervention

Oxygen to relieve hypoxemia in moderate or severe

exacerbations

SABA to relieve airflow obstruction

Addition of inhaled

ipratropium bromide in severe exacerbations

Systemic corticosteroids in moderate or severe

exacerbations or for patients who fail to promptly and

completely to SABA

Consideration of adjunct treatment - magnesium

sulfate or heliox, in severe exacerbations unresponsive

to initial treatments mentioned

Referral to followup care within 1-4 weeks, Asthma

Action Plan, Education

Prevention

Patient Education

Recognition of early signs of worsening

Appropriate intensification of therapy by increasing SABA and adding short course of

OCS

Removal or withdrawal from of the environmental factor

contributing to exacerbation

Prompt communication between patient and clinician about serious deterioration in

symptoms or peak flow, decreased responsiveness to

SABAs, or decreased duration of effect

Special SituationsExercise Induced

Bronchospasm (EIB)Activity

Diagnosis

• Exercise challenge • Undertake task that caused previous

symptoms • Finding of 15 percent decrease in PEF or

FEV1

Management Strategies

• Inhaled beta2-agonists. SABA shortly before exercise or as close as exercise as possible. LABA can be protective up to 12 hours. With LABA some shortening of the duration of protection can occur with daily use.

• LTRAs can attenuate EIB • Cromolyn taken shortly before exercise is an

alternative treatment, but not as effective as SABA

• Warmup period prior to exercise can reduce degree of EIB

• Mask or scarf over mouth may attenuate cold-induced EIB

Special Situations

Surgery and Asthma Activity

Pre-surgery

• Review of systems • Review medication use (use of OCS for

longer than 2 weeks in the past 6 months

• Measurement of pulmonary function • If possible attempts should be made to

improve lung function to either their predicted values (FEV1) or their personal best level (peak flow PEFR)

• Short course of OCS may be necessary to optimize lung function

Intra and Post-surgery

• For patients who have been on a long-term high-dose ICS, give 100mg hydrocortisone every 8 hours intravenously during the surgical period

• Reduce the dose rapidly within 24 hours after surgery

• Stress doses of corticosteroids may be considered for select patients treated with prior high-dose ICS

Special SituationsPregnancy and

AsthmaActivity

MonitoringRecommendations

• Monitoring of asthma status during prenatal visits is encouraged since asthma improves for one-third and worsens for one-third of women

• Monthly evaluations of asthma history • Monthly PFT • Measurement with a peak flow meter may

be sufficient • Evaluations will determine whether to step

up or step down treatment

Medications

• Albuterol is the preferred SABA due to its safety profile and most data related to safety during human pregnancy

• ICS are the preferred treatment for long-term control medication. Budesonide is the preferred ICS due to its safety profile and most data related to safety during human pregnancy

• For treatment of comorbid conditions, intranasal corticosteroids are recommended for treatment of allergic rhinitis because of its low risk of systemic effect. Current second-generation antihistamines of choice are loratadine and cetirizine

Medications - Long-term Usual Dosages Age 5-11

Medications - Long-term Usual Dosages Age 5-11

Medications - Quick-relief Usual Dosages Age 5-11

Medications - Quick-relief Usual Dosages Age 5-11

Medications - Long-term Usual Dosages Age12+

Medications - Long-term Usual Dosages Age12+

Medications - Quick-relief Usual Dosages Age 12+

Medications - Quick-relief Usual Dosages Age 12+

Medications Long-term

Medications Long-term

Medications Long-term

Medications Long-term

Medications Quick-Relief

Medications Quick-Relief

Delivery Devices

Delivery Devices

Delivery Devices

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GREEN ZONE RED ZONEYELLOW ZONE

See

the

reve

rse

side

for t

hing

s yo

u ca

n do

to a

void

you

r ast

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trigg

ers.

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t

Sec

ond

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man

do e

l med

icam

ento

de

la Z

ON

A V

ERD

E.

____

____

____

____

____

____

____

____

____

__(a

goni

sta

beta

2 de

acci

ón c

orta

)q

2 o

q 4

des

carg

as c

ada

20 m

inut

os p

or u

n m

áxim

o de

1 ho

ra

q U

se e

l neb

uliz

ador

una

vez

SEG

UN

DO

Si s

us s

ínto

mas

(y e

l fluj

o m

áxim

o, s

i se

lo m

ide)

regr

esan

a la

ZO

NA

VER

DE

desp

ués

de 1

hor

a de

l tr

atam

ient

o an

terio

r:q

Con

tinúe

vig

ilánd

olos

par

a as

egur

arse

de

perm

anec

er e

n la

Zon

a Ve

rde.

O b

ien,

Si

sus

sín

tom

as (y

el fl

ujo

máx

imo,

si s

e lo

mid

e) n

o re

gres

an a

la Z

ON

A V

ERD

E de

spué

s de

una

hor

a de

l tr

atam

ient

o an

terio

r:q

Tom

e: _

____

____

____

____

____

____

____

_(a

goni

sta

beta

2 de

acci

ón c

orta

) q

2 o

q

4 d

esca

rgas

o

q U

se e

l neb

uliz

ador

q A

greg

ue: _

____

____

_m

g di

ario

s de

___

____

____

____

____

____

____

____

____

(est

eroi

de o

ral)

dur

ante

___

____

(3–1

0) d

ías

q L

lam

e al

doc

tor q

ant

es d

e to

mar

el e

ster

oide

ora

l o q

den

tro d

e la

s __

____

hor

as s

igui

ente

s de

hab

erlo

tom

ado.

ZONA ROJA

¡Ale

rta

méd

ica!

■Ti

ene

muc

ha d

ificu

ltad

para

resp

irar o

■

Los

med

icam

ento

s de

aliv

io rá

pido

no

le h

an a

yuda

do o

■

No

pued

e ha

cer s

us a

ctiv

idad

es n

orm

ales

o

■Lo

s sí

ntom

as s

on ig

uale

s o

empe

oran

des

pués

de

habe

r pa

sado

24

hora

s en

la Z

ona

Amar

illa

O b

ien,

Su fl

ujo

máx

imo

está

en

men

os d

e __

____

____

___

(el 5

0% d

e m

i val

or ó

ptim

o pe

rson

al d

e flu

jo m

áxim

o)

Tom

e es

te m

edic

amen

to:

q _

____

____

____

____

____

____

____

____

____

____

___

(ago

nist

a be

ta2 d

e ac

ción

cor

ta)

q 4

o

q 6

des

carg

as o

q

Use

el n

ebul

izad

or

q _

____

____

____

____

____

____

____

____

____

____

___

mg

(est

eroi

de o

ral)

Lueg

o, ll

ame

al d

octo

r IN

MED

IATA

MEN

TE. V

aya

al h

ospi

tal o

pid

a un

a am

bula

ncia

si:

■

Toda

vía

está

en

la Z

ona

Roja

des

pués

de

15 m

inut

os Y

AD

EMÁS

… ■

No

se h

a po

dido

com

unic

ar c

on e

l doc

tor.

SEÑ

ALE

S D

E PE

LIG

RO

■

Tien

e di

ficul

tad

para

cam

inar

y h

abla

r por

la fa

lta d

e ai

re.

■

Tien

e lo

s la

bios

o la

s uñ

as a

zule

s.

■

Tom

e q

4 o

q 6

des

carg

as d

el m

edic

amen

to d

e al

ivio

rápi

do y

…

■Va

ya a

l hos

pita

l o ll

ame

al _

____

____

____

____

___

para

ped

ir un

a am

bula

ncia

AH

OR

A M

ISM

O.

(telé

fono

)

Al re

vers

o en

cont

rará

qué

pue

de h

acer

par

a ev

itar l

os fa

ctor

es q

ue le

des

enca

dena

n el

asm

a.