Overview of childhood asthma
Transcript of Overview of childhood asthma
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Overview ofChildhoodAsthma
Dr Mazen QUISAIBATY
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INTRODUCTIONChallenges in Asthma
Children The natural history and comorbidities
Diagnosis
Drugs:: Efficacy/Safety
UsingtheDrugs
Thelackofdataonnewtherapies
Developing New GuidelineDeveloping New Guideline
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www.brit-thoracic.org.ukwww.brit-thoracic.org.uk
www.ginasthma.orgwww.ginasthma.org
www.sign.ac.ukwww.sign.ac.uk
wwwwww..thoracicthoracic..orgorgwww.nhlbi.nih.gov/guidelines/www.nhlbi.nih.gov/guidelines/
asthma/asthgdln.htmasthma/asthgdln.htm
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AA
BB
CC
DD
Grade AGrade A Randomized clinicalRandomized clinical
trials andtrials and High-quality evidenceHigh-quality evidence
Levels of EvidenceLevels of Evidence
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AA
BB
CC
DD
Grade AGrade A Randomized clinicalRandomized clinical
trials andtrials and High-quality evidenceHigh-quality evidence
Grade BGrade B Randomized clinicalRandomized clinical
trials buttrials but Moderate -qualityModerate -quality
evidenceevidence
Grade CGrade C Nonrandomized clinicalNonrandomized clinical
trials andtrials and Low-quality evidenceLow-quality evidence
Levels of EvidenceLevels of Evidence
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AA
BB
CC
DD
Grade AGrade A Randomized clinicalRandomized clinical
trials andtrials and High-quality evidenceHigh-quality evidence
Grade BGrade B Randomized clinicalRandomized clinical
trials buttrials but Moderate -qualityModerate -quality
evidenceevidence
Grade CGrade C Nonrandomized clinicalNonrandomized clinical
trials andtrials and Low-quality evidenceLow-quality evidence
Grade DGrade D Panel consensusPanel consensus
Levels of EvidenceLevels of Evidence
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How do patients present?
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Phenotype of wheezingillnesses
Non-atopic Childhood Asthma:Non-atopic Childhood Asthma:1.1. Transient wheezingTransient wheezing
2.2. Persistent wheezingPersistent wheezing
AtopicChildhood Asthma
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Phenotype of wheezingillnesses
Non-atopic Childhood Asthma:Non-atopic Childhood Asthma:1.1. Transient wheezingTransient wheezing
2.2. Persistent wheezingPersistent wheezing
AtopicAtopicChildhood AsthmaChildhood Asthma
N t i Childh d
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Non-atopic ChildhoodAsthma Transient
wheezing 30-50% ofpreschool children have at
least one episode
Which is often outgrown in the first 3years
This is often associated with:
1. Prematurity
2. Parental smoking
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Non-atopic Childhood AsthmaPersistent wheezing (before age 3)
Recurrent episodes of wheezingRecurrent episodes of wheezing
associated with acute viral respiratoryassociated with acute viral respiratory
infectionsinfections No evidence of atopy
No family history of atopy.
Their symptoms normally persist through schoolage and are still present at age 12 in a large
proportion of children
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Non-atopic Childhood AsthmaPersistent wheezing (before age 3)
Recurrent episodes of wheezingRecurrent episodes of wheezing
associated with acute viral respiratoryassociated with acute viral respiratory
infectionsinfectionsNo evidence of atopyNo evidence of atopy
No family history of atopyNo family history of atopy.
Their symptoms normally persist through schoolage and are still present at age 12 in a large
proportion of children
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Non-atopic Childhood AsthmaPersistent wheezing (before age 3)
Recurrent episodes of wheezing
associated with acute viral respiratory
infections
No evidence of atopy
No family history of atopy.
Their symptoms normally persist throughTheir symptoms normally persist throughschool age and are still present at age 12school age and are still present at age 12
in a large proportion of childrenin a large proportion of children
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Non-atopic Childhood AsthmaPersistent wheezing (before age 3)
CausesRespiratory Syncytial VirusRespiratory Syncytial Virus in childrenin children
younger than age 2younger than age 2
Other viruses predominate in childrenOther viruses predominate in childrenages 2-5ages 2-5
Smaller airway dimensionsSmaller airway dimensions
Silverman M, ed. Childhood asthma and other wheezSilverman M, ed. Childhood asthma and other wheezining disorders. 2nd ed.g disorders. 2nd ed.
London: Hodder Arnold, 2002London: Hodder Arnold, 2002
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AtopicChildhood Asthma
Is more common than non-atopicchildhood asthma
85% ofschool aged children with asthma
are atopic
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AtopicChildhood Asthma
This commonly presents as the schoolaged child
who complains of:
1. Episodic wheeze
2. Cough
3. Shortness of breath
Evidence of atopy, such as eczema and hayfever
Likely of family history of atopy.
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AtopicChildhood Asthma
This commonly presents as the schoolaged child
who complains of:
1. Episodic wheeze
2. Cough
3. Shortness of breath Evidence of atopy, such as eczema and hay
fever Likely of family history of atopy.
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AtopicChildhood Asthma
This commonly presents as the schoolaged child
who complains of:
1. Episodic wheeze
2. Cough
3. Shortness of breath
Evidence of atopy, such as eczema andhay fever
Likely of family history of atopy.
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AtopicChildhood Asthma
This commonly presents as the schoolaged child
who complains of:
1. Episodic wheeze2. Cough
3. Shortness of breath
Evidence of atopy, such as eczema andhay fever
Likely of family history of atopy.
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Diagnosi
s ofAsthma
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Diagnosis of Asthma
Frequent episodesof wheeze(more than once amonth)
Activity-induced cough or wheeze Nocturnal cough in periods without viral
Infections
Absence of seasonal variation in wheeze Symptoms that persist after age 3
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Simple Clinical Index that
predict the presence ofasthma in
later childhood
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A simple clinical index
Presence of a wheeze before the age of 3
and the presence of one major riskfactor:
1. Parental history of asthma
2. Parental history of Eczema
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Presence of a wheeze before the age of 3
and the presence oftwo from three
minor risk factors:
1. Eosinophilia
2. wheezing without colds3. Allergic rhinitis
A simple clinical index
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Alternative causes ofrecurrent wheezing
1.1. Chronic rhino-sinusitisChronic rhino-sinusitis
2.2. Gastroesophageal refluxGastroesophageal reflux
3.3. Recurrent viral lower respiratory tract infectionsRecurrent viral lower respiratory tract infections
4.4. Cystic fibrosisCystic fibrosis
5.5. Bronchopulmonary dysplasiaBronchopulmonary dysplasia6.6. TuberculosisTuberculosis
7.7. Congenital malformation causing narrowing of theCongenital malformation causing narrowing of theintrathoracic airwaysintrathoracic airways
8.8. Foreign body aspirationForeign body aspiration9.9. Primary ciliary dyskinesia syndromePrimary ciliary dyskinesia syndrome
10.10. Immune deficiencyImmune deficiency
11.11. Congenital heart diseaseCongenital heart disease
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Tests for diagnosis andmonitoring
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In children 5 yearsand younger
The diagnosis of asthma has to be basedThe diagnosis of asthma has to be based
largely on:largely on:Clinical judgment:
2. History
3. Symptoms4. physical findings
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In children 5 yearsand younger
Trial of
treatment with
SABA and ICS
Marked clinicalMarked clinicalimprovementimprovement
during theduring the
treatmenttreatment And deteriorationAnd deterioration
when it iswhen it is
stoppedstopped
Supports aSupports a
diagnosis ofdiagnosis of
asthmaasthma
I hild 5
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In children over 5 yearsand older
Peak expiratory flow monitoring
PFM is useful to establishPFM is useful to establish diurnaldiurnal
variationvariation and theand the severity ofseverity of
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Skin Prick Tests
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Other Tests
Pulmonary function testsPulmonary function tests( Reversibility of( Reversibility of
FEV1 more than 15% afterFEV1 more than 15% afterininhalation of ahalation of abronchodilator)bronchodilator)
MeasurMeasurining total serum IgEg total serum IgE
Chest radiographyChest radiography
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AsthmaMedications
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Short-Acting inhaled 2-Agonists
(SABA) Ev. A
Systemic GlucoCorticoSteroids
(SGCS) Ev. D
Long-Acting inhaled 2-
Agonists (LABA) Ev. A
Theophylline (THEO) Ev .B
Leukotriene Modifiers (LM) Ev
A
Inhaled gluCocorticoSteroids(ICS) Ev. A
AsthmaMedications
Reliever Medications
Controller Medications
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Short-Acting inhaled 2-Agonists
(SABA) Ev. A
Systemic GlucoCorticoSteroids
(SGCS) Ev. D
Long-Acting inhaled 2-
Agonists (LABA) Ev. A
Theophylline (THEO) Ev .B
Leukotriene Modifiers (LM) Ev
A
Inhaled gluCocorticoSteroids(ICS) Ev. A
AsthmaMedications
Reliever Medications
Controller Medications
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Short-Acting inhaled 2-Agonists
(SABA) Ev. A
Systemic GlucoCorticoSteroids
(SGCS) Ev. D
Long-Acting inhaled 2-
Agonists (LABA) Ev. A
Theophylline (THEO) Ev .B
Leukotriene Modifiers (LM)
Ev A
Inhaled gluCocorticoSteroids
(ICS) Ev. A
AsthmaMedications
Reliever Medications
Controller Medications
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Short-Acting inhaled 2-Agonists
(SABA) Ev. A
Systemic GlucoCorticoSteroids
(SGCS) Ev. D
Long-Acting inhaled 2-
Agonists (LABA) Ev. A
Theophylline (THEO) Ev .B
Leukotriene Modifiers (LM)
Ev A
Inhaled gluCocorticoSteroids(ICS) Ev. A
AsthmaMedications
Reliever Medications
Controller Medications
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Short-Acting inhaled 2-
Agonists
(SABA) Ev. A
Systemic GlucoCorticoSteroids
(SGCS) Ev. D
Long-Acting inhaled 2-
Agonists (LABA) Ev. A
Theophylline (THEO) Ev .B
Leukotriene Modifiers (LM)
Ev A
Inhaled gluCocorticoSteroids
(ICS) Ev. A
AsthmaMedications
Reliever Medications
Controller Medications
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Short-Actinginhaled 2-Agonists
(SABA) Ev. A
Systemic GlucoCorticoSteroids
(SGCS) Ev. D
Long-Acting inhaled 2-
Agonists (LABA) Ev. A
Theophylline (THEO) Ev .B
Leukotriene Modifiers (LM)
Ev A
Inhaled gluCocorticoSteroids
(ICS) Ev. A
AsthmaMedications
Reliever Medications
Controller Medications
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Short-Actinginhaled 2-
Agonists(SABA) Ev. A
Systemic GlucoCorticoSteroids
(SGCS) Ev. D
Long-Acting inhaled 2-
Agonists (LABA) Ev. A
Theophylline (THEO) Ev .B
Leukotriene Modifiers (LM)
Ev A
Inhaled gluCocorticoSteroids
(ICS) Ev. A
AsthmaMedications
Reliever Medications
Controller Medications
n a e
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n a egluCocorticoSteroids
(ICS)
Inhaled glucocorticosteroids are the mosteffective controller therapy in all ages
Evidence A in LongTermasthmaManagement
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InhaledgluCocorticoSteroids (ICS)
The benefits of ICS include:
1. Reduced bronchialhyperresponsiveness
2. Prevention of the late asthmatic
response
3. Enhanced lung function
Estimate Comparative Daily Dosages for
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Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
>1000>500-
1000250 -500
Budesonide-NebInhalation Suspension
>1000 >400600-1000 >200-400200-600 100-200Budesonide
>800-1200 >400> 400-800 >200-400200-400 100-
200Mometasone furoate
>2000 >1200>1000-2000 >800-1200400-1000 400-
800
Triamcinolone
acetonide
>500 >500>250-500 >200-500100-250 100-
200Fluticasone
>2000 >1250>1000-2000 >750-1250500-1000 500-
750Flunisolide
>320-1280 >320>160-320 >160-32080 160 80-160Ciclesonide
>1000 >400>500-1000 >200-400200-500 100-200Beclomethasone
Estimate Comparative Daily Dosages for
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Estimate Comparative Daily Dosages for
Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
>1000>500-
1000250 -500
Budesonide-Neb
Inhalation Suspension
>1000 >400600-1000 >200-400200-600 100-200Budesonide
>800-1200 >400> 400-800 >200-400200-400 100-
200Mometasone furoate
>2000 >1200>1000-2000 >800-1200400-1000 400-
800
Triamcinolone
acetonide
>500 >500>250-500 >200-500100-250 100-
200Fluticasone
>2000 >1250>1000-2000 >750-1250500-1000 500-
750Flunisolide
>320-1280 >320>160-320 >160-32080 160 80-160Ciclesonide
>1000 >400>500-1000 >200-400200-500 100-200Beclomethasone
I h l d
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InhaledgluCocorticoSteroids (ICS)
Use of ICS does not induce remission ofUse of ICS does not induce remission ofasthma, and symptoms return whenasthma, and symptoms return when
treatment is stoppedtreatment is stopped
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n a egluCocorticoSteroids
(ICS)No EvidenceNo Evidence
Maintenance or Intermittent low-dose (ICS)Maintenance or Intermittent low-dose (ICS)
PreventingPreventing Non-atopic Childhood AsthmaNon-atopic Childhood Asthma
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LeukotrieneModifiers(LM)
Evidence A in LongTermasthmaManagement
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LeukotrieneModifiers(LM)
One multicenter, randomized, double-blind, parallel-group study
Examined children (aged 2 to 5 years) (approximately270 children per group)
Intermittent asthma associated with viral infections andminimal asthma symptoms between exacerbations
Children were given Montelukast or placebo andfollowed for 12 months
Bisgaard, H, Zielen, S, Garcia-Garcia, ML, et al. Montelukast reduces asthmaexacerbations in 2- to 5-year-old children with intermittent asthma. Am JRespir Crit Care Med 2005; 171:315.
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LeukotrieneModifiers(LM)
One multicenter, randomized, double-blind, parallel-group study
Examined infants (aged 2 to 5 years) (approximately 270children per group)
Intermittent asthma associated with viral infections andminimal asthma symptoms between exacerbations
Children were given Montelukast or placebo andfollowed for 12 months
Bisgaard, H, Zielen, S, Garcia-Garcia, ML, et al. Montelukast reduces asthmaexacerbations in 2- to 5-year-old children with intermittent asthma. Am JRespir Crit Care Med 2005; 171:315.
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LeukotrieneModifiers(LM)
One multicenter, randomized, double-blind, parallel-group study
Examined infants (aged 2 to 5 years) (approximately 270children per group)
Intermittent asthma associated with viral infections andminimal asthma symptoms between exacerbations
infants were given Montelukast orplacebo and followedfor 12 months
Bisgaard, H, Zielen, S, Garcia-Garcia, ML, et al. Montelukast reduces asthmaexacerbations in 2- to 5-year-old children with intermittent asthma. Am JRespir Crit Care Med 2005; 171:315.
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LeukotrieneModifiers(LM)
Montelukast significantly:
Reduced the rate of asthma
exacerbations by 32 % compared withplacebo (from 2.3 episodes per year to 1.6)
Decreased the use of ICSby 30%
Bisgaard, H, Zielen, S, Garcia-Garcia, ML, et al. Montelukast reduces asthma
exacerbations in 2- to 5-year-old children with intermittent asthma. Am J Respir
Crit Care Med 2005; 171:315.
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LeukotrieneModifiers(LM)
Montelukast significantly:
Reduced the rate of asthma
exacerbations by 32 % compared withplacebo (from 2.3 episodes per year to 1.6)
Decreased the use of ICSby 30%
Bisgaard, H, Zielen, S, Garcia-Garcia, ML, et al. Montelukast reduces asthma
exacerbations in 2- to 5-year-old children with intermittent asthma. Am J Respir
Crit Care Med 2005; 171:315.
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DOSING
10 mg/dayAdolescents >14 years
and Adults
5 mg/day6-14 years
4 mg/day6 months to 5 years
Montelukast
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Theophylline
A few studies in infants 5 years andyounger suggest some clinical benefit
The efficacy is less than that of low-dose
ICS
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Theophylline
The side effects are more pronouncedEvidence B inLongTermasthma
Management in children adolescents and
adults
Long Acting inhaled 2
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Long-Acting inhaled 2-Agonists (LABA)
Evidence A in LongTermasthmaManagement in children adolescents and
adults:
Control of chronic symptoms
Prevent nocturnal symptoms
Exercise-induced bronchoconstriction
Long Acting inhaled 2
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Long-Acting inhaled 2-Agonists (LABA)
The effect of (LABA) has not yet beenadequately studied in infants 5 years and
younger
Long Acting inhaled 2
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Long-Acting inhaled 2-Agonists (LABA)
Recent studies in adults have shown anincrease in the relative risk of death from
asthma with the use of salmeteroll
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Inhalation
50 mcg / 12
hours
> 4 years oldSalmeterol
inhalation
12 mcg / 12hours
> 5 years oldFormoterol
Long-Acting inhaled 2-Agonists LABA
Short-Acting inhaled 2-
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g Agonists(SABA)
Evidence A:
Relief bronchospasm during acute
exacerbations of asthma
Pretreatment of exercise-induced
bronchoconstriction
Salbutamol, Terbutaline, Fenoterol, Reproterol,And Pirbuterol.
Short-Acting inhaled 2-
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g Agonists(SABA)
Evidence A:
1. Relief bronchospasm during acute
exacerbations of asthma2. Pretreatment of exercise-induced
bronchoconstriction
Salbutamol, Terbutaline, Fenoterol,Reproterol, And Pirbuterol.
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Short-Acting inhaled 2-
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g Agonists(SABA)
Evidence also exists of reducedEvidence also exists of reducedprotection against exercise inducedprotection against exercise induced
asthmaasthma
Bisgaard H, Szefler S. Long actBisgaard H, Szefler S. Long actiningg LancetLancetagonists andagonists and
paediatric asthmapaediatric asthma
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Anticholinergics
In Acute Asthma
B. Reliever medication but less effectivethan SABA
C. Not recommended for long-term
management of asthma in children
Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in
adults with acute asthma. Am J Med1999;107(4):363-70/McDonald NJ, Bara AI.Anticholinergic therapy for chronic
asthma in children over two years of age. Cochrane DatabaseSyst Rev2003(3):CD003535
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Anticholinergics
A. The combination between SABA &Anticholinergics:
1. Significant Improvement in pulmonaryfunction
2. Significantly reduces the risk of hospital
admission
Rodrigo G, Rodrigo C, Burschtin O. A meta-analysis of the effects of ipratropium bromide in
adults with acute asthma. Am J Med1999;107(4):363-70/McDonald NJ, Bara AI.Anticholinergic therapy for chronic
asthma in children over two years of age. Cochrane DatabaseSyst Rev2003(3):CD003535
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AsthmaAsthma
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SuccessfulSuccessful
AsthmaAsthmaManagementManagement
ManagementManagementandand
PreventionPrevention
AsthmaAsthmaM t d
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PharmacologicPharmacologic
TherapyTherapy
SuccessfulSuccessful
AsthmaAsthmaManagementManagement
ManagementManagementandand
PreventionPrevention
Patient educationPatient educationAsthmaAsthma
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to createto create
a partnershipa partnership
betweenbetween
clinicianclinician
& patient& patient
PharmacologicPharmacologic
TherapyTherapy
SuccessfulSuccessful
AsthmaAsthmaManagementManagement
ManagementManagementandand
PreventionPrevention
RoutineRoutineAsthmaAsthma
M tM t dd
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RoutineRoutine
Monitoring ofMonitoring of
Symptoms &Symptoms &
Lung FunctionLung Function
Patient educationPatient education
to createto create
a partnershipa partnership
betweenbetween
clinicianclinician& patient& patient
PharmacologicPharmacologic
TherapyTherapy
SuccessfulSuccessful
AsthmaAsthmaManagementManagement
ManagementManagementandand
PreventionPrevention
PreventionPreventionAsthmaAsthma
M tM t dd
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PreventionPreventionTrigger factorsTrigger factors
coco--morbidmorbid
conditionsconditions
RoutineRoutine
Monitoring ofMonitoring ofSymptoms &Symptoms &
Lung FunctionLung Function
Patient educationPatient education
to createto create
a partnershipa partnership
betweenbetween
clinicianclinician
& patient& patient
PharmacologicPharmacologicTherapyTherapy
SuccessfulSuccessful
AsthmaAsthmaManagementManagement
ManagementManagementandand
PreventionPrevention
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Initial Evaluation before treatment to classifyAsthma Severity
Treating for 4-6 weeksto achieve control: 5 steps
Pharmacologic Therapy
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Total evaluation after treatment to identify the
Level of Control
Initial Evaluation before treatment to classifyAsthma Severity
Treating for 4-6 weeksto achieve control: 5 steps
Pharmacologic Therapy
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Treatment Modification : Step up or Step down
Total evaluation after treatment to identify the
Level of Control
Initial Evaluation before treatment to classifyAsthma Severity
Treating for 4-6 weeksto achieve control: 5 steps
Pharmacologic Therapy
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Adequate management ofExacerbation
Treatment Modification : Step up or Step down
Total evaluation after treatment to identify the
Level of Control
Initial Evaluation before treatment to classifyAsthma Severity
Treating for 4-6 weeksto achieve control: 5 steps
Pharmacologic Therapy
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Initial Evaluation before treatment to classifyAsthma Severity
Pharmacologic Therapy
Classification of asthma severity before treatment (0-
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Several
times
per day
Activity
SABA use for
symptom control
Nighttime
awakeningsImpairment
Extremely
limited
Some
limitation
Minor
limitationNone
Daily>2 days/week
but not daily>2
days/week
>1x/week3-
4x/month1-2x/month0
Daily
Moderate>2 days/week
but not daily
Mild
Persistent
Severe> 2
days/week
Intermittent
Throughout
the daySymptoms
Classification of asthma severity before treatment (0-
4 years of age(
Components of severity
Classification of asthma severity before treatment (0-
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86
Several
times
per day
Activity
SABA use for
symptom control
Nighttime
awakeningsImpairment
Extremely
limited
Some
limitation
Minor
limitationNone
Daily>2 days/week
but not daily>2
days/week
>1x/week3-
4x/month1-2x/month0
Daily
Moderate>2 days/week
but not daily
Mild
Persistent
Severe> 2
days/week
Intermittent
Throughout
the daySymptoms
Classification of asthma severity before treatment (0
4 years of age(
Components of severity
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Classification of asthma severity before treatment (0-
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88
Several
times
per day
Activity
SABA use for
symptom control
Nighttime
awakeningsImpairment
Extremely
limited
Some
limitation
Minor
limitationNone
Daily>2 days/week
but not daily>2
days/week
>1x/week3-
4x/month1-2x/month0
Daily
Moderate>2 days/week
but not daily
Mild
Persistent
Severe> 2
days/week
Intermittent
Throughout
the daySymptoms
Classification of asthma severity before treatment (0
4 years of age(
Components of severity
Classification of asthma severity before treatment (0-
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89
Several
times
per day
Activity
SABA use for
symptom control
Nighttime
awakeningsImpairment
Extremely
limited
Some
limitation
Minor
limitationNone
Daily>2 days/week
but not daily>2
days/week
>1x/week3-
4x/month1-2x/month0
Daily
Moderate>2 days/week
but not daily
Mild
Persistent
Severe> 2
days/week
Intermittent
Throughout
the daySymptoms
Classification of asthma severity before treatment (0
4 years of age(
Components of severity
ModerateIntermittent SevereMild
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0-1/year
Exacerbations of any severity may occur in patients in any
severity category may be related to FEV 1 in children 5-11 years
of age
Frequency and severity may fluctuate over time
Consider severity and interval since last exacerbation
2 exacerbations in 6
months requiring oral
systemic
corticosteroids or 4 wheezing
episodes/1 year lasting
>1 day AND risk
factors for persistent
asthma
2/year in children 5-11
years of age
Exacerbations
requiringoral
systemic
corticosteroids
Risk
ModerateIntermittent SevereMild
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91
0-1/year
Exacerbations of any severity may occur in patients in any
severity category may be related to FEV 1 in children 5-11 years
of age
Frequency and severity may fluctuate over time
Consider severity and interval since last exacerbation
2 exacerbations in 6
months requiring oral
systemic
corticosteroids or 4 wheezing
episodes/1 year lasting
>1 day AND risk
factors for persistent
asthma
2/year in children 5-11
years of age
Exacerbations
requiringoral
systemic
corticosteroids
Risk
ModerateIntermittent SevereMild
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92
0-1/year
Exacerbations of any severity may occur in patients in any
severity category may be related to FEV 1 in children 5-11 years
of age
Frequency and severity may fluctuate over time
Consider severity and interval since last exacerbation
2 exacerbations in 6
months requiring oral
systemic
corticosteroids or 4 wheezing
episodes/1 year lasting
>1 day AND risk
factors for persistent
asthma
2/year in children 5-11
years of age
Exacerbations
requiringoral
systemic
corticosteroids
Risk
ModerateIntermittent SevereMild
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93
0-1/year
Exacerbations of any severity may occur in patients in any
severity category may be related to FEV1 in children 5-11 years
of age
Frequency and severity may fluctuate over time
Consider severity and interval since last exacerbation
2 exacerbations in 6
months requiring oral
systemic
corticosteroids or 4 wheezing
episodes/1 year lasting
>1 day AND risk
factors for persistent
asthma
2/year in children 5-11
years of age
Exacerbations
requiringoral
systemic
corticosteroids
Risk
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FEV 1 80 %
Normal FEV 1
between
exacerbations
FEV 1 >80 %predicted
FEV 1/FVC
>85 %
ModerateMild
Persistent
SevereIntermittent
Classification of asthma severity before treatment
(5-11
years
of
age)
Lungfunction
Ph l i Th
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95
Initial Evaluation before treatment to classifyAsthma Severity
Treating for 4-6 weeksto achieve control: 5 steps
Pharmacologic Therapy
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96
As needed Short-acting
inhaled 2-agonist(SABA)
Indicated in all agegroups
Evidence A
Step 1IntermittentAsthma
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97
Step 2Step 2
MildMildAsthmaAsthma
Preferred
Low-dose ICSLow-dose ICS
Evidence AEvidence A
AlternativeMontelukast
Evidence A
Indicated in all age groups
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98
Step 2Step 2
Mild AsthmaMild Asthma
PreferredLow-dose ICSLow-dose ICS
Evidence AEvidence A
AlternativeMontelukastMontelukast
EvidenceEvidenceAA
Indicated in all age groups
Stepwise approach for managing asthma
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99
Step 3Step 3
Moderate & Severe AsthmaModerate & Severe Asthma
Medium-dose ICSMedium-dose ICSEvidence AEvidence A
Stepwise approach for managing asthma
in children 0- 4 years of age
Stepwise approach for managing asthma
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100
Step 4Step 4Moderate & SevereModerate & Severe
AsthmaAsthma
Medium-dose ICSMedium-dose ICS
Evidence AEvidence A
LABALABA
EvidenceEvidenceAA
Montelukast
EvidenceA
Stepwise approach for managing asthma
in children 0- 4 years of age
Stepwise approach for managing asthma
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101
Step 4Step 4Moderate & SevereModerate & Severe
AsthmaAsthma
Medium-dose ICSMedium-dose ICS
Evidence AEvidence A
LABALABA
EvidenceEvidenceAA
MontelukastMontelukast
EvidenceEvidenceAAOrOr
PreferredPreferred
Stepwise approach for managing asthma
in children 0- 4 years of age
Stepwise approach for managing asthma
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102
Step 5Step 5Severe AsthmaSevere Asthma
HighHigh-dose ICS-dose ICS
Evidence AEvidence A
LABALABA
EvidenceEvidenceAA
Montelukast
EvidenceA
Stepwise approach for managing asthma
in children 0- 4 years of age
Stepwise approach for managing asthma
-
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103
Step 5Step 5Severe AsthmaSevere Asthma
HighHigh-dose ICS-dose ICS
Evidence AEvidence A
LABALABA
EvidenceEvidenceAA
MontelukastMontelukast
EvidenceEvidenceAAOrOr
PreferredPreferred
Stepwise approach for managing asthma
in children 0- 4 years of age
Stepwise approach for managing asthma in children
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104
SABA ICS -DoseDrugs
Stepwiseapproachformanagingasthmainchildren
0-4 years of age
Stepwise approach for managing asthma in children
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105
1
Intermittent
SABA ICS -Dose
3
Moderate- Severe
542Steps
SevereMildSeverity
Drugs
Stepwiseapproachformanagingasthmainchildren
0-4 years of age
Stepwise approach for managing asthma in children
-
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106
LABA
Immunotherapy
Montelukast
HighMediumMedium
Montelukast
Low
1
Intermittent
SABA ICS -Dose
3
Moderate- Severe
542Steps
SevereMildSeverity
Drugs
Stepwiseapproachformanagingasthmainchildren
0-4 years of age
Stepwise approach for managing asthma in children
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107
LABA ???
Immunotherapy
Montelukast
HighMediumMedium
Montelukast
Low
1
Intermittent
SABA ICS -Dose
3
Moderate- Severe
542Steps
SevereMildSeverity
Drugs
Stepwiseapproachformanagingasthmainchildren
0-4 years of age
Stepwise approach for managing asthma in children
-
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108
LABA???
Immunotherapy
Montelukast
HighMediumMedium
Montelukast
Low
1
Intermittent
SABA ICS -Dose
3
Moderate- Severe
542Steps
SevereMildSeverity
Drugs
Stepwiseapproachformanagingasthmainchildren
0-4 years of age
Stepwise approach for managing asthma in
Children older than 5 years Adolescents and
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109
Step 3Step 3Moderate & SevereModerate & Severe
AsthmaAsthma
Low-dose ICSEvidence A
LABA
EvidenceA
MontelukastEvidenceA
SR-Theo
EvidenceB
Medium- dose ICS High dose ICSHigh dose ICS
Children older than 5 years, Adolescents and
Adults
Stepwise approach for managing asthma in
Children older than 5 years Adolescents and
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110
Step 3Step 3Moderate & SevereModerate & Severe
AsthmaAsthma
Low-dose ICS
Evidence A
LABA
EvidenceA
Montelukast
EvidenceA
SR-Theo
EvidenceB
Medium- dose ICSMedium- dose ICS High dose ICSHigh dose ICS
Children older than 5 years, Adolescents and
Adults
Stepwise approach for managing asthma in
Children older than 5 years Adolescents and
-
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111
Step 3Step 3Moderate & SevereModerate & Severe
AsthmaAsthma
Low-dose ICSLow-dose ICS
Evidence AEvidence A
LABALABA
EvidenceEvidenceAA
MontelukastEvidenceA
SR-Theo
EvidenceB
Medium- dose ICSMedium- dose ICS High dose ICSHigh dose ICS
Children older than 5 years, Adolescents and
Adults
PreferredPreferred
Stepwise approach for managing asthma in
Children older than 5 years, Adolescents and
-
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112
Step 3Step 3Moderate & SevereModerate & Severe
AsthmaAsthma
Low-dose ICSLow-dose ICS
Evidence AEvidence A
LABALABA
EvidenceEvidenceAA
MontelukastMontelukast
EvidenceEvidenceAA
SR-Theo
EvidenceB
Medium- dose ICSMedium- dose ICS
OrOr
High dose ICSHigh dose ICS
Children older than 5 years, Adolescents and
Adults
PreferredPreferred
Stepwise approach for managing asthma in
Children older than 5 years, Adolescents and
-
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113
Step 3Step 3Moderate & SevereModerate & Severe
AsthmaAsthma
Low-dose ICSLow-dose ICS
Evidence AEvidence A
LABALABA
EvidenceEvidenceAA
MontelukastMontelukast
EvidenceEvidenceAA
SR-TheoSR-Theo
EvidenceEvidenceBB
Medium- dose ICSMedium- dose ICS
OrOr
High dose ICSHigh dose ICS
OrOr
Children older than 5 years, Adolescents and
Adults
PreferredPreferred
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Stepwise approach for managing asthma in
-
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115
Step 4Step 4Moderate & SevereModerate & Severe
AsthmaAsthma
Medium -dose ICS plusMedium -dose ICS plus
LABALABA
MontelukastMontelukast
Evidence AEvidence ASR-TheoSR-Theo
EvidenceEvidence BB-/+-/+
High-doseHigh-doseICSICSplusplus
LABALABA
Children older than 5 years, Adolescents and
Adults
Stepwise approach for managing asthma in
-
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116
Step 5Step 5Severe AsthmaSevere Asthma
MediumMedium
dose ICS plusdose ICS plus
LABALABA
MontelukastMontelukast
Evidence AEvidence ASR-TheoSR-Theo
EvidenceEvidence BB
OralOral
GlucocorticosteroidsGlucocorticosteroids
low doselow dose Evidence DEvidence D
Anti-IgE
Evidence A
High-dose ICS plusHigh-dose ICS plus
LABALABA
Children older than 5 years, Adolescents and
Adults
Stepwise approach for managing asthma in
C
-
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117
Step 5Step 5Severe AsthmaSevere Asthma
MediumMedium
dose ICS plusdose ICS plus
LABALABA
MontelukastMontelukast
Evidence AEvidence ASR-TheoSR-Theo
EvidenceEvidence BB
-/+-/+OralOral
GlucocorticosteroidsGlucocorticosteroids
low doselow dose Evidence DEvidence D
Anti-IgEAnti-IgE
Evidence AEvidence A
High-dose ICS plusHigh-dose ICS plus
LABALABA
Children older than 5 years, Adolescents and
Adults
Stepwise approach for managing asthma in Children older than 5 years, Adolescents and
Adults
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118
+/- AntiIgE
Oral
Glucocorticosteroids
lowdose
5
SR-Theo
Montelukast
LABA
Medium or High
+/- SR-Theo
Montelukast
LABA
SR-Theo
Montelukast or
Immunotherapy
Medium or HighMedium or
High
LABA or
Low
Moderate- Severe
43
Severe
ICS
Immunotherapy in Children older thanAd l d Ad l
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119
5 years, Adolescents and Adults
For steps 2-4 is basedFor steps 2-4 is based
onon Evidence BEvidence B for:for:HouseHouse--dustdust mitesmites
Animal dandersAnimal danders
PollensPollens
Immunotherapy in Children older than5 Ad l t d Ad lt
-
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120
5 years, Adolescents and Adults
Evidence isEvidence is
strongeststrongest forfor
immunotherapy withimmunotherapy with
single allergenssingle allergens
Immunotherapy in Children older than5 Ad l t d Ad lt
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121
5 years, Adolescents and Adults
The role of allergy inThe role of allergy in
asthma is greater inasthma is greater in
childrenchildren than inthan in
adultsadults
Pharmacologic Therapy
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122
Total evaluation after treatment to identify the
Level of Control
Initial Evaluation before treatment to classifyAsthma Severity
Treatingto achieve control: 5 steps
Pharmacologic Therapy
Le el Of ControlLevel Of Control
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123
ExacerbationExacerbation
Level Of ControlLevel Of Control
Level Of ControlLevel Of Control
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124
UncontrolledUncontrolled
ExacerbationExacerbation
Level Of ControlLevel Of Control
Level Of ControlLevel Of Control
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125
Partly ControlledPartly Controlled
UncontrolledUncontrolled
ExacerbationExacerbation
Level Of ControlLevel Of Control
Level Of ControlLevel Of Control
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ControlledControlled
Partly ControlledPartly Controlled
UncontrolledUncontrolled
ExacerbationExacerbation
Level Of ControlLevel Of Control
UncontrolledPartly controlled
( )
Controlled
Levels of Asthma ControlLevels of Asthma Control
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Uncontrolled(Any present in any week)(All of the following)
UncontrolledPartly controlled
(A t i k)
Controlled
Levels of Asthma ControlLevels of Asthma Control
Characteristic
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Uncontrolled(Any present in any week)(All of the following)
Daytime symptoms
Characteristic
UncontrolledPartly controlled
(A t i k)
Controlled
Levels of Asthma ControlLevels of Asthma Control
Characteristic
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(Any present in any week)(All of the following)
Limitations of
activities
Daytime symptoms
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UncontrolledPartly controlled
(Any present in any week)
Controlled
(All f th f ll i )
Levels of Asthma ControlLevels of Asthma Control
Characteristic
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(Any present in any week)(All of the following)
Need for rescue /
reliever treatment
Nocturnal symptoms /awakening
Limitations of
activities
Daytime symptoms
UncontrolledPartly controlled
(Any present in any week)
Controlled
(All f th f ll i )
Levels of Asthma ControlLevels of Asthma Control
Characteristic
Characteristic
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(Any present in any week)(All of the following)
Lung function
(PEF or FEV1)
Need for rescue /
reliever treatment
Nocturnal symptoms /awakening
Limitations of
activities
Daytime symptoms
Lung function
(PEF or FEV1)
Need for rescue /
reliever treatment
Nocturnal symptoms /awakening
Limitations of
activities
Daytime symptoms
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-
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134
None (2 or less / week)
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135
NONO
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Limitations Of Activities
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137
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138
None (2 or less / week)
Typical Spirometric (FEV1)
Tracings
-
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139
Tracings
11Time (sec)22 33 44 55
FEV1
Volume
Normal SubjectNormal Subject
Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurements
NormalNormal
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NoE
xacerbation
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UncontrolledPartly controlled
(Any present in any week)
Controlled
(All of the following)
Levels of Asthma ControlLevels of Asthma Control
Characteristic
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143
( y p y )(All of the following)
None (2 or less /week)
None
None
None (2 or less /
week)
Normal
None
More thantwice / week
Any
Any
More than
twice / week
< 80% predicted or
personal best (if known)
on any day
One or more / year 1 in any week
3 or more
features of
partly
controlled
asthma
present in any
week
Exacerbation
Lung function
(PEF or FEV1)
Need for rescue /
reliever treatment
Nocturnal symptoms /awakening
Limitations of
activities
Daytime symptoms
Pharmacologic Therapy
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144
Treatment Modification : Step up or Step down
Total evaluation after treatment to identify the
Level of Control
Initial Evaluation before treatment to classifyAsthma Severity
Treating for 2-4 weeksto achieve control: 5 steps
Treatment Modification
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145
STEP
1
S
TEP
2
STEP
3
STEP
4
STEP
5
Step upStep up
afterafter
weeks 4-6weeks 4-6
ofof
TreatmentTreatment
Step downStep down
AfterAfter
months 3-6months 3-6
ofof
TreatmentTreatment
Pharmacologic Therapy
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146
Adequate management ofExacerbation
Treatment Modification : Step up or Step down
Total evaluation after treatment to identify the
Level of Control
Initial Evaluation before treatment to classifyAsthma Severity
Treating for 2-4 weeksto achieve control: 5 steps
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147
PreventionPreventionTrigger factorsTrigger factors
co bidmorbid
AsthmaAsthma
ManagementManagementandand
PreventionPrevention
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148
coco--morbidmorbid
conditionsconditions
PharmacologicPharmacologic
TherapyTherapy
SuccessfulSuccessful
AsthmaAsthmaManagementManagement
Prevention
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149
CoCo--morbid conditionsmorbid conditions Trigger factorsTrigger factors
Influenza VaccinationInfluenza Vaccination
Chronic Rhino-Sinusitis
-
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150
RecurrentMilk
Gastroesopha
-
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151
Milk
Aspirationgeal Reflux
Trigger factorsTrigger factors
-
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152
Prevention /InfluenzaVaccination
-
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153
Vaccination
PreventionPreventionTrigger factorsTrigger factors
coco-morbidmorbid
AsthmaAsthma
ManagementManagementandand
PreventionPrevention
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154
coco--morbidmorbid
conditionsconditions
Patient educationPatient education
to createto create
a partnershipa partnership
betweenbetween
clinicianclinician
& patient& patient
PharmacologicPharmacologic
TherapyTherapy
SuccessfulSuccessful
AsthmaAsthmaManagementManagement
Patient Education
-
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155
-
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PreventionPreventionTrigger factorsTrigger factors
coco--morbidmorbid
AsthmaAsthma
ManagementManagementandand
PreventionPrevention
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157
coco--morbidmorbid
conditionsconditions
RoutineRoutine
Monitoring ofMonitoring of
Symptoms &Symptoms &Lung FunctionLung Function
Patient educationPatient educationto createto create
a partnershipa partnership
betweenbetween
clinicianclinician
& patient& patient
PharmacologicPharmacologic
TherapyTherapy
SuccessfulSuccessful
AsthmaAsthmaManagementManagement
out neMonitoring
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158
Exacerbation
Lung function
(PEF or FEV1)
Need for rescue /
reliever treatment
Nocturnal symptoms /
awakening
Limitations of
activities
Daytime symptoms
Adequate use ofspacers / neublizer
Peak Flow Meter
Co-morbidconditions
Level of control
Treatment
StepStep
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