• Respiratory - Wheezing, Crackling, tachypnea
• Increased nasal secretions, nasal polyps
• Eczema, Atopic dermatitis

• Frequency, pattern, and symptoms
• Triggers
• Family History

Hyperexpansion of chest x-ray

Spirometery

12 + years old

Symptoms

(Intermittent, Mild, Moderate, Severe)

Intermittent: =< 2 Days

Mild: > 2days/week

Moderate: Daily

Severe: Throughout the day

12 + years old

Nighttime awakenings

(Intermittent, Mild, Moderate, Severe)

Intermittent: =< 2x/Month

Mild: 3-4x/month

Moderate: >=1x/week(not nightly)

Severe: 7x/Week

12 + years old

LABA use for control

(Intermittent, Mild, Moderate, Severe)

Intermittent: =<2days/week

Mild: >2 days/week

Moderate: Daily

Severe: Several times per day

12 + years old

Interference with normal activity

(Intermittent, Mild, Moderate, Severe)

Intermittent: None

Mild: Minor

Moderate: Some

Severe: extremely limited

12 + years old

Lung function

(Intermittent, Mild, Moderate, Severe)

Intermittent: FEV1>80%predicted

Mild: FEV1 =>80%predicted

Moderate: FEV1= 60-80% predicted (FEV1/FVC reduc. 5%)

FEV 1 =< 60% predicted (FEV1/FVC reduced 5%)

5-11 years old

Lung Function

(Intermittent, Mild, Moderate, Severe)

Intermittent: FEV1>80% predicted, FEV1/FVC > 85%

Mild: FEV1=> 80% predicted, FEV1/FVC > 80%

Moderate: FEV1 60-80% prediceted, FEV1/FVC 75-80%

Severe: FEV1=< 60% predicted FEV1/FVC< 75%

0-4 years old

Nighttime awakenings

(Intermittent, Mild, Moderate, Severe)

Intermittent: 0

Mild: 1-2x/ month

Moderate: 3-4x/month

Severe: >1x/month

• Corticosteroids
• Mast Cell stabilizers
• LABA
• Leukotriene modifiers
• Methylxantines
• Monoclonal antibodies
• SABA
• Anticholinergics

• Prevent chronic symptoms
• Prevent exacerbations
• Maintain normal activity levels
• Maintain normal pulmonary function
• Optimize drug therapy
• Satisfy patient's and Families' goals for care

Initiation of therapy

(12 and older, 5-11, and 4 and under)

12+: do not start past step 4 or 5

5-11: do not start past 3 or 4

4 and under: do not start past step 3

Step1: SABA PRN

Step2: Low dose ICS or (MCS, LTRA, theophylline)

Step 3: Low dose ICS + LABA, LTRA, or Theoph (or med dose ICS)

Step 4: Med-dose ICS + LABA

Step 5: High-Dose ICS + LABA (Consider Omalizumab)

Step6: High Dose ICS + LABA + Oral Corticosteroids (Consider omalizumab)

Step1: SABA PRN

Step2: Low dose ICS

Step 3: Med Dose ICS

Step 4: Med-dose ICS + LABA or Singulair

Step 5: High Dose ICS + LABA or Singulair

Step 6: High Dose ICS + LABA or Singulair + Oral corticosteroids

Most effective long-term control - NOT for acute

some evidence suggests double or quadruple dose for exacerbation

Dosage forms: MDI, DPI, Diskus, nebules

Dosage Frequency: daily or twice daily

Alternative Tx, not prefered

ADE: Possible association with suicidal behavior

Dosage: Once daily at bedtime

Zafirlukast and Zileuton - p450 Inhib. Monitor hepatic enzymes

Moderate or severe asthma

ADE: rapid heart rate and Dizziness

Not intended for Monotherapy or acute symptoms

Not used for acute symptom relief or exacerbations

Dosage: MDI, Diskus

Dosage frequency: twice daily

Alternative Treatment

May be used as preventive treatment

ADE: Cough, Bad taste in mouth, throat irritation

Patient counseling: not for acute asthma, 4 weeks till benefits

Always part of patients regimen

Rapid acting bronchodilaters

ADE: Rapid Heart rate, headache, dizziness

Not for long term treatment. Only for hospital/ER

ADE: Dry mouth, dizziness, upset stomach, vision changes

Alternate in patients who cant tolerate SABA

Short courses of oral corticosteroids to gain immediate control of asthma.

May cause hyperglycemia, report signs/symptoms of infection, take full course

0-4 yrs:1mg/kg/day 3-10 days

5-11 yrs: 40-60mg/day

12+: 40-80 mg/day

PEF >= 80

No symptoms

Maintenance treatment reduce symptoms

PEF >= 50-79%

• Symptoms: Wheezing, coughing, chest tightness, shortness of breath, decrease in activity

• Contact healthcare professional
• Treatment -- SABA maintenance - PO Corticoid

PEF <=50%

• Symptoms: harder to breath, unable to sleep or minimal
• Contact physician and Visit ER
• Treatment: SABA + PO Corticoid + change + additional

Managing Exacerbations at Home

• Intial - SABA

Good Initial -- Double dose ICS for 7-10 days

Incomplete -- Add oral steroid

Poor -- add oral, call phys or ER

ABX is purulent sputum or pneumonia

Decrease Intubation via MgSulfate, Terbuataline: IV Beta-Agonist, Heliox, mixture of helium/oxygen for improved gas exchange