40 Guidelines for the Diagnosis and Management of Asthma FIGURE 11. CLASSIFYING ASTHMA SEVERITY AND INITIATING THERAPY IN CHILDREN Key: FEV 1 , forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroids; ICU, intensive care unit; N/A, not applicable Notes: ■ Level of severity is determined by both impairment and risk. Assess impairment domain by caregiver’s recall of previous 2–4 weeks. Assign severity to the most severe category in which any feature occurs. ■ Frequency and severity of exacerba- tions may fluctuate over time for patients in any severity category. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and severe exacerba- tions (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients with ≥2 exacerbations described above may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
Transcript
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uidelines for the Diagnosis and Managem
ent of Asthma
FIGURE 11. CLASSIFYING ASTHMA SEVERITY AND INITIATING THERAPY IN CHILDREN
Key: FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity;ICS, inhaled corticosteroids; ICU,intensive care unit; N/A, not applicable
Notes:n Level of severity is determined by
both impairment and risk. Assessimpairment domain by caregiver’srecall of previous 2–4 weeks.Assign severity to the most severecategory in which any featureoccurs.
n Frequency and severity of exacerba-tions may fluctuate over time forpatients in any severity category.At present, there are inadequatedata to correspond frequencies of exacerbations with different levels of asthma severity. In general,more frequent and severe exacerba-tions (e.g., requiring urgent,unscheduled care, hospitalization,or ICU admission) indicate greaterunderlying disease severity. Fortreatment purposes, patients with ≥2exacerbations described above maybe considered the same as patientswho have persistent asthma, even inthe absence of impairment levels consistent with persistent asthma.
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FIGURE 12. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN
Key: EIB, exercise-induced bron-chospasm, FEV1, forced expiratory volume in 1 second; FVC, forced vitalcapacity; ICU, intensive care unit; N/A, not applicable
Notes:n The level of control is based on the
most severe impairment or risk category. Assess impairmentdomain by patient’s or caregiver’s recall of previous 2–4 weeks.Symptom assessment for longerperiods should reflect a globalassessment, such as whether the patient’s asthma is better orworse since the last visit.
n At present, there are inadequatedata to correspond frequencies ofexacerbations with different levels ofasthma control. In general, morefrequent and intense exacerbations(e.g., requiring urgent, unscheduledcare, hospitalization, or ICU admission) indicate poorer disease control.
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sthma
FIGURE 13. STEPWISE APPROACH FOR MANAGING ASTHMA LONG TERM IN CHILDREN, 0–4 YEARS OF AGE AND 5–11 YEARS OF AGE
Oral corticosteriodsICS
LABA orMontelukast
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FIGURE 14. CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS 12 YEARS OF AGE AND ADULTS
Assessing severity and initiating treatment for patients who are not currently takinglong-term control medications
Key: EIB, exercise-induced bron-chospasm, FEV1, forced expiratory volume in 1 second; FVC, forced vitalcapacity; ICU, intensive care unit
Notes:• The stepwise approach is meant to
assist, not replace, the clinical decisionmaking required to meetindividual patient needs.
• Level of severity is determined byassessment of both impairment andrisk. Assess impairment domain bypatient’s/caregiver’s recall of previous 2–4 weeks and spirometry.Assign severity to the most severecategory in which any featureoccurs.
• At present, there are inadequatedata to correspond frequencies ofexacerbations with different levels of asthma severity. In general, morefrequent and intense exacerbations(e.g., requiring urgent, unscheduledcare, hospitalization, or ICU admission) indicate greater underlying disease severity. Fortreatment purposes, patients whohad ≥2 exacerbations requiring oralsystemic corticosteroids in the pastyear may be considered the same as patients who have persistentasthma, even in the absence ofimpairment levels consistent withpersistent asthma.
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FIGURE 15. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS ≥12 YEARS OF AGE AND ADULTS
*ACQ values of 0.76–1.4 are indeterminate regarding well-controlled asthma.Key: EIB, exercise-induced bronchospasm; ICU, intensive careunit
Notes:
• The stepwise approach is meant to assist, not replace,the clinical decisionmaking required to meet individual patient needs.
• The level of control is based on the most severe impair-ment or risk category. Assess impairment domain bypatient’s recall of previous 2–4 weeks and by spirometry/or peak flow measures. Symptom assessmentfor longer periods should reflect a global assessment, suchas inquiring whether the patient’s asthma is better orworse since the last visit.
• At present, there are inadequate data to correspond fre-quencies of exacerbations with different levels of asthmacontrol. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care,hospitalization, or ICU admission) indicate poorer diseasecontrol. For treatment purposes, patients who had ≥2exacerbations requiring oral systemic corticosteroids in thepast year may be considered the same as patients whohave not-well-controlled asthma, even in the absence ofimpairment levels consistent with not-well-controlled asthma.
ACT = Asthma Control Test™ Minimal Important Difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT.
Before step up in therapy:
— Review adherence to medication, inhaler technique,environmental control, and comorbid conditions.
— If an alternative treatment option was used in a step,discontinue and use the preferred treatment for that step.
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FIGURE 16. STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS ≥12 YEARS OF AGE AND ADULTS
Key: Alphabetical order is used when more than onetreatment option is listed within either preferred oralternative therapy. ICS, inhaled corticosteroid; LABA, long-acting inhaled beta2-agonist; LTRA, leukotriene receptorantagonist; SABA, inhaled short-acting beta2-agonist
Notes:
• The stepwise approach is meant to assist, not replace, theclinical decisionmaking required to meet individual patientneeds.
• If alternative treatment is used and response is inadequate,discontinue it and use the preferred treatment before stepping up.
• Zileuton is a less desirable alternative due to limited studies as adjunctive therapy and the need to monitor liver function. Theophylline requires monitoring of serumconcentration levels.
• In step 6, before oral corticosteroids are introduced, a trialof high-dose ICS + LABA + either LTRA, theophylline, orzileuton may be considered, although this approach hasnot been studied in clinical trials.
• Step 1, 2, and 3 preferred therapies are based on EvidenceA; step 3 alternative therapy is based on Evidence A forLTRA, Evidence B for theophylline, and Evidence D forzileuton. Step 4 preferred therapy is based on Evidence B,and alternative therapy is based on Evidence B for LTRAand theophylline and Evidence D zileuton. Step 5 preferred therapy is based on Evidence B. Step 6 preferredtherapy is based on (EPR—2 1997) and Evidence B for omalizumab.
• Immunotherapy for steps 2–4 is based on Evidence B forhouse-dust mites, animal danders, and pollens; evidence isweak or lacking for molds and cockroaches. Evidence isstrongest for immunotherapy with single allergens. The roleof allergy in asthma is greater in children than in adults.
• Clinicians who administer immunotherapy or omalizumabshould be prepared and equipped to identify and treat anaphylaxis that may occur.
