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At-A-Glance Asthma
Management Reference
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Revised 2009
DIAGNOSING ASTHMA
Asthma can often be diagnosed on the basis of a patients symptoms and
medical history (e.g., see below).
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ASTHMA CONTROL
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Controlled
None
Any
Nocturnal symptoms/
awakening
None
Lung function
(PEF or FEV1)
Normal
Daytime symptoms
Limitations of activities
(Al l of th e f ol low in g)
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Characteristic
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Th r e e o r m or e
fea t u r es of
pa r t ly con t r olle d
as t h m a pr e s en t
in a n y w eek *
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Any
Uncontrolled
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B. Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side-effects)
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Features that are associated with increased risk of adverse events in the future include:
Poor clinical control, frequent exacerbations in past year, ever admission to critical care for asthma, low FEV1,
exposure to cigarette smoke, high dose medications.
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* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.
By definition, an exacerbation in any week makes that an uncontrolled asthma week.
Lung function testing is not reliable for children 5 years and younger.
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DOCTOR-PATIENT PARTNERSHIP
Essential Features of the Doctor-Patient Partnership to
Achieve Guided Self-Management in Asthma
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Education
Joint setting of goals
Self-monitoring. The person with asthma is taught to combine assessment of asthma control with
educated interpretation of key symptoms
Regular review of asthma control, treatment, and skills by a health care professional
Written action plan. The person with asthma is taught which medications to use regularly and which
to use as needed, and how to adjust treatment in response to worsening asthma control
Self-monitoring is integrated with written guidelines for both the long-term treatment of asthma and
the treatment of asthma exacerbations.
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Goal: To provide the person with asthma, their family, and other caregivers with suitable information
and training so that they can keep well and adjust treatment according to a medication plan developed
with the health care professional.
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Key components:
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Diagnosis
Difference between relievers and controllers
Use of inhaler devices
Prevention of symptoms and attacks
Signs that suggest asthma is worsening and actions to take
Monitoring control of asthma
How and when to seek medical attention
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Drug factors
Difficulties with inhaler devices
Awkward regimes (e.g., four times
daily or multiple drugs)
Side effects
Cost of medication
Dislike of medication
Distant pharmacies
Non-drug factors
Misunderstanding or lack of instruction
Fears about side effects
Dissatisfaction with health care professionals
Unexpressed/undiscussed fears or concerns
Inappropriate expectations
Poor supervision, training, or follow-up
Anger about condition or its treatment
Underestimation of severity
Cultural issues
Stigmatization
Forgetfulness or complacency
Attitudes toward ill health
Religious issues
MANAGEMENT APPROACH
BASED ON CONTROL
Management Approach Based On Control
options***
Controller
modifier**
Leukotriene
ICS*
Low-dose inhaled
Select one
acting 2-agonist
As needed rapid-
theophylline
Sustained release
modifier
Leukotriene
high-dose ICS
Medium-or
long-acting 2-agonist
Low-dose ICS plus
2-agonist
ICS plus long-acting
Medium-or high-dose
select one or more
To Step 3 treatment,
Select one
treatment
Anti-IgE
(lowest dose)
Oral glucocorticosteroid
add either
To Step 4 treatment,
Step
Step
Step
Step
Treatment Steps
Reduce
Exacerbation
Step
Increase
Treat as exacerbation
esaercnI
Uncontrolled
Controlled
ecudeR
Partly controlled
Level of Control
Treatment Action
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Treatment Action
Partly controlled
Uncontrolled
Treat as exacerbation
Step
Step
Step
Increase
Step
Step
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Treatment Steps
Reduce
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Exacerbation
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Increase
Controlled
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Level of Control
Reduce
Asthma education
Environmental control
As needed rapidacting 2-agonist
Select one
To Step 3 treatment,
select one or more
To Step 4 treatment,
add either
Low-dose inhaled
ICS*
Medium-or high-dose
ICS plus long-acting
2-agonist
Oral glucocorticosteroid
(lowest dose)
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Medium-or
high-dose ICS
Leukotriene
modifier
Anti-IgE
treatment
Sustained release
theophylline
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Select one
Leukotriene
modifier**
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Controller
options***
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Alternative reliever treatments include inhaled anticholinergics, short-acting oral 2-agonists, some
long-acting 2-agonists, and short-acting theophylline. Regular dosing with short and long-acting
2-agonist is not advised unless accompanied by regular use of an inhaled glucocorticosteroid.
For guidelines on management of asthma in children 5 years and younger, please refer to the
Global Strategy for the Diagnosis and Management of Asthma in Children 5 Years and Younger,
available at www.ginasthma.org.
SEVERITY OF ASTHMA
EXACERBATIONS
Respiratory
arrest imminent
Severe
Moderate
Mild
Walking
Talking
Infant - softer,
shorter cry;
difficulty feeding
Talks in
Sentences
Phrases
Words
Alertness
May be agitated
Usually agitated
Usually agitated
Respiratory rate
Increased
Increased
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Breathless
At rest
Infant stops
feeding
Drowsy or
confused
Paradoxical
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Paradoxical
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Pulse/min.
< 100
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Moderate, often
only end
expiratory
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Wheeze
100-120
Usually Loud
Absence of
wheeze
> 120
Bradycardia
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PEF
after initial
bronchodilator
% predicted or
% personal best
PaO2 (on air)*
and/or
PaCO2*
Normal Test
not usually
necessary
< 45 mmHg
> 95%
Approximately
60-80%
> 60 mmHg
< 45 mmHg
91-95%
Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.
Initial Treatment
Oxygen to achieve O2 saturation 90% (95% in children)
Inhaled rapid-acting 2-agonist continuously for one hour.
Systemic glucocorticosteroids if no immediate response, or if patient recently took oral
glucocorticosteroid, or if episode is severe.
Sedation is contraindicated in the treatment of an exacerbation.
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Incomplete Response
within 1-2 Hours:
Risk factors for near fatal
asthma
Physical exam: mild to
moderate signs
PEF < 60%
O2 saturation not improving
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Reassess at intervals
Home Treatment:
Continue inhaled 2-agonist
Consider, in most cases, oral glucocorticosteroids
Consider adding a combination inhaler
Patient education: Take medicine correctly
Review action plan
Close medical follow-up
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>500 - 1000
>400 - 800
>160 - 320
>1000 - 2000
>250 - 500
>400 - 800
>1000 - 2000
Medium Daily
Dose (g)
Low Daily
Dose (g)
200 - 500
200 - 400
80 - 160
500 - 1000
100 - 250
200 - 400
400 - 1000
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Drug
Beclomethasone dipropionate
Budesonide*
Ciclesonide*
Flunisolide
Fluticasone
Mometasone furoate*
Triamcinolone acetonide
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*In these sections recommendations for doses of inhaled glucocorticosteroids are given as /day budesonide or equivalent, because a
majority of the clinical literature on these medications uses this standard.
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Estimated Equipotent Daily Doses of Inhaled Glucocorticosteroids for Children Older Than 5 Years
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Drug
Low Daily
Dose (g)
100 - 200
100 - 200
80 - 160
500 - 750
100 - 200
100 - 200
400 - 800
Medium Daily
Dose (g)
>200 - 400
>200 - 400
>160 - 320
>750 - 1250
>200 - 500
>200 - 400
>800 - 1200
High Daily
Dose (g)
>400
>400
>320
>1250
>500
>400
>1200
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Beclomethasone dipropionate
Budesonide*
Ciclesonide*
Flunisolide
Fluticasone
Mometasone furoate*
Triamcinolone acetonide
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The Global Initiative for Asthma is supported by educational grants from: AstraZeneca, Boehringer Ingelheim,
Chiesi Group, Cipla, GlaxoSmithKline, Meda Pharma, Merck Sharp & Dohme, Mitusubishi Tanabe, Novartis,
Nycomed, and PharmAxis.
P r in t in g a n d d is t r ib u t ion h a s b e e n m a d e p os s ib l e b y a n e d u ca t io n a l g r a n t .