PEDIATRIC ASTHMA GUIDELINES TEAM, 1998 REVISION
CLINICAL LEADERS
Richard Pastcan, MD: Pediatrics, Napa, Co-Chair
Laura Prager, MD, Pediatrics. Redwood City, Co-Chair
CPG TEAM
Thomas Duprey, RPh, MPA: Pharmacy Operations
Harold I. Farber, MD: Pediatrics, Vallejo
Al Haas, MD: Allergy. Santa Rosa
Albin Leong. MD: Pediatrics, Sacramento
Tracy Lieu. MD, MPH: Division of Research
Guillermo Mendoza. MD: Allergy, Vacaville
Diana Powell, B.A. RCP, RRT: Medicine, Santa Teresa
Greg Shay, MD: Pediatrics, Oakland
Jennifer Torresen, MPH: Regional Health Education
CaskeyWeston. RN; Pediatrics, Oakland
REVIEWERS
Gordon Garcia. MD: Allergy, South Sacramento
Gabriel Pino, MD: Pediatrics, Fresno
David Nunez. MD: Pediatrics, San Francisco
Patricia Sullivan, MD: Pediatrics, Roseville
DATA ANALYSIS
Don Fordham, MPH, TPMG Department of Quality and Utilization
Patricia Kipnis, PhD. TPMG Department of Quality and Utilization
Timothy Ko, DrPH, TPMG Department of Quality and Utilization
PROJECT MANAGEMENT
Laura Finkler, MPH: TPMG Department of Quality and Utilization
Patti Hallam, MPH: Division of Research
Kathleen Martin: TPMG Department of Quality and Utilization
Laura Skabowski, MS: TPMG Department of Quality and Utilization
EDITING
Linda Bine. TPMG Communications
DESIGN & PRODUCTION
Gail Holan. Curvey
Produced by:
TPMG Department of Quality and Utilization
Kaiser Pennanente Northern California
1800 Harrison Street, Ste. 410, Oakland, CA 94612
510-987-2950 or tie-line 8-427-2950
To obtain more information about KPNC Clinical Practice Guidelines, printed copies, or permission to reproduce any portion, please contact the TPMG
Dept. of Quality & Utilization, or send an e-mail message to clinical.guidelines@ncal.kaiperm.org.
Within the KPNC Lotus Notes network mail to clinical guidelines or kpnc-cpg. The Clinical Practice Guidelines for the Management
of Asthma in Children are accompanied by a Tool Kit which you can request. It contains dosage charts, treatment algorithms, and practical tips to asist
clinicians in their practice. KPNC Clinical Practice Guidelines can be viewed online on the Kaiser Permanente Northern California
intranet website at hffp://clinical-library.ca.kp.org. This website is accessible only from the Kaiser Permanente computer network.

Contents 
INTRODUCTION 
NEW INFORMATION & KEY
DIFFERENCES FROM
THE 1995 GUIDELINE 

KEY PRINCIPLES OF PEDIATRIC ASTHMA MANAGEMENT  GOALS OF ASTHM\ MANAGEMENT 
DIAGNOSIS OF ASTHMA  ASSESSMENT & CLASSIFICATION OF DISEASE SEVERITY 
DRUG THERAPY 
LONG-TERM AND QUICK RELIEF THERAPY 

STEPWISE APPROACH TO DRUG THERAPY 

SPECIAL CONSIDERATIONS FOR INFANTS AND YOUNG CHILDREN

Figure 3: STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN MORE THAN FIVE YEARS OF AGE

Figure 4: STEPWISE APPROACH FOR  MANAGING ASTHMA IN CHILDREN  FIVE YEARS OF AGE AND YOUNGER

Figure 5: Usual Dosages for Quick-Relief and Long-Term Control Medications in Childhood Asthma

Figure 6:  Estimated Daily Dosages for Inhaled Corticosteroids in Children

CONTROL OF FACTORS CONTRIBUTING TO ASTHMA SEVERITY 
IMMUNOTHERAPY
IMMUNIZATIONS 
WRITTEN PLANS FOR ASTHMA
SELF-MANAGEMENT
EDUCATION FOR A PARTNERSHIP
IN ASTHMA CARE 
PERIODIC ASSESSMENT & MONITORING 
INDICATIONS FOR REASSESSMENT OR REFERRAL 
TREATMENT OF ACUTE EXACERBATIONS
BIBLIOGRAPHY 

Asthma severity is now classified into four categories: intermittent*, mild persistent*,
moderate persistent, and severe persistent.

KPNC Clinical Practice Guidelines can he viewed on-line on the Kaiser
Permanente Northern California intranet webbsite at http://clincal-library.ca.kp.org.

These guidelines have been developed by the Regional Pediatric Asthma Guideline Team, an
interdisciplinary group charged with developing and overseeing the implementation of
recommendations for the ambulatory treatment of children with asthma. In developing these
recommendations, team members reviewed clinical literature, existing guidelines, and
internal practices and outcomes. The approach endorsed here is based on the 1997 National
Asthma Education and Prevention Program's Guidelines for the Diagnosis and Management of
Asthma (referred to as the NIH [National Institutes of Health] Guidelines in this document) and is
consistent with other recent national and international guidelines

These Clinical Practice Guidelines will be reviewed and revised as necessary on a regular basis,
approximately every two years. Additional information on each topic can be
found in the NIH Guidelines, which are available in your facilities Health Services Library. The NIH
Guidelines can also be located on the internet at 
http://www.nhlbi.nih.gov/nhlbi/lung/asthma/prof/asthgdln.htm. 
You will need to activate the Adobe Acrobat Reader which is available at no cost
via http://www.adobe.com/prodindex/acrobat/readstep.html.

NEW INFORMATION and KEY DIFFERENCES from the 1995 GUIDELINE
There is strong evidence that asthma is a chronic inflammatory disorder of the airways,
resulting from complex interactions among inflammatory cells, mediators, and other cells
and tissues resident in the airways.

Asthma medications are now classified as either long-term control (preventer) or quick-relief
(reliever) medications. There is a stronger emphasis on the use of anti-inflammatory
medications, particularly inhaled corticosteroids, for control of persistent asthma.

There is increased emphasis on the fundamental importance of an accurate
asthma diagnosis in order to manage symptoms effectively. Asthma severity is now
classified into four categories: intermittent*, mild persistent, moderate persistent, and severe
persistent.

Education should be   integrated into every step of asthma care.

The patient's active role in managing his/her asthma is emphasized, as is the partnership
between the patient and members of the health care team.

Ongoing monitoring, including self-monitoring and self-management tools, is stressed. School
and/or child care action plans are recommended.

There is more emphasis on meeting patients' and families' expectations of their asthma care.

There are more specific recommendations for allergy testing to identify specific triggers, for
when to consider immunotherapy, and for referral to a specialist.

The NIH Guidelines refer to this category as Mild Intermittent. Because many children with
intermittent asthma can experience a moderate or severe episode, we will refer to this category as
Intermittent. Treatment is determined by severity of the episode.
 

KEY PRINCIPLES of PEDIATRIC ASTHMA MANAGEMENT
 Since asthma is a chronic disease, it is especially important that a patient have a
primary physician, or other health professional, to manage his or her health care.

Prompt reassessment of asthma management is needed after any asthma-related
hospitalization, or emergency department, after-hours, or urgent care visit.

Key educational messages should be integrated into every step of asthma care. The principal
clinician should introduce the concepts, and other members of the patient care team should
reinforce and expand on them at every opportunity (see Figure 9).

Peak flow rates should be  routinely documented in the clinic during follow-up visits when the
patient is asymptomatic. These values eventually will provide a baseline against which
peak flow changes can be compared.

Written  plans should be developed together with the family to help the patient determine: when
and how to step-up anti-inflammatory medications; when to start bursts of oral
steroids: and when to seek help. In addition to a daily self-management and action plan, a
plan should be prepared for the patient's school or child care center, emphasizing reliable and
prompt access to medications.

Appropriate anti-inflammatory management should reduce symptoms and decrease the need
for bronchodilators (inhaled, short-acting beta-agonists).

Spacer devices are recommended for children using metered-dose inhalers (MDI). The patient
should rinse his or her mouth after using

Monitoring the patient's inhalation  technique is an essential part of the asthma visit.

Response to therapy should be carefully monitored. If clear benefit is not observed,
alternative therapies should be attempted, or other diagnoses, such as chronic sinusitis,
should be considered.

Once control of asthma symptoms is established and sustained, a careful step-down in therapy
should be attempted.

Allergic and irritant triggers play a prominent role for most children with daily asthma, as
well as for those with seasonal asthma. Environmental controls are important in the
long-term management of asthma, as they can decrease the need for medications.

Prompt reassessment of asthma management is needed after any
asthma-related hospitalization. or ernergency department.
after-hours, or urgent carevisit.

Spacer devices are recommended for children using metered-dose inhalers (MDI).

It is possible for most children with asthma to lead normal active lives and
avoid emergency room visits and hospitalizations.

An important goal is to eliminate, or reduce to a minimum, the need for
daily, short-acting beta-agonists (except pre-exercise).

Through an increased reliance on anti-inflammatorv medications and an emphasis on
environmental control and patient self-management, it is possible for most children with
asthma to lead normal, active lives and avoid emergency room visits and hospitalizations.

The goals of asthma therapy are to:

Prevent symptoms that may interfere with daily living (e.g. school attendance, normal physical
activity, uninterrupted sleep)

Prevent exacerbations of asthma, minimizing the need for emergency department visits or
hospitalizations

Reduce the risk of death

Restore and maintain normal, or best possible, lung function

Restore normal peak flow variability; that is, keep morning peak flow within 80-100% of
personal best

Eliminate, or reduce to a minimum,  the need for daily, short-acting beta-agonists 
(except pre-exercise)

Provide optimal pharmacotherapy and prevent adverse effects from drug?

Empower patients/parents to manage the disease properly and effectively

Meet patients' and families' expectations of their asthma care

Symptoms of asthma can vary widely among individual patients and may mimic those present
in other disease states. An accurate diagnosis is essential to effective management. To establish a
diagnosis of asthma, the clinician should determine that:

episodic symptoms of airway obstruction are present

airflow obstruction is at least partially reversible

alternate diagnoses are excluded

Consider a diagnosis of asthma if any of the indicators in Figure I are present. These
indicators are not diagnostic by themselves, but the presence of multiple, key indicators increases
the probability of an asthma diagnosis. Spirometry or peak expiratory flow before and
after bronchodilator use helps to establish a diagnosis of asthma in Questionable cases.
 

FIGURE I, KEY INDICATORS FOR CONSIDERING A DIAGNOSIS OF ASTHMA
 Wheeling  (Note that a normal chest examination and the absence of wheezing do
not exclude asthma.) 

 History of any of the following:

Cough,  particularly  when  worse  at  night

Recurrent wheeze

Recurrent  difficulty  in  breathing

Recurrent  chest  tightness

Revenible airflow limitation and diumal variation as measured by a peak flow meter.
For example: the peak expiratory flow (PEF) measurement in the morning (before taking an
inhaled short-acting beta-agonist) varies 20% or more when compared to the PEP measurement in
the early afternoon (after taking an inhaled short-acting beta-agonist).

Symptoms occur or worsen in the presence of any of the following: 

Exercise
Viral infections
Animals with fur or feathers
House-dust mites (in mattresses, pillows, upholstered furniture, carpets)
Mold
Smoke (tobacco, wood)
Pollen
Changes in weather
Strong emotional expression (laughing or crying hani)
Airborne chemicals or dust
Menses

Symptoms   occur   or  worsen   at   night,  awakening   the   patient

Eczema. hay fever, or a family history of asthma or atopic diseases are often associated with asthma, 
but they are not key indicators.

A normal chest exammation and the absence of wheezing do not exclude asthma.

It is recommended that peak flow be measured at all asthma visits,
both to track progression of the disease and to ensure that the patient
is using thepeak flow meter correctly.

ASSESSMENT and CLASSIFICATION of  DISEASE SEVERITY
The recommended therapy for asthma varies with the severity of the disease. Severity should be
assessed between flares. It can be estimated by objective criteria and/or by symptoms.

FEV₁, the forced volume of air expired from full inspiration in one second, measured with
spirometry, is considered the single best measure of airflow obstruction because it is sensitive in
both large and small airways. An alternate measure, peak expiratory flow rate (PEF or peak
flow), is only sensitive to airflow in the large airways. However, it correlates quite well with the
FEV₁ and can be assessed with a simple, readily accessible peak flow meter. A practical measure
for both home and clinician's office, peak flow rate is useful for assessing trends over time;
identifying asthma flares in their early stages; monitoring the effects of therapy; and identifying
triggers.

Peak flow tends to be lowest in the early morning and highest at midday. Daily peak flow variability
correlates well with airway hyperactivity and is an important characteristic of asthma that cannot be
assessed by a single determination of FEV₁. Aggressive asthma therapy with oral and/or
inhaled corticosteroids may be needed to establish the personal best PEF. See the Tool Kit for
Practical Advice for Treating Asthma in Children.

Tables with predicted peak flow values are available (see Tool Kit). However, it is best to rely
on the patient's own "personal best" peak flow, particularly if it is higher than the predicted value.
Appropriate management and a high index of suspicion that the child is unstable may reveal a
best peak flow value as high as 150% of the predicted value. On the other hand, when the best
peak flow is less than predicted, and there is a suspicion that best lung function has not been
achieved, it may be prudent to judge severity based on the predicted value.

It is recommended that peak flow be measured at all asthma visits, both to track progression of the
disease and to ensure that the patient is using the peak flow meter correctly. Have patients bring
their own peak flow meters to visits since different brands of peak flow meters give different readings.

An individual should be assigned to the most severe grade in which any feature occurs.

Some patients with intermittent asthma experience severe and life-threatening exacerhations separated by long 
periods of normal lung function and no symptoms.

An individual patient's classification may change over time.

Inhaled corticosteroids are the most potent of the inhaled anti-inflammatory medications.

Use of quick-relief medications more than two times a week. For symptom relief, on a regular basis, indicates that asthma
is not being well controlled. A step-up in care is recommended.

DRUG THERAPY LONG-TERM and QUICK-RELIEF THERAPY
Preliminary data suggest that appropriate control of childhood asthma may prevent more serious
asthma or irreversible obstruction in later years, and there is evidence that anti-inflammatory
treatment can reduce morbidity from wheezing in early childhood.

LONG-TERM ANTMNFIAMMATORY ("CONTROL") THERAPY
Daily use of these medications is the most effective treatment for persistent asthma.

Inhaled corticosteroidsare the most potent of the inhaled anti-inflammatory medications
currently available. Early intervention can improve asthma control, normalize lung
function, and may prevent irreversible lung injury. Inhaled corticosteroids are generally
safe and well tolerated at recommended doses. The potential, but small, risk of adverse effects
on linear growth is offset by their efficacy in long-term control. This adverse effect appears
to be dose-dependent.

In order to minimize potential local side effects, all patients using inhaled stenrids should
use spacer devices. They improve delivery of medication and reduce the incidence of oral
candidiasis. Patients should always rinse their mouths after the dose is administered, and use 
the lowest possible dose to maintain control.

Cromolyn  sodium  or nedocromil is often considered as initial therapy for mild persistent
asthma in children, because of its safety profile. Their disadvantage is that they have a
less predictable clinical response, and may require administration up to four times per day.

Home nebulizers may be an alternative for managing children who cannot coordinate
inhalers and for some patients with severe asthma. However, three to four consecutive, inhaler/spacer
bronchodilator treatments may be equivalent to nebulizer treatments in most patients. (Additional
puffs may be required.)

OTHER LONG-ACTING MEDICATIONS

Long-acting  beta-agonists  (e.g., salmeterol) and methyixanthines (e.g., theophylline) may
be used in children as adjuncts to anti-inflammatory therapy for long-term control.
They are especially appropriate to treat nocturnal symptoms and to prevent exercise-
induced bronchospasm. They should never be used as quick-relief medications.

Lenkotriene  modifiers  (e.g.,  montelukast, zafirlukast) are promising long-term drugs.
However, there is insufficient clinical experience and data to indicate specific recommendations
for their role in asthma therapy. These medications should be used in consultation
with a specialist. For more specific information, please refer to the NIH Guidelines.

QUICK-RELIEF MEDICATIONS ("RELIEVERS")
Quick-relief medications include short-acting, inhaled beta-agonists and systemic
corticosteroids. Anticholinergic drugs, such as ipratropium bromide are also used 
in special circumstances. Relievers are used for prompt treatment of acute airway obstruction.
Use of quick-relief medications more than two times a week, for symptom relief on a regular
basis, indicates that asthma is not well controlled. A step-up in care is recommended.
 

STEPWISE APPROACH to DRUG THERAPY

The amount and frequency of medication is determined by the asthma severity and is directed
toward suppression of airway inflammation. Continual monitoring is essential to ensure that
asthma control is achieved and maintained. Figures 3 and 4 present this approach.

GAINING CONTROL

The preferred approach is to begin with more intensive therapy to achieve rapid control, and
then to step-down to the minimum therapy to maintain control. A higher level of therapy can
be achieved by either adding a course of oral corticosteriods to inhaled corticosteroids,
cromolyn, or nedocromil, or by using a higher dose of inhaled steroids.

Alternatively, treatment can start at the step appropriate to the severity of the patient's
asthma at the time of evaluation. If control is not achieved, step up the therapy until it is
achieved and maintained.

MAINTAINING CONTROL

be needed. Follow-up visits every one to six months, depending upon disease severity, are
essential for monitoring asthma.

Patients and/or parents should be instructed to monitor symptoms and/or peak flow, and to
adjust the therapy according to the asthma action plan.

STEP-DOWN: After several weeks to months of stable asthma, a reduced, gradual "step-down"
in treatment should be considered.

STEP-UP: Poor asthma control indicates a need for increased or "step-up" therapy.
Consider alternative reasons for poorly controlled asthma before increasing
medications. Reasons may include poor inhaler technique, non-adherence to therapy.
environmental factors, and coexisting or alternative diagnoses (such as chronic
sinusitis). Specialty consultation or co-management with a specialist may be
appropriate.

At any step,  a rescue course of systemic corticosteroids and increased bronchodilator
therapy may be required for acute, severe exacerbations.

SPECIAL CONSIDERATIONS INFANTS and YOUNG CHILDREN

Asthma is frequently underdiagnosed and undertreated in infants and young children.

Alternative diagnoses such as foreign body aspiration, respiratory tract illness, congenital
airway abnormality, cystic fibrosis, and gastroesophageal reflux should be
considered if no clear benefit from asthma medication is observed.

Viral  respiratory infection is the most common cause of asthma symptoms in young children.
Oral corticosteroids should be considered in moderate to severe exacerbations. For patients
with a history of severe exacerbations due to viral infections, consider corticosteroids at the
onset of viral infection.

The ability of young children to use inhaled medications varies widely. In general,
nebulizer therapy is preferred for the administration of cromolyn or high doses of
short-acting beta-agonists for children less than two years of age. A metered-dose inhaler (MDI)
with a face mask spacer device may be used to administer inhaled steroids.

Aerosolized nasal steroid solutions are not advised, due to questions about the effects of
additive agents, and lack of data on safety and efficacy.

The preferred approach is to begin with more intensive therapy
to achieve rapid control, and then to step-down to the minimum
therapy to maintain control.

Note: Available data from clinical and in-vitro studies indicate that the different inhaled corticostcroid
preparations are not equivalent on a per microgram or per puff basis.  Based on currently available data, the
NIH Guidelines indicate that

Beclomethasone and budesonide are comparable at similar microgram doses by UDI.

Budesonide  achieves  effects at twice the  dose  of triamcinolone  on  a microgram  basis.

Fluticasone achieves effects similar to twice the dose of Beclomethasone and Budesonide via MDI on a
microgram basis.

For many patients, a twice-a-day dosing schedule maintains control of asthma: even high doses of some
preparations are effective when given twice a day.  Some studies show that once-daily dosing is effective in
mild persistent asthma.
 

Approximate Comparison of Inhaled Corticosteroids:
1 puff Flovent
(110 mcg)
= 4 puffs Beclovent
(42 mcg)
= 4 puffs Azmacort
(100 mcg)

Aerosolized nasal steroid solutions are not advised, due to questions about
the effects of additive agents, and lack of data on safety and efficacy.
 

Reducing exposure to factors that may precipitate or aggravate exacerhations
is an important component in the management of asthma.

Children with daily or seasonal asthma are very likely to be allergically triggered, whereas those with
purely intermittent asthma are more likely to be either non-allergic and/or primarily triggered by upper
respiratoy infections. Confirmation of allergies by in vivo or in vitro methods is likelv to improve
compliance by focusing on allergens which are clinically relevant to the child's specific triggers.
 

The clinician should do the following for patients with persistent asthma on daily medication, and
consider these measures for patients with less serious disease:

identify allergen exposures

use the patient's history to assess sensitivity to seasonal allergens

use skin testing or in vitro testing to assess sensitivity to perennial indoor allergens

assess the significance of positive tests in context of the patient's medical history

consider a consultation with an allergist

Allergic rhinitis is a common trigger for asthma.

Simple environmental controls may significantly reduce asthma symptoms
or exacerhations.

Influenza mid varicella vaccines should be considered for
patients with asthma.

Written asthma action plans should be given to
all patients/parents with frequent or persistent asthma.
 

IMMUNOTHERAPY
Immunotherapy can either prevent or delay the development of airway hyperreactivity in non-
asthmatic allergic patients, or it can reduce hyperreactivity in patients with established
asthma. The following asthma patients are most likely to respond to immunotherapy:

patients with mild levels of asthma

patients with a relatively small number of well-characterized allergenic triggers for which high
quality antigens are available

Allergy shots can be considered as an adjunct to a standard, comprehensive asthma management
program when:
    there is difficulty controlling symptoms, despite avoidance measures and pharmacological
    management there is clear evidence of a relationship between symptoms and exposure to an unavoidable
    allergen such as pollen, dust mites, or animal dander

Immunotherapy is a long-term therapeutic option (three to five years), which takes about four to six
months to reduce airway hyperreactivity. Allergy consultation can help the patient understand the
risks and benefits of immunotherapy.

IMMUNIZATIONS

An influenza vaccine is recommended for children six months of age and older who have
needed regular medical follow-up and/or have been hospitalized in the previous year. The
vaccine should be given yearly in the fall.

Varicella vaccination is recommended for patients with asthma who have not experienced
natural infection. Because of safety concerns, live virus vaccines like varicella should not be
given during use of high dosage systemic corticosteroids:

<> for children <10 kg, >2 mg/kg/d
<> for children ³.l0 kg, 20 mg/d or qod of prednisone

WRITTEN ASTHMA PLANS for SELF-MANAGEMENT
Because even simple and effective verbal asthma instructions may be forgotten after a clinic visit,
written asthma action plans should be given to all patients/parents with frequent or persistent
asthma.

An Asthma Action Plan should be developed in consultation with the parent and/or patient. It
should address:

early recognition of worsening control

self-administered step-up in therapy

when to start bursts of oral steroids and when to seek help

Action plans can be based on peak flow values or on symptoms, depending upon the age of the
patient and his or her ability to notice and report symptoms consistently. Symptom-based plans
should be used with children under five years of age, because they generally cannot use a peak
flow meter reliably. Symptom-based plans also may be adequate for children with mild asthma
who are good at perceiving symptoms. Other children do best with peak-flow based plans. (A
sample plan is included in the Tool Kit.)

Ideally, children with intermittent asthma should be provided with written contingency plans to deal
with exacerbations. At a minimum, children with intermittent asthma and a history of an
emergency department visit or hospitalization should have a written plan, with a copy kept on-
site at the child's school or child-care center.

In consultation with the family, the clinician also can develop an individualized Self-Management
Plan listing treatment goals, activities needed to achieve them (such as environmental control),
and recommended doses and frequencies of daily medications.

EDUCATION for a PARTNIRSHIP in ASTHMA CARE
Current management approaches require patients and families to carry out complex pharmacologic
regimens effectively, institute environmental control strategies, detect and self-treat most
asthma exacerbations, and communicate appropriately with physicians and other health
care professionals. Education is a powerful tool for helping patients and parents gain the motivation,
skill and confidence to control the disease.

STRATEGIES for ENHANCING DELIVERY of PATIENT EDUCATION 

DEVELOP TREATMENT GOALS JOINTLY
Establish a partnership with patients, parents, and members of the health care team for all aspects of
care. Ask how asthma interferes with the patient's life and incorporate the responses into personal
treatment goals. (Use the Goals on page 4 to guide development of the patient's personal list.)

PROVIDE TOOLS FOR SELF-MANAGEMENT
Make the written, daily self-management plan and action plans simple and realistic for the patient to
follow. Give patients simple, brief, written materials that reinforce the actions recommended
and the skills taught.

ENCOURAGE ADHERENCE

Elicit patient concerns early in each visit.

Encourage family involvement.

Some patients require referral for asthma case management.

Assess the patient's and family's perceptions of the severity level of the disease, and their level
of social support. Evaluate any socioeconomic barriers to patient compliance with the medical
regimen, such as separate households, lack of drug coverage, misunderstandings about the
treatment plan, or other issues.

Consider referral to a behavioral medicine specialist or other licensed professional when
stress seems to interfere unduly with daily asthma management.

TAILOR EDUCATION TO THE NEEDS OF THE PATIENT
 Assess cultural or ethnic beliefs or practices that may influence self-management activities and
modify educational approaches as needed. Discuss topics in the patient's preferred
language and supply materials in that language, as available.

Consider referral to an asthma education class.

Education is a powerful tool for helping patients and parents gain the motivation,
skill and confidence to control the disease.

Evaluate any socioeconomic barriers to patient compliance with the medical regimen,
such as separate households, lack of drug coverage, misunderstandings about
the treatment plan, or other issues.

The CIPS
(the Clinical Information Presentation System) can help you to identify
asthma visits as an aid to tracking patient history.

Patient use of medications can be monitored by using Kaiser Permanente
Northern California's PIMS (Pharmacy Information Management System) database.
 

MAINTAIN THE PARTNERSHIP

Educational efforts should be continuous. Review key educational messages and skills
periodically, because patient self-management behavior is likely to decline over time.

Review short-term goals, the daily self-management plan and the steps the patient
was to take; adjust plans every one to six months.

SUPPLEMENT PATIENT EDUCATION DELIVERED BY CLINICIANS

Asthma education programs, such as the Health Skills for Pediatric Asthma program, should be
offered to all patients. Encourage participation in smoking cessation programs if appropriate. Give
patients information about educational and support services available locally.

PERIODIC ASSESSMENT and MONITORING
The 1997 NIH Guidelines recommend that periodic assessments be performed for optimal
management of asthmatic patients. Six domains of patient health have been identified that
correspond to the goals of therapy:

Signs and symptoms

Pulmonary function

Quality of life

History of exacerbations

Pharmacotherapy
Adherence to the management and action plans

Inhaler technique
Use of short acting beta-agonists
Frequency of corticosteroid bursts
Changes in long-term control medicines
Side effects of medications
Patient's and or parents' satisfaction with their asthma care

INDICATIONS or REASSESSMENT OR REFERRAL
The following are indications for a major reassessment of either the patient's status or
treatment program. Consider a consultation with an allergist or pulmonologist if any of the
following are true:

The patient has had a life-threatening asthma exacerbation.

The patient has severe persistent asthma, or requires continuous oral corticosteroid therapy
or high-dose inhaled corticosteroids.

An infant or toddler requires daily inhaled or oral corticosteroids.

The patient is not meeting the goals of asthma therapy after three to six months of treatment.

An earlier referral or consultation is appropriate if the physician concludes that the
patient is unresponsive to therapy.

Signs and symptoms are atypical, or there are problems in differential diagnosis.

Other conditions complicating asthma or its diagnosis are present, such as nasal polyps,
allergic bronchopulmonary aspergillosis, severe rhinitis, vocal cord dysfunction, or
gastroesophageal reflux.

Additional diagnostic testing is indicated, such as allergy skin testing, rhinoscopy, complete
pulmonary function studies, exercise challenge, or bronchoscopy.

The patient requires additional education and guidance on complications of therapy, or
problems with adherence or allergen avoidance, and these needs are not being met
by other available resources.

The patient is being considered for immunotherapy.

The parent requests a consultation.

TREATMENT of ACUTE EXACERBATIONS KEY PRINCIPLES
Exacerbations of asthma are acute or sub-acute episodes of progressively worsening shortness of
breath, coughing, wheezing, chest tightness, or some combination of these symptoms.

Management of acute asthma exacerbations includes:

 inhaled beta-agonist to provide prompt relief ofairflow obstruction
systemic corticosteroids for moderate-to-severe exacerbations, to suppress and reverse airway inflammation

oxygen to relieve hypoxemia

monitoring response to therapy with serial measurements of lung function

education about managing acute exaceibations in the home

a plan for follow-up care and education

ASSESSMENT
Assessment is required before, during, and after treatment. The history should note current
medications, onset and possible cause(s) of the exacerbation, as well as history of risk factors.

The severity of an asthma flare when wheezing is absent is often underestimated.  Patients
with severe or life-threatening asthma, especially infants, may not have all of the
symptoms and signs of severe asthma.

Infants and young children are at greater risk of respiratory failure. Use of accessory muscles,
paradoxical breathing, cyanosis, and a respiratory rate greater than 60 breaths/minute
are key signs of serious distress. Impending or present respiratory failure require rapid
treatment and admission for intensive care.

An objective measure of lung function  (peak flow, FEV₁) should be attempted in any child
over five years of age. These measurements should be compared to the child's persona] best
peak flow or a PEF standards chart.

Hypoxemia is often  underappreciated.   Oxygen saturation should be quickly assessed and
monitored. An oxygen saturation of less than 91% may indicate serious distress. A
determination of arterial blood gas (ABG) should be considered if the oxygen saturation is
significantly less than 90%, if very high oxygen is required, or if the child is responding poorly
to treatment.

A chest x-ray should be obtained only if complications such as atelectasis, air leak, or
pneumonia are suspected.

TREATMENT
The primary therapies are: administration of oxygen, inhaled beta-agonists, and corticosteroids.
The dosage and frequency of administration may vary.

Oxygen  should be  administered to patients with hypoxemia to maintain an oxygen saturation
of greater than 90%. It should be continued until a clear response to the bronchodilators is
seen. There is no need to obtain an ABG determination or pulse oximetry reading before
instituting oxygen therapy in the acute setting.

For patients with a severe exacerbation, give the inhaled beta-agonist at a higher dose (see
Management of Asthma Eracerbations in the Tool Kit) either repeatedly every 20 minutes, or
continuously. Give corticosteroids immediately. Nebulized therapy is preferred in patients whose
exacerbations are severe or who cannot coordinate inhalation using the MDI.

Studies have shown that equivalent bronchodilation can also be achieved in
cooperative patients with higher doses of metered-dose inhalers by using a spacer, under
the supervision of trained personnel (see Figures 5 and 6).

Anticholinergics should be considered in children with a severe exacerbation.
Ipratroprium bromide (0.25 mg/ml) added to the aerosolized beta-agonist has been shown to
provide additional bronchodilation (see Management of Asthma Exacerbations in
the Tool Kit).

Patients with severe or life-threatening asthma, especially infants,
may not have all of the symptoms and signs of severe asthma.

A chest x-ray should he obtained only if complications such as
atelectasis. air leak, or pneumonia are suspected.

Signs of active varicella infection in a child recently or currently
taking high doses of oral steroids should prompt consideration for
the use of acyclovir.

The written discharge treatment plan should outline the medications,follow-up plan.
and indications for return.

FIGURE 10. RISK FACTORS FOR DEATH FROM ASTHMA

History of sudden, severe exacerbations

Frequent recent visits

Paroxysmal episodes, especially nocturnal

History of hospitalization or emergency room visit within the past year

Prior intubation or respiratory failure due to asthma

Use of >2 canisters per month of inhaled, short-acting beta-agonist

Current or recent use of, or withdrawal from systemic corticosteroids

Difficulty perceiving airflow obstruction or its  severity

Co-morbidity from underlying cardio-pulmonary disease

History of panic attacks or premonitions of death

Psychiatric or psychosocial problems

Low socioeconomic status and urban residence

Noncompliance with asthma medication plan

 Give systemic steroids by the intravenous or intramuscular route only when the patient is vomiting.

In the patient with severe asthma and incomplete response to therapy who will
probably need admission, consider starting continuous nebulization therapy. Begin at 0.5
mg/kg/hour of albuterol. with a maximum of 15mg/hour. (Higher doses may be required in
consultation with a specialist or intensivist.) While providing continuous albuterol,
administer oxygen to maintain oxygen saturation at or above 95%.

Additional considerations

Initiating methyixanthines is not generally recommended in the acute setting.

Signs of active varicella infection in a child recently or currently taking high doses
of oral steroids should prompt consideration for the use of acyclovir. When possible, the
acyclovir should be started within 24 hours of the onset of the rash. Parents of children
taking oral steroids should be advised to notify their physician if their child is exposed
to, or comes down with varicella.

Sedation or narcotic antitussives are contraindicated during an exacerbation, as
they may mask signs of respiratory failure, or result in respiratory depression.

DISCHARGE

Discharge from the clinic or emergency department following treatment of an acute
exacerbation is considered when a good response to bronchodilator therapy is noted. It is
recommended that a written plan be provided to the patient and a follow-up appointment
arranged. A Peak Flow meter and spacer device should be prescribed, if needed. The written
discharge treatment plan should outline the medications, follow-up plan, and indications for
return.

BIBLIOGRAPHY

(Sources used since 1995 edition)
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the Committee on Infectious Diseases, 24th ed. Elk
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