___________________________________________________________ Asthma: Diagnosis and Management
The goal of each step of treatment is to prevent asthma symptoms and provide the best therapy for the patient. Physicians and other healthcare providers may differ in their “step” approach to medication prescriptions. Some may treat symptoms with the weakest medications for a specific step and add stronger medications if symptoms are difficult or persist; others may prefer to rapidly control symptoms and then reduce medications to the smallest effective doses. The NAEPP recommends the step-down approach to managing asthma symptoms (if asthma is well controlled for at least three consecutive months) [9; 10]. In any case, the goal of the treatment plan should be expressed to the patient and outlined clearly, to ensure the best patient adherence possible. Each step of the management plan requires a short-acting inhaled beta 2 agonist or combination inhaled corticosteroid/ formoterol for relief of sudden onset and/or infrequent symp- toms. Steps 2 (mild persistent classification) and above include long-term control measures. There are separate step plans for children 0 to 4 years of age and children 5 to 11 years of age, as will be discussed later in this course [9; 10]. Adolescents 12 years of age and older follow the plan established for adults.
Regular follow-ups are vital to monitor the progress in the management of asthma symptoms. A review of current symp- toms and improvements should be undertaken every two to six weeks initially and then every three months, depending on the patient’s condition, stage in treatment, and management process. If symptoms start to subside and appear controlled after 3 months, consider stepping down to less intense treat- ment [9; 10]. The NAEPP also recommends that any patients who require treatment for steps 4 or above be referred to an asthma special- ist. Other factors that may require referral include initiation of immunotherapy, difficulty achieving or maintaining control of asthma symptoms, or the presence of life-threatening asthma episodes. Referral to a specialist may also be considered for those who require step 3 treatment [9; 10]. Asthma biologic therapies should be considered for patients who require treat- ment at step 5 or 6. In each of the six steps, the NAEPP recommends assessment of environmental factors to provide applicable patient education and manage comorbidities.
CLASSIFICATION OF ASTHMA SEVERITY IN PATIENTS 12 YEARS OF AGE OR OLDER Component Intermittent Persistent Mild Moderate Severe Symptoms <2 days/week >2 days/week but not daily Daily Throughout the day Nighttime awakenings <2 times/month 3 to 4 times/month >1 time/week but not nightly Often every night Short-acting beta 2 agonist use for symptom control <2 days/week >2 days/week but not daily and not more than once per day Daily Several times per day
Interference with normal activity Lung function
None
Minor limitation
Some limitation
Extremely limited
Normal FEV 1 between exacerbations FEV 1 >80% predicted FEV 1 /FVC normal a
FEV 1 >80% predicted FEV 1 /FVC normal a
FEV 1 >60% predicted but <80% predicted FEV 1 /FVC a reduced 5%
FEV 1 <60% predicted FEV 1 /FVC a reduced >5%
Recommended step for initiating treatment
Step 1
Step 2
Step 3 or 4
Step 5 or 6
a Normal FEV
1 /FVC values are 85% for individuals 8 to 19 years of age; 80% for those 20 to 39 years of age; 75% for those 40
to 59 years of age; and 70% for those 60 to 80 years of age. Source: [9; 10]
Table 1
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MDVT1726
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