






Study with the several resources on Docsity
Earn points by helping other students or get them with a premium plan
Prepare for your exams
Study with the several resources on Docsity
Earn points to download
Earn points by helping other students or get them with a premium plan
Community
Ask the community for help and clear up your study doubts
Discover the best universities in your country according to Docsity users
Free resources
Download our free guides on studying techniques, anxiety management strategies, and thesis advice from Docsity tutors
2 Nursing summary easy review fast quiz and quick
Typology: Cheat Sheet
1 / 12
This page cannot be seen from the preview
Don't miss anything!
The goal of this asthma care quick
reference guide is to help clinicians
provide quality care to people who
have asthma.
This guide summarizes recommendations developed by the
National Asthma Education and Prevention Program’s expert panel
after conducting a systematic review of the scientific literature on
asthma care. See www.nhlbi.nih.gov/guidelines/asthma for the full
report and references. Medications and dosages were updated in
September 2011 for the purposes of this quick reference guide to
reflect currently available asthma medications.
DIAGNOSING AND MANAGING ASTHMA
2
Prevent EIB. *
Teach patients to take treatment before exercise. SABAs* will prevent EIB in most patients;
LTRAs,* cromolyn, or LABAs* also are protective. Frequent or chronic use of LABA to
ICSs* are the preferred long-term control medication.
Recognize early signs, symptoms, and PEF* measures that indicate worsening asthma.
Adjust medications (increase SABA* and, in some cases, add oral systemic corticosteroids)
Treat with repetitive or continuous SABA,* with the addition of inhaled ipratropium
Medications: SABA, oral systemic corticosteroids; consider starting ICS*
Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting beta
2
-agonist; LTRA, leukotriene receptor
antagonist; PEF, peak expiratory flow; SABA, short-acting beta 2
-agonist.
Ages
0–4 years
Ages
5–11 years
Ages
12 years
Ages
0–4 years
Ages
5–11 years
Ages
12 years
Ages
0–4 years
Ages
5–11 years
Ages
12 years
Ages
0–4 years
Ages
5–11 years
Ages
12 years
Symptoms
2 days/week
2 days/week but not daily
Daily
Throughout the day
Nighttime awakenings
2x/month
1–2x/month
3–4x/month
3–4x/month
1x/week but not nightly
1x/week
Often 7x/week
use for
symptom control (not to prevent EIB
2 days/week
2 days/week
but not daily
2 days/week but
not daily and not more
than once on any day
Daily
Several times per day
Interference with normal activity
None
Minor limitation
Some limitation
Extremely limited
Lung function
FEV
1
(% predicted)
FEV
1
/FVC
Not
applicable
Normal FEV
1
between
exacerbations
Normal FEV
1
between
exacerbations
Normal
Not
applicable
Normal
Not
applicable
Reduced 5%
Not
applicable
Reduced >5%
Asthma exacerbations requiring oral systemic corticosteroids
0–1/year
2 exacerb.
in 6 months, or wheezing
4x
per
year lasting
1 day
AND risk
factors for persistent
asthma
2/year
Consider severity and interval since last asthma exacerbation. Frequency and severity may fluctuate over time for patients in any severity category.
Relative annual risk of exacerbations may be related to FEV
1
Recommended Step for Initiating Therapy (See “Stepwise Approach for Managing Asthma Long Term,” page 7) The stepwise approach is meant to help, not replace, the clinical decisionmaking needed to meet individual patient needs.
Step 1
Step 2
Step 3
Step 3
medium-dose
option
Step 3
Step 3
Step 3
medium-dose
option
or Step 4
Step 4
or 5
Consider short course of oral systemic corticosteroids.
In 2–6 weeks, depending on severity, assess level of asthma control achieved and adjust therapy as needed.
For children 0–4 years old, if no clear benefit is observed in 4–6 weeks, consider adjusting therapy or alternate diagnoses.
Abbreviations:
EIB, exercise-induced bronchospam; FEV
1
, forced expiratory volume in 1 second; FVC, forced vital capacity; ICS, inhaled corticosteroid; SABA, short-acting beta
2
-agonist.
Normal FEV
1
/FVC by age: 8–19 years, 85%; 20–39 years, 80%; 40–59 years, 75%; 60–80 years, 70%.
Data are insufficient to link frequencies of exacerbations with different levels of asthma severity. Generally, more frequent and intense exacerbations (e.g., requiring urgent care, hospital or intensive care admission, and/or oral corticosteroids) indicate greater underlying disease severity. For treatment purposes, patients with
≥
2 exacerbations may be considered to have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
Generally, more frequent and intense events indicate greater severity.
Generally, more frequent and intense events indicate greater severity.
At each step: Patient education, environmental control, and management of comorbidities
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 3 care or higher is required. Consider consultation at step 2.
Preferred
Treatment
SABA as
needed
low-dose ICS medium-dose
medium-dose
either LABA or
montelukast
high-dose ICS
either LABA or
montelukast
high-dose ICS
either LABA or
montelukast
oral corticosteroids
Alternative
Treatment
,
‡
cromolyn or
montelukast
If clear benefit is not observed in 4–6 weeks, and medication technique and adherence are satisfactory,
consider adjusting therapy or alternate diagnoses.
Quick-Relief
Medication
course of oral systemic corticosteroids if asthma exacerbation is severe or patient has history of severe exacerbations.
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.
Preferred
Treatment
SABA as needed low-dose ICS low-dose ICS
either LABA,
LTRA, or
theophylline
(b)
medium-dose
medium-dose
high-dose ICS
high-dose ICS
oral corticosteroids
Alternative
Treatment
,
‡
cromolyn, LTRA,
or theophylline
§
medium-dose ICS
either LTRA or
theophylline
§
high-dose ICS
either LTRA or
theophylline
§
high-dose ICS
either LTRA or
theophylline
§
oral corticosteroids
Consider subcutaneous allergen immunotherapy for
patients who have persistent, allergic asthma.
Quick-Relief
Medication
every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.
inadequate control and the need to step up treatment.
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if step 4 care or higher is required. Consider consultation at step 3.
Preferred
Treatment
†
SABA as needed low-dose ICS low-dose ICS
medium-dose ICS
medium-dose
high-dose ICS
consider
omalizumab for
patients who
have allergies
high-dose ICS
oral
corticosteroid
§§
consider
omalizumab for
patients who
have allergies
Alternative
Treatment
, ‡
cromolyn, LTRA,
or theophylline
§
low-dose ICS
either LTRA,
theophylline,
§
or zileuton
medium-dose ICS
either LTRA,
theophylline,
§
or zileuton
Consider subcutaneous allergen immunotherapy
for patients who have persistent, allergic asthma.
Quick-Relief
Medication
every 20 minutes as needed. Short course of oral systemic corticosteroids may be needed.
and the need to step up treatment.
Abbreviations: EIB, exercise-induced bronchospasm; ICS, inhaled corticosteroid; LABA, inhaled long-acting beta 2
-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled
short-acting beta 2
-agonist.
† Treatment options are listed in alphabetical order, if more than one.
If alternative treatment is used and response is inadequate, discontinue and use preferred treatment before stepping up.
§ Theophylline is a less desirable alternative because of the need to monitor serum concentration levels.
Based on evidence for dust mites, animal dander, and pollen; evidence is weak or lacking for molds and cockroaches. Evidence is strongest for immunotherapy with single allergens.
The role of allergy in asthma is greater in children than in adults.
Clinicians who administer immunotherapy or omalizumab should be prepared to treat anaphylaxis that may occur.
Zileuton is less desirable because of limited studies as adjunctive therapy and the need to monitor liver function.
§§ Before oral corticosteroids are introduced, a trial of high-dose ICS + LABA + either LTRA, theophylline, or zileuton, may be considered, although this approach has not been studied
in clinical trials.
40 mcg/puff 80 mcg/puff
80–160 mcg
1–2 puffs
2x/day
1 puff 2x/day
160–320 mcg
3–4 puffs
2x/day
2 puffs 2x/day
320 mcg
3 puffs 2x/day
80–240 mcg
1–3 puffs
2x/day
1 puff am,
2 puffs pm
240–480 mcg
4–6 puffs
2x/day
2–3 puffs
2x/day
480 mcg
4 puffs
2x/day
Budesonide DPI
90 mcg/inhalation 180 mcg/ inhalation
180–360 mcg
1–2 inhs
2x/day
360–720 mcg 3–4 inhs
2x/day
2 inhs
2x/day
720 mcg
3 inhs
2x/day
180–540 mcg
1–3 inhs
2x/day
1 inh
am,
2 inhs
pm
540–1,080 mcg 2–3 inhs
2x/day
1,080 mcg
4 inhs
2x/day
Budesonide Nebules 0.25 mg 0.5 mg 1.0 mg
0.25–0.5 mg
1–2 nebs
/day
1 neb
/day
0.5–1.0 mg 2 nebs
/day
1 neb
/day
1.0 mg
3 nebs
/day
2 nebs
/day
0.5 mg
1 neb
2x/day
1 neb
/day
1.0 mg
1 neb
2x/day
1 neb
/day
2.0 mg
1 neb
2x/day
Ciclesonide MDI
80 mcg/puff 160 mcg/puff
80–160 mcg
1–2 puffs/day
1 puff/day
160–320 mcg
1 puff am,
2 puffs pm–
2 puffs 2x/day
1 puff 2x/day
320 mcg
3 puffs 2x/day
2 puffs 2x/day
160–320 mcg
1–2 puffs 2x/day
320–640 mcg 3–4 puffs 2x/day
2 puffs 2x/day
640 mcg
3 puffs 2x/day
Flunisolide MDI
80 mcg/puff
160 mcg
1 puff 2x/day
320–480 mcg
2–3 puffs 2x/day
480 mcg
4 puffs 2x/day
320 mcg
2 puffs 2x/day
320–640 mcg 3–4 puffs 2x/day
640 mcg
5 puffs 2x/day
It is preferable to use a higher mcg/puff or mcg/inhalation formulation to achieve as low a number of puffs or inhalations as possible.
Abbreviations:
DPI, dry powder inhaler (requires deep, fast inhalation); inh, inhalation; MDI, metered dose inhaler (releases a puff of medication); neb, nebule.
2
Fluticasone/Salmeterol —
100 mcg/50 mcg, 250 mcg/50 mcg, or
500 mcg/50 mcg
45 mcg/21 mcg, 115 mcg/21 mcg, or
230 mcg/21 mcg
Budesonide/Formoterol —
80 mcg/4.5 mcg or 160 mcg/4.5 mcg
Mometasone/Formoterol —
100 mcg/5 mcg
1 inhalation 2x/day; dose
depends on level of
severity or control
2 puffs 2x/day; dose
depends on level of
severity or control
1 inhalation 2x/day; dose
depends on level of severity
or control
2 puffs 2x/day; dose depends
on level of severity or control
2 inhalations 2x/day; dose
depends on severity of asthma
Leukotriene Receptor Antagonists (LTRAs)
Montelukast — 4 mg or 5 mg chewable tablet,
4 mg granule packets, 10 mg tablet
Zafirlukast — 10 mg or 20 mg tablet
Take at least 1 hour before or 2 hours after a meal.
Monitor liver function.
5-Lipoxygenase Inhibitor
Zileuton — 600 mg tablet
Monitor liver function.
4 mg every night at
bedtime (1–5 years of age)
5 mg every night at
bedtime (6–14 years of age)
10 mg 2x/day
(7–11 years of age)
10 mg every night at
bedtime
40 mg daily
(20 mg tablet 2x/day)
2,400 mg daily
(give 1 tablet 4x/day)
Omalizumab (Anti IgE
Subcutaneous injection, 150 mg/1.2 mL following
reconstitution with 1.4 mL sterile water for injection
Monitor patients after injections; be prepared to treat
anaphylaxis that may occur.
150–375 mg subcutaneous
every 2–4 weeks, depending
on body weight and
pretreatment serum IgE level
Cromolyn — Nebulizer: 20 mg/ampule 1 ampule 4x/day, N/A
<2 years of age
1 ampule 4x/day 1 ampule 4x/day
Theophylline —
Liquids, sustained-release tablets, and capsules
Monitor serum concentration levels.
Starting dose 10 mg/kg/
day; usual maximum:
weeks) + 5 = mg/kg/day
16 mg/kg/day
Starting dose 10 mg/
kg/day; usual maximum:
16 mg/kg/day
Starting dose 10 mg/kg/day
up to 300 mg maximum;
usual maximum:
800 mg/day
2
for long-term control; LABA is NOT to be used as monotherapy
Salmeterol — DPI
50 mcg/blister
Formoterol —DPI
12 mcg/single-use capsule
1 blister every 12 hours
1 capsule every 12 hours
1 blister every 12 hours
1 capsule every 12 hours
Methylprednisolone — 2, 4, 8, 16, 32 mg tablets
Prednisolone — 5 mg tablets; 5 mg/5 cc, 15 mg/5 cc
Prednisone — 1, 2.5, 5, 10, 20, 50 mg tablets;
5 mg/cc, 5 mg/5 cc
in single dose in a.m.
or every other day as
needed for control
1–2 mg/kg/day, max 60
mg/d for 3–10 days
in single dose in a.m.
or every other day as
needed for control
1–2 mg/kg/day, max 60
mg/d for 3–10 days
dose in a.m. or every other
day as needed for control
achieve control, 40–60 mg/
day as single or 2 divided
doses for 3–10 days
appropriate age ranges to support their use.
† Abbreviations: DPI, dry powder inhaler; IgE, immunoglobulin E; MDI, metered-dose inhaler; N/A, not available (not approved, no data available, or safety and efficacy not
established for this age group).
The most important determinant of appropriate dosing is the clinician’s judgment of the patient’s response to therapy. The clinician
must monitor the patient’s response on several clinical parameters (e.g., symptoms; activity level; measures of lung function) and adjust
the dose accordingly. Once asthma control is achieved and sustained at least 3 months, the dose should be carefully titrated down to the
minimum dose necessary to maintain control.
2
2
2
Usual therapy included a wide range of regimens, from those in which no other daily therapy was taken to those in which varying doses of other daily medications were taken.