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Development
And Consultation
Dissemination
Target Audience
Implementation
The NCD Pilot Working Group is responsible for ensuring that this
Guideline is implemented and all required staff receives the
training in the application of the guideline.
Training
The NCD Pilot Working Group will work with health center
managers to ensure that all required staff receives appropriate
training and support in implementing this guideline.
Audit
Review
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Table of Contents
1.
Introduction .................................................................................................................................... 1
2.
3.
Definitions / Abbreviation................................................................................................................ 2
4.
5.
6.
7.
Guideline ........................................................................................................................................ 3
8.
9.
Recommendation ......................................................................................................................... 12
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Version
Paragraph No
Description of Change
Ossama Mansy
All
1.
Date Approved
Introduction
Asthma is a major cause of chronic morbidity and mortality throughput the world and there
is evidence that its prevalence has increased considerably over the past 20 years,
especially in children. According to WHO about 235 million people currently suffer from
asthma around the world. Like other countries in the world Asthma is also common in GCC,
it is particularly common among children. According to one study the prevalence of Asthma
in Qatari school children stands at around 19.8%1 which is comparatively higher than in
some of the neighboring Gulf countries. Asthma is occasionally under-diagnosed and
under-treated. It creates substantial burden to individuals and families and often restricts
individuals activities for a lifetime. Minimizing the risk factor, proactively controlling the
symptoms through medication and avoiding the triggers can result in better outcome and
quality of life for individuals suffering with the disease.
These Clinical Practice Guidelines (CPGs) and Recommendations are based upon the best
information available at the time of preparation. They are designed to provide information
and assist decision-making. They are not intended to define a standard of care, and should
not be construed as one. Neither should they be interpreted as prescribing an exclusive
course of management.
Variations in practice will inevitably and appropriately occur when clinicians take into
account the needs of individual patients, available resources, and limitations unique to an
institution or type of practice. Every health-care professional making use of these CPGs
and Recommendations is responsible for evaluating the appropriateness of applying them
in the setting of any particular clinical situation.
2.
Prevalence of Asthma Among Qatari Schoolchildren, Pediatric Pulmonology, Prevalence of Asthma Among Qatari School children
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3.
Definitions / Abbreviation
Asthma
Wheezing
Cough-variant asthma
Exercise-induced
bronchoconstriction.
Occupational asthma.
Airway Obstruction
Revisable obstruction
Exacerbation
Bronchial
hyper Where the bronchial airways are extra sensitive or hyper reactive. It is a
responsiveness
state characterized by easily triggered bronchospasm.
ACQ
ACT
C-ACT
COPD
FEV1
GCC
GINA
IgE
LABAs
PEF
PHCC
SABAs
WHO
NCD
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4.
Clinical Specialty
Allergy and Immunology
Emergency Medicine
Family Practice
Internal Medicine
Pediatrics
Pharmacology
Pulmonary Medicine
5.
Intended Users
All Health Care Providers in PHCC.
6.
Target Population
This guideline applies to all patients diagnosed with Asthma aged 5 years and above of
both genders attending PHCC health centers. Patient less than 5 years should be treated
as per the Emergency Guideline.
7.
Guideline2
7.1.
This guideline has been developed based on the Global Institute for Asthma Pocket Guide for Asthma Management and
Prevention. http://www.ginasthma.org/local/uploads/files/GINA_Pocket2013_May15.pdf
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patients own previous best measurements using his/her own peak flow
meter. An improvement of 60 L/min (or 20% of the pre-bronchodilator PEF)
after inhalation of a bronchodilator, or diurnal variation in PEF of more than
20% (with twice-daily readings, more than 10%), suggests a diagnosis of
asthma.
5. Other Tests: (if indicated and applicable)
a) Skin Prick tests with allergens or measurement of specific IgE in serum:
The presence of allergies increases the probability of a diagnosis of asthma
and can help to identify risk factors that cause asthma symptoms in individual
patients.
b) Exercise challenging test
c)
Recurrent wheeze
Exercise
Viral infection
Inhalant allergens (e.g. animals with fur or hair, house-dust mites, mold,
pollen)
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-
Changes in weather
Stress
Treatment/Management :
7.2.1. Four components considered essential to effective asthma management:
a) Obtained measures by objective tests, physical examination, patient history
and patient report can determine the characteristics and severity of asthma
and accordingly if control is achieved and maintained or not.
b) Education for a partnership in asthma care.
c) Control of environmental factors and comorbid conditions that affect asthma.
d) Pharmacologic therapy.
7.2.2. The assessment of asthma control
a) Each patient should be assessed to establish his or her current treatment
regimen, adherence to the current regimen, and level of asthma control.
b) A simplified scheme for recognizing controlled, partly controlled, and
uncontrolled asthma is provided in Table 1 below.
c) Lung function is not a reliable test for children younger than 5 years of age.
d) Measures for assessing clinical control of asthma include:
e) Asthma Control Test (ACT): www.asthmacontrol.com (Appendix 6)
f) Childhood Asthma Control test (C-Act)
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Controlled
(All of the following)
Partly Controlled
(Any
measure
presented)
Uncontrolled
Daytime symptoms
None
(twice
less/week)
More
twice/week
Limitation of activities
None
Any
Three
or
more
features of partly
controlled asthma*
Nocturnal
symptoms/awaking
None
Any
None
(twice
less/week)
Normal
or
or
More
twice/week
than
than
Assessment of Future Risk (risk of exacerbations, instability, rapid decline in lung function, side
effects)
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 FEV , exposure to cigarette smoke, high dose medications
* 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
Without administration of bronchodilator
7.2.3. Pharmacological Treatment
Management Approach based on control
a) Each patient is assigned to one of five treatment steps. Figure 1 below
details the treatments at each step for adults and children age 5 and over.
b) At each treatment step, reliever medication should be provided for quick relief
of symptoms as needed (regular or increased use indicates that asthma is not
well controlled.)
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c) At Steps 2 through 5, patients also require one or more regular controller
Inhaled glucocorticosteroids medications, which keep symptoms and
attacks from starting (see appendix 2 and appendix 3 for details).
d) For most patients newly diagnosed with asthma or not yet on medication,
treatment should be started at Step 2 (or if the patient is very symptomatic, at
Step 3). If asthma is not controlled on the current treatment regimen,
treatment should be stepped up until control is achieved.
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2. Long term control medications: According to the case and treatment flow
sheet.
a) Inhaled Corticosteroids: They are the most potent and effective antiinflammatory medication currently available.
b) Long-Acting Beta Agonists (LABAs): have duration of bronchodilation of at
least 12 hours after a single dose. LABAs are not to be used as monotherapy
for long-term control of asthma.
c) Combines. (Long acting Beta agonist & ICS).
d) Leukotriene modifiers: Are alternatives, but not necessarily preferred, therapy
for the treatment of mild persistent asthma.
e) Cromolyn sodium and nedocromil: They are used as alternative, but not
preferred, medication for the treatment of mild persistent asthma.
f) Immunomodulators: Are used as adjunctive therapy for patients 12 years of
age that have allergies and severe persistent asthma.
3. Special Considerations in Managing Asthma:
a) Pregnancy: During pregnancy the severity of asthma often changes and
patients may require close follow-up and adjustment of medications. Pregnant
patients with asthma should be advised that the greater risk to their baby lies
with poorly controlled asthma, and the safety of most modern asthma
treatments should be stressed. Acute exacerbations should be treated
aggressively to avoid fetal hypoxia.
b) Obesity: Management of asthma in the obese should be the same as patients
with normal weight. Weight loss in the obese patient improves asthma control,
lung function and reduces medication needs.
c) Rhinitis, Sinusitis, and Nasal Polyps: can often coexist in the same patient,
and treatment of rhinitis may improve asthma symptoms. Both acute and
chronic sinusitis can worsen asthma, and should be treated. Nasal polyps are
associated with asthma and rhinitis, often with aspirin sensitivity and most
frequently in adult patients. They are normally quite responsive to topical
glucocorticosteroids.
d) Respiratory infections: can provoke wheezing and increased asthma
symptoms in many patients.
e) Gastro esophageal reflux: is more common in patients with asthma
compared to the general population. However, treatments with proton pump
inhibitors, H2 antagonists or surgery fail to improve asthma control.
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f) Aspirin-induced asthma: Up to 28 percent of adults with asthma, but rarely
children, suffer from asthma exacerbations in response to aspirin and other
nonsteroidal anti-inflammatory drugs. The diagnosis can only be confirmed by
aspirin challenge, which must be conducted in a facility with cardiopulmonary
resuscitation capabilities. Complete avoidance of the drugs that cause
symptoms is the standard management.
g) Anaphylaxis: is a potentially life-threatening condition that can both mimic
and complicate severe asthma. Prompt treatment is crucial and includes
oxygen, intramuscular epinephrine, injectable antihistamine, intravenous
hydrocortisone, and intravenous fluid.
4. Establishment of Witten ASTMA ACTION PLAN
a) Like inhaler technique, asthma action plans (AAPs) are seen by many
guidelines as an essential component of asthma care. Guidelines such as
BTS/SIGN (2010) recommend AAPs for all patients who have exacerbated as
a minimum. As most patients, even those who are well controlled may
experience some loss of control 6-7 times per year (Partridge et al, 2007), this
may be interpreted as all asthma patients should have an AAP please refer to
b) Refer to My Asthma Plan in Appendix 6
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7.2.6. Manage Exacerbations: Refer to the primary urgent care guidelines.
Severity of Asthma Exacerbation:
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8.
9.
Recommendation
1) Before changing a patients treatment due to poor control try to eliminate any possible
trigger factors
2) Review inhaler use periodically, checks their compliance with medication treatment.
3) Engage and educate patients and caregivers regarding asthma management, to follow
asthma action plan.
4) Spirometry should be made available as tools for diagnosing asthma at all PHCC and
appropriate training should be provided.
10.
Guideline Linked
My Asthma Plan.
11.
Appendices
Appendix 1 Strategies for Avoiding Common Allergens and Pollutants
Appendix 2 Estimated Equipotent Daily Doses of Inhaled Glucocoticosteroids
Appendix 3 Glossary of Asthma Medications
Appendix 4 Questions for Monitoring Asthma Care
Appendix 5 Asthma Control Test (ACT)
Appendix 5 How to teach inhaler technique
Appendix 6 My Asthma Plan
12.
References
1) Prevalence of Asthma Among Qatari Schoolchildren,
Prevalence of Asthma Among Qatari School children
Pediatric
Pulmonology,
2) Global Institute for Asthma Pocket Guide for Asthma Management and Prevention.
http://www.ginasthma.org/local/uploads/files/GINA_Pocket2013_May15.pdf
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3) National Heart, Lung and Blood Institute. Expert Panel Report 3 (EPR3): Guidelines for
the Diagnosis and Management of Asthma Component 4: Medication.
http://www.nhlbi.nih.gov/guidelines/asthma/07_sec3_comp4.pdf
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Appendix 3 Glossary of
Asthma Medications
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Sodium Cromoglycate
Cromolyn
Side Effects
Comments
Tablets or syrups:
Long term use: alternate
day a.m. dosing produces
less toxicity. Short term:
3- 10 day bursts are
Tablets or syrups: Used effective for gaining
long term, may lead to prompt control.
osteoporosis,
hypertension, diabetes,
cataracts,
adrenal
suppression,
growth
suppression,
obesity,
skin thinning or muscle
weakness.
Consider
coexisting
conditions
that could be worsened
by
oral
glucocorticosteroids,
e.g.
herpes
virus
infection,
Varicella,
tuberculosis,
hypertension, diabetes
and osteoporosis.
MDI 2 mg or 5 mg 2-4 Minimal side effects. May take 4-6 weeks to
inhalations 3-4 times Cough may occur upon determine
maximum
Appendix 3 Glossary of
Asthma Medications
cromones
Nedocromil
cromones
Long-acting 2- agonists
Beta-adrenergis
Sympathomimetics
LABAs
Inhaled:
Formoterol (F)
Salmeterol (Sm)
Sustainedrelease
tablets:
Salbutamol (S)
Terbutaline(T)
Aminophylline
Methylxanthine
Xanthine
daily.
Nebulizer 20 mg 3-4
times daily
MDI 2 mg/puff 2-4
inhalations 2-4 times
daily.
Inhaled:
DPI F: 1 inhalation
(12 g) bid.
MDI F: 2 puffs bid.
DPI Sm: 1 inhalation
(50 g) bid.
MDI Sm: 2 puffs bid.
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inhalation.
Appendix 3 Glossary of
Asthma Medications
(6-14 y)
M 4 mg qhs (2-5 y)
Z 10 mg bid (7-11 y)
Immunomodulators
Omalizumab
Anti-IgE
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and
limited
case
reports of reversible
hepatitis
and
hyperbilirubinemia
with Zileuton and
hepatic failure with
afirlukast.
Adults:
Dose Pain and bruising at
administered
injection site (5-20%)
subcutaneously every and
very
rarely
2-4 weeks dependent anaphylaxis (0.1%)
on weight and IgE
concentration.
Need to be stored
under refrigeration 2-8
degree Celsius and
maximum of 150 mg
administered
per
injection site.
Formulation
Fluticasone
Propionate/
salmeterol
Fluticasone
Propionate/
salmeterol
Budesonide/
formoterol
Budesonide/
formoterol
Beclomethasone/
formoterol
Mometasone/
formoterol
Inhaler Devices
DPI
pMDI
(Suspension)
DPI
pMDI
(Suspension)
pMDI
(Solution)
pMDI
Doses Available
(g) ICS/LABA
100/50
250/50
500/50
50/25
125/25
250/25
80/4.5
160/4.5
320/9.0
100/6
200/6
Inhalations/day
1 inhalation x 2
2 inhalations x 2
Therapeutic Use
Maintenance
Maintenance
Maintenance
100/6
1-2 inhalations x
Maintenance
2
100/5
200/5
2 inhalations x 2
Maintenance
ICS = inhaled corticosteriod; LABA = long-acting 2-agonist; pDMI = pressurized metered dose inhaler; DPI
= dry powder inhaler
Appendix 3 Glossary of
Asthma Medications
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1 Refers to metered dose. For additional information about doses and products available in specific
countries, please consult www.gsk.com to find a link to your country website or contract your local
company representatives for products approved for use in your country.
2 Refers to delivered dose. For additional information about doses and products available in specific
countries, please consult www.astrazeneca.com to find a link to your country website or contract your
local company representatives for products approved for use in your country.
3 Refers to metered dose. For additional information about doses and products available in specific
countries, please consult www.chiesigroup.com to find a link to your country website or contract your local
company representatives for products approved for use in your country.
Anticholinergics
Comments
Drug of choice for
acute bronchospasm.
Inhaled route has
faster onset and is
more effective than
tablets or syrup.
Increasing use, lack of
expected effect, or
use of 1 canister a
month indicate poor
asthma
control;
adjust long term
therapy accordingly.
Use of 2 conisters
as per month is
associated with an
increased risk of a
severe,
lifethreatening asthma
attack.
Appendix 3 Glossary of
Asthma Medications
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Ipratropium
bromide q6h or q20 min in the dryness or bad taste effects to 2-agonst
(IB)
emergency
in the mouth.
but has slower onset
Oxitropium bromide
department.
of action. Is an
Nebulizer 500 g
alternative
for
q20min x 3 then q2
patients
with
4hrs for adults and
intolerance to 2250 - 500 g for
agonists.
children.
Short-acting
theophylline
Aminophylline
Nausea,
vomiting,
headache. At higher
serum
concentrations:
seizures, tachycardia
and arrhythmias.
Theophylline
level
monitoring
is
required.
Obtain
serum levels 12 and
24
hours
into
infusion.
Maintain
between 10-15 g/ml.
In
general,
not
recommended
for
treating
asthma
attacks if selective 2agonists are available.
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Appendix 5 Asthma
Control Test (Act)
Appendix 5 Asthma Control Test (Act)
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Appendix 6 My Asthma
Plans
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