Building Healthy Lifestyles

Chronic Respiratory
Asthma
Clinical Guide

Building
Healthy 388-6654
1-866-506-6654 Lifestyles
 Asthma

We would like to acknowledge the contribution of the following groups:

Chronic Respiratory Interdisciplinary Working Group

Chronic Disease Physician Advisory Group

Chronic Disease Clinical Leadership Group

Specialist Consultants

Chronic Respiratory Clinical Champions

CHR Asthma Program Committee

Utilizing the Chronic Care model, these groups developed the Asthma Clinical Guide as a decision-
support tool for improved functional and clinical outcomes. This Guide supports primary care
interdisciplinary team-based practice with a strong focus on self-management.

Please use and reproduce with acknowledgement to the Chinook Health Region.

Chronic Disease Management and Prevention Network:

An Alberta Health Capacity Building Initiative

Chinook Health Region

Lethbridge, Alberta
April 2006

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 Asthma

Table of Contents

1. Diagnosis
a. Definition ............................................................................................................5
b. Risk Factors .........................................................................................................5
c. Screening .............................................................................................................6
d. Signs and Symptoms............................................................................................6
e. Testing and Evaluation ........................................................................................6
f. Further Testing ....................................................................................................7
g. Algorithm ............................................................................................................8

2. Classification/Type/Staging
a. Stages/Types of Disease ........................................................................................11

3. Patient Care Flow Sheet for Health Teams

a. Patient Care Flow Sheet ......................................................................................13
b. Key Clinical Summary .........................................................................................14

4. Management Strategies for Health Teams

a. Goals of Management ..........................................................................................15
b. Key Clinical Targets .............................................................................................15
c. Non-Pharmacologic Strategies .............................................................................15
d. Pharmacologic Strategies......................................................................................16

5. Management Strategies for Patients/Clients

a. Self-Care Support Information/Handouts/Tools .................................................21
b. Patient/Client Checklist for Evidence-Based Care ................................................25

6. Referral to Specialists/Specialty Program

a. Indications for Referral to Medical Specialists ......................................................27
b. Indications for Referral to Specialty Programs ......................................................27
c. Local Contacts .....................................................................................................27

7. References
a. Evidence ..............................................................................................................29
b. On-line Resources ...............................................................................................29
c. Supplementary Handouts Available .....................................................................29

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 Asthma

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 1. Diagnosis Asthma

BUILDING HEALTHY LIFESTYLES

CHRONIC RESPIRATORY-ASTHMA
Unless clinical practice guidelines are followed, the danger of both
under- and over-diagnosis exists. The interpretation and availability
of tests to assess variable airway obstruction is inconsistent. Because
of the variable nature of the disease over time, the tests for airway
obstruction and hyper-responsiveness may not reveal a problem even
when asthma exists.
1. Diagnosis
a. Definitions:
Reactive Airways Disease (RADS) is poorly defined, confusing and
should not be used in lieu of “possible or probable Asthma”.
b. Risk Factors
Major risk factors:
i. Personal history of atopy, especially atopic dermatitis
ii. Parental history of asthma or eczema
iii. Three or more episodes of wheeze during the first three years
of life

Asthma: is characterized by paroxysmal or persistent symptoms Minor risk factors:

such as dyspnea, wheezing, chest tightness, sputum production and i. Eosinophilia
cough associated with variable airflow limitation and airway hyper- ii. Wheezing without colds
responsiveness to endogenous or exogenous stimuli. iii. Allergic rhinitis
iv. Environmental tobacco smoke (ETS)
Exercise Induced Bronchospasm (EIB): is a reversible airway
obstruction that occurs during or after strenuous physical exertion. OCCUPATIONAL ASTHMA (OA)
Solitary EIB is not asthma and it is important to distinguish if exercise
induced symptoms are the result of poorly controlled asthma. Highest risk occupations and asthma-producing substances

EIB versus Asthma OCCUPATION ASTHMA-PRODUCING

SUBSTANCES
A therapeutic trial is a practical way to confirm EIB. The client Adhesive handlers Chemicals such as acrylate
takes B-2 agonists, 15 minutes prior to exercise; the EIB diagnosis is
confirmed if the medications prevent or diminish symptoms. The Animal handlers, vets, researcher Animal proteins
challenge is to distinguish whether or not the patient has asthma Bakers, Millers Cereal Grains
with an exercise exacerbation or has solitary EIB. Because treatment Carpet makers Gums
is different for these two conditions, it is important to evaluate
the patient for asthma using patient history, physical exam and Electronic workers Soldering resin
pulmonary function tests (spirometry). Forest workers, Carpenters, Wood dust
Cabinet makers
Occupational Asthma (OA) – is asthma induced by exposure to a
specific agent in the workplace; is the most common occupational Hairdressers Chemicals such as persulfate
lung disease in developed countries. OA has been estimated to cause Healthcare professionals Latex and chemicals such as
5 – 15 % of adult onset asthma. glutaraldehyde
• An occupational cause should be suspected for all new cases of Janitors, Cleaning staff Chemicals such as chloramine-T
asthma in adults Pharmaceutical workers Drugs, enzymes
• Temporal associations are not sufficient to diagnose work-related Seafood processors Seafood
asthma and objective tests are required to confirm the diagnosis.
Workers with asthma symptoms should not be told to leave their Shellac handlers Chemicals such as amines
job until diagnosis is proven because part of the diagnostic work- Solderers, Refiners Metals
up of OA may involve a return trial to work. Spray painters, Insulation Chemicals such as diisocyanates
• Referral to a medical specialist for evaluation of OA installers, Plastic & Foam
industry workers
Irritant-induced Asthma – is caused by single or multiple exposures
to high concentrations of an irritant vapour, fume or smoke in people Textile workers Dyes
who have no previous diagnosis or history of asthma symptoms. The Users of plastics, epoxy resins Chemicals such as anhydrides
term “Reactive airways dysfunction syndrome” or RADS is used
when the condition is caused by a single exposure.

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 1. Diagnosis
c. Screening
There is currently no organized approach to screening for asthma in
Canada.
d. Signs and Symptoms
Asthma
• Coughing
• Wheezing
• Chest tightness
• Shortness of breath
• Trouble sleeping because of breathing difficulty
• Reduced physical activity due to breathing difficulty
EIB:
• Coughing, wheezing, shortness of breath and chest tightness
immediately following 6 to 8 minutes of strenuous exercise.
These symptoms may occur during or after exercise.
e. Testing and Evaluation
Evaluation and diagnosis of asthma in clients able to perform
lung function tests (Usually 6 years of age and older):
There is no one definitive test that can be used to diagnose asthma,
requiring the bringing together of many sources of information in
order to reach such a diagnosis. At the present time, diagnosing
asthma is based on the following:
• the presence of typical symptoms of asthma and an improvement
in these symptoms with asthma medication
• evidence of variable airflow limitation and/or obstruction
• in some circumstances, evidence of hyper-responsiveness of the
airways using a provocation challenge test
Steps in primary care setting to accurately diagnosis asthma, suspect
asthma based on symptoms, physical exam and patient history.
Next, confirm diagnosis through lung function tests showing
variable airflow obstruction and/or response to trial of asthma
medications.
• Thorough history: covering symptoms and pattern of symptoms
as well as what triggers the symptoms. Personal history of atopy
(eczema, hay fever, hives, allergic rhinitis, allergies) and family
history of atopy or asthma in close relatives.
• Physical exam: should focus on upper respiratory airway
(nasopharynx) and lower respiratory airway (chest) as well as
the skin. Physical exam may help confirm the diagnosis of
asthma, but does not generally provide the diagnosis. Physical
exam alone tends to underestimate the severity of an asthma
exacerbation. Co-morbid conditions such as rhinitis, sinusitis,
post nasal drip or Gastroesphageal Reflux Disease (GERD) that
mimic or worsen asthma symptoms should be evaluated and
addressed.
Chinook Health Region
Asthma
Findings with asthma that may be present are:
• use of accessory muscles of respiration
• tracheal tug
• indrawing
• hyperinflation of the chest
• decreased air entry
• prolonged expiration
• wheezing
• wheeze with forced expiration
• silent chest
• Lung function tests (2 types): Objective measurements are
needed to confirm the diagnosis of asthma and to assess its
severity accurately in all symptomatic patients.
i. Spirometry (preferred method)
- A 12% (at least 180 mL in adults) or greater improvement in
Forced Expiratory Volume (FEV)1.0 15 minutes (10 minutes
is more practical and used in the LRH PFT lab) after use of
an inhaled short-acting beta-2 agonist will confirm diagnosis
of asthma*
- A 20% (at least 250mL in adults) or greater improvement in
FEV1.0 after 10-14 days of inhaled glucocorticosteriods or
ingested prednisone, when symptoms are stable will confirm
diagnosis of asthma
- A 20% (at least 250 mL in adults) or greater spontaneous
variability in FEV1.0 over time is considered significant and
will confirm the diagnosis of asthma
ii. Peak Expiratory Flow or PEF (used when spirometry is
unavailable or home monitoring is required to diagnose)
- Variable airflow obstruction can be documented by home
measured PEF that shows a 20% or greater diurnal variability
over a period of several weeks. This can confirm the
diagnosis of asthma.
- A 20% or greater improvement in PEF, 15 minutes (10
minutes is more practical) after the administration of a short
acting beta-2 agonist may be used to confirm asthma in a
physician’s office when spirometry is not available.
- Both these methods are not as reliable as spirometry.
• Therapeutic trial of asthma medications, which should include
Inhaled Corticosteroids (ICSs) daily and short-acting B-2 agonist
as needed for a period of 2-4 weeks may be helpful in confirming
the diagnosis of asthma.
Evaluation and diagnosis of asthma in clients unable to perform
lung function tests (Usually less than 6 years of age):
NOTE: There are no age criteria for the diagnosis of asthma
as it can be diagnosed at any age. However, caution should be
used when diagnosing asthma in clients less than one year of
age. Persistent respiratory symptoms in infants and children may
warrant a referral to a specialist.
• The diagnosis rests on careful and sometimes repeated history
taking and physical examination as stated above
*Please note- in children age 6-17 only a ≥ 12% improvement in FEV 1.0 is
required after bronchodilator.
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 1. Diagnosis Asthma

• Factors particularly useful in establishing a diagnosis in young

patients:
• severe episodes of wheezing
• wheezing after 1 year of age
• more than 3 episodes of wheezing in a given year
• family history of asthma/atopy
• personal history of asthma/atopy
• maternal smoking
• clinical benefits from acute bronchodilator therapy
• clinical evidence of improvement after anti-inflammatory
treatment
• chronic cough (especially nocturnal or associated with
exercise)
• wheezing when viral etiology is unlikely

The likelihood of a diagnosis of asthma increases with the number

of these factors present.

Clinical Index for the Diagnosis of Asthma

Stringent Index: 3 or more episodes of wheeze during the first

3 years of life with either one of the major risk
factors: parental history of asthma or eczema, or
2 of 3 minor risk factors; eosinophilia, wheezing
without colds, allergic rhinitis

Loose Index: any wheezing during the first 3 years of life plus 1
major or 2 minor risk factors

Clinical Clues to Alternate Diagnosis

Not asthma: poor response to therapy after ensuring compliance

with trigger avoidance strategies, proper inhaler use and compliance
with medical treatment. No history of atopy.
• Cystic fibrosis: malabsorption, finger clubbing, nasal polyps
• Pertussis: paroxysmal cough, ill contacts
• Rhinitis/Sinusitis: no wheeze, throat clearing
• Gastroesophageal Reflux (GER): previous regurgitation, night
time
• Congenital malformation: age under one year
• Foreign Body: sudden onset without Upper Respiratory Infection
(URI), focal findings

f. Further Testing
• Referral to a medical specialist for bronchoprovocation testing to
help confirm or rule out asthma.
• Appropriate allergy assessment is warranted in patients with
asthma and must be interpreted in light of patient’s history.
Allergen exposure is a risk factor for severe, acute asthma,
especially if the patient is exposed to high concentrations of
the specific allergen. Therefore, allergens to which a person
is sensitized should be identified through allergy testing.
Once identified, steps should be taken to eliminate or at least
substantially reduce allergen exposure.

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 1. Diagnosis Asthma

g. Algorithms
Approach to Asthma Diagnosis in Clients Able to Perform Spirometry Tests
Reliably (usually 6 years of age or greater) in the Primary Care Setting

Suspect asthma based on symptoms, patient history & physical exam

Confirm diagnosis of asthma with Pre & Post Spirometry Testing

Is there a >12% improvement in Forced Expiratory Asthma diagnosis confirmed

Volume FEV1.0 (of at least 180ml in adults 18+) 10 YES Initiate treatment & asthma education
minutes after short-acting bronchodilator* (Referral to asthma educator)

NO

Does pre & post spirometry test meet the following criteria to be considered normal
• FEV1.0/FVC ratio > 0.7
• FVC > 80% of predicted value
• FEV1.0 > 80% of predicted value

NO YES

• If FVC is < 80% predicted and Consider diagnosis of restrictive

FEV1.0/FVC ratio is > 0.7
• Post bronchodilator FEV1.0/FVC
ratio is < 0.7 and post
bronchodilator FEV1.0 is < 80%
predicted
• If post bronchodilator
FEV1.0/FVC ratio is < 0.7
lung defect not consistent with a
diagnosis of asthma - referral to a
specialist may be warranted
Diagnosis of COPD can be Initiate proper COPD treatment
confirmed alone or co-existing with
asthma
Consider diagnosis of irreversible
obstructive lung defect

Is client currently symptomatic

YES NO

• Initiate proper asthma therapy of • Repeat spirometry if and when

inhaled corticosteroids and short- symptoms recur to confirm
acting bronchodilators for one month diagnosis of asthma or dismiss
then follow up and reassess diagnosis of asthma

• Clinical benefits after proper asthma

therapy?

YES NO

• Asthma diagnosis may be confirmed

• Consider re-test with spirometry Referral to a specialist for bronchoprovocation testing to help confirm / rule out diagnosis of asthma
• Initiate treatment and asthma and investigate other conditions that mimic asthma (i.e. Gastroesophageal Reflux Disease (GERD),
education (referral to an asthma vocal cord dysfunction)
educator)
years of age. Some children as young as 5 can give
Notes:
reliable spirometry testing. Therefore, this may need
• FVC is forced vital capacity, FEV1.0 is forced to be decided by the person performing the test.
expiratory volume in 1 second.
*• In children age 6 - 17 only a ≥12% improvement in
• Normal predicted values in spirometry are available FEV1.0 10 minutes after a short-acting bronchodilator
for people 5 years of age and older. No normal is required to confirm a diagnosis of asthma.
predicted values exist for children younger than 5

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 1. Diagnosis Asthma

Asthma
Approach to Asthma Diagnosis in Clients Able to Perform Peak Expiratory Flow Tests
Reliably (usually 6 years of age or greater) in the Primary Care Setting

Suspect asthma based on symptoms, patient history & physical exam

Spirometry is not available

(Spirometry is the preferred method according to the CPG’s)

Confirm Diagnosis of asthma with Peak Expiratory Flows (PEF)

>20% improvement in PEF 10 minutes after >20% or greater diurnal variability in PEF
administration of short-acting B-2 agonist over a period of several weeks

YES NO YES NO

Asthma diagnosis confirmed Asthma diagnosis confirmed

Initiate treatment and asthma education Initiate treatment and asthma education
(referral to an asthma educator) (referral to an asthma educator)

Is client currently symptomatic

YES NO

Initiate proper asthma therapy of inhaled Repeat PEF if and when symptoms recur
corticosteroids and short-acting bronchodilators
for one month then follow up and reassess

Clinical benefits after proper asthma therapy

YES NO

Asthma diagnosis may be confirmed
Consider retesting with spirometry
Initiate treatment and asthma
education
Consider a referral to an asthma
educator
Consider a referral to have pre & post spirometry done or referral to a
specialist for bronchoprovocation test to help confirm / rule out
asthma diagnosis and investigate other conditions that mimic asthma
(i.e. Gastroesophageal Reflux Disease (GERD), vocal cord
dysfunction).

Note:
• PEF is less reliable than spirometry for confirming the diagnosis of asthma
To calculate a 20% improvement in PEF following administration of a short-acting B-2 agonist:
1. Obtain a peak flow reading prior to medication, e.g. 400 lpm
2. Multiply that number by 1.2 to give value needed to confirm a 20% improvement in PEF (400 x 1.2 = 480).
3. Give B-2agonist, wait 10 minutes then repeat PEF; this value must be > 480 lpm to show a 20% improvement in
PEF and confirm diagnosis of asthma
To calculate diurnal variation of PEF:
1. Client is to measure peak flows in the am and pm of each day for 2-4 weeks and record the best value of 3 tries
in a diary
2. Once this data has been recorded, calculate the diurnal variation of each day by using the following formula:
Highest PEF – Lowest PEF (on the same day) x 100
Highest PEF
For example: Day 1 Day 2 Day 3
PEF am pm am pm am pm
400 500 400 450 350 500
500 – 400 x 100 450 – 400 x 100 500 – 350 x 100
500 450 500
= 20% diurnal variation = 11.1% diurnal variation = 30% diurnal variation
• Children as young as 5 years of age may be able to properly perform PEF. There are no predicted values for children
under 5 years of age for peak flow.

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January 2006 Building Healthy Lifestyles
 1. Diagnosis Asthma
Asthma

Approach to Asthma Diagnosis in Clients Unable to Perform Reliable

Pulmonary Function Tests (less than 6 years of age) in the Primary Care Setting

Suspect asthma based on symptoms, patient history & physical exam

First, determine the presence of airway sensitivity – by inquiring about symptoms such as cough,
wheeze, limited physical activity, chest tightness and shortness of breath.

Second, look for evidence of inherited ability to react to stimuli - is there a family history of atopy
and a personal history of eczema or atopy.

Third, establish that there is no underlying lung disease - look for anything else that could be
causing cough.

Therapeutic trial of asthma medications to confirm diagnosis of asthma in preschool children

Beta-2 agonists for relief of symptoms such as wheeze, chest tightness and shortness of breath (SOB)

AND

Inhaled Corticosteroid for coughing for a period of one month

OR
Oral prednisone for therapeutic trial for coughing, 1mg/kg per day up to a maximum of 50 mg x 5 days

CAUTION: ensure child is not incubating varicella virus. A comprehensive varicella history should be
done

Reassess response to asthma therapy in child

• Did Beta-2 agonist provide relief from wheeze, chest tightness and SOB?
• Did cough subside after one month of inhaled corticosteroids?
• Did cough subside after 5 days of oral prednisone?

YES NO

Asthma diagnosis may be confirmed Consider an alternate diagnosis

especially if symptoms recur when Consider a referral to a Pediatrician
medications are stopped
Initiate treatment and asthma education
Referral to an asthma educator

• NOTE- there is no age criteria for the diagnosis of asthma as it can be diagnosed at any age. However,
caution should be used when diagnosing asthma in children less than one year of age. Persistent
respiratory symptoms in infants and children may warrant a referral to a specialist.

January 2006 Building Healthy Lifestyles

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 2. Classification/Type/Staging Asthma

2. Classification/Type/Staging
Determining the Severity of Asthma

Assessment of asthma severity will help physician determine

appropriate level of therapy required, as well as when a client
should be referred to a specialist.

The severity of asthma can be evaluated in two ways:

1. Before or without treatment – which takes into account
symptoms, physiological indicators of airway disease (lung
function tests) and morbidity.
2. With treatment or when controlled asthma amount of
medication required to maintain control.

The primary measure of asthma severity in the treated patient

should be the minimum therapy required to achieve acceptable
control.

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 2. Classification/Type/Staging Asthma

Asthma severity before or without proper treatment

Event or measurement Mild Moderate Severe
FEV1.0 or PEF, % of predicted >80% 60 – 79% <60%
Need for short-acting B-2 agonist Every 8 or more h Every 4-8 hours Every 2-4 hours
Night-time symptoms 0 to + + +++
Limitation of daily activities 0 to + + to ++ +++
Probability of:
Recent admission to hospital 0 0 +
Previous near fatal episode 0 0 +

Note: FEV1.0 = Forced Expiratory Volume in 1 second; PEF = Peak Expiratory Flow

0 = none
+ = minimal (infrequent)
++ = moderate (frequent)
+++ = severe (very frequent)

Asthma severity with treatment (controlled)

Asthma severity Symptoms Treatment required for control
Very Mild mild- infrequent none, or inhaled beta-2 agonist rarely (less than 3 times per week)
Mild well-controlled beta-2agonist (occasionally) & low dose inhaled corticosteroids
beta-2 agonist (occasionally) & low to moderate doses of inhaled corticosteroids with
Moderate well-controlled
or without additional therapy
Severe well-controlled beta-2 agonist & high doses of inhaled corticosteroids with add on therapy
beta-2 agonist & high doses of inhaled corticosteroids plus add on therapy plus oral
Very Severe not well-controlled
glucocorticosteroid

Dose equivalencies for inhaled corticosteroids (All ages)

Daily Dose (mcg/day)
Product Low Moderate High
BUD turbuhaler <400 401 - 800 >800
FP pMDI and spacer <250 251 - 500 >500
FP Diskus <250 251 - 500 >500
BDP pMDI (HFA) <250 251 - 500 >500
BUD wet nebulization <1000 1001 - 2000 >2000

BDP = Beclomethasone dipropionate (Q-var)

BUD = Budesonide (pulmicort)
FP = Fluticasone propionate (Flovent)

Note: Children will “auto-scale” their inhaled medication dose, (take proportionately smaller inspiratory volumes compared to adults, which
results in less of the dispensed dose of inhaled medication reaching the lungs). The same dose can be used for all medications at all ages.

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 3. Chronic Disease Patient Care Flow Sheet Asthma

3. Chronic Disease Patient Care Flowsheet

Asthma Patient Care Flow Sheet Patient Name

Comorbid Conditions PHN

Year of Diagnosis

DATE: _________ _________ _________ ________ _________ _________

REVIEW ITEMS
Needs reliever medication ≥ 4 times/week
(may use 1 dose/day for exercise)
Physical activity limited by symptoms (in past 3 months)
(Sx: coughing, wheezing or chest tightness)
Symptoms wake patient at night ≥ 1 times/week
Asthma Control
ASTHMA

Symptoms ≥ 4 days/week

Any urgent visits for asthma since last regular appointment

Absence from work/school because of asthma

(in last 3 months)
*Client must answer all with NO to have Control , if Yes to one or more questions asthma is not controlled reassess
REGULAR OFFICE VISITS FOR

Smoker or secondhand smoke in the home/vehicles. If yes

address smoking (ask, advise, assist, arrange 4As)
Trigger Avoidance

Identified asthma triggers:

Have steps been taken to reduce exposure to asthma triggers

A client that is not reducing exposure to allergens and asthma triggers will be difficult to control. Referral to asthma program
Does client have a written asthma action plan
* If not, provide a written CHR asthma action plan

Client understands how to use the asthma action plan

Is controller medication used regularly?
Compliance

Controller medications:

Reliever Medications:

Economic Concerns (cost of meds):

Have patient demonstrate how they use their inhaler device(s)

*Ensure Proper Inhaler Technique
Sx of GERD, Rhinitis, Sinusitis
Comorbidities

Asthma meds that may affect other diseases

(Prednisone use, test blood glucose)
Sx of depression, anxiety

* If any comorbidities exist with asthma, treat appropriately as these may affect proper asthma control
Perform Pre & Post Spirometry testing yearly & prn
Tests

Height and weight (especially for pediatrics)

ANNUALLY

BMD for osteoporosis (If on ICSs and has risk factors)

Review asthma action plan, try to reduce medication required
while maintaining asthma control
Management

Referrals: Asthma educator for education & evaluation

• for initial education & follow up as needed
Medical Specialist – as needed
Vaccinations: Annual Influenza vaccine
Pneumoccocal vaccine if > 65 years
Immunizations up to date
Revised as of May 9, 2005 developed by the BHL/chronic respiratory/ Chinook Health Region

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 3. Patient Care Flow Sheet Asthma

Asthma Continuum of Care Reliever (Rescue) medications

� Salbutamol (Ventolin) MDI 100 mcg per dose
� 1 or 2 inhalations as needed
� Salbutamol (Ventolin) Diskus 200 mcg per dose
� Adults & children 6 and older, 1 inhalation as needed
� Terbutaline (Bricanyl) Turbuhaler 0.5 mg per dose
� Adults & children 6 and older, 1 inhalation as needed
� Salbutamol (Airomir) MDI 100 mcg per dose
� 1 to 2 inhalations as needed

Inhaled Corticosteriods (Preventer/controller medications)

ICSs should be introduced as the initial maintenance treatment for asthma,
even in subjects who have very mild asthma and use their reliever
medication less than 3 times/week. Refer to chart on left for proposed
doses for ICSs
� Fluticasone (Flovent) MDI 50, 125 & 250 mcg per dose
� BID dosing most effective
� Fluticasone (Flovent) Diskus 50, 100, 250, 500 mcg per dose
� BID dosing most effective
� Budesonide (Pulmicort) Turbuhaler 100, 200 & 400 mcg per dose
� BID dosing most effective
Daily Long Term Inhaled Steroid Agents and Doses � Beclomethasone (Q-var) MDI 50 & 100 mcg per dose
Mcg/day (all ages) � BID dosing most effective
Product Low Medium High
Add on Therapy if required
BUD Turbuhaler < 400 401 – 800 > 800 If asthma is not controlled by low doses of ICSs, additional therapy
Pulmicort should be considered:
FP pMDI and spacer < 250 251 – 500 > 500 FIRST OPTION – Add long-acting beta2 agonist to existing therapy of
Flovent ICSs and short-acting beta 2 agonists, or replace ICSs with a combination
FP Diskus < 250 251 – 500 > 500 medication.
BDP pMDI (HFA) < 250 251 – 500 > 500 � Salmeterol (Serevent) MDI 25 mcg per dose
Q-var � Adults 1 or 2 inhalations BID
BUD wet nebulization < 1000 1001- 2000 > 2000 � Children 4 years of age and older 1 or 2 inhalations BID
� Salmeterol (Serevent) Diskus 50 mcg per dose
� Adults 1 inhalation BID
Note: children will “auto scale” their inhaled medication dose, (take � Children 6 years of age and older 1 inhalation BID
smaller inspiratory volumes which results in less dose reaching the � Formoterol (Oxeze) Turbuhaler 6 or 12 mcg per dose
lower airways) the same dose can be used for all asthma medications � Adults 1 inhalation of 6 or 12 mcg BID (max 48 mcg per day)
at all ages. � Children 6-16 1 inhalation of 6 or 12 mcg BID (max 24 mcg day)
FP= Fluticasone propionate (GSK Canada Inc) OR
BUD= Budesonide (AstraZeneca Canada Inc) � Advair (Serevent 50 mcg/Flovent 100, 250 & 500 mcg per dose) Diskus
BDP= Beclomethosone dipropionate (3M Pharmaceuticals Canada) � Adults and children 12 and older, 1 inhalation BID
� Children 6-11 years of age, 1 inhalation BID
Asthma Severity based on treatment needed to obtain control � Advair (Serevent 25 mcg/Flovent 125 & 250 per dose) MDI
Asthma Severity Symptoms Treatment required
� Adults and children 12 and older, 1 or 2 inhalations BID
� Children 4 years of age and older, 1 or 2 inhalations BID
Very mild Mild-infrequent None, or inhaled short- � Symbicort (Oxeze 6 mcg/Pulmicort 100 & 200 mcg per dose) Turbuhaler
acting B-2 agonist rarely � Adults and children 12 years of age and older, 1 or 2 inhalations BID
� Children 6 to 11 years of age, 1 or 2 inhalations BID
Mild Well-controlled Short-acting B-2 agonist
(occasionally) and low dose
SECOND OPTION- Increase the inhaled corticosteriods (ICSs) to a
inhaled steroids moderate dosage as per chart or add in a leukotriene receptor antagonist.
� Montelukast (Singulair) 4, 5 & 10 mg chewable tablet
Moderate Well-controlled Short-acting B-2 agonist and � Adults and children 15 years of age and older one 10 mg tablet daily
low to moderate doses of at bedtime
inhaled steroids with or � Children 6 to 14 years of age one 5 mg tablet daily at bedtime
without add on therapy � Children 2 to 5 years of age one 4 mg tablet daily in the evening
� Zarfirlukast (Accolate) 20 mg tablet
Severe Well-controlled Short-acting B-2 agonist and
high doses on inhaled � Adults and children 12 years of age and older two 20 mg tablets daily
steroids and add on therapy THIRD OPTION – consider theophylline, severe asthma may require
additional treatment with Prednisone. If required to maintain control, refer
Very severe May be Short-acting B-2 agonist and to the CPS for dosing requirements & refer to medical specialist.
controlled or not high doses of inhaled
well-controlled steroids and add on therapy Prednisone – for acute exacerbations of asthma, use the following
and oral steroids dosages:
� For ages 12 and over: 50 mg po daily for 3-10 days
� For ages under 12: 1mg/kg po daily for 3-10 days (maximum dose: 2
mg/kg po daily)
No Prednisone dose tapering required if less than 2 weeks

Treatment options from the Canadian Asthma Consensus Guidelines update 2003, medications updated as of January 12, 2006

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 4. Management Strategies for Health Teams Asthma

4. Management Strategies for Health Teams

a. Goals of Management • Allergy testing to identify allergens to which a person is
sensitized; once these allergens are identified, steps should
To maintain acceptable asthma control use nonpharmacologic and be taken to eliminate or at least substantially reduce allergen
pharmacologic strategies. Asthma control is defined under Key exposure
Clinical Targets.
• Current recommendations for protecting against development
of allergy and asthma in subsequent pregnancies and subsequent
b. Key Clinical Targets
children:
1. Elimination of exposure to ETS (includes during pregnancy)
Criteria for asthma control 2. Promotion of exclusive breast feeding for at least 4 months
Parameter Frequency or value 3. For families with biparental atopy, maternal asthma or both,
it appears that there is substantive data to recommend against
Daytime symptoms less than 4 days/week the presence of a cat or dog in the home
Night-time symptoms less than 1 night/week
IMPORTANT! Medication should not be substituted for
Physical activity Normal
environmental control and trigger avoidance strategies.
Exacerbations Mild, infrequent
Asthma Action Plan:
Absence from work/school None
• Devise a written action plan for the management of
Need for short-acting beta-2 agonist Less than 4 doses/week*
exacerbations that includes medication adjustment in response
FEV1.0 or PEF > 85% of personal best to changes in severity or frequency of symptoms, the need for
Ideally 90% symptom relief medication or changes in PEF. Provide the
PEF diurnal variation < 15% of diurnal variation written document or ask an asthma educator to do so. Please
refer to Section 5, subsection “a” for a copy of the CHR Asthma
*May use 1 dose/day for prevention of exercise-induced symptoms Action Plan.

To be considered controlled asthma, all the above criteria must
be met. If they are not met, it is then considered uncontrolled
asthma.
Control can be achieved in uncontrolled asthma through patient
education, trigger avoidance and medications.
Education and Follow-up:
Education is an essential component of asthma therapy and should
be offered to all patients. Educational interventions may be of
particular benefit to patients with high asthma-related morbidity or
severe asthma and at the time of emergency department visits and
admissions to hospital.
• All patients should self-monitor their asthma using symptoms or
PEF or both
• Ensure regular follow-up (every 6 months). Asthma control
criteria should be assessed at each visit. Measurement of
pulmonary function, preferably spirometry, should be done
regularly in adults and children 6 years of age and older. Review
written action plan and medication required with an aim to
reduce amount of medication while maintaining asthma control.

Smoking Cessation:
• Smoking cessation interventions (4A model) should be offered
to patients who smoke, or parents of children with asthma who
smoke.

c. Non-Pharmacologic Strategies for Asthma Influenza vaccination:

• All patients with asthma should be encouraged to have an annual
Environmental Control:
influenza vaccination, as well as any family members living with
• Elimination of exposure to environmental tobacco smoke (ETS) patient (parents & siblings).
• Identification of asthma triggers and implement trigger
avoidance strategies

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 4. Management Strategies for Health Teams Asthma

Immunotherapy in Adults: Inhaled Corticosteroids (ICSs) low dose – maintenance

• Immunotherapy is generally not recommended in the treatment
of asthma
• Immunotherapy should not be used in place of avoidance of
environmental allergens
• Immunotherapy with clinically relevant allergens may be
considered if disease activity is inadequately controlled by
avoidance of allergens and pharmacotherapy
• Immunotherapy should be avoided while asthma is poorly
controlled
• Regular use of low dose ICSs is currently the recommended
treatment for persons with asthma of all ages, even for those
with intermittent asthma symptoms
• Physicians should recommend that children with frequent
symptoms, severe asthma exacerbations or both receive regular,
not intermittent, treatment with ICSs
• The use of intermittent treatment as a strategy for management
of intermittent asthma in childhood is not validated and requires
further research especially in very young children

• Well-controlled asthma is not a contraindication for • For patients who cannot or will not use ICSs, leukotriene
immunotherapy for allergic rhinoconjunctivitis or insect venom receptor antagonists (LTRAs) should be the primary treatment
hypersensitivity choice, although they are less effective than low dose ICSs
• Fluticasone (Flovent) MDI 50, 125 & 250 mcg per dose
• Immunotherapy must be administered only by trained personnel ○ BID dosing most effective
in centres where there is medical supervision and resuscitative
equipment (for both children & adults) • Fluticasone (Flovent) Diskus 50, 100, 250, 500 mcg per dose
○ BID dosing most effective
Immunotherapy in Children:
• Although debate about the value of immunotherapy continues, • Budesonide (Pulmicort) Turbuhaler 100, 200 & 400 mcg per
meta-analysis and review of immunotherapy support the dose
potential value of immunotherapy in childhood; early ○ BID dosing most effective
immunotherapy may prevent development of asthma in children • Beclomethasone (Q-var) MDI 50 & 100 mcg per dose
sensitized to house dust mite allergen ○ BID dosing most effective
• Physicians should consider injection immunotherapy using
appropriate allergens for the treatment of allergic asthma only
when allergic component is well documented
• Physicians should not recommend the use of injection
immunotherapy in place of avoidance of environmental allergens
• Physicians may consider injection immunotherapy in addition to
appropriate environmental control and pharmacotherapy when
asthma control remains inadequate
• Immunotherapy is not recommended when asthma is unstable

d. Pharmacologic Strategies for Asthma

First Line Therapy:

Reliever medications – rescue

• Salbutamol (Ventolin) MDI 100 mcg per dose
○ 1 or 2 inhalations as needed
• Salbutamol (Ventolin) Diskus 200 mcg per dose
○ Adults 1 inhalation as needed
○ Children 6 years and older 1 inhalation as needed
• Terbutaline (Bricanyl) Turbuhaler 0.5 mg per dose
○ Adults 1 inhalation as needed
○ Children 6 years and older 1 inhalation as needed
• Salbutamol (Airomir) MDI 100 mcg per dose
○ 1 to 2 inhalations as needed

AND

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 4. Management Strategies for Health Teams Asthma

Dose equivalencies for inhaled corticosteroids - ICSs (All ages)

Daily Dose (mcg/day)
Product Low Moderate High
BUD turbuhaler < 400 401 - 800 > 800
FP pMDI and spacer < 250 251 - 500 > 500
FP Diskus < 250 251 - 500 > 500
BDP pMDI (HFA) < 250 251 - 500 > 500
BUD wet nebulization < 1000 1001 - 2000 > 2000

BDP= Beclomethasone dipropionate (Q-var)

BUD= Budesonide (Pulmicort)
FP= Fluticasone propionate (Flovent)
* Note: Children will “auto-scale” their inhaled medication dose, (take proportionately smaller inspiratory volumes compared to adults, which
results in less of the dispensed dose of inhaled medication reaching the lungs). The same dose can be used for all medications at all ages.

Add on Therapy as Required:
• If after reassessment of compliance with treatment, trigger
avoidance strategies, inhaler technique and co-morbidities,
asthma is not controlled by low dose ICSs, additional therapy
should be considered:
FIRST OPTION – Add long-acting beta-2 agonist to existing
therapy of ICSs and short-acting beta-2 agonist, or replace ICSs
with a combination medication.
• Salmeterol (Serevent) MDI 25 mcg per dose
○ Adults 1 or 2 inhalations BID
○ Children 4 years of age and older 1 or 2 inhalations BID
• Salmeterol (Serevent) Diskus 50 mcg per dose
○ Adults 1 inhalation BID
○ Children 6 years of age and older 1 inhalation BID
• Formoterol (Oxeze) Turbuhaler 6 or 12 mcg per dose
○ Adults 1 inhalation of 6 or 12 mcg BID (max 48 mcg per
day)
○ Children 6-16 1 inhalation of 6 or 12 mcg BID (max 24
mcg day)
OR
• Advair (Serevent 50 mcg/Flovent 100, 250 & 500 mcg per dose)
Diskus
○ Adults and children 12 and older, 1 inhalation BID
○ Children 6-11 years of age, 1 inhalation BID
• Advair (Serevent 25 mcg/Flovent 125 & 250 per dose) MDI
○ Adults and children 12 and older, 1 or 2 inhalations BID
○ Children 4 years of age and older, 1 or 2 inhalations BID
• Symbicort (Oxeze 6 mcg/Pulmicort 100 & 200 mcg per dose)
Turbuhaler
○ Adults and children 12 years of age and older, 1 or 2
inhalations BID
○ Children 6 to 11 years of age, 1 or 2 inhalations BID
SECOND OPTION- Increase the inhaled corticosteroids (ICSs)
to a moderate dosage as per chart or add in a leukotriene receptor
antagonist (LTRAs)
• Montelukast (Singulair) 4, 5 & 10 mg chewable tablet
○ Adults and children 15 years of age and older one 10 mg
tablet daily at bedtime
○ Children 6 to 14 years of age one 5 mg tablet daily at
bedtime
○ Children 2 to 5 years of age one 4 mg tablet daily in the
evening
• Zarfirlukast (Accolate) 20 mg tablet
○ Adults and children 12 years of age and older two 20 mg
tablets daily
THIRD OPTION – Consider theophylline; severe asthma may
require additional treatment with prednisone. If required to
maintain control, refer to the CPS for dosing requirements and
refer to a medical specialist.
Prednisone:
For acute exacerbations of asthma, use the following dosages:
• For ages 12 and over: 50 mg po daily for 3-10 days
• For ages under 12: 1mg/kg po daily for 3-10 days (maximum
dose: 2 mg/kg po daily)
No Prednisone dose tapering required if less than 2 weeks

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 4. Management Strategies for Health Teams
Management of Acute Asthma Exacerbations (excluding ER and
acute care facilities)
Acute asthma exacerbation – is defined as deterioration of asthma
control that is not responding to B-2 agonist rescue treatment in
the usual manner or a sustained worsening of asthma symptoms
leading to increased use of B-2 agonists as well as increased use of
maintenance medications and/or supplementation with additional
medicine. The following are loose criteria that can define an acute
asthma exacerbation:
• Bronchodilator use ≥ 4 times/week (excluding 1 dose/day for
exercise)
• Nocturnal awakenings due to asthma ≥ 2 times/week
• Daytime asthma symptoms ≥ 4 days/week
• Recent absence from work or school due to asthma
• Recent unscheduled physician visit due to asthma
• Spirometry testing shows FEV1.0 < 80% of predicted normal
• PEF tests fall below 80% of personal best value, or predicted
value if personal best is not known
• Studies have shown that the major cause (80%) of asthma
exacerbations is viral upper respiratory infections. With viral
upper respiratory infections the inflammatory response tends to
be more neutrophilic than eosinophilic. Inhaled corticosteroids
may not be effective during neutrophilic inflammatory responses
seen with viral upper respiratory infections.
Non-Pharmacologic Strategies:
• Avoid contact with environmental tobacco smoke
• Continue to avoid personal asthma triggers
• Refer to personalized written asthma action plan as to how to
temporarily modify asthma medications
Pharmacologic Strategies:
• Prevention of asthma exacerbations needs to be the primary
target of asthma treatment and ICSs. This can be accomplished
through regular use of ICSs as maintenance treatment for
asthma.
• Previous asthma guidelines have recommended the use of an
action plan to manage asthma exacerbations. Many of these
plans advocate a doubling of the dose of maintenance ICS as
one of the first steps in the management of worsening asthma.
However, there are no randomized controlled trials to support
doubling the dose of ICS on identification of exacerbations of
asthma.
• 2 recent studies (adult & pediatric populations) have provided
evidence that early or impending asthma exacerbations are
not always effectively treated by doubling the dose of inhaled
corticosteroids at the first sign of an exacerbation. These results
apply to those patients with asthma who regularly use their
preventer or controller medication as maintenance therapy when
well.
Chinook Health Region
Asthma
• There is some evidence for the potential benefit of a more
substantial increase in the dose of ICS such as tripling or
quadrupling the regular maintenance dose at the first sign of an
asthma exacerbation.
• The standard of care is that ICS dose should be increased during
an asthma exacerbation, but there is not enough good evidence
to make a generic recommendation as what dose to increase the
ICS from the maintenance dose during the exacerbation.
• Through the COPD & Asthma Network of Alberta (CANA),
as well as consulting local CHR specialists we have summarized
current clinical practices utilized by both pediatric and adult
respiratory specialists throughout Alberta in managing acute
asthma exacerbations:
○ If the client is on high doses of ICS for maintenance
(or maximum daily dosage for that client as decided by
physician), the clinical practice is to double the maintenance
dose of ICS or maintain the current dose of ICS and add in
a long-acting beta agonist (LABA) or leukotriene receptor
antagonist (LTRA) for a period of approximately 2 weeks.
○ If client is on low to moderate doses of ICS for maintenance,
the clinical practice is to increase to the full dose of the
specific ICS for approximately 2 weeks, then return to
maintenance dose.
Full dose:
Fluticasone (Flovent) 500 – 1000 mcg/day
Beclamethasone (Q-Var) 400 – 800 mcg/day
Budesonide (Pulmicort) 800 – 1600 mcg/day
○ The clinical practice of many respiratory specialists is to
increase the dose of ICS at the first sign of an exacerbation
and whether the dose is doubled or quadrupled depends on
the client’s maintenance dose as well as personal history of
exacerbations. Those who become ill quickly upon exposure
to triggers treat more aggressively than those who generally
manage trigger exposure without significant incident.
○ If the asthma exacerbation is not responding to increased
doses of ICS and add on therapy, a short course of oral
prednisone should be considered. Recommended doses:
For ages 12 and over: 50 mg po daily for 3-10 days
For ages under 12: 1mg/kg po daily for 3-10 days
(maximum dose: 2 mg/kg po daily)
No Prednisone dose tapering required if less than 2 weeks
The above evidence is based on the opinions of those who have written
and reviewed the asthma guidelines, based on their experience,
knowledge of the relevant literature and discussion with their peers.
18 Building Healthy Lifestyles
 4. Management Strategies for Health Teams
Special Considerations:
Asthma in the Elderly
Diagnosis
• A diagnosis of asthma should be more widely considered in
elderly patients with dyspnea, wheezing or nocturnal cough.
Asthma may be difficult to diagnosis in the elderly because of
misconceptions about its prevalence and also because older
patients have diseases and disorders that mask the classic features
of asthma.
Treatment
• In the elderly patient with asthma, it is particularly important to
take a careful medication history. Use of self-prescribed ASA has
become common and may go unrecognized. ASA and NSAIDS
are commonly prescribed in the elderly and may cause late-on-
set asthma. Oral and topical B-adrenergic blocking agents and
other anti-arrhythmic agents, including verapamil and others
with acknowledged B-blocker potential, can exacerbate or cause
asthma in those who are predisposed to the disease. Whenever
possible, medications that might induce or aggravate asthma
should be withdrawn.
• Special care should be taken to allow elderly patients with asthma
to choose an inhaler device with which they are both comfortable
and competent.
• Measures should be taken to prevent osteoporosis in elderly
patients with asthma who require prolonged treatment with oral
corticosteroids.
• Elderly patients with asthma require careful follow-up because
they have an increased risk for exacerbations, which may be
related to impaired perception of their disease severity.
Asthma in Pregnancy
• Asthma is present in 4 – 7 % of pregnant women and is the
respiratory disorder that most frequently complicates pregnancy.
• The course of asthma during pregnancy is variable and asthma
control may remain unchanged or become worse or improve
and return to the pre-pregnancy state within 3 months after
parturition.
• Overall, asthma control improves significantly in the last 4 weeks
of pregnancy.
• Asthmatic, pregnant women have been variably reported to
have an increased risk of pregnancy-induced hypertension, pre-
eclampsia, caesarean section, placenta previa and antepartum or
postpartum hemorrhage.
Recommendations
• Do not stop asthma therapy during pregnancy. Poorly controlled
asthma may affect maternal comfort, safety and pregnancy
outcome for both mother and child. Several well designed
studies have shown fewer adverse infant and maternal outcomes
than those without therapy.
Chinook Health Region
Asthma
• Physicians should discuss medication choices and the rationale
for treatment plan; they should emphasize that the treatment
program is considered to entail less risk than the uncontrolled
illness that could result in its absence.
• The use of systemic glucocorticosteriods for severe asthma,
especially for prolonged periods, may be associated with a greater
risk of pre-eclampsia, antepartum or postpartum hemorrhage,
low birth weight, preterm birth and hyperbilirubinemia.
• Patients requiring systemic glucocorticosteroid therapy should be
considered to be in a higher risk pregnancy.
Treatment
• Avoidance of allergic and non-allergic triggering factors should
be the first form of therapy for asthma during pregnancy.
• Treatment should take the same approach as the non-pregnant
patient and may include inhaled B-2 agonists, inhaled
corticosteroids, ipratropium bromide, cromolyn and systemic
steroids. Theophylline may increase nausea and reflux and is less
desirable. There is significantly less information about the effects
of long-acting B-2 agonists and leukotriene inhibitors and there
is less clinical experience with these drugs than with other classes
of drugs. These drugs should be used only for patients whose
asthma cannot be controlled using the more studied therapies.
• For drugs with a longer history of usage, there tends to be more
data to support a lack of adverse effects. Use of most common
asthma medications (B-2 agonists, theophylline, cromolyn,
inhaled glucocorticosteroids) during pregnancy has not been
shown to be associated with increased perinatal risks including
congenital malformations.
• Although no asthma medications can be considered proven
safe for use during pregnancy, the ones listed above are used
to prevent the potential direct and indirect consequences of
uncontrolled asthma.
• The patient must be aware of the risks and benefits of
appropriate asthma control and must give her informed consent
to the therapeutic approach recommended during pregnancy.
19 Building Healthy Lifestyles
 4. Management Strategies for Health Teams Asthma

Inhalation Devices for drug delivery In Asthma

Metered Dose Inhalers (MDIs)

Metered Dose Inhalers can be used with any age group. A spacer or
chamber should be used with children and elderly adults. A spacer
should also be used if patient is receiving inhaled corticosteroids.
• Under one year of age - a valved spacer and face mask should be
used with MDI. (orange infant aerochamber with face mask)
• From 2 to 6 years of age - a valved spacer and face mask should
be used with MDI. (yellow pediatric aerochamber with face
mask)
• More than 6 years of age - a valved spacer with a mouthpiece
should be used, rather than a face mask. (blue aerochamber)
• Try to use a valved spacer with mouthpiece in children at the
earliest age it becomes feasible. This will eliminate breathing
through the nose and maximize the chance of increased airway
deposition in the lungs. It has been clearly shown in children
that breathing through a mask via the nose decreases lung
deposition by up to 67% compared with breathing through a
mouthpiece using a jet nebulizer.

Dry Powder Inhalers (DPIs)

Dry Powder Inhalers can be used by most patients by the time they
reach 5 years of age. Spacer devices are not required with these
devices. The two devices in Canada are the Turbuhaler and the
Diskus inhaler.

MDIs vs Nebulizers:

Wet nebulizers for home use are rarely indicated in the

management of asthma at any age. The wet nebulizer device is
cumbersome and expensive and for the amount of medication
delivered the most costly of all methods.

Three meta-analyses of studies in children and adults evaluating

MDI and wet nebulization indicate that the use of MDI with
a chamber or spacer is associated with a more rapid onset of
bronchodilation, shorter duration of emergency department
treatment, fewer side effects and greater patient preference. More
rapid and profound bronchodilation is achieved when sufficient
doses are given with an MDI plus spacer than when conventional
doses are administered with a wet nebulizer.

Note: Proper inhaler technique must be taught to client. Referral

to an asthma education program can ensure this is done. There are
devices available to measure inspiratory flow rate to ensure patient
can adequately use a DPI.

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 5. Management Strategies for Patients / Clients Asthma

5. Management Strategies for Patients / Clients

ASTHMA ACTION PLAN Patient Name:

(Last and First) _______________________________
Update yearly and as needed
Date of Birth: _________________________________

GREEN ZONE Action:

YOUR ASTHMA IS IN GOOD CONTROL IF:
• You do not wheeze, cough, feel tight or have
trouble breathing with your usual activities,
with exercise, or at night.
• You require your reliever medicine less than
three times per week
Your peak flow is
between ________ and ________
(80% to 100% of personal best)
• Personal best or predicted peak flow _______
• Avoid your personal asthma triggers
• Avoid tobacco smoke exposure
• Yearly flu immunization
• Watch for asthma symptoms
• If you have symptoms with exercise take
___________ 15 minutes beforehand and remember
to warm up and cool down with exercise
• Check your peak flow _______ per day
• Controller(s): ____________________________
____________________________
• Reliever(s): ____________________________
____________________________

• Other Actions: ____________________________

Action:
YELLOW ZONE
• Avoid your personal asthma triggers
YOUR ASTHMA CONTROL IS DECREASING IF: • Avoid tobacco smoke exposure
• Check your peak flow _______ per day
• You wheeze, cough, feel tight or have if not already doing so
trouble breathing with your usual activities,
• Controller(s): ____________________________
with exercise or at night
• You develop cold symptoms ____________________________
• You require your reliever medicine more than • Reliever(s): ____________________________
three times per week
____________________________
• Your peak flow is
between ________ and ________ • Other Actions: ____________________________
(60% to 80% of personal best)
____________________________
• Seek medical attention if your asthma control is
not improving within 2 or 3 days

Action:
ORANGE ZONE • Avoid your personal asthma triggers
• Avoid tobacco smoke exposure
YOUR ASTHMA IS OUT OF CONTROL IF: • Check your peak flow _______ per day
if not already doing so
• You wheeze, cough, feel tight or have
trouble breathing even at rest • Controller(s): ____________________________
• Your symptoms are interrupting your sleep
____________________________
• You require your reliever medicine more than
four times in twenty four hours • Reliever(s): ____________________________
• Your peak flow is below _________ ____________________________
(60% of personal best)
• Other Actions: ____________________________

____________________________
• Seek medical attention if your asthma control is
not improving within 12-24 hours

RED ZONE
Action:
• Call 911 or go to the nearest emergency department
YOU ARE IN THE DANGER ZONE IF: immediately
• You can repeat your reliever medicine every ____
• You are getting little relief to no relief in 20
minutes times ____ doses while assistance is being
to 30 minutes after your reliever medicine
arranged
• You are struggling to breathe or having
trouble walking or talking
• Your lips or fingernails are turning blue

Prepared by: Appointments:

______________________________M.D./RT/CAE Date: ____________
Physician Signature:____________________________________________
FC-532-01/06 adapted with permission: Alberta Lung Association White: Chart Canary: Patient Pink: Physician

Chinook Health Region 21 Building Healthy Lifestyles

 Asthma

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 5. Management Strategies for Patients / Clients
YOU HAVE JUST BEEN TOLD THAT YOU OR
YOUR CHILD HAS ASTHMA, NOW WHAT?
WHAT IS ASTHMA?
Asthma is an inflammatory disease of the small airways in the
lungs that results in recurring episodes of difficult breathing due to
the airways becoming more narrow (smaller) than normal. These
episodes may occur quite often or may come and go intermittently.
Asthma ranges from very mild to severe.
WHAT ARE THE SYMPTOMS OF ASTHMA?
When the small airways in lungs begin to narrow, people with
asthma usually notice some or all of the following problems:
• Coughing
• Wheezing
• Chest tightness
• Shortness of breath
• Reduced ability to exercise
WHAT CAUSES AN ASTHMA EPISODE?
(See diagram on back of this page)
• First, a “trigger” is inhaled into the lungs and irritates the small
airways in the lungs.
• Once the small airways are irritated, the insides of the airways
become red, swollen and narrower than normal. If nothing is
done about the swelling it can get worse and people tend to
develop more asthma symptoms.
• Due to the swelling, the small airways in the lungs become quite
“twitchy”. This causes the muscles on the outside of the airway
to tighten and narrow the airways even more. Breathing becomes
much harder than normal at this point and could lead to a
serious asthma episode.
• Asthma episodes, like asthma itself, can range from mild to
severe. Severe asthma episodes can be life threatening and can
result in a hospital stay or even death. Therefore, prevention of
episodes is very important.
• Common asthma triggers are smoke, colds, animal dander, dust,
pollen, cold air and exercise. Please note that exercise should
not be avoided. If you or your child develops asthma symptoms
with exercise, it may be a sign that your or your child’s asthma
is poorly controlled. Contact a healthcare professional to learn
how to improve asthma control. Triggers vary from person to
person. Each person should learn about their own triggers and
try to prepare for them and avoid them when possible.
Chinook Health Region
Asthma
IS ASTHMA A LIFELONG CONDITION?
As a general rule, asthma diagnosed in childhood is a lifelong
condition. Asthma symptoms may diminish in adolescence, but
can often return in adulthood. People with the following factors
are most likely to have asthma that persists into adulthood:
• A parent with asthma
• A history of eczema (scaly red rashes on the skin)
• Allergies or hay fever; allergic rhinitis (inflammation of the lining
in the nose)
THE GOOD NEWS FOR PEOPLE WITH ASTHMA:
• Researchers are constantly seeking a cure. In the meantime,
asthma can be controlled. If asthma is well controlled, there is
a low risk for a serious asthma episode and a person can be as
active as they like.
• To control asthma you need to avoid contact with things that
trigger your asthma and use your asthma medications regularly as
directed by your doctor.
• There are people with well-controlled asthma who are OLYMPIC
ATHLETES!
WHO WILL HELP YOU TO MANAGE YOUR ASTHMA?
• Your family doctor will diagnose and help manage your or your
child’s asthma and should provide you with a written asthma
action plan.
• Your pharmacist can also provide helpful information about
asthma and asthma medications.
• The Chinook Asthma Program is where you will meet with
asthma educators who can perform breathing tests to make sure
your lungs are working at their best as well as provide you with
information about asthma and asthma medications. The asthma
educators will work with your doctor to develop a written
asthma plan and ensure you have the tools and confidence to feel
at ease managing your or your child’s asthma.
• To contact an asthma educator in your community, contact the
Building Healthy Lifestyles toll-free number at 1-866-506-6654
or 388-6654.
23 Building Healthy Lifestyles
 5. Management Strategies for Patients / Clients Asthma

What is asthma?
As the swelling in the airway increases,
the lining of the airway becomes very
sensitive and small muscles around it
start to twitch and tighten. 6 Emergency room visit

5 Muscles around
airway tighten

coug
g
g
cough

1 Normal airway =
normal function h ee
w he ezze

2 Something starts
inflammation

3 Inflammation of
airway and mucous

Reprinted with permission from the

Asthma Society of Canada
www.asthma.ca
www.asthma-kids.ca

Chinook Health Region 24 Building Healthy Lifestyles

 5. Management Strategies for Patients / Clients Asthma

Client Checklist for Asthma

 What to expect at each office visit with your family physician:
Assess asthma control:

Discuss frequency of asthma symptoms

Amount of rescue medication required (blue inhaler usage)

Review triggers and trigger avoidance strategies

Demonstrate use of inhaler device

Make or review a written asthma action plan

Discuss roles and use of asthma medications

Aim to reduce asthma medication dosage while maintaining proper control of asthma

Discuss any other concerns about asthma with your doctor

Tests & Measurements that should be done or discussed on a yearly basis,

 or as recommended by your family physician:
Lung function testing (spirometry)

Height and weight measurements

Screening for osteoporosis if on inhaled corticosteroids for asthma and you have the following risk factors:
• Age > 60 years
• Postmenopausal state without hormone replacement therapy
• Male impotence or infertility
• Previous fractures with minor trauma
• Family history of fractures (parental)
• Past or current chronic glucocorticoid therapy
• Smoking or alcoholism
• Physical inactivity

Referral to an Asthma educator for education & evaluation

Vaccinations

Annual influenza vaccine

Ensure immunizations are up to date

Chinook Health Region 25 Building Healthy Lifestyles

 Asthma

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 6. Indications for a Referral to Medical Specialist or Specialty Program Asthma

6. Indications for a Referral to Medical Specialist or Specialty Program

a. and b. Indications for Referral to Medical Key contacts in the CHR for Asthma:
Specialists and Specialty Programs
Adult Specialists
The following circumstances warrant a referral to an appropriate
Dr. Eric Wilde, Telephone 320-0633
specialist:
• There is doubt about the diagnosis of asthma Pediatric Specialists
• Factors, including aeroallergens and occupational exposures, Dr. K. Chan, Telephone 328-8101
could be involved and have not been properly evaluated; or Dr. M. Harilal, Telephone 320-2236
suspected occupational asthma Dr. J. Holland, Telephone 320-7825
• Asthma is severe according to severity rating criteria
Lethbridge Educators
• There is an apparent discrepancy between the severity of
symptoms and success of treatment Pediatric Asthma clinic, Telephone 388-6180
• There has been a need for emergency treatment or hospital Adult Asthma Clinic, Telephone 388-6180
admission
Rural Educators
• Any persistent respiratory symptoms in infants (under 1 year of
age) and young children (age 1-6) Taber Asthma program, Telephone 223-3525
Cardston Telephone 653-4411
• Normal spirometry tests and/or peak flows, but client requires
Magrath Telephone 758-4411
excessive medication for symptom control or fails to respond
Pincher Creek, Telephone 627-1234
to therapy after the clinician has confirmed compliance with
Crowsnest Pass, Telephone 562-2831
treatment and proper inhaler device technique
Fort Macleod, Telephone 553-5311
Raymond, Telephone 752-4561
c. Local Contacts Milk River, Telephone 647-3500
In the CHR the primary care physicians would refer their adult Picture Butte, Telephone 732-4762
patients to see Dr. Wilde. Once the specialist has seen the client,
By contacting Building Healthy Lifestyles 388-6654 or
they will book additional tests as they see fit.
1-866-506-6654 an appointment can be booked for the patient
Dr. E. Wilde, Specialist Internal & Respiratory Medicine and BHL will notify the appropriate asthma educator.
phone 320-0633
Clinical Guides are available on-line at:
In the CHR the primary care physicians would refer their pediatric
www.chinookprimarycarenetwork.ab.ca/extranet/resources/guides.php
patients to see the following pediatricians:

Dr. K. Chan, Telephone 328-8101

Dr. M. Harilal, Telephone 320-2236
Dr. J. Holland, Telephone 320-7825

Or

The primary care physician could refer pediatric clients to the

Lethbridge Pediatric Asthma Clinic. A pediatrician will assess and
make recommendations for each child who attends the clinic. The
primary care physician would complete a referral form and fax it to
the Building Healthy Lifestyles Program.

Telephone: 388-6654 or 1-866-506-6654

Fax: 317-0435

Chinook Health Region 27 Building Healthy Lifestyles

 Asthma

Chinook Health Region 28 Building Healthy Lifestyles

 7. References Asthma

7. References
a. Evidence
1. Becker, Allan, MD; Berube, Denis, MD; Montgomery, Mark, MD; Sears, Malcolm, MD; Spier, Sheldon, MD; on behalf of
the Canadian Pediatric Asthma Consensus Guidelines 2003 (updated to December 2004) Supplement to CMAJ 2005; 173
(6 suppl): S1-S56
2. Boulet,Louis-Philippe, MD; Becker, Allan, MD; Berube, Denis, MD; Beveridge,Robert, MD; Ernst, Pierre MD; on behalf
of the Canadian Asthma Consensus group. Canadian Asthma Consensus Report 1999. Supplement to CMAJ 1999; 161
(11 suppl)
3. British Columbia Guidelines & Protocols Advisory Committee, Diagnosis and Management of Asthma July 1, 2003
4. FitzGerald JM, Becker A, Sears MR, et al. Doubling the dose of budesonide versus maintenance treatment in asthma
exacerbations. Thorax 2004;59:550-6
5. Green RH, Brightling CE, McKenna S, et al. Asthma exacerbations and sputum eosinophil counts: a randomised controlled
trial. Lancet 2002; 360:1715-21
6. Harrison TW, Oborne J, Newton S, et al. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations:
randomised controlled trial. Lancet 2004;363:271-5
7. Jarjour NN, Gern JE, Kelly EA, et al. The effect of an experimental rhinovirus 16 infection on bronchial lavage neutrophils.
J Allergy Clin Immunol 2000;105:1169-77
8. Johnston SL, Pattemore PK, Sanderson G, et al. Community study of role of viral infections in exacerbations of asthma in
9-11 year old children. BMJ 1995;310:1225-9
9. Lemiere,C; Bai,T; Balter, M, et al, on behalf of the Canadian Adult Consensus group of the Canadian Thoracic Society.
Adult Asthma Consensus guidelines update 2003. Can Respir J 2004; 11 (Suppl A); 9A – 18A
10. Respiratory Division, Cardio-Respiratory diseases and diabetes bureau, laboratory centre for disease control, Health Canada.
The national asthma control task force. The prevention and management of asthma in Canada 2000

b. On-line Resources
1. Canadian Lung Association www.lung.ca
2. Canadian Thoracic Society www.lung.ca/cts/
3. COPD & Asthma Network of Alberta (CANA) www.canahome.org
4. Family Physicians Airways Group of Canada www.fpagc.com
5. Canadian Network for Asthma Care (CNAC) www.cnac.net
6. Child Asthma Network iCan www.calgaryhealthregion.ca/ican/
7. National Institute of Health www.nhlbi.nih.gov
8. Canadian Society of Allergy & Clinical Immunology www.csaci.medical.org
9. Global Initiative for Asthma www.ginaasthma.com
10. Calgary Allergy Network www.calgaryallergy.ca
11. American Academy of Allergy, Asthma & Immunology www.aaaai.org
12. Asthma Society of Canada www.asthma.ca

Available CHR Resources

Winning with Asthma www.chr.ab.ca

Chinook Health Region 29 Building Healthy Lifestyles