Summary of the NHLBI EPR3: Guidelines for the Diagnosis and Management of Asthma

Children age 5-11 years

NHLBI Classification of Asthma Severity (if not currently taking long-term control medications)
PERSISTENT
Components of Severity INTERMITTENT
MILD MODERATE SEVERE
Symptoms* ≤ 2 days/week > 2 days/week but not daily Daily Throughout the day
Impairment Night time awakenings* ≤ 2 x/month 3-4x/month > 1 x/week but not nightly Often 7x/week
SABA use for symptom control
≤ 2 days/week > 2 days/week but not daily Daily Several times per day
(not for prevention of EIB)*
Interference with normal activity* None Minor limitation Some limitation Extremely limited
> 80%
FEV1 > 80% > 60% - < 80% < 60%
Lung function Normal between exacerbations
FEV1/FVC > 85% > 80% > 75% - < 80% < 75%
Exacerbations requiring 0-1/year > 2/year
Risk

oral systemic corticosteroids Consider severity and interval since last exacerbation. Relative annual risk of exacerbations may be related to FEV1
Step 3, medium-dose ICS
Step 3, medium-dose ICS option
Recommended Step for Initiating Treatment
Step 1 Step 2 option, or Step 4
(see Stepwise Approach)
Also consider short course of oral systemic corticosteroids

NHLBI Classification of Asthma Control

Components of Control WELL CONTROLLED NOT WELL CONTROLLED VERY POORLY CONTROLLED
< 2 days/week, but not more than
Symptoms* >2 days/week, or multiple times on < 2 days/week Throughout the day
once per day
< 1x/month > 1x/month > 1x/week
Impairment

Night time awakenings*

SABA use for symptom control
< 2 days/week > 2 days/week Several times per day
(not for prevention of EIB)*
Interference with normal activity* None Some limitation Extremely limited
FEV1 or peak flow > 80% predicted or personal best > 60% to < 80% predicted or personal best < 60% predicted or personal best
FEV1/FVC > 80% > 75% - < 80% < 75%
0-1/year > 2/year
Risk

Exacerbations requiring Consider severity and interval since last exacerbation

oral systemic corticosteroids
Recommended Action for Treatment
(see Stepwise Approach)
* based on patient's/caregiver's recall of previous 2-4 weeks
FEV1 = forced expiratory volume in 1 second
FVC = forced vital capacity
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ƒ Maintain current step with ƒ Consider short course of oral systemic corticosteroids
ƒ Step up at least 1 step, and
followups every 1-6 months. ƒ Step up 1-2 steps, and
ƒ Reevaluate in 2-6 weeks
ƒ Consider step down if well ƒ Reevaluate in 2 weeks
controlled for > 3 months For side effects, consider alternative treatment options.
EIB = exercise-induced bronchospasm
SABA = inhaled short-acting beta2-agonist
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 Summary of the NHLBI EPR3: Guidelines for the Diagnosis and Management of Asthma
Children age 5-11 years

Medical Management Education/Self Care

• History and physical • Patient/Caregiver knows PEF meter personal best reading, and has
ƒ Identify possible alternative diagnoses PEF meter value parameters and/or symptoms as guideline for
ƒ History of episodic airflow obstruction taking actions
ƒ Identify triggers • Patient/Caregiver knows triggers
ƒ Identify comorbidities that may aggravate asthma
• Pulmonary function tests (spirometry with pre- and post-bronchodilator) to establish that airflow obstruction is at least partially reversible.
Initial Assessment

ƒ Spirometry is generally valuable in children > 5 years of age, but some children under age 7 are not able to perform the test
ƒ Obstruction: Reduction in FEV1 and FEV1/FVC relative to reference or predicted values
ƒ Reversibility: an increase in FEV1 of > 200 ml and > 12% from baseline after inhaling SABA FEV1 = forced expiratory volume in 1 second
ƒ A 2-3 week trial of oral corticosteroid therapy may be required to demonstrate reversibility of airflow obstruction. FVC = forced vital capacity
• If initial spirometry is normal
ƒ Further testing as appropriate (lung volumes and inspiratory loops, diffusing capacity, or bronchoprovocation)
ƒ Consider Chest -ray to exclude other diagnoses
• Classify asthma severity (see table)
ƒ Assess both domains: impairment and risk.
ƒ Impairment: present effects on quality of life and functional capacity
ƒ Risk: future adverse events such as exacerbations and progressive loss of pulmonary function
ƒ Assign severity to the most severe category in which any feature occurs.
ƒ The 2 domains may respond differently to treatment

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 Summary of the NHLBI EPR3: Guidelines for the Diagnosis and Management of Asthma
Children age 5-11 years

Medical Management Education/Self Care

• All patients: quick relief medication Medications:
ƒ SABA PRN for symptoms: up to 3 treatments at 20-minute intervals. Short course of oral systemic corticosteroids may be needed. • Carry a medication list
ƒ For children with exercise-induced asthma symptoms: treatment immediately before activity • Patient/Caregiver understand:
ƒ Use of SABA > 2 days a week for symptom relief, (not prevention of EIB) indicative of inadequate control; step up treatment. ƒ Purpose
• Initial treatment: ƒ Side effects
ƒ See Recommended Step on Classification of Severity table ƒ Drug interactions
ƒ After 2-6 weeks of treatment, evaluate level of control and adjust therapy accordingly ƒ Difference between "quick-relief" and "long-term control"
• Continuing treatment: medicines
Stepwise Approach to Medications and Treatment

ƒ See Recommended Action on Classification of Control table • Use correct inhaler technique
ƒ Before step up in therapy: • Use spacer or nebulizer as appropriate
o Review adherence to medication, inhaler technique, environmental control and comorbid conditions. • Maintain adequate supply
o If an alternative treatment option was used in a step, discontinue and use the preferred treatment for that step. • Have prompt and reliable access to quick-relief medicine at school
Stepwise Approach: and childcare setting
• STEP 1 • Avoid B-blockers
ƒ no daily medication required • Avoid ASA and NSAIDS in selected patients
• STEP 2
ƒ Preferred: Low dose ICS.
ƒ Alternatives: cromolyn, LTRA, nedocromil, or theophylline. EIB = exercise-induced bronchospasm
• STEP 3 ICS = inhaled corticosteroid
ƒ Preferred: Low dose ICS and either LABA, LTRA, or theophylline or Medium dose ICS (alone). LABA = long-acting inhaled beta2-agonist
• STEP 4 LTRA = leukotriene receptor antagonist
ƒ Preferred: Medium dose ICS and LABA. SABA = inhaled short-acting beta2-agonist
ƒ Alternatives: Medium dose ICS and either LTRA or theophylline.
• STEP 5
ƒ Preferred: High dose ICS and LABA.
ƒ Alternative: High dose ICS and either LTRA or theophylline
• STEP 6
ƒ Preferred: High dose ICS and LABA and oral corticosteroid.
ƒ Alternative: High dose ICS and either LTRA or theophylline, and oral corticosteroid
For steps 4-6, consult asthma specialist. Consider consultation at step 3. For steps 2-4, consider immunotherapy for allergic asthma
• LABA
ƒ Weigh benefits of LABA for asthma that is not well controlled with ICS alone against the small but increased risk of severe
exacerbations associated with LABA.
ƒ LABA are not to be used as monotherapy for long-term control.

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 Summary of the NHLBI EPR3: Guidelines for the Diagnosis and Management of Asthma
Children age 5-11 years

Medical Management Education/Self Care

Achieve asthma control by • Written Action plan
• Reducing impairment: ƒ symptom management
Goals of Therapy

o Prevent chronic and troublesome symptoms day and night. ƒ daily management
o Maintain normal activity levels (including exercise and school/work attendance) ƒ copy provided to school and childcare setting
o Maintain (near) normal pulmonary function. Trigger avoidance
o Require infrequent use of SABA for symptom relief (< 2 days a week). • Monitor and track PEF meter values as recommended and/or monitor frequency of daytime and
o Meet patients' and families' expectations of and satisfaction with asthma care nocturnal symptoms
• Reducing risk: • Monitor frequency of quick-relief medicine use
o Prevent recurrent exacerbations and minimize need for ED visits or hospitalizations
o Prevent progressive loss of lung function
o Provide optional pharmacotherapy with minimal or no adverse effects.

• Tobacco Smoke • Tobacco cessation programs for adults who smoke and have children with asthma in the household
ƒ Advise caregivers to not expose child to environmental tobacco smoke • For GERD:
Comorbid Conditions

• Gastroesophageal reflux disease o Avoid heavy meals, fried food, and caffeine
ƒ Proton Pump Inhibitor, H2 blocker o Avoid food and drink within 3 hours of retiring
• Rhinitis/Sinusitis o Elevate head of bed on 6-8 inch blocks
ƒ Intranasal steroids • For obesity, weight loss
ƒ Antihistamines (for rhinitis only)
ƒ Antibiotics for bacterial infection
ƒ Immunotherapy for allergic rhinitis
• Obesity
ƒ Weight loss may improve asthma control

Prevention
Influenza vaccine, yearly, per recommendation of the Advisory Committee on Immunization Practices of the CDC.

National Heart, Lung, and Blood Institute. Expert Panel 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health, NHLBI;
2007. NIH publication 07-4051. Available at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf Accessed September 17, 2007.

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