Asthma:

Treatment and
Management
Mary Worthington, PharmD, BCPS
February 15, 2016
Asthma Packet Two
Acute Asthma Management

1
 Treating Asthma
Exacerbations in the
ED & Hospital
Relieving Acute
Symptoms
Educating Patients
and Caregivers how to
Self-Manage at Home

Asthma Therapy
Controlling Mild
Persistent Asthma

Controlling Chronic Classifying Severity of Controlling Moderate

Inflammation Chronic Asthma Persistent Asthma

Controlling Severe
Persistent Asthma

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 Sources of Information

2015
2007 2012

http://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf
http://www.nhlbi.nih.gov/guidelines/asthma/asthma_qrg.pdf
http://www.ginasthma.org/local/uploads/files/GINA_Report_2015_Aug11.pdf
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Patient Case: Luke Williams, a 6 year old, 29 kg male
HOPI: Luke presents to the ED with his mother at 0500 due to difficulty breathing. His symptoms began 1
day prior with a “runny nose”. His mom gave him an albuterol neb yesterday for his “cold.” Overnight,
he awakened with coughing and his mother was worried that he was breathing fast and using his
chest muscles.

Luke’s mother also notes that he averages 4 “colds” per year usually associated with nighttime
coughing. Mom has used albuterol for these colds in the last year and remembers wheezing with
them. She has given Luke albuterol twice in the last week. In the last month, the mother notes he has
woke up coughing at night three times.
Past Medical Full term birth
History:
Two previous hospitalizations: 1) at 9 months for bronchiolitis due to RSV – first time received
albuterol; 2) at 30 months for “reactive airway disease” related to a “cold” *received albuterol,
prednisone during that hospitalization]

Seasonal allergies
Medication • NKDA
History: • Albuterol 2.5 mg /3 ml for nebulizer, prescribed by PMD for colds
• Montelukast 5 mg po nightly for seasonal allergies
• IUTD, Flu Shot 10/14
Family/Social Luke lives with mother, father and 3 year old sister
History: + Paternal history for asthma
+ smoke exposure from grandmother who keeps after school
Insurance: Alabama Medicaid
Patient Case: Luke Williams, a 6 year old, 29 kg male

Physical Vitals: Afebrile RR 42 () HR 140 () BP 100/60 (nl)

Exam:
O2 sats – 94% on 1 L/min by nasal cannula (started in triage, 88% pre O2)

Gen: Awake, agitated, in discomfort, talks in words

HEENT: NC/AT, + nasal crease, no LAD

Chest: Wheezing on inhalation/exhalation throughout lung fields, 2+ Subcostal

retractions

CV: RRR, no m/r/g

Abd: soft, NT/ND

Extremities: No clubbing or cyanosis, well perfused, cap refill < 2 sec

 Assessing Luke’s Case
1. What are the main clinical symptoms that
suggest asthma?

2. What are Luke’s risk factors for asthma?

3. What phenotype of asthma describes Luke?

4. What are some key pathophysiologic findings

we need to address?
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Patient Case: Luke Williams, a 6 year old, 29 kg male
Physical Vitals: Afebrile RR 42 () HR 140 () BP 100/60 (nl)
Exam: O2 sats – 94% on 1 L/min by nasal cannula (started in triage, 88% pre O2)
Gen: Awake, agitated, in discomfort, talks in words
HEENT: NC/AT, + nasal crease, no LAD
Chest: Wheezing on inhalation/exhalation throughout lung fields, 2+ Subcostal
retractions
CV: RRR, no m/r/g
Abd: soft, NT/ND
Extremities: No clubbing or cyanosis, well perfused, cap refill < 2 seconds
Assessment: Acute asthma exacerbation

Overall goals:
1) Treat acute asthma exacerbation
2) Initiate therapy for chronic asthma
3) Provide asthma education
 Acute Asthma Exacerbation
• Definition: acute or sub-acute worsening in symptoms and
lung function from the patient’s usual status
– Requires a change in treatment
• Occurs in patients already diagnosed with asthma or may
be the initial presentation of asthma
• Usually occurs in response to a “trigger” or if known
asthmatic, poor adherence to controller therapy
• Other terms: acute severe asthma, flare-up
• Hallmark signs:
– Shortness of breath
– Cough
– Wheezing
– Chest tightness
• Characterized by decreases in expiratory airflow
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 Initial Assessment of Acute Asthma Exacerbations

Mild-Moderate Severe Life-Threatening

Talks in phrases
Prefers sitting to lying
Not agitated
RR increased
HR 100 – 120 bpm
≤ 200 bpm (0-3 years)
≤ 180 bpm (4 -5 years)
Accessory muscles not used
O2 saturation 90 – 95% on RA
≥ 92% (0-5 years)
PEF > 50% predicted or best
Talks in words Drowsiness
Sits hunched forward Confusion
Agitated Silent chest
RR > 30/min (>40 (2-5 years))
HR > 120 bpm
> 200 bpm (0-3 years)
> 180 bpm (4-5 years)
Accessory muscles being used
O2 saturation < 90% on RA
< 92% (0-5 years)
PEF ≤ 50% predicted or best

Global Strategy for Asthma Management and Prevention. 2015. 9

Patient Case: Luke Williams, a 6 year old, 29 kg male
Physical Vitals: Afebrile RR 42 () HR 140 () BP 100/60 (nl)
Exam: O2 sats – 94% on 1 L/min by nasal cannula (started in triage, 88% pre O2)
Gen: Awake, agitated, in discomfort, talks in words
HEENT: NC/AT, + nasal crease, no LAD
Chest: Wheezing on inhalation/exhalation throughout lung fields, 2+ Subcostal
retractions
CV: RRR, no m/r/g
Abd: soft, NT/ND
Extremities: No clubbing or cyanosis, well perfused, cap refill < 2 seconds
Assessment: Acute asthma exacerbation
Overall goals:
1) Treat acute asthma exacerbation
2) Initiate therapy for chronic asthma
3) Provide asthma education
How do you assess the severity of Luke’s asthma exacerbation and why?
 Additional Tests in Asthma Exacerbations
• ABG’s recommended for:
1. FEV1 or PEF < 50% predicted
2. Lack of response to initial treatment
3. Patients who are deteriorating
Pa O2 < 60 mm Hg and normal or increased PaCO2 (especially > 45 mm Hg)
Indicates respiratory failure

• CXR if unclear diagnosis, fever, consolidation on

auscultation, elevated WBC

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Mild-Moderate
Talks in phrases
Prefers sitting to lying
Not agitated
RR increased
HR 100 – 120 bpm
≤ 200 bpm (0-3 years)
≤ 180 bpm (4 -5 years)
Accessory muscles not used
O2 saturation 90 – 95% on RA
≥ 92% (0-5 years)
PEF > 50% predicted or best
Short Acting Beta2-Agonists
Consider ipratropium bromide
O2 for saturation 93-95%
(children 94-98%)
Oral corticosteroids
Global Strategy for Asthma Management and Prevention. 2015.
Severe Life-Threatening
Talks in words Drowsiness
Sits hunched forward Confusion
Agitated Silent chest
RR > 30/min (> 40 (2-5 years))
HR > 120 bpm
> 200 bpm (0-3 years)
> 180 bpm (4-5 years)
Accessory muscles being used
O2 saturation < 90% on RA
< 92% (0-5 years)
PEF ≤ 50% predicted or best
Short Acting Beta2-Agonists Consult ICU
Ipratropium bromide Short Acting Beta2-Agonists
O2 for saturation 93-95% O2
(children 94-98%) Prepare patient for intubation
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
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Treatment Priorities in Acute Asthma Exacerbations
1. Oxygen
– Given by mask or nasal cannula
– Guided by pulse oximetry
– Maintain O2 Sats > 93 -95% (94-98% children)
– Albuterol may transiently decrease O2
2. Inhaled albuterol +/- inhaled ipratropium
3. Oral or IV corticosteroids
4. Supportive care
5. Additional adjunctive or therapies
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 Albuterol in the ED and Hospital
• After O2 if needed, most critical to initiate quick
• Dosing
– MDI+spacer/mask 4-8 puffs q 1-4 hr Up To 3 doses in
st
1 Hour
– Nebulization 2.5 – 10 mg q 1-4 hr
– MDI + spacer most cost effective, efficient (mild/mod)
– Can use continuous nebulization
• Severely obstructed patients
• Dose 10-15 mg/hr
• Typical patient
– Pending respiratory arrest
– Minimal pulmonary air movement
– Initial PEF or FEV1 < 30%

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 Ipratropium Bromide (Atrovent)
• When used with albuterol in the ED:
– 10-15% improvement in lung function
– Use in children reduced hospitalization
• Recommended in severe exacerbations and to consider in
mild/moderate exacerbations
• Useful in patients on beta blockers or if stress is trigger

MDI with Spacer/Mask Nebulization

4-8 puffs every 2 – 4 hours Adult: 500 mcg (1 vial) every 2-4 hours
Children: 250 mcg (1/2 vial) every 2-4 hours

• Often given with every other albuterol treatment

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 Systemic Corticosteroids
• Speed resolution of airflow obstruction
• Reduce rate of relapse
• Indications
– All but mildest exacerbations
– Particularly if incomplete response to initial SABA
– Also important if currently on OCS or previously required
OCS
• Effect delayed 4-8 hours, give in 1st hour if possible
• Oral as effective as IV
• IV recommended if patient is too dyspneic to swallow,
vomiting or if being intubated
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 Systemic Corticosteroid “Bursts”
Systemic Corticosteroid Dosing in Exacerbations
Drug Adult Dose Pediatric Dose Pearls
Methylprednisolone 40 mg IV BID 1 mg/kg/dose IV BID Transitioned to oral therapy
(max 40 mg/dose) as soon as tolerated

Prednisolone or 40 – 80 mg/day 1 – 2 mg/kg/day orally • Prednisolone liquid

Prednisone orally in 1 – 2 in 1 – 2 divided doses better taste
divided doses (Maximum 60 mg/day) • Tablets small often
children can take
Dexamethasone 16 mg/day in 1 dose 0.6 mg/kg/day in 1 dose “Newer” choice for shorter
for 1 -2 days for 1 -2 days courses
(Max 16 mg/day)

• For “pred” regimens, 5 – 7 days as effective as 10 – 14 days

• For “pred” regimens, 3 -5 days effective in children
• Tapering not necessary
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 Supportive Care
• Young children
– IV fluids indicated if dehydrated
• Antibiotics if evidence of lung infection
– Fever
– Purulent sputum
– CXR shows pneumonia

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Magnesium Sulfate as Adjunctive Therapy
• When given as one time infusion in the ED
decreased hospital admissions if:
– Adults with FEV1< 25-30% of predicted
– Adults and children who fail to respond to initial therapy and are
hypoxemic
– Children whose FEV1 < 60% predicted after an hour of therapy
• Dosing: 25 – 40 mg/kg up to 2 gm infused over 20 - 60 min
• May also nebulize 150 mg in children ≥ 2 years
– Can be given with albuterol and ipratropium in 1st hr
– Recommended if severe exacerbation, O2 < 92% (GINA)

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 Other Treatments
• IM epinephrine – if exacerbation associated with
anaphylaxis or angioedema
• Leukotriene receptor antagonists – small studies
demonstrate improved lung function in exacerbations,
further study needed
• Heliox – not routinely recommended, consider in
refractory patients, may have lack of availability
• Aminophylline/Theophylline – not recommended, poor
efficacy and safety profile
• Strictly avoid sedative due to respiratory depression
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Patient Case: Luke Williams, a 6 year old, 29 kg male
Physical Vitals: Afebrile RR 42 () HR 140 () BP 100/60 (nl)
Exam: O2 sats – 94% on 1 L/min by nasal cannula (started in triage, 88% pre O2)
Gen: Awake, agitated, in discomfort, talks in words
HEENT: NC/AT, + nasal crease, no LAD
Chest: Wheezing on inhalation/exhalation throughout lung fields, 2+ Subcostal
retractions
CV: RRR, no m/r/g
Abd: soft, NT/ND
Extremities: No clubbing or cyanosis, well perfused, cap refill < 2 seconds
Assessment: Acute asthma exacerbation
Overall goals:
1) Treat acute asthma exacerbation
2) Initiate therapy for chronic asthma
3) Provide asthma education
What initial treatments do you recommend for Luke?
Patient Case: Luke Williams, a 6 year old, 29 kg male
Initial 1. Albuterol 2.5 mg/3 mls nebulized every 20 min x 3 doses
Therapies 2. Ipratropium 250 mcg nebulized with 1st dose of albuterol
3. Prednisolone 15 mg/5 mls: 30 mg (10 mls) po X 1 dose
1 hour later: Vitals: Afebrile RR 34 () HR 122 () BP 105/62 (nl)
O2 sats – 94% on 1 L/min by nasal cannula, dropped to 90% when removed
Gen: Awake, less agitated, talks in words and phrases
Chest: Wheezing improved but still present on exhalation throughout lung
fields, 1+ Subcostal retractions
Questions: How do we assess Luke’s response?
Does he require hospital admission?
How do we continue therapies and monitor for efficacy and ADE’S?
 Monitoring for Treatment Effectiveness in
Asthma Exacerbations
• Patients require frequent assessment
• All patients should be monitored 1 hr after initial treatment
Good Response Partial Response Deterioration
-Symptoms improved -Symptoms improved but still -Worsening clinical picture
-Not needing SABA present (particularly if severe)
-O2 > 94% room air -Need for O2
-PEF improved -PEF < 60% predicted or best
> 60-80% predicted or best
-Resources available at home
Likely Discharge Continued Care Increase dose SABA
-PEF < 40% - admit Utilize additional therapies
-PEF 40-60% assess other risks Re-evaluate for intensive care

Global Strategy for Asthma Management and Prevention. 2015. 23

Increased Likelihood for Hospital Admission
Female sex
Older age
Non-white race
>8 puffs of SABA in the previous 24 hours
Past history of severe exacerbations
Previous unscheduled doctor’s office or ED visits resulting in use of OCS
Severity on presentation (needed resuscitation, RR > 22, O2 sats , 95%, final PEF < 50%)

Increased Risk of Asthma-Related Death

History of near-fatal asthma requiring intubation and mechanical ventilation
Hospitalization or ED care for asthma in the past year
Currently using of having recently stopped OCS
Not currently using ICS
Over-use of SABAs, especially > 1 MDI monthly
History of psychiatric disease or psychosocial problems
Poor adherence with asthma medications and/or written asthma action plan
Food allergy

Global Strategy for Asthma Management and Prevention. 2015. 24

Patient Case: Luke Williams, a 6 year old, 29 kg male
Initial 1. Albuterol 2.5 mg/3 mls nebulized every 20 min x 3 doses
Therapies 2. Ipratropium 250 mcg nebulized with 1st dose of albuterol
3. Prednisolone 15 mg/5 mls: 30 mg (10 mls) po X 1 dose
1 hour later: Vitals: Afebrile RR 34 () HR 122 () BP 105/62 (nl)
O2 sats – 94% on 1 L/min by nasal cannula, dropped to 90% when removed
Gen: Awake, less agitated, talks in words and phrases
Chest: Wheezing improved but still present on exhalation throughout lung
fields, 1+ Subcostal retractions
Questions: How do we assess Luke’s response?

Does he require hospital admission?

How do we continue therapies and monitor for efficacy and ADE’S?

Patient Case: Luke Williams, a 6 year old, 29 kg male
3 hours later Luke is a now admitted to the hospital from the ED for an acute asthma
exacerbation.
He is currently receiving:
1. O2 by nasal cannula, currently 0.5 L/min to maintain saturation ≥ 94%
2. Albuterol 2.5 mg/3 mls NS nebulized every 2 hours
3. Ipratropium 250 mcg nebulized every 4 hours
4. Magnesium Sulfate 1000 mg IV over 1 hr x 1 dose
5. Prednisolone 30 mg by mouth once a day, starting in hospital the next day
Exam and
Lab Results 1 136 111 15 13
hour later 125 10.8 257
2.8 23 0.5 40

Calcium – 9.3 Vitals: Afebrile, HR 140, RR 29, BP 95/48

Magnesium – 2.3 General: shaky and complaining of nausea
Phosphorous -4.6
What are your concerns?
Monitoring Asthma Exacerbation Therapies for ADEs
Drug ADEs
Albuterol Trembling, agitation common
Tachycardia, palpitations with higher dosing
Hypokalemia (20%) with higher dosing
Hyperglycemia with high doses
Ipratropium Poorly absorbed so few ADE’s
Dry mouth, pupil dilation due to anticholinergic effects
Systemic Corticosteroids With short-term “bursts” most common ADE’s:
GI irritation
Headache
Mood changes
On labs, can see elevated WBC’s, hyperglycemia, hypokalemia
Magnesium With one dose generally safe
Infuse slowly to avoid:
Hypotension
Facial flushing, sweating, nausea
With toxicity see loss of deep tendon reflexes, respiratory depression
Can follow magnesium levels
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Patient Case: Luke Williams, a 6 year old, 29 kg male
The following Luke has continued to improve overnight. He is currently receiving albuterol 2.5 mg nebulized every 3
day hours, ipratropium 250 mcg every 6 hours and prednisolone 30 mg by mouth once a day. He is off
oxygen with good oxygen saturations on room air. As a team, you decide to discontinue his
ipratropium and the respiratory therapist hopes to space his albuterol treatments to every 4 hours
later in the day. Luke’s mom attend asthma education and discharge Luke later today.
Assessment and Resolving acute asthma exacerbation
Plan:  Discontinue ipratropium
 Space albuterol 2.5 mg/3 mls nebulized to q4h later in day
 Continue current prednisolone dosing
 Provide asthma education to Luke and his mom on how to use albuterol for asthma flare-ups at
home
 Assess severity of Luke’s chronic asthma and potentially initiate controller therapy
 Provide asthma education to Luke and his mom on maintaining asthma control
 Provide written asthma action plan
 Ensure availability of needed medications at discharge
After ED or hospital exacerbations, prior to discharge:
– Assess patient’s chronic management of asthma and
adjust treatment if needed
– Educate regarding:
• Disease
• Plan for self management of acute symptoms
• Drug therapy(s)
• Triggers and avoidance
• Smoking cessation if indicated
– Provide written Asthma Action Plan
– Ensure availability of medicines and follow-up

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 Self Management of Acute Asthma
• All asthma patients should be prescribed an inhaled
short acting beta2 agonist for use as a reliever (or
rescue) therapy.
• They are used on as needed (PRN) basis to relieve
breakthough symptoms included worsening asthma
or exacerbations.
• They are also recommended for short-term
prevention of exercise-induced bronchoconstriction.
• Goal in asthma management is to eliminate need for
reliever therapy.

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 Why SABAs for Relievers?
• Most effective drugs for treatment of breakthrough symptoms
• Physiologic effects:
– Smooth muscle relaxation
– Mast cell membrane stabilization
– Skeletal muscle stimulation
Why Inhaled?
• Bronchodilation ≥ oral or intravenous
• More rapid onset and less erratic absorption than oral

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 Albuterol for Quick Relief
• Used by majority of patients
Formulations
HFA ProAir, Proventil, Ventolin
DPI ProAir RespiClick
Nebulizer Albuterol Sulfate Soln 2.5 mg/3ml
• Typical Outpatient Dosing
– HFA: 2 to 4 puffs every 4 – 6 hrs inhaler PRN + directions on asthma action plan
– DPI: 1 – 2 inhalations every 4 – 6 hrs PRN (≥ 12 years) + asthma action plan
– Neb: 2.5 mg nebulized every 4 – 6 hrs PRN + asthma action plan
– Regular scheduled use NOT recommended
– Use > 2/week (except EIB): start/intensify controller therapy
• Increasing use or lack of expected effects also indicates poor control of
asthma!
– > 1 canister/month over-reliance on drug
– > 2 canisters/month indicates increased adverse asthma risks
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 Choosing an Inhaler Product
• Consider patient skills (age? Barriers- arthritis?)
• Consider cost and insurance coverage
• Encourage the patient to participate
• If MDI, recommend a spacer to improve
delivery and with ICS, minimize ADE’s
• If on more than one inhaler, try to use same
type of inhaler

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 Choosing an Inhaler Product ≤ 5 Years
Age Preferred Device Alternate Device

0–3 MDI with Spacer and Face Mask Nebulizer with Face Mask
years

4–5 MDI with Spacer (Mouthpiece) MDI with Spacer and Face Mask
years
Nebulizer with Mouthpiece

Nebulizer with Face Mask

Global Strategy for Asthma Management and Prevention. 2015.

 Albuterol MDI
• Preferred to use with spacers (valve holding
chambers [VHC])
• If no spacer, open mouth technique has no clinical
benefit over closed mouth technique.
• Closed mouth technique is easier to use
• For SABA’s, wait 15-30 seconds between puffs

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 Procedure for Proper Use of MDI

1. Assemble MDI if necessary

2. Remove cap and inspect mouthpiece for foreign objects
3. Shake MDI
4. Prime MDI if necessary
5. Tilt head back slightly and exhale
6. Wrap lips around spacer mouthpiece
7. Just as you begin to inhale, depress canister once to release medication
8. Continue to inhale slowly over 3-5 seconds
9. Hold breath for 10 seconds
10. Wait a brief period prior to next puff if needed

Remember – A Spacer is Recommended for all MDI Prescriptions

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Assignment

37
 Spacers and Face Masks

• Delivery ~ ½ dose of MDI or MDI + spacer

• Mask fits over both nose and mouth
• Usually come in multiple sizes
– Best to individualize fit
• Use 6 breaths or 5-10 seconds/spray
• Clean appropriately
– Weekly
– Rinse with dilute household dish soap to enhance delivery

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 Proventil RespiClick
• Dry powder, breath actuated inhaler
• Approved for patients ≥ 12 years
• Match reliever technique for patients
using DPI for controller therapy
• No priming, no shaking
• Steps
1. Open cap, clicks to load dose
2. Exhale (not into inhaler)
3. Place mouth on mouthpiece, but do not cover vent
4. Breath in, breath actuates release of dose
5. Hold breath 10 seconds
6. Repeat all steps for 2nd puff
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 Albuterol Nebulized
• Slow tidal breathing with occasional deep breaths
• If mask, should fit tightly over mouth and nose
• Do not use blow-by
• May be expensive and time-consuming
• Risk of infection if not cleaned properly

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 The Other SABA…. Levalbuterol
• Xopenex HFA and Solution
• Active (r) – enantiomer of albuterol
• ? (s) enantiomer associated with albuterol’s ADEs
– Tremor, agitation, tachycardia
– If eliminate (s) enantiomer, less ADEs
– Controversial if decreased adverse effects or dose-related
– Use ½ albuterol dose if ADEs
• FDA labeling ≥ 4 years
• May be costly in some environments

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 Translating Reliever Self-Management to Action Plan

• Know early signs of deterioration

• Know how to monitor peak flow if applicable
• Seek help early if
– Exacerbation is severe
– Therapy does not provide improvement
– Symptoms deteriorate
• Have treatments and equipment ready

42
 Peak Expiratory Flow
•Maximal rate of flow
•Measured easily with handheld meters
•Useful for:
–Older children and adults
–Moderate persistent or severe persistent disease
–Poor perception of airflow obstruction or
worsening disease
–Unexplained response to environmental or
occupational exposures

43
 Peak Expiratory Flow
• When initiating use:
– Perform maneuver twice a day over a 2 week period
– Each time, record best of 3 attempts
• Zones:
 Red – medical alert
 < 50% personal best
 Yellow – caution
 50-80% personal best
 Green – good control
 80% personal best

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 Point of Care Testing – Peak Flow
Adult Men
Age Height
(Yrs) 60” 65” 70” 75” 80”
20 554 602 649 693 740
25 543 590 636 679 725
30 532 577 622 664 710
35 521 565 609 651 695
40 509 552 596 636 680
45 498 540 583 622 665
50 486 527 569 607 649
55 475 515 556 593 634
60 463 502 542 578 618
65 452 490 529 564 603
70 440 477 515 550 587

Leiner GC. AM Rev Respir Dis. 1963; 88:644.

45
 Point of Care Testing – Peak Flow
Adult Women
Age Height
(Yrs) 55” 60” 65” 70” 75”
20 390 423 460 496 529
25 385 418 454 490 523
30 380 413 448 483 516
35 375 408 442 476 509
40 370 402 436 470 502
45 365 397 430 464 495
50 360 391 424 457 488
55 355 386 418 451 482
60 350 380 412 445 475
65 345 375 406 439 468
70 340 369 400 432 461

Leiner GC. AM Rev Respir Dis. 1963; 88:644.

46
 Point of Care Testing – Peak Flow
Children and Adolescents
Height (Inches) Males and Females
43” 147
44” 160
45” 173
46” 187
47” 200
48” 214
49” 227
50” 240
51” 254
52” 267
53” 280
54” 293
55” 307
56” 320
57” 334

Polgar G. Pulmonary Function Testing in Children: Techniques and Standards. 1971. 47

48
49
 Albuterol Algorithm for Self-Management
Initial Treatment: How we use
Up to two treatments 20 minutes Albuterol in
apart of 2 – 6 puffs by MDI or 2.5 mg nebulizer Yellow and
treatment Red Zones

Good Response:
No Wheezing or dyspnea
PEF > 80% Incomplete Response:
Albuterol q 3-4 hr Persistent wheeze
Contact clinician Or dyspnea
Short course steroids? PEF 50-79% Poor Response:
Continue Albuterol Marked wheeze
Contact clinician today Or dyspnea
Short course steroid PEF < 50%
Repeat Albuterol now
Call MD and go to ED
Short course steroid
NAEPP 50
 Additional Guidance on Using Yellow Zone Plan:
• Use for acute loss of control in the outpatient setting:
1. Peak flow ≤ 80% of personal best
2. Peak flow decrease of ≥ 15% of personal best
3. An increase in asthma symptoms
4. An increase in use of reliever medications
5. The presence of or increase in nighttime symptoms
• At the onset of an upper respiratory infection if this has
been a previous trigger

Dinaker C, et al. Ann Allergy Asthma Immunol. 2014; 113:143-59.

51
More Guidance for Yellow Zone Plan
• Use SABA at 2 to 4 puffs every 4 – 6 hours
• If SABA use > 12 puffs per day, contact provider
• If receiving low to medium ICS, consider increasing (ie,
quadrupling [BID – QID]) ICS dose to manage loss of
control
• If < 6 years with recurrent wheezing and risk factors,
consider initiating high dose ICS or oral montelukast at
early signs of wheezing
• If mild to moderate [persistent] asthma, consider use of
concomitant ICS with each reliever dose.

Dinaker C, et al. Ann Allergy Asthma Immunol. 2014; 113:143-59.

52
Patient Case: Luke Williams, a 6 year old, 29 kg male
Later that day Luke has continued to do well. He is now receiving an albuterol MDI with spacer 4 puffs every 4
hours and prednisolone 30 mg by mouth once a day. He has remained off oxygen. Luke and his mom
attend the first part of asthma education and feel they learned “a lot” about asthma, it’s symptoms
and what to do during a flare-up. Before discharge several things still need to be addressed on Luke’s
plan. To decide about controller therapy, you review chronic symptoms of asthma with Luke’s mom as
well as common triggers.
Assessment and Resolving acute asthma exacerbation
Updated Plan:  Discontinue ipratropium
 Albuterol MDI with spacer 4 puffs q4h
 Continue current prednisolone dosing
 Provide asthma education to Luke and his mom on how to use albuterol for asthma flare-ups at
home
 Assess severity of Luke’s chronic asthma and potentially initiate controller therapy
 Provide asthma education to Luke and his mom on maintaining asthma control
 Provide written asthma action plan (In progress)
 Ensure availability of needed medications at discharge
Patient Case: Luke Williams, a 6 year old, 29 kg male
Chronic Asthma You are assessing Luke’s chronic asthma management, and have obtained the following information.
Daytime Symptoms SABA Use
 ≤ 2 /week  ≤ 2 /week
 > 2/ week, < daily  > 2/ week, < daily
 Daily  Daily
 Throughout the day  Throughout the day
Nighttime Symptoms Limitations
 ≤ 2 /month  None
 3 – 4 /month  Minor limitation
 > 1 /week, < nightly  Some limitation
 Often 7 x /week  Extremely limited
Triggers:  Exercise  Cold weather
 Pollens, seasonal allergies  Viral infections, “colds”
 Dust  Smoke exposure
 Cockroaches  Stress or strong emotions
 Pet Dander