Pharmaceutical Care 5: Clinical Pharmacy Asthma

Pharmaceutical Care 5:
Clinical Pharmacy
Asthma
Course Facilitators:
Bartolome, Michelle D., MSc, CPS, RPh
Maclan, Grace Marie A., MSc, CPS, RPh
Dela Cruz, Sharmaine Y., RPh
Objectives:
• To be able to define asthma
• To understand the pathophysiology of asthma
• To describe causes and clinical features of asthma
• To define treatment goals and stretegies in
addressing asthma
Asthma
• “laboured breathing” (Greek)
“….heterogeneous disease, usually characterized by chronic

airway inflammation. It is defined by the history of respiratory
symptoms such as wheeze, shortness of breath, chest tightness
and cough that vary over time and in intensity, together with
variable expiratory airflow limitation.” [GINA 2018]
Types
• Extrinsic
• Intrinsic
Causes
Allergens
• Early response
• Late response
Title
• xxxxxx
Clinical Manifestations
Asthma Triad:
1. Wheezing
2. Dyspnea
3. Coughing
Patient with
respiratory symptoms
Are the symptoms typical of asthma?
NO
YES
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
Clinical urgency, and other
YES Alternative diagnosis confirmed?
diagnoses unlikely
Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?
Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?
Empiric treatment with YES NO YES

ICS and prn SABA
Review response
Consider trial of treatment for
Diagnostic testing most likely diagnosis, or refer
within 1-3 months for further investigations
Treat for ASTHMA Treat for alternative diagnosis
GINA 2018, Box 1-1 (4/4) © Global Initiative for Asthma www.ginasthma.org
Diagnosis
1. Pulmonary function tests - determine the degree of
airway obstruction. **ASTHMA = reduced FEV1/FVC ratio and PEF
a. Forced expiratory volume in 1 second (FEV1)
• measure of the FEV in the first second of exhalation
• patient inhales as deeply as possible and then exhales forcefully and
completely into a mouthpiece connected to a spirometer.
b. Forced vital capacity (FVC)
• assessment of the maximum volume of air exhaled with maximum effort after
maximum inspiration
Typical spirometric tracings
Volume Flow
Normal
FEV1
Asthma
(after BD)
Normal
Asthma
(before BD) Asthma
(after BD)
Asthma
(before BD)
1 2 3 4 5 6 Volume
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements
GINA 2018 © Global Initiative for Asthma www.ginasthma.org

Diagnosis
1. Pulmonary function tests
c. Peak Expiratory Flow Rate (PEFR)

• Self assessment for the patient
• best measured in early morning, before medication administration
• Measures maximum flow rate that can be forced during expiration
• Peak Flow Meter
Diagnosis
1. Pulmonary function tests
d. Plethysmography (Whole body)

• Allows to assess functional residual capacity (FRC pleth ) and primary
airway resistance (sRaw) as primary measures
• In asthma = increased airway resistance, increased total lung capacity
and residual volume, normal gas diffusion
2. Exhaled nitric oxide (FeNO)
• Used to check severity of airway
• noninvasive test measuring eosinophilic airway
inflammation.
• It may also be useful in demonstrating insufficient anti-
inflammatory therapy
• to monitor adequacy of treatment & compliance
Goals of asthma treatment
• The long-term goals of asthma management are:
1. Symptom control: to achieve good control of symptoms and
maintain normal activity levels
2. Risk reduction: to minimize future risk of exacerbations, fixed
airflow limitation and medication side-effects
The control-based asthma
management cycle
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
GINA 2018, Box 3-2

Medications
1. β2-Agonists
• stimulate β2-receptors, activating adenyl cyclase  increases cyclic
adenosine monophosphate (cAMP) which causes:
• bronchodilation,
• improved mucociliary clearance
• reduced inflammatory cell mediator release
• SABA (albuterol, terbutaline) – duration of 3 to 6 hours
• LABA (formoterol, salmeterol) – duration of over 12 hours
Medications
2. Anticholinergics Muscarinic Receptor Antagonists
• prevent cholinergic nerve-induced bronchoconstriction and mucus
secretion
• Much less effective than β2 agonists in asthma therapy
• inhibit only the cholinergic reflex component bronchoconstriction, whereas
β2-agonists prevent all bronchoconstrictor mechanisms.
• only used as an additional bronchodilator in patients with asthma that is
not controlled by other inhaled medications
• Ipratropium bromide
Medications
3. Theophylline
• inhibit phosphodiesterase of airway smooth muscles  ↑cAMP
• need high dose for bronchodilator effect
• was widely prescribed as an oral bronchodilator several years ago,
especially as it was inexpensive.
• It has now fallen out of favor as side effects are common and inhaled β2-
agonists are much more effective as bronchodilators.
Medications
4. Corticosteroids
• reducing inflammatory cell numbers and their activation in the airways
• reduce eosinophils in the airways and sputum, and numbers of activated T-
lymphocytes and surface mast cells in the airway mucosa.
• Major effect of corticosteroids:
• switch off the transcription of multiple activated genes that encode inflammatory
proteins such as: cytokines, chemokines, adhesion molecules, and inflammatory
enzymes.
• Increase expression of β2-receptors
Medications
4. Corticosteroids
• Inhaled (ICS) – fluticasone, budesonide; are by far the most effective
controllers for asthma, and their early use has revolutionized asthma
therapy, effective in preventing asthma symptoms.
• Systemic - hydrocortisone or methylprednisolone, treatment of acute
severe asthma
• Oral – prednisolone or prednisone, to treat acute exacerbations of asthma
Medications
5. Antileukotrienes Cysteinyl – Leukotrienes
• Potent bronchoconstrictors:
• Microvascular leakage
• increase eosinophilic inflammation through the activation of cys-LT 1 –receptors
• inflammatory mediators are produced predominantly by mast cells and, to a
lesser extent, eosinophils in asthma.
• montelukast and zafirlukast (Antileukotrienes)

• Block cys-LT 1 -receptors and provide modest clinical benefit in asthma.
• less effective than ICS in controlling asthma and have less effect on airway inflammation
• Given orally once or twice daily and are well tolerated
Medications
5. Cromones
• Cromolyn sodium and nedocromil sodium
• inhibit mast cell and sensory nerve activation effective in blocking trigger-
induced asthma
• very safe and were popular in the treatment of childhood asthma, although
now low doses of ICS are preferred as they are more effective and have a
proven safety profile.
• Short acting with little benefit
Medications
6. Antihistamines
• are useful for patients with coexisting allergic rhinitis; however, their role in
the treatment of asthma remains unclear.
• compete with histamine for H1 -receptor sites on effector cells and thus
help prevent the histamine-mediated responses that influence asthma.
Medications
7. Magnesium sulfate
• administered intravenously, may be useful in some patients because of its
modest ability to cause bronchodilation. When administered intravenously,
it also improves respiratory muscle strength in hypomagnesemic patients.
• Research has suggested that magnesium may reduce admission rate and
improve FEV1 in severe, acute asthma exacerbations and in stable, chronic
asthma.
Medications
8. Immunotherapy
• using injected extracts of pollens or house dust mites has not been very
effective in controlling asthma and may cause anaphylaxis
Medications
9. Omalizumab (Xolair)
• is an anti-IgE compound used for severe asthma and concurrent allergies
• shown to reduce the number of exacerbations in patients with severe
asthma and may improve asthma control.
• It is usually administered twice monthly as an injection in a specialty
physician’s office.
• Life-threatening anaphylaxis has rarely been reported with this medication.
• Very expensive
Stepwise management - pharmacotherapy
Diagnosis
(including lung function)
Patient preference
Symptoms
Exacerbations
Side-effects Asthma medications
Patient satisfaction Non-pharmacological strategies
Lung function Treat modifiable risk factors
STEP 5
STEP 4
Refer for
STEP 3 add-on *Not for children <12 years
PREFERRED STEP 1 STEP 2 treatment
e.g. **For children 6-11 years, the
CONTROLLER Med/high preferred Step 3 treatment is
tiotropium,*
CHOICE anti-IgE,
ICS/LABA medium dose ICS
Low dose anti-IL5/5R*
#For patients prescribed
Low dose ICS ICS/LABA**
BDP/formoterol or BUD/
formoterol maintenance and
Other Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium* Add low reliever therapy
controller dose ICS Low dose theophylline* Low dose ICS + LTRA Med/high dose dose OCS
options (or + theoph*) ICS + LTRA  Tiotropium by mist inhaler is
(or + theoph*) an add-on treatment for
patients ≥12 years with a
As-needed short-acting beta2-agonist (SABA) As-needed SABA or history of exacerbations
RELIEVER low dose ICS/formoterol#
GINA 2018, Box 3-5 (2/8) (upper part) © Global Initiative for Asthma www.ginasthma.org
Asthma flare ups (EXACERBATIONS)
• A flare-up or exacerbation is an acute or sub-acute worsening of

symptoms and lung function compared with the patient’s usual status
© Global Initiative for Asthma www.ginasthma.org

Managing exacerbations in primary care
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
MILD or MODERATE SEVERE

Talks in phrases, prefers
LIFE-THREATENING
Talks in words, sits hunched
sitting to lying, not agitated forwards, agitated Drowsy, confused
Respiratory rate increased Respiratory rate >30/min or silent chest
Accessory muscles not used Accessory muscles in use
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) <90%
PEF >50% predicted or best PEF ≤50% predicted or best URGENT
START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg While waiting: give inhaled SABA and
ipratropium bromide, O2, systemic
Controlled oxygen (if available): target saturation 93–95% corticosteroid
(children: 94-98%)
CONTINUE TREATMENT with SABA as needed

WORSENING
ASSESS RESPONSE AT 1 HOUR (or earlier)
IMPROVING
ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

Symptoms improved, not needing SABA Reliever: continue as needed rather than routinely
PEF improving, and >60-80% of personal Controller: start, or step up. Check inhaler technique, adherence
best or predicted Prednisolone: continue, usually for 5–7 days
Oxygen saturation >94% room air (3-5 days for children)
Resources at home adequate Follow up: within 2–7 days
FOLLOW UP
Reliever: as-needed rather than routinely
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Action plan: Is it understood? Was it used appropriately? Does it need modification?
GINA 2018, Box 4-3 (1/7)

Is it asthma?
LIFE-THREATENING
Drowsy, confused
or silent chest
URGENT
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA and ipratropium
bromide, O2, systemic corticosteroid
© Global
www.goldcopd.org
Initiative for Asthma www.ginasthma.org
Is it asthma?

Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA and ipratropium
© Global
www.goldcopd.org
Is it asthma?

Talks in phrases, prefers Talks in words, sits hunched LIFE-THREATENING
START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max. While waiting: give inhaled SABA and ipratropium
50 mg, children 1–2 mg/kg, max. 40 mg
Controlled oxygen (if available): target saturation 93–95%
(children: 94-98%)
© Global
www.goldcopd.org
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour
WORSENING
CARE FACILITY
ipratropium bromide, O2, systemic corticosteroid
Controlled oxygen (if available): target saturation 93–
95% (children: 94-98%)

WORSENING
IMPROVING
ASSESS FOR DISCHARGE

Symptoms improved, not needing SABA
PEF improving, and >60-80% of personal
best or predicted
Oxygen saturation >94% room air
Resources at home adequate
START TREATMENT
TRANSFER TO ACUTE
WORSENING
CARE FACILITY
95% (children: 94-98%)

WORSENING
IMPROVING

Symptoms improved, not needing SABA Reliever: continue as needed, rather than routinely
START TREATMENT
TRANSFER TO ACUTE
WORSENING
CARE FACILITY
95% (children: 94-98%)

WORSENING
IMPROVING

Symptoms improved, not needing SABA Reliever: continue as needed, rather than routinely
FOLLOW UP
Reliever: as-needed rather than routinely
Controller: continue higher dose for short term (1–2 weeks) or long term (3 months), depending
on background to exacerbation
Risk factors: check and correct modifiable risk factors that may have contributed to exacerbation,
including inhaler technique and adherence
Managing exacerbations in acute care settings
INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
Talks in phrases Talks in words

Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best
Short-acting beta2-agonists Short-acting beta2-agonists

Consider ipratropium bromide Ipratropium bromide
Controlled O2 to maintain Controlled O2 to maintain
saturation 93–95% (children 94-98%) saturation 93–95% (children 94-98%)
Oral corticosteroids Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat as

severe and re-aassess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or

personal best and symptoms improved personal best,or lack of clinical response
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning and reassess frequently
GINA 2018, Box 4-4 (1/4)

INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation


GINA 2018, Box 4-4 (3/4)

If continuing deterioration, treat as

severe and re-assess for ICU
ASSESS CLINICAL PROGRESS FREQUENTLY

MEASURE LUNG FUNCTION
in all patients one hour after initial treatment
FEV1 or PEF <60% of predicted or

FEV1 or PEF 60-80% of predicted or personal best and
personal best,or lack of clinical response
symptoms improved
SEVERE
MODERATE
Continue treatment as above
Consider for discharge planning
and reassess frequently
Diagnosis and Management for Asthma
in children 5 years and younger
Features suggesting asthma in children ≤5 years
Feature Characteristics suggesting asthma

Cough Recurrent or persistent non-productive cough that may be worse at night or accompanied by
some wheezing and breathing difficulties.
Cough occurring with exercise, laughing, crying or exposure to tobacco smoke in the absence
of an apparent respiratory infection
Prolonged cough in infancy, and cough without cold symptoms, are associated with later
parent-reported physician-diagnosed asthma, independent of infant wheeze
Wheezing Recurrent wheezing, including during sleep or with triggers such as activity, laughing, crying
or exposure to tobacco smoke or air pollution
Difficult or heavy breathing Occurring with exercise, laughing, or crying
or shortness of breath
Reduced activity Not running, playing or laughing at the same intensity as other children; tires earlier during
walks (wants to be carried)
Past or family history Other allergic disease (atopic dermatitis or allergic rhinitis)
Asthma in first-degree relatives
Therapeutic trial with low Clinical improvement during 2–3 months of controller treatment and worsening when
dose ICS and as-needed treatment is stopped
SABA
GINA 2018, Box 6-2 © Global Initiative for Asthma www.ginasthma.org

GINA assessment of asthma control in children ≤5
years
A. Symptom control Level of asthma symptom control

Well-controlled Partly Uncontrolled
In the past 4 weeks, has the child had:
controlled
• Daytime asthma symptoms for more than
few minutes, more than once/week? Yes No
• Any activity limitation due to asthma?
(runs/plays less than other children,
tires easily during walks/playing) Yes No None of these
1-2 of 3-4 of
these these
• Reliever needed* more than once a
week? Yes No
• Any night waking or night coughing
due to asthma? Yes No
B. Risk factors for poor asthma outcomes

ASSESS CHILD’S RISK FOR:
• Exacerbations within the next few months
• Fixed airflow limitation
• Medication side-effects
GINA 2018, Box 6-4A © Global Initiative for Asthma www.ginasthma.org

Risk factors for poor asthma outcomes in children ≤5
years
Risk factors for exacerbations in the next few months

• Uncontrolled asthma symptoms
• One or more severe exacerbation in previous year
• The start of the child’s usual ‘flare-up’ season (especially if autumn/fall)
• Exposures: tobacco smoke; indoor or outdoor air pollution; indoor allergens (e.g. house dust mite, cockroach, pets,
mold), especially in combination with viral infection
• Major psychological or socio-economic problems for child or family
• Poor adherence with controller medication, or incorrect inhaler technique
Risk factors for fixed airflow limitation
• Severe asthma with several hospitalizations
• History of bronchiolitis
Risk factors for medication side-effects

• Systemic: Frequent courses of OCS; high-dose and/or potent ICS
• Local: moderate/high-dose or potent ICS; incorrect inhaler technique; failure to protect skin or eyes when using ICS
by nebulizer or spacer with face mask
GINA 2018, Box 6-4B (3/3) © Global Initiative for Asthma www.ginasthma.org
Stepwise approach to control symptoms and reduce risk
(children ≤5 years)
Diagnosis
Parent preference
Symptoms
Exacerbations
Side-effects
Asthma medications
Parent satisfaction
Non-pharmacological strategies
Treat modifiable risk factors
STEP 4
STEP 3
PREFERRED STEP 1 STEP 2 Continue controller
CONTROLLER & refer for
CHOICE Double specialist
‘low dose’ assessment
Daily low dose ICS ICS
Other Leukotriene receptor antagonist (LTRA) Add LTRA

Low dose ICS + LTRA
controller Intermittent ICS Inc. ICS
frequency
options Add intermitt ICS
RELIEVER As-needed short-acting beta2-agonist (all children)
CONSIDER Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and not well- Not well-
viral wheezing and and asthma symptoms not well-controlled, or controlled on controlled
THIS STEP FOR CHILDREN no or few interval ≥3 exacerbations per year low dose ICS on double
WITH: symptoms ICS
Symptom pattern not consistent with asthma but wheezing episodes occur
frequently, e.g. every
First check diagnosis, inhaler skills, adherence,
6–8 weeks.
exposures
Give diagnostic trial for 3 months.
ALL CHILDREN
KEY
ISSUES • Assess symptom control, future risk, comorbidities
• Self-management: education, inhaler skills, written asthma action plan, adherence
• Regular review: assess response, adverse events, establish minimal effective treatment
• (Where relevant): environmental control for smoke, allergens, indoor/outdoor air pollution
GINA 2018, Box 6-5 (2/8)

Stepwise approach – pharmacotherapy
(children ≤5 years)
STEP 4
PREFERRED STEP 3
STEP 1 STEP 2 Continue controller
CONTROLLER
CHOICE & refer for specialist
Double assessment
‘low dose’
Daily low dose ICS ICS
Other Leukotriene receptor antagonist (LTRA) Low dose ICS + LTRA Add LTRA
controller Inc. ICS
Intermittent ICS frequency
options Add intermitt ICS
RELIEVER As-needed short-acting beta2-agonist (all children)
CONSIDER Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and not well- Not well-
THIS STEP FOR viral wheezing and and asthma symptoms not well-controlled, or controlled on low dose ICS controlled on
CHILDREN WITH: no or ≥3 exacerbations per year double ICS
few interval
Symptom pattern not consistent with asthma but wheezing episodes occur
symptoms First check diagnosis, inhaler skills, adherence,
frequently, e.g. every
6–8 weeks. exposures
Give diagnostic trial for 3 months.
GINA 2018, Box 6-5 (3/8)

Choosing an inhaler device for children ≤5 years
Age Preferred device Alternate device

0–3 years Pressurized metered dose inhaler plus Nebulizer with face mask
dedicated spacer with face mask
4–5 years Pressurized metered dose inhaler plus Pressurized metered dose inhaler plus
dedicated spacer with mouthpiece dedicated spacer with face mask, or
nebulizer with mouthpiece or face mask
GINA
GINA2018,
2018, Box 6-6
Box 6-7 © Global Initiative for Asthma www.ginasthma.org
Primary care management of acute asthma or
wheezing in pre-schoolers
Child presents with acute or sub-acute asthma exacerbation
PRIMARY CARE or acute wheezing episode
Consider other diagnoses

ASSESS the CHILD Risk factors for hospitalization
MILD or MODERATE SEVERE OR LIFE THREATENING

Breathless, agitated any of:
Pulse rate ≤200 bpm (0-3 yrs) or ≤180 bpm (4-5 yrs) Unable to speak or drink
Oxygen saturation ≥92% Central cyanosis
Confusion or drowsiness
Marked subcostal and/or sub-glottic retractions
START TREATMENT Oxygen saturation <92%
Salbutamol 100 mcg two puffs by pMDI + spacer Silent chest on auscultation
or 2.5mg by nebulizer Pulse rate > 200 bpm (0-3 yrs)
Repeat every 20 min for the first hour if needed or >180 bpm (4-5 yrs)
Controlled oxygen (if needed and available):
target saturation 94-98% URGENT
MONITOR CLOSELY for 1-2 hours

TRANSFER TO HIGH LEVEL CARE
Transfer to high level care if any of:
Worsening, (e.g. ICU)
• Lack of response to salbutamol over 1-2 hrs or lack of While waiting give:
• Any signs of severe exacerbation improvement
Salbutamol 100 mcg 6 puffs by pMDI+spacer (or 2.5mg
• Increasing respiratory rate
nebulizer). Repeat every 20 min
• Decreasing oxygen saturation as needed.
Oxygen (if available) to keep saturation 94-98%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs; max. 30 mg for
2–5 yrs) as a starting dose
Consider 160 mcg ipratropium bromide
(or 250 mcg by nebulizer). Repeat every
20 min for 1 hour if needed.
MONITOR CLOSELY for 1-2 hours
Transfer to high level care if any of: TRANSFER TO HIGH LEVEL CARE
• Lack of response to salbutamol over 1-2 hrs Worsening, (e.g. ICU)
or lack of While waiting give:
• Any signs of severe exacerbation improvement
Salbutamol 100 mcg 6 puffs by pMDI+spacer (or 2.5mg
• Increasing respiratory rate nebulizer). Repeat every 20 min
• Decreasing oxygen saturation as needed.
IMPROVING Oxygen (if available) to keep saturation 94-98%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs; max. 30 mg for
2–5 yrs) as a starting dose
CONTINUE TREATMENT IF NEEDED Consider 160 mcg ipratropium bromide
Worsening, or
Monitor closely as above failure to respond (or 250 mcg by nebulizer). Repeat every
If symptoms recur within 3-4 hrs to 20 min for 1 hour if needed.
10 puffs
• Give extra salbutamol 2-3 puffs per hour
salbutamol over
• Give prednisolone 2mg/kg (max. 20mg for 3-4 hrs
<2 yrs; max. 30mg for 2-5 yrs) orally
IMPROVING
DISCHARGE/FOLLOW-UP PLANNING
Ensure that resources at home are adequate.
Reliever: continue as needed
Controller: consider need for, or adjustment of, regular controller
Check inhaler technique and adherence
Follow up: within 1-7 days
Provide and explain action plan
FOLLOW UP VISIT
Reliever: Reduce to as-needed
Controller: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamol
Risk factors: Check and correct modifiable risk factors that may have contributed to exacerbation, including
inhaler technique and adherence
Schedule next follow up visit
Initial assessment of acute asthma exacerbations in
children ≤5 years
Symptoms Mild Severe*

Altered consciousness No Agitated, confused or drowsy
Oximetry on presentation >95% <92%

(SaO2)**
Speech† Sentences Words
Pulse rate <100 beats/min >200 beats/min (0–3 years)

>180 beats/min (4–5 years)
Central cyanosis Absent Likely to be present
Wheeze intensity Variable Chest may be quiet
*Any of these features indicates a severe exacerbation

**Oximetry before treatment with oxygen or bronchodilator
† Take into account the child’s normal developmental capability

Indications for immediate transfer to hospital for
children ≤5 years
Transfer immediately to hospital if ANY of the following are present:

Features of severe exacerbation at initial or subsequent assessment
 Child is unable to speak or drink
 Cyanosis
 Subcostal retraction
 Oxygen saturation <92% when breathing room air
 Silent chest on auscultation
Lack of response to initial bronchodilator treatment
 Lack of response to 6 puffs of inhaled SABA (2 separate puffs, repeated
3 times) over 1-2 hours
 Persisting tachypnea* despite 3 administrations of inhaled SABA, even if the child shows other clinical signs of
improvement
Unable to be managed at home
 Social environment that impairs delivery of acute treatment
 Parent/carer unable to manage child at home
*Normal respiratory rates (breaths/minute): 0-2 months: <60; 2-12 months: <50; 1-5 yrs: <40
Initial management of asthma exacerbations
in children ≤5 years
Therapy Dose and administration

Supplemental 24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 94-98%
oxygen
Inhaled SABA 2–6 puffs of salbutamol by spacer, or 2.5mg by nebulizer, every 20 min for first hour,
then reassess severity. If symptoms persist or recur, give an additional 2-3 puffs per
hour. Admit to hospital if >10 puffs required in 3-4 hours.
Systemic Give initial dose of oral prednisolone (1-2mg/kg up to maximum of 20mg for children
corticosteroids <2 years; 30 mg for 2-5 years)
Additional options in the first hour of treatment
Ipratropium bromide For moderate/severe exacerbations, give 2 puffs of ipratropium bromide 80mcg
(or 250mcg by nebulizer) every 20 minutes for one hour only
Magnesium sulfate Consider nebulized isotonic MgSO4 (150mg) 3 doses in first hour for children ≥2
years with severe exacerbation
Devices
References
Kasper, D., et al. (2015). Harrisons Principles of Internal
Medicine 19th edition. McGraw-Hill.
Shargel, L. (2009). Comprehensive pharmacy review. Lippincott
Williams & Wilkins.
Walker, R. & Whittlesea, C. (2012). Clinical Pharmacy and
Therapeutics 5th edition. Elsevier.
www.ginasthma.org accessed April 2018

Pharmaceutical Care 5: Clinical Pharmacy Asthma

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Pharmaceutical Care 5: Clinical Pharmacy Asthma

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Pharmaceutical Care 5:

“….heterogeneous disease, usually characterized by chronic

Empiric treatment with YES NO YES

Treat for ASTHMA Treat for alternative diagnosis

GINA 2018 © Global Initiative for Asthma www.ginasthma.org

c. Peak Expiratory Flow Rate (PEFR)

d. Plethysmography (Whole body)

GINA 2018, Box 3-2

• montelukast and zafirlukast (Antileukotrienes)

• A flare-up or exacerbation is an acute or sub-acute worsening of

© Global Initiative for Asthma www.ginasthma.org

MILD or MODERATE SEVERE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

GINA 2018, Box 4-3 (1/7)

MILD or MODERATE SEVERE

MILD or MODERATE SEVERE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

CONTINUE TREATMENT with SABA as needed

ASSESS FOR DISCHARGE ARRANGE at DISCHARGE

MILD or MODERATE SEVERE

Talks in phrases Talks in words

Short-acting beta2-agonists Short-acting beta2-agonists

If continuing deterioration, treat as

ASSESS CLINICAL PROGRESS FREQUENTLY

FEV1 or PEF 60-80% of predicted or FEV1 or PEF <60% of predicted or

GINA 2018, Box 4-4 (1/4)

MILD or MODERATE SEVERE

Short-acting beta2-agonists Short-acting beta2-agonists

GINA 2018, Box 4-4 (3/4)

If continuing deterioration, treat as

ASSESS CLINICAL PROGRESS FREQUENTLY

FEV1 or PEF <60% of predicted or

Feature Characteristics suggesting asthma

GINA 2018, Box 6-2 © Global Initiative for Asthma www.ginasthma.org

A. Symptom control Level of asthma symptom control

B. Risk factors for poor asthma outcomes

GINA 2018, Box 6-4A © Global Initiative for Asthma www.ginasthma.org

Risk factors for exacerbations in the next few months

Risk factors for medication side-effects

Other Leukotriene receptor antagonist (LTRA) Add LTRA

RELIEVER As-needed short-acting beta2-agonist (all children)

GINA 2018, Box 6-5 (2/8)

RELIEVER As-needed short-acting beta2-agonist (all children)

GINA 2018, Box 6-5 (3/8)

Age Preferred device Alternate device

Consider other diagnoses

MILD or MODERATE SEVERE OR LIFE THREATENING

MONITOR CLOSELY for 1-2 hours

Symptoms Mild Severe*

Oximetry on presentation >95% <92%

Pulse rate <100 beats/min >200 beats/min (0–3 years)

Wheeze intensity Variable Chest may be quiet

*Any of these features indicates a severe exacerbation

GINA 2018, Box 6-9 © Global Initiative for Asthma www.ginasthma.org

Transfer immediately to hospital if ANY of the following are present:

Therapy Dose and administration

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