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If PEF or FEV1
<60% best, or not
improving after
48 hours
Continue reliever
EARLY OR MILD
All patients
Continue controller
Increase reliever
Add prednisolone
4050 mg/day
Early increase in
controller as below
Contact doctor
Review response
LATE OR SEVERE
Is it asthma?
MILD or MODERATE
SEVERE
LIFE-THREATENING
Drowsy, confused
or silent chest
URGENT
START TREATMENT
SABA410 puffs by pMDI + spacer,
repeat every 20 minutes for 1 hour
Prednisolone:adults 1 mg/kg, max.
50 mg, children 12 mg/kg, max. 40 mg
WORSENING
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled
SABA and ipratropium bromide,
O2, systemic corticosteroid
WORSENING
IMPROVING
ARRANGE at DISCHARGE
Reliever:continue as needed
Resources at homeadequate
FOLLOW UP
Reliever: reduce to as-needed
Controller:continue higher dose for short term (12 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?
START TREATMENT
TRANSFER TO ACUTE
CARE FACILITY
WORSENING
WORSENING
IMPROVING
ARRANGE at DISCHARGE
Reliever:continue as needed
Resources at homeadequate
FOLLOW UP
Reliever: reduce to as-needed
Controller:continue higher dose for short term (12 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?
NO
YES
MILD or MODERATE
SEVERE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100120 bpm
O2 saturation (on air) 9095%
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
Short-acting beta2-agonists
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
INITIAL ASSESSMENT
NO
YES
MILD or MODERATE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100120 bpm
O2 saturation (on air) 9095%
SEVERE
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
MILD or MODERATE
SEVERE
Talks in phrases
Prefers sitting to lying
Not agitated
Respiratory rate increased
Accessory muscles not used
Pulse rate 100120 bpm
O2 saturation (on air) 9095%
PEF >50% predicted or best
Talks in words
Sits hunched forwards
Agitated
Respiratory rate >30/min
Accessory muscles being used
Pulse rate >120 bpm
O2 saturation (on air) < 90%
PEF 50% predicted or best
Short-acting beta2-agonists
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 9395% (children 94-98%)
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
Short-acting beta2-agonists
Short-acting beta2-agonists
Ipratropium bromide
Controlled O2 to maintain
saturation 9395% (children 94-98%)
Controlled O2 to maintain
saturation 9395% (children 94-98%)
Oral corticosteroids
Oral or IV corticosteroids
Consider IV magnesium
Consider high dose ICS
If continuing deterioration, treat
as
severe and re-assess for ICU
The opportunity
Exacerbations often represent failures in chronic asthma care,
and they provide opportunities to review the patients asthma
management
Background
For patients with respiratory symptoms, infectious diseases and nonpulmonary conditions need to be distinguished from chronic airways
disease
In patients with chronic airways disease, the differential diagnosis
differs by age
Children and young adults: most likely to be asthma
Adults >40 years: COPD becomes more common, and distinguishing asthma
from COPD becomes more difficult
Background
Patients with features of both asthma and COPD have worse
outcomes than those with asthma or COPD alone
Frequent exacerbations
Poor quality of life
More rapid decline in lung function
Higher mortality
Greater health care utilization
Reported prevalence of ACOS varies by definitions used
Concurrent doctor-diagnosed asthma and COPD are found in
1520% of patients with chronic airways disease
Reported rates of ACOS are between1555% of patients with
chronic airways disease, depending on the definitions used for
asthma and COPD, and the population studied
Prevalence varies by age and gender
Definitions
Asthma
Asthma is a 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 2015]
COPD
COPD is a common preventable and treatable disease, characterized by persistent
airflow limitation that is usually progressive and associated with enhanced chronic
inflammatory responses in the airways and the lungs to noxious particles or gases.
Exacerbations and comorbidities contribute to the overall severity in individual patients.
[GOLD 2015]
STEP 1
Yes
STEP 2
No
Lung function
Lung function between
symptoms
Past history or family
history
Time course
Chest X-ray
COPD
After age 40 years
Normal
Abnormal
NOTE: These features best distinguish between asthma and COPD. Several positive features (3 or more) for either asthma or
COPD suggest that diagnosis. If there are a similar number for both asthma and COPD, consider diagnosis of ACOS
DIAGNOSIS
Asthma
Some features
of asthma
CONFIDENCE IN
DIAGNOSIS
Asthma
Asthma
STEP 3
Marked
reversible airflow limitation
(pre-post bronchodilator) or other
proof of variable airflow limitation
PERFORM
SPIROMETRY
STEP 4
INITIAL
TREATMENT*
STEP 5
SPECIALISED
INVESTIGATIONS
or REFER IF:
Features of
both
Could be
ACOS
Some features
of COPD
Possibly
COPD
COPD
COPD
ICS, and
Asthma
Asthma drugs
COPD
COPD
usually
drugs
No LABA
drugs
drugs
LABA
No LABA
monotherapy
monotherapy
+/or LAMA
*Consult GINA and GOLD documents for recommended treatments.
STEP 1
Yes
GINA 2015
STEP 2
ASTHMA
COPD
Age of onset
Pattern of symptoms
Worse during the night or early morning Good and bad days but always daily
symptoms and exertional dyspnea
Triggered by exercise, emotions
including laughter, dust or exposure
to allergens
Lung function
Normal
Abnormal
Chest X-ray
Normal
Severe hyperinflation
NOTE: These features best distinguish between asthma and COPD. Several positive features (3 or more) for either asthma or COPD suggest
that diagnosis. If there are a similar number for both asthma and COPD, consider diagnosis of ACOS
GINA 2014
DIAGNOSIS
Asthma
Some features
of asthma
Features of
both
Some features
of COPD
COPD
CONFIDENCE IN
DIAGNOSIS
Asthma
Asthma
Could be ACOS
Possibly COPD
COPD
Global Initiative for Asthma
STEP 3
PERFORM
SPIROMETRY
Marked
reversible airflow limitation
(pre-post bronchodilator) or other
proof of variable airflow limitation
Step 3 - Spirometry
Essential if chronic airways disease is suspected
Confirms chronic airflow limitation
More limited value in distinguishing between asthma with
fixed airflow limitation, COPD and ACOS
Measure at the initial visit or subsequent visit
If possible measure before and after a trial of treatment
Medications taken before testing may influence results
Peak expiratory flow (PEF)
Not a substitute for spirometry
Normal PEF does not rule out asthma or COPD
Repeated measurement may confirm excessive variability,
found in asthma or in some patients with ACOS
Step 3 - Spirometry
Spirometric variable
Normal FEV1/FVC
pre- or post-BD
Asthma
COPD
Post-BD
FEV1/FVC <0.7 Indicates airflow
limitation; may improve
ACOS
Not compatible unless
other evidence of chronic
airflow limitation
Usual in ACOS
FEV1<80% predicted
Indicates severity of
airflow limitation and risk
of exacerbations and
mortality
Post-BD
increase in
FEV1>12% and 400mL
from baseline
Unusual in COPD.
Consider ACOS
Compatible with
diagnosis of ACOS
High probability of
asthma
STEP 4
INITIAL
TREATMENT*
Asthma Asthma
drugs
drugs
No LABA No LABA
monother monother
apy
apy
ICS and
consider
LABA
+/or
LAMA
COPD
drugs
COPD
drugs
STEP 3
PERFORM
SPIROMETRY
STEP 5
SPECIALISED
INVESTIGATIONS
or REFER IF:
GINA 2015
Asthma
COPD
DLCO
Often reduced
Normal between
exacerbations
Airway
hyperresponsiveness
High resolution CT
scan
Conforms to background
prevalence; does not rule out COPD
FENO
Blood eosinophilia
Sputum inflammatory
cell analysis