How do we manage asthma?
Well, every patient with asthma
should have an asthma action plan.
The goal of asthma self-management
is to achieve better health
through controlling and
preventing the asthma attacks.
An asthma action plan is a written plan
that is created with the child's health
care provider to help control their asthma.
The goal is to reduce and prevent flare-ups
and decrease emergency department visits.
Here's an example of an asthma action plan.
The patients kind of perform
their peak expiratory flows
and then calculate which percentage
of their expected they have achieved.
If the peak flow result is > 80% of
their predicted or expected amount,
then they're in the safe zone.
They're in the green zone,
and they're going to persist with
their normal baseline regimen.
If the peak flow result is between 50%
and 79% of their predicted amount,
the patient is in the yellow zone.
This is the caution zone.
They're going to initiate their
interventions in the yellow section,
which may be to increase
their inhaled bronchodilator
and continue to adhere to
their routine asthma care.
Now, if the patient's result is <50% of
their predicted and expected amount,
then the patient is in the
danger zone or the red zone.
And they're supposed to attempt
to aggressively resolve
their exacerbation with their medications.
And if there's no improvement
in about 15 minutes,
they need to call 911 or get to a hospital.
To achieve good asthma control,
the patient is going to need
to use a stepwise approach.
They should be able to step
up their treatment if needed,
and if they're well controlled, they may
be able to step down the treatment.
Before stepping up, you would want to
review the adherence to medication,
review the patient's inhaler technique,
ask about their environmental controls,
and also assess for co-morbid conditions.
If an alternative treatment
option was used in a step,
discontinue that and use the
preferred treatment for that step.
So, in step 1, with intermittent asthma,
the patient's only going to need access
to a short-acting beta-2 agonist,
that they can use PRN, or as needed.
This patient needs rare asthma
medication less than 2 times per week.
Next, we go to step 2, and this is a patient
who may have more persistent asthma
and may need daily medications.
These patients will have access to step 1,
which is their short-acting beta
agonist that they can use as needed,
and they will be put on a low-dose
inhaled corticosteroid or ICS.
The next step would be the patient
requiring a higher dose
of the steroid inhalation
and this would be a medium-dose
Now, patients in step 3, remember,
also have access to their short-acting
bronchodilator in step 1.
Step 4 is a patient who needs a
medium-dose inhaled corticosteroid,
and then they also need access
to a long-acting beta agonist.
This is sort of a long-acting
In step 5, the patient's steroid
dose is going to go up even higher
to a high-dose inhaled corticosteroid with,
again, a long-acting bronchodilator.
Remember, these patients can still use their
as needed short-acting
bronchodilator in step 1.
In step 6, these patients have a
high-dose inhaled corticosteroid,
a long-acting beta agonist, and
these patients may also need
a burst of oral corticosteroids,
The patient should be able to move
up and down on this continuum
with the help of their health care provider.
If the patient's not well
controlled on one step,
they may need to go to the higher step.
And once they've tolerated that pretty
well, sometimes for a few weeks,
you can attempt to step the patient
down and see how they tolerate these.
The clinician also needs to decide
if the patient has intermittent
or persistent asthma.
You can also determine if the patient's
tolerating their current step,
if they need to move up or
down on the management plan.
This includes the assessment
of the patient's symptoms.
How are they doing?
How many times at night
are they waking to cough?
And what's their interference
with normal activity?
In persistent asthma, you're going to ask
about their short-acting beta agonist use,
you're going to compare
their lung function scores,
and you're also going to consider the
exacerbations requiring oral steroids.
Now, don't get your asthma blinders on.
A patient can develop other infections
along with their asthma exacerbation.
Patients sometimes will develop
a secondary pneumonia
and that pneumonia is going
to require treatment
in addition to their asthma exacerbation.
A pneumothorax, or a collapsed part
of the lung, can also develop.
A patient can go into respiratory failure
as the levels of oxygen in the
blood become dangerously low,
and the levels of carbon
dioxide become too high.
Now, status asthmaticus.
This is a severe, unrelenting asthma attack
that is not responding to treatment.
This is a life-threatening emergency.
Increase patient asthma education
on recognition in worsening signs,
and understanding how to
use their management plan
can be very useful in
preventing status asthmaticus.
There are some chronic complications
associated with asthma:
fatigue, under performance,
or absence from school.
And this can be that something
is triggering the child,
they're coughing too much,
they're not sleeping at night,
and they have to miss school.
The inability to exercise leading
to weight gain because,
remember, some patients have
And the patient may develop permanent
problems with their lungs, such as COPD.
The patient may also have
repeated hospital visits
and this may include visits to
the emergency department
or stays overnight, and this can be costly.