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The primary goal of asthma management
to achieve and maintain control
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Long term benefits of asthma control
- 1. Improve quality of life by maintaining the pt's lung function and activity level as normal as possible
- 2. Reduce the risk of exacerbations, hospitializations, loss of lung function, or impared development
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Two people responsible for achieving control
Professional and patient
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Define Severity
The intrinsic intensity of the disease
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Define Control
The degree to which manifistations are minimized and goals of therapy are met
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Define Responsiveness
The ease by which control is achieved
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Define Impairment
The frequency and intensity of symptoms and funcitonal limitations the patient is experiencing or recently experienced (present)
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Define Risk
The likelihood of exacerbations, decline in lung function, imparement of development or adverse effects of medication (future)
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Early vs Late Phase Reactions
- Early: within 1 hour of exposure to allergen, use SABA and antihistamines
- Late: 3 to eight hours after exposure, often more severe, use corticosteroids
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Phases and parts of management
- Phase I: Initial Control
- (Classification and Initial Therapy)
- Phase II: Maintaining Control
- (Patient Monitoring and Therapy Adjustment)
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Classification Requirements
Age and SALSA
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Goal of Initial Therapy
To quickly achieve control
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Patient Monitioring Requirements
- SALSA
- Peak Flow
- Follow-up visits
- Questionaires
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Peak Flow
- Primary assessment tool
- Early detection of deteriorating airflow
- Most helpful for moderate to severe asthma
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Obtaining Personal Best Peak Flow
- Record PF every morning and afternoon for 2-3 weeks
- Record PF after SABA and DO
- Highest is Personal Best
- Repeat occasionally to note changes in Personal Best
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Green Zone
- 80-100% of Personal Best
- Good control
- Children <6: No cough, wheeze, chest tightness, SOB day or night, normal activities
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Yellow Zone
- 50-79% Personal Best
- Worsening Asthma
- Children <6: has cough, wheeze, chest tightness, SOB, waking at night with symptoms, most activities
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Red Zone
- <50% of Personal Best
- Medical attention is needed
- Children <6: very SOB, SABA has no effect, cannot do usual activities, symptoms same / worse after time in yellow zone
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Peak Flow Frequecy
- 1. Every morning before meds
- 2. During symptoms
- 3. After meds during attack
- 4. During clinical visit
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Cleaining Peak Flow Meter
- Dust and dirt, germs and mucuous affect readings
- Wash once a week normally
- Wash after every use if a virus
- Remove mouthpiece
- Wash both in warm soapy water
- Rinse and air dry
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Follow up medical visit frequency
every 6 months
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Three QOL Questionaires
- ATAQ: <1 is good
- ACQ: <1 is good
- ACT: >20 is good
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Therapy Adjustment: Well Controlled
- 1. Maintain at current step
- 2. FU every 1 to 6 months
- 3. Consider step down if well controlled 3 months
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Therapy Adjustment: Not Well Controlled
- 1. Step up one step
- 2. Re-eval 2 to 6 weeks
- 3. If side effects, consider alt treatment options
- 4. FU every 1 to 6 months
- 5. Consider step down if well controlled 3 months
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Therapy Adjustment: Poorly Controlled
- 1. Step up 1 to 2 steps
- 2. Re-eval in 2 weeks
- 3. Consider short course oral systemic steroids
- 4. If side effects, consider alt treatment options
- 5. FU every 1 to 6 months
- 6. Consider step down if well controlled 3 months
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What if no improvement in 0-4 years old after stepping up their therapy?
Consider alternative diagnosis
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Before stepping up therapy, evaluate:
- MDI/DPI technique
- Adherence to medication regime
- Environmental control
- Co-morbities
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How to reduce oral steroids
25% every 2 to 3 months until lowest dose to maintain control is reached.
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Poor Control
- > 1 SABA canister per month
- Awakened at night with symptoms
- Have urgent care visit
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School allergens and irritants
- Chemicals, pollens, mold spores
- Animal dander
- Mold in vents, odors from printers, fumes from AC/heat
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School considerations
- Do other children have same symptoms?
- Improve away from bldg?
- Appear after pesticides, painting or construction?
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Smoking Control
- Number one source of indoor pollution
- Not permitted in house
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Air Filtration System Control
- Use HEPA filters (3 microns)
- Use ULPA (0.12 microns)
- Vacuums and air purifiers should use these
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Most important area of home to have trigger free from allergens and irritants
Bedroom
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Animal Dander Control
- No pets best, keep outside 2nd best
- If must have indoors, not in bedroom
- Bathe once per week
- After playing, wash hands before touching pt/bedroom
- Have someone else clean hamster/mice cage
- Exterminate cockroaches
- Control mice with block access or low-toxic pesticide
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Dust and Dust Mite Control
- Plastic zippered covers for matress and pillows
- Wash linen in water >130 or detergent and bleach
- Use synthetic materials for bedding
- Remove carpet
- Keep humidity between 30 to 50%
- Avoid upholstered furniture
- Vacuum one per week
- Use mask when dusting
- Use AC instead of windows
- Avoid stuffed animals (freeze once per wk for 6 hrs)
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Pollen Control
- Use no windows, but AC
- Clean / replace AC filters regularly
- Know triggers and avoid outdoor activities then
- Bathe before bedtime
- Don't dry clothes outdoors
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Mold Control
- Keep humidity <50%
- Clean mold from refrigerator and inside house
- Don't dry clothes outside
- Avoid live or dried plants inside house
- Have someone else mow and garden
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Food Allergy Control
- Avoid food completely
- Carry EpiPen
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Treatment for Food Allergy
- Epinephrine
- Antihistamines
- Hydrocortisone
- O2
- Orpharyngeal Airway
- IV fluids
- Ambulance called, keep at leat 12 hours
- (attacks happen up to 8 hours later)
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Aspirin or NSAID Control
- Avoid
- Use Acetaminophen instead
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Occupation Trigger Control
- Common causes are:
- Lates
- Gases, chemicals, fumes
- Tobacco smoke, perfume
- Temp and humidity
- Formaldehyde and volitile organic compounds
- Platinum, chromium and nickel sulfate
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EIB Control
- Use SABA 15 to 30 minutes before
- Use midway if needed
- Use LABA 30 minutes before
- Use Cromolyn Sodium or Nedocromil 15 to 30 min
- Use inhaled corticosteroids to control
- Use leukotriene modifiers regularly
- Wear mask or scarf in cold weather
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