Overhauled asthma guidelines: The way you care for patients will be revamped
Revised classifications of severity, new treatment options are spelled out
A teenager with mild intermittent asthma used a quick relief inhaler only one day a week or less, but still developed a viral upper respiratory infection, recalls Karen Huss, RN, DNSc, CANP, FAAN, associate professor at the Johns Hopkins University School of Nursing in Baltimore, and member of the National Asthma Education Program Nurses’ Committee, part of the Bethesda, MD-based National Heart, Lung, and Blood Institute.
"She went to a family outing for the day, which included horseback riding and being around other furred animals to which she was allergic," Huss says. "Later that evening, she had a severe attack which was not helped by her quick relief medication. She required hospitalization, including intubation for a severe attack."
Recognizing that even a patient with mild intermittent asthma can have a severe exacerbation is one of the many dramatic changes to asthma guidelines from the institute, titled Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. (See excerpt, p. 63. See ordering information, p. 65.)
The guidelines can help you develop a cutting-edge strategy to manage asthma, emphasizes Richard Nowak, MD, FACEP, vice chairman of the emergency medicine department at Henry Ford Health System in Detroit.
"We need to have some scientific basis for our overall approach to asthma," Nowak says. "The guidelines represent a comprehensive, multidisciplinary overview of both chronic and acute exacerbation management."
"The idea of the guidelines is to provide quick, efficient care of the asthmatic with exacerbation and have it driven by objective guides such as pulmonary function instead of just a gestalt," says Rita Cydulka, MD, emergency medicine department residency director at Case Western Reserve University in Cleveland. "The guidelines are very clear-cut and easy to institute. Following them will allow for quick, efficient care of the asthmatic patient."
The guidelines are lengthy, which makes it difficult for busy practitioners to read them in their entirety, notes Huss. "There is a Practical Guide for the Diagnosis and Management of Asthma, which is based on the full report," she explains. "It concentrates on improving asthma care by health care providers within the time constraints of their practices."
Here are some key points in the revised guidelines:
• Know changed definitions of severity.
Asthma severity classifications have been changed from mild, moderate, and severe to the following: mild intermittent, mild persistent, moderate persistent, and severe persistent. "These categories better reflect the clinical manifestations of the disease," says Huss.
• Use a stepwise approach.
In a stepwise approach to therapy, the dose and number of medications and frequency of administration are increased or decreased whenever possible. The changed categories for severity make it possible to use a stepwise approach to treat asthma, says Huss. The stepwise approach also emphasizes initiating higher level therapy at the onset to establish prompt control, then stepping down, she explains.
• Be familiar with the new peak flow parameters.
"It used to be that a severe exacerbation had a peak flow of less than 40% predicted; now it’s less than 50% predicted," Cydulka says. "Moderate is now from 50% to 80%, and mild is above 80%."
• Understand the two categories of medications.
The guidelines now categorize medications into two general classes: long-term control medications for control of persistent asthma and quick relief medications to treat acute symptoms and exacerbations. Patients with persistent asthma require both classes of medication, notes Huss.
"The most effective medications for long-term therapy are those having anti-inflammatory effects," she says. Inhaled steroids are the most effective anti-inflammatory medications, according to the guidelines.
• Start therapy at triage.
"The guidelines address the recognition of acute exacerbations, objective measurements of that, and initiation of appropriate therapy by nursing staff," notes Nowak. "Nurses should establish the level of severity and initiate albuterol inhalation. If patient can’t be seen immediately, you should continue to give beta agonists until they are seen."
Understand how to assess severity during presentation and the patient’s therapy, says Nowak. "In our ED, nurses administer albuterol, not the respiratory department. There is definitely a role for nurses not only to assess, but to treat," he adds.
• Know correct dosages.
"The guidelines give you a framework for dosage of the beta agonists. If you’re severe, it’s 5 mg. If you’re not, it’s 2.5 mg, with three treatments in the first hour," says Nowak. "That’s an approach to start with. Then you can follow them closely in terms of repetitive pulmonary function testing."
• Look at the big picture.
"We are managing a disease, and acute asthma is a small part of that," says Nowak. "We need to be sure patients are appropriate with medicines and have some sort of plan, including peak flow monitoring. It’s important that they understand not only the acute management, but also the chronic strategies to keep them out of the hospital." (See questions to ask asthma patients, p. 67.)
• Make sure patients are well-oxygenated.
"The guidelines say that inhaled ß2 agonists are the first line treatment, and systemic corticosteroids should be considered for all exacerbations in the moderate to severe range," says Cydulka. "The guidelines also say to consider oxygen to relieve hypoxemia for moderate to severe exacerbations.
"Response to therapy should be monitored with a serial measurement of lung function," she adds. "The goal of treatment is to correct hypoxemia to rapidly restore airway function and reduce relapses."
• Consider anticholinergics for patients with moderate and severe exacerbation.
"Even though the research is mixed, the guidelines say anticholinergics should be considered," notes Cydulka.
• Consider higher dose beta agonists.
"Consideration of higher dose beta agonists for everyone except the mildest of exacerbations is new in this set of guidelines," says Cydulka. "The current thinking is that .5 mg instead of .25 mg seems to be more effective."
• Be familiar with ventilation issues.
"The new treatment addressed in these guidelines is permissive hypocapnea. This is a ventilator strategy that minimizes airway pressures and hopefully minimizes barotrauma," says Cydulka. "Whereas in the past we’d try and make sure that the CO2 level was normal, now we’ll allow hypocapnea and just treat the respiratory acidosis with bicarbonate."
• Know recommended treatments.
"The mainstay of therapy is short-acting inhaled ß2 agonists every two to three minutes for three treatments for all patients," says Huss. "Subsequent therapy and disposition depends on response." (See story on new and controversial asthma treatments, p. 66.)
Corticosteroids are given to most patients, usually orally, Huss says. "Onset of action is four hours or longer," she explains. "Often, a three- to 10-day course of moderate to high dose steroids is given [in adults, usually 400 to 600 mg daily]. When given in a short course, tapering is not necessary." (See related story on asthma myths, p. 66.)
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