Figure 78-3 Estimated comparative daily dosages for inhaled corticosteroids. (From National Heart Lung Blood Institute, National Asthma Education and Prevention Program: Expert panel report 3: guidelines for the diagnosis and management of asthma. Summary report 2007, NIH Publication No. 08-5846, Bethesda, MD, 2007, U.S. Department of Health and Human Services, p 49, http://www.nhlbi.nih.gov/ guidelines/asthma/asthsumm.pdf following: allergic rhinitis, wheezing with a cold, or eosino-teaching basic asthma facts, explaining the role of medica philia of greater than 4%. Atopy is the strongest predictor for tions, teaching environmental control measures, and improv wheezing continuing into persistent asthma (Table 78-4). ing patient skills in the use of spacer devices for metered dose inhalers and peak flow monitoring. Families should have an asthma management plan (Fig. 78-5) for daily care and for
PREVENTION exacerbations.
Education plays an important role in helping patients and Peak flow monitoring is a self-assessment tool that is help- their families adhere to the prescribed therapy and needs to ful for children over 5 years of age. It is advisable for children begin at the time of diagnosis. Successful education involves who are poor perceivers of airway obstruction, have moderate
FEV1 or PEF <40% (severe)      Oxygen to achieve SaO2 ˜90%  High-dose inhaled SABA plus       Ipratropium by nebulizer or MDI plus valved holding chamber, every 20 minutes or continuously for 1 hour      Oral systemic corticosteroids
FEV1 or PEF ˜40% (mild-to-moderate)      Oxygen to achieve SaO2 ˜90%      Inhaled SABA by nebulizer or MDI with valved holding chamber, up to 3 doses in first hour      Oral systemic corticosteroids if no immediate response or if patient recently took oral systemic       corticosteroids
Initial assessment Brief history, physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate), PEF or FEV1, oxygen saturation, and other tests as indicated
Severe exacerbation FEV1 or PEF <40% predicted/personal best Physical exam: severe symptoms at rest, accessory muscle use, chest retraction History: high-risk patient No improvement after initial treatment  Oxygen      Nebulized SABA plus Ipratropium, hourly or continuous      Oral systemic corticosteroids  Consider adjunct therapies
Moderate exacerbation FEV1 or PEF 40–69% predicted/personal best Physical exam: moderate symptoms  Inhaled SABA every 60 minutes      Oral systemic corticosteroid      Continue treatment 1–3 hours, provided       there is improvement; make admit decision in <4 hours