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Pharmaceutical Care 5: Clinical Pharmacy Asthma
Pharmaceutical Care 5: Clinical Pharmacy Asthma
Clinical Pharmacy
Asthma
Course Facilitators:
Bartolome, Michelle D., MSc, CPS, RPh
Maclan, Grace Marie A., MSc, CPS, RPh
Dela Cruz, Sharmaine Y., RPh
Objectives:
• To be able to define asthma
• To understand the pathophysiology of asthma
• To describe causes and clinical features of asthma
• To define treatment goals and stretegies in
addressing asthma
Asthma
• “laboured breathing” (Greek)
NO
YES
Detailed history/examination
for asthma
History/examination supports
asthma diagnosis?
Further history and tests for
NO alternative diagnoses
Clinical urgency, and other
YES Alternative diagnosis confirmed?
diagnoses unlikely
Perform spirometry/PEF
with reversibility test
Results support asthma diagnosis?
Repeat on another
NO
occasion or arrange
NO
YES other tests
Confirms asthma diagnosis?
GINA 2018, Box 1-1 (4/4) © Global Initiative for Asthma www.ginasthma.org
Diagnosis
1. Pulmonary function tests - determine the degree of
airway obstruction. **ASTHMA = reduced FEV1/FVC ratio and PEF
a. Forced expiratory volume in 1 second (FEV1)
• measure of the FEV in the first second of exhalation
• patient inhales as deeply as possible and then exhales forcefully and
completely into a mouthpiece connected to a spirometer.
b. Forced vital capacity (FVC)
• assessment of the maximum volume of air exhaled with maximum effort after
maximum inspiration
Typical spirometric tracings
Volume Flow
Normal
FEV1
Asthma
(after BD)
Normal
Asthma
(before BD) Asthma
(after BD)
Asthma
(before BD)
1 2 3 4 5 6 Volume
Time (seconds)
Note: Each FEV1 represents the highest of
three reproducible measurements
Symptoms
Exacerbations
Side-effects
Patient satisfaction
Lung function
Asthma medications
Non-pharmacological strategies
Treat modifiable risk factors
Diagnosis
Symptom control & risk factors
(including lung function)
Inhaler technique & adherence
Patient preference
Symptoms
Exacerbations
Side-effects Asthma medications
Patient satisfaction Non-pharmacological strategies
Lung function Treat modifiable risk factors
STEP 5
STEP 4
Refer for
STEP 3 add-on *Not for children <12 years
PREFERRED STEP 1 STEP 2 treatment
e.g. **For children 6-11 years, the
CONTROLLER Med/high preferred Step 3 treatment is
tiotropium,*
CHOICE anti-IgE,
ICS/LABA medium dose ICS
Low dose anti-IL5/5R*
#For patients prescribed
Low dose ICS ICS/LABA**
BDP/formoterol or BUD/
formoterol maintenance and
Other Consider low Leukotriene receptor antagonists (LTRA) Med/high dose ICS Add tiotropium* Add low reliever therapy
controller dose ICS Low dose theophylline* Low dose ICS + LTRA Med/high dose dose OCS
options (or + theoph*) ICS + LTRA Tiotropium by mist inhaler is
(or + theoph*) an add-on treatment for
patients ≥12 years with a
As-needed short-acting beta2-agonist (SABA) As-needed SABA or history of exacerbations
RELIEVER low dose ICS/formoterol#
GINA 2018, Box 3-5 (2/8) (upper part) © Global Initiative for Asthma www.ginasthma.org
Asthma flare ups (EXACERBATIONS)
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg While waiting: give inhaled SABA and
ipratropium bromide, O2, systemic
Controlled oxygen (if available): target saturation 93–95% corticosteroid
(children: 94-98%)
IMPROVING
FOLLOW UP
Reliever: as-needed rather than routinely
Controller: continue higher dose for short term (1–2 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?
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
LIFE-THREATENING
Drowsy, confused
or silent chest
URGENT
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA and ipratropium
bromide, O2, systemic corticosteroid
GINA 2018, Box 4-3 (2/7) © Global Initiative for Asthma www.ginasthma.org
© Global
www.goldcopd.org
Initiative for Asthma www.ginasthma.org
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
TRANSFER TO ACUTE
CARE FACILITY
While waiting: give inhaled SABA and ipratropium
bromide, O2, systemic corticosteroid
GINA 2018, Box 4-3 (3/7) © Global Initiative for Asthma www.ginasthma.org
© Global
www.goldcopd.org
Initiative for Asthma www.ginasthma.org
PRIMARY CARE Patient presents with acute or sub-acute asthma exacerbation
Is it asthma?
ASSESS the PATIENT Risk factors for asthma-related death?
Severity of exacerbation?
START TREATMENT
SABA 4–10 puffs by pMDI + spacer, TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour CARE FACILITY
WORSENING
Prednisolone: adults 1 mg/kg, max. While waiting: give inhaled SABA and ipratropium
50 mg, children 1–2 mg/kg, max. 40 mg
bromide, O2, systemic corticosteroid
Controlled oxygen (if available): target saturation 93–95%
(children: 94-98%)
GINA 2018, Box 4-3 (4/7) © Global Initiative for Asthma www.ginasthma.org
© Global
www.goldcopd.org
Initiative for Asthma www.ginasthma.org
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour
WORSENING
CARE FACILITY
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg While waiting: give inhaled SABA and
ipratropium bromide, O2, systemic corticosteroid
Controlled oxygen (if available): target saturation 93–
95% (children: 94-98%)
IMPROVING
GINA 2018, Box 4-3 (5/7) © Global Initiative for Asthma www.ginasthma.org
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour
WORSENING
CARE FACILITY
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg While waiting: give inhaled SABA and
ipratropium bromide, O2, systemic corticosteroid
Controlled oxygen (if available): target saturation 93–
95% (children: 94-98%)
IMPROVING
GINA 2018, Box 4-3 (6/7) © Global Initiative for Asthma www.ginasthma.org
START TREATMENT
SABA 4–10 puffs by pMDI + spacer,
TRANSFER TO ACUTE
repeat every 20 minutes for 1 hour
WORSENING
CARE FACILITY
Prednisolone: adults 1 mg/kg, max.
50 mg, children 1–2 mg/kg, max. 40 mg While waiting: give inhaled SABA and
ipratropium bromide, O2, systemic corticosteroid
Controlled oxygen (if available): target saturation 93–
95% (children: 94-98%)
IMPROVING
FOLLOW UP
Reliever: as-needed rather than routinely
Controller: continue higher dose for short term (1–2 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?
GINA 2018, Box 4-3 (7/7) © Global Initiative for Asthma www.ginasthma.org
Managing exacerbations in acute care settings
INITIAL ASSESSMENT Are any of the following present?
A: airway B: breathing C: circulation Drowsiness, Confusion, Silent chest
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
NO
YES
Further TRIAGE BY CLINICAL STATUS Consult ICU, start SABA and O2,
according to worst feature and prepare patient for intubation
GINA 2018, Box 4-4 (2/4) © Global Initiative for Asthma www.ginasthma.org
MILD or MODERATE SEVERE
Talks in phrases Talks in words
Prefers sitting to lying Sits hunched forwards
Not agitated Agitated
Respiratory rate increased Respiratory rate >30/min
Accessory muscles not used Accessory muscles being used
Pulse rate 100–120 bpm Pulse rate >120 bpm
O2 saturation (on air) 90–95% O2 saturation (on air) < 90%
PEF >50% predicted or best PEF ≤50% predicted or best
GINA 2018, Box 4-4 (4/4) © Global Initiative for Asthma www.ginasthma.org
Diagnosis and Management for Asthma
in children 5 years and younger
Features suggesting asthma in children ≤5 years
GINA 2018, Box 6-4B (3/3) © Global Initiative for Asthma www.ginasthma.org
Stepwise approach to control symptoms and reduce risk
(children ≤5 years)
Diagnosis
Symptom control & risk factors
Inhaler technique & adherence
Parent preference
Symptoms
Exacerbations
Side-effects
Asthma medications
Parent satisfaction
Non-pharmacological strategies
Treat modifiable risk factors
STEP 4
STEP 3
PREFERRED STEP 1 STEP 2 Continue controller
CONTROLLER & refer for
CHOICE Double specialist
‘low dose’ assessment
Daily low dose ICS ICS
CONSIDER Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and not well- Not well-
viral wheezing and and asthma symptoms not well-controlled, or controlled on controlled
THIS STEP FOR CHILDREN no or few interval ≥3 exacerbations per year low dose ICS on double
WITH: symptoms ICS
Symptom pattern not consistent with asthma but wheezing episodes occur
frequently, e.g. every
First check diagnosis, inhaler skills, adherence,
6–8 weeks.
exposures
Give diagnostic trial for 3 months.
ALL CHILDREN
KEY
ISSUES • Assess symptom control, future risk, comorbidities
• Self-management: education, inhaler skills, written asthma action plan, adherence
• Regular review: assess response, adverse events, establish minimal effective treatment
• (Where relevant): environmental control for smoke, allergens, indoor/outdoor air pollution
STEP 4
PREFERRED STEP 3
STEP 1 STEP 2 Continue controller
CONTROLLER
CHOICE & refer for specialist
Double assessment
‘low dose’
Daily low dose ICS ICS
Other Leukotriene receptor antagonist (LTRA) Low dose ICS + LTRA Add LTRA
controller Inc. ICS
Intermittent ICS frequency
options Add intermitt ICS
CONSIDER Infrequent Symptom pattern consistent with asthma Asthma diagnosis, and not well- Not well-
THIS STEP FOR viral wheezing and and asthma symptoms not well-controlled, or controlled on low dose ICS controlled on
CHILDREN WITH: no or ≥3 exacerbations per year double ICS
few interval
Symptom pattern not consistent with asthma but wheezing episodes occur
symptoms First check diagnosis, inhaler skills, adherence,
frequently, e.g. every
6–8 weeks. exposures
Give diagnostic trial for 3 months.
4–5 years Pressurized metered dose inhaler plus Pressurized metered dose inhaler plus
dedicated spacer with mouthpiece dedicated spacer with face mask, or
nebulizer with mouthpiece or face mask
GINA
GINA2018,
2018, Box 6-6
Box 6-7 © Global Initiative for Asthma www.ginasthma.org
Primary care management of acute asthma or
wheezing in pre-schoolers
GINA 2018, Box 6-8 (1/3) © Global Initiative for Asthma www.ginasthma.org
Child presents with acute or sub-acute asthma exacerbation
PRIMARY CARE or acute wheezing episode
GINA 2018, Box 6-8 (2/3) © Global Initiative for Asthma www.ginasthma.org
MONITOR CLOSELY for 1-2 hours
Transfer to high level care if any of: TRANSFER TO HIGH LEVEL CARE
• Lack of response to salbutamol over 1-2 hrs Worsening, (e.g. ICU)
or lack of While waiting give:
• Any signs of severe exacerbation improvement
Salbutamol 100 mcg 6 puffs by pMDI+spacer (or 2.5mg
• Increasing respiratory rate nebulizer). Repeat every 20 min
• Decreasing oxygen saturation as needed.
IMPROVING Oxygen (if available) to keep saturation 94-98%
Prednisolone 2mg/kg (max. 20 mg for <2 yrs; max. 30 mg for
2–5 yrs) as a starting dose
CONTINUE TREATMENT IF NEEDED Consider 160 mcg ipratropium bromide
Worsening, or
Monitor closely as above failure to respond (or 250 mcg by nebulizer). Repeat every
If symptoms recur within 3-4 hrs to 20 min for 1 hour if needed.
10 puffs
• Give extra salbutamol 2-3 puffs per hour
salbutamol over
• Give prednisolone 2mg/kg (max. 20mg for 3-4 hrs
<2 yrs; max. 30mg for 2-5 yrs) orally
IMPROVING
DISCHARGE/FOLLOW-UP PLANNING
Ensure that resources at home are adequate.
Reliever: continue as needed
Controller: consider need for, or adjustment of, regular controller
Check inhaler technique and adherence
Follow up: within 1-7 days
Provide and explain action plan
FOLLOW UP VISIT
Reliever: Reduce to as-needed
Controller: Continue or adjust depending on cause of exacerbation, and duration of need for extra salbutamol
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?
Schedule next follow up visit
GINA 2018, Box 6-8 (3/3) © Global Initiative for Asthma www.ginasthma.org
Initial assessment of acute asthma exacerbations in
children ≤5 years
*Normal respiratory rates (breaths/minute): 0-2 months: <60; 2-12 months: <50; 1-5 yrs: <40
GINA 2018, Box 6-10 © Global Initiative for Asthma www.ginasthma.org
Initial management of asthma exacerbations
in children ≤5 years
GINA 2018, Box 6-11 (2/2) © Global Initiative for Asthma www.ginasthma.org
Devices
References
Kasper, D., et al. (2015). Harrisons Principles of Internal
Medicine 19th edition. McGraw-Hill.
Shargel, L. (2009). Comprehensive pharmacy review. Lippincott
Williams & Wilkins.
Walker, R. & Whittlesea, C. (2012). Clinical Pharmacy and
Therapeutics 5th edition. Elsevier.
www.ginasthma.org accessed April 2018