Pocket Guide for Asthma Management and Prevention in Children 5 Years and Younger
®
A Pocket Guide for Physicians and Nurses 2009 BASED ON THE GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION IN CHILDREN 5 YEARS AND YOUNGER Available from www.ginasthma.org
© 2010 Medical Communications Resources, Inc
Disclaimer: Although the recommendations of this document are based on the best published evidence, it is the responsibility of practicing physicians to consider the cost and benefit of all treatments prescribed in young children, with due reference to recommendations and licensed formulations, dosing, and indications for use in their country.
®
®
GLOBAL INITIATIVE F OR A STHMA
®
GLOBAL INITIATIVE FOR ASTHMA Executive Committee (2009)
Pediatric Writing Group
Eric D. Bateman, M.D., South Africa, Chair Louis-Philippe Boulet, MD, Canada Alvaro Cruz, MD, Brazil Mark FitzGerald, M.D., Canada Tari Haahtela, M.D., Finland Mark Levy, MD, UK Paul O'Byrne, M.D., Canada Ken Ohta, M.D., Japan Pierluigi Paggario, M.D., Italy Soren Pedersen, M.D., Denmark Manuel Soto-Quiroz, M.D., Costa Rica Gary Wong, M.D., Hong Kong ROC
Allan Becker, MD, Canada Robert F. Lemanske, Jr, MD, USA Soren Erik Pedersen, MD, Denmark Peter D. Sly MD, Australia Manuel Soto-Quiroz, MD, Costa Rica Gary W. Wong, MD, Hong Kong ROC Heather J. Zar, MD, South Africa
© 2009 Medical Communications Resources, Inc.
TABLE OF CONTENTS PREFACE .......................................................................................2 WHAT IS KNOWN ABOUT ASTHMA?...........................................3 DIAGNOSING ASTHMA ..............................................................4
Table 1. Is it Asthma? ..........................................................4 CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL ...............5
Table 2. Levels of Asthma Control in Children 5 Years and Younger ...............................................5 MANAGEMENT AND PHARMACOLOGIC TREATMENT .................6
Develop a Partnership – Family/Caregivers and Health Care Providers Identify and Reduce Exposure to Risk Factors ......................................6 Table 3. Strategies for Avoiding Common Allergens and Pollutants................................................................7
Assess, Treat, and Monitor Asthma ....................................................8 Table 4. Asthma Management Approach Based on Control for Children 5 Years and Younger .............................9 Table 5. Low Daily Doses of Inhaled Glucocorticosteroids for Children 5 Years and Younger ..............................10 Manage Acute Exacerbations ..........................................................12 Table 6. Initial Assessment of Acute Asthma in Children 5 Years and Younger...............................................13 Table 7. Indications for Immediate Referral to Hospital (Health Center) .......................................................14 Table 8. Initial Management of Acute Asthma in Children 5 Years and Younger...............................................15
1
PREFACE Asthma is a major cause of chronic morbidity and mortality throughout the world and there is evidence that its prevalence has increased considerably over the past 20 years, especially in children. The Global Initiative for Asthma was created to increase awareness of asthma among health professionals, public health authorities, and the general public, and to improve prevention and management through a concerted worldwide effort. The Initiative prepares reports on asthma management based on the best available scientific evidence, encourages dissemination and implementation of the recommendations, and promotes international collaboration on asthma research. Recommendations in this Pocket Guide present special challenges that must be taken into account to manage asthma in children during the first 5 years of life, including difficulties with diagnosis, and efficacy and safety of drugs and delivery systems. Approaches to these issues will vary among populations based on socioeconomic conditions, genetic diversity, cultural beliefs, and differences in health care access and deliver. The Global Initiative for Asthma offers a framework to achieve and maintain asthma control for most patients that can be adapted to local health care systems and resources. Program publications include: • Global Strategy for Asthma Management and Prevention (2008). Scientific information and recommendations for asthma programs. • Pocket Guide for Asthma Management and Prevention (2008). Summary of patient care information for primary health care professionals. • Pocket Guide for Asthma Management and Prevention in Children 5 Years and Younger (2009). Summary of patient care information for pediatricians and other healthcare professionals • What You and Your Family Can Do About Asthma. An information booklet for patients and their families. Publications are available from www.ginasthma.org.
This Pocket Guide has been developed from the Global Strategy for Asthma Management and Prevention in Children 5 Years and Younger (2009). Technical discussions of asthma, evidence levels, and specific citations from the scientific literature are included in the source document.
2
WHAT IS KNOWN ABOUT ASTHMA? Unfortunately… asthma is the most common chronic disease of child-
hood and the leading cause of childhood morbidity from chronic disease as measured by absence from day care, emergency department visits, and hospitalizations. There are special challenges that must be taken into account in managing asthma in children during the first 5 years of life. Fortunately… asthma in this young age group can be effectively treated
and control can be achieved in most patients. When asthma is under control children can: 3 Avoid troublesome symptoms night and day 3 Use little or no reliever medication 3 Have productive, physically active lives 3 Avoid serious attacks • Asthma causes recurring episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. • Asthma is a chronic inflammatory disorder of the airways. Chronically inflamed airways are hyperresponsive; they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs, and increased inflammation) when airways are exposed to various risk factors. • Common risk factors for asthma symptoms in young children include exposure to allergens (such as those from house dust mites, animals, cockroaches, fungi), exposure to tobacco smoke and biomass fuels, respiratory (viral) infections and emotional stress. • Pharmacologic treatment to achieve and maintain control of asthma should take into account the safety of treatment, potential for adverse effects, and the cost of treatment required to achieve control. • Asthma attacks (or exacerbations) are episodic, but airway inflammation is chronically present. • For many patients, controller medication must be taken daily to prevent symptoms, improve lung function, and prevent attacks. Reliever medications may occasionally be required to treat acute symptoms such as wheezing, chest tightness, and cough. • To reach and maintain asthma control in young children requires the development of a partnership between the family/care giver and the health care team. 3
DIAGNOSING ASTHMA Making a definite diagnosis of asthma in children 5 years and younger is challenging because episodic respiratory symptoms such as wheezing and cough are also common in children who do not have asthma, particularly in those younger than 3 years. Not all young children who wheeze have asthma, and the younger the child, the greater the likelihood that an alternative diagnosis may explain recurrent wheeze . These alternatives must be considered and excluded before an asthma diagnosis is made. Alternative causes of recurrent wheezing, particularly in early infancy, include infections (recurrent viral lower respiratory tract infections, chronic rhino-sinusitis, tuberculosis); congenital problems (cystic fibrosis, bronchopulmonary dysplasia, congenital malformation causing narrowing of the intrathoracic airways, primary ciliary dyskinesia syndrome, immune deficiency, and congenital heart disease) and mechanical problems (foreign body aspiration). A difficulty with diagnosing asthma in children 5 years and younger is that the lung function measurements that are key to diagnosis in older children and adults are not reliable in this age group. A trial of treatment with short-acting bronchodilators and inhaled glucocorticosteroids can help confirm an asthma diagnosis: look for marked clinical improvement during the treatment and deterioration when treatment is stopped. The presence of atopy or allergic sensitization also increases the likelihood that a wheezing child will have asthma. Taking all of these factors into account, a diagnosis of asthma in these young children can often be made based largely on symptom patterns and on a careful clinical assessment of family history and physical findings (Table 1). Table 1. Is It Asthma? Consider asthma if any of the following signs or symptoms are present: n Frequent episodes of wheezing—more than once a month. n Activity-induced cough or wheeze. n Cough particularly at night during periods without viral infections. n Absence of seasonal variation in wheeze. n Symptoms that persist after age 3. n Symptoms occur or worsen in the presence of: • Aeroallergens (house dust mites, companion animals, cockroach, fungi) • Exercise • Pollen • Respiratory (viral) infections • Strong emotional expression • Tobacco smoke n The child’s colds repeatedly “go to the chest” or take more than 10 days to clear up. n Symptoms improve when asthma medication is given.
4
CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL For all patients with a confirmed diagnosis of asthma, the goal of treatment is to achieve and maintain control of the disease. However, assessing asthma control in children 5 years and younger is difficult, because health care providers are almost exclusively dependent on the reports of the child’s family members and caregivers who might be unaware of the presence of asthma symptoms, or of the fact that they represent uncontrolled asthma. Additional information about asthma control may be gleaned from the child’s need for reliever/rescue treatment (with increased use indicating worsening control). Table 2 presents a working scheme to assess asthma control in children 5 years and younger based on these two sources of information. Table 2. Levels of Asthma Control in Children 5 Years and Younger* Characteristic
Daytime symptoms: wheezing, cough , difficult breathing
Controlled (All of the following)
Partly Controlled (Any measure present in any week)
None More than twice/week (less than twice/week, (typically for short typically for short periods periods on the order of on the order of of minutes and rapidly minutes and rapidly relieved by use of relieved by the use of a rapid-acting a rapid-acting bronchodilator) bronchodilator)
Limitations of activities
None (child is fully active, plays and runs without limitation or symptoms)
Nocturnal symptoms/awakening
None (including no nocturnal coughing during sleep)
Need for reliever/rescue treatment
≤ 2 days/week
Any (may cough, wheeze, or have difficulty breathing during exercise, vigorous play, or laughing)
Uncontrolled (Three or more of features of partly controlled asthma in any week) More than twice/week (typically last minutes or hours or recur, but partially or fully relieved with rapid-acting bronchodilators)
Any (may cough, wheeze, or have difficulty breathing during exercise, vigorous play, or laughing)
Any Any (typically coughs during (typically coughs during sleep or wakes with sleep or wakes with cough, wheezing, cough, wheezing, and/or difficult breathing) and/or difficult breathing) > 2 days/week
> 2 days/week
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequete. Although patients with current clinical control are less likely to experience exacerbations, they are still at risk during viral upper respiratory tract infections and may still have one or more exacerbations per year.
5
MANAGEMENT AND PHARMACOLOGIC TREATMENT Control of asthma can be achieved in a majority of children 5 years and younger with an intervention strategy that includes: • A partnership between the child’s family/caregivers and the health care team • Avoidance of risk factors • A plan to assess, treat with appropriate pharmacologic therapy, and monitor asthma control • An action plan to enable the child’s family members and caregivers to recognize an asthma attack and initiate treatment, recognize a severe episode, and identify when urgent treatment at a hospital (health care facility) is required.
Develop a Partnership – Family/Caregivers and Health Care Providers With the help of everyone on the health care team, families/caregivers can be actively involved in managing asthma to prevent problems and enable children to live productive, physically active lives. They can learn to: • Help the child avoid risk factors • Ensure that the child takes medications correctly • Understand the difference between “controller” & “reliever” medications • Monitor asthma control status using symptoms • Recognize signs that asthma is worsening and take action • Seek medical help as appropriate Education should be an integral part of all interactions between health care professionals and the family/caregivers of young children with asthma. Using a variety of methods—such as discussions (with a physician, nurse, outreach worker, counselor, or educator), demonstrations, written materials, group classes, video or audio tapes, dramas, and family support groups— helps reinforce educational messages. For wheezy children 5 years and younger, when wheeze is suspected to be caused by asthma, a written asthma action plan based on the levels of respiratory symptoms can be an effective tool to help family members/caregivers improve and maintain control of the child’s asthma. 6
Identify and Reduce Exposure to Risk Factors To improve control of asthma and reduce medication needs, patients should take steps to avoid the risk factors that cause their asthma symptoms (Table 3). However, many asthma patients react to multiple factors that are ubiquitous in the environment, and avoiding some of these factors completely is nearly impossible. Thus, medications to maintain asthma control have an important role because patients are often less sensitive to these risk factors when their asthma is under control. Table 3. Strategies for Avoiding Common Allergens and Pollutants Avoidance measures that improve control of asthma and reduce medication needs: • Tobacco smoke: Stay away from tobacco smoke. Parents and caregivers should not smoke. • Drugs, foods, and additives: Avoid if they are known to cause symptoms.
Reasonable avoidance measures that can be recommended but have not been shown to have clinical benefit: • House dust mites: Wash bed linens and blankets weekly in hot water and dry in a hot dryer or the sun. Encase pillows and mattresses in air-tight covers. Replace carpets with hard flooring, especially in sleeping rooms. (If possible, use vacuum cleaner with filters. Use acaricides or tannic acid to kill mites—but make sure the patient is not at home when the treatment occurs.) • Animals with fur: Use air filters. (Remove animals from the home, or at least from the sleeping area. Wash the pet.) • Cockroaches: Clean the home thoroughly and often. Use pesticide spray— but make sure the patient is not at home when spraying occurs. • Outdoor pollens and mold: Close windows and doors and remain indoors when pollen and mold counts are highest. • Indoor mold: Reduce dampness in the home; clean any damp areas frequently.
7
ASSESS, TREAT, AND MONITOR ASTHMA
The goal of asthma treatment—to achieve and maintain clinical control— can be reached in most patients through a continuous cycle that involves • Assessing Asthma Control • Treating to Achieve Control • Monitoring to Maintain Control
Assessing Asthma Control Each patient should be assessed to establish his or her current treatment regimen, adherence to the current regimen, and level of asthma control. Current impairment (day and night symptoms, activity level impairment, need for rescue medications) and future risk (likelihood of acute exacerbation in the future) should both be addressed. A simplified scheme for recognizing controlled, partly controlled, and uncontrolled asthma is provided in Table 2. Treating to Achieve Control For the treatment of asthma inhaled medications are preferred because they deliver drugs directly to the airways where they are needed, resulting in potent therapeutic effects with fewer systemic side effects. Devices recommended to deliver inhaled medication for children 5 years and younger include pressurized metered-dose inhalers (pMDIs) and nebulizers. Spacer (or valved holding-chamber) devices make inhalers easier to use and reduce systemic absorption and side effects of inhaled glucocorticosteroids.
Among children in this young age group, inhaler technique may be poor and should be monitored closely. Teach family members/caregivers how to use the specific inhaler device(s) prescribed for their child, as different devices need different inhalation techniques. • Give demonstrations and illustrated instructions. • Ask family members/caregivers to show how their children use the inhalers at every visit. For each child, select the most appropriate device. In general: • Children younger than 4 years of age should use a pMDI plus a spacer with face mask, or a nebulizer with face mask. • Children aged 4 to 5 years should use a pMDI plus a spacer with mouthpiece, or a pMDI plus a spacer with a face mask or, if necessary, a nebulizer with face mask. • For children using spacers, the spacer must fit the inhaler. 8
Information about use of various inhaler devices is found on the GINA Website (www.ginasthma.org) . A variety of controller and reliever medications for asthma are available. The recommended treatments discussed below are guidelines only. Local resources and individual patient circumstances should determine the specific therapy prescribed for each patient. All young children with asthma should be prescribed a reliever medication to use as needed for quick relief of symptoms. (Parents and caregivers should be aware of how much reliever medication the child is using—regular or increased use indicates that asthma is not well controlled.) A rapid-acting inhaled β 2-agonist is the recommended choice of reliever medication for most patients in this age group. If the child’s asthma is not controlled with as-needed use of reliever medication, a low-dose inhaled glucocorticosteroid is the recommended initial controller treatment (Table 4). This initial treatment should be given for at least 3 months to establish its effectiveness in reaching control. If at the end of this period the low dose of inhaled glucocorticosteroid does not control symptoms, and the child is using optimal technique and is adherent to therapy, doubling the initial dose of glucocorticosteroid given in Table 5 may be the best option. Addition of a leukotriene modifier to the low-dose inhaled glucocorticosteroid may also be considered.
9
Table 4. Asthma Management Approach Based on
Control for Children 5 Years and Younger Asthma education, Environmental control, and As needed rapid-acting β 2-agonists Controlled on as needed rapid-acting β 2-agonists
Partly controlled on as needed rapid- acting β 2-agonists
Uncontrolled or only partly controlled on low-dose inhaled glucocorticosteroid*
Controller options Continue as needed rapid-acting β 2-agonists
Low-dose inhaled glucocorticosteroid
Double low-dose inhaled glucocorticosteroid
Leukotriene modifier
Low-dose inhaled glucocorticosteroid plus Leukotriene modifier
*Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma. Shaded boxes represent preferred treatment options.
Table 5. Low Daily Doses* of Inhaled Glucocorticosteriods for Children 5 Years and Younger Drug
Low Daily Dose ( g)
Beclomethasone dipropionate
100
Budesonide MDI+spacer Budesonide nebulized
200 500
Ciclesonide
NS
Fluticasone propionate
100
†
Mometasone furoate
NS
Triamcinolone acetonide
NS
†
†
* A low daily dose is defined as the dose which has not been associated with clinically adverse effects in trials including measures of safety. This is not a table of clinical equivalence. † NS = Not studied in this age group.
10
Monitoring to Maintain Control Ongoing monitoring is essential to maintain control and establish the lowest step and dose of treatment to minimize cost and maximize safety. Typically, patients should be seen one to three months after the initial visit, and every three months thereafter. After an exacerbation, follow-up should be offered within two weeks to one month. Adjusting medication: • If asthma is not controlled within one to three months by doubling the initial dose of inhaled glucocorticosteroids, assess and monitor the child’s inhalation technique, compliance with medication regimen, and avoidance of risk factors.
• If control is maintained for at least 3 months, decrease treatment to the least medication necessary to maintain control. Monitoring is still necessary even after control is achieved, as asthma is a variable disease; treatment has to be adjusted periodically in response to loss of control as indicated by worsening symptoms or the development of an exacerbation. Asthma symptoms remit in a substantial proportion of children 5 years and younger, and some children have symptoms only during certain seasons of the year. It is recommended that the continued need for asthma treatment in children under age 5 should be regularly assessed (every 3-6 months). If asthma therapy is discontinued, a follow-up visit should be scheduled 3-6 weeks later to verify that the remission of symptoms persists. Consult with an asthma specialist when other conditions complicate asthma, if the child does not respond to therapy, or if asthma remains uncontrolled.
Approach to the Child with Intermittent Wheezing Episodes Intermittent episodic wheezing of any severity may represent unrecognized uncontrolled asthma, an isolated viral-induced wheezing episode, or an episode of seasonal or allergen-induced asthma. The initial treatment recommended includes a dose of rapid-acting inhaled β 2-agonist every 4–6 hours as needed for a day or more until symptoms disappear. If a detailed history suggests the diagnosis of asthma, and wheezing episodes are frequent (e.g., 3 in a season), regular controller treatment should be initiated. Regular controller treatment may also be indicated in a child with less frequent, but more severe, episodes of viral-induced wheeze. Where the diagnosis is in doubt, and when rapid-acting inhaled β 2-agonist therapy needs to be repeated more frequently than every 6-8 weeks, a diagnostic trial of regular controller therapy should be considered to confirm whether the symptoms are due to asthma. 11
Manage Acute Exacerbations Exacerbations of asthma (asthma attacks) are acute episodes of deterioration in symptom control that are sufficient to cause distress or risk to health necessitating a visit to a health care provider or requiring treatment with systemic glucocorticosteroids. Do not underestimate the severity of an attack (Table 6); severe asthma attacks may be life threatening. Early symptoms may include any of the following:
• An increase in wheeze and shortness of breath • An increase in coughing, especially nocturnal cough • Lethargy or reduced exercise tolerance • Impairment of daily activities, including feeding • A poor response to reliever medication Upper respiratory symptoms frequently precede the onset of an asthma exacerbation. Home Management
A health care provider may recommend steps for the family/caregiver to care for an asthma attack at home: . • Initiate treatment with two puffs of inhaled rapid-acting β 2-agonist, given one puff at a time via a mask or spacer device. • Observe the child and maintain a restful atmosphere for one hour or more • Seek medical attention the same day if inhaled bronchodilator is required for symptom relief more than every 3 hours or for more than 24 hours. Oral glucocorticosteroid treatment by family/caregivers in the home management of asthma exacerbations in children should be considered only where the physician is confident that this medication will be used appropriately. Immediate medical attention should be sought …. • For children younger than 1 year requiring repeated rapid-acting inhaled β 2-agonists over the course of hours • If the child is acutely distressed • If the symptoms are not relieved promptly by inhaled bronchodilator • If the period of relief after a dose of inhaled β 2-agonist becomes progressively shorter 12
Table 6. Initial Assessment of Acute Asthma in Children Five Years and Younger Symptoms
Mild
Severea
Altered consciousness
No
Agitated, confused or drowsy
Oximetry on presentationb (SaO2)
94%
< 90%
Talks inc
Sentences
Words
Pulse rate
< 100 bpmd
> 200 bpm (0-3 years) > 180 bpm (4-5 years)
Central cyanosis
Absent
Likely to be present
Wheeze intensity
Variable
May be quiet
a Any of these features indicates a severe asthma exacerbation b Oximetry performed before treatment with oxygen or bronchodilator c The normal developmental capability of the child must be taken into account. d bpm = beats per minute.
If a severe exacerbation fails to resolve in 1 to 2 hours in spite of repeated dosing with rapid-acting inhaled β 2-agonists, with or without the addition of oral glucocorticosteroids, refer the child to the hospital (or health center) for observation and further treatment ( Table 7). Other indications for referral to the hospital/health center include: • respiratory arrest or impending arrest • lack of supervision in the home • recurrence of signs of severity within 48 hours of the initial exacerbation (particularly if treatment with systemic glucocorticosteroids has been given). For children younger than 2 years, early medical attention should be sought as the risk of dehydration and respiratory fatigue is increased.
13
Table 7. Indications for Immediate Referral to Hospital ANY of the following: • No response to three (3) administrations of an inhaled short-acting β 2-agonist within 1-2 hours • Tachypnea despite 3 administrations of an inhaled short-acting β 2-agonist (Normal respiratory rate < 60 breaths per minute in children 0 – 2 months; < 50 in children 2 –12 months; < 40 in children 1 – 5 years) • Child is unable to speak or drink or is breathless • Cyanosis • Subcostal retractions • Oxygen saturation when breathing room air < 92% • Social environment that impairs delivery of acute treatment; caregivers unable to manage acute asthma at home
Asthma attacks require prompt treatment (Table 8):
• Oxygen delivered by face mask given at hospital (health center) if the patient is hypoxemic (achieve O2 saturation above 94%). • Inhaled rapid-acting β 2-agonists in adequate doses are essential (two puffs at 20-minute intervals for an hour). • Failure to respond to bronchodilator therapy at 1 hour, or earlier if the child deteriorates, requires urgent admission to hospital and a short course of oral glucocortiocosteroids. • Children prescribed maintenance therapy with inhaled glucocorticosteroids or leukotriene modifier or both should continue to take the prescribed dose during and after an attack. Therapies not recommended for treating attacks include: • Sedatives. • Mucolytic drugs. • Chest physical therapy/physiotherapy. • Epinephrine (adrenaline) may be indicated for acute treatment of anaphylaxis and angioedema but is not indicated during asthma attacks. • Intravenous magnesium sulphate has not been studied in young children. 14
Table 8: Initial Management of Acute Severe Asthma in Children 5 Years and Younger* Therapy
Dose and Administration
Supplemental oxygen
Deliver by 24% face mask (flow set to manufacturer’s instructions, usually 4L/minute) Maintain oxygen saturation above 94%
Short-acting β 2-agonist
2 puffs salbutamol by spacer, or 2.5 mg salbutamol by nebulizer Every 20 minutes for first hours a
Ipratropium
2 puffs every 20 minutes for first hour only
Systemic glucocorticosteroids
Aminophyllineb
Oral prednisolone (1-2 mg/kg daily for up to 5 days) or Intravenous methylprednisolone 1 mg/kg every 6 hours on day 1; every 12 hours on day 2; then daily Consider in ICU: loading dose 6-10mg/kg lean body weight Initial maintenance: 0.9 mg/kg/hour Adjustment according to plasma theophylline levels
Oral β 2-agonists
No
Long-acting β 2-agonist
No
a If inhalation is not possible an intravenous bolus of 5 µg/kg given over 5 minutes, followed by continuous infusion of 5 µg/kg/hour. The dose should be adjusted according to clinical effect and side effects84. b Loading dose should not be given to patients already receiving theophylline.
15
Follow up:
Before discharge from the emergency department or hospital, the condition of the patient should be stable, e.g., out of bed and able to eat and drink without problem. Family/caregivers should receive: • Instruction on recognition of signs of recurrence and worsening of asthma. The factors that precipitated the exacerbation should be identified and strategies for future avoidance of these factors implemented • A written individualized action plan including details of accessible emergency services • A supply of bronchodilator and, where applicable, the remainder of the course of oral or inhaled glucocorticosteroids or leukotriene modifier • Careful review of inhaler technique • Further treatment advice • A follow-up appointment within 1 week and another within 1-2 months depending on the clinical, social, and practical context of the exacerbation
16
The Global Initiative for Asthma is supported by educational grants from:
Copies of this document are available at www.ginasthma.org www.us-health-network.com
