Medical Archive

SECTION 1. ADULTS, ADOLESCENTS AND CHILDREN 6 YEARS AND OLDER

Chapter 1. Definition, description, and diagnosis of asthma

Chapter 2. Assessment of asthma

Chapter 3. Treating asthma to control symptoms and minimize risk

Part A. General principles of asthma management

3?? ?? ?? ? ?? ?? ?? ?? step ??.

• Symptom severity ??
  • “?2? ??? ??? ?? ?2? ??? ??” (6? ??? ?2? ? ?1?)
  • 1-3?? ?? ?? ??. ?? ?? ??.
• Lung function ??
  • ????: PEFR(peak expiratory flow rate) ?? ??. ??? 500
    • ?? PEFR variability >20%: step 3
    • ?? PEFR variability >30%: step 4-5
  • ????: FEV1
    • FEV <80%: step 3
    • FEV <60%: step 4-5
• Exacerbations requiring systemic corticosteroids
  • ? 1? ??: step 1
  • ? 2? ??: step 2-5

Part B. Medications and strategies for symptom control and risk reduction

SABA: albuterol, terbutaline, salbutamol
LABA: salmeterol, formoterol
ICS: beclomethasone, fluticasone, budesonide, ciclesonide, mometasone, triamcinolone
LT modifiers: montelukast, zafirlukast, zileuton
SAMA: ipratropium bromide
LAMA: tiotropium bromide
Biologics: omalizumab, mepolizumab
Methylxanthines: theophylline
Mast cell stabilizers: cromolyn sodium, nedocromil sodium
Oral corticosteroids: methylprednisolone, prednisone

• Step 1
  • ??? ?? ???, night waking ?? ??? exacerbation ?? ?, FEV1 ??? ????.
  • ???(salbutamol)
• Step 2
  • ICS/LABA? ICS????? Sx & FEV1 ??? ???? ?? ???? ??.
  • [ICS/LABA] ?????(salmeterol+fluticasone), ??(vilanterol+fluticasone) 
  • ?? ??? allergic asthma?? ICS? ??? ?? ??? 4? ? ??.
  • LTRA<ICS.
• Step 3
  • ?????? ?????? ????(monteleukast) ???? ?.
  • [Low dose ICS/LABA] ????(Budesonide/Formoterol)? maintenance, reliever ???? ??? ????.
• Step 4
  • ?? ??? tiotropium by mist inhaler? ??? ??.
• Step 5
  • Omalizumab (anti-IgE) for severe allergic asthma. Mepolizumab (anti-IL5) for severe eosinophilic asthma. low dose OCS? ??? ? ??? long-term systemic S/E ? ?? ? ??. 

6? ????? ???. 6? ??? step1 ?? ???, step3? ‘Double low dose ICS’? ? ??

?? ????? ? ?? step 2? ??. (?? ???? step 1)
?? ?? 3?? ?? ??? ???!
Acute attack? SABA? ? 1??? 20? ???? 3? ??.
?? 3???? controlled ?? ????? step down

????? ???	????, metered dose inhaler, MDI	??? ??? ???? ?? (?????)
?? ???	???, dry powder inhaler, DPI	?? ? ?? ???.

ICS-containing controller inhaler for every adult and adolescent with asthma (no more SABA-only treatment)

???? ?? ???? ?? ? ?? ????? ??? ??.

??? MDI, DPI? ???? ???? spacer? ??? ? ???. ???? ??? ???? ? ??.

Nebulizer
??? ??? ?? ??? ???. ?? ? ?? ???? ?? ?.
But ??? ???? ???, ??? ????!

Side effects

ICS
Orah thrush (candidiasis)
Nystatin ??. ??? ????, spacer ???? ??.

Part C. Guided asthma self-management education and skills training

Part D. Managing asthma with comorbidities and in specific populations

Part E. Difficult-to-treat and severe asthma in adults and adolescents

Chapter 4. Management of worsening asthma and exacerbations

Summary

1. O2
   • to achieve SaO2>90% (??? 95%)
2. SABA
   • 1?? ?? 20? ?? ??, ?? 3?
3. po steroid
   • SABA? ?? ??? po steroid ???? ??, ?? ??(PEFR<60%, ?? ? ??, ????) ?.

Medication	Short-term change (1–2 weeks) for worsening asthma	Evidence level
Increase usual reliever:
Low dose ICS-formoterolâ€	Increase frequency of as-needed ICS-formoterolâ€	A
Short-acting beta 2-agonist (SABA)	Increase frequency of SABA use 
For pMDI, add spacer	A A
Increase usual controller:
Maintenance and reliever ICS-formoterolâ€	Continue maintenance ICS-formoterol and increase reliever ICS-formoterol as neededâ€	A
Maintenance ICS with SABA as reliever	In adults and adolescents, quadruple ICS dose. In children with high adherence, 5x increase in ICS dose is not effective	B
Maintenance ICS-formoterol with SABA as relieverâ€	Quadruple maintenance ICS-formoterolâ€	B
Maintenance ICS plus other LABA with SABA as reliever	Step up to higher dose formulation of ICS plus other LABA 
In adults, consider adding a separate ICS inhaler to quadruple ICS dose	B 
 D
Add oral corticosteroids (OCS) and contact doctor; review before ceasing
OCS (prednisone or prednisolone)	Add OCS for severe exacerbations (e.g. PEF or FEV 1<60% personal best or predicted), or patient not responding to treatment over 48 hours. Once started, morning dosing is preferable. Adults: prednisolone 40-50mg/day, usually for 5–7 days. 
 Children 6–11 years: 1–2 mg/kg/day (maximum 40 mg) usually for 3–5 days.

 Tapering is not needed if OCS are prescribed for <2 weeks	A

 D

 B

Chapter 5. Diagnosis and initial treatment of adults with features of asthma, COPD or both (‘asthma-COPD overlap’)

SECTION 2. CHILDREN 5 YEARS AND YOUNGER

Chapter 6. Diagnosis and management of asthma in children 5 years and younger

Part A. Diagnosis

Part B. Assessment and management

2014 guideline? ??? step 3??? ??? ICS? 2? ???? ??.

Part C. Management of worsening asthma and exacerbations in children 5 years and younger

• ?? ???
  • <2??: <60?/m
  • 2-12??: <50?/m
  • 1-5?: <40?/m
  • 6-8?: <30?/m
• ?? ???
  • 2-12??: 160?/m
  • 1-2?: 120?/m
  • 2-8?: 110?/m

Chapter 7. Primary prevention of asthma

SECTION 3. TRANSLATION INTO CLINICAL PRACTICE

Chapter 8. Implementing asthma management strategies into health systems