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8/13/2019 GINA Under5 Pocket 20091 1

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A Pocket Guide for Physicians and Nurses2009

BASED ON THE GLOBAL STRATEGY FORASTHMA MANAGEMENT AND PREVENTION IN CHILDREN 5 YEARS AND YOUNGER

Available from www.ginasthma.org

Pocket Guide forAsthma Management and

Prevention in Children5 Years and Younger


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Disclaimer: Although the recommendations of this document are based on the best publishedevidence, it is the responsibility of practicing physicians to consider the cost and benefit of alltreatments prescribed in young children, with due reference to recommendations and licensedformulations, dosing, and indications for use in their country.


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GLOBAL INITIATIVE FOR ASTHMA

GLOBAL INITIATIVE

FOR ASTHMA

2009 Global Initiative for Asthma

Executive Committee (2009)

Eric D. Bateman, M.D., South Africa, ChairLouis-Philippe Boulet, MD, CanadaAlvaro Cruz, MD, BrazilMark FitzGerald, M.D., CanadaTari Haahtela, M.D., FinlandMark Levy, MD, UKPaul O'Byrne, M.D., Canada

Ken Ohta, M.D., JapanPierluigi Paggario, M.D., ItalySoren Pedersen, M.D., DenmarkManuel Soto-Quiroz, M.D., Costa RicaGary Wong, M.D., Hong Kong ROC

Pediatric Writing Group

Allan Becker, MD, CanadaRobert F. Lemanske, Jr, MD, USASoren Erik Pedersen, MD, DenmarkPeter D. Sly MD, AustraliaManuel Soto-Quiroz, MD, Costa RicaGary W. Wong, MD, Hong Kong ROCHeather J. Zar, MD, South Africa


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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 Children5 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 Controlfor Children 5 Years and Younger .............................9

Table 5. Low Daily Doses of Inhaled Glucocorticosteroids forChildren 5 Years and Younger ..............................10

Manage Acute Exacerbations ......................................................12

Table 6. Initial Assessment of Acute Asthma in Children5 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


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PREFACE

Asthma is a major cause of chronic morbidity and mortality throughout the

world and there is evidence that its prevalence has increased considerablyover the past 20 years, especially in children. The Global Initiative forAsthma was created to increase awareness of asthma among health pro-fessionals, public health authorities, and the general public, and to improveprevention and management through a concerted worldwide effort. TheInitiative prepares reports on asthma management based on the best avail-able scientific evidence, encourages dissemination and implementation ofthe recommendations, and promotes international collaboration on asthmaresearch.

Recommendations in this Pocket Guide present special challenges that mustbe taken into account to manage asthma in children during the first 5years of life, including difficulties with diagnosis, and efficacy and safetyof drugs and delivery systems. Approaches to these issues will varyamong 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 andmaintain asthma control for most patients that can be adapted to localhealth 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 careprofessionals.

Pocket Guide for Asthma Management and Prevention in Children5 Years and Younger (2009). Summary of patient care informationfor pediatricians and other healthcare professionals

What You and Your Family Can Do About Asthma. An informationbooklet for patients and their families.

Publications are available from www.ginasthma.org.

This Pocket Guide has been developed from the Global Strategy forAsthma Management and Prevention in Children 5 Years and Younger(2009). Technical discussions of asthma, evidence levels, and specific cita-tions from the scientific literature are included in the source document.

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WHAT IS KNOWNABOUT ASTHMA?

Unfortunately asthma is the most common chronic disease of child-hood and the leading cause of childhood morbidity from chronic diseaseas measured by absence from day care, emergency department visits, andhospitalizations. There are special challenges that must be taken intoaccount in managing asthma in children during the first 5 years of life.

Fortunately asthma in this young age group can be effectively treatedand control can be achieved in most patients.

When asthma is under control children can: Avoid troublesome symptoms night and day Use little or no reliever medication Have productive, physically active lives Avoid serious attacks

Asthma causes recurring episodes ofwheezing, breathlessness, chesttightness, and coughing, particularly at night or in the early morning.

Asthma is a chronic inflammatory disorderof the airways. Chronicallyinflamed airways are hyperresponsive; they become obstructed and air-flow is limited (by bronchoconstriction, mucus plugs, and increasedinflammation) when airways are exposed to various risk factors.

Common risk factors for asthma symptoms in young children includeexposure to allergens (such as those from house dust mites, animals,cockroaches, fungi), exposure to tobacco smoke and biomass fuels, res-piratory (viral) infections and emotional stress.

Pharmacologic treatment to achieve and maintain control of asthmashould take into account the safety of treatment, potential for adverseeffects, and the cost of treatment required to achieve control.

Asthma attacks (or exacerbations) are episodic, but airway inflammationis chronically present.

For many patients, controllermedication must be taken daily to preventsymptoms, improve lung function, and prevent attacks. Relievermedica-

tions may occasionally be required to treat acute symptoms such aswheezing, chest tightness, and cough.

To reach and maintain asthma control in young children requires thedevelopment of a partnership between the family/care giver and thehealth care team.

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DIAGNOSING ASTHMAMaking a definite diagnosis of asthma in children 5 years and younger ischallenging because episodic respiratory symptoms such as wheezing andcough are also common in children who do not have asthma, particularly inthose younger than 3 years. Not all young children who wheeze have asth-ma, and the younger the child, the greater the likelihood that an alterna-tive diagnosis may explain recurrent wheeze. These alternatives must beconsidered 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, chronicrhino-sinusitis, tuberculosis); congenital problems (cystic fibrosis, bronchopul-

monary dysplasia, congenital malformation causing narrowing of theintrathoracic airways, primary ciliary dyskinesia syndrome, immune deficien-cy, and congenital heart disease) and mechanical problems (foreign bodyaspiration).

A difficulty with diagnosing asthma in children 5 years and younger is thatthe lung function measurements that are key to diagnosis in older childrenand adults are not reliable in this age group.

A trial of treatment with short-acting bronchodilators and inhaled glucocorti-costeroids can help confirm an asthma diagnosis: look for marked clinicalimprovement during the treatment and deterioration when treatment isstopped. The presence of atopy or allergic sensitization also increases thelikelihood that a wheezing child will have asthma.

Taking all of these factors into account, a diagnosis of asthma in these youngchildren can often be made based largely on symptom patterns and on acareful clinical assessment of family history and physical findings (Table 1).

Consider asthma if any of the following signs or symptoms are present:

Frequent episodes of wheezingmore than once a month. Activity-induced cough or wheeze. Cough particularly at night during periods without viral infections. Absence of seasonal variation in wheeze. Symptoms that persist after age 3. 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

The childs colds repeatedly go to the chest or take more than 10 days to clear up. Symptoms improve when asthma medication is given.

Table 1. Is It Asthma?


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For all patients with a confirmed diagnosis of asthma, the goal of treatmentis to achieve and maintain control of the disease. However, assessingasthma control in children 5 years and younger is difficult, because healthcare providers are almost exclusively dependent on the reports of thechilds family members and caregivers who might be unaware of the pres-ence of asthma symptoms, or of the fact that they represent uncontrolledasthma. Additional information about asthma control may be gleaned fromthe childs need for reliever/rescue treatment (with increased use indicating

worsening control).

Table 2 presents a working scheme to assess asthma control in children 5years and younger based on these two sources of information.

CLASSIFICATION OF ASTHMABY LEVEL OF CONTROL

Characteristic Controlled

(All of the following)

Partly Controlled

(Any measure

present in any week)

Uncontrolled

(Three or more of

features of partly

controlled asthma

in any week)

Daytime symptoms:

wheezing, cough ,

difficult breathing

None

(less than twice/week,

typically for short periods

of on the order of

minutes and rapidly

relieved by the use of

a rapid-acting

bronchodilator)

More than twice/week

(typically for short

periods on the order

of minutes and rapidly

relieved by use of

a rapid-acting

bronchodilator)

More than twice/week

(typically last minutes

or hours or recur, but

partially or fully relieved

with rapid-acting

bronchodilators)

Limitationsof activities

None(child is fully active,

plays and runs witout

limitation or symptoms)

Any(may cough, wheeze,

or have difficulty

breathing during

exercise, vigorous

play, or laughing)

Any(may cough, wheeze,

or have difficulty

breathing during

exercise, vigorous

play, or laughing)

Nocturnal

symptoms/awakening

None

(including no nocturnal

coughing during sleep)

Any

(typically coughs during

sleep or wakes with

cough, wheezing,

and/or difficult breathing)

Any

(typically coughs during

sleep or wakes with

cough, wheezing,

and/or difficult breathing)

Need for

reliever/rescue

treatment

2 days/week > 2 days/week > 2 days/week

Table 2. Levels of Asthma Control in Children 5 Years and Younger*

* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequete. Although patientswith current clinical control are less likely to experience exacerbations, they are still at risk during viral upperrespiratory tract infections and may still have one or more exacerbations per year.


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Control of asthma can be achieved in a majority of children 5 years andyounger with an intervention strategy that includes:

A partnership between the childs family/caregivers and the health care team

Avoidance of risk factors

A plan to assess, treat with appropriate pharmacologic therapy, andmonitorasthma control

An action plan to enable the childs family members and caregivers torecognize an asthma attack and initiate treatment, recognize a severeepisode, and identify when urgent treatment at a hospital (health carefacility) 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 enablechildren 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 careprofessionals and the family/caregivers of young children with asthma.Using a variety of methodssuch as discussions (with a physician, nurse,outreach worker, counselor, or educator), demonstrations, written materials,group classes, video or audio tapes, dramas, and family support groupshelps reinforce educational messages.

For wheezy children 5 years and younger, when wheeze is suspected to becaused by asthma, a written asthma action plan based on the levels of res-piratory symptoms can be an effective tool to help family members/care-givers improve and maintain control of the childs asthma.

MANAGEMENT ANDPHARMACOLOGIC TREATMENT


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Avoidance measures that improve control of asthma and reducemedication needs:

Tobacco smoke: Stay away from tobacco smoke. Parents and caregiversshould 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 anddry in a hot dryer or the sun. Encase pillows and mattresses in air-tight cov-ers. Replace carpets with hard flooring, especially in sleeping rooms.(If possible, use vacuum cleaner with filters. Use acaricides or tannic acid tokill mitesbut make sure the patient is not at home when the treatmentoccurs.)

Animals with fur: Use air filters. (Remove animals from the home, or at leastfrom the sleeping area. Wash the pet.)

Cockroaches: Clean the home thoroughly and often. Use pesticide spraybut make sure the patient is not at home when spraying occurs.

Outdoor pollens and mold: Close windows and doors and remain indoorswhen pollen and mold counts are highest.

Indoor mold: Reduce dampness in the home; clean any damp areas fre-quently.

Table 3. Strategies for Avoiding Common Allergens and Pollutants

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 symp-

toms (Table 3). However, many asthma patients react to multiple factorsthat are ubiquitous in the environment, and avoiding some of these factorscompletely is nearly impossible. Thus, medications to maintain asthmacontrol have an important role because patients are often less sensitive tothese risk factors when their asthma is under control.


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ASSESS, TREAT, AND MONITOR ASTHMA

The goal of asthma treatmentto achieve and maintain clinical controlcan 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 regi-men, adherence to the current regimen, and level of asthma control. Currentimpairment (day and night symptoms, activity level impairment, need for res-

cue medications) and future risk (likelihood of acute exacerbation in thefuture) should both be addressed. A simplified scheme for recognizing con-trolled, partly controlled, and uncontrolled asthma is provided in Table 2.

Treating to Achieve Control

For the treatment of asthma inhaled medications are preferred becausethey deliver drugs directly to the airways where they are needed, resultingin potent therapeutic effects with fewer systemic side effects.

Devices recommended to deliver inhaled medication for children 5 years andyounger include pressurized metered-dose inhalers (pMDIs) and nebulizers. Spacer(or valved holding-chamber) devices make inhalers easier to use and reducesystemic absorption and side effects of inhaled glucocorticosteroids.

Among children in this young age group, inhaler technique may be poorand 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 theinhalers 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 aspacer with face mask, or a nebulizer with face mask.

Children aged 4 to 5 years should use a pMDI plus a spacer withmouthpiece, or a pMDI plus a spacer with a face mask or, if nec-essary, a nebulizer with face mask.

For children using spacers, the spacer must fit the inhaler.


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Information about use of various inhaler devices is found on the GINAWebsite (www.ginasthma.org).

A variety of controller and reliever medications for asthma are available.

The recommended treatments discussed below are guidelines only. Localresources and individual patient circumstances should determine the spe-cific therapy prescribed for each patient.

All young children with asthma should be prescribed a reliever medica-tion to use as needed for quick relief of symptoms. (Parents and care-givers should be aware of how much reliever medication the child isusingregular or increased use indicates that asthma is not well con-trolled.) A rapid-acting inhaled

2-agonist is the recommended choice of

reliever medication for most patients in this age group.

If the childs asthma is not controlled with as-needed use of reliever med-ication, a low-dose inhaled glucocorticosteroid is the recommended initialcontroller treatment (Table 4).

This initial treatment should be given for at least 3 months to establish itseffectiveness in reaching control. If at the end of this period the low dose

of inhaled glucocorticosteroid does not control symptoms, and the child isusing optimal technique and is adherent to therapy, doubling the initialdose of glucocorticosteroid given in Table 5 may be the best option.Addition of a leukotriene modifier to the low-dose inhaled glucocorticos-teroid may also be considered.


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Controlled

on as needed

rapid-acting 2-agonists

Partly controlled

on as needed

rapid- acting 2-agonists

Uncontrolled or onlypartly controlled on

low-dose inhaledglucocorticosteroid*

Table 4. Asthma Management Approach Based on

Control for Children 5 Years and Younger

Asthma education, Environmental control, and As needed rapid-acting 2-agonists

Continue as neededrapid-acting 2-agonists

Low-dose inhaledglucocorticosteroid

Double low-dose inhaledglucocorticosteroid

Leukotriene modifier Low-dose inhaledglucocorticosteroid plus

Leukotriene modifier

Controller options

*Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma.

Shaded boxes represent preferred treatment options.

Drug Low Daily Dose (g)

Beclomethasone dipropionate 100

Budesonide MDI+spacerBudesonide nebulized

200500

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 adverseeffects in trials including measures of safety. This is not a table of clinical equivalence.

NS = Not studied in this age group.

Table 5. Low Daily Doses* of Inhaled Glucocorticosteriodsfor Children 5 Years and Younger


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Manage Acute Exacerbations

Exacerbations of asthma (asthma attacks) are acute episodes of deteriora-tion in symptom control that are sufficient to cause distress or risk to healthnecessitating a visit to a health care provider or requiring treatment with sys-temic glucocorticosteroids.

Do not underestimate the severity of an attack (Table 6); severe asthmaattacks may be life threatening. Early symptoms may include any of thefollowing:

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 asthmaexacerbation.

Home Management

A health care provider may recommend steps for the family/caregiver tocare for an asthma attack at home:.

Initiate treatment with two puffs of inhaled rapid-acting 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 man-agement of asthma exacerbations in children should be considered onlywhere the physician is confident that this medication will be used appropri-ately.

Immediate medical attention should be sought .

For children younger than 1 year requiring repeated rapid-actinginhaled 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 2-agonist becomes pro-


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Table 6. Initial Assessment of Acute Asthma in Children

Five Years and Younger

Symptoms Mild Severea

Altered consciousness No Agitated, confused ordrowsy

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 exacerbationb Oximetry performed before treatment with oxygen or bronchodilatorc 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 repeateddosing with rapid-acting inhaled 2-agonists, with or without the additionof 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 exacerba-tion (particularly if treatment with systemic glucocorticosteroids hasbeen given).

For children younger than 2 years, early medical attention should besought as the risk of dehydration and respiratory fatigue is increased.


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Table 7. Indications for Immediate Referral to Hospital

ANY of the following:

No response to three (3) administrations of an inhaledshort-acting 2-agonist within 1-2 hours

Tachypnea despite 3 administrations of an inhaled short-acting 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 thepatient is hypoxemic (achieve O2 saturation above 94%).

Inhaled rapid-acting 2-agonists in adequate doses are essential (twopuffs at 20-minute intervals for an hour).

Failure to respond to bronchodilator therapy at 1 hour, or earlier if thechild deteriorates, requires urgent admission to hospital and a shortcourse of oral glucocortiocosteroids.

Children prescribed maintenance therapy with inhaled glucocorticos-teroids or leukotriene modifier or both should continue to take the pre-scribed 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 ana-

phylaxis and angioedema but is not indicated during asthma attacks.

Intravenous magnesium sulphate has not been studied in young children.


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Table 8: Initial Management of Acute

Severe Asthma in Children 5 Years and Younger*

Therapy Dose and Administration

Supplementaloxygen

Deliver by 24% face mask (flow set to manufacturersinstructions, usually 4L/minute)

Maintain oxygen saturation above 94%

Short-acting

2-agonist

2 puffs salbutamol by spacer,or

2.5 mg salbutamol by nebulizer

Every 20 minutes for first hoursa

Ipratropium 2 puffs every 20 minutes for first hour only

Systemic

glucocorticosteroids

Oral prednisolone(1-2 mg/kg daily for up to 5 days)

or

Intravenous methylprednisolone1 mg/kg every 6 hours on day 1;

every 12 hours on day 2; then daily

AminophyllinebConsider in ICU: loading dose6-10mg/kg lean body weight

Initial maintenance: 0.9 mg/kg/hourAdjustment according to plasma theophylline levels

Oral 2-agonists No

Long-acting 2-agonist No

a If inhalation is not possible an intravenous bolus of 5 g/kg given over 5 minutes, followed bycontinuous infusion of 5 g/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.


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Follow up:

Before discharge from the emergency department or hospital, the conditionof the patient should stable, e.g., out of bed and able to eat and drinkwithout problem. Family/caregivers should receive:

Instruction on recognition of signs of recurrence and worsening of asth-ma. The factors that precipitated the exacerbation should be identifiedand strategies for future avoidance of these factors implemented

A written individualized action plan including details of accessibleemergency 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 monthsdepending on the clinical, social, and practical context of the exacer-bation


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NOTES


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The Global Initiative for Asthma is supported by educational grants from:

Copies of this document are available at

www.ginasthma.org

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