Overview
This implementation guide is designed for health professionals
with a wide range of experiences in delivering clinical healthcare
services. The goal of this manual is to provide clear and easily
applied guidance to facilitate implementation of the Creating
a Medical Home for Asthma program (CMHA) program in your health care
organization. It is designed to recommend practical steps that
can be carried out by any member of the clinic staff. The CMHA
program is also flexible enough that it can be easily adapted
to fit the needs of any clinic or health care organization.
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Adaptation of the CMHA Program
The strategies outlined in the CMHA program can be used as
presented in this manual or tailored to the specific needs of
each individual clinic. Because the organizational and management
structures of clinics may vary, slight modifications may be necessary
to the serve the needs of clinic staff and clinic operations.
The basic principles of CMHA should be used as a guide when
considering how to modify and adapt the program. The implementation
process is designed to be flexible, and it is important that
the philosophy of the team-based "system of care"
approach (described below) is clearly communicated throughout
the program. Thus, you should not reject any portion of the program
unless your clinic self-assessment ("See Getting Started with CMHA")
demonstrates that your system is meeting appropriate asthma care
goals, which are integrated with the goals of the CMHA program.
The remaining sections of the manual are organized around
three key components of the CMHA program: implementing the team-based
approach; developing a CMHA management plan; and using CMHA resources.
Goals of Creating a Medical Home For Asthma
- To provide continuous care in primary and specialized clinics
to greater numbers of children with asthma.
- To improve the health status of the children suffering from
asthma through appropriate therapy, patient education, and guided
self-management by the family.
- To improve quality of life for the entire family through
communication between the clinic staff and the family about asthma.
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Understanding the "System of Care" Philosophy
The CMHA implementation plan as presented in this manual is
a set of flexible and specific activities for creating a team-based
approach to asthma management in the clinic, based on the system
of care philosophy.
The system of care philosophy represents a set of central
beliefs about how services should be delivered to children and
their families. At its core, the system of care concept is:
Child-centered and family focused, with the needs of the child
and family influence the types and mix of services provided.
Community-based, with the bulk of services, management and
decision-making responsibility resting at the community level.
Culturally competent, with agencies, programs, and services
that are responsive to the cultural, racial, and ethnic differences
of the populations they serve.
The system of care philosophy is a core concept of the CMHA
program. A fundamental principal in this philosophy is the concept
of the team based approach, which describes how staff should
interact as a team to provide coordinated and comprehensive services
that focus on the needs of families of children with asthma.
Figure 1. The System of Care Team Based Approach
to Asthma Management
Understanding the Team-Based Approach: The Health Clinic Team
The Roles and Responsibilities of Clinic Personnel
Implementing the CMHA program requires a committed team working
together to build relationships with families who have children
with asthma. Thus, creating and maintaining a health care clinic
team is a key to its success. Each member of the health clinic
staff plays an distinctive role that contributes to the overall
goals of the care and treatment of asthma. Below is a description
of how each member of the health clinic staff uniquely contributes
to the team.
Clinic Managers/Supervisors
The clinic managers provide the resources and authority to
facilitate and supervise implementation the CMHA program. Their
activities and decisions have a direct impact on the quality
and delivery of the program. They are also active members of
the CMHA health care team because they are responsible for developing
a management plan to integrate and maintain the program in their
clinic.
Physicians and Other Clinicians
Physicians and other clinicians, such as pulmonologists and allergists, play
a major role in this program because they provide direct care
and treatment for the patients with asthma. The CMHA program,
emphasizes increased communication between the physician and
family. Physicians work with families to help them develop the
skills to manage their child's chronic asthma at home, and encourage
adherence to the treatment regimen. Often, physicians must rely
on the information gathered from the other members of the health
care team to ensure they are effectively identifying the needs
of their patients and providing appropriate treatment and care.
Nurses
Nurses play a primary role in identifying and educating patients
with asthma in the clinic. They monitor patients, and recognize
various trends that may be early warning signs of increasing
severity in the patients' condition. By building rapport and
developing trusting relationships, nurses encourage families
to schedule regular visits and maintain their appointments. Nurses
are in a position to address most problems or concerns that may
arise as well as to provide asthma education to families.
Administrative Staff
Administrative staff includes all support personnel (e.g.,
receptionists, receptionists, orderlies, and medical records
staff). They are a very important part of the team because they
generally are the first to greet families as they enter the clinic
and the last to acknowledge them as they leave. Families generally
develop their impression of the clinic based on their interaction
with the administrative and support staff. Information should
be shared with the administrative staff so that they understand
their role in maintaining good relationships with families.
Other Clinic Personnel
Outreach counselors are a good resource for clinics implementing
the CMHA program; however, they are not mandatory. They can provide
aide and counseling to families in crisis as well as follow up
with families when they do not keep their scheduled visits. Outreach
counselors can play a pivotal role in extending the systems of
care philosophy by serving as a liaison with the clinic, the
family, and the community. Developing relationships with various
community organizations allows the counselors to provide families
with information on community resources that are available to
support their needs.
The Benefits of Teamwork
It is important for all members of the clinic team to understand
the key concepts of the CMHA program, and to be alert to how
they can help families solve asthma management problems. For
example, in the New York City Child Health Clinics (CHCs), the
receptionists and public health assistants often found it necessary
to tell families that it was important to keep appointments for
follow-up visits even if the child was well, so the Physician
could see how the treatment was working to keep asthma under
control. They also routinely let families know that the clinic
had a special asthma program, and that was why they were asking
the family to fill out a screening form. Clinics whose receptionists
and public health assistants participated actively tended to
have larger gains in numbers of asthma patients than other clinics.
Helping Families Understand How They and the Clinic Staff
Can Work as a Team
Another key to successful implementation of this program is
to make sure the families understand the responsibilities of
each health care professional in which they come into contact.
For example, families should understand that:
- All staff members understand and can talk about asthma.
- Parents and caregivers work with staff to establish and keep
appointments.
- Parents and caregivers are encouraged to take an active role
in learning to control their child's asthma.
- Family participation and observations are necessary:
- To evaluate whether the treatment plan is workable at home
- To evaluate how the treatment plan is working
- To make medication adjustments.
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Creating a Management Plan for CMHA
As previously described, the manager or clinic supervisor
provides the leadership to manage the implementation and integration
of CMHA-related activities. The delegation of activities helps
ensure that clinic staff understand their role in preventing
and solving any problems that arise with changing the way the
clinic currently operates. Because this program represents a
team-based approach, the program is more likely to be effectively
implemented and therefore successful when the entire staff support
the process than if one or two people were trying to carry it
out alone.
The most important responsibilities for the manager or supervisor
to incorporate into the management planning process are to:
Oversee the work
and ask questions that will help you ensure the program is being
properly implemented.
Identify goals
and ask clinic staff to demonstrate that they have met those
goals.
There are also the dimensions of the management planning process, which are described in more detail below:
- Establish policies to support the integration of CMHA.
- Improve communication and problem solving skills.
- Monitor implementation progress and performance goals.
- Support ongoing professional development.
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Establish Policies to Support the Integration of CMHA
A critical step in successfully implementing the Creating
a Medical Home for Asthma program is helping staff to understand
the new approach to asthma management and how it should be integrated
into the current clinic operations.
The first step in the management plan is to establish policies
that support the implementation of CMHA.
Policies are guidelines that represent goals for performance
and establish criteria for determining a course of action. By
establishing criteria and goals, staff are encouraged to achieve
and maintain high standards of performance. The advantage of
developing policies that are staff friendly and supportive is
that it limits the confusion that often accompanies the implementation
of new procedures.
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The New York City Child Health Clinics made a policy change
to improve care and support the program by converting from a
first-come, first-served session appointment system to a timed
appointment for each individual family.
In addition, the clinic administration reduced staff fears
that the CMHA program would encourage families to treat the clinics
as a new emergency room by reiterating an existing policy that
the clinic was not required to serve unregistered families who
walked in without an appointment.
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Improve Communication and Problem-Solving Skills
An underlying goal of the management plan is to develop strategies
for communication that are designed to (1) prevent and resolve
any CMHA-related problems by assessing communication skills and
(2) determine whether changes are needed to improve your ability
to:
Respond to complaints
and incidents quickly with staff and patients.
Solve problems
effectively among staff and patients.
Communicate in
a way that reduces concerns of clinic staff and/or patients during
a potential crisis.
The CMHA program emphasizes the involvement and interaction
of all clinic personnel as a team in preventing and treating
asthma. By encouraging increased dialogue through meetings and
other activities, clinic staff learn to share ideas about particular
problems and identify issues that are relevant to the CMHA program.
Some of these problems and issues can be addressed by the following
questions (used in training during Session 1-the Interview Technique):
What concerns
you in expanding services to create a medical home for asthma?
What would help
you feel more comfortable in implementing this program?
What do you see
as potential aids to implementing the program?
As a member of
the health care team, how do you plan to encourage clients to
communicate their questions and concerns about asthma to you?
What special needs
of your client population may affect how they receive asthma
messages?
Monitor Implementation Progress and Performance Goals
The purpose of monitoring the implementation processes
and performance goals is to obtain timely feedback and provide
advice on the extent to which the program is meeting the needs
of the patients and clinic. It also helps provide insight into
revisions or adjustments that may be necessary to improve performance,
and ensures that the vision of the clinic aligns with the goals
of the program.
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The supervisor should meet with each physician to review the
asthma patients who have been identified. Then use of an electronic
database, if available to record the diagnoses for each patient
and problems treated at each visit. In addition the database
should include information on medications dispensed or described
at the visit.
This database could produce printouts that were reviewed by the
supervisor and the physician, and enabled the supervisors to
discuss both the identification of new cases and the use of appropriate
therapy with the physicians and the entire clinic team.
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In the New York City Child
Health Clinics, for example, the supervising physician and nurse
for each region set up monthly meetings with each clinic team
to discuss progress of the program. They obtained feedback about
progress and problems from all clinic personnel. Many clinics
found that trying to screen every patient who came in for asthma
proved to be too large a task, so a strategy was developed to
screen children during the 6 months, 1-, 3-, and 5-year visits. |
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Support Ongoing Professional Development
Knowledge of the updated guidelines from the National Heart,
Lung, and Blood Institute (NHLBI) is important for the treatment
of children with asthma. Clinic staff should be familiar with
the up-to-date recommendations on:
Medications -
long-term management of asthma in children with mild or moderate
persistent asthma, combination therapy in moderate persistent
asthma, and use of antibiotics to treat acute exacerbations of
asthma.
Monitoring - written
action plans compared to medical management alone, and peak flow-based
compared to symptom-based written action plans.
Prevention- effects
of early treatment on the progression of asthma.
Additionally, clinic staff should be comfortable with:
Talking about
a treatment plan for a child with his or her caregiver.
Demonstrating
the proper use of the peak flow meter, nebulizer, and MDI with
both spacers and other asthma devices
Asthma Screening
form (Appendix A)
Visit forms (i.e.,
first visit and second visit) (Appendix B)
Treatment plan/asthma
action plans (Appendix C)
Asthma equipment
and devices (e.g. peak flow meter)
Using the Screening, Visit, and Treatment Plan Forms in Your Clinic
Screening Procedures for Clinic Personnel
During the initial implementation of CMHA an asthma screening
form was developed as a way to help identify children with asthma
in busy health care settings. The screening form was used as
a resource to obtain information that families may not offer
about their child's asthma, to remind other health care staff
may not know to request such information. By using the Asthma
Screening questionnaire pediatricians in New York City's Child
Health Clinics were able to identify more than 5,000 children
with asthma as of 1996, as opposed to less than 1,000 in 1991
(Lobach, 1996). Therefore, the asthma screening forms has become
an essential tool for clinics that plan to increase their care
of children with asthma by implementing the CMHA program.
Since the CMHA program focuses on a team-based management
approach to treating children with asthma, it is natural that
the clinic's screening procedure also follows the path from one
clinic staff member to another, in a seamless fashion. Figures
2a and 2b describe the approach to using the screening form that
was adopted by the New York City Child Health Clinics.
All members of the health clinic team should be aware how
the screening form is used and the path the screening from follows
once it is completed by the parent/caregiver. The information
on the screening form will provide the physician with the necessary
input to recommend appropriate treatments or follow-up exams.
Other members of the health clinic team can use the information
to schedule asthma visits for families and children as needed.
Figure 2a: Illustrated Path of Asthma Screening Form
Figure 2b: Asthma Screening Form-Sample Instructions
Path of the Asthma Screening Form 1. Receptionist or Nurse
a. Gives caregiver the Asthma Screening Form at the reception
desk
b. Explains the purpose of the form
c. Answers general questions caregiver may have
2. Receptionist or Nurse
a. Helps caregiver complete the Asthma Screening Form
b. Writes any additional questions or observations on the form
for the Physician
3. Physician
a. Reviews the form during the exam to see if the patient
has asthma
b. Invites the caregiver to make the clinic the "medical
home for asthma," if indicated
4. Physician
a. Places both copies of the Asthma Screening Form in the
chart
5. Receptionist or Nurse
a. Enters screening information on data sheet in the chart
b. Makes a follow-up appointment, if needed
c. Enters appointment date on Asthma Screening Form
6. Receptionist or Nurse
a. Makes copy of the completed form
b. Places copy in a folder or box for the supervisor's review
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Procedures for Establishing and Conducting
Patient Visits
After the family has completed the form, the physician (or
healthcare provider) will review and discussed the details with
the family during their regular visit. If the physician concludes
that asthma is a likely diagnosis, s/he may recommend that the
family schedule another appointment to specifically discuss their
child's asthma. The figure below describes the appropriate forms
associated with each follow-up visit, followed by the procedures
to follow once children have been identified as having asthma
during their regular visit.
Sample Protocol for Conducting Patient Visits:
Visit Forms and Treatment Plans |
1. Children who have been identified during the regular visit
as having asthma are scheduled for a First Visit for Asthma at
a later date. Only the Asthma Screening Form needs to be completed
during the regular visit.
2. When the child returns for the scheduled asthma visit,
the clinician conducts the visit using the two-part First Visit
for Asthma form and the two-part Treatment Plan, rather than
the progress notes.
The original portion
of the Treatment Plan is given to the family
The original portion
of the First Visit for Asthma form and the copy of the Treatment
Plan remain in the chart as a permanent part of the child's record.
Both forms are needed in order to complete the record of the
visit.
The copy of the
First Visit for Asthma form and the copy of the Treatment Plan
are stapled together and put in the folder, along with copies
of the Screening Forms. Always be sure to include the following
information on the appropriate form:
a. All forms: clinic identification; child's full name; date
of visit
b. Visit form: child's registration number
c. Treatment plan: clinician's name
3. When the child returns for scheduled follow-up asthma visits,
the same procedure is followed, except the clinician uses the
shorter Return Visit for Asthma form and Treatment Plan. Both
forms are still needed to have a complete record of the visit.
The date of the visit is especially important on the Treatment
Plan, so the family will not confuse current forms with previously
issued forms.
Two exceptions:
1. Emergency visits -If a clinician wants to treat a child with asthma symptoms
in the clinic before a scheduled First Visit for Asthma, the
shorter Return Visit for Asthma form can be used. Cross out the
word "Return" on the form and write "Emergency"
in its place. The child will still be given a Treatment Plan
for instructions to follow until a scheduled visit can be arranged.
When the child returns for the scheduled asthma visit, the more
complete First Visit for Asthma form and Treatment Plan are used.
2. Return visits where the prescribed Treatment Plan has not
changed - The only time a Treatment Plan form is not needed is
when a child returns for one or more follow-up visits, and there
is no change in treatment, AND the caregiver still has this plan
and can show it to you. Then the clinician may use a blank place
on the bottom of the Return Visit for Asthma form to write that
there is no attached Treatment Plan form because the treatment
has not changed, and then sign it.
Instructions for the First Asthma Visit |
- Give the Asthma Screening Form to the caregiver of each child
older than 6 months who has come for a regular visit and who
has not been screened before.
- Tell the caregiver that the clinic is now offering continuing
medical care for asthma and that you want to find out how many
children enrolled in the clinic have asthma.
- When the caregiver returns the form, check to see that it
is complete and help finish it, if necessary. Even if the child
does not have asthma, it is important that the heading and questions
1, 2, and 3 be completed. Please check to see that the caregiver
has listed a current telephone number.
- If the caregiver has any questions, answer them if you can.
If there is a question you cannot answer, encourage the caregiver
to ask the Physician or nurse, and write a note on the screening
form describing the question. Also, feel free to write any observations
you have that might be helpful to the Physician (for example,
coughing in the waiting area). The goal of the program is to
make people feel that the clinic is responsive to their needs,
by "creating a medical home for asthma" for them.
- Place the form in the chart for the Physician to review during
the visit. The Physician will review the form with the caregiver.
If it is agreed that the child's asthma will be treated at the
clinic, the Physician will request an appointment in a certain
period of time. This will be written at the bottom of the Screening
Form.
- When the chart comes back to the appointment desk, check
the Screening Form to see if the Physician has requested an appointment.
If an appointment is requested, schedule it as close as possible
to the time requested. Enter the appointment date and the child's
registration number on the Screening Form. If a timely appointment
cannot be made, please check with the Physician before making
an appointment.
- Once all information has been recorded, separate the two
copies of the form. The original stays in the chart, and the
copy goes into a folder or box for the supervisor's review.
- Children who were screened but who do not have asthma should
be re-screened at one, three, and five years of age, and at every
visit thereafter. To keep track of when children should be screened,
keep a record of the screening on the data sheet at the front
of the chart.
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Appendix A
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Appendix B
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Appendix C
Recommended Treatment Protocols
for Children
with Asthma at different levels of severity
SAMPLE LONG TERM TREATMENT PLAN FOR MILD INTERMITTENT ASTHMA
Name ________________ Date
___________ Spacer ____________
CLINICAL
CONDITION |
Baseline Plan
&
When asthma is
under control |
At the FIRST
sign of a coldor
mild attackb |
For rapidly
worsening asthma
(severe attack) |
For cough or
wheeze with exercise |
Peak Flow
(% personal best) |
80% or above |
50 to 80% |
below 50% |
2 puffs
5-10 minutes
before exercise |
|
MEDICATION
Reliever:
Inhaled short-acting
beta2-agonista
Albuterol
|
2 puffs
as needed |
2 puffs
every
4 hrc,f |
2-4 puffs
every 20 minutes
for 3 dosesee
then 2-4 puffs
every 4 hr
|
Corticosteroid
Tablet or Syrup |
0 |
0 |
Begin with
1-2 mg/kg/dayd
NOTIFY MD
|
Footnotes for clinicians only
|
a |
Use more than 2x/week may indicate need to initiate
long term controller (anti-inflammatory) therapy. See Long Term
Treatment Plan for Mild Persistent Asthma. |
|
b |
If viral infections provoke severe attacks (exacerbations)
consider short course of corticosteroid tablets or syrup at the
first sign of a cold or viral illness; see dose next column. |
|
c |
The need for beta2-agonist for more
than 24-48 hrs indicates at least a moderate attack; consider
short course of corticosteroid tablets or syrup. |
|
d |
Maximum corticosteroid dose 60 mg/day; 3-11 day
course. |
|
e |
If there is not a good response, seek emergency
care immediately. If there is a good response continue in this
column and notify MD. |
|
f |
If beta2-agonist needs to be given
for 24 hr or longer more often than every 6 weeks, initiate long
term controller (anti-inflammatory) therapy. See Sample Long
Term Treatment Plan for Mild Persistent Asthma. |
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SAMPLE LONG TERM TREATMENT PLAN FOR MILD PERSISTENT ASTHMA
Name ________________ Date
___________ Spacer ____________
CLINICAL
CONDITION |
Baseline
Plan &
When asthma
is under control |
At
the FIRST
sign of a cold
Or mild attack |
For
rapidly
worsening asthma
(severe attack) |
When there is
no cough or
wheeze for 2 months |
For
cough or wheeze with exercise |
Peak Flow
(% personal best) |
80% or above |
50 to 80% |
below 50% |
over 80%
for 2 months |
2 puffs
5-10 minutes
before exerciseh |
|
MEDICATION
Reliever:
Inhaled short-acting
beta2
-agonista
Albuterol
|
2 puffs
as needed |
2 puffs
every
4 hrc |
2-4 puffs
every 20 minutes
for 3 dosesee
then 2-4 puffs
every 4 hr |
2 puffs
as needed |
|
Controller
1) inhaled low dose
corticosteroidb Beclomethasone
42 mcg or
|
1-4 puffs
2x/day |
1-4 puffs
2x/day |
1-4 puffs
2x/day |
0 |
| 2) nonsteroidg Nedocromil |
0 |
0 |
0 |
2 puffs
2-3x/dayf |
Corticosteroid
Tablet or Syrup |
0 |
0 |
Begin with
1-2 mg/kg/dayd
NOTIFY MD
|
0 |
|
a |
Daily or increasing use indicates need for more
long term controller (anti-inflammatory) therapy. |
|
b |
Equivalent drugs: fluticasone 44 (1-2 puffs,
2x/day), flunisolide 250 (1 puff, 2x/day), budesonide 200 (inhalation
1x/day) or triamcinolone 100 (2-4 puffs, 2x/day). |
|
c |
The need for beta2-agonist for more than 24-48
hrs indicates at least a moderate attack; consider short course
of corticosteroid tablets or syrup. |
|
d |
Maximum corticosteroid dose 60mg/day; 3-11 day
course. |
|
e |
If there is not a good response, seek emergency
care immediately. If there is a good response, remain in this
column and notify MD. |
|
f |
When free of symptoms for 4 to 6 months may try
discontinuing controller medicines. |
|
g |
Nonsteroids include cromolyn and nedocromil:
In young children, these may be tried before inhaled corticosteroids.
Antileukotriene agents may also be considered as an alternative:
zafirlukast (20 mg 2x/day) or zileuton (600 mg 4x/day) for patients
12 yrs; montelukast 5 mg 1x/day for patients 6-14 yrs, 10 mg
1x/day for 15 yrs. |
|
h |
If it is difficult to take short acting beta2-agonist
before exercise consider long-acting beta2-agonist
(salmeterol) to protect against exercise induced bronchospasm
for up to 8 hr. |
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SAMPLE LONG TERM TREATMENT PLAN FOR MODERATE PERSISTENT ASTHMA
Name ________________ Date
___________ Spacer ____________
CLINICAL
CONDITION |
Baseline
Plan &
When asthma
is under control |
At
the FIRST
sign of a cold
Or mild attack |
For
rapidly
worsening asthma
(severe attack) |
When there is
no cough or
wheeze for 2 months |
For
cough or wheeze with exercise |
Peak Flow
(% personal best) |
Baseline-60 to 80%
Under control-
80% or above |
50 to 80% |
below 50% |
over 80% for 2 months |
2 puffs
5-10 minutes
before exerciseg |
|
MEDICATION
Reliever:
Inhaled short-acting
beta2
-agonista
Albuterol
|
0 |
2 puffs
every
4 hrc |
2-4 puffs
every 20 minutes
for 3 dosesee
then 2-4 puffs
every 4 hr
|
0 |
|
Controller:
1) inhaled medium
dose
corticosteroidb Beclomethasone 84 mcg
and
2) Long-acting
beta2
-agonisth
Salmeterol
and
3) Antileukotrienei
|
2-4 puffs
2x/day |
2-4 puffs
2x/day |
2-4 puffs
2x/day |
1 puffsf
2x/day |
| |
|
|
|
| |
|
|
|
Corticosteroid
Tablet or Syrup |
0 |
0 |
Begin with
1-2 mg/kg/dayd
NOTIFY MD
|
0 |
Footnotes for clinician only
|
a |
Daily or increasing use indicates the need for
more long term controller (anti-inflammatory) therapy. |
|
b |
Equivalent drugs: fluticasone 110 (1-2 puffs,
2x/day), flunisolide 250 (2 puffs, 2x/day), budesonide 200 (1
inhalation 2x/day) or triamcinolone 100 (4-6 puffs, 2x/day).
If night time symptoms not controlled, add long acting inhaled
beta2-agonist 2x/day. |
|
c |
The need for beta2-agonist for more than 24-48
hrs indicates at least a moderate attack; consider short course
of corticosteroid tablets or syrup. |
|
d |
Maximum corticosteroid dose 60 mg/day; 3-11 day
course. |
|
e |
If there is not a good response, seek emergency
care immediately. If there is a good response continue in this
column and notify MD. |
|
f |
When free of symptoms for 4 months use low dose inhaled
corticosteroid. |
|
g |
If it is difficult to take short acting beta2-agonist
before exercise consider long-acting beta2-agonist
(salmeterol) to protect against exercise induced bronchospasm
for up to 8 hr. |
|
h |
If needed, consider long-acting inhaled beta2-agonist
(salmeterol 2 puffs, 2x/day) especially for night time symptoms. |
|
i |
Antileukotriene agents may be used as additive
therapy: zafirlukast (20 mg 2x/day) or zileuton (600 mg 4x/day)
for patients 12 yrs; montelukast 5 mg 1x/day for patients 6-14
yrs, 10 mg 1x/day for 15 yrs. |
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SAMPLE LONG TERM TREATMENT PLAN FOR SEVERE PERSISTENT ASTHMA
Name ________________ Date
___________ Spacer ____________
CLINICAL
CONDITION |
Baseline Plan
&
When asthma is
under control |
For rapidly
worsening asthma
(severe attack) |
When there is
no cough or
wheeze for
2 months |
For cough or
wheeze with exercise |
Peak Flow
(% personal best) |
Baseline-below 60%
Under control-
80% or above |
below 50% |
above 80% for 2 months |
2 puffs
5-10 minutes
before exercise |
|
MEDICATION
Reliever:
Inhaled short-acting
beta2-agonista
Albuterol
|
2-4 puffs
as needed |
2-4 puffs
every 20 minutes
for 3
dosesee
then 2-4 puffs
every 4 hr
|
2-4 puffs
as needed |
|
Controller:
1) Inhaled high dose Corticosteroidb
Beclomethasone
84 mcg
|
4-5 puffs
2x/day |
4-5 puffs
2x/day |
2-4 puffs
2x/dayf |
|
and
2) Long-acting
beta2-agonist
Salmeterol
and
3) Antileukotrieneg
|
2 puffs
2x/day |
2 puffs
2x/day |
2 puffs
2x/day |
| |
|
|
Corticosteroid
Tablet or Syrup |
0.25-2
mg/kg/dayd |
2 mg/kg/day
|
0 |
Footnotes for clinician only
|
a |
Daily or increasing use indicates need for more
long term controller (antiinflammitory) therapy. |
|
b |
Equivalent drugs: fluticasone 110 (2-3 puffs,
2x/day), flunisolide 250 (2-3 puffs, 2x/day), budesonide 200
(1-2 inhalations 2x/day) or triamcinolone 100 (>6 puffs, 2x/day). |
|
d |
Maximum corticosteroid dose 60 mg/day. With improvement
gradually lower dose and if possible change to every other day
schedule. |
|
e |
If there is not a good response, seek emergency
care immediately. If there is a good response continue in this
column and notify MD. |
|
f |
When free of symptoms for 4-6 months reduce inhaled
corticosteroids to medium dose. |
|
g |
Antileukotriene agents may be used as additive
therapy: zafirlukast (20 mg 2x/day) or zileuton (600 mg 4x/day)
for patients 12 yrs; montelukast 5 mg 1x/day for patients 6-14 yrs, 10 mg
1x/day for 15 yrs. |
| |
LONG TERM TREATMENT PLAN FOR MILD INTERMITTENT ASTHMA
Name ________________ Date
___________ Spacer ____________
CLINICAL
CONDITION |
Baseline Plan &
When asthma is
under control |
At the FIRST
sign of a cold
or mild attack |
For rapidly
worsening
asthma
(severe attack) |
For cough or wheeze with exercise |
Peak Flow
(% personal best) |
80% or above |
50 to 80% |
below 50% |
|
|
MEDICATION
Reliever:
Inhaled short-acting
beta2-agonist
|
|
|
|
Corticosteroid
Tablet or Syrup |
|
|
|
| |
LONG TERM TREATMENT PLAN FOR MILD PERSISTENT ASTHMA
Name ________________ Date
___________ Spacer ____________
CLINICAL
CONDITION |
Baseline
Plan &
When asthma
is under control |
At
the FIRST
sign of a cold
Or mild attack |
For
rapidly
worsening asthma
(severe attack) |
When there is
no cough or
wheeze for 2 months |
For
cough or wheeze with exercise |
Peak Flow
(% personal best) |
80% or above |
50 to 80% |
below 50% |
over 80% for 2 months |
|
|
MEDICATION
Reliever:
Inhaled short-acting
beta2
-agonist
|
|
|
|
|
|
Controller:
1) inhaled low
dose corticosteroid
or
|
|
|
|
|
| 2) nonsteroid |
|
|
|
|
Corticosteroid
Tablet or Syrup |
|
|
|
|
| |
LONG TERM TREATMENT PLAN FOR MODERATE PERSISTENT ASTHMA
Name ________________ Date
___________ Spacer ____________
CLINICAL
CONDITION |
Baseline
Plan &
When asthma
is under control |
At
the FIRST
sign of a cold
Or mild attack |
For
rapidly
worsening asthma
(severe attack) |
When there is
no cough or
wheeze for 2 months |
For
cough or wheeze with exercise |
Peak Flow
(% personal best) |
Baseline-60 to 80% Under
control-
80% or above |
50 to 80% |
below 50% |
over 80% for 2 months |
|
|
MEDICATION
Reliever:
Inhaled short-acting
beta2
-agonist
|
|
|
|
|
|
Controller:
1) inhaled medium
dose corticosteroid
and
2) Long-acting
beta2
-agonist
and
3) Antileukotriene
|
|
|
|
|
| |
|
|
|
| |
|
|
|
Corticosteroid
Tablet or Syrup |
|
|
|
|
| |
LONG TERM TREATMENT PLAN FOR SEVERE PERSISTENT ASTHMA
Name ________________ Date
___________ Spacer ____________
CLINICAL
CONDITION |
Baseline Plan
&
When asthma is
under control |
For rapidly
worsening asthma
(severe attack) |
When there is
no cough or
wheeze for
2 months |
For cough or
wheeze with exercise |
Peak Flow
(% personal best) |
Baseline-below 60%
Under control-
80% or above |
below 50% |
above 80% for 2 months |
|
|
MEDICATION
Reliever:
Inhaled short-acting
beta2-agonist
|
|
|
|
|
Controller:
1) Inhaled high dose Corticosteroid
|
|
|
|
|
and
2) Long-acting
beta2-agonist
and
3) Antileukotriene
|
|
|
|
| |
|
|
Corticosteroid
Tablet or Syrup |
|
|
|
| |
