asthma fan huizhen pulmonary medicine zhujiang hospital southern medical university
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Asthma
Fan HuizhenPulmonary MedicineZhujiang Hospital Southern medical university
Definition of AsthmaDefinition of Asthma
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation
A chronic inflammatory disorder of the airways
Many cells and cellular elements play a role
Chronic inflammation is associated with airway hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness, and coughing
Widespread, variable, and often reversible airflow limitation
Source: Peter J. Barnes, MDSource: Peter J. Barnes, MD
Asthma Inflammation: Cells and Mediators
Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD
Mechanisms: Asthma Inflammation
Source: Peter J. Barnes, Source: Peter J. Barnes, MDMD
Asthma Inflammation: Cells and Mediators
哮喘病理生理学
• 支气管高反应性• 平滑肌增生 /体积增大
• 炎症介质释放增多
• 炎症细胞数增加• 黏膜水肿• 支气管高反应• 气道分泌物增加• 上皮损伤
• 细胞增生 (平滑肌细胞、黏液腺)• 基质蛋白沉积增加• 基底膜增厚• 血管新生
平滑肌功能障碍平滑肌功能障碍
气道炎症气道炎症
气道重塑气道重塑
Burden of Asthma
Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals
Prevalence increasing in many countries, especially in children
A major cause of school/work absence
Asthma is one of the most common chronic diseases worldwide with an estimated 300 million affected individuals
Prevalence increasing in many countries, especially in children
A major cause of school/work absence
Burden of Asthma
Health care expenditures very high
Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand
Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care
Health care expenditures very high
Developed economies might expect to spend 1-2 percent of total health care expenditures on asthma. Developing economies likely to face increased demand
Poorly controlled asthma is expensive; investment in prevention medication likely to yield cost savings in emergency care
Asthma Prevalence and Mortality
SourceSource: Masoli M et al. Allergy 2004: Masoli M et al. Allergy 2004
中国是哮喘病死率最高的国家之一5~34 岁年龄组患者哮喘病死率( case-fatality rates )
36.7/10 万
( >10.0/10 万,处于高水平 )
Masoli M (2004). The global burden of asthma GINA report. Masoli M (2004). The global burden of asthma GINA report.
在中国,每 100,000 位哮喘患者中有 36.7 位哮喘患者会因哮喘死亡。 GINA2004
Risk Factors for Asthma
Host factors: predispose individuals to, or protect them from, developing asthma
Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist
Host factors: predispose individuals to, or protect them from, developing asthma
Environmental factors: influence susceptibility to development of asthma in predisposed individuals, precipitate asthma exacerbations, and/or cause symptoms to persist
Factors that Exacerbate AsthmaFactors that Exacerbate Asthma
Allergens Respiratory infections Exercise and hyperventilation Weather changes Sulfur dioxide Food, additives, drugs
Factors that Influence Asthma Development and Expression
Host Factors Genetic - Atopy - Airway
hyperresponsiveness Gender Obesity
Host Factors Genetic - Atopy - Airway
hyperresponsiveness Gender Obesity
Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet
Environmental Factors Indoor allergens Outdoor allergens Occupational sensitizers Tobacco smoke Air Pollution Respiratory Infections Diet
Is it Asthma?Is it Asthma?
Recurrent episodes of wheezing Troublesome cough at night Cough or wheeze after exercise Cough, wheeze or chest tightness after
exposure to airborne allergens or pollutants
Colds “go to the chest” or take more than 10 days to clear
Asthma Diagnosis
History and patterns of symptoms
Measurements of lung function
- Spirometry - Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identify risk factors
Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly
History and patterns of symptoms
Measurements of lung function
- Spirometry - Peak expiratory flow
Measurement of airway responsiveness
Measurements of allergic status to identify risk factors
Extra measures may be required to diagnose asthma in children 5 years and younger and the elderly
Typical Spirometric (FEV1) TracingsTypical Spirometric (FEV1) Tracings
11Time (sec)Time (sec)22 33 44 55
FEV1FEV1
VolumeVolume
Normal SubjectNormal Subject
Asthmatic (After Bronchodilator)Asthmatic (After Bronchodilator)
Asthmatic (Before Bronchodilator)Asthmatic (Before Bronchodilator)
Note: Each FEV1 curve represents the highest of three repeat measurementsFEV1 increased ≥12% and ≥200ml
Measuring Airway Responsiveness
FEV1 decreased ≥20%
Clinical Control of Asthma
No (or minimal)* daytime symptoms
No limitations of activity
No nocturnal symptoms
No (or minimal) need for rescue medication
Normal lung function
No exacerbations_________* Minimal = twice or less per week
Levels of Asthma Control
CharacteristicControlled
(All of the following)Partly controlled
(Any present in any week)Uncontrolled
Daytime symptomsNone (2 or less / week)
More than twice / week
3 or more features of partly controlled asthma present in any week
Limitations of activities
None Any
Nocturnal symptoms / awakening
None Any
Need for rescue / “reliever” treatment
None (2 or less / week)
More than twice / week
Lung function (PEF or FEV1)
Normal< 80% predicted or
personal best (if known) on any day
Exacerbation None One or more / year 1 in any week
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
1. Develop Patient/Doctor Partnership
2. Identify and Reduce Exposure to Risk Factors
3. Assess, Treat and Monitor Asthma
4. Manage Asthma Exacerbations
5. Special Considerations
Asthma Management and PreventionProgram: Five ComponentsAsthma Management and PreventionProgram: Five Components
Revised 2006
Asthma Management and Prevention Program
Goals of Long-term Management
Achieve and maintain control of symptoms
Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels as possible
Prevent asthma exacerbations Avoid adverse effects from asthma
medications Prevent asthma mortality
Achieve and maintain control of symptoms
Maintain normal activity levels, including exercise
Maintain pulmonary function as close to normal levels as possible
Prevent asthma exacerbations Avoid adverse effects from asthma
medications Prevent asthma mortality
Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Guidelines on asthma management should be available but adapted and adopted for local use by local asthma planning teams
Clear communication between health care professionals and asthma patients is key to enhancing compliance
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Educate continually
Include the family
Provide information about asthma
Provide training on self-management skills
Emphasize a partnership among health care providers, the patient, and the patient’s family
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Asthma Management and Prevention Program
Component 1: Develop Patient/Doctor Partnership
Key factors to facilitate communication:
Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
Key factors to facilitate communication:
Friendly demeanor
Interactive dialogue
Encouragement and praise
Provide appropriate information
Feedback and review
Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.
HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]
WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROLIf you have severe shortness of breath, and can only speak in short sentences,If you are having a severe attack of asthma and are frightened,If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.
Asthma Management and Prevention Program
Component 2: Identify and Reduce Exposure to Risk Factors
Asthma Management and Prevention Program
Component 2: Identify and Reduce Exposure to Risk Factors
Measures to prevent the development of asthma, and asthma exacerbations by avoiding or reducing exposure to risk factors should be implemented wherever possible.
Asthma exacerbations may be caused by a variety of risk factors – allergens, viral infections, pollutants and drugs.
Reducing exposure to some categories of risk factors improves the control of asthma and reduces medications needs.
Reduce exposure to indoor allergens Avoid tobacco smoke Avoid vehicle emission Identify irritants in the workplace Explore role of infections on asthma
development, especially in children and young infants
Asthma Management and Prevention Program
Component 2: Identify and Reduce Exposure to Risk Factors
Asthma Management and Prevention Program
Component 2: Identify and Reduce Exposure to Risk Factors
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional
The goal of asthma treatment, to achieve and maintain clinical control, can be achieved in a majority of patients with a pharmacologic intervention strategy developed in partnership between the patient/family and the health care professional
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Depending on level of asthma control, the patient is assigned to one of five treatment steps
Treatment is adjusted in a continuous cycle driven by changes in asthma control status. The cycle involves:
- Assessing Asthma Control
- Treating to Achieve Control
- Monitoring to Maintain Control
基于哮喘临床控制的哮喘管理
评估评估哮喘控制水平水平
治疗并达到治疗并达到哮喘控制
监测并维持监测并维持哮喘控制
2006 GINA2006 GINA2006 GINA2006 GINA
哮喘管理模式
A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least possible medication
A stepwise approach to pharmacological therapy is recommended
The aim is to accomplish the goals of therapy with the least possible medication
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability
of the various forms of asthma treatment Economic considerations
Cultural preferences and differing health caresystems need to be considered
The choice of treatment should be guided by: Level of asthma control Current treatment Pharmacological properties and availability
of the various forms of asthma treatment Economic considerations
Cultural preferences and differing health caresystems need to be considered
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Asthma Management and Prevention Program
Component 3: Assess, Treat and Monitor Asthma
Component 4: Asthma Management and Prevention Program
Controller MedicationsComponent 4: Asthma Management and Prevention Program
Controller Medications
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Hormones Long-acting oral β2-agonists Anti-IgE
Inhaled glucocorticosteroids Leukotriene modifiers Long-acting inhaled β2-agonists Systemic glucocorticosteroids Theophylline Hormones Long-acting oral β2-agonists Anti-IgE
Estimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by AgeEstimate Comparative Daily Dosages for Inhaled Glucocorticosteroids by Age
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
Drug Low Daily Dose (g) Medium Daily Dose (g) High Daily Dose (g)
> 5 y Age < 5 y > 5 y Age < 5 y > 5 y Age < 5 y
倍氯米松 200-500 100-200 >500-1000 >200-400 >1000 >400
布地奈德 200-600 100-200
600-1000 >200-400 >1000 >400
布地奈德混悬液 250-500
>500-1000
>1000
环索奈德 80 – 160 80-160 >160-320 >160-320 >320-1280 >320
氟尼缩松 500-1000 500-750
>1000-2000 >750-1250 >2000 >1250
氟替卡松 100-250 100-200
>250-500 >200-500 >500 >500
糠酸莫米松 200-400 100-200
> 400-800 >200-400 >800-1200 >400
曲安奈德 400-1000 400-800
>1000-2000 >800-1200 >2000 >1200
Component 4: Asthma Management and Prevention Program
Reliever MedicationsComponent 4: Asthma Management and Prevention Program
Reliever Medications
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral β2-agonists
Rapid-acting inhaled β2-agonists
Systemic glucocorticosteroids
Anticholinergics
Theophylline
Short-acting oral β2-agonists
Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy
Component 4: Asthma Management and Prevention Program Allergen-specific Immunotherapy
Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is limited
Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma
Perform only by trained physician
Greatest benefit of specific immunotherapy using allergen extracts has been obtained in the treatment of allergic rhinitis
The role of specific immunotherapy in asthma is limited
Specific immunotherapy should be considered only after strict environmental avoidance and pharmacologic intervention, including inhaled glucocorticosteroids, have failed to control asthma
Perform only by trained physician
controlled
partly controlled
uncontrolled
exacerbation
LEVEL OF CONTROLLEVEL OF CONTROL
maintain and find lowest controlling step
consider stepping up to gain control
step up until controlled
treat as exacerbation
TREATMENT OF ACTIONTREATMENT OF ACTION
TREATMENT STEPSREDUCE INCREASE
STEP
1STEP
2STEP
3STEP
4STEP
5
RE
DU
CE
INC
RE
AS
E
Step 1 – As-needed reliever medication
Patients with occasional daytime symptoms of short duration
A rapid-acting inhaled β2-agonist is the recommended reliever treatment (Evidence A)
When symptoms are more frequent, and/or worsen periodically, patients require regular controller treatment (step 2 or higher)
Treating to Achieve Asthma Control
Step 2 – Reliever medication plus a single controller
A low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment for patients of all ages (Evidence A)
Alternative controller medications include leukotriene modifiers (Evidence A) appropriate for patients unable/unwilling to use inhaled glucocorticosteroids
Treating to Achieve Asthma Control
Step 3 – Reliever medication plus one or two controllers
For adults and adolescents, combine a low-dose inhaled glucocorticosteroid with an inhaled long-acting β2-agonist either in a combination inhaler device or as separate components (Evidence A)
Inhaled long-acting β2-agonist must not be used as monotherapy
For children, increase to a medium-dose inhaled glucocorticosteroid (Evidence A)
Treating to Achieve Asthma Control
Additional Step 3 Options for Adolescents and Adults
Increase to medium-dose inhaled glucocorticosteroid (Evidence A)
Low-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline (Evidence B)
Treating to Achieve Asthma Control
Step 4 – Reliever medication plus two or more controllers
Medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence A)
Medium- or high-dose inhaled glucocorticosteroid combined with leukotriene modifiers (Evidence A)
Low-dose sustained-release theophylline added to medium- or high-dose inhaled glucocorticosteroid combined with a long-acting inhaled β2-agonist (Evidence B)
Treating to Achieve Asthma Control
Treating to Achieve Asthma Control
Step 5 – Reliever medication plus additional controller options
Addition of oral glucocorticosteroids to other controller medications may be effective (Evidence D) but is associated with severe side effects (Evidence A)
Addition of anti-IgE treatment to other controller medications improves control of allergic asthma when control has not been achieved on other medications (Evidence A)
Treating to Maintain Asthma Control
When control as been achieved, ongoing monitoring is essential to:
- maintain control
- establish lowest step/dose treatment
Asthma control should be monitored by the health care professional and by the patient
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled When controlled on medium- to high-
dose inhaled glucocorticosteroids: 50% dose reduction at 3 month intervals (Evidence B)
When controlled on low-dose inhaled glucocorticosteroids: switch to once-daily dosing (Evidence A)
Treating to Maintain Asthma Control
Stepping down treatment when asthma is controlled When controlled on combination inhaled
glucocorticosteroids and long-acting inhaled β2-agonist, reduce dose of inhaled glucocorticosteroid by 50% while continuing the long-acting β2-agonist (Evidence B)
If control is maintained, reduce to low-dose inhaled glucocorticosteroids and stop long-acting β2-agonist (Evidence D)
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control Rapid-onset, short-acting or long-
acting inhaled β2-agonist bronchodilators provide temporary relief.
Need for repeated dosing over more than one/two days signals need for possible increase in controller therapy
MDI使用方法
MDI使用方法
贮雾罐使用方法
贮雾罐使用方法
雾化吸入方法
雾化吸入方法
Treating to Maintain Asthma Control
Stepping up treatment in response to loss of control Use of a combination rapid and long-acting
inhaled β2-agonist (e.g., formoterol) and an inhaled glucocorticosteroid (e.g., budesonide) in a single inhaler both as a controller and reliever is effecting in maintaining a high level of asthma control and reduces exacerbations (Evidence A)
Doubling the dose of inhaled glucocortico-steroids is not effective, and is not recommended (Evidence A)
大多数哮喘患者可以达到哮喘控制
控制改善良好控制完全控制
(~40%)
(~40%)
(~20%)
Bateman ED et al. AJRCCM 2004
哮喘控制
基于哮喘临床控制的哮喘管理
2006 GINA2006 GINA2006 GINA2006 GINA
使用哮喘管理工具评估哮喘控制
哮喘控制测试 (ACT) 、哮喘控制问卷 (ACQ) 、哮喘治疗评估问卷( ATAQ )是:
经验证的、用于评估哮喘控制的工具,通过提供具体数值区分哮喘控制的不同水平
不仅被推广用于研究,也用于基层医疗单位中患者哮喘控制评估
可改善对哮喘控制的评估,并提供可反复使用的客观指标,有助于改善医生和患者间的交流
Schatz et al. 2004.
基于哮喘临床控制的哮喘管理
25 分:哮喘完全控制20 - 24 分:哮喘良好控制<20 分:哮喘未得到控制
需要改变治疗方案,以达到哮喘控制
ACT 评分的使用
基于哮喘临床控制的哮喘管理
控制:确定维持哮喘控制所需最低治疗级别
部分控制:考虑升级治疗以达到哮喘控制
未控制:升级治疗直至达到哮喘控制
2006 GINA2006 GINA2006 GINA2006 GINA
为达到哮喘控制的治疗方案
Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness
Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)
Severe exacerbations are potentially life-threatening and treatment requires close supervision
Exacerbations of asthma are episodes of progressive increase in shortness of breath, cough, wheezing, or chest tightness
Exacerbations are characterized by decreases in expiratory airflow that can be quantified and monitored by measurement of lung function (FEV1 or PEF)
Severe exacerbations are potentially life-threatening and treatment requires close supervision
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Treatment of exacerbations depends on: The patient Experience of the health care professional Availability of medications Emergency facilities
Treatment of exacerbations depends on: The patient Experience of the health care professional Availability of medications Emergency facilities
Primary therapies for exacerbations:
• Repetitive administration of rapid-acting inhaled β2-agonist
• Early introduction of systemic glucocorticosteroids
• Oxygen supplementation
Closely monitor response to treatment with serialmeasures of lung function
Primary therapies for exacerbations:
• Repetitive administration of rapid-acting inhaled β2-agonist
• Early introduction of systemic glucocorticosteroids
• Oxygen supplementation
Closely monitor response to treatment with serialmeasures of lung function
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Asthma Management and Prevention Program
Component 4: Manage Asthma Exacerbations
Emergency Department Management
Acute AsthmaEmergency Department Management
Acute Asthma
Good Response
Observe for at least 1
hour
If Stable, Discharge to
Home
Initial AssessmentHistory, Physical Examination, PEF or FEV1
Initial TherapyBronchodilators; O2 if needed
Incomplete/Poor Response
Add Systemic Glucocorticosteroids
Good Response
Discharge
Poor Response
Admit to Hospital
Respiratory Failure
Admit to ICU
Asthma Management and Prevention Program
Special ConsiderationsAsthma Management and Prevention Program
Special Considerations
Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
Special considerations are required tomanage asthma in relation to: Pregnancy Surgery Rhinitis, sinusitis, and nasal polyps Occupational asthma Respiratory infections Gastroesophageal reflux Aspirin-induced asthma Anaphylaxis and Asthma
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Asthma can be effectively controlled in most patients by intervening to suppress and reverse inflammation as well as treating bronchoconstriction and related symptoms
Although there is no cure for asthma, appropriate management that includes a partnership between the physician and the patient/family most often results in the achievement of control
Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary
A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication
The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered
A stepwise approach to pharmacologic therapy is recommended. The aim is to accomplish the goals of therapy with the least possible medication
The availability of varying forms of treatment, cultural preferences, and differing health care systems need to be considered
Asthma Management and Prevention Program: SummaryAsthma Management and Prevention Program: Summary