CONCORD INTERNAL MEDICINE

Protocol for Asthma

Douglas G. Kelling, Jr., MD C. Gismondi-Eagan, MD, FACP

George C. Monroe, III, MD

Revised March 2, 2012

The information contained in this protocol should never be used as a substitute for clinical judgment. The clinician and the patient need to develop an individual treatment plan that is tailored to the specific needs and circumstances of the patient.

ASTHMA PROTOCOL TABLE OF CONTENTS

PAGE(S)

ELEMENTS OF CONTROL

1

MONITORING 2

PERIODIC OFFICE VISITS

3

ASTHMA CONTROL TEST ENGLISH 4 SPANISH 5

ASSESSING ASTHMA CONTROL

6

CLASSIFYING ASTHMA SEVERITY 7-8

PULMONARY FUNCTION TESTS

9

WRITTEN ACTION PLAN ENGLISH 10 SPANISH 11

PEAK FLOW MONITORING 12

EDUCATION 13

BASIC FACTS ABOUT ASTHMA ENGLISH 14-15 SPANISH 16-17

USING MDI ENGLISH 18 SPANISH 19

SPACER ENGLISH 20 SPANISH 21

CONTROL OF ENVIRONMENTAL AND CO-MORBID CONDITIONS 22

MEDICATIONS 23

REFERRAL TO ASTHMA SPECIALIST 24

1

Asthma

Monitoring

Refer to Page 23

Refer to Page 22Refer to Page 13

Refer to Page 2

Medications

Control of Environ- mental factors and

co-morbid conditions

Education

Elements of Control

2

Asthma

Monitoring

Refer to Page 3

Periodic Office

Visits Pulmonary

Function Tests Peak Flow Meter

Written Action Plan

Refer to Page 9

Refer to Page 10-English Refer to Page 11-Spanish

Refer to Page 12

3

Periodic Office Visits

Administer Asthma Control Test (ACT)

Refer to Page 4- for English Refer to Page 5- for Spanish

Refer to Page 6 to assess control

Patient on Long Term Control Medication

No Yes

Refer to Page 8 to Assess Severity

Refer to Page 7 to Assess Severity

Office visit every 6 months with ACT and assessment of

severity

Patient has intermittent or mild persistent asthma that has been

under control for at least 3 months

Office visit every 1 to 3 months with ACT and assessment of severity

Uncontrolled and/or moderate to severe asthma and patient who

needs additional supervision to help follow their treatment plans

FOR PHYSICIANS:

The ACT is:

Reference: 1. Nathan RA et al. J Allergy Clin Immunol. 2004;113:59-65.

If your score is 19 or less, your asthma may not be controlled as well as it could be.Talk to your doctor.

FOR PATIENTS:

Take the Asthma Control TestTM (ACT) for people 12 yrs and older.Know your score. Share your results with your doctor.

Copyright 2002, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated.

All ofthe time 2

More thanonce a day 2

4 or morenights a week 2

3 or moretimes per day 2

Not controlled at all

1

1

1

1

1

Most ofthe time

Once a day

2 or 3 nightsa week

1 or 2 timesper day

Poorlycontrolled 2

Some ofthe time

3 to 6 timesa week

Once a week

2 or 3 timesper week

Somewhatcontrolled

3

3

3

3

3

A little ofthe time

Once or twicea week

Once or twice

Once a weekor less

Wellcontrolled

4

4

4

4

4

None of the time

Not at all

Not at all

Not at all

Completelycontrolled

TOTAL

SCORE

5

5

5

5

5

2. During the past 4 weeks, how often have you had shortness of breath?

3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning?

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)?

5. How would you rate your asthma control during the past 4 weeks?

1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?

Step 1 Write the number of each answer in the score box provided.

Step 2 Add the score boxes for your total.

Step 3 Take the test to the doctor to talk about your score.

Today’s Date:

Patient’s Name:

• A simple, 5-question tool that is self-administered by the patient

• Clinically validated by specialist assessment and spirometry1• Recognized by the National Institutes of Health

PARA LOS MÉDICOS:

La Prueba ACT:• Ha sido convalidada clínicamente por espirometría y evaluaciones de especialistas1

• Tiene el apoyo de la American Lung Association (Asociación Americana del Pulmón)• Consiste en un breve cuestionario de 5 preguntas al que el paciente responde independientemente y que puede ayudarle

al médico a evaluar el asma de sus pacientes durante las últimas 4 semanas.

Referencia: 1. Nathan RA et al. J Allergy Clin Immunol. 2004;113:59-65.

Si obtuvo 19 puntos o menos, es posible que su asma no esté tan bien controladacomo podría. Hable con su médico.

PARA LOS PACIENTES: Tome la Prueba de Control del Asma (Asthma Control TestTM – ACT)para personas de 12 años de edad en adelante.Averigüe su puntaje. Comparta sus resultados con su médico.

Derechos de autor 2002, por QualityMetric IncorporatedAsthma Control Test es una marca comercial de QualityMetric Incorporated.

Siempre 2

Más de una vez al día 2

4 o más noches por semana 2

3 o más veces al día 2

No controlada, en absoluto

1

1

1

1

1

La mayoría del tiempo

Una vez por día

2 ó 3 veces por semana

1 ó 2 veces al día

Mal controlada 2

Algo del tiempo

De 3 a 6 veces por semana

Una vez por semana

2 ó 3 veces por semana

Algo controlada

3

3

3

3

3

Un poco del tiempo

Una o dos veces por semana

Una o dos veces

Una vez por semana o menos

Bien controlada

4

4

4

4

4

Nunca

Nunca

Nunca

Nunca

Completamente controlada

TOTAL

PUNTAJE

5

5

5

5

5

2. Durante las últimas 4 semanas, ¿con qué frecuencia le ha faltado aire?

3. Durante las últimas 4 semanas, ¿con qué frecuencia sus síntomas del asma (respiración sibilante o un silbido en el pecho, tos, falta de aire, opresión en el pecho o dolor) lo/la despertaron durante la noche o más temprano de lo usual en la mañana?

4. Durante las últimas 4 semanas, ¿con qué frecuencia ha usado su inhalador de rescate o medicamento en nebulizador (como albuterol)?

5. ¿Cómo evaluaría el control de su asma durante las últimas 4 semanas?

1. En las últimas 4 semanas, ¿cuánto tiempo le ha impedido su asma hacer todo lo que quería en el trabajo, en la escuela o en la casa?

Paso 1 Anote el número correspondiente a cada respuesta en el cuadro de la derecha.

Paso 2 Sume todos los puntos en los cuadros para obtener el total.

Paso 3 Llévele la prueba a su doctor para hablar sobre su puntaje total.

Fecha de hoy:

Nombre y apellido del paciente:

6

ASSESSING ASTHMA CONTROL IN YOUTHS >12 YEARS OF AGE AND ADULTS

Classification of Asthma Control (Youths >12 years of age and adults) Components of Control

Well-Controlled Not Well-Controlled

Very Poorly Controlled

Symptoms <2 days/week > 2 days/week Throughout the day Nighttime awakening <2x/month 1-3x/week >4x/week

Interference with normal activity None Some limitation Extremely limited

Short-acting beta2-agonist use for

symptom control (not prevention of EIB)

<2 days/week >2 days/week Several times per day

FEV1 or peak flow >80% predicted/ personal best

60-80% predicted/ personal best

<60% predicted/ personal best

Impairment

Validated Questionnaire ACT >20 16-19 <15

0-1/year >2/year (see note) Exacerbations Consider severity and interval since last exacerbation

Progressive loss of lung function Evaluation requires long-term follow up care

Risk

Treatment-related adverse effects

Medication side effects can vary in intensity from none to very troublesome and worrisome. The le3vel of intensity does not

correlate to specific levels of control but should be considered in the overall assessment of risk.

*ACQ values of 0.76-1.4 are indeterminate regarding well-controlled asthma. Key: EIB, exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; ACT, Asthma Control Test.

Notes: The level of control is based on the most severe impairment or risk category. Assess impairment

domain by patient's recall of previous 2–4 weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit.

At present, there are inadequate data to correspond frequencies of exacerbations with different

levels of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.

CLASSIFYING ASTHMA SEVERITY IN YOUTHS >12 YEARS OF AGE AND ADULTS

Classifying severity for patients who are not currently taking long-term control medications

Classification of Asthma Severity (Youths >12 years of age and adults)

Persistent Components of Severity

Intermittent Mild Moderate Severe

Symptoms ≤2 days/week >2 days/week

but not daily Daily Throughout the day

Nighttime awakenings ≤2x/month 3−4x/month >1x/week but not nightly

Often 7x/week

Short-acting Beta2-agonist

use for symptom control

(not prevention of EIB)

≤2 days/week >2 days/week but not >1x/day

Daily Several times per day

Interference with normal activity

None Minor limitation

Some limitation Extremely limited

Impairment

Normal FEV1/FVC: 8−19 yr 85%

20 −39 yr 80% 40 −59 yr 75% 60 −80 yr 70%

Lung function

• Normal FEV1 between exacerbations

• FEV1 >80% predicted

• FEV1 /FVC normal

• FEV1 >80% predicted

• FEV1 /FVC normal

• FEV1 >60% but <80% predicted

• FEV1 /FVC reduced 5%

• FEV1 <60% predicted

• FEV1 /FVC reduced >5%

0-1/yr (see note) >2 year (see note)

Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category.

Risk

Exacerbations requiring oral

systemic corticosteroids

Relative annual risk of exacerbations may be related to FEV1

Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by

patient’s/caregiver’s recall of previous 2–4 weeks and spirometry. Assign severity to the most severe category in which any feature occurs.

At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma

severity. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.

Key: EIB, Exercise-induced bronchospasm; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, intensive care unit.

7

8

Asthma

Classification of Asthma Severity-lowest level of treatment required to maintain control

Preferred:

Low-dose ICS A

lternative:

Cromolyn, LTRA, Nedocromil Theophylline

Preferred:

Low-dose ICS + LABA Or Medium-dose ICS A

lternative:

Low-dose ICS+ either LTRA, Theophylline, or Zileuton

OR

Preferred:

Medium-dose ICS + LABA A

lternative:

Medium-dose ICS + either LTRA, Theophylline, or Zileuton

Severe PersistentModerate PersistentMild Persistent

Preferred:

High-dose ICS + LABA + corticosteroid

AND

Consider Omalizumab for patients who have allergies

OR

Preferred:

High-dose ICS + LABA

AND

Consider Omalizumab for patients who have allergies

Preferred:

SABA PRN

Intermittent

Key: EIB, exercise-inducted bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting inhaled beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist.

9

Asthma Pulmonary Function Tests

(Spirometry measurements – FEV, forced expiratory volume in 6 seconds (FEV6), FVC, FEV1/FVC- before and after the patient inhales a short-acting bronchodilator.)

At time of initial assessment

After treatment is initiated and symptoms and peak expiratory

flow have stabilized

Symptoms under control?

Yes No

During periods of progressive or

prolonged loss of asthma control

1-2 Years

10 Concord Internal Medicine

200 Medical Park Drive, Suite 550 ~ Concord, NC 28025 704-403-1307

WRITTEN ACTION PLAN

Peak Expiratory Flow (PEF) Important Peak Flow Numbers Patient’s Name ____________________________ Personal Best Baseline _____________ SS# ___________________________ 80% of baseline ___________________ Date of Birth ____________________ 50% of baseline ___________________

MANAGEMENT OF EXACERBATION OF ASTHMA: HOME TREATMENT

PEF > 80% of baseline

Begin Medrol Dose Pack or Prednisone taper Continue rescue inhaler 2-4 puffs every 3-4 hours while awake for 24-48 hours Contact Dr. Kelling or his office immediately

PEF 50 - 80% of baseline

Begin Medrol Dose Pack or Prednisone taper Repeat rescue inhaler 4 puffs Arrange for immediate transportation to hospital emergency department, call 911 if necessary

Repeat PEF 3 times. Use the best measurement.

Use your rescue inhaler (Proventil, Ventolin, ProAir, or Combivent) 2-4 puffs every 20 minutes for up to 3 treatments (wait 30 seconds between each puff).

PEF < 50% of baseline

You have symptoms or PEF < 80% of baseline.

Measure PEF every morning and whenever you have symptoms of asthma such as cough, shortness of breath, wheezing, and / or chest tightness.

Continue rescue inhaler 2-4 puffs every 3-4 hours as necessary Contact Dr. Kelling or his office immediately

Symptoms worse

Continue rescue inhaler 2-4 puffs every 3-4 hours as necessary

Symptoms same or improved

11 Concord Internal Medicine

200 Medical Park Drive, Suite 550 ~ Concord, NC 28025 704-403-1307

PLAN ESCRITO DE ACCIÓN

W R I T T E N A C T I O N P L A N

Nombre del paciente_______________________________ Flujo Espiratorio Máximo (PEF, en inglés) Patient’s Name Números importantes de flujo máximo Número de Seguro Social___________________________ Mejor valor inicial personal SS# 80% del valor inicial _______________ Fecha de nacimiento___________________ 50% del valor inicial _______________ DOB

ATENCIÓN A LA REAGUDIZACIÓN DEL ASMA: TRATAMIENTO EN CASA

Mida el Flujo Espiratorio Máximo (PEF, en inglés) cada mañana y cuando tenga síntomas de asma tales como tos, respiración dificultosa, sibilancias y /u opresión en el pecho.

Tiene síntomas o PEF < 80% del valor inicial.

Use su inhalador de rescate (Proventil, Ventolin, ProAir, o Combivent) entre 2 y 4 inspiraciones cada 20 minutos y hasta 3 tratamientos (espere 30 segundos entre cada inspiraciones).

PEF > 80% del valor inicial

Empiece el paquete con la dosis de Medrol o el Prednisone de disminución Continúe con el inhalador de rescate entre 2 y 4 inspiraciones cada 3 a 4 horas mientras esté despierto durante 24 a 48 horas Llame inmediatamente al Dr. Kelling o a su consultorio

Continúe con el inhalador de rescate entre 2 y 4 inspiraciones cada 3 a 4 horas cuando sea necesario Llame inmediatamente al Dr. Kelling o a su consultorio

Síntomas peores

Continúe con el inhalador de rescate entre 2 y 4 inspiraciones cada 3 a 4 horas cuando sea necesario

Síntomas iguales o mejorados

PEF 50 - 80% del valor inicial

Repita PEF 3 veces. Use la mejor medida.

PEF < 50% del valor inicial

Empiece el paquete con la dosis de Medrol o el Prednisone de

isminución gradual d

Repita 4 inspiraciones con el inhalador de rescate

Haga arreglos para transporte inmediato al departamento de emergencia del hospital, llame al 911 si es necesario

12

Asthma

Peak Flow Monitoring

Patient with moderate or severe persistent asthma

-or- Patient who has had a history

of severe exacerbations -or-

Patient who poorly perceives airflow obstruction

and worsening asthma

13

Asthma

Education

Basic facts about asthma

Role of medication

Inhaler technique

Use of

spacer

Identifying and avoiding

environmental exposures

Written asthma plans

Peak flow monitoring

Refer to page 22 Refer to Page 18-English

Refer to Page 19-Spanish

Refer to pages 14 & 15-English

Refer to pages 16 & 17-Spanish

Refer to page 10-English

Refer to page 11-Spanish

Refer to Page 20-English

Refer to Page 21- Spanish

14

What Is Asthma?

Asthma (AZ-ma) is a chronic (long-term) lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. The coughing often occurs at night or early in the morning.

Asthma affects people of all ages, but it most often starts during childhood. In the United States, more than 22 million people are known to have asthma. Nearly 6 million of these people are children.

Overview

The airways are tubes that carry air into and out of your lungs. People who have asthma have inflamed airways. This makes the airways swollen and very sensitive. They tend to react strongly to certain inhaled substances.

When the airways react, the muscles around them tighten. This narrows the airways, causing less air to flow into the lungs. The swelling also can worsen, making the airways even narrower. Cells in the airways may make more mucus than normal. Mucus is a sticky, thick liquid that can further narrow your airways.

This chain reaction can result in asthma symptoms. Symptoms can happen each time the airways are inflamed.

Asthma

Figure A shows the location of the lungs and airways in the body. Figure B shows a cross-section of a normal airway. Figure C shows a cross-section of an airway during asthma symptoms.

http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhatIs.html

15

Sometimes, asthma symptoms are mild and go away on their own or after minimal treatment with an asthma medicine. Other times, symptoms continue to get worse.

When symptoms get more intense and/or more symptoms occur, you're having an asthma attack. Asthma attacks also are called flareups or exacerbations (eg-zas-er-BA-shuns).

It's important to treat symptoms when you first notice them. This will help prevent the symptoms from worsening and causing a severe asthma attack. Severe asthma attacks may require emergency care, and they can be fatal.

Outlook

Asthma can't be cured. Even when you feel fine, you still have the disease and it can flare up at any time.

However, with today's knowledge and treatments, most people who have asthma are able to manage the disease. They have few, if any, symptoms. They can live normal, active lives and sleep through the night without interruption from asthma.

You can take an active role in managing your asthma. For successful, thorough, and ongoing treatment, build strong partnerships with your doctor and other health care providers.

http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_WhatIs.html

16

¿Qué es el asma?

El asma es una enfermedad crónica de los pulmones que inflama y estrecha las vías respiratorias. (Las enfermedades crónicas son enfermedades que duran mucho tiempo). El asma causa períodos repetidos de sibilancias (silbidos al respirar), presión en el pecho, dificultad para respirar y tos . Con frecuencia la tos se presenta por la noche o en las primeras horas de la mañana.

El asma afecta a personas de todas las edades, pero por lo general comienza durante la infancia. En los Estados Unidos hay más de 22 millones de personas con asma comprobada. Casi 6 millones de estas personas son niños.

Revisión general

Las vías respiratorias son tubos que conducen el aire que entra y sale de los pulmones. Las personas que sufren de asma tienen vías respiratorias inflamadas. Esto hace que las vías respiratorias estén hinchadas y muy sensibles, y tiendan a reaccionar fuertemente a ciertas sustancias que se inhalan.

Cuando las vías respiratorias reaccionan, los músculos que las rodean se contraen. Esto las estrecha y hace que llegue menos aire a los pulmones. La hinchazón también puede empeorar y estrechar las vías respiratorias aún más. Las células de estas vías pueden producir más mucosidad que en condiciones normales. La mucosidad es un líquido pegajoso y espeso que puede estrechar más las vías respiratorias.

Esta reacción en cadena puede causar síntomas de asma. Cada vez que las vías respiratorias se inflaman pueden presentarse síntomas.

Asma

17

La figura A muestra la ubicación de los pulmones y las vías respiratorias en el cuerpo. La figura B muestra un corte transversal de una vía respiratoria normal. La figura C muestra un corte transversal de una vía respiratoria durante los síntomas de asma.

A veces los síntomas son leves y desaparecen espontáneamente o después de un tratamiento mínimo con una medicina para el asma. Otras veces siguen empeorando.

Cuando los síntomas se vuelven más intensos o se presentan más síntomas, se dice que hay un ataque de asma. Los ataques de asma también se llaman crisis o exacerbaciones.

Es importante tratar los síntomas en cuanto se presentan. Así se evita que empeoren y causen un ataque de asma grave. Los ataques de asma graves pueden requerir atención de urgencias y pueden ser mortales.

Perspectivas

El asma no tiene cura. Aunque usted se sienta bien, sigue teniendo la enfermedad y podría empeorar en cualquier momento.

Sin embargo, debido a los conocimientos y tratamientos que tenemos en la actualidad, la mayoría de las personas con asma pueden controlar la enfermedad. Es posible que tengan pocos síntomas o que no los tengan. Pueden vivir una vida normal y activa, y dormir toda la noche sin interrupciones causadas por el asma.

Usted puede participar activamente en el control de su asma. Si desea un tratamiento exitoso, completo y constante, forme un equipo sólido con su médico y otros profesionales de salud encargados de atenderlo.

The American College of Chest Physicians is the leading resource for the improvement of cardiopulmonary health and critical care worldwide. Its mission is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication.This publication’s content contains general information, is not intended to be and is not complete, is not medical advice, and does not replace professional medical care and physician advice, which always should be sought for any specifi c condition. The American College of Chest Physicians and its offi cers, regents, executive committee, members, and employees specifi cally disclaim all responsibility for any liability, damages (actual or consequential), loss, or risk, personal or otherwise, based on any legal theory whatsoever, alleged to have been incurred as a result, directly or indirectly, of the use of any of the material herein.

© 2006 by The American College of Chest Physicians

Patient Education Guide

American College of Chest Physicians3300 Dundee Road, Northbrook, IL 60062(847) 498-1400 phone (847) 498-5460 faxwww.chestnet.org

To make your breathing better, you MUST take your medicine as explained below. Following these instructions puts more of the medicine into your lungs. This will open up your air passages and help you breathe easier and feel better. You need to ask your health-care provider or pharmacist how many puff s of medicine your metered-dose inhaler (MDI) has when it is full. You need to keep track of how many puff s of medicine you take every day, so you can have your MDI refi lled before you run out of medicine. Before using your MDI, please read the priming or preparing instructions. Your MDI should be cleaned once a week. See the instructions on cleaning your MDI.

1 2

6543

7 9

Recap the MDI. If you need to take another puff of medicine, wait 1 minute. After 1 minute, repeat steps 2-6.

Rinse your mouth out after you take your last puff of medicine. Make sure you spit the water out; do not swallow it. Rinsing is only necessary if the medicine you just took was a corticosteroid, such as Flovent®, Beclovent®, Vanceril®, Aerobid®, or Azmacort®.

Breathe out all the way. Tilt MDI up slightly. Put MDI in your mouth, between your teeth, tongue fl at under the mouthpiece, with lips sealed.

As you begin to BREATHE IN SLOWLY, PRESS DOWN ON THE MDI, as shown in this picture. Keep breathing in until your lungs are completely full.

HOLD your breath for 10 seconds. If you cannot hold your breath for 10 seconds, hold your breath as long as you can.

Sit up straight or stand up.Take cap off MDI. Check for and remove any dust, lint, or other objects. Shake MDI well.

Using Your MDI—Closed-Mouth Technique

8

SM

American College of Chest Physicians3300 Dundee Road, Northbrook, IL 60062(847) 498-1400 teléfono (847) 498-5460 faxwww.chestnet.org

Propiedad literaria © 2006 por el American College of Chest Physicians

Guía Educacional para Pacientes

El American College of Chest Physicians es el recurso eminente para el mejoramiento de la salud cardiopulmonar y cuidado crítico a nivel mundial. Su misión es la de promover la prevención y tratamiento de enfermedades del pecho por medio de liderazgo, educación, investigaciones, y comunicación.El contenido de esta publicación contiene información general, no tiene la intención de ser completa y no lo es, no es consejo médico, y no reemplaza el cuidado médico profesional ni los consejos de un médico, los cuales siempre debe solicitar para cualquier condición específica. El American College of Chest Physicians y sus directores, regentes, comité ejecutivo, miembros, y empleados especificamente renuncian a toda responsabilidad acerca de cualquier cuestión legal, daños (actuales o a consecuencia), pérdida, o riesgo, personal o de cualquier otro tipo, basados en cualquier teoría legal sea la que sea, que se suponga que haya sufrido como resultado, directo e indirecto, por el uso de cualquier material aquí mencionado. Para imprimir copias gratuitas de este folleto vaya a www.chestnet.org/patients/guides/inhaledDevices.php.

Para mejorar su respiración, TIENE QUE usar su medicamento según se le explica en las siguientes instrucciones. Si sigue estas instrucciones, más medicina entrará a sus pulmones. Esto abrirá sus vias respiratorias y le ayudará a respirar más fácilmente y a sentirse mejor. Le necesita preguntar a su proveedor de cuidado médico o a su farmacéutico cuantas dosis de medicina contiene su inhalador de dosis medida (MDI por sus siglas en inglés) cuando está lleno. Necesita llevar la cuenta del número de dosis de medicina que usa todos los dias, y así poder encargar un repuesto antes de que se le termine la medicina. Antes de usar su MDI, por favor lea las instrucciones sobre como prepararlo. Su MDI se debe limpiar una vez por semana. Vea las instrucciones sobre como limpiarlo.

1 2

6543

7 9

Vuelva a tapar el MDI.Si necesita tomar otra dosis de medicina, espere un minuto. Después de un minuto, repita los pasos del 2 al 6.

Enjuáguese la boca después de tomar su última dosis de medicina. Escupa el agua; no se la tome. Solo es necesario enjuagarse la boca si el medicamento que acaba de usar es un corticoesteroide, tal como Flovent®, Beclovent®, Vanceril®, Aerobid®, o Azmacort®.

Respire para afuera completamente. Incline un poquito hacia arriba el MDI. Ponga el MDI en su boca, entre los dientes, con la lengua plana debajo de la boquilla, con los labios bien cerrados para evitar fugas.

Al comenzar a RESPIRAR PARA ADENTRO LENTAMENTE, OPRIMA PARA ABAJO EL MDI, como muestra esta foto. Siga respirando para adentro hasta que sus pulmones esten completamente llenos.

CONTENGA la respiración por 10 segundos. Si no la puede contener por 10 segundos, conténgala por el mayor tiempo que pueda.

Siéntese derecho o párese.Quítele la tapa al MDI. Fíjese si tiene cualquier polvo, pelusa, u otro objeto y quíteselo. Agite bien el MDI.

Como usar su MDI— técnica de la boca cerrada

8

The American College of Chest Physicians is the leading resource for the improvement of cardiopulmonary health and critical care worldwide. Its mission is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication.This publication’s content contains general information, is not intended to be and is not complete, is not medical advice, and does not replace professional medical care and physician advice, which always should be sought for any specifi c condition. The American College of Chest Physicians and its offi cers, regents, executive committee, members, and employees specifi cally disclaim all responsibility for any liability, damages (actual or consequential), loss, or risk, personal or otherwise, based on any legal theory whatsoever, alleged to have been incurred as a result, directly or indirectly, of the use of any of the material herein.

© 2006 by The American College of Chest Physicians

Patient Education Guide

American College of Chest Physicians3300 Dundee Road, Northbrook, IL 60062(847) 498-1400 phone (847) 498-5460 faxwww.chestnet.org

To make your breathing better, you MUST take your medicine as explained below. Following these instructions puts more of the medicine into your lungs. This will open up your air passages and help you breathe easier and feel better. You need to ask your health-care provider or pharmacist how many puff s of medicine your metered-dose inhaler (MDI) has when it is full. You need to keep track of how many puff s of medicine you take every day, so you can have your MDI refi lled before you run out of medicine. Before using the MDI, please read the priming or preparing instructions. Your MDI and spacer should be cleaned once a week. See instructions on cleaning your MDI.

1 2

6543

7

If you need to take another puff of medicine, wait 1 minute. After 1 minute, repeat steps 3-6.

Recap the MDI. Rinse your mouth with water after you have taken your last puff of medicine. Make sure you spit the water out, do not swallow it. Rinsing is only necessary if the medicine you just took was a corticosteroid, such as Flovent®, Beclovent®, Vanceril®, Aerobid®, or Azmacort®.

Sit up straight and breathe out normally. Put mouthpiece of spacer in your mouth. Close your lips around the mouthpiece and make a tight seal. Press down on the MDI. This puts one puff of medicine into the spacer.

To breathe in that one puff of medicine, TAKE A SLOW, DEEP BREATH. Breathe in as much air as you can. Try to fi ll up your lungs completely. It is important that the breath be SLOW and DEEP.DEEP.DEEP

Remove the mouthpiece from your mouth. HOLD your breath for 10 seconds. If you cannot hold your breath for 10 seconds, hold your breath as long as you can.

Attach MDI to spacer. Take cap off MDI. Check for and remove any dust, lint, or other objects. Shake MDI well.

Using Your MDI With a Spacer

8

El American College of Chest Physicians es el recurso eminente para el mejoramiento de la salud cardiopulmonar y cuidado crítico a nivel mundial. Su misión es la de promover la prevención y tratamiento de enfermedades del pecho por medio de liderazgo, educación, investigaciones, y comunicación.El contenido de esta publicación contiene información general, no tiene la intención de ser completa y no lo es, no es consejo médico, y no reemplaza el cuidado médico profesional ni los consejos de un médico, los cuales siempre debe solicitar para cualquier condición específica. El American College of Chest Physicians y sus directores, regentes, comité ejecutivo, miembros, y empleados especificamente renuncian a toda responsabilidad acerca de cualquier cuestión legal, daños (actuales o a consecuencia), pérdida, o riesgo, personal o de cualquier otro tipo, basados en cualquier teoría legal sea la que sea, que se suponga que haya sufrido como resultado, directo e indirecto, por el uso de cualquier material aquí mencionado. Para imprimir copias gratuitas de este folleto vaya a www.chestnet.org/patients/guides/inhaledDevices.php.

Para mejorar su respiración, TIENE QUE usar su medicamento según se le explica en las siguientes instrucciones. Si sigue estas instrucciones, más de la medicina entrará a sus pulmones. Esto abrirá sus vias respiratorias y le ayudará a respirar más fácilmente y a sentirse mejor. Le necesita preguntar a su proveedor de cui-dado médico o a su farmacéutico cuantas dosis de medicina contiene su inhalador de dosis medida (MDI por sus siglas en inglés) cuando está lleno. Necesita llevar la cuenta del número de dosis de medicina que usa todos los dias, y así poder encar-gar un repuesto antes de que se le termine la medicina. Antes de usar su MDI, por favor lea las instrucciones sobre como prepararlo. Su MDI y la cámara de inhalación se deben limpiar una vez por semana. Vea las instrucciones sobre como limpiarlo.

1 2

6543

7

Si necesita tomar otra dosis de medicina, espere un minuto. Después de un minuto, repita los pasos del 3 al 6.

Vuelva a tapar el MDI. Enjuáguese la boca después de tomar su última dosis de medicina. Es-cupa el agua; no se la tome. Solo es necesario enjuagarse la boca si el medicamento que acaba de usar es un corticoesteroide, tal como Flovent®, Beclovent®, Vanceril®, Aerobid®, o Azmacort®.

Siéntese derecho y respire para afuera normalmente.

Ponga la boquilla de la cámara de inhalación en su boca. Cierre bien los labios sobre la boquilla para evitar fugas. Oprima para abajo el MDI. Esto pone una dosis de medicina en la cámara de inhalación.

Para inhalar esa dosis de medicina, RESPIRE PARA ADENTRO LENTA Y PROFUNDAMENTE. Inhale cuanto aire pueda. Trate de llenar sus pulmones completamente. Es importante que esta respiración sea LENTA y PROFUNDA.

Quite la boquilla de su boca. CONTENGA la respiración por 10 segundos. Si no la puede CONTENER por 10 segundos, conténgala por el mayor tiempo que pueda.

Coloque el MDI en la apertura de la cámara de inhalación.

Quítele la tapa al MDI. Fíjese si tiene cualquier polvo, pelusa, u otro objeto y quíteselo. Agite bien el MDI.

Como usar su MDI con una cámara de inhalación

8

American College of Chest Physicians3300 Dundee Road, Northbrook, IL 60062(847) 498-1400 teléfono (847) 498-5460 faxwww.chestnet.org

Guía Educacional para Pacientes

SM

Propiedad literaria © 2006 por el American College of Chest Physicians

22

Asthma

Stop

smoking if applicable

Control of Environmental and Co-morbid Conditions

Avoid exposure

to allergens based on

history and allergy testing

Avoid exposure to irritants such

as smoke, substances with strong odors, air pollutants

Avoid use of nonselective beta-blockers (carvedilol, labetalol, nadelol, pindolol,

propanolol, sotalol)

Avoid sulfite-

containing foods and

other foods to which patient is sensitive

Immuniza-

tions

Evaluate

and control co-morbid conditions

Avoid aspirin and NSAIDS if patient has

severe persistent

nasal polyps of history of sensitivity to

aspirin or NSAIDS

Flu and Pneumovax

ABPA (Allergic Broncho-Pulmonary Aspergillosi

GERD Obesity OSA

(Obstructive Sleep Apnea)

Rhino/sinusitis Chronic stress/

depression

23

Asthma

Medications

Referral to Asthmaspecialist ‐ see pg. 23 

24

Referral to an Asthma Specialist for Consultation or Comanagement The Expert Panel recommends referral for consultation or care to a specialist in asthma care (usually, a fellowship-trained allergist or pulmonologist; occasionally, other physicians who have expertise in asthma management, developed through additional training and experience) when:

• Patient has had a life-threatening asthma exacerbation.

• Patient is not meeting the goals of asthma therapy after 3–6 months of treatment. An earlier referral or consultation is appropriate if the physician concludes that the patient is unresponsive to therapy.

• Signs and symptoms are atypical, or there are problems in differential

diagnosis.

• Other conditions complicate asthma or its diagnosis (e.g., sinusitis, nasal polyps, aspergillosis, severe rhinitis, VCD, GERD, COPD).

• Additional diagnostic testing is indicated (e.g., allergy skin testing, rhinoscopy,

complete pulmonary function studies, provocative challenge, bronchoscopy).

• Patient requires additional education and guidance on complications of therapy, problems with adherence, or allergen avoidance.

• Patient is being considered for immunotherapy.

• Patient requires step 4 care or higher (step 3 for children 0–4 years of age). Consider referral if patient requires step 3 care (step 2 for children 0–4 years of age).

• Patient has required more than two bursts of oral corticosteroids in 1 year or

has an exacerbation requiring hospitalization.

• Patient requires confirmation of a history that suggests that an occupational or environmental inhalant or ingested substance is provoking or contributing to asthma. Depending on the complexities of diagnosis, treatment, or the intervention required in the work environment, it may be appropriate in some cases for the specialist to manage the patient over a period of time or to co-manage with the PCP.