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<sup>1</sup> <b>Severe Persistent</b> = sx/SABA use throughout day, night sx often 7x/wk, extreme limitations to NL activity, FEV1 <60%, FEV1/FVC ↓ by >5%, ≥2 exac/yr requiring PO/IV steroids (inadequate data to correlate exac freq w/ severity; but ≥2/yr considered persistent despite impairment level). Dx: hx/exam to determine sx d/t recurrent airway obstruction: cough, recurrent wheeze/difficult breathing/chest tightness worse @ night or w/ exercise, viral infxn, allergens/irritants, weather, laugh/cry, stress, etc. ✓ spirometry to determine at least partial reversibility.<br><br>
<sup>2</sup> <b>Differential Dx:</b><br>
<b>Child:</b> allergic rhinitis, sinusitis, foreign body, vocal cord dysfxn, bronchostenosis, LN/tumor, viral or obliterative bronchiolitis, CF, heart dz, aspiration.<br>
<b>Adult:</b> chronic bronchitis, emphysema, CHF, PE, mechanical obstruction (eg, tumor), pulm infiltration w/ eosinophilia, drug-induced cough, vocal cord dysfxn.
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<sup>3</sup> <b>Asthma biologics:</b> anti-IgE, anti-IL5, anti-IL5R, anti-IL4/IL13
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<sup>4</sup> If SABA not tolerated, ipratropium may be used as alternative. Theophylline less desirable d/t level monitoring. Zileuton less desirable d/t limited studies as adjunct tx, LFT monitoring.
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<sup>5</sup> SABA >2x/wk indicates poor control except for EIB pre-exercise prevention. LTRAs, cromolyn, or LABAs also protect in EIB. Frequent/chronic LABA to prevent EIB discouraged (may disguise poorly controlled persistent dz). Consider long-term controllers; EIB often marks inadequate control and responds to regular anti-inflammatory tx. EIB should not limit either participation or success in vigorous activities. If cold-induced EIB: Warm-up period or mask/scarf over mouth.
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<sup>6</sup> <b>Oral steroids</b> (options listed in EPR-3 Quick Reference 2012, in alpha order): methylprednisolone, prednisolone, or prednisone: 7.5–60 mg daily (single AM dose) or every other day as needed for control. Short-course burst to gain control: 40–60 mg/day single dose (or 2 divided doses) x3–10 days.
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<sup>7</sup> <b>Allergens, irritants, pollutants:</b> ✓ hx exposure-related sx. Avoid tobacco smoke. If persistent asthma, use skin/in vitro tests for perennial indoor allergens. If clear connection b/t sx and allergen, consider immuno-tx by trained personnel. Evidence best for dust mite, animal dander, pollen; evidence weak/lacking for molds, cockroaches; evidence strongest for single-allergen immuno-tx. Allergy role greater in children vs adults.
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<sup>8</sup> <b>Identify comorbidities:</b> rhinitis, sinusitis, GERD, obesity, OSA, ABPA, stress, depression, etc.
<sup>2</sup> <b>Differential Dx:</b><br>
<b>Child:</b> allergic rhinitis, sinusitis, foreign body, vocal cord dysfxn, bronchostenosis, LN/tumor, viral or obliterative bronchiolitis, CF, heart dz, aspiration.<br>
<b>Adult:</b> chronic bronchitis, emphysema, CHF, PE, mechanical obstruction (eg, tumor), pulm infiltration w/ eosinophilia, drug-induced cough, vocal cord dysfxn.
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<sup>3</sup> <b>Asthma biologics:</b> anti-IgE, anti-IL5, anti-IL5R, anti-IL4/IL13
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<sup>4</sup> If SABA not tolerated, ipratropium may be used as alternative. Theophylline less desirable d/t level monitoring. Zileuton less desirable d/t limited studies as adjunct tx, LFT monitoring.
<br><br>
<sup>5</sup> SABA >2x/wk indicates poor control except for EIB pre-exercise prevention. LTRAs, cromolyn, or LABAs also protect in EIB. Frequent/chronic LABA to prevent EIB discouraged (may disguise poorly controlled persistent dz). Consider long-term controllers; EIB often marks inadequate control and responds to regular anti-inflammatory tx. EIB should not limit either participation or success in vigorous activities. If cold-induced EIB: Warm-up period or mask/scarf over mouth.
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<sup>6</sup> <b>Oral steroids</b> (options listed in EPR-3 Quick Reference 2012, in alpha order): methylprednisolone, prednisolone, or prednisone: 7.5–60 mg daily (single AM dose) or every other day as needed for control. Short-course burst to gain control: 40–60 mg/day single dose (or 2 divided doses) x3–10 days.
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<sup>7</sup> <b>Allergens, irritants, pollutants:</b> ✓ hx exposure-related sx. Avoid tobacco smoke. If persistent asthma, use skin/in vitro tests for perennial indoor allergens. If clear connection b/t sx and allergen, consider immuno-tx by trained personnel. Evidence best for dust mite, animal dander, pollen; evidence weak/lacking for molds, cockroaches; evidence strongest for single-allergen immuno-tx. Allergy role greater in children vs adults.
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<sup>8</sup> <b>Identify comorbidities:</b> rhinitis, sinusitis, GERD, obesity, OSA, ABPA, stress, depression, etc.
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Step 4/5 for Severe Persistent dz,<sup>1,2</sup> consider asthma biologics at Step 5