Step Care Management of Asthma
What is step care management?
Step Care Management is like a staircase. We start treatment at the appropriate step. Then we shall step up along the stairs if asthma is not controlled or becomes more severe and shall step down when patient's asthma is fully controlled for 3 months or more.
We have divided the asthma management plan into five steps. At first, we should understand basic principles of five steps. Then we can construct any step by combining available drugs.
Basic Principles of Step Care Management
Step - I: Inflammation is so minimal that no Preventer or anti-inflammatory medication is required. Patient will only take Reliever drug (bronchodilator) as per need. Onwards Step-I is kept as a part of Step II to Step V.
Step - II: For control of inflammation, low dose Preventer (anti-inflammatory medication) is required. Reliever drug will be used in step-II to step-V as per need, like step-I. We can get desired low dose anti-inflammatory action by using "full dose Cromones" or "low dose Inhaled Corticosteroids (LDICS)" or “Leukotrienes antagonists”.
Step - III: To control airway inflammation, high dose Preventer (anti-inflammatory medication) is required. This means high dose inhaled Corticosteroids (HDICS). But we may give low dose inhaled Corticosteroids (LDICS) along with Cromones or long-acting b2-agonist (Salmeterol) inhaler or Sustained release Theophyllin (protectors) to get the desired effect. Any of these combinations is equivalent to high dose inhaled Corticosteroids (HDICS).
Step - IV: We have two divisions of step-IV viz. IVA and IVB. When high dose anti-inflammatory drugs (HDICS) are thought to be insufficient to control asthma then we use step - IVA or IVB. Step IVA (A=alone) means addition of either Salmeterol inhaler or Theophyllin SR alone with HDICS. Step IVB (B= both) means both Salmeterol inhaler and Theophyllin SR will be added with HDICS.
Step - V: It is the highest step. Oral Corticosteroid added as single morning dose with step-IVB is known as step-V. We give this step when step IVB is thought to be inadequate to control asthma.
The Stair Case of Step Care Management
For children >5 years to adults
For children <5 years
Economic Schedule
Scoring system for appropriate step care management
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See Also:
Home Management of Asthma
Emergency Management of Asthma
Hospital Based Care of Asthma
Concomitant Disease management of Asthma
Pitfalls of Asthma Management
Topics:
Why management at home ?
Since asthma is a chronic disease, it can be and should be managed at home up to a certain level. If home management plan is applied intelligently and skillfully, most asthmatics can lead symptom free normal life, avoid hospitalization thereby cutting down the financial expenditure significantly. All patients of asthma, except those with acute exacerbation, should be treated at home.
What are the components of home management plan ?
Pitfalls of Asthma Management - Incorrect diagnosis, Inappropriate management plan, Inadequate education, Improper inhalation technique
Management of Asthma Attacks :
Hospital-Based Care
Initial Assessment:
History, Physical examination (auscultation, use of accessory muscles, heart rate, respiratory rate) and Investigations (PEF or FEV1, Oxygen saturation SaO2, arterial blood gas analysis and other tests)
Initial Treatment:
- Inhaled short-acting b2-agonist, usually by nebulization, one dose every 20 minutes for 1 hour
- Oxygen to achieve O2 saturation >90% (95% in children)
What are the medicines used to treat asthma?
There are basically three kinds of medicines:
Relievers (Bronchodilators) are medicines that relax smooth muscles that have tightened around the airways. They relieve asthma symptoms. Short acting b2-agonists, short acting aminophylline, and ipratropium are bronchodilators or relievers.
There are some common concerns about Asthma prevailing in the society. In majority of cases, these are misconceptions or baseless fears. For optimum control of asthma, these points should be dealt with proper care. Otherwise the management plan may go in vain. It the physicians responsibility to eradicate such worries, if present, from the patient’s mind. Some common concerns and suggested clinicians responses are listed below. Model answers to some frequently asked questions (FAQs) are also given. These will help the physician to deal with such situations more confidently.
Why do we define asthma?
We define asthma to identify the disease correctly and to differentiate it from other diseases. To fulfill this goal, definition of asthma has been changing over last 40 years. The clinician, physiologist, immunologist, pathologist or epidemiologist - all have different perspective of asthma.
In the year 1997, the following working definition has been formulated by Expert Panel-2 of National Asthma Education and Prevention Program, USA.
Asthma is a chronic inflammatory disorder of the airways:
Using a metered dose inhaler (MDI) is a good way to take asthma medicines. There are few side effects because the medicine goes right to the lungs and not to other parts of the body. It takes only 5 to 10 minutes for the medicine to have an effect compared to oral asthma medicines, which can take 1 to 3 hours. Inhalers can easily be used by all asthma patients of age 5 and older. A spacer or holding chamber attached to the inhaler can help make taking the medicine easier for even younger children.
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