Management of Asthma: Telephone Triage (C4)

VETERANS HEALTH ADMINISTRATION CLINICAL PRACTICE GUIDELINE FOR THE MANAGEMENT OF COPD OR ASTHMA

Management of Asthma: Telephone Triage (C4)

A. Can the Patient be Managed Safely at Home? - Is provider familiar with patient?

Can patient follow instructions?
Does the patient have an adequate supply of appropriate medications at home?
Does the patient have a peak flow meter at home and know how to use it?
Does the patient have access and transportation to emergency treatment if attack becomes severe?

B. Manage at Home - Initial treatment with inhaled short-acting beta2-agonist: up to three treatments of 2 to 4 puffs by MDI at 20-minute intervals or single nebulizer treatment.

1. Good response (mild exacerbation) includes:

PEF > 80 percent personal best or predicted
No wheezing or shortness of breath
Response to beta2-agonist sustained for 4 hours

May continue beta2-agonist every 3 to 4 hours for 24 to 48 hours. For patients on inhaled corticosteroids, double-dose for 7 to 10 days. Contact clinician for follow-up instructions. Patients without a prior diagnosis of asthma or not known to the provider should be seen within a week.

2. Incomplete response (moderate exacerbation) includes:

PEF 50 to 80 percent personal best or predicted
Persistent wheezing and shortness of breath

Add oral corticosteroids and continue inhaled short acting beta2-agonist. Contact clinician the same day for instructions. Patients without a prior diagnosis of asthma or not known to the provider should be seen within 24 hours.

C. Has the Plan Worked? - Assess severity: measure PEF.

1. Severe: PEF < 50 percent personal best or predicted suggests severe exacerbation requiring medical attention

2. Partial: PEF > 50 percent < 70 percent of personal best or predicted

3. Good: PEF >70 percent of personal best or predicted

Note signs and symptoms: degree of cough, breathlessness, wheeze, and chest tightness, correlates imperfectly with severity of exacerbation. (Difficult for patient to self-assess).

TABLE OF EVIDENCE Poor Reliability of Traditional Methods (e.g., non-PEF meters) to Assess Asthma Severity

Intervention	References	Grade of Evidence	Strength of Recommendation
Symptoms (in severe +/-) are poor predictors of severity in severe asthma.	NAEPP, Expert Panel Report 2 1997 Grampian 1994 Charlton et al. 1994	B	1
Auscultated wheezes are poor predictors of severity.	Kikuchi et al. 1994 Holleman et al. 1995	C	2a
Physician's impressions are inaccurate predictors of severity.	Kerem et al. 1991 Dales et al. 1988 Pratter et al. 1983	C	2a

TABLE OF EVIDENCE Utility of PEF Meters to Assess Asthma Severity, Along with Self-Management Medication Plans, Medications, and Education is Confidently Documented in Adults

Intervention

References

Grade of Evidence

Strength of Recommendation

PEF meters and self-management plans are effective in improving control of severe and moderately severe asthma.

NAEPP, Expert Panel Report 2 1997

Hargreave et al. 1990

Woolcock et al. 1988

Ignacio-Gracia et al. 1995

Lahdensno et al. 1996

Beasley et al. 1989

Malo et al. 1993

Correlation with FEV_1.

Malo et al. 1993

D. Instruct Patient to Come to Office or Emergency Room to be Seen Immediately - Poor response (severe exacerbation) includes:

1. PEF < 50 percent personal best or predicted

2. Marked wheezing and shortness of breath

3. Repeat beta2-agonist immediately, call doctor or proceed to emergency department; consider calling ambulance or 911.

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