Curr Allergy Asthma Rep (2014) 14:475 DOI 10.1007/s11882-014-0475-z
PEDIATRIC ALLERGY AND IMMUNOLOGY (JM PORTNOY AND CE CIACCIO, SECTION EDITORS)
Empowering the Child and Caregiver: Yellow Zone Asthma Action Plan Chitra Dinakar & Jay M. Portnoy
Published online: 3 September 2014 # Springer Science+Business Media New York 2014
Abstract Current guidelines, both national and international, elegantly describe evidence-based measures to attain and maintain long-term control of asthma. These strategies, typically discussed between the provider and patient, are provided in the form of written (or electronic) instructions as part of the green zone of the color-coded Asthma Action Plan. The red zone of the Asthma Action Plan has directives on when to use systemic corticosteroids and seek medical attention. The transition zone between the green zone of good control and the red zone of asthma exacerbation is the yellow zone. This zone guides the patient on self-management of exacerbations outside a medical setting. Unfortunately, the only recommendation currently available to patients per the current asthma guidelines is the repetitive use of reliever bronchodilators. This approach, while providing modest symptom relief, does not reliably prevent progression to the red zone. In this document, we present new, evidence-based, yellow zone intervention options.
Keywords Yellow zone . Asthma management . Asthma control . Practice parameter . Home exacerbation
This article is part of the Topical Collection on Pediatric Allergy and Immunology C. Dinakar (*) Division of Allergy, Asthma and Immunology, Children’s Mercy Hospitals, University of Missouri—Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA e-mail: [email protected] J. M. Portnoy Division of Allergy, Asthma and Immunology, The Children’s Mercy Hospitals and Clinics, University of Missouri—Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA e-mail: [email protected]
Introduction The keystone of asthma management is the establishment of an ongoing partnership between the patient/caregiver and the provider regarding the goals of asthma therapy and the strategies to achieve the goals. This approach has long been espoused by national organizations such as the National Heart Lung and Blood Institute (NHLBI) and international bodies such as the Global Initiative for Asthma (GINA). One of the instruments successfully used to create and foster empowerment in patients has been the symptom-based, or peak flow-based, Asthma Action Plan (AAP) [1, 2]. Commonly based on the traffic signal color-coded concept of green (go), yellow (caution), and red (danger), the AAP contains explicit instructions on pharmacotherapy recommendations in the green zone (asthma doing well), the yellow zone (asthma deterioration detected, intervention needed), and the red zone (asthma exacerbation requiring urgent treatment) (http://www. nhlbi.nih.gov/health/public/lung/asthma/actionplan_text.htm). Interventions focusing on achievement and maintenance of long-term asthma control have been elegantly laid out in the Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma [2] and in the GINA guidelines [3]. These evidence-based, stepwise interventions are intended to treat variations in symptoms that occur over a protracted time frame of months. Most patients with asthma additionally experience sporadic acute loss of control in response to exposure to triggers that occur over an abbreviated time frame of hours to days. Since these episodes typically occur in a setting outside a medical facility such as the home, patients and caregivers need to be provided with a pre-agreed upon AAP that they can utilize. Effective recognition and prompt use of therapeutic maneuvers in this zone of acute loss of control, the yellow zone (YZ), may empower patients to regain control. It may also help arrest the rapid decline of control into the red zone (RZ), or
475, Page 2 of 8
the zone of requiring systemic corticosteroids and urgent medical attention. Current recommended interventions in the YZ include increasing administration of inhaled short-acting beta2-agonist (SABA) (such as two to six puffs of albuterol) every 3–4 h for 24–48 h [2]. If control is not reclaimed using that approach, the next step is to consider a short course of systemic corticosteroids. In other words, the tactic to stabilize the volatility in the YZ is to escalate the frequency of reliever SABA therapy. However, recent studies exploring other pharmacological options have been published in a practice parameter [4••] and will be reviewed in this document. Why Is the Yellow Zone Important? Asthma is a labile illness associated with morbidity when control is lost acutely. Untreated impending exacerbations could worsen and lead to the use of systemic corticosteroids, emergency department (ED) visits, hospitalizations, or even death. Oral corticosteroids (OCS) have been shown to be effective in treating most RZ asthma exacerbations if started early [3, 5], though recent studies have questioned their clinical benefit in preschool children with acute wheezing episodes [6, 7••]. However, repetitive courses of OCS, such as in children with recurrent respiratory tract infections (RTIs) during the viral seasons, may result in cumulative doses that can be associated with significant side effects [8–10]. Patients often spontaneously escalate their asthma medications (both relievers and controllers) with worsening symptoms [11••]. Even though only 29 % of patients in a study stated they were instructed to step up their maintenance therapy with worsening asthma, 52 % acknowledged doing it anyway. The risk of a “false” start, or initiating YZ treatment when not needed, should be balanced with the risk of a “late” start, resulting in downstream morbidity. The majority of caretakers of asthmatic children (90 %) attending a general pediatric clinic provided with written AAPs acknowledged it to be of value in managing exacerbations [12•]. Criteria for Recognition of Yellow Zone A number of criteria have been proposed to identify the YZ. These include one or more of the following: an increase in asthma symptoms (two or more times per day) greater than baseline [13, 14], asthma symptoms that do not improve or recur (within 4 h or less) after treatment with an inhaled SABA [2, 14, 15••], increase in nocturnal symptoms [16], and peak flow decline of 15 % or more or at 12 puffs per day in older children and adults and >8 puffs per day in younger children has been used in clinical trials to define a RZ exacerbation; we therefore recommend adopting that ceiling in the yellow zone [4••].
Page 3 of 8, 475
Doubling the Dose of Inhaled Corticosteroids Previous versions of the NAEPP guidelines 1997 [23] advocated the practice of doubling ICS dose at the commencement of worsening symptoms since earlier studies had found these interventions helpful. Improvement in symptom scores and parental preference for increased ICS were noted in two pediatric studies [26, 27], with another showing a significant impact on OCS use and hospitalization with increasing doses of ICS [28]. Reconciliation of the widespread adoption of the practice of doubling ICS doses in the YZ with results of several recent RCTs failing to demonstrate the effectiveness of this strategy [29, 2] has led to skepticism regarding the study design. A major criticism relates to the variation in timing of the increase in ICS dosing used in the studies with the definition of the onset of an exacerbation ranging from as late as 2–3 days [14] after peak expiratory flow (PEF) decline from baseline. As noted in observations of the chronology of an exacerbation, this reference point may be already too late. Future studies should consider dose augmentation at first symptom or immediately following exposure to a known trigger. Phenotypic differences and variations in response based on the triggers may also be contributory factors that merit further evaluation. Additionally, all the studies were conducted on subjects already on controller ICS; none were performed on steroid-naïve or intermittent asthmatics, and thus, the response in this group is not known. Based on our experience with successfully managing children with asthma, coupled with feedback from our patients [12•], we believe that there is justification in prescribing doubling doses of ICS during a YZ episode, particularly in those who are timely in steppingup care and in whom this strategy has been previously effective.
Quadrupling the Dose of Inhaled Corticosteroids The EPR3 mentions the possibility that prompt administration of quadrupling doses of ICS for 7 days may prevent exacerbations [2] referencing the study by Foresi et al. [30••] randomizing patients with asthma on budesonide to the following groups: group 1: 400 μg twice daily (bid)+placebo; group 2: 100 μg bid+200 μg four times daily (qid); and group 3: 100 mg bid+placebo. The primary outcome was an asthma exacerbation defined by a fall in peak expiratory flow 24 h) and worse severity (FEV1
PEDIATRIC ALLERGY AND IMMUNOLOGY (JM PORTNOY AND CE CIACCIO, SECTION EDITORS)
Empowering the Child and Caregiver: Yellow Zone Asthma Action Plan Chitra Dinakar & Jay M. Portnoy
Published online: 3 September 2014 # Springer Science+Business Media New York 2014
Abstract Current guidelines, both national and international, elegantly describe evidence-based measures to attain and maintain long-term control of asthma. These strategies, typically discussed between the provider and patient, are provided in the form of written (or electronic) instructions as part of the green zone of the color-coded Asthma Action Plan. The red zone of the Asthma Action Plan has directives on when to use systemic corticosteroids and seek medical attention. The transition zone between the green zone of good control and the red zone of asthma exacerbation is the yellow zone. This zone guides the patient on self-management of exacerbations outside a medical setting. Unfortunately, the only recommendation currently available to patients per the current asthma guidelines is the repetitive use of reliever bronchodilators. This approach, while providing modest symptom relief, does not reliably prevent progression to the red zone. In this document, we present new, evidence-based, yellow zone intervention options.
Keywords Yellow zone . Asthma management . Asthma control . Practice parameter . Home exacerbation
This article is part of the Topical Collection on Pediatric Allergy and Immunology C. Dinakar (*) Division of Allergy, Asthma and Immunology, Children’s Mercy Hospitals, University of Missouri—Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA e-mail: [email protected] J. M. Portnoy Division of Allergy, Asthma and Immunology, The Children’s Mercy Hospitals and Clinics, University of Missouri—Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO 64108, USA e-mail: [email protected]
Introduction The keystone of asthma management is the establishment of an ongoing partnership between the patient/caregiver and the provider regarding the goals of asthma therapy and the strategies to achieve the goals. This approach has long been espoused by national organizations such as the National Heart Lung and Blood Institute (NHLBI) and international bodies such as the Global Initiative for Asthma (GINA). One of the instruments successfully used to create and foster empowerment in patients has been the symptom-based, or peak flow-based, Asthma Action Plan (AAP) [1, 2]. Commonly based on the traffic signal color-coded concept of green (go), yellow (caution), and red (danger), the AAP contains explicit instructions on pharmacotherapy recommendations in the green zone (asthma doing well), the yellow zone (asthma deterioration detected, intervention needed), and the red zone (asthma exacerbation requiring urgent treatment) (http://www. nhlbi.nih.gov/health/public/lung/asthma/actionplan_text.htm). Interventions focusing on achievement and maintenance of long-term asthma control have been elegantly laid out in the Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma [2] and in the GINA guidelines [3]. These evidence-based, stepwise interventions are intended to treat variations in symptoms that occur over a protracted time frame of months. Most patients with asthma additionally experience sporadic acute loss of control in response to exposure to triggers that occur over an abbreviated time frame of hours to days. Since these episodes typically occur in a setting outside a medical facility such as the home, patients and caregivers need to be provided with a pre-agreed upon AAP that they can utilize. Effective recognition and prompt use of therapeutic maneuvers in this zone of acute loss of control, the yellow zone (YZ), may empower patients to regain control. It may also help arrest the rapid decline of control into the red zone (RZ), or
475, Page 2 of 8
the zone of requiring systemic corticosteroids and urgent medical attention. Current recommended interventions in the YZ include increasing administration of inhaled short-acting beta2-agonist (SABA) (such as two to six puffs of albuterol) every 3–4 h for 24–48 h [2]. If control is not reclaimed using that approach, the next step is to consider a short course of systemic corticosteroids. In other words, the tactic to stabilize the volatility in the YZ is to escalate the frequency of reliever SABA therapy. However, recent studies exploring other pharmacological options have been published in a practice parameter [4••] and will be reviewed in this document. Why Is the Yellow Zone Important? Asthma is a labile illness associated with morbidity when control is lost acutely. Untreated impending exacerbations could worsen and lead to the use of systemic corticosteroids, emergency department (ED) visits, hospitalizations, or even death. Oral corticosteroids (OCS) have been shown to be effective in treating most RZ asthma exacerbations if started early [3, 5], though recent studies have questioned their clinical benefit in preschool children with acute wheezing episodes [6, 7••]. However, repetitive courses of OCS, such as in children with recurrent respiratory tract infections (RTIs) during the viral seasons, may result in cumulative doses that can be associated with significant side effects [8–10]. Patients often spontaneously escalate their asthma medications (both relievers and controllers) with worsening symptoms [11••]. Even though only 29 % of patients in a study stated they were instructed to step up their maintenance therapy with worsening asthma, 52 % acknowledged doing it anyway. The risk of a “false” start, or initiating YZ treatment when not needed, should be balanced with the risk of a “late” start, resulting in downstream morbidity. The majority of caretakers of asthmatic children (90 %) attending a general pediatric clinic provided with written AAPs acknowledged it to be of value in managing exacerbations [12•]. Criteria for Recognition of Yellow Zone A number of criteria have been proposed to identify the YZ. These include one or more of the following: an increase in asthma symptoms (two or more times per day) greater than baseline [13, 14], asthma symptoms that do not improve or recur (within 4 h or less) after treatment with an inhaled SABA [2, 14, 15••], increase in nocturnal symptoms [16], and peak flow decline of 15 % or more or at 12 puffs per day in older children and adults and >8 puffs per day in younger children has been used in clinical trials to define a RZ exacerbation; we therefore recommend adopting that ceiling in the yellow zone [4••].
Page 3 of 8, 475
Doubling the Dose of Inhaled Corticosteroids Previous versions of the NAEPP guidelines 1997 [23] advocated the practice of doubling ICS dose at the commencement of worsening symptoms since earlier studies had found these interventions helpful. Improvement in symptom scores and parental preference for increased ICS were noted in two pediatric studies [26, 27], with another showing a significant impact on OCS use and hospitalization with increasing doses of ICS [28]. Reconciliation of the widespread adoption of the practice of doubling ICS doses in the YZ with results of several recent RCTs failing to demonstrate the effectiveness of this strategy [29, 2] has led to skepticism regarding the study design. A major criticism relates to the variation in timing of the increase in ICS dosing used in the studies with the definition of the onset of an exacerbation ranging from as late as 2–3 days [14] after peak expiratory flow (PEF) decline from baseline. As noted in observations of the chronology of an exacerbation, this reference point may be already too late. Future studies should consider dose augmentation at first symptom or immediately following exposure to a known trigger. Phenotypic differences and variations in response based on the triggers may also be contributory factors that merit further evaluation. Additionally, all the studies were conducted on subjects already on controller ICS; none were performed on steroid-naïve or intermittent asthmatics, and thus, the response in this group is not known. Based on our experience with successfully managing children with asthma, coupled with feedback from our patients [12•], we believe that there is justification in prescribing doubling doses of ICS during a YZ episode, particularly in those who are timely in steppingup care and in whom this strategy has been previously effective.
Quadrupling the Dose of Inhaled Corticosteroids The EPR3 mentions the possibility that prompt administration of quadrupling doses of ICS for 7 days may prevent exacerbations [2] referencing the study by Foresi et al. [30••] randomizing patients with asthma on budesonide to the following groups: group 1: 400 μg twice daily (bid)+placebo; group 2: 100 μg bid+200 μg four times daily (qid); and group 3: 100 mg bid+placebo. The primary outcome was an asthma exacerbation defined by a fall in peak expiratory flow 24 h) and worse severity (FEV1
