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Department of Medicine

Acute Care

Practice Guidelines

 

PRACTICE GUIDELINES

 

    ADULT_EYE

    ALTERED_MENTAL   

    ANTIBIOTICS

    ANTIEMETICS

    ASTHMA

    ASTHMA_MAMC

    BRONCHODILATOR

    CANCER_PAIN

    CARDIAC_VALVULAR

    CARPAL_TUNNEL

    CATARACT

    CHOLESTEROL_DRUGS_MAMC

    CHRONIC_PAIN

    COMPLEX_REGIONAL

    CONGESTIVE_HEART

    CONJUNCTIVITIS

    CONSTIPATION

    COPD_MAMC

    DEPRESSION_MAMC

    DIABETES_MELLITUS

    DIABETIC_FOOT

    DYSPEPSIA

    ELDERS_WITH_GENETIC

    FIBROMYALGIA

    GASTROESOPHAGEAL_REFLUX_MAMC

    H_PYLORI_MAMC

    HYPERTENSION

    HYPERTENSION_MAMC

    IMMUNIZATION

    KNEE_MAMC

    LOW_BACK_PAIN_MAMC

    LOW_VISION

    METFORMIN_MAMC

    MUSCULOSKELETAL_CONDITIONS

    MYOCARDIAL_ISC

    NONSTEROIDALS_MAMC

    OCCULT_BLOOD

    OSTEOARTHRITIS_OF_THE_KNEE

    OSTEOPOROSIS

    OSTEOPOROSIS_MAMC

    PEPTIC_ULCER

    PHARYNGITIS

    PLANTAR_FASCIITIS_MAMC

    PROSTATIC_CANCER

    RHEUMATOID_ARTHRITIS

    RHINITIS

    RHINITIS_MAMC

    SINUSITIS

    STREPTOCOCCAL_PHARYNGITIS

    SUBSTANCE_ABUSE

    SYNCOPE

    THYROID_DISEASE_HYPER_HYPO

    VISION_EVALUATION

 

 

 

 

ADULT_EYE

{1} ADULT EYE EVALUATION - 22 Feb 2000 (PRIVATE) 334 Lines

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------------------------------------------------------------------------

 

Brief Summary

 

TITLE:

Comprehensive adult eye evaluation.

 

SOURCE(S):

San Francisco (CA): AAO; 1996. 13 p [30 references]

 

ADAPTATION:

Not applicable: The guideline was not adapted from another

source.

 

RELEASE DATE:

1996 Sep

 

MAJOR RECOMMENDATIONS:

Evaluation Process

 

A comprehensive eye evaluation includes history,

examination,

diagnosis and initiation of management. Included within

each are

a series of items particularly relevant to the detection,

diagnosis and choice of appropriate therapy for ocular,

visual

and systemic disease. The items listed are basic areas of

evaluation or investigation and are not meant to exclude

additional elements when appropriate. For example, because

history taking is an interactive process, additional

questions

and evaluation may be suggested by the patient's responses.

 

History

 

In general, a thorough history includes the following

items,

although the exact composition varies with the patient's

particular problems and needs.

 

* Demographic data: includes name, date of birth, gender

and

race.

* The identity of the patient's other pertinent health care

 

providers.

* Chief complaint and history of present illness (including

a

review of systems relevant to eye conditions).

* Present status of visual function: includes a review of

the

patient's assessment of his/her visual status, visual

needs,

any recent or current ocular symptoms, and use of

eyeglasses

or contact lenses (type, wearing habits).

* Past history (ocular): prior eye disease (e.g.,

amblyopia),

injuries, diagnoses, surgery or other treatments and

medications.

* Past history (systemic): allergies or adverse reactions

to

medications, medication use, pertinent medical conditions

and previous surgery.

* Family history: poor vision (and cause, if known) and

other

pertinent familial ocular and systemic disease.

* Medications: ophthalmic and systemic medications

currently

used.

* Social history: occupation, smoking history, alcohol use,

 

for example.

 

Examination

 

The comprehensive examination consists of an evaluation of

the

physiologic function and the anatomic status of the eye,

visual

system and its related structures. In general, this will

include,

but not necessarily be limited to, the following elements:

 

* Visual acuity with present correction (the power of the

present correction recorded) at distance and at near.

* Measurement of best corrected visual acuity (with

refraction

when indicated).

* Ocular alignment and motility.

* Pupillary function.

* Intraocular pressure measurement.

* Visual fields by confrontation when indicated.

* External examination: lids, lashes and lacrimal

apparatus,

orbit and pertinent facial features.

* Slit-lamp examination: eyelid margins and lashes, tear

film,

conjunctiva, sclera, cornea, anterior chamber and

assessment

of peripheral anterior chamber depth, iris, lens and

anterior vitreous.

* Examination of the fundus: vitreous, retina (including

posterior pole and periphery), vasculature and optic nerve.

 

Examination of anterior segment structures routinely

involves

gross and biomicroscopic evaluation prior to and after

dilation.

Evaluation of structures situated posterior to the iris may

 

require a dilated pupil. Optimal examination of the

peripheral

retina requires the use of an indirect ophthalmoscope and

sometimes a Goldmann three-mirror lens.

 

Based on the patient's history and findings, additional

tests or

evaluations might be indicated to evaluate further a

particular

structure or function. Components that are not routinely

part of

the comprehensive eye evaluation include:

 

* Gonioscopy

* Visual fields by perimetry

* Color-vision testing

* Microbiology and cytology

* Amsler grid

* Functional evaluation of the lacrimal system

* Fluorescein angiography

* Radiologic testing

* Electrophysiological testing

* Stereophotography and/or analysis of the optic disc

 

Diagnosis and Management

 

The ophthalmologist evaluates and integrates the findings

of the

comprehensive ophthalmologic examination with all aspects

of the

patient's health status and social situation in determining

an

appropriate course of action. The evaluation results may be

 

considered in one of three general categories: patients

with no

risk factors, patients with risk factors and patients with

conditions requiring intervention.

 

Category I: Patients With No Risk Factors

 

When the comprehensive evaluation is normal or involves

only

optical abnormalities requiring spectacle correction, the

ophthalmologist reviews the findings with the patient and

advises

him/her of the appropriate interval for re-examination.

Although

this group of patients is considered low risk, periodic

examination is indicated to detect asymptomatic or

unrecognized

ocular disease, the incidence of which increases with age.

All

patients are advised to return promptly if ocular symptoms

or

related problems develop.

 

Interim Evaluation

Appropriate interim evaluations, such as screenings,

refractions

or less extensive evaluations, are indicated when

addressing

episodic problems and complaints (such as vision changes or

 

ocular irritation) and for refraction or patient

reassurance. The

extent of the interim evaluation will be determined by the

patient's condition and complaints and by the

ophthalmologist's

medical judgment.

 

Comprehensive Eye Evaluation

There is no evidence in the literature regarding the

optimal

frequency of examination of patients with no eye symptoms

or

signs. However, the clinical rationale for examining these

patients at the recommended intervals is as follows. The

most

prevalent eye conditions that may be asymptomatic are

glaucoma,

diabetic retinopathy and age-related macular degeneration.

These

conditions increase in incidence with age, particularly in

elderly patients. Periodic evaluations provide an

opportunity to

detect disease at an early stage. At the time of each

comprehensive eye evaluation, the ophthalmologist will

reassess

the patient to determine the appropriate follow-up

interval.

 

After an initial comprehensive eye evaluation, in the

absence of

symptoms or other indications, patients should generally be

 

scheduled for a comprehensive examination within the period

 

indicated in Table 2, which takes into account the

relationship

between age and the risk of asymptomatic or undiagnosed

disease.

 

Table 2

 

Comprehensive Eye Evaluations for Patients With No Risk

Factors

 

--------------------------------------------------------------------

 

Age Frequency of Evaluation

 

65 or older Every 1-2 years

 

40-64 Every 2-4 years

 

20-39 At least once during period

 

NOTE: interim eye evaluations may be performed during these

periods

as well.

 

Category II: Patients With Risk Factors

 

A patient is considered to be at risk when the evaluation

reveals

signs that are suggestive of a potentially abnormal

condition or

when risk factors for developing ocular disease are

identified,

but the patient does not yet require intervention. These

situations require closer follow-up to monitor the

patient's

ocular health and to detect early signs of disease.

 

The ophthalmologist determines an appropriate follow-up

interval

for each patient based on the signs and/or the risk

factors, the

incidence of disease and rapidity of progression. For

example,

the earlier onset, higher incidence and more rapid

progression of

glaucoma in individuals of African descent require frequent

 

examinations. Patients with conditions and risk factors

listed in

Table 3 would benefit from a comprehensive eye evaluation

at the

suggested intervals.

 

Table 3

 

Comprehensive Eye Evaluations for Patients With Risk

Factors

 

--------------------------------------------------------------------

 

Condition/Risk Factor Frequency of Evaluation

 

Diabetes without retinopathy

 

Onset after age 30 Once a year

 

Onset before age 30 5 years after onset and yearly

thereafter

 

Pregnancy Prior to conception or early in

the first trimester; every 3

months thereafter

 

Risk factors for glaucoma (individuals of African descent,

family

history of glaucoma)

 

Age 65 or older Every 1-2 years

 

Age 40 - 64 Every 2-4 years

 

Age 20 - 39 Every 3-5 years

 

Category III: Conditions Requiring Intervention

 

The response of the ophthalmologist depends on the nature

of the

abnormal findings. For a patient with ophthalmic

abnormalities,

the ophthalmologist prescribes glasses, contact lenses or

other

optical devices; treats with medications; arranges for

additional

evaluation and testing, and follow-up as appropriate; and

performs nonsurgical procedures or surgical procedures

including

laser surgery when indicated. For a patient with

nonophthalmic

abnormalities, the ophthalmologist will arrange for further

 

evaluation and/or referral, as appropriate.

 

The ophthalmologist must discuss with the patient the

importance

of the findings and the need for further evaluation,

testing

and/or treatment. He/she should share the findings with the

 

patient's primary care physician or other specialist when

appropriate.

 

The vast majority of patients with abnormal signs and

symptoms

can be diagnosed and treatment can be initiated after a

comprehensive ophthalmologic evaluation. Additional details

of

that evaluation and recommendations for appropriate

treatment and

follow-up will necessarily vary with the abnormalities and

diseases identified.

 

Provider

A comprehensive eye evaluation is best performed by an

ophthalmologist, a doctor of medicine or osteopathy trained

to

distinguish normal from abnormal states accurately and

efficiently. An ophthalmologist has a thorough

understanding of

pathology and disease processes, systemic disorders with

ocular

manifestations, as well as skills and experience in medical

 

decision making. The ophthalmologist's knowledge of medical

and

surgical management options allows him/her to provide

patients

with the most complete information about conditions and

prognoses. While it is the ophthalmologist's responsibility

to

perform the comprehensive eye evaluation, certain aspects

of data

collection may be conducted by trained individuals under

the

supervision of an ophthalmologist.

 

CLINICAL ALGORITHM(S):

None provided

 

DEVELOPER(S):

American Academy of Ophthalmology - Medical Specialty

Society

 

COMMITTEE:

Preferred Practice Patterns Committee

 

GROUP COMPOSITION:

 

Names of Committee Members: Arlo C. Terry, MD, Chair; J.

Bronwyn

Bateman, MD, Joseph Caprioli, MD, Sid Mandelbaum, MD, Alice

Y.

Matoba, MD, Stephen A. Obstbaum, MD, Oliver D. Schein, MD,

Charles P. Wilkinson, MD.

 

ENDORSER(S):

Not stated

 

GUIDELINE STATUS:

 

This is the current release of the guideline.

 

This document is valid for 5 years from the "approved by"

date

unless superseded by an earlier version. All Preferred

Practice

Patterns are reviewed by their parent panel annually or

earlier

if developments warrant.

 

GUIDELINE AVAILABILITY:

Print and CD-ROM copies: Available from the American

Academy of

Ophthalmology (AAO), P.O. Box 7424, San Francisco, CA

94120-7424.

 

COMPANION DOCUMENTS:

None available

 

PATIENT RESOURCES:

Not stated

 

NGC STATUS:

This summary was completed by ECRI on June 30, 1998. The

information was verified by the guideline developer on

December

1, 1998.

 

COPYRIGHT STATEMENT:

This NGC summary is based on the original guideline, which

is

subject to the guideline developer's copyright

restrictions.

Information about the content, ordering, and copyright

permissions can be obtained by calling the American Academy

of

Ophthalmology at (415) 561-8500.

 

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Date Modified: Thursday, June 03, 1999

 

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{60} ALL PRACTICE GUIDELINES - 22 Feb 2000 (PRIVATE) 107

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PRACTICE GUIDELINES FOR MIKE MARSHALL

 

Mike: The following 57 Practice Guidelines should cover ANY

reason for forward

Telephone Consults to the Patient's Own Assigned Provider!

They are all in you IN Box in CHCS Mailman. They involved 4

hours of work on

the WWW and CHCS, so give them a good try!

I can automate some of this for you from your DESKTOP if

you would like!

SWS

 

925 Subj: ADULT EYE EVALUATION (22 Feb 2000)

Tue, 22 Feb 2000 09:31:35 334 Lines

926 Subj: ALTERED MENTAL (22 Feb 2000) Tue, 22 Feb 2000

09:31:40 442 Lines

927 Subj: ANTIBIOTICS (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:31:46 336

Lines

928 Subj: ANTIEMETICS (22 Feb 2000) Tue, 22 Feb 2000

09:31:51 481 Lines

929 Subj: ASTHMA (22 Feb 2000) Tue, 22 Feb 2000 09:31:57

1411 Lines

930 Subj: ASTHMA (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:32:04 202 Lines

931 Subj: BRONCHODILATOR (22 Feb 2000) Tue, 22 Feb 2000

09:32:11 385 Lines

932 Subj: CANCER PAIN (22 Feb 2000) Tue, 22 Feb 2000

09:32:15 569 Lines

933 Subj: CARDIAC VALVULAR DISEASE (22 Feb 2000)

Tue, 22 Feb 2000 09:32:22 1162 Lines

934 Subj: CARPAL TUNNEL (22 Feb 2000) Tue, 22 Feb 2000

09:32:26 328 Lines

935 Subj: CATARACT (22 Feb 2000) Tue, 22 Feb 2000 09:32:30

377 Lines

936 Subj: CHOLESTEROL DRUGS (MAMC) (22 Feb 2000)

Tue, 22 Feb 2000 09:32:33 338 Lines

937 Subj: CHRONIC PAIN (22 Feb 2000) Tue, 22 Feb 2000

09:32:38 561 Lines

938 Subj: COMPLEX REGIONAL PAIN (22 Feb 2000)

Tue, 22 Feb 2000 09:32:43 294 Lines

939 Subj: CONGESTIVE HEART FAILURE (22 Feb 2000)

Tue, 22 Feb 2000 09:32:48 567 Lines

 

940 Subj: CONJUNCTIVITIS (22 Feb 2000) Tue, 22 Feb 2000

09:32:53 460 Lines

941 Subj: CONSTIPATION (22 Feb 2000) Tue, 22 Feb 2000

09:32:59 208 Lines

942 Subj: COPD (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:33:05 65 Lines

943 Subj: DEPRESSION (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:33:09 151 Lines

944 Subj: DIABETES MELLITUS (22 Feb 2000) Tue, 22 Feb 2000

09:33:13 204 Lines

945 Subj: DIABETIC FOOT CARE (22 Feb 2000) Tue, 22 Feb 2000

09:33:17 217

Lines

946 Subj: DYSPEPSIA (22 Feb 2000) Tue, 22 Feb 2000 09:33:21

165 Lines

947 Subj: ELDERS WITH GENETIC CONDITIONS (22 Feb 2000)

Tue, 22 Feb 2000 09:33:31 272 Lines

948 Subj: FIBROMYALGIA (22 Feb 2000) Tue, 22 Feb 2000

09:33:33 256 Lines

949 Subj: GASTROESOPHAGEAL REFLUX (MAMC) (22 Feb 2000)

Tue, 22 Feb 2000 09:33:36 189 Lines

950 Subj: H PYLORI (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:33:40 60 Lines

951 Subj: HYPERTENSION (22 Feb 2000) Tue, 22 Feb 2000

09:33:44 644 Lines

952 Subj: HYPERTENSION (MAMC) (22 Feb 2000)

Tue, 22 Feb 2000 09:33:47 222 Lines

953 Subj: IMMUNIZATION (22 Feb 2000) Tue, 22 Feb 2000

09:33:51 256 Lines

954 Subj: KNEE (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:33:56 103 Lines

955 Subj: LOW BACK PAIN (MAMC) (22 Feb 2000)

Tue, 22 Feb 2000 09:34:01 124 Lines

 

956 Subj: LOW VISION (22 Feb 2000) Tue, 22 Feb 2000

09:34:04 176 Lines

957 Subj: METFORMIN (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:34:08 96 Lines

958 Subj: MUSCULOSKELETAL CONDITIONS (22 Feb 2000)

Tue, 22 Feb 2000 09:34:13 375 Lines

959 Subj: MYOCARDIAL ISCHEMIA (22 Feb 2000)

Tue, 22 Feb 2000 09:34:17 224 Lines

960 Subj: NONSTEROIDALS (MAMC) (22 Feb 2000)

Tue, 22 Feb 2000 09:34:19 105 Lines

961 Subj: OCCULT BLOOD IN THE STOOL (22 Feb 2000)

Tue, 22 Feb 2000 09:34:24 178 Lines

962 Subj: OSTEOARTHRITIS OF THE KNEE (22 Feb 2000)

Tue, 22 Feb 2000 09:34:28 158 Lines

963 Subj: OSTEOPOROSIS (22 Feb 2000) Tue, 22 Feb 2000

09:34:31 246 Lines

964 Subj: OSTEOPOROSIS (MAMC) (22 Feb 2000) Tue, 22 Feb

2000 09:34:36 84

Lines

965 Subj: PEPTIC ULCER (22 Feb 2000) Tue, 22 Feb 2000

09:34:40 128 Lines

966 Subj: PHARYNGITIS (22 Feb 2000) Tue, 22 Feb 2000

09:34:45 157 Lines

967 Subj: PLANTAR FASCIITIS (MAMC) (22 Feb 2000)

Tue, 22 Feb 2000 09:34:49 253 Lines

968 Subj: PROSTATIC CANCER (22 Feb 2000) Tue, 22 Feb 2000

09:34:52 218 Lines

969 Subj: RHEUMATOID ARTHRITIS (22 Feb 2000)

Tue, 22 Feb 2000 09:35:01 450 Lines

 

970 Subj: RHINITIS (22 Feb 2000) Tue, 22 Feb 2000 09:35:05

394 Lines

971 Subj: RHINITIS (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:35:08 71 Lines

972 Subj: SINUSITIS (22 Feb 2000) Tue, 22 Feb 2000 09:35:13

120 Lines

973 Subj: SINUSITIS (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:35:16 334 Lines

974 Subj: SSRI (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:35:19 96 Lines

975 Subj: STREPTOCOCCAL PHARYNGITIS (22 Feb 2000)

Tue, 22 Feb 2000 09:35:23 350 Lines

976 Subj: SUBSTANCE ABUSE (22 Feb 2000) Tue, 22 Feb 2000

09:35:26 191 Lines

977 Subj: SYNCOPE (22 Feb 2000) Tue, 22 Feb 2000 09:35:31

159 Lines

978 Subj: THYROID DISEASE (HYPER/HYPO) (22 Feb 2000)

Tue, 22 Feb 2000 09:35:35 420 Lines

979 Subj: URINARY INCONTINENCE (22 Feb 2000)

Tue, 22 Feb 2000 09:35:39 621 Lines

980 Subj: VENOUS THROMBOEMBOLISM (22 Feb 2000)

Tue, 22 Feb 2000 09:35:43 172 Lines

981 Subj: VIAGRA (MAMC) (22 Feb 2000) Tue, 22 Feb 2000

09:35:46 76 Lines

982 Subj: VISION EVALUATION (22 Feb 2000) Tue, 22 Feb 2000

09:35:50 215 Lines

 

GOOD LUCK, MIKE, AND LET ME KNOW WHAT I CAN DO TO MAKE THIS

EASIER.

I BELIEVE THAT YOU SHOULD DISCONTINUE REFILLS COMPLETELY AS

TOO DANGEROUS FOR

THE SWEATSHOP TO DO THOROUGHLY.

 

SWS

 

[PAGE]

 

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ALTERED_MENTAL

 

{2} ALTERED MENTAL - 22 Feb 2000 (PRIVATE) 442 Lines

----------------------------------------------------------------------------

 

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Guideline

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Organization

 

Options: Brief Summary Complete Summary

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Guideline

Collection

 

------------------------------------------------------------------------

 

Brief Summary

 

TITLE:

Altered mental states.

 

SOURCE(S):

Columbia (MD): The American Medical Directors Association

(AMDA);

1998. 20 [17 references]

 

ADAPTATION:

Not applicable: Guideline was not adapted from another

source.

 

RELEASE DATE:

1998

 

MAJOR RECOMMENDATIONS:

 

The steps involved in addressing altered mental states were

 

summarized by NGC:

 

I. Recognition

 

Step 1

1. Determine if the individual has a history of altered

mental states (AMS)

* Review the individual's physical, functional,

cognitive, and behavioral history. Document

pertinent information (onset, duration, frequency,

course, causes or precipitating factors,

aggravating/ameliorating factors) about any recent

alterations in mental state to help understand and

clarify the current situation. Relevant history

might include confusion, disorientation,

hallucinations, delusions, suspiciousness or

paranoia. These symptoms may be constant or

periodic, and stable or fluctuating. Changes in

nutritional status, eating habits, and physical

function may help identify causes or complications

of impaired mood or cognition.

* For new admissions or re-admissions, review

available transfer information -including any

recent hospital discharge summaries - and other

referral data-and the patient's medical, surgical,

family, and social history. Also look for related

diagnoses in the physician's admission history and

physical or a pertinent consultation report. Check

current orders for treatments and medications that

address behavioral, cognitive, or mood impairments

(e.g., anti-depressants, antipsychotics, etc.).

Seek information about the baseline mental status

and prior diagnostic work-up and management.

 

Step 2

1. Assess the current signs and symptoms of AMS

* Assess the patient's current physical functional

or psychosocial status

2. Document the AMS or disturbed behaviors

* Assessment categories should include level of

consciousness, cognition, mood, behavior, and

general function. Use objective and valid measures

and well-defined terms to describe and measure

mental status and behaviors.

* Record the results of any assessments in the

appropriate location in the medical record

* Quality rather than quantity of documentation is

important. Recording information that assists in

recognizing and managing problems should be

emphasized.

 

Step 3

1. Determine if the patient is at high risk for developing

AMS

* The physician, nursing and social services staff

should collaborate to identify risks and formulate

a plan to anticipate, monitor, and evaluate

occurrence or progression (e.g., examine lungs and

obtain a urinalysis if the patient becomes

confused and febrile).

* Significant alterations in mental state or

behavior may require urgent physician input.

Examples of such situations are given in the

guideline document.

II. Diagnosis

* Diagnostic efforts should focus on correctly

identifying the causes of AMS

* Examples of conditions or situations that may affect

mental status include

o Medications/non-compliance with regimen

o Fluid or electrolyte imbalance

o Infections

o Hypo- or hyperglycemia

o Recent hospitalization

o Recent surgery under general anesthesia

o Recent change in living situation or environment

o Recent fall or other trauma

o Significant pain

o Alcohol or drug abuse

o Hypo- or hyperthyroidism

o Nutritional deficiency

o Recent stroke or seizure

o Primary metastatic brain tumors or other

malignancies

o Cardiac arrhythmia/myocardial infarction

* Always review the patient's medications, as these are a

common source of AMS

 

Step 4

1. Define the duration and course of symptoms

* Define the course (progression, fluctuation, and

times of occurrence) and duration (length of time

present) of symptoms

 

Step 5

1. Determine if a medical work-up is medically necessary,

useful, and appropriate

* The physician must decide if a work-up could be

medically useful (i.e., whether testing and

examination may better define the patient's

current status or the correct cause of his or her

problems) and if such information might help guide

management. The physician then should consult with

the patient (if possible), the patient's surrogate

or family, and appropriate staff to determine if a

work-up is appropriate, i.e., whether the

potential benefits of any interventions determined

by the work-up results outweigh any risks or

expense cause by the work-up itself. A work-up may

not be indicated if an individual has a terminal

or end-stage condition, if the results of the

work-up would not change the management of course,

if the individual would refuse treatment, in case

of advance directives requesting such

restrictions, or if the burden or risk of a

work-up is greater than the benefit of the

treatment.

* An appropriate work-up for AMS may include a

history (usually obtained indirectly from the

family, staff, and the medical record), physical

examination (including a mental status

examination), and pertinent diagnostic tests

* Possible diagnostic tests to assess causes of AMS

o Electrolytes, BUN, glucose, creatinine, serum

osmolality/urine sodium (to identify fluid/

electrolyte imbalance)

o Urinalysis and/or urine culture (if urinary

tract infection is suspected)

o TSH/free T4 (to identify possible thyroid

dysfunction)

o Complete blood count (CBC) (if infection,

inflammatory processes, bleeding, or anemia

are suspected)

o Chest x-ray/Oxygen saturation (if pneumonia

or pulmonary embolism are suspected)

o EKG/rhythm strip (if a cardiac arrhythmia or

other heart dysfunction is suspected)

o Albumin (if undernutrition is suspected)

o Serum drug levels, when appropriate

* Whenever possible, this work-up should take place

in the facility. Hospitalization should be

avoided, since it in itself is a risk factor for

delirium in the elderly

* As part of any work-up, review the patient's

medication regimen and determine whether or not it

recently has been changed. Even if the regimen has

been stable and has not caused adverse reactions

in the past, it may contribute to or cause

symptoms of newly developed conditions.

 

Step 6

1. Determine if delirium is present

* Delirium is a state of acute confusion,

inattention, and altered level of consciousness

(LOC), usually abrupt in onset (over several hours

to several days).

* Typical symptoms of delirium may include anxiety,

disorientation, tremors, hallucinations,

delusions, and incoherence. In patients with

dementia, delirium may present as a subtle shift

or a marked decline in the usual level of activity

or responsiveness. Delirium is commonly related to

acute illnesses, heart or lung disease,

infections, poor nutrition, endocrine disorders,

medications (including over-the-counter and

prescription medications) or alcohol use.

* Some iatrogenic risk factors associated with

delirium include:

o Medications, especially neuroleptics and

sedatives/hypnotics

o Surgery under general anesthesia

o Presence of an indwelling urinary catheter

o Use of physical restraints

* If delirium is identified or suspected (regardless

of whether the Delirium Resident Assessment

Protocol (RAP) is triggered), a physician should

be involved as soon as possible so that medical

causes may be identified and managed promptly.

 

Step 7

1. Identify the presence of depression

* Signs and symptoms of depression

o Depressed mood most of the day, almost every

day

o Irritable mood

o Diminished interest/pleasure in most

activities, most of the time

o Weight loss accompanied by poor appetite

o Insomnia/hypersomnia nearly every day

o Psychomotor agitation/retardation

o Fatigue or loss of energy, worse than

baseline

o Feelings of worthlessness, hopelessness, or

helplessness

o Guilt

o Change in ability to think or concentrate

o Recurrent thoughts of death or suicide

o Social isolation

 

Step 8

1. Identify other causes of AMS

* Other common medical/neurological causes of AMS

o Hyper- or hypothyroidism

o Nutritional deficiencies (Vitamin B12 folate,

thiamine, iron, and protein-calorie

malnutrition)

o Multiple small strokes (vascular dementia)

o Central neurodegenerative disorders

(Alzheimer's Disease, Parkinson's Disease,

etc.)

III. Treatment

 

Step 9

1. Determine if interventions are useful and appropriate

* It is important to review any advance directive or

other specific written or verbal instructions from

patient or surrogate. Useful, appropriate

treatment should address the underlying medical

problem and improve or stabilize the patient's

functioning and quality of life, consistent with

his or her wishes and values

 

Step 10

1. Generate an interdisciplinary care plan

* The care plan should address risk assessment and

prevention, cause identification and treatment,

management of the underlying causes, areas for

staff support, patient and family education,

prevention and handling of existing complicating

conditions, changes in other components of the

existing treatment regimen, monitoring, and other

aspects of the patient's care. Team work and

communication are important.

* Changes in the current care plan should be based

on skilled assessment and identification of

supporting evidence.

 

Step 11

1. Initiate the appropriate interventions

* It is essential to weigh the potential effects of

the treatment, including the relative burdens and

benefits, on the patient. It also is important to

document reasons for not treating an identified

cause of AMS

* If a patient is already taking psychoactive

medications, this should always be considered as a

possible cause of AMS and reduced or discontinued

when possible.

* Specific considerations in treatment should

include functional and social impact, ethical

issues, and indirect complications.

* Impact on personal and social functioning should

be evaluated. A patient with AMS may require

additional Activities of Daily Living support.

* Identify and address ethical issues relevant to

the individual with AMS and disturbed behavior.

These include defining decision making capacity,

identifying situation that require informal and

formal direct or substitute decision making, and

defining possible limitations on medical

interventions such as artificial nutrition or

hydration, or cardiopulmonary resuscitation (CPR)

* Decisions about the scope and nature of any

interventions should arise from appropriate

discussions with the patient or family members, as

appropriate, and documented adequately in the

medical record. Such decisions may need to be

modified if the patient's decision-making capacity

improves after treating a cause of AMS.

* Prevent and manage complications and problems

associated with AMS such as impaired mobility and

urinary incontinence.

* Prevent and manage indirect consequences of AMS

such as aspiration pneumonia in a tube-fed

patient, decreased food intake in patients whose

alertness and cognition have been affected by

antihypertensive medications, or falls in patients

with poor balance who are taking psychoactive and

cardiac medications.

 

Step 12

1. Educate patients, families and staff regarding the

conditions and proposed treatments

* The physician and other members of the

interdisciplinary team should present families and

staff with a clear picture of the patient's

situation. This information should be updated as

new findings or condition changes develop.

IV. Monitoring

 

Step 13

1. Monitor and adjust treatment as indicated

* Document the patient's course carefully, and

relate symptoms to various causes and

interventions.

* Documentation should be frequent enough to track

the patient's progress and should help communicate

critical information to other members of the

interdisciplinary team.

 

Step 14

1. Is the individual stable or improving?

* Examples of situations when current diagnosis and

treatment should be reconsidered:

o Persistent reduced or widely fluctuating

level of consciousness

o Progressive decline in function or worsening

of behavior

o Failure to return to baseline function or

behavior

o Significant physical or functional

consequences

o Flare-ups of other chronic conditions or

acute illnesses

* If the patient is stable or improving, continue

appropriate management. The physician should

periodically reevaluate and discuss the patient's

condition and risk factors with the nursing staff.

* If the patient declines or remains stable but does

not return to his or her previous baseline, it may

be important to reconsider the diagnosis or

management plan.

 

CLINICAL ALGORITHM(S):

A clinical algorithm is provided that summarizes the steps

involved in addressing altered mental states, including

recognition, diagnosis, management, and monitoring the

condition.

 

DEVELOPER(S):

American Health Care Association - Professional Association

 

American Medical Directors Association (AMDA) -

Professional

Association

 

COMMITTEE:

Steering Committee

 

GROUP COMPOSITION:

Members: Sarah Greene Burger; Thomas J. Cali, PharmD; Laura

Fain,

RN; Janet George, RN; Janet M. Harrington, MSN; Carolyn

Harris,

RN; Keith Knapp; Steven Levenson, MD, CMD; Geri Mendelson,

RN,

M.Ed., MA; Reg Warren, PhD; Christine Williams, M.Ed.

 

ENDORSER(S):

Not stated

 

GUIDELINE STATUS:

This is the current release of the guideline.

 

An update is not in progress at this time. Planned revision

 

cycles will occur every three years.

 

GUIDELINE AVAILABILITY:

Print copies: Available from the American Medical Directors

 

Association, 10480 Little Patuxent Pkwy, Suite 760,

Columbia, MD

21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax

(410)

740-4572. Web site: http://www.amda.com/

 

COMPANION DOCUMENTS:

The following companion documents are available:

 

* Guideline implementation: clinical practice guidelines.

Columbia, MD: American Medical Directors Association, 1998,

 

28 p.

* Dementia. Columbia, MD: American Medical Directors

Association; 1998. 32 p.

 

Print copies: Available from the American Medical Directors

 

Association, 10480 Little Patuxent Pkwy, Suite 760,

Columbia, MD

21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax

(410)

740-4572. Web site: www.amda.com.

 

The guideline developers recommend that the guideline

should be

used in conjunction with the "Nursing Facility Minimum Data

Set

and Resident Assessment Instrument" (MDS/RAI), as well as

with

appropriate "Resident Assessment Protocols" (RAPs).

 

These tools are available from the U.S. Health Care

Financing

Administration (HCFA), 7500 Security Boulevard, Baltimore,

Maryland 21244; Telephone: (410) 786-3000; Web site:

http://www.hcfa.gov/

 

PATIENT RESOURCES:

Not stated

 

NGC STATUS:

This summary was completed by ECRI on July 12, 1999. The

information was verified by the American Medical Directors

Association as of August 8, 1999.

 

COPYRIGHT STATEMENT:

This NGC summary is based on the original guideline, which

is

copyrighted by the American Medical Directors Association

(AMDA)

and the American Health Care Association. Written

permission from

AMDA must be obtained to duplicate or disseminate

information

from the original guideline. For more information, contact

AMDA

at (410) 740-9743.

 

Return to top

 

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Date Modified: Tuesday, August 24, 1999

 

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ANTIBIOTICS

{41} ANTIBIOTICS (MAMC) - 22 Feb 2000 (PRIVATE) 336 Lines

----------------------------------------------------------------------------

 

Oral Antibiotic Department of Pharmacy

[Mamclogo.gif (11446 bytes)]

Oral Antibiotic Prescribing Guidelines

------------------------------------------------------------------------

 

The following prescribing guidelines have been endorsed by

the Madigan Army

Medical Center Pharmacy and Therapeutics Committee. These

guidelines

serve as an education tool for accepted antibiotics. While

general

prescribing guidelines can be written, not every patient

will fit these

guidelines. When faced with a therapeutic dilemma, the

Infectious Disease

Service provides timely consults. The costs are available

to authorized

parties upon written request.

 

------------------------------------------------------------------------

 

COMMUNITY ACQUIRED PNEUMONIA (Adult)

 

Common Pathogens 1st line 2nd line 3rd line agents

agents agents

 

Typical

Erythromycin

Streptococcus 500mg QID x Azithromycin

pneumoniae 10 days 500mg x 1,

then

Haemophilus ($) (typical

influenza or atypical) 250mg QD x 4

days ($$$)**

Enterobacteriaceae Doxycycline Amoxicillin/Clavulanic

(avoid in Cefpodoxime Acid

Staphyloccus pregnancy) 200mg BID x

aureus 14 days 875mg Q12 hr x 10 days

100mg BID x

Anaerobic bacteria 14 days ($)* ($$$$$)*** ($$$$$)

 

Atypical Amoxicillin Ofloxacin

(typical) 400mg Q 12hr

Mycoplasma x

pneumoniae 500mg TID x

10 days ($) 10 days ($$$)

Legionella

 

* Avoid if Strep pneumoniae suspected - better for atypical

pathogens

 

** Most cost effective second choice for patients who are

erythromycin

failures

 

Only 6 x 250mg tabs dispensed per Rx; unless diagnosis of

Legionella

 

*** Good choice if Strep pneumoniae or H. Influenza is

suspected and

patient is macrolide intolerant

 

STREP PHARYNGITIS

 

Common Pathogens Agent of Choice

 

*Penicillin VK *Erythromycin (if PCN allergic)

 

250 - 500 mg QID x 10 days ($) 250mg QID x 10 days

($)

 

Group A *Peds: <30 lbs 125mg BID-TID *Peds: EES 40mg/kg/day

 

Streptoccocci + TID-QID

 

>30 lbs 250mg BID-TID

 

If patient doesn't respond consider atypical

organism - use erythromycin

 

URETHRITIS/CERVICITIS

 

Common Pathogens 1st line Agents 2nd line Agents

 

*Doxycycline (not in

pregnancy)

 

100mg BID x 7 days ($)

 

*Erythromycin (if

pregnant) *Azithromycin 1gm PO

Chlamydia trachomatis x 1 dose ($$) (use

500mg QID x 7 days ($) sachet for single

or one gram dose)

 

250mg QID x 14 days if

GI

 

intolerance to 500mg

dose ($)

 

Neisseria gonorrhoeae

 

(since a high

percentage of patients *Ceftriaxone 125mg IM x *Ofloxacin

400mg x 1

have coexisting 1 ($) ($)

Chlamydia, all

patients should also *Metronidazole *Cefixime 400mg PO x

be treated for both) 1 ($)

(pregnancy - used after

Trichomoniasis 1st trimester) 2g PO x 1 Metronidazole 500mg

 

($) BID x 7 days ($)

(partners should be

treated)

 

Bacterial vaginosis

 

Gardneralla vaginalis *Metronidazole 500mg BID Clindamycin

300mg PO

x 7 days BID x 7 days ($$)

Mycoplasma hominin

($) (used after the *Clindamycin 2% vag

Basteroides spp crm one appl intr

1st trimester) vag HS x 7 days ($$)

Mobiluncus spp

 

*Clotrimazole 200mg (2 X

100mg)

Vulvovaginal

Candidiasis vag tab HS X 3 days ($)

 

Candida albicans *Fluconazole 150mg PO X *Terconazole 0.4%

1 ($) vag crm one appl. HS

Candida spp X 7 days ($$)

*ONLY 1 tab will be

Torulopsis spp dispensed

 

per RX)

 

SKIN AND SOFT TISSUE (Adults and Pediatrics)

 

1st Line Agents

Common 2nd Line

Pathogens (Cost per Agents 3rd Line Agents

source)

 

*Dicloxacillin

250mg QID x 7

days

 

($)

 

*Peds:

Streptococci 20mg/kg/day +

QID

Staphyloccocci

*Erythromycin *Ofloxacin

250mg QID x 10 400mg Q

days 12hr x 10 *Amoxicillin/Clavulanic

days (for Acid

($) Adults)

($$$) 500mg Q12H x 7 days

*Peds: ($$$)

40mg/kg/day + Clindamycin

TD or QID 20mg/Kg QD *Peds: 45mg/kg/day

* If MRSA call divided TID (Amox)+Q12H

Infectious Cephalexin

Disease 250mg QID/500mg

BID x 7 days

($) mod.

infection:

500mg QID ($)

 

*Peds:

25-50mg/kg/day

+ QID

 

UNCOMPLICATED URINARY TRACT INFECTIONS

(Adults)

 

1st line Agents

Common

Pathogens (Cost per 2nd Agents

source)

 

Escherichia

coli

 

Proteus *TMP/SMZ (avoid *Ofloxacin

in pregnancy) 200mg QD 12

Enterococci x

1DS BID x 3

Straphylococcus days ($) 3 days ($)

 

saprophyticus

 

ACUTE OTITIS MEDIA (Adults and Pediatrics)

 

Common 1st line 2nd Line

Pathogens Agents (Cost Agents 3rd Line Agents

per course)¤

 

Streptococus *Amoxicillin *Azithromycin

*Amoxicillin/Clavulanic

pneumonia 500mg TID x 10 500mg x 1 then 875mg Q12H x 10

days

days ($)

Haemophilus 250mg QD x 4 *Peds: for patients 3

influenza *Peds: days ($$) months& older

60mg/kg/day + 45mg/kg/day (Amox) +

Moraxella BID *Peds: 10mg/kg Q12H

catarrhalis QD day 1, then

*TMP/SMZ 1 DS

Staphlococcus BID x 10 days 5mg/kg QD days

aureus ($) 2-5

 

avoid in *Cefpodoxime

pregnancy 200mg BID x 10

days ($$$)

*Peds:

8-10mg/kg/day *Peds:

(TMP) + BID 10mg/kg/day +

BID or

or 1ml/kg/day

+ BID QD

 

*Pediazole®

(peds only)

 

50mg/kg/day

(EES) + TID or

QID

 

1.25ml/kg/day

+ TID or QID

 

* May use 5 day courses of therapy in children > than 2

years of age who

are not prone to multiple episodes of acute otitis media

 

For patients** who you suspect penicillin resistant

streptococcus

pneumoniae infections use:

 

1. High dose amoxicillin 80mg/Kg per day divided BID

 

2. Ceftriaxone 50mg/Kg IM x 1

 

3. Amoxicillin 40mg/Kg per day plus Augmentin 40mg/Kg per

day

divided BID

 

4. Cefpodoxime 10mg/Kg/Day divided BID or QD

 

** Patients who attend Day Care or Child Care Centers or

those that

don't respond to multiple courses of antibiotics

 

SINUSITIS (Adults) * For Peds see Acute Otitis Media

recommendations.

For chronic Otitis Media in Peds use Clindamycin

20mg/Kg/Day divided TID

 

1st line

Common Agents (Acute) 3rd Line Agents

Pathogens 2nd Agents (Chronic)

(Cost per

course)¤

 

*TMP/SMZ

(avoid in

Streptococus pregnancy) *Azithromycin

pneumonia 500mg x 1, *Clindamycin 300mg TID

1 DS BID x 10 then 250mg QD x 10 days ($$$)

Haemophilus days ($) x 4 days ($$)

influenza *Cefixine 400mg QD x 10

*Amoxicillin *Cefpodoxime days ($$$) - NO staph

Moraxella 500mg TID x 10 200mg BID x10 coverage

catarrhalis days ($) days ($$$$)

*Amoxicillin/Clavulanic

Staphlococcus *Erythromycin Clarithromycin Acid 875mg Q12H

x 10

aureus 500mg QID x 10 500mg Q12h X days ($$$$)

days ($) for 14 days ($$$)

PCN allergy

 

¤Cost of selected oral antibiotic suspensions (prices

subject to change).

 

125mg/5ml 150ml.... $ 0.72

Amoxicillin

250mg/15ml 150ml.... $ 1.25

 

75ml.. 100ml..

200mg/5ml 50ml.... $ 8.07 $10.45 $15.70

Augmentin

400mg/5ml 50ml.... $15.28 75ml.. 100ml..

$19.81 $29.73

 

100mg/5ml 15ml.... $15.42

Azithromycin

200mg/5ml 11.5ml.. $15.42

 

100mg/5ml 50ml.... $18.05

Cefixime

100ml.... $35.53

 

50mg/5ml 100ml.... $13.01

Cefpodoxime

100mg/5ml 100ml.... $26.02

 

100ml.... $ 4.38

Erythomycin/sulfisox

200ml.... $ 5.51

 

TMP/SMZ 100ml.... $ 5.47

 

The following prescribing guidelines have been endorsed by

the Madigan Army

Medical Center Pharmacy and Therapeutics Committee. These

guidelines serve

as an education tool for accepted antibiotics. While

general prescribing

guidelines can be written, not every patient will fit these

guidelines.

When faced with a therapeutic dilemma, the Infectious

Disease Service

provides timely consults. The costs listed are current at

the time of

writing, but are subject to change.

 

Comment: In most cases an alternate first (1st) line

antibiotic should be

used in lieu of a second (2nd) line agent when a first

(1st) line agent has

proven unsuccessful.

 

Last Update - June 1999

 

Cost Key

 

$ = $0 to $10.00

 

$$ = $10.01 - $20.00

 

$$$ = $20.01 - $30.00

 

$$$$ = $30.01 - $40.00

 

$$$$$ = $40.01 and higher

 

Pharmacy Home Page MAMC Home Page

 

------------------------------------------------------------------------

 

Send mail to Pharmacy Pagemaster with questions or comments

about this web

site.

Copyright © 1999

Last modified: January 04, 2000

 

[PAGE]

 

@1323

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{3} ANTIEMETICS - 22 Feb 2000 (PRIVATE) 481 Lines

----------------------------------------------------------------------------

 

National

Guideline

Clearinghouse

 

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Options: Brief Summary Complete Summary Full Text

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------------------------------------------------------------------------

 

Brief Summary

 

TITLE:

Recommendations for the use of antiemetics.

 

SOURCE(S):

J Clin Oncol 1999 Sep;17(9):2971 [277 references]

 

ADAPTATION:

Not applicable: Guideline was not adapted from another

source.

 

RELEASE DATE:

1999 Sep

 

MAJOR RECOMMENDATIONS:

Levels of evidence (I-V) and grades of evidence (A-D, NG)

for

recommendations are defined at the end of the Major

Recommendation field.

 

I. Chemotherapy-Induced Emesis

A. Acute Emesis (vomiting occurring 0 to 24 hours after

chemotherapy)

1. Antiemetic Agents: Highest Therapeutic Index

a. Serotonin Receptor Antagonists

i. Agent equivalence

 

Guideline: At equivalent doses,

serotonin receptor antagonists have

equivalent safety and efficacy and can

be used interchangeably based on

convenience, availability, and cost.

 

Level of Evidence: I

 

Grade of Recommendation: A

 

ii. Drug dosage

 

Guideline: Established, proven doses of

all agents are recommended.

 

Level of Evidence: I

 

Grade of Recommendation: A

 

iii. Drug schedule

 

Guideline: Single doses of antiemetics

are effective and preferred for

convenience and cost.

 

Level of Evidence: I

 

Grade of Recommendation: A

 

iv. Route of administration

 

Guideline: At biologically equivalent

doses, oral agents are equally effective

and are as safe as intravenous

antiemetics. In most settings, oral

agents are less costly and more

convenient; for these reasons, they are

recommended over intravenous therapy.

 

Level of Evidence: I

 

Grade of Recommendation: A

 

b. Corticosteroids

i. Agent equivalence and route of

administration

 

Guideline: At equivalent doses,

corticosteroids have equivalent safety

and efficacy and can be used

interchangeably.

 

Level of Evidence: IV and Expert

Consensus

 

Grade of Recommendation: C

 

ii. Drug dose and schedule

 

Guideline: Single doses of

corticosteroids are recommended.

 

Level of Evidence: II

 

Grade of Recommendation: B

 

2. Antiemetic Agents: Lower Therapeutic Index -

Dopamine Antagonists, Butyrophenones,

Phenothiazines, and Cannabinoids

 

Guideline: For chemotherapy with a high risk of

emesis, selective serotonin antagonists (with

dexamethasone) are recommended.

 

Level of Evidence: I

 

Grade of Recommendation: A

 

3. Antiemetic Agents: Adjunctive Drugs -

Benzodiazepines and Antihistamines

 

Guideline: Benzodiazepines and antihistamines are

useful adjuncts to antiemetic drugs but are not

recommended as single agents.

 

Level of Evidence: II

 

Grade of Recommendation: B

 

4. Antiemetic Agents: Combinations of Antiemetics

 

Guideline: It is recommended that serotonin

antagonists be given with corticosteroids.

 

Level of Evidence: I

 

Grade of Recommendation: A

 

5. Risk Factors for Acute Emesis

a. Patient Characteristics

b. Chemotherapeutic Agents

c. Guidelines

i. (a) High risk: Cisplatin

 

Guideline: The combination of a 5-HT3

antagonist plus a corticosteroid is

recommended before chemotherapy.

 

Level of Evidence: I

 

Grade of Recommendation: A

 

i. (b) High risk: noncisplatin

 

Guideline: The combination of a 5-HT3

antagonist plus a corticosteroid is

recommended before chemotherapy.

 

Level of Evidence: I, II, III, and

Expert Consensus

 

Grade of Recommendation: A-B

 

ii. Intermediate risk

 

Guideline: A corticosteroid is suggested

for patients being treated with agents

of intermediate emetic risk.

 

Level of Evidence: III, IV, and Expert

Consensus

 

Grade of Recommendation: B, D

 

iii. Low risk:

 

Guideline: It is suggested that for

patients being treated with agents of

low emetic risk, no antiemetic be

routinely administered before

chemotherapy.

 

Level of Evidence: V and Expert

Consensus

 

Grade of Recommendation: D

 

iv. Combination chemotherapy

 

Guideline: It is suggested, that when

combination chemotherapy is given, the

patient be given antiemetics appropriate

for the chemotherapeutic agent of

greatest emetic risk.

 

Level of Evidence: IV

 

Grade of Recommendation: D

 

v. Multiple consecutive days of

chemotherapy

 

Guideline: It is suggested that

antiemetics appropriate for the risk

class of the chemotherapy, as outlined

above, be administered for each day of

the chemotherapy.

 

Level of Evidence: II and III

 

Grade of Recommendation: B

 

B. Delayed Emesis (vomiting occurring >24 hours after

chemotherapy)

1. Antiemetic Agents

a. Single Agents

i. Corticosteroids

ii. Metoclopramide and serotonin receptor

antagonists

b. Combinations of Agents

2. Risk Factors for Delayed Emesis

a. Patient Characteristics

b. Chemotherapeutic Agents

c. Guidelines

i. (a) High risk: cisplatin

 

Guideline: For all patients receiving

cisplatin, a corticosteroid plus

metoclopramide or plus a 5-HT3

antagonist is recommended for the

prevention of delayed emesis.

 

Level of Evidence: I

 

Grade of Recommendation: A

 

i. (b) High risk: noncisplatin

 

Guideline: A prophylactic corticosteroid

as a single agent, a prophylactic

corticosteroid plus metoclopramide, and

a prophylactic corticosteroid plus a

5-HT3 antagonist are regimens suggested

for the prevention of delayed emesis.

 

Level of Evidence: III - V

 

Grade of Recommendation: B-D

 

ii. Intermediate- to low-risk

 

Guideline: No regular preventive use of

antiemetics for delayed emesis is

suggested for patients receiving these

chemotherapeutic agents.

 

Level of Evidence: V and Expert

Consensus

 

Grade of Recommendation: D

 

C. Anticipatory Emesis

1. Prevention

 

Guideline: Use of the most active antiemetic

regimens appropriate for the chemotherapy being

given to prevent acute or delayed emesis is

suggested. Such regimens must be used with the

initial chemotherapy, rather than after assessment

of the patient's emetic response to less effective

treatment.

 

Level of Evidence: III

 

Grade of Recommendation: D

 

2. Treatment

 

Guideline: If anticipatory emesis occurs,

behavioral therapy with systematic desensitization

is effective and is suggested.

 

Level of Evidence: III

 

Grade of Recommendation: B

 

D. Special Emetic Problems

1. Emesis in Pediatric Oncology

 

Guideline: The combination of a 5-HT3 antagonist

plus a corticosteroid is suggested before

chemotherapy in children receiving chemotherapy of

high emetic risk.

 

Level of Evidence: III

 

Grade of Recommendation: B

 

2. High-Dose Chemotherapy

 

Guideline: A 5-HT3 antagonist plus a

corticosteroid is suggested.

 

Level of Evidence: II and III

 

Grade of Recommendation: C

 

3. Vomiting and Nausea Despite Optimal Prophylaxis in

Current or Prior Cycles

 

Guideline: It is suggested that clinicians (1)

conduct a careful evaluation of risk, antiemetic,

chemotherapy, tumor, and concurrent disease and

medication factors, (2) ascertain that the best

regimen is being given for the emetic setting, (3)

consider adding an antianxiety agent to the

regimen, and (4) consider substituting a dopamine

receptor antagonist, such as high-dose

metoclopramide, for the 5-HT3 antagonist (or add

the dopamine antagonist to the regimen).

 

Level of Evidence: V and Panel Consensus

 

Grade of Recommendation: D and Panel Consensus

 

II. Radiation-Induced Emesis

A. Risk Factors for Radiation-Induced Emesis

1. Guidelines

a. High Risk: Total Body Irradiation

 

Guideline: A serotonin receptor antagonist

should be given with or without a

corticosteroid before each fraction and for

at least 24 hours after.

 

Level of Evidence: II and III

 

Grade of Recommendation: B and C

 

b. Intermediate Risk: Hemibody Irradiation,

Upper Abdomen, Abdominal-Pelvic, Mantle,

Cranial Radiosurgery, and Craniospinal

Radiotherapy

 

Guideline: A serotonin receptor antagonist or

a dopamine receptor antagonist should be

given before each fraction.

 

Level of Evidence: II and III

 

Grade of Recommendation: B

 

c. Low Risk: Radiation of the Cranium Only,

Breast, Head and Neck, Extremities, Pelvis,

and Thorax

 

Guideline: Treatment should be given on an

as-needed basis only. Dopamine or serotonin

receptor antagonists are advised. Antiemetics

should be continued prophylactically for each

remaining radiation treatment day.

 

Level of Evidence: IV and V

 

Grade of Recommendation: B-D

 

Definitions

 

Type of Evidence for Recommendation

 

Level I: Evidence obtained from meta-analysis of multiple

well-designed controlled studies; randomized trials with

low

false-positive and low false-negative errors (high power)

 

Level II: Evidence obtained from at least one well-designed

 

experimental study; randomized trials with high

false-positive

and/or negative errors (low power)

 

Level III: Evidence obtained from well-designed

quasi-experimental studies, such as nonrandomized

controlled

single-group pre-post, cohort, time or matched case-control

 

series

 

Level IV: Evidence from well-designed nonexperimental

studies,

such as comparative and correlation descriptive and case

studies

 

Level V: Evidence from case reports and clinical examples

 

Grade of Evidence for Recommendation

 

Category A: There is evidence of type I or consistent

findings

from multiple studies of types II, III, or IV

 

Category B: There is evidence of types II, III, or IV and

findings are generally consistent

 

Category C: There is evidence of types II, III, or IV, but

findings are inconsistent

 

Category D: There is little or no systematic empirical

evidence

 

Category NG: Grade not given

 

CLINICAL ALGORITHM(S):

None provided

 

DEVELOPER(S):

American Society of Clinical Oncology (ASCO) - Medical

Specialty

Society

 

COMMITTEE:

ASCO Antiemetic Guideline Expert Panel

 

GROUP COMPOSITION:

The Panel was composed of experts in clinical medicine,

clinical

research, outcomes/health services research, medical

decision-making, and health economics, with a focus on

expertise

in supportive care and in antiemetics. A patient

representative

was also included on the Panel. Clinical experts

represented all

relevant disciplines, including medical oncology, oncology

nursing, radiation oncology, pediatric oncology and

oncologic

pharmacy practice.

 

Members: Richard J. Gralla, MD (Co-chair); David Osoba, MD

(Co-chair); Mark G. Kris, MD; Peter Kirkbride, MD; Paul J.

Hesketh; Lawrence W. Chinnery; Rebecca Clark-Snow, RN, BSN,

OCN;

David P. Gill, MD; Susan Groshen, PhD; Steven Grunberg, MD;

James

M. Koeller, MD; Gary R. Morrow, PhD; Edith A. Perez, MD;

and

Jeffrey H. Silber, MD, PhD; David G. Pfister, MD.

 

ENDORSER(S):

Not stated

 

GUIDELINE STATUS:

This is the current release of the guideline.

 

An update is not in progress at this time.

 

GUIDELINE AVAILABILITY:

Electronic copies: Available from the American Society of

Clinical Oncology (ASCO) Web site.

 

Print copies: Available from ASCO, 225 Reinekers Lane,

Suite 650,

Alexandria, VA 22314; guideline@asco.org

 

COMPANION DOCUMENTS:

None available

 

PATIENT RESOURCES:

None available

 

NGC STATUS:

This summary was completed by ECRI on January 3, 2000. It

was

verified by the guideline developer on January 18, 2000.

 

COPYRIGHT STATEMENT:

This summary is based on content contained in the original

guideline, which is subject to terms as specified by the

guideline developer. Please refer to the guideline

developer's

disclaimer, available at:

www.asco.org/prof/oc/html/m_dr.htm.

 

According to this statement, you are free to download a

copy of

the materials and information on a single computer for

personal,

noncommercial use only; provided that any copyright,

trademark or

other proprietary notices are not removed from any

materials and

information downloaded. Any other use requires written

permission

from the guideline developer.

 

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Brief Summary

 

TITLE:

Practice parameters for the diagnosis and treatment of

asthma.

 

SOURCE(S):

J Allergy Clin Immunol 1995 Nov;96(5 Pt 2):707-870 [1195

references]

 

ADAPTATION:

Not applicable: Guideline was not adapted from another

source.

 

RELEASE DATE:

1995 Nov

 

MAJOR RECOMMENDATIONS:

 

CONSULTATION WITH AN ASTHMA SPECIALIST

 

* The cooperative interaction between the patient and/or

the

patient's representative(s), the primary care

physician/provider, and the asthma specialist is necessary

to maximize the possibility of meeting the goals of asthma

therapy, as stated in the guideline document.

* It is important that the primary care physician/provider

recognize the contribution that can be made by the asthma

specialist in the management of asthma.

* The asthma specialist should recognize the importance of

the

primary care physician/provider in the continuing care of

patients with asthma, which enhances the possibility of a

successful outcome for the patient.

* Active participation of an asthma specialist in the

continuing care of patients with asthma is associated with

lower asthma morbidity, including fewer emergency room

visits, decreased hospitalizations, reduced length of stay

in the hospital, reduced number of days lost from school

and

work, and a reduction in the global cost of asthma care

* There are a number of compelling reasons for recommending

 

that a patient consult an asthma specialist, such as

instability of the patient's asthma, the need for

identification of possible allergenic or non-allergenic

triggers, patient education and when the diagnosis of

asthma

is in doubt. For patients who meet these criteria,

consultation with an asthma specialist should be obtained

early during the treatment program.

 

DIAGNOSIS AND EVALUATION

 

A. Clinical evaluation of asthma

 

* Evaluation of asthma should include a detailed medical

and

environmental history and focus on potential allergic and

non-allergic triggers.

* Other illnesses and medications may impact on the safety

and

effectiveness of treatment.

* Asthma may present only with chronic cough or dyspnea.

* Illnesses other than asthma may also present with cough,

wheezing, dyspnea, and tightness in the chest.

* Asthma severity should be accurately determined on the

basis

of the history, physical examination, and some measure of

pulmonary function.

* Known or suspected "triggers" of asthma can often be

identified in the home, work, school, and recreational

environments.

* An appropriate physical examination is essential.

* Clinical symptoms should be categorized according to

intensity, duration, frequency, environmental or geographic

 

changes, diurnal or circadian variation, and seasonal or

non-seasonal occurrence.

* A careful assessment of the effectiveness and adverse

effects of past medications is necessary.

* Treatment of patients with asthma must be individualized.

 

B. Physiologic evaluation

 

1. Pulmonary function testing

 

* The patient's perception and the physician's assessment

of

asthma severity may correlate poorly with the degree of

airway obstruction.

* The degree of physiologic impairment of asthma can be

significantly underestimated in some patients unless

appropriate pulmonary function studies are obtained.

* A new patient evaluation for asthma generally should

include

spirometric determinations.

* Asthmatic patients may require some measurement of

pulmonary

function at each follow-up visit.

* Spirometry and peak expiratory flow rates are useful

measures of airway function; spirometry provides more

detailed information than does a peak flow rate.

* Spirometry helps differentiate obstructive from

restrictive

airway disease. However, other tests, such as lung volume

and diffusing capacity, may be required.

* During treatment, lung function may remain significantly

abnormal long after symptoms have abated and physical

findings have returned to normal. Some patients may have

complete resolution of symptoms despite little or no

improvement in pulmonary function.

* A direct correlation exists between the amount of

improvement in pulmonary function measurements after 4 to 6

 

hours of treatment for acute asthma, the rate of overall

recovery, and the likelihood of relapse.

* High-dose systemic corticosteroid therapy should be

continued for acute asthma until the patient has

sufficiently improved as measured by the clinical response

and/or pulmonary function tests.

 

2. Bronchoprovocation

 

* A positive inhalation challenge to "nonspecific"

bronchoconstrictive substances, such as methacholine or

histamine, demonstrates the presence of bronchial

hyperresponsiveness and is highly associated with asthma

but

may also be seen in patients with other pulmonary diseases

and even some normal individuals.

* A positive "nonspecific" challenge can help identify

patients with atypical asthma, patients who have cough,

chest tightness, or dyspnea alone, or patients with asthma

who are in relative remission.

* A negative "nonspecific" bronchoconstrictive challenge

can

also alert the clinician to the possibility that the

patient's "asthmatic" symptoms could be caused by other

respiratory disorders such as endobronchial disease (e.g.

tumor) or vocal cord adduction.

* Viral infections, viral vaccines, certain occupational

exposures, and pollutants may produce bronchial

hyperresponsiveness and thus a positive response to

methacholine or other "nonspecific" challenge.

* A relationship may exist between the degree of bronchial

hyper-responsiveness and the extent of treatment required

to

control symptoms in a certain subset of patients.

* Methacholine or other "nonspecific" forms of challenge

need

not be carried out in those with well-established asthma

and

should not be carried out in those with compromised

pulmonary function.

 

C. Specific diagnostic techniques

 

1. Skin testing in the asthmatic patient

 

* Allergen skin testing, as performed by percutaneous and

intracutaneous techniques, is the most sensitive method for

 

detecting specific IgE antibody. However, the presence of

specific IgE antibody does not alone establish the clinical

 

relevance of specific allergens. Determination of the

relevance of the skin test data depends on a detailed and

enlightened evaluation of the history and appropriate

follow-up.

* A positive immediate skin test reaction is a function of

(1)

the presence of IgE antibody for a specific allergen, (2)

the releasability of mast cell mediators, (3) the

reactivity

of the patient's skin to histamine (the primary mediator of

 

the immediate wheal-and-flare skin test), and (4) the

amount

of allergen injected.

* Allergen skin testing as part of an allergy evaluation is

 

indicated to (1) aid in establishing an allergic basis for

the patient's symptoms, (2) assist in establishing specific

 

causes of the patient's symptoms, and/or (3) help evaluate

the degree of sensitivity to a specific allergen.

* The number of skin tests appropriate at any one time may

vary depending on the nature of the clinical problem, the

age of the patient, potential allergen exposures, and the

area of the country in which the patient resides. To

properly interpret the results of allergen skin testing, it

 

is essential to know which aeroallergens are present

locally

and clinically important. Furthermore, it is important to

know which allergens in the area cross-react extensively

with botanically related species.

* Skin testing is not without risk; although rare, fatal

reactions from skin testing have occurred, more commonly

with intracutaneous than with percutaneous testing. Skin

testing should be deferred in patients experiencing an

asthma exacerbation.

* Most antihistamines will suppress allergen skin tests for

 

several days, although astemizole may produce skin test

suppression for many weeks. Other medications commonly used

 

to treat allergic conditions and asthma do not

significantly

suppress immediate skin test reactions to histamine or

allergens.

 

2. Laboratory evaluation of the asthmatic patient

 

* No single laboratory test or group of tests can

conclusively

establish the diagnosis of asthma.

* Determination of total serum IgE is an imperfect

determinant

of the presence or absence of allergy. If high, it supports

 

the presence of allergy and/or a condition such as allergic

 

bronchopulmonary aspergillosis.

* Determination of allergen-specific IgE by in vitro assays

 

may be preferable to skin testing in a small number of

asthmatic patients, such as those with severe skin

disorders

or those taking certain medications.

* The eosinophil is considered an important effector cell

in

asthma because of its ability to produce respiratory

epithelial damage and bronchocentric inflammation. Total

serum eosinophil counts may be elevated in untreated

patients with asthma.

* If recurrent pneumonia or sinus infection occurs in

asthmatic patients, immune deficiencies could be evaluated

by determination of quantitative immunoglobulin levels, IgG

 

subclass levels, and specific antibody responses after

natural infection and immunization.

* Allergic bronchopulmonary aspergillosis can be diagnosed

by

several criteria including elevated total serum IgE levels

and the presence of allergen-specific IgE and IgG

antibodies

 

3. Allergen inhalation challenge

 

* Allergen inhalation challenge is used m often as an

experimental procedure to clarify mechanisms of bronchial

hyper-responsiveness.

* Allergen challenge can be used to clarify the role of

specific allergens in patients with asthma or to establish

causal relationship of asthma with an occupational agent.

* Allergen challenges may also be useful to evaluate

therapeutic effectiveness of medications and immunotherapy.

 

* Allergen inhalation challenge can document specific

allergenic sensitivity in certain patients when skin tests

cannot be performed or as a comparison with in vitro

diagnostic tests when evaluating specific IgE-mediated

sensitivity.

* Allergen inhalation challenge can trigger severe

late-phase

bronchial obstruction in certain patients, and precautions

should be taken to prevent or treat this type of reaction.

 

4. Other diagnostic techniques

 

* The presence of eosinophils and other formed elements

(Curschmann's spirals, Charcot-Leyden crystals, and creola

bodies) in the sputum may have diagnostic significance.

* A chest radiograph should be considered in some patients

to

aid in (1) differentiating asthma from other conditions

that

may cause wheezing and (2) demonstrating possible

complications of asthma.

* Sinus radiographs and/or computed tomographic (CT) scans

should be considered if chronic sinusitis is suspected.

* Direct visualization of the upper and/or lower airway may

be

required to determine if wheezing is caused by mechanical

obstruction.

* Special diagnostic procedures may be required to exclude

the

diagnosis of pulmonary embolism.

* Special tests are available to distinguish other

diseases,

such as carcinoid, mastocytosis, cystic fibrosis, and alpha

 

1-antitrypsin deficiency, which may masquerade as or

coexist

with asthma.

 

ASTHMA MANAGEMENT

 

A. Classification of asthma severity

 

* Attempts have been made to categorize severity of asthma

on

the basis of symptoms, impairment of activity, pulmonary

function, degree of bronchial hyper-reactivity, number of

emergency visits, number of hospitalizations, and

medication

use. Although there is no universal acceptance of formal

severity designations, a combination of subjective and

objective criteria can be used as a guide to severity in

individual patients.

* Severity of asthmatic symptoms can be ranked on the basis

of

duration throughout the day or night, as well as

persistence

throughout the week.

* Restriction of activity in asthmatic patients can be

based

on inability to work or attend school, as well as how many

days per week or month the restriction is present.

* Pulmonary function testing can be used to assess severity

of

asthma, based on the predicted normal value or the

patient's

best attainable value.

* Severity of asthma can be based on the number of office

or

emergency room visits, as well as the number of

hospitalizations required because of exacerbations of

asthma.

* Treatment philosophies vary considerably; however, most

physicians only prescribe daily oral corticosteroids for

patients with severe asthma and avoid their use in patients

 

with mild asthma. Therefore long-term administration of

oral

corticosteroids can be used to classify asthma as severe.

 

B. Severe acute intractable asthma

 

* Severe acute intractable asthma (status asthmaticus)

requires prompt recognition, and intervention.

* The treatment of intractable asthma requires an

understanding of physiologic abnormalities occurring as a

consequence of increased air flow resistance resulting from

 

bronchospasm, inflammation, and mucus plugging.

* The history must establish the features of the current

attack and the presence of medical conditions that could

complicate treatment of intractable asthma.

* Early in an asthma exacerbation, ventilation/ perfusion

mismatches are the predominant physiologic abnormality, and

 

partial pressure of oxygen in arterial blood (PaO2)

decreases. Therefore oxygen administration is indicated in

patients with severe acute intractable asthma.

* With increasing obstruction, ventilation is compromised

and

partial pressure of carbon dioxide in arterial blood

(PaCO2)

rises from initially low levels to "normal" levels.

Therefore a PaCO2 of 40 torr may be a sign of severe

asthma.

* Early in the treatment of intractable asthma, parenteral

and

inhaled sympathomimetic agents are equally effective in

most

patients. However, parenteral sympathomimetic agents may be

 

indicated for patients who are not ventilating well enough

to deliver adequate amounts of nebulized drug to the lower

respiratory tract.

* Patients with severe, acute, intractable asthma will

require

corticosteroid administration. Early use is recommended

because a lag time of several hours may occur before any

clinical effect is noted.

* If aminophylline/theophylline is used, it is especially

important to monitor blood levels and cardiopulmonary

function.

* Overhydration may increase vascular hydrostatic pressure

and

decrease plasma colloid pressure, increasing the

possibility

of pulmonary edema, which is also favored by large negative

 

peak inspiratory intrapleural pressures associated with

acute asthma.

* The need for mechanical ventilation should be

anticipated,

intubation may be difficult and if possible should be done

by an individual experienced with such procedures.

* Hospital management of an acute asthma exacerbation

includes

repetitive administration of nebulized beta2-selective

agents and systemic corticosteroids.

 

C. Identification of the fatality-prone asthmatic patient:

Crisis

plans

 

* Risk factors for life-threatening exacerbations of asthma

 

include severe asthma, poor control of symptoms, atopy,

psychological factors and failure by patient and/or

physician to recognize the severity of the patient's

asthma.

* Poor asthma control is undesirable; poor control of

asthma

symptoms is a special risk factor in the period after

hospitalization.

* Allergic response to airborne mold (Alternaria) has been

associated with life-threatening or fatal exacerbations in

asthmatic patients.

* Psychological factors that may place the patient at risk

of

severe life-threatening asthmatic exacerbations include

poor

ongoing care by the patient and/or family, disregarding

asthma symptoms, manipulative use of asthma, and

significant

emotional problems.

* Fatality-prone asthmatic patients require special

planning,

including regular follow-up visits for assessment of asthma

 

control, measurement of pulmonary function in the office

and

at home, monitoring of the patient's course with regard to

the need for specialist referral, specific treatment of

factors that result in fatality-prone status,

identification

of a reliable advocate, involvement of community resources,

 

development of a crisis plan, and notification of

patient/parents of fatality-prone status.

 

D. Environmental avoidance

 

1. Airborne triggers

 

* Important steps in environmental control are as follows:

 

* Minimize house dust mite exposure in mite- allergic

patients

with asthma.

* Reduce exposure to domestic animals in appropriate

patients.

* Do not allow smoking in the home.

* Avoid strong odors and chemical fumes.

* Install kitchen and bathroom exhaust fans,

* Use humidifiers with caution in mite and mold sensitive

patients.

* Use air conditioners in bedrooms and family rooms when

appropriate.

* Use high-efficiency particulate air filters (HEPA) or

electrostatic air purifiers.

* Install a dehumidifier and reduce water entry in damp

basements.

* Initiate other measures for specific allergies as

appropriate.

 

* Health care providers should identify allergic and

nonallergic environmental triggers of asthma and implement

environmental measures to eliminate or to minimize exposure

 

to these factors.

* House dust mite sensitivity is a significant risk factor

for

many patients with allergic asthma. Extensive cleaning

procedures minimize mite exposure, decrease bronchial

hyper-responsiveness, and reduce asthma morbidity.

Pro-posed

environmental controls should be commensurate with the

severity of the patient's disease, economic status of the

family, and other practical considerations.

* Cockroach allergen has been recognized as a major cause

of

allergic rhinitis and asthma, especially in inner-city

urban

asthmatic patients. Exposure to rodent allergen may also be

 

a significant factor in some asthmatic patients living in

this setting.

* Tree, grass, and weed pollen can produce significant

exacerbations of asthma at specific times of year. Every

effort should be made to minimize indoor pollen

contamination at home and at work by keeping windows closed

 

and using filtration devices and air conditioning.

* Molds and fungi are aeroallergens that are recognized as

triggers for asthma and rhinitis. Their ability to produce

severe life-threatening exacerbations of asthma is well

documented. For indoor molds, environmental control

procedures include use of dehumidifiers and air

conditioning. Avoidance out outdoor molds requires an

understanding of areas where extensive mold growth can be

anticipated.

* Nonallergic environmental triggers, such as cigarette

smoke,

chemical irritants, or strong odors, can also produce

significant exacerbations of asthma. Avoidance of these

allergic triggers.

* Domestic animals, especially cats and dogs, are a common

cause of allergic reactions in individuals with allergic

rhinitis and asthma.

 

2. Food hypersensitivity and asthma

 

* Allergies to foods can induce wheezing in a small number

of

patients with asthma.

* Evaluation of food hypersensitivity should be considered

in

patients with chronic symptoms, especially those in the

pediatric age group with a history of atopic dermatitis.

* A positive prick test to suspected foods may suggest

specific food allergens that require further study.

* A definitive diagnosis of food allergy is based on a

double-blind, placebo-controlled oral challenge. Under

certain circumstances, a presumptive diagnosis may suffice

based on less stringent criteria.

 

3. Other nutritional considerations in the asthmatic

patient

 

* Adequate nutrition is an essential part of the general

treatment plan for asthmatic patients and should be

emphasized especially when there are dietary restrictions

related to food sensitivities or blunted appetite caused by

 

medications.

 

E. Pharmacotherapy

 

Beta-adrenergic agonist bronchodilators

 

* Treatment of the asthmatic patient must be

individualized.

* Beta-agonist bronchodilators vary in their degree of

selectivity and range from non-selective (e.g.

isoproterenol) to relatively Beta-selective agonists

(beta2-agonists) (e.g. albuterol)

* It is preferable to use a beta 2-agonist rather than a

non-selective beta-agonist because beta 2-agonists have a

longer duration of action and are less likely to produce

cardiovascular side effects.

* The use of sustained release oral beta2-agonists may be

appropriate and indicated for some asthmatic patients,

especially in situations in which a long duration of effect

 

is desired or the patient does not tolerate inhaled

beta2-agonists. Otherwise, inhaled beta2-agonists are

preferable to oral drugs of this type in the treatment of

chronic asthma because rapid onset of action, are generally

 

more effective than other routes of administration, and

infrequently produce adverse reactions.

* Inhaled beta2-agonists may be more effective when

administered on an as needed basis rather than on a regular

 

basis in the treatment of many patients with chronic

asthma.

If greater than eight inhalations per day (or approximately

 

one canister per month) are needed, the addition of

cromolyn, nedocromil, or inhaled cortosteroids should be

considered.

* Inhaled beta2-agonists are generally the safest and most

effective treatment for acute asthma. In general, oral

beta2-agonists should not be administered for the treatment

 

of acute severe asthma.

* The administration of beta2-agonists in the treatment of

acute or chronic asthma is not a substitute for the early

use of anti-inflammatory drugs.

* Patients must be carefully instructed, often more than

once,

in the use of inhaled beta2-agonists because a large

percentage of patients fail to use inhaler devices

correctly. Spacers attached to inhaled beta2-agonists

improve drug delivery in patients who do not correctly use

inhalers.

* Inhaled beta2-agonists, when administered 15 to 30

minutes

before exercise, prevent exercise-induced bronchospasm in

many patients. Inhaled beta2-agonists are generally

considered the agent of choice for this purpose.

* Tolerance to beta2-agonists, which is usually reversible

after the administration of corticosteroids, may develop

after continued use of these drugs and may be associated

with an unrecognized decrease in efficacy and delay in

seeking medical attention.

* Bronchial hyper-responsiveness may increase in patients

who

receive inhaled beta2-agonists on a regular basis. This

possibility should be considered in patients whose asthma

is

worsening on a regimen that includes the regular use of

these drugs.

* Tremor and central nervous system effects are minimized

by

inhalation of beta2-agonists, although hypokalemia and

significant cardiovascular effects can occur when these

drugs are administered by this route.

* Serious adverse effects from the administration of

beta2-agonists, when administered in recommended dose, are

uncommon when given orally and extremely uncommon when

administered by inhalation.

* Both beta2-agonists and non-selective beta-agonists, when

 

administered by inhalation, can produce a sudden

paradoxical

increase in bronchospasm, which may be life-threatening in

some asthmatic patients.

* Salmeterol is a long-acting, highly beta2-selective

beta-agonist bronchodilator.

* Well-controlled studies have shown that the duration of

action of salmeterol is 12 hours or longer in most

patients.

* Pretreatment with single doses of salmeterol also

prevents

bronchospasm from histamine, methacholine, and cold air

challenge.

* Salmeterol can protect patients against exercise-induced

bronchospasm for up to 12 hours after administration.

* Because salmeterol is inherently different than

short-acting

inhaled beta agonists, special recommendations must be

considered when prescribing salmeterol for patients. In

this

regard salmeterol metered dose inhaler: (1) should not be

initiated in patients with significantly worsening or

acutely deteriorating asthma; (2) should not be used to

treat acute symptoms; and (3) should not be considered a

substitute for inhaled or oral corticosteroids.

 

Theophylline

 

* For the treatment of acute severe asthma, theophylline is

 

less effective than inhaled or injected beta2-selective

agonists.

* Maintenance therapy with theophylline is effective in

reducing the frequency and severity of the symptoms of

chronic asthma. It may be similar in effectiveness to

cromolyn or beta2-agonists, and long-acting preparations

allow for effective control of nocturnal symptoms.

* Patients with mild chronic asthma may be controlled at

steady-state theophylline serum concentrations less than 10

 

ug/ml; patients with more severe disease may require

concentrations greater than 10 ug/ml for effective control

of symptoms. Although patients may experience significant

adverse reactions at less than 10 ug/ml, as the serum

concentration increases the frequency and severity of

toxicity increase. With levels less than 15 ug/ml severe

adverse reactions are unlikely to occur.

* The rate of theophylline metabolism varies greatly among

patients in the same age group and is influenced by

numerous

medical conditions and pharmaceutical interventions.

* The rate of theophylline metabolism is reduced, thereby

leading to increased serum levels and increased potential

for toxicity, in the presence of such conditions as cardiac

 

decompensation, respiratory failure, hepatic cirrhosis,

sustained high fever, viral infections, hypothyroidism, and

 

after administration of cimetidine, oral contraceptives,

troleandomycin, erythromycin, ciprofloxacin, and

disulfiram.

In contrast, factors such as cigarette or marijuana

smoking,

hyperthyroidism, rifampin, phenytoin, carbamazipine, and

phenobarbital increase the rate of metabolism.

* Oral slow-release formulations generally provide stable

serum concentrations and favor patient compliance. However,

 

the rate and extent of absorption vary between

formulations,

between individuals, and possibly in the same individual

from time to time. Food ingestion may also affect the rate

of absorption in different ways depending on the specific

formulation.

* Dosage for long-term therapy is based on the principle of

 

slowly titrating the dose over several days to circumvent

transient caffeine-like side effects. Final dosage is

usually based on the peak serum concentration measurement

obtained at steady state.

* Elevated blood levels may produce neurologic,

gastrointestinal (including gastroesophageal reflux [GER]),

 

and/or cardiovascular side effects.

* Orally administered activated charcoal or charcoal

hemoperfusion dialysis should be considered at toxic

theophylline concentrations. Intravenous phenobarbital

should also be considered to prevent seizures; diazepam,

but

not phenytoin, should be used to terminate seizures.

 

Anticholinergic agents

 

* The regular use of anticholinergic bronchodilators

appears

to be most effective in patients with chronic obstructive

pulmonary disease who have partially reversible airflow

obstruction.

* Inhaled anticholinergic medication is not sufficiently

effective to be used as a single agent in the treatment of

acute severe asthma but may provide benefit when combined

with a Beta-agonist or other primary therapeutic agent.

* Inhaled anticholinergic agents, such as ipratropium,

appear

to be more effective when used to treat patients with

chronic mild to moderate degrees of airflow obstruction.

* Inhaled anticholinergic medications, such as ipratropium,

 

may be indicated in patients in whom alternative agents

have

not been sufficiently effective, are inappropriate because

of other medical conditions, or have produced unacceptable

side effects.

 

Antihistamines

 

* Antihistamines can be safely used in most patients with

asthma.

* Antihistamines may be effective in the treatment of

asthma

because histamine, acting through H1 receptors, produces

smooth muscle contraction, an increase in vascular

permeability, and stimulation of parasympathetic nerves,

all

of which are pathophysiologic features of asthma.

* Based on their ability to block late-phase responses to

allergen exposure, newer antihistamines may play a greater

role in the future treatment of asthma.

* Antihistamines may alleviate asthma somewhat through

their

direct effect on the bronchial passageways.

* There is a strong clinical impression that improvement of

 

upper respiratory tract symptoms by antihistamines in

patients who have concomitant allergic rhinitis and asthma

may facilitate the treatment of lower respiratory tract

symptoms.

* Although antihistamines are not the treatment of choice

for

exercise-induced bronchospasm, pretreatment may attenuate

exercise-induced bronchospasm in some patients.

* Histamine is not the only mediator responsible for asthma

 

symptoms, and therefore antihistamines, if used, should be

considered adjunctive therapy in the treatment of asthma.

 

Cromolyn and nedocromil

 

* Cromolyn can be effective in many patients, alone or in

conjunction with bronchodilators, in preventing the

symptoms

of mild-to-moderate asthma.

* Cromolyn has been demonstrated to be extremely safe,

although serious adverse effects, such as bronchospasm,

have

been reported.

* Cromolyn can be effective in preventing or diminishing

exercise-induced asthma when given 15 to 30 minutes before

exercise.

* Overall, there is similar effectiveness with use of the

metered-dose inhaler, Spinhaler, and solution for

nebulization, although individual response must be

considered in the choice of the product.

* Cromolyn has the ability to attenuate both early and

late-phase IgE-mediated reactions.

* Nedocromil sodium is a topically active

anti-inflammatory,

pyranoquinoline that has mast cell-stabilizing properties.

* Nedocromil sodium has a number of putative mechanisms of

action, as suggested by both animal in vivo experiments and

 

in vitro effects on a variety of animal and human cell

preparations.

* Nedocromil sodium is primarily indicated as a preventive

drug in the management of asthma-associated chronic

inflammation. If used appropriately in this manner, it is

effective in improving symptom scores, reducing use, and in

 

some cases, other concomitant medications such as inhaled

corticosteroids or cromolyn sodium.

* Clinical dosing is based on its long-term preventive

effects. Because it is not a bronchodilator, it is not

indicated in the treatment of acute asthma.

* Long-term use of nedocromil sodium is generally safe.

* Nedocromil sodium is clinically useful in the preventive

treatment of mild and moderate asthma.

 

Corticosteroids

 

* With renewed awareness of the importance of airway

inflammation in the pathogenesis and chronicity of asthma,

it is generally felt that inhaled corticosteroids should be

 

used as primary therapy in patients with moderate and

severe

chronic asthma.

* Systemic corticosteroids should be considered in the

management of acute asthma when the patient does not

respond

readily to bronchodilators. Early use of corticosteroids

shortens the course of asthma, prevents relapses, and

reduces the need for hospitalization. The early use of

corticosteroids is of particular importance in patients who

 

have a history consistent with fatality-prone asthma.

* Intravenous corticosteroids may be lifesaving in the

treatment of severe intractable asthma. After episodes of

severe intractable asthma, complete restoration of

pulmonary

function may require weeks of treatment. Therefore after

such events, corticosteroids should be continued at least

until symptoms are controlled and pulmonary function is

restored.

* Because of the potential for significant side effects

from

the prolonged use of systemic corticosteroids (and possibly

 

high-dose inhaled corticosteroids), the need for oral

corticosteroids should be monitored by pulmonary function

tests, and inadequate control with maximal use of other

treatment approaches should be a prerequisite for the

long-term administration of systemic corticosteroids.

* Patients receiving systemic corticosteroids on a chronic

basis may need to be carefully monitored for changes in the

 

hypothalamo-pituitary-adrenocortical axis, bone changes,

glucose metabolism, hypertension, and other potential side

effects of such therapy under certain circumstances.

 

Hydration and pharmacomucolytic agents

 

* Adequate hydration is recommended for patients with

asthma,

but overhydration should be prevented by careful monitoring

 

of fluid and electrolyte balance, especially in infants, in

 

severely ill patients, and in the elderly. Dehydration may

occur with severe asthma and should be corrected. However,

fluid overload may have adverse pulmonary and circulatory

effects and must be prevented by careful monitoring of

fluid

and electrolyte balance.

* Guaifenesin and potassium iodide may be worth a trial in

some asthmatic patients, although the mechanisms of action

are unclear.

 

Other considerations

 

a. Alternative therapy

 

* Whatever the reasons for failure to respond to

corticosteroids, several treatment regimens for asthmatic

patients who have not responded to systemic corticosteroids

 

now exist.

* Steroid-sparing regimens or alternatives to systemic

corticosteroid therapy include troleandomycin,

methotrexate,

gold and intravenous globulin therapy, which may be

effective in some patients with asthma.

* It should be recognized that certain of these regimens

are

contraindicated in some patients and/or may be associated

with significant adverse effects.

 

b. Role of antibiotics/antivirals

 

* Infections associated with asthma exacerbations are

almost

always viral in origin and do not require antibiotic

therapy. Under these circumstances, however, reevaluation

of

the patient's treatment program, including bronchodilators

and corticosteroids, may be important.

* Bacterial infections, such as acute and chronic

sinusitis,

should be treated appropriately, including the prompt and

adequate use of antibiotics.

* Influenza can be associated with increased asthma.

Therefore

appropriate immunization is essential in patients with

moderately severe or severe asthma.

 

Immunizations

 

* Routine vaccinations are not contraindicated in patients

with asthma or other allergic conditions.

* Patients who have a history of egg sensitivity should be

skin-tested with the vaccination material. If results of

the

skin test are positive, the patient may be immunized with

small increasing doses with use of an established protocol.

 

* Short-term, low-to-moderate dose systemic

corticosteroids,

alternate-day corticosteroids, or topical corticosteroids

are not immunosuppressive and are not a contraindication

for

immunization.

* Influenza vaccine and pneumococcal vaccine are

recommended

for patients with chronic pulmonary disease including

asthma.

 

Comparability of therapeutic products

 

* Comparability of inhaled products cannot be assumed

because

of potential differences in patient response to excipients

or other "inactive" components in these products.

* Substitution of a theophylline product different from the

 

one the patient was previously receiving can produce

decreased efficacy or toxicity in some patients.

* Any adverse reaction that is temporally related to use of

a

drug product may be caused by the drug product even if the

patient has tolerated the same drug in another product.

 

Polypharmacy

 

* Polypharmacy may be necessary and indeed desirable in the

 

management of patients with asthma. *The physician must

guard against the unnecessary addition of medications that

could increase morbidity and mortality in asthmatic

patients.

 

F. Immunotherapy in the asthmatic patient

 

* Allergen immunotherapy can be effective in patients with

asthma and may reduce the effect of chronic allergen

stimulation on hyper-responsive airways. In most cases

allergen immunotherapy should be considered as a part of a

well-planned program that includes pharmacotherapy and

avoidance measures.

* Allergen immunotherapy should be considered a long-term

therapeutic modality in patients with allergic asthma.

* Patient compliance is essential for the effective and

safe

application of allergen immunotherapy.

* Although precise mechanisms for efficacy of allergen

immunotherapy are unknown, several specific

immunomodulatory

pathways have been implicated.

* Immediate and delayed local and systemic reactions may

occur

in the course of allergen immunotherapy.

* Patients should be informed about the relative risks of

immediate and delayed reactions associated with allergen

immunotherapy.

* Both patients and medical personnel should be instructed

in

detail about prevention and treatment of reactions to

allergen immunotherapy.

* Although life-threatening reactions during allergen

immunotherapy are rare, fatalities can occur. Therefore

supervising health care providers should be prepared to

treat such reactions as promptly and effectively as

possible.

 

G. Patient education

 

Cooperative management through education

 

* Educating asthmatic patients, parents, and family about

their disease and methods of treatment is essential in the

effective control of asthma.

* Educational programs for asthmatic patients have

generally

been successful in producing increased patient

understanding

of asthma and decreased morbidity.

* Patients should be educated to effectively monitor their

asthmatic status and know how to respond to changes in

their

status.

* Patients should be educated in the proper technique

required

for the effective use of inhaled medications.

* Physicians should recognize patient concerns and resolve

these concerns through increased patient confidence in the

management approach and their ability to implement this

approach in the treatment of their asthma.

* Asthma education requires an understanding by the patient

 

and physician of certain basic concepts related to

pathophysiology and treatment but must also be

individualized for each asthmatic patient.

 

Compliance in asthma

 

* Patient non-compliance can be manifested as underuse,

overuse, or erratic use of prescribed medication.

* Improvement in patient compliance may be influenced by

knowledge about therapy, the patient-physician

relationship,

perceived seriousness of the condition, perceived benefit

of

intervention, complexity of the program, frequency of

taking

the medication, and cost.

* The most successful programs to improve patient

compliance

combine techniques of education, reinforcement, and family

interactions.

* Lack of patient compliance is one of the most important

under-recognized problems in medicine today and can be the

result of psychological, economic, or educational factors.

 

Rehabilitation of the patient with asthma

 

* Specific goals of rehabilitation include maximizing

school/work attendance, encouraging participation and

productivity, encouraging participation in age-appropriate

physical activities with peers, promoting self-esteem and

self-confidence, and decreasing anxiety about the illness.

* Information needed to evaluate the need for and the

effectiveness of a rehabilitation program should be

obtained

on a regular basis in the continuing care of a patient.

* Problems in any area of rehabilitation should prompt the

initiation of specific measures to correct this deficiency.

 

* Community resources including structured fitness programs

 

are available and should be used when appropriate.

* Rehabilitation goals should be coordinated and monitored

by

the physician so that therapy can be adjusted

appropriately.

 

Asthma camps

 

* The major goal of a camp for children with asthma is to

provide a positive learning experience in an enjoyable

setting. The camp provides an environment that encourages

social interests, reduces anxiety, and allows for a sense

of

independence.

* Operational guidelines for the camp should include

administrative structure, medical structure, appropriate

structure of activities, and camp format.

 

SPECIAL CONDITIONS

 

A. Concomitant Conditions

 

* Weight control should be advised in patients with asthma

because exogenous obesity may complicate the treatment of

asthma.

* Although the coexistence of obstructive sleep apnea and

asthma is rare, nocturnal asthma may be exacerbated in

patients with both conditions.

* A decision regarding antituberculous chemotherapy in an

asthmatic patient who requires corticosteroids should be

carefully individualized if there is a documented past

history of tuberculosis.

* Hyperthyroidism may aggravate asthma and complicate the

management of asthmatic patients.

* Asthma in patients with Addison's disease is usually

severe

but improves with glucocorticoids.

* The best method of avoiding the diabetogenic properties

of

corticosteroids in asthmatic patients with diabetes is use

of inhaled corticosteroids if the patient's asthma can be

controlled with this form of therapy.

* The treatment of asthma in patients with coexisting

hypertension and/or heart disease should be based on an

understanding of the potential for asthma medications to

exacerbate cardiovascular status and the potential for

antihypersensitive medication and cardiac drugs to

exacerbate asthma.

* Asthma medications are often useful in managing so-called

 

"fixed" obstructive lung diseases in adults and children.

* Cessation of smoking by patient and family members should

be

a major goal in the overall management of asthma.

 

B. Asthma and anaphylaxis

 

* Anaphylaxis may be accompanied by sudden severe

bronchospasm.

* Patients taking beta-blockers who develop

life-threatening

anaphylaxis may respond poorly to usual treatment for

anaphylaxis.

* Inhaled beta2-selective agonist bronchodilators and

intravenous aminophylline may be required to reverse

bronchospasm in patients not immediately responsive to

subcutaneous epinephrine.

* Oxygen, 5 to 10 L/min, should be used when bronchospasm

is

accompanied by significant dyspnea or cyanosis.

* Prolonged therapy, including corticosteroids, may be

necessary to reverse protracted anaphylaxis or anaphylaxis

that occurs later after exposure to the triggering agent.

 

C. Management of asthma during pregnancy

 

* There is more risk to the mother and fetus during

pregnancy

from poorly controlled asthma than from the usual

medications used to treat asthma.

* Asthmatic patients should not smoke, especially during

pregnancy.

* Identification and avoidance of potential triggers of

asthma

are essential during pregnancy.

* Assessment of asthma should include regular measurements

of

pulmonary function during pregnancy.

* Pregnancy is not a contraindication to continued allergen

 

immunotherapy in patients who are at maintenance.

* Additional considerations apply to the management of

asthma

during labor and delivery.

* In general, the same medications used during pregnancy

are

appropriate during labor and delivery.

* Oxytocin is the preferred medication for labor induction,

 

and intracervical prostaglandin E2 gel can be used for

cervical ripening before labor induction.

* For regional anesthesia during labor and delivery, the

concomitant use of epidural analgesia should be considered;

 

for general anesthesia, ketamine may be the agent of

choice,

possibly with preanesthetic use of a beta2-agonist.

 

* Currently, oxytocin is considered the medication of

choice

for postpartum hemorrhage. Ergonovine and methylergonovine

have been associated with bronchospasm.

 

D. Nocturnal Asthma

 

* A high percentage of deaths occur during nocturnal and

early

morning periods.

* Nocturnal asthma has been associated with factors such as

 

decreased pulmonary function, hypoxemia, decreased

mucociliary clearance, and circadian variations of

histamine, epinephrine, and cortisol concentrations.

* A general goal of asthma therapy should be the complete

control of nocturnal symptoms.

* Longer acting, sustained-release theophylline

preparations,

long-acting preparations of oral beta2-agonists, or

long-acting beta2-agonists may be an effective way to

control nocturnal asthma in many patients.

* Better overall control of the patient's asthma may be

necessary before nocturnal symptoms will be adequately

controlled (i.e., avoidance, immunotherapy, and daytime

medications, especially anti-inflammatory drugs such as

corticosteroids and cromolyn).

 

E. Exercise-induced asthma

 

* Exercise-induced asthma (EIA) occurs in up to 90% of

patients with asthma.

* EIA is probably triggered by heat and water loss from the

 

respiratory tract, which causes mediator release resulting

from bronchial hyperosmolality.

* Inhalation of a beta2-agonist 15 to 30 minutes before

exercise is the treatment of choice for EIA.

* Inhaled cromolyn sodium, taken alone or in conjunction

with

an inhaled beta2-agonist 15 to 30 minutes before exercise,

can also effectively prevent or modify EIA.

* Pretreatment with theophylline, anticholinergic agents,

antihistaminic agents, and other medications (see text) may

 

benefit some patients with EIA.

* General stabilization of the patient's asthma may be

required before effective control of EIA can be achieved.

* Nonpharmacologic methods can be effectively used in some

patients to prevent EIA (e.g., exercise under conditions in

 

which warm, humid air is inhaled).

 

F. Nasal and sinus disease and asthma

 

* Frequently there is an association between asthma and

sinusitis, and improvement in asthma may occur when

sinusitis is properly treated.

* Sinusitis should be considered in patients with

refractory

asthma.

* Evaluation of sinus disease may require sinus

radiographs,

CT scans, and/or endoscopic procedures.

* Many local and/or systemic factors may increase the risk

of

sinusitis developing. Certain diseases, such as cystic

fibrosis, and local factors, such as nasal polyps, may

increase the risk of developing sinusitis.

* Nasal polyps may occur in association with sinus disease

and

both conditions may affect asthma.

 

G. Gastroesophageal reflux (GER) and asthma

 

* GER occurs commonly in patients with asthma.

* GER should be suspected in patients with nocturnal asthma

or

in patients who are not responding adequately to optimal

medical management.

* A number of objective diagnostic modalities are available

 

for establishing a relationship between GER and asthma.

* Medical or surgical treatment of GER in asthmatic

patients

may improve their respiratory symptoms.

* Surgical correction of GER should only be considered when

 

medical therapy is unsuccessful and a causal relationship

between GER and asthma has been objectively established.

 

H. Aspirin-sensitive asthma/nonsteroidal anti-inflammatory

drug/preservative sensitivity

 

* Aspirin-sensitive asthma (ASA) and nonsteroidal

anti-inflammatory drug (NSAID) idiosyncrasy occurs in up to

 

10% to 15% of all asthmatic patients and in 30% to 40% of

asthmatic patients with nasal polyps and pansinusitis.

These

reactions are non-IgE mediated and designated as

idiosyncracies.

* Ultimately, many of these patients become steroid

dependent.

* ASA desensitization may be a useful therapeutic adjunct

in

some of these patients, especially those who have

concurrent

diseases that require ASA or NSAIDS.

* Sulfite additives in drugs and foods may induce severe

adverse reactions in susceptible asthmatic patients.

* Tartrazine in foods or drugs may induce asthma in a small

 

number of patients with ASA idiosyncrasy.

* Similar to ASA reactions, almost all of the reactions to

tartrazine are not IgE mediated.

* Asthma may occur in a few monosodium

glutamate-susceptible

patients after challenge with this food-flavoring agent.

* Several other dye and preservative additives in foods and

 

drugs have also been implicated as inducers of asthma.

 

I. The effects of air pollution in asthmatic patients

 

* Although asthmatic patients living in urban environments

are

generally exposed to a large number of pollutants, only a

few have been implicated in causing adverse effects.

* Inhalation of sulfur dioxide, nitrogen dioxide, or ozone

is

capable of inducing bronchospasm in patients with asthma.

* One of the common sources of air pollution in residential

 

areas, especially in western states, is household

woodburning devices.

* Albuterol is the most selective and potent blocker of

sulfur

dioxide (SO)-induced airflow obstruction in asthmatic

patients, and cromolyn sodium has also been shown to block

S02-induced bronchoconstriction.

 

J. Psychological factors

 

* Asthma affects psychological and social aspects of life

for

virtually all patients with this disease.

* The patient may or may not be aware of the presence of

psychological problems, which may constitute significant

impediments to the optimal management of asthma.

* The management of psychological or social problems that

accompany asthma depends on the extent to which they

interfere with medical management or produce severe

dysfunction in the patient's life.

* Age and maturity are important considerations in both the

 

medical and psychological treatment of asthma.

* Family members of patients with severe asthma or asthma

that

is out of control require support from the clinician

because

of the demands of caring for an individual with asthma.

Referral to support groups and/or counseling can be helpful

 

in these situations.

 

K. Occupational asthma

 

* Occupational asthma may be induced or aggravated by

variable

periods of exposure to fumes, gases, dusts, or vapors.

* Symptom patterns of occupational asthma are variable and

range from acute symptoms at work to late-onset responses

after work.

* Specific causes of occupational asthma include

immunologic,

irritant, and direct pharmacologic stimuli. Many patients

with immunologically induced occupational asthma have

IgE-mediated sensitization to a variety of animal and

plant-derived proteins that provoke their symptoms.

* Preexisting atopy may constitute an increased risk factor

 

for asthma caused by many occupational proteins but not by

most low molecular weight chemicals.

* Other obstructive airway diseases such as chronic

bronchitis, bronchiolitis obliterans, and emphysema may

mimic occupational asthma.

* Some low molecular weight chemicals may also induce

IgE-mediated clinical sensitization.

* After careful review of past medical records and a

detailed

history and physical examination, the diagnosis of

occupational asthma can be accomplished by a combination of

 

pulmonary function tests, skin tests, and blood tests.

inhalation challenge should be done when warranted.

* Removal of either the patient or the precipitant from the

 

workplace environment is the most effective long-term

treatment strategy.

* Some workers have persistent asthma for years after they

are

removed from the offending occupational agent.

 

L. Asthma in the school setting

 

* Asthma must be identified early to optimize treatment

that

can decrease school absenteeism and increase opportunities

for participation in physical activity.

* Asthma can be effectively treated in most children by the

 

use of readily available inhaled medications.

* Every effort should be made to normalize physical

activity

in children with asthma.

* Education programs for patients, parents, and teachers

should be encouraged to provide better management of asthma

 

in the school setting.

 

M. Special problems in asthma management due to

socioeconomic,

geographic, and cultural factors

 

* Asthma may present special problems in management related

to

living conditions, geographic location, availability of and

 

access to health care professionals and health care

facilities, socioeconomic status of the patient, and

cultural differences in orientations to disease.

* Exposure to outdoor and indoor respiratory pollutants and

 

allergens may be intensified in relation to socioeconomic

and geographic factors.

* Inaccessibility to specialists who care for asthma may

lead

to episodic care, lack of follow-up, inadequate patient

education, and possibly increased asthma mortality in urban

 

African-Americans.

* Inaccessibility to specialists who care for asthma can be

 

the result of difficult geographic or economic conditions,

lack of health care coverage, and structured health care

plans ("gatekeeper" concept).

* The selection of medications for the treatment of

specific

patients with asthma should take into consideration the

education of the patient, the patient's mental status, the

economic status of the patient, cultural approaches to the

use of medications, and accessibility to medical care while

 

providing the best approach to treatment possible for that

individual patient.

 

N. Asthma in children

 

* Asthma is the most common chronic condition of childhood.

 

The prevalence and severity of childhood asthma have

increased substantially in recent years. Age-related

differences in diagnostic and therapeutic considerations in

 

childhood require special attention.

* Asthma can begin in infancy, although rarely in the first

 

few months of life. Wheezing is a common symptom

encountered

in infancy through the first 2 to 3 years of life and may

be

a transient phenomenon in this age group. Many children

develop persistent or recurrent wheezing, i.e., asthma.

Persistent asthma that begins early is likely to be more

severe.

* Atopy in the child, parental atopy or asthmatic history

and

maternal smoking are risk factors for persistent and

recurrent asthma. Low lung function and maternal smoking

are

risk factors for transient wheezing.

* The history and physical examination, the mainstay of

diagnosis in all age groups, present special problems in

infants and young children. The diagnosis and estimation of

 

asthma severity must depend more on the history and

response

to therapy as assessed by inconstant third-party

observations than more continuous as well as more objective

 

assessments possible in the older child and adult.

Information from observers in and out of the home is

important. Education of parents and other caretakers

regarding how to assess possible signs and symptoms, their

severity, and possible incitants can aid in diagnosis and

therapy.

 

* Recurrent symptoms of prolonged cough, often with

shortness

of breath, with or without wheeze, suggest asthma.

Demonstration of a favorable clinical response to

bronchodilator therapy and, when measurable,

bronchodilation

as demonstrated by pulmonary function testing helps confirm

 

the diagnosis. A positive family history for allergic

diseases or asthma, although not essential, tends to

support

a suspected diagnosis of asthma.

* It is important to realize that asthma may coexist with

other conditions. Alternative or additional diagnosis

should

be entertained when the history is atypical or the response

 

to good medical management is poor.

* Any aspect of the history that is atypical for asthma,

such

as a history of sudden onset of symptoms, coughing or

wheezing with feedings, neonatal requirement for

ventilatory

support, or symptoms of stridor, may suggest the need to

consider alternative diagnoses.

* A large number of conditions can result in symptoms

suggestive of asthma. The most common nonasthmatic

conditions in childhood that involve obstruction of the

large airways include foreign body in the trachea, bronchus

 

or esophagus, and laryngotracheomalacia. Obstruction

involving both the large and small airways are most

commonly

due to viral bronchiolitis and cystic fibrosis.

 

* The differential diagnosis of the child with wheezing can

be

approached on an age-related basis. Infants are at a higher

 

risk for congenital abnormalities and some infectious

conditions. Aspiration of a foreign body and cystic

fibrosis

may occur in any age group, but most commonly present early

 

in life. GER with pulmonary involvement may occur at any

age. Vocal cord dysfunction and the hyperventilation

syndrome merit consideration mainly in the adolescent age

group.

* General observations that may be helpful in the

evaluation

of the infant or young child include assessment of clubbing

 

of fingers or toes (suggesting cystic fibrosis, other

chronic lung disease such as bronchiectasis, congenital

heart disease, hepatobiliary disease rather than asthma),

activity level, and status of growth and nutrition.

 

* In addition to physical findings pertinent to all age

groups, the evaluation of respiratory effort and

speech-hoarseness, stridor, and the ability to speak or cry

 

normally-is particularly helpful in the infant and young

child, especially during symptomatic episodes.

* Objective measurement of pulmonary function is important

whenever possible not only to confirm the clinical

diagnosis

but to monitor asthma as well. Expiratory spirometry should

 

be used as soon as the child is old enough to cooperate.

Peak flow monitoring and pulmonary function measurements

can

generally be done by age 6 or 7 years and in some children

peak flow measured as young as 3 to 4 years old.

 

* A chest x-ray film should be obtained at least once in

any

child with asthmatic symptoms sufficient to require

hospitalization.

* The child who has had several exacerbations of asthma

requiring in-hospital treatment or who has had a history of

 

recurrent pneumonia should be considered a candidate for a

sweat chloride test to rule out cystic fibrosis.

 

* Children with recurrent wheezing who have repeated

bronchopneumonia confirmed by x-ray film should have an

immunologic evaluation, including quantitative

immunoglobulins and possibly specific antibody titers.

* The determination of specific IgE antibody by skin or in

vitro tests is useful to evaluate potential allergic

trigger

factors in children with asthma or when a history

suspicious

of atopic etiology is obtained. Allergy testing can be used

 

even in infancy, but it is most commonly useful in children

 

over two years of age.

 

* Treatment of the child with asthma includes all of the

following: (1) environmental control; (2) use of

appropriate

medications; (3) immunotherapy when indicated; (4)

education

of patient, family, and caregivers; and (4) close

monitoring

and follow-up.

 

* Aspects of responsibility for treatment may apply to all

environments in which the child spends a significant amount

 

of time, such as preschool, school, or day care.

* Environmental control for the child includes limiting

exposure to cigarette smoke and other irritants, as well as

 

to house dust mite, cockroach, mold, animal, and pollen

allergens. The greatest effort is spent in relation to the

bedroom, where children spend a major part of their time.

* Pharmacologic management of the child with asthma

includes

the use of short-acting beta2-adrenergic bronchodilators as

 

needed to relieve acute symptoms and anti-inflammatory

agents routinely to control chronic symptoms.

Anti-inflammatory agents for the child include cromolyn

sodium and inhaled steroids. Nedocromil sodium is approved

for use beginning in adolescence. Theophylline and oral

long-acting beta2-adrenergic agents are used as adjunctive

therapy. Systemic corticosteroids are used in short bursts

(usually days) for acute severe asthma; long-term use is

reserved for severe chronic asthma not adequately

con-trolled with inhaled steroids at approved higher doses,

 

and bronchodilators.

 

* Aerosolized preparations are preferred for the child

because

these generally induce fewer side effects; however, not all

 

agents are available for use or have Food and Drug

Administration approval for use in this age group.

beta-agonists, ipratropium bromide, and cromolyn sodium can

 

be delivered by nebulizer; nebulized corticosteroids are

not

available in the United States. Spacers with a face mask

can

be helpful for delivery of medications through metered dose

 

inhalers in very young children.

* Present data are inadequate to establish if inhaled

steroids

pose a risk for a more complicated course with varicella or

 

other viral infections in children. The use of acyclovir

and/or varicella immune globulin should be considered in

children who have a negative varicella history and/or

antibody titer and who receive or recently have received

systemic steroids and have been exposed to varicella.

* Immunotherapy can be safe and effective for children with

 

well-defined allergies whose clinical symptoms correlate

with the sensitivities identified on allergy testing.

* Exercise-induced bronchospasm is common in children.

Pretreatment with beta2-agonists and/or cromolyn sodium can

 

prevent symptoms; beta2-agonists are useful in reversing

symptoms. Optimal control of chronic asthma by

anti-inflammatory therapy also can decrease the frequency

and intensity of exercise induced asthma.

 

* Children with asthma need to have their medications

conveniently available at school. Designated school

personnel and children themselves need to understand the

use

of each medication. The physician and parent have a joint

responsibility to provide simple instructions for

medication

use.

 

CLINICAL ALGORITHM(S):

None provided

 

DEVELOPER(S):

American Academy of Allergy, Asthma and Immunology (AAAAI)

-

Medical Specialty Society

American College of Allergy, Asthma and Immunology (ACAAI)

-

Medical Specialty Society

Joint Council of Allergy, Asthma and Immunology (JCAAI) -

Medical

Specialty Society

 

COMMITTEE:

Joint Task Force on Practice Parameters

 

GROUP COMPOSITION:

Editors: Sheldon l. Spector, MD; Richard A. Nicklas, MD.

Associate Editors: I. Leonard Bernstein, MD; Joann

Blessing-Moore, MD; Robert C. Strunk, MD.

 

Contributors: Hugh A. Sampson, MD; Michael Schatz, MD;

Sheldon C.

Siegel, MD; Ronald A. Simon, MD; Raymond G. Slavin, MD; R.

Michael Sly, MD; Samuel V. Spagnolo, MD; Sheldon L.

Spector, MD;

Robert C. Strunk, MD; Stanley J. Szefler, MD; Abba I. Terr,

MD;

David G. Tinkelman, MD; Frank S. Virant, MD; George W.

Ward, Jr.,

MD; James H. Wedner, MD; Miles Weinberger, MD; Stephen C.

Weisberg, MD; Michael J. Welch, MD; Paul V. Williams, MD;

Bruce

L. Wolf, MD.

 

Additional Contributors: Joseph Gaddy, MD; Elaine K.

Kravitz, MD;

Nancy Ostrow.

 

ENDORSER(S):

Not stated

 

GUIDELINE STATUS:

 

This is the current release of the guideline.

 

This is the second version of the guideline. An update of

the

current guideline is in progress at this time.

 

GUIDELINE AVAILABILITY:

Electronic copies: Available from the Joint Council of

Allergy,

Asthma, and Immunology (JCAAI) Web site at:

http://www.jcaai.org/Param/Asthma.htm (HTML format) and

http://www.jcaai.org/Param/ParamDocs/Asthma.doc (MSWord

format).

 

Print copies: Available from JCAAI, 50 N. Brockway, Ste 3-3

 

Palatine, IL 60067.

 

COMPANION DOCUMENTS:

None available

 

PATIENT RESOURCES:

Not stated

 

NGC STATUS:

This summary was completed by ECRI on October 1, 1998. The

information was verified by the guideline developer on

December

15, 1998.

 

COPYRIGHT STATEMENT:

This NGC summary is based on the original guideline, which

is

subject to the guideline developer's copyright

restrictions. This

copyrighted material may only be used personally and may

not be

distributed further. All rights reserved. Mosby-Year Book,

Inc.

[Practice parameters for the diagnosis and treatment of

asthmaJ

Allergy Clin Immunol. 1995 Nov;96(5 Pt 2):707-870]

 

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Date Modified: Monday, June 14, 1999

 

[PAGE]

 

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I. TITLE: MADIGAN ARMY MEDICAL CENTER CLINICAL STANDARD FOR

THE MANAGEMENT

OF ASTHMA.

 

Three clinical pathways: pathway #1 - acute outpatient

management, pathway

# 2 - Inpatient management, and pathway # 3 - chronic

outpatient

management.

 

II. INDICATIONS FOR THE STANDARD:

 

Asthma is the most common chronic respiratory illness of

childhood and

adulthood. The morbidity and cost of treating asthma are

tremendous. The

National Heart, Lung, and Blood Institute (NHLBI) has

emphasized the

importance of consistency in treating asthma across all

care provider

groups. This prompted the publication of the NHLBI

Guidelines. The

Department of Defense has mandated that military facilities

comply with

these guidelines. Our proposed asthma pathways are derived

from the NHLBI

Guidelines and are designed to facilitate and ensure the

consistency of

asthma care amongst care providers at MAMC.

 

III. METRICS WHICH WILL BE USED TO MONITOR ADHERENCE TO THE

 

PRACTICE RECOMMENDATIONS:

 

The proposed asthma clinical pathways will be used to

manage more than 1000

asthmatics per year. Documentation of the following

parameters are

recommended to be used to assess adherence to these

management

recommendations.

 

For assessing adherence to attachment # 1 (acute outpatient

asthma) these

following metrics will be audited:

 

Prompt use of aerosolized beta agonists.

 

Corticosteroids administered at the appropriate time.

 

Written asthma plan provided, and appropriate instruction

on

MDI/nebulizer use documented.

 

Follow-up care was arranged.

 

Primary care provider identified or a referral to obtain

one was

made.

 

For assessing adherence to attachment # 2 (inpatient

asthma) the following

metrics will be audited:

 

Corticosteroids administered in the appropriate dosage.

 

Oxygen saturation monitored, and supplemental oxygen

administered

when indicated.

 

Asthma education and written instructions provided.

 

Follow-up care arranged.

 

Primary care provider identified or the referral made.

 

For the assessing adherence to attachment # 3 (chronic

outpatient asthma)

the following metrics will be audited:

 

The prescribing of controller asthma medications for

patients

with persistent asthma.

 

Written asthma plan given to the patient.

 

Identification of a primary care provider or a referral

made for

establishing a primary care provider.

 

IV. DATE: Completed 17 October 1997.

 

V. AUTHORS:

 

LTC Ted Carter, Dept. of Pediatrics

 

LTC Marcia Muggleberg, Division of Allergy/Immunology,

Dept. of Medicine,

 

LTC Paul Whittaker, Dept. of Family Practice,

 

CPT Risa Bator, Dept. of Nursing

 

LTC Suzanne Evans, Utilization Management

 

MS Marion Christiansen, Clinical Pathways Coordinator

 

Point of Contact: LTC Edward (Ted) Carter: ccmail: LTC

Edward Carter

 

phone: 968-1876

 

FAX: 968-0384

 

VI. AREAS OF DISAGREEMENT:

 

There were no major areas of disagreement. Discussion

centered about the

timing of follow-up appointments, drug doses, and the best

use of peak flow

meters. A consensus opinion concerning asthma management

was achieved.

 

VII. PUBLISHED STANDARDS OF CARE RELATING TO CURRENT

STANDARD:

 

The three proposed asthma clinical pathways were based upon

the National

Heart, Lung,

 

and Blood Institute revised guidelines for the management

of asthma.

 

Guidelines for the Diagnosis and Management of Asthma:

Expert Panel Report

2 - Clinical Practice Guidelines. April 1997. NIH

Publication No. 97-4051.

 

VIII. CLINICAL PRACTICE RECOMMENDATIONS:

 

Please refer to the three attachments which accompany this

document.

Attachment # 1 - acute outpatient asthma clinical pathway,

attachment # 2 -

inpatient asthma clinical pathway, and attachment # 3 -

chronic outpatient

asthma clinical pathway.

 

IX. IMPACT TO THE INSTITUTION:

 

These clinical pathways impact many areas of the hospital

and all providers

who care for patients with asthma. This includes all of the

primary care

divisions, allergy and pulmonology divisions, and the

emergency department.

It will also impact upon the Department of Respiratory Care

and the

Department of Nursing.

 

X. LINKS WITHIN THE MAMC INTRANET:

 

All three of the proposed clinical pathways should be

published on the MAMC

Intranet under the heading of: clinical pathways - asthma.

The chronic

outpatient asthma clinical pathway (attachment # 3) should

be linked to the

pediatric referral guideline and adult referral guidelines

for the referral

of asthmatics for subspecialty evaluation. The pathways for

the management

of acute asthma (outpatient - attachment # 1, and inpatient

Asthma -

attachment # 2) should be installed in CIS to be used in

the Emergency

Department, observation units, and inpatient arena. We also

recommend

placing a brief reminder about the asthma pathways in CHCS

when a provider

prescribes a "controller" asthma medication. Any time that

a provider

prescribes inhaled corticosteroids, cromolyn, nedocromil,

or a leukotriene

antagonist, a statement will appear which refers them to

the asthma

clinical pathways.

 

XI. METHODS OF PROVIDER EDUCATION:

 

Inservices to discuss the guidelines and emphasize the use

of the

clinical asthma pathways should be conducted annually. For

these

pathways to be effective and universally implemented staff

physicians in the primary care areas must not only be aware

of

them, but they must also emphasize their use. Initially

this will

require frequent reminding and some pressure to comply with

the

pathways. Department Chiefs must be aware of the pathways

and

emphasize their use. Each time that an asthmatic patient is

 

presented at morning report the pathways should be

mentioned.

 

The acute outpatient pathway (attachment # 1) should be

available

on paper at the time a patient is being treated for an

acute

exacerbation of asthma. The pathway can become a part of

the

clinic note for that visit.

 

Make the inpatient pathway ( attachment # 2) a part of the

CIS

notes in such a manner that it can be used to chart a

patients

course with prompts for medication doses, PEF monitoring,

and

discharge planning. At a minimum have the pathway available

on

CIS so that providers can refer to them when a patient is

admitted to an observation unit or the hospital.

 

Make the chronic asthma pathway (attachment # 3) readily

available in the clinic, and encourage providers to place a

copy

of this pathway in each asthmatic patients outpatient

record and

continuity file.

 

Have a reminder concerning the asthma clinical pathways

appear on

the CHCS screen when "controller" asthma medications are

being

ordered.

 

Link the asthma pathways to the asthma referral guidelines.

 

All three asthma pathways should be listed on the MAMC

Intranet

as well as on the MAMC Internet site.

 

XII. REVISION FREQUENCY:

 

These pathways should be reviewed by the Clinical Standards

Committee

annually. However, major revisions should only be required

every 3-5 years.

Minor changes, especially in controller medications, may be

necessary each

year. The point of contact for this proposal, LTC Ted

Carter, should review

the asthma pathways with a group of pediatric and adult

asthma experts each

year, and ask them to suggest revisions. These revisions

will be

incorporated into revisions of the asthma clinical

pathways, which will

then be forwarded to the Clinical Standards Committee for

approval.

 

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------------------------------------------------------------------------

 

Brief Summary

 

TITLE:

Assessing response to bronchodilator therapy at point of

care

 

SOURCE(S):

Respir Care 1995 Dec;40(12):1300-7 [67 references]

 

ADAPTATION:

 

Not applicable: The guideline was not adapted from another

source.

 

RELEASE DATE:

1995 Dec

 

MAJOR RECOMMENDATIONS:

 

Description:

 

Assessment of airflow (i.e., forced expiratory maneuvers

and

other clinical indicators) is important to determine the

presence

or absence of an immediate response (ie, at time of

expected

onset of effect), proper dose, frequency of administration,

and

overall response to long-term therapy). It is essential

that the

clinician have complete knowledge of the main effects, mode

of

action, time course, side effects, and dosage constraints

of any

medications administered.

 

Setting:

 

Settings include:

 

* critical care;

* acute care;

* extended care or skilled care facility;

* outpatient clinic;

* home; and

* pulmonary rehabilitation program.

 

Indications:

 

Assessment of airflow and other clinical indicators are

indicated

when the need exists:

 

* to confirm the appropriateness of therapy;

* to individualize the patient's medication dose per

treatment

and/or frequency of administration;

* to help determine patient status during acute and

long-term

pharmacologic therapy;

* to determine a need for change in therapy (dose,

frequency,

or type of medication).

 

Limitations of Procedure or Device:

 

* Conventional spirometry:

 

1. cost and accessibility;

2. the patient's inability to perform forced vital

capacity.

 

* peak-flow measurement:

 

1. Patient's inability to perform peak-flow maneuver or

forced

expiration;

2. The accuracy and reproducibility of peak-flow meters may

 

vary among models and among units of the same model.

 

a. For consistency and reproducibility of results the same

device (unit) should be used for a given patient.

b. If peak-flow meter is changed, the patient's range

should be

re-established because of variability among units and

models.

c. Peak flow measurement primarily reflects changes in

upper

airway conductance and may be of lim