CONCORD INTERNAL MEDICINE

CONCORD INTERNAL MEDICINE Protocol for Asthma Douglas G. Kelling, Jr., MD C. Gismondi-Eagan, MD, FACP George C. Monroe, III, MD Revised March 2, 2012 The information contained in this protocol should never be used as a substitute for clinical judgment. The clinician and the patient need to develop an individual treatment plan that is tailored to the specific needs and circumstances of the patient.

ASTHMA PROTOCOL TABLE OF CONTENTS ELEMENTS OF CONTROL 1 PAGE(S) MONITORING 2 PERIODIC OFFICE VISITS ASTHMA CONTROL TEST ENGLISH SPANISH ASSESSING ASTHMA CONTROL 6 CLASSIFYING ASTHMA SEVERITY 7-8 PULMONARY FUNCTION TESTS 9 WRITTEN ACTION PLAN ENGLISH 10 SPANISH 11 PEAK FLOW MONITORING 12 EDUCATION 1 BASIC FACTS ABOUT ASTHMA ENGLISH 1-1 SPANISH 16-17 USING MDI ENGLISH 18 SPANISH 19 SPACER ENGLISH 20 SPANISH 21 CONTROL OF ENVIRONMENTAL AND CO-MORBID CONDITIONS 22 MEDICATIONS 2 REFERRAL TO ASTHMA SPECIALIST 2

1 Asthma Elements of Control Monitoring Education Control of Environmental factors and co-morbid conditions Medications Refer to Page 2 Refer to Page 1 Refer to Page 22 Refer to Page 2

2 Asthma Monitoring Periodic Office Visits Pulmonary Function Tests Written Action Plan Peak Flow Meter Refer to Page Refer to Page 9 Refer to Page 10-English Refer to Page 11-Spanish Refer to Page 12

Periodic Office Visits Administer Asthma Control Test (ACT) Refer to Page - for English Refer to Page - for Spanish Refer to Page 6 to assess control Patient on Long Term Control Medication No Yes Refer to Page 7 to Assess Severity Refer to Page 8 to Assess Severity Patient has intermittent or mild persistent asthma that has been under control for at least months Uncontrolled and/or moderate to severe asthma and patient who needs additional supervision to help follow their treatment plans Office visit every 6 months with ACT and assessment of severity Office visit every 1 to months with ACT and assessment of severity

Today s Date: Patient s Name: FOR PATIENTS: Take the Asthma Control Test TM (ACT) for people 12 yrs and older. Know your score. Share your results with your doctor. Step 1 Write the number of each answer in the score box provided. Step 2 Add the score boxes for your total. Step Take the test to the doctor to talk about your score. 1. In the past weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? All of Most of the time 1 the time 2 Some of the time A little of the time None of the time SCORE 2. During the past weeks, how often have you had shortness of breath? More than once a day 1 Once a day 2 to 6 times a week Once or twice a week Not at all. During the past weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night or earlier than usual in the morning? or more 2 or nights nights a week 1 a week 2 Once a week Once or twice Not at all. During the past weeks, how often have you used your rescue inhaler or nebulizer medication (such as albuterol)? or more 1 or 2 times times per day 1 per day 2 2 or times per week Once a week or less Not at all. How would you rate your asthma control during the past weeks? Not controlled at all 1 Poorly controlled 2 Somewhat controlled Well controlled Completely controlled TOTAL Copyright 2002, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated. If your score is 19 or less, your asthma may not be controlled as well as it could be. Talk to your doctor. FOR PHYSICIANS: The ACT is: A simple, -question tool that is self-administered by the patient Clinically validated by specialist assessment and spirometry 1 Recognized by the National Institutes of Health Reference: 1. Nathan RA et al. J Allergy Clin Immunol. 200;11:9-6.

Fecha de hoy: Nombre y apellido del paciente: PARA LOS PACIENTES: Tome la Prueba de Control del Asma (Asthma Control Test TM ACT) para personas de 12 años de edad en adelante. Averigüe su puntaje. Comparta sus resultados con su médico. Paso 1 Anote el número correspondiente a cada respuesta en el cuadro de la derecha. Paso 2 Sume todos los puntos en los cuadros para obtener el total. Paso Llévele la prueba a su doctor para hablar sobre su puntaje total. 1. En las últimas semanas, cuánto tiempo le ha impedido su asma hacer todo lo que quería en el trabajo, en la escuela o en la casa? Siempre La mayoría 1 del tiempo 2 Algo del tiempo Un poco del tiempo Nunca PUNTAJE 2. Durante las últimas semanas, con qué frecuencia le ha faltado aire? Más de una vez al día 1 Una vez por día 2 De a 6 veces por semana Una o dos veces por semana Nunca. Durante las últimas semanas, con qué frecuencia sus síntomas del asma (respiración sibilante o un silbido en el pecho, tos, falta de aire, opresión en el pecho o dolor) lo/la despertaron durante la noche o más temprano de lo usual en la mañana? o más noches 2 ó veces por semana 1 por semana 2 Una vez por semana Una o dos veces Nunca. Durante las últimas semanas, con qué frecuencia ha usado su inhalador de rescate o medicamento en nebulizador (como albuterol)? o más veces 1 ó 2 veces al día 1 al día 2 2 ó veces por semana Una vez por semana o menos Nunca. Cómo evaluaría el control de su asma durante las últimas semanas? No controlada, en absoluto 1 Mal controlada 2 Algo controlada Bien controlada Completamente controlada Derechos de autor 2002, por QualityMetric Incorporated Asthma Control Test es una marca comercial de QualityMetric Incorporated. TOTAL Si obtuvo 19 puntos o menos, es posible que su asma no esté tan bien controlada como podría. Hable con su médico. PARA LOS MÉDICOS: La Prueba ACT: Ha sido convalidada clínicamente por espirometría y evaluaciones de especialistas 1 Tiene el apoyo de la American Lung Association (Asociación Americana del Pulmón) Consiste en un breve cuestionario de preguntas al que el paciente responde independientemente y que puede ayudarle al médico a evaluar el asma de sus pacientes durante las últimas semanas. Referencia: 1. Nathan RA et al. J Allergy Clin Immunol. 200;11:9-6.

6 ASSESSING ASTHMA CONTROL IN YOUTHS >12 YEARS OF AGE AND ADULTS Classification of Asthma Control (Youths >12 years of age and adults) Components of Control Not Very Poorly Well-Controlled Well-Controlled Controlled Symptoms <2 days/week > 2 days/week Throughout the day Nighttime awakening <2x/month 1-x/week >x/week Interference with normal activity None Some limitation Extremely limited Short-acting beta 2 - agonist use for Impairment symptom control (not <2 days/week >2 days/week Several times per day prevention of EIB) FEV 1 or peak flow >80% predicted/ 60-80% predicted/ <60% predicted/ personal best personal best personal best Validated Questionnaire ACT >20 16-19 <1 Exacerbations 0-1/year >2/year (see note) Consider severity and interval since last exacerbation Progressive loss of lung function Evaluation requires long-term follow up care Risk Treatment-related adverse effects *ACQ values of 0.76-1. are indeterminate regarding well-controlled asthma. Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Key: EIB, exercise-induced bronchospasm; FEV 1, forced expiratory volume in 1 second; ACT, Asthma Control Test. Notes: The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient's recall of previous 2 weeks and by spirometry/or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient's asthma is better or worse since the last visit. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma.

7 CLASSIFYING ASTHMA SEVERITY IN YOUTHS >12 YEARS OF AGE AND ADULTS Classifying severity for patients who are not currently taking long-term control medications Components of Severity Symptoms Classification of Asthma Severity (Youths >12 years of age and adults) Persistent Intermittent Mild Moderate Severe 2 days/week >2 days/week but not daily Daily Throughout the day Impairment Normal FEV1/FVC: 8 19 yr 8% 20 9 yr 80% 0 9 yr 7% 60 80 yr 70% Risk Nighttime awakenings Short-acting Beta 2 -agonist use for symptom control (not prevention of EIB) Interference with normal activity Lung function Exacerbations requiring oral systemic corticosteroids 2x/month x/month >1x/week but not nightly 2 days/week >2 days/week Daily but not >1x/day None Normal FEV 1 between exacerbations FEV 1 >80% predicted FEV 1 /FVC normal 0-1/yr (see note) Minor limitation FEV 1 >80% predicted FEV 1 /FVC normal >2 year (see note) Some limitation FEV 1 >60% but <80% predicted FEV 1 /FVC reduced % Often 7x/week Several times per day Extremely limited FEV 1 <60% predicted FEV 1 /FVC reduced >% Consider severity and interval since last exacerbation. Frequency and severity may fluctuate over time for patients in any severity category. Relative annual risk of exacerbations may be related to FEV 1 Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by patient s/caregiver s recall of previous 2 weeks and spirometry. Assign severity to the most severe category in which any feature occurs. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma. Key: EIB, Exercise-induced bronchospasm; FEV 1, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, intensive care unit.

8 Asthma Classification of Asthma Severity-lowest level of treatment required to maintain control Intermittent Mild Persistent Moderate Persistent Severe Persistent Preferred: Preferred: Preferred: Preferred: SABA PRN Low-dose ICS Alternative: Cromolyn, LTRA, Nedocromil Theophylline Low-dose ICS + LABA Or Medium-dose ICS Alternative: Low-dose ICS+ either LTRA, Theophylline, or Zileuton High-dose ICS + LABA AND Consider Omalizumab for patients who have allergies OR OR Preferred: Preferred: Medium-dose ICS + LABA Alternative: Medium-dose ICS + either LTRA, Theophylline, or Zileuton High-dose ICS + LABA + corticosteroid AND Consider Omalizumab for patients who have allergies Key: EIB, exercise-inducted bronchospasm; ICS, inhaled corticosteroid; LABA, long-acting inhaled beta 2 -agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta 2 -agonist.

9 Asthma Pulmonary Function Tests (Spirometry measurements FEV, forced expiratory volume in 6 seconds (FEV 6 ), FVC, FEV 1 /FVC- before and after the patient inhales a short-acting bronchodilator.) At time of initial assessment After treatment is initiated and symptoms and peak expiratory flow have stabilized Symptoms under control? Yes No 1-2 Years During periods of progressive or prolonged loss of asthma control

10 Concord Internal Medicine 200 Medical Park Drive, Suite 0 ~ Concord, NC 2802 70-0-107 WRITTEN ACTION PLAN Patient s Name SS# Date of Birth Peak Expiratory Flow (PEF) Important Peak Flow Numbers Personal Best Baseline 80% of baseline 0% of baseline MANAGEMENT OF EXACERBATION OF ASTHMA: HOME TREATMENT Measure PEF every morning and whenever you have symptoms of asthma such as cough, shortness of breath, wheezing, and / or chest tightness. You have symptoms or PEF < 80% of baseline. Use your rescue inhaler (Proventil, Ventolin, ProAir, or Combivent) 2- puffs every 20 minutes for up to treatments (wait 0 seconds between each puff). Repeat PEF times. Use the best measurement. PEF > 80% of baseline PEF 0-80% of baseline PEF < 0% of baseline Symptoms same or improved Continue rescue inhaler 2- puffs every - hours as necessary Symptoms worse Continue rescue inhaler 2- puffs every - hours as necessary Contact Dr. Kelling or his office immediately Begin Medrol Dose Pack or Prednisone taper Continue rescue inhaler 2- puffs every - hours while awake for 2-8 hours Contact Dr. Kelling or his office immediately Begin Medrol Dose Pack or Prednisone taper Repeat rescue inhaler puffs Arrange for immediate transportation to hospital emergency department, call 911 if necessary

11 Concord Internal Medicine 200 Medical Park Drive, Suite 0 ~ Concord, NC 2802 70-0-107 PLAN ESCRITO DE ACCIÓN WRITTEN ACTION PLAN Nombre del paciente Flujo Espiratorio Máximo (PEF, en inglés) Patient s Name Números importantes de flujo máximo Número de Seguro Social Mejor valor inicial personal SS# 80% del valor inicial Fecha de nacimiento DOB 0% del valor inicial ATENCIÓN A LA REAGUDIZACIÓN DEL ASMA: TRATAMIENTO EN CASA Mida el Flujo Espiratorio Máximo (PEF, en inglés) cada mañana y cuando tenga síntomas de asma tales como tos, respiración dificultosa, sibilancias y /u opresión en el pecho. Tiene síntomas o PEF < 80% del valor inicial. Use su inhalador de rescate (Proventil, Ventolin, ProAir, o Combivent) entre 2 y inspiraciones cada 20 minutos y hasta tratamientos (espere 0 segundos entre cada inspiraciones). Repita PEF veces. Use la mejor medida. PEF > 80% del valor inicial PEF 0-80% del valor inicial PEF < 0% del valor inicial Síntomas iguales o mejorados Continúe con el inhalador de rescate entre 2 y inspiraciones cada a horas cuando sea necesario Síntomas peores Continúe con el inhalador de rescate entre 2 y inspiraciones cada a horas cuando sea necesario Llame inmediatamente al Dr. Kelling o a su consultorio Empiece el paquete con la dosis de Medrol o el Prednisone de disminución Continúe con el inhalador de rescate entre 2 y inspiraciones cada a horas mientras esté despierto durante 2 a 8 horas Llame inmediatamente al Dr. Kelling o a su consultorio Empiece el paquete con la dosis de Medrol o el Prednisone de disminución gradual Repita inspiraciones con el inhalador de rescate Haga arreglos para transporte inmediato al departamento de emergencia del hospital, llame al 911 si es necesario

12 Asthma Peak Flow Monitoring Patient with moderate or severe persistent asthma -or- Patient who has had a history of severe exacerbations -or- Patient who poorly perceives airflow obstruction and worsening asthma

1 Asthma Education Basic facts about asthma Role of medication Inhaler technique Use of spacer Identifying and avoiding environmental exposures Written asthma plans Peak flow monitoring Refer to pages 1 & 1-English Refer to pages 16 & 17-Spanish Refer to Page 18-English Refer to Page 19-Spanish Refer to page 22 Refer to Page 20-English Refer to Page 21- Spanish Refer to page 10-English Refer to page 11-Spanish

1 What Is Asthma? Asthma (AZ-ma) is a chronic (long-term) lung disease that inflames and narrows the airways. Asthma causes recurring periods of wheezing (a whistling sound when you breathe), chest tightness, shortness of breath, and coughing. The coughing often occurs at night or early in the morning. Asthma affects people of all ages, but it most often starts during childhood. In the United States, more than 22 million people are known to have asthma. Nearly 6 million of these people are children. Overview The airways are tubes that carry air into and out of your lungs. People who have asthma have inflamed airways. This makes the airways swollen and very sensitive. They tend to react strongly to certain inhaled substances. When the airways react, the muscles around them tighten. This narrows the airways, causing less air to flow into the lungs. The swelling also can worsen, making the airways even narrower. Cells in the airways may make more mucus than normal. Mucus is a sticky, thick liquid that can further narrow your airways. This chain reaction can result in asthma symptoms. Symptoms can happen each time the airways are inflamed. Asthma Figure A shows the location of the lungs and airways in the body. Figure B shows a crosssection of a normal airway. Figure C shows a cross-section of an airway during asthma symptoms. http://www.nhlbi.nih.gov/health/dci/diseases/asthma/asthma_whatis.html

1 Sometimes, asthma symptoms are mild and go away on their own or after minimal treatment with an asthma medicine. Other times, symptoms continue to get worse. When symptoms get more intense and/or more symptoms occur, you're having an asthma attack. Asthma attacks also are called flareups or exacerbations (eg-zas-er-ba-shuns). It's important to treat symptoms when you first notice them. This will help prevent the symptoms from worsening and causing a severe asthma attack. Severe asthma attacks may require emergency care, and they can be fatal. Outlook Asthma can't be cured. Even when you feel fine, you still have the disease and it can flare up at any time. However, with today's knowledge and treatments, most people who have asthma are able to manage the disease. They have few, if any, symptoms. They can live normal, active lives and sleep through the night without interruption from asthma. You can take an active role in managing your asthma. For successful, thorough, and ongoing treatment, build strong partnerships with your doctor and other health care providers. http://www.nhlbi.nih.gov/health/dci/diseases/asthma/asthma_whatis.html

16 Qué es el asma? El asma es una enfermedad crónica de los pulmones que inflama y estrecha las vías respiratorias. (Las enfermedades crónicas son enfermedades que duran mucho tiempo). El asma causa períodos repetidos de sibilancias (silbidos al respirar), presión en el pecho, dificultad para respirar y tos. Con frecuencia la tos se presenta por la noche o en las primeras horas de la mañana. El asma afecta a personas de todas las edades, pero por lo general comienza durante la infancia. En los Estados Unidos hay más de 22 millones de personas con asma comprobada. Casi 6 millones de estas personas son niños. Revisión general Las vías respiratorias son tubos que conducen el aire que entra y sale de los pulmones. Las personas que sufren de asma tienen vías respiratorias inflamadas. Esto hace que las vías respiratorias estén hinchadas y muy sensibles, y tiendan a reaccionar fuertemente a ciertas sustancias que se inhalan. Cuando las vías respiratorias reaccionan, los músculos que las rodean se contraen. Esto las estrecha y hace que llegue menos aire a los pulmones. La hinchazón también puede empeorar y estrechar las vías respiratorias aún más. Las células de estas vías pueden producir más mucosidad que en condiciones normales. La mucosidad es un líquido pegajoso y espeso que puede estrechar más las vías respiratorias. Esta reacción en cadena puede causar síntomas de asma. Cada vez que las vías respiratorias se inflaman pueden presentarse síntomas. Asma

17 La figura A muestra la ubicación de los pulmones y las vías respiratorias en el cuerpo. La figura B muestra un corte transversal de una vía respiratoria normal. La figura C muestra un corte transversal de una vía respiratoria durante los síntomas de asma. A veces los síntomas son leves y desaparecen espontáneamente o después de un tratamiento mínimo con una medicina para el asma. Otras veces siguen empeorando. Cuando los síntomas se vuelven más intensos o se presentan más síntomas, se dice que hay un ataque de asma. Los ataques de asma también se llaman crisis o exacerbaciones. Es importante tratar los síntomas en cuanto se presentan. Así se evita que empeoren y causen un ataque de asma grave. Los ataques de asma graves pueden requerir atención de urgencias y pueden ser mortales. Perspectivas El asma no tiene cura. Aunque usted se sienta bien, sigue teniendo la enfermedad y podría empeorar en cualquier momento. Sin embargo, debido a los conocimientos y tratamientos que tenemos en la actualidad, la mayoría de las personas con asma pueden controlar la enfermedad. Es posible que tengan pocos síntomas o que no los tengan. Pueden vivir una vida normal y activa, y dormir toda la noche sin interrupciones causadas por el asma. Usted puede participar activamente en el control de su asma. Si desea un tratamiento exitoso, completo y constante, forme un equipo sólido con su médico y otros profesionales de salud encargados de atenderlo.

Using Your MDI Closed-Mouth Technique Patient Education Guide American College of Chest Physicians 00 Dundee Road, Northbrook, IL 60062 (87) 98-100 phone (87) 98-60 fax www.chestnet.org To make your breathing better, you MUST take your medicine as explained below. Following these instructions puts more of the medicine into your lungs. This will open up your air passages and help you breathe easier and feel better. You need to ask your health-care provider or pharmacist how many puffs of medicine your metered-dose inhaler (MDI) has when it is full. You need to keep track of how many puffs of medicine you take every day, so you can have your MDI refilled before you run out of medicine. Before using your MDI, please read the priming or preparing instructions. Your MDI should be cleaned once a week. See the instructions on cleaning your MDI. 1 2 Take cap off MDI. Check for and remove any dust, lint, or other objects. Shake MDI well. Sit up straight or stand up. 6 Breathe out all the way. Tilt MDI up slightly. Put MDI in your mouth, between your teeth, tongue flat under the mouthpiece, with lips sealed. As you begin to BREATHE IN SLOWLY, PRESS DOWN ON THE MDI, as shown in this picture. Keep breathing in until your lungs are completely full. HOLD your breath for 10 seconds. If you cannot hold your breath for 10 seconds, hold your breath as long as you can. 7 8 9 If you need to take another puff of medicine, wait 1 minute. After 1 minute, repeat steps 2-6. Rinse your mouth out after you take your last puff of medicine. Make sure you spit the water out; do not swallow it. Rinsing is only necessary if the medicine you just took was a corticosteroid, such as Flovent, Beclovent, Vanceril, Aerobid, or Azmacort. Recap the MDI. The American College of Chest Physicians is the leading resource for the improvement of cardiopulmonary health and critical care worldwide. Its mission is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication. This publication s content contains general information, is not intended to be and is not complete, is not medical advice, and does not replace professional medical care and physician advice, which always should be sought for any specific condition. The American College of Chest Physicians and its officers, regents, executive committee, members, and employees specifically disclaim all responsibility for any liability, damages (actual or consequential), loss, or risk, personal or otherwise, based on any legal theory whatsoever, alleged to have been incurred as a result, directly or indirectly, of the use of any of the material herein. 2006 by The American College of Chest Physicians

SM Como usar su MDI técnica de la boca cerrada Guía Educacional para Pacientes American College of Chest Physicians 00 Dundee Road, Northbrook, IL 60062 (87) 98-100 teléfono (87) 98-60 fax www.chestnet.org Para mejorar su respiración, TIENE QUE usar su medicamento según se le explica en las siguientes instrucciones. Si sigue estas instrucciones, más medicina entrará a sus pulmones. Esto abrirá sus vias respiratorias y le ayudará a respirar más fácilmente y a sentirse mejor. Le necesita preguntar a su proveedor de cuidado médico o a su farmacéutico cuantas dosis de medicina contiene su inhalador de dosis medida (MDI por sus siglas en inglés) cuando está lleno. Necesita llevar la cuenta del número de dosis de medicina que usa todos los dias, y así poder encargar un repuesto antes de que se le termine la medicina. Antes de usar su MDI, por favor lea las instrucciones sobre como prepararlo. Su MDI se debe limpiar una vez por semana. Vea las instrucciones sobre como limpiarlo. 1 2 Quítele la tapa al MDI. Fíjese si tiene cualquier polvo, pelusa, u otro objeto y quíteselo. Agite bien el MDI. Siéntese derecho o párese. 6 Respire para afuera completamente. Incline un poquito hacia arriba el MDI. Ponga el MDI en su boca, entre los dientes, con la lengua plana debajo de la boquilla, con los labios bien cerrados para evitar fugas. Al comenzar a RESPIRAR PARA ADENTRO LENTAMENTE, OPRIMA PARA ABAJO EL MDI, como muestra esta foto. Siga respirando para adentro hasta que sus pulmones esten completamente llenos. CONTENGA la respiración por 10 segundos. Si no la puede contener por 10 segundos, conténgala por el mayor tiempo que pueda. 7 8 9 Si necesita tomar otra dosis de medicina, espere un minuto. Después de un minuto, repita los pasos del 2 al 6. Enjuáguese la boca después de tomar su última dosis de medicina. Escupa el agua; no se la tome. Solo es necesario enjuagarse la boca si el medicamento que acaba de usar es un corticoesteroide, tal como Flovent, Beclovent, Vanceril, Aerobid, o Azmacort. Vuelva a tapar el MDI. El American College of Chest Physicians es el recurso eminente para el mejoramiento de la salud cardiopulmonar y cuidado crítico a nivel mundial. Su misión es la de promover la prevención y tratamiento de enfermedades del pecho por medio de liderazgo, educación, investigaciones, y comunicación. El contenido de esta publicación contiene información general, no tiene la intención de ser completa y no lo es, no es consejo médico, y no reemplaza el cuidado médico profesional ni los consejos de un médico, los cuales siempre debe solicitar para cualquier condición específica. El American College of Chest Physicians y sus directores, regentes, comité ejecutivo, miembros, y empleados especificamente renuncian a toda responsabilidad acerca de cualquier cuestión legal, daños (actuales o a consecuencia), pérdida, o riesgo, personal o de cualquier otro tipo, basados en cualquier teoría legal sea la que sea, que se suponga que haya sufrido como resultado, directo e indirecto, por el uso de cualquier material aquí mencionado. Para imprimir copias gratuitas de este folleto vaya a www.chestnet.org/patients/guides/inhaleddevices.php. Propiedad literaria 2006 por el American College of Chest Physicians

Using Your MDI With a Spacer Patient Education Guide American College of Chest Physicians 00 Dundee Road, Northbrook, IL 60062 (87) 98-100 phone (87) 98-60 fax www.chestnet.org To make your breathing better, you MUST take your medicine as explained below. Following these instructions puts more of the medicine into your lungs. This will open up your air passages and help you breathe easier and feel better. You need to ask your health-care provider or pharmacist how many puffs of medicine your metered-dose inhaler (MDI) has when it is full. You need to keep track of how many puffs of medicine you take every day, so you can have your MDI refilled before you run out of medicine. Before using the MDI, please read the priming or preparing instructions. Your MDI and spacer should be cleaned once a week. See instructions on cleaning your MDI. 1 2 Take cap off MDI. Check for and remove any dust, lint, or other objects. Shake MDI well. Attach MDI to spacer. 6 Sit up straight and breathe out normally. Put mouthpiece of spacer in your mouth. Close your lips around the mouthpiece and make a tight seal. Press down on the MDI. This puts one puff of medicine into the spacer. To breathe in that one puff of medicine, TAKE A SLOW, DEEP BREATH. Breathe in as much air as you can. Try to fill up your lungs completely. It is important that the breath be SLOW and DEEP. Remove the mouthpiece from your mouth. HOLD your breath for 10 seconds. If you cannot hold your breath for 10 seconds, hold your breath as long as you can. 7 8 If you need to take another puff of medicine, wait 1 minute. After 1 minute, repeat steps -6. Recap the MDI. Rinse your mouth with water after you have taken your last puff of medicine. Make sure you spit the water out, do not swallow it. Rinsing is only necessary if the medicine you just took was a corticosteroid, such as Flovent, Beclovent, Vanceril, Aerobid, or Azmacort. The American College of Chest Physicians is the leading resource for the improvement of cardiopulmonary health and critical care worldwide. Its mission is to promote the prevention and treatment of diseases of the chest through leadership, education, research, and communication. This publication s content contains general information, is not intended to be and is not complete, is not medical advice, and does not replace professional medical care and physician advice, which always should be sought for any specific condition. The American College of Chest Physicians and its officers, regents, executive committee, members, and employees specifically disclaim all responsibility for any liability, damages (actual or consequential), loss, or risk, personal or otherwise, based on any legal theory whatsoever, alleged to have been incurred as a result, directly or indirectly, of the use of any of the material herein. 2006 by The American College of Chest Physicians

Como usar su MDI con una cámara de inhalación Guía Educacional para Pacientes American College of Chest Physicians 00 Dundee Road, Northbrook, IL 60062 (87) 98-100 teléfono (87) 98-60 fax www.chestnet.org SM Para mejorar su respiración, TIENE QUE usar su medicamento según se le explica en las siguientes instrucciones. Si sigue estas instrucciones, más de la medicina entrará a sus pulmones. Esto abrirá sus vias respiratorias y le ayudará a respirar más fácilmente y a sentirse mejor. Le necesita preguntar a su proveedor de cuidado médico o a su farmacéutico cuantas dosis de medicina contiene su inhalador de dosis medida (MDI por sus siglas en inglés) cuando está lleno. Necesita llevar la cuenta del número de dosis de medicina que usa todos los dias, y así poder encargar un repuesto antes de que se le termine la medicina. Antes de usar su MDI, por favor lea las instrucciones sobre como prepararlo. Su MDI y la cámara de inhalación se deben limpiar una vez por semana. Vea las instrucciones sobre como limpiarlo. 1 2 Quítele la tapa al MDI. Fíjese si tiene cualquier polvo, pelusa, u otro objeto y quíteselo. Agite bien el MDI. Coloque el MDI en la apertura de la cámara de inhalación. 6 Siéntese derecho y respire para afuera normalmente. Ponga la boquilla de la cámara de inhalación en su boca. Cierre bien los labios sobre la boquilla para evitar fugas. Oprima para abajo el MDI. Esto pone una dosis de medicina en la cámara de inhalación. Para inhalar esa dosis de medicina, RESPIRE PARA ADENTRO LENTA Y PROFUNDAMENTE. Inhale cuanto aire pueda. Trate de llenar sus pulmones completamente. Es importante que esta respiración sea LENTA y PROFUNDA. Quite la boquilla de su boca. CONTENGA la respiración por 10 segundos. Si no la puede contener por 10 segundos, conténgala por el mayor tiempo que pueda. 7 8 Si necesita tomar otra dosis de medicina, espere un minuto. Después de un minuto, repita los pasos del al 6. Vuelva a tapar el MDI. Enjuáguese la boca después de tomar su última dosis de medicina. Escupa el agua; no se la tome. Solo es necesario enjuagarse la boca si el medicamento que acaba de usar es un corticoesteroide, tal como Flovent, Beclovent, Vanceril, Aerobid, o Azmacort. El American College of Chest Physicians es el recurso eminente para el mejoramiento de la salud cardiopulmonar y cuidado crítico a nivel mundial. Su misión es la de promover la prevención y tratamiento de enfermedades del pecho por medio de liderazgo, educación, investigaciones, y comunicación. El contenido de esta publicación contiene información general, no tiene la intención de ser completa y no lo es, no es consejo médico, y no reemplaza el cuidado médico profesional ni los consejos de un médico, los cuales siempre debe solicitar para cualquier condición específica. El American College of Chest Physicians y sus directores, regentes, comité ejecutivo, miembros, y empleados especificamente renuncian a toda responsabilidad acerca de cualquier cuestión legal, daños (actuales o a consecuencia), pérdida, o riesgo, personal o de cualquier otro tipo, basados en cualquier teoría legal sea la que sea, que se suponga que haya sufrido como resultado, directo e indirecto, por el uso de cualquier material aquí mencionado. Para imprimir copias gratuitas de este folleto vaya a www.chestnet.org/patients/guides/inhaleddevices.php. Propiedad literaria 2006 por el American College of Chest Physicians

22 Asthma Control of Environmental and Co-morbid Conditions Stop smoking if applicable Avoid exposure to allergens based on history and allergy testing Avoid exposure to irritants such as smoke, substances with strong odors, air pollutants Avoid use of nonselective beta-blockers (carvedilol, labetalol, nadelol, pindolol, propanolol, sotalol) Avoid aspirin and NSAIDS if patient has severe persistent nasal polyps of history of sensitivity to aspirin or NSAIDS Avoid sulfitecontaining foods and other foods to which patient is sensitive Immunizations Flu and Pneumovax Evaluate and control co-morbid conditions ABPA (Allergic Broncho- Pulmonary Aspergillosi GERD Obesity OSA (Obstructive Sleep Apnea) Rhino/sinusitis Chronic stress/ depression

2 Asthma Medications Referral toasthma specialist see pg. 2

2 Referral to an Asthma Specialist for Consultation or Comanagement The Expert Panel recommends referral for consultation or care to a specialist in asthma care (usually, a fellowship-trained allergist or pulmonologist; occasionally, other physicians who have expertise in asthma management, developed through additional training and experience) when: Patient has had a life-threatening asthma exacerbation. Patient is not meeting the goals of asthma therapy after 6 months of treatment. An earlier referral or consultation is appropriate if the physician concludes that the patient is unresponsive to therapy. Signs and symptoms are atypical, or there are problems in differential diagnosis. Other conditions complicate asthma or its diagnosis (e.g., sinusitis, nasal polyps, aspergillosis, severe rhinitis, VCD, GERD, COPD). Additional diagnostic testing is indicated (e.g., allergy skin testing, rhinoscopy, complete pulmonary function studies, provocative challenge, bronchoscopy). Patient requires additional education and guidance on complications of therapy, problems with adherence, or allergen avoidance. Patient is being considered for immunotherapy. Patient requires step care or higher (step for children 0 years of age). Consider referral if patient requires step care (step 2 for children 0 years of age). Patient has required more than two bursts of oral corticosteroids in 1 year or has an exacerbation requiring hospitalization. Patient requires confirmation of a history that suggests that an occupational or environmental inhalant or ingested substance is provoking or contributing to asthma. Depending on the complexities of diagnosis, treatment, or the intervention required in the work environment, it may be appropriate in some cases for the specialist to manage the patient over a period of time or to co-manage with the PCP.