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Empowering the Child and Caregiver: Yellow Zone Asthma Action Plan

  • Pediatric Allergy and Immunology (JM Portnoy and CE Ciaccio, Section Editors)
  • Published:
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Abstract

Current guidelines, both national and international, elegantly describe evidence-based measures to attain and maintain long-term control of asthma. These strategies, typically discussed between the provider and patient, are provided in the form of written (or electronic) instructions as part of the green zone of the color-coded Asthma Action Plan. The red zone of the Asthma Action Plan has directives on when to use systemic corticosteroids and seek medical attention. The transition zone between the green zone of good control and the red zone of asthma exacerbation is the yellow zone. This zone guides the patient on self-management of exacerbations outside a medical setting. Unfortunately, the only recommendation currently available to patients per the current asthma guidelines is the repetitive use of reliever bronchodilators. This approach, while providing modest symptom relief, does not reliably prevent progression to the red zone. In this document, we present new, evidence-based, yellow zone intervention options.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev. 2003;1, CD001117. doi:10.1002/14651858.CD001117.

    PubMed  Google Scholar 

  2. Expert Panel Report 3 (EPR-3). Guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol. 2007;120(5 Suppl):S94–138. doi:10.1016/j.jaci.2007.09.043.

    Google Scholar 

  3. GINA—The Global Strategy for Asthma Management and Prevention. Available at http://www.ginasthmacom/GuidelinesResourcesasp. 2006.

  4. Dinakar C, Oppenheimer J, Portnoy J, Bacharier LB, Li J, Kercsmar CM, et al. Management of acute loss of asthma control in the yellow zone: a practice parameter. Ann Allergy Asthma Immunol. 2014;113(2):143–59. A ground-breaking practice parameter critically reviewing pharmacological interventions for the management of yellow zone (home) exacerbations of asthma, exposing missing gaps in current recommendations, and suggesting evidence-based options.

  5. Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA, Bota GW. Corticosteroids for preventing relapse following acute exacerbations of asthma. Cochrane Database Syst Rev. 2007;3, CD000195. doi:10.1002/14651858.CD000195.pub2.

    PubMed  Google Scholar 

  6. Panickar J, Lakhanpaul M, Lambert PC, Kenia P, Stephenson T, Smyth A, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med. 2009;360(4):329–38. doi:10.1056/NEJMoa0804897.

    Article  PubMed  CAS  Google Scholar 

  7. Beigelman A, King TS, Mauger D, Zeiger RS, Strunk RC, Kelly HW, et al. Do oral corticosteroids reduce the severity of acute lower respiratory tract illnesses in preschool children with recurrent wheezing? J Allergy Clin Immunol. 2013;131(6):1518–25. doi:10.1016/j.jaci.2013.01.034. A provocative study that questions the widely-accepted belief that oral corticosteroids reliably influence outcomes in preschool children with wheezing illnesses.

  8. Dolan LM, Kesarwala HH, Holroyde JC, Fischer TJ. Short-term, high-dose, systemic steroids in children with asthma: the effect on the hypothalamic-pituitary-adrenal axis. J Allergy Clin Immunol. 1987;80(1):81–7.

    Article  PubMed  CAS  Google Scholar 

  9. Kayani S, Shannon DC. Adverse behavioral effects of treatment for acute exacerbation of asthma in children: a comparison of two doses of oral steroids. Chest. 2002;122(2):624–8.

    Article  PubMed  CAS  Google Scholar 

  10. van Staa TP, Cooper C, Leufkens HG, Bishop N. Children and the risk of fractures caused by oral corticosteroids. J Bone Mineral Res Offic J Am Soc Bone Min Res. 2003;18(5):913–8. doi:10.1359/jbmr.2003.18.5.913.

    Article  Google Scholar 

  11. Partridge MR, van der Molen T, Myrseth SE, Busse WW. Attitudes and actions of asthma patients on regular maintenance therapy: the INSPIRE study. BMC Pulm Med. 2006;6:13. doi:10.1186/1471-2466-6-13. An eye-opening study that enlightens providers regarding the self-expressed confidence of patients to recognize impending exacerbations and up-regulate their asthma medications, including controllers, during periods of worsening symptoms.

  12. Dinakar C, Van Osdol TJ, Wible K. How frequent are asthma exacerbations in a pediatric primary care setting and do written asthma action plans help in their management? J Asthma Offi J Assoc Care Asthma. 2004;41(8):807–12. This study affirms the belief that patients with asthma like to be empowered with asthma plans containing well-written and clear instructions on managing asthma.

  13. Bateman ED, Boushey HA, Bousquet J, Busse WW, Clark TJ, Pauwels RA, et al. Can guideline-defined asthma control be achieved? The Gaining Optimal Asthma ControL study. Am J Respir Crit Care Med. 2004;170(8):836–44.

    Article  PubMed  Google Scholar 

  14. FitzGerald JM, Becker A, Sears MR, Mink S, Chung K, Lee J. Doubling the dose of budesonide versus maintenance treatment in asthma exacerbations. Thorax. 2004;59(7):550–6.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  15. Tattersfield AE, Postma DS, Barnes PJ, Svensson K, Bauer CA, O’Byrne PM, et al. Exacerbations of asthma: a descriptive study of 425 severe exacerbations. The FACET International Study Group. Am J Respir Crit Care Med. 1999;160(2):594–9. This ageless study provides invaluable information on the chronology and kinetics of an asthma exacerbation.

  16. Strunk RC, Sternberg AL, Bacharier LB, Szefler SJ. Nocturnal awakening caused by asthma in children with mild-to-moderate asthma in the childhood asthma management program. J Allergy Clin Immunol. 2002;110(3):395–403.

    Article  PubMed  Google Scholar 

  17. Harrison TW, Oborne J, Newton S, Tattersfield AE. Doubling the dose of inhaled corticosteroid to prevent asthma exacerbations: randomised controlled trial. Lancet. 2004;363(9405):271–5.

    Article  PubMed  CAS  Google Scholar 

  18. Bacharier LB, Phillips BR, Zeiger RS, Szefler SJ, Martinez FD, Lemanske Jr RF, et al. Episodic use of an inhaled corticosteroid or leukotriene receptor antagonist in preschool children with moderate-to-severe intermittent wheezing. J Allergy Clin Immunol. 2008;122(6):1127–35 e8. doi:10.1016/j.jaci.2008.09.029.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  19. Ducharme FM, Lemire C, Noya FJ, Davis GM, Alos N, Leblond H, et al. Preemptive use of high-dose fluticasone for virus-induced wheezing in young children. N Engl J Med. 2009;360(4):339–53. doi:10.1056/NEJMoa0808907.

    Article  PubMed  CAS  Google Scholar 

  20. Van Metre Jr TE, Marsh DG, Adkinson Jr NF, Fish JE, Kagey-Sobotka A, Norman PS, et al. Dose of cat (Felis domesticus) allergen 1 (Fel d 1) that induces asthma. J Allergy Clin Immunol. 1986;78(1 Pt 1):62–75.

    PubMed  Google Scholar 

  21. Covar RA, Szefler SJ, Zeiger RS, Sorkness CA, Moss M, Mauger DT, et al. Factors associated with asthma exacerbations during a long-term clinical trial of controller medications in children. J Allergy Clin Immunol. 2008;122(4):741–7 e4.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  22. Thomas A, Lemanske RF, Jr., Jackson DJ. Approaches to stepping up and stepping down care in asthmatic patients. J Allergy Clin Immunol. 128(5):915–24; quiz 25–6.

  23. National Heart, Lung, and Blood Institute. Guidelines for the diagnosis and management of asthma. Expert Panel Report 2, National Institutes of Health, Bethesda, MD. 1997.

  24. Blake K, Madabushi R, Derendorf H, Lima J. Population pharmacodynamic model of bronchodilator response to inhaled albuterol in children and adults with asthma. Chest. 2008;134(5):981–9. This study provides reassurance on the commonly used doses of inhaled short acting beta2 agonists used to treat asthma symptoms.

  25. Schuh S, Johnson DW, Stephens D, Callahan S, Winders P, Canny GJ. Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma. J Pediatr. 1999;135(1):22–7.

    Article  PubMed  CAS  Google Scholar 

  26. Wilson NM, Silverman M. Treatment of acute, episodic asthma in preschool children using intermittent high dose inhaled steroids at home. Arch Dis Child. 1990;65(4):407–10.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  27. Connett G, Lenney W. Prevention of viral induced asthma attacks using inhaled budesonide. Arch Dis Child. 1993;68(1):85–7.

    Article  PubMed  CAS  PubMed Central  Google Scholar 

  28. Volovitz B, Nussinovitch M, Finkelstein Y, Harel L, Varsano I. Effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home. Clin Pediatr. 2001;40(2):79–86.

    Article  CAS  Google Scholar 

  29. Rice-McDonald G, Bowler S, Staines G, Mitchell C. Doubling daily inhaled corticosteroid dose is ineffective in mild to moderately severe attacks of asthma in adults. Intern Med J. 2005;35(12):693–8. doi:10.1111/j.1445-5994.2005.00972.x.

    Article  PubMed  CAS  Google Scholar 

  30. Foresi A, Morelli MC, Catena E, On behalf of the Italian Study Group. Low-dose budesonide with the addition of an increased dose during exacerbations is effective in long-term asthma control. Chest. 2000;117(2):440–6. A pivotal study indicating the effectiveness of the strategy of quadrupling inhaled corticosteroids for controlling asthma exacerbations (yellow zone).

  31. Oborne J, Mortimer K, Hubbard RB, Tattersfield AE, Harrison TW. Quadrupling the dose of inhaled corticosteroid to prevent asthma exacerbations: a randomized, double-blind, placebo-controlled, parallel-group clinical trial. Am J Respir Crit Care Med. 2009;180(7):598–602. doi:10.1164/rccm.200904-0616OC. Per protocol analysis in this study demonstrated effectiveness of quadrupling of inhaled corticosteroids in treating early asthma exacerbations.

  32. Yousef E, Hossain J, Mannan S, Skorpinski E, McGeady S. Early intervention with high-dose inhaled corticosteroids for control of acute asthma exacerbations at home and improved outcomes: a randomized controlled trial. Allergy Asthma Proc. 2012;33(6):508–13.

    Article  PubMed  CAS  Google Scholar 

  33. Toogood JH, Baskerville JC, Jennings B, Lefcoe NM, Johansson SA. Influence of dosing frequency and schedule on the response of chronic asthmatics to the aerosol steroid, budesonide. J Allergy Clin Immunol. 1982;70(4):288–98.

    Article  PubMed  CAS  Google Scholar 

  34. Boushey HA, Sorkness CA, King TS, Sullivan SD, Fahy JV, Lazarus SC, et al. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med. 2005;352(15):1519–28. doi:10.1056/NEJMoa042552. A landmark study exploring the notion of piggy-backing anti-inflammatory inhaled steroid medication with rescue short-acting beta agonist use in the management of well-controlled, mild persistent asthma.

  35. Papi A, Canonica GW, Maestrelli P, Paggiaro P, Olivieri D, Pozzi E, et al. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med. 2007;356(20):2040–52.

    Article  PubMed  CAS  Google Scholar 

  36. Martinez FD, Chinchilli VM, Morgan WJ, Boehmer SJ, Lemanske RF, Jr., Mauger DT et al. Use of beclomethasone dipropionate as rescue treatment for children with mild persistent asthma (TREXA): a randomised, double-blind, placebo-controlled trial. Lancet. 377(9766):650–7. An important study validating the coupling anti-inflammatory inhaled steroid medication with rescue short-acting beta agonist use in the management of well-controlled, mild persistent asthma in children.

  37. Calhoun WJ, Ameredes BT, King TS, Icitovic N, Bleecker ER, Castro M et al. Comparison of physician-, biomarker-, and symptom-based strategies for adjustment of inhaled corticosteroid therapy in adults with asthma: the BASALT randomized controlled trial. JAMA. 308(10):987–97.

  38. Rabe KF, Atienza T, Magyar P, Larsson P, Jorup C, Lalloo UG. Effect of budesonide in combination with formoterol for reliever therapy in asthma exacerbations: a randomised controlled, double-blind study. Lancet. 2006;368(9537):744–53. doi:10.1016/S0140-6736(06)69284-2.

    Article  PubMed  CAS  Google Scholar 

  39. O’Byrne PM, Bisgaard H, Godard PP, Pistolesi M, Palmqvist M, Zhu Y, et al. Budesonide/formoterol combination therapy as both maintenance and reliever medication in asthma. Am J Respir Crit Care Med. 2005;171(2):129–36. doi:10.1164/rccm.200407-884OC.

    Article  PubMed  Google Scholar 

  40. Scicchitano R, Aalbers R, Ukena D, Manjra A, Fouquert L, Centanni S, et al. Efficacy and safety of budesonide/formoterol single inhaler therapy versus a higher dose of budesonide in moderate to severe asthma. Curr Med Res Opin. 2004;20(9):1403–18. doi:10.1185/030079904X2051.

    Article  PubMed  CAS  Google Scholar 

  41. Vogelmeier C, D’Urzo A, Pauwels R, Merino JM, Jaspal M, Boutet S, et al. Budesonide/formoterol maintenance and reliever therapy: an effective asthma treatment option? Eur Respir J. 2005;26(5):819–28. doi:10.1183/09031936.05.00028305.

    Article  PubMed  CAS  Google Scholar 

  42. Cates CJ, Karner C. Combination formoterol and budesonide as maintenance and reliever therapy versus current best practice (including inhaled steroid maintenance), for chronic asthma in adults and children. Cochrane Database Syst Rev. 2013;4:CD007313. doi:10.1002/14651858.CD007313.pub3. An evidence-based review validating the effectiveness of the adjustable maintenance dosing strategy in ensuring maintenance of asthma control in adults.

  43. Chowdhury BA, Seymour SM, Levenson MS. Assessing the safety of adding LABAs to inhaled corticosteroids for treating asthma. N Engl J Med. 2011;364(26):2473–5. doi:10.1056/NEJMp1104375.

    Article  PubMed  CAS  Google Scholar 

  44. Symbicort® Prescribing Information Taking Symbicort SMART is simple. AstraZeneca. 2014. http://www.symbicort.com/asthma/prescribing-information.html http://www.symbicort.co.nz/smart/taking_smart.php. Accessed 30 Apr 2014.

  45. Bisgaard H, Le Roux P, Bjamer D, Dymek A, Vermeulen JH, Hultquist C. Budesonide/formoterol maintenance plus reliever therapy: a new strategy in pediatric asthma. Chest. 2006;130(6):1733–43. doi:10.1378/chest.130.6.1733. An important study exploring the role of adjustable maintenance therapy in the management of children with asthma.

  46. Cates CJ, Lasserson TJ. Regular treatment with formoterol and an inhaled corticosteroid versus regular treatment with salmeterol and an inhaled corticosteroid for chronic asthma: serious adverse events. Cochrane Database Syst Rev. 2010;(1):CD007694. doi:10.1002/14651858.CD007694.pub2. An insightful critical appraisal of safety issues related to the use of combination therapy in asthma management.

  47. Leuppi JD, Downie SR, Salome CM, Jenkins CR, Woolcock AJ. A single high dose of inhaled corticosteroids: a possible treatment of asthma exacerbations. Swiss Med Wkly. 2002;132(1–2):7–11.

    PubMed  CAS  Google Scholar 

  48. Qureshi F, Pestian J, Davis P, Zaritsky A. Effect of nebulized ipratropium on the hospitalization rates of children with asthma. N Engl J Med. 1998;339(15):1030–5. doi:10.1056/NEJM199810083391503.

    Article  PubMed  CAS  Google Scholar 

  49. Karpel JP, Schacter EN, Fanta C, Levey D, Spiro P, Aldrich T, et al. A comparison of ipratropium and albuterol vs albuterol alone for the treatment of acute asthma. Chest. 1996;110(3):611–6.

    Article  PubMed  CAS  Google Scholar 

  50. Rodrigo GJ, Rodrigo C. First-line therapy for adult patients with acute asthma receiving a multiple-dose protocol of ipratropium bromide plus albuterol in the emergency department. Am J Respir Crit Care Med. 2000;161(6):1862–8. doi:10.1164/ajrccm.161.6.9908115.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

The authors would like to thank the members of the Practice Parameters Joint Task Force and, in particular, the members of the Yellow Zone Practice Parameter Workgroup (Drs. John Oppenheimer, Len Bacharier, James Li, and Carolyn Kerscmar) for their invaluable contributions to the development of the practice parameter.

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Conflict of Interest

Chitra Dinakar is a speaker for GlaxoSmithKline, Teva Pharmaceuticals, and Merck. Jay M. Portnoy is connected with Thermo Fisher and Mylan.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Division of Allergy, Asthma and Immunology, Children’s Mercy Hospitals, University of Missouri—Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA

    Chitra Dinakar

  2. Division of Allergy, Asthma and Immunology, The Children’s Mercy Hospitals and Clinics, University of Missouri—Kansas City School of Medicine, 2401 Gillham Road, Kansas City, MO, 64108, USA

    Jay M. Portnoy

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  1. Chitra Dinakar
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Correspondence to Chitra Dinakar.

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This article is part of the Topical Collection on Pediatric Allergy and Immunology

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Dinakar, C., Portnoy, J.M. Empowering the Child and Caregiver: Yellow Zone Asthma Action Plan. Curr Allergy Asthma Rep 14, 475 (2014). https://doi.org/10.1007/s11882-014-0475-z

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