Asthma

1
Asthma

• Debbie King FNP PNP
• 8800

2
Epidemiology of Asthma Affects over 30 million
people as of 2007 More children and adults
effected than ever associated with atopic
sensitization and is equal to increases in
allergies The rate increases as more of the world
adopts western lifestyles and become
urbanized 100 million additional people are
predicated to be affected in 2025 Accounts for 1
in every 250 deaths each year Largest populations
effected are African Americans and Children
3
ASTHMA A CHRONIC DISORDER OF THE TRACHEOBRONCHIAL
TREE CHARACTERIZED BY MILD TO SEVERE OBSTRUCTION
TO AIRFLOW IN RECURRENT EPISODES. CHARACTERIZED
BY SPASM OF BRONCHIAL SMOOTH MUSCLE EDEMA MUCUS
PRODUCTION REVERSIBILITY
4
Global Initiative for Asthma definition Chronic
inflammatory disorder (involving) Mast cells,
eosinophils, T lymphocytes, neutrophils, and
epithelial cells leading to air way
hyper-responsiveness that leads to recurrent
episodes of wheezing with airflow obstruction
5
Differential Diagnosis

• COPD
• CHF
• Pulmonary embolism
• Laryngeal dysfunction
• Obstruction tumors
• Cough due to medications (ACE inhibitors)
• Vocal cord dysfunction
• GERD
• In younger patients consider reflux, sinusitis,
  rhinitis, foreign body, Cystic Fibrosis,
  bronchiolitis

6
Host Factors

• Genetics
• Multiple genes involved
• Different genes for different ethnic groups
• Sex
• Children- boys 2x more likely
• Adults - women more likely
• Obesity
• Certain mediators such as leptin more prevalent

7

• PATHOPHYSIOLOGY OF ASTHMA
• Reduction of airway diameter due to bronchial
  smooth muscle contraction
• Edema of the bronchial wall
• Production of excessive, thick, tenacious mucus
• LEADS TO
• A NET INCREASE IN AIRWAY RESISTANCE
• INCREASE WORK OF BREATHING
• DECREASED FORCED EXPIRATORY VOLUMES
• AIR TRAPPING AND HYPERINFLATION

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Treatment Focus

• 2007 Asthma Guidelines A new Treatment Approach
  That Focuses on Achieving and Maintaining control
• Variability of asthma
• Asthma control
• Asthma assessments
• Even patients who have asthma that is well
  controlled at the time of the clinical assessment
  must by monitored over time, for the processes
  underlying asthma can vary in intensity over
  time, and treatment should be adjusted
  accordingly NHLBI/NAEPP

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Variability of Asthma

• Because of the variability of the disease, asthma
  severity should be considered with of initiation
  treatment, but from that point on the focus
  should be on monitoring for asthma control

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Asthma Control

• Once treatment is initiated, the ongoing focus
  should be on achieving and maintaining control
  through a stepwise approach
• ICS's are part of a preferred treatment-all ages
• When stepping up treatment, combination therapy
  is recommended and LABAs are the preferred agents
  to combine with ICS for over those over 12 years
  old

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Determine Severity

• Components of severity
• Intermittent
• Persistent
• Mild
• Moderate
• Severe
• Details later in lecture

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Levels of Asthma Control

• Well Controlled
• Not well Controlled
• Very poorly controlled

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Levels of control

• Well Controlled
• Daytime symptoms 2x or less per week
• No limitations to activity
• Night time symptoms one or less times per month
• Rescue med used 2x or less per week
• One or no exacerbations requiring oral systemic
  corticosteroids a year

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Levels of control

• Not Well controlled
• Day time symptoms more than 2x a week
• Some limitations to any activity
• More than one night time awakenings
• Rescue med needed more than 2x a week
• Two or more exacerbations per year requiring oral
  steroids

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Levels of control

• Very poorly controlled
• Symptoms occur though out the day
• Night time awakenings occur more than once a week
• Activity is extremely limited
• Use of SABA is several times a day
• Three or more exacerbations in one year requiring
  oral steroids
• Tools to assess control
• http//www.asthmacontrol.com/
• www.ataqinstrument.com

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Goals of Asthma Care

• Achieve and Maintain Control
• Four components
• Patient/Provider Relationship
• Education is the key
• Provide a written action plan
• ID and reduce exposure to risk factors
• With good control patient is less sensitive to
  triggers
• Assess Treat and Monitor Asthma
• Manage Exacerbations

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Barriers to Care

• Generic barriers
• Poverty, poor education
• Environmental barriers
• Pollution, tobacco smoke, occupational exposures
• Low public health priority
• TB, pneumonia and others have more priority
• Lack of symptom-based rather than disease-based
  approaches to the management

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Barriers to care

• Limited availability and use of medications
• Omission of basic medications on national
  essential drug lists
• Poor supply or distribution
• Poor/uneducated
• Cultural attitudes towards drug delivery systems
  e.g. inhalers

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Barriers to care

• Patient barriers Biggest Problem!
• Cultural factors
• Lack of information
• Under use of self-medications!!
• Over reliance on acute care!!
• Use of alternative unproven therapies

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• TRIGGERS OF HYPER-REACTIVITY OF BRONCHIAL TREE
• ALLERGENS
• PHARMACOLOGIC AGENTS
• ENVIRONMENTAL/AIR POLLUTION
• OCCUPATIONAL HAZARDS
• INFECTION
• EXERCISE
• PSYCHOGENIC FACTORS

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ALLERGENS Sensitization occurs via
antibody-mediated immunity in which 1) macrophage
s ingest the antigen (allergen), process it,
present the antigen on their cell
membranes 2) CD4 lymphocytes encounter the
presenting macrophage, recognize the antigen as
foreign and bind the antigen to its cell
membrane 3) the activated CD4s then contact B
lymphocytes and cause them to proliferate into B
memory cells (sustain the memory of the exposure)
and plasma cells (proliferate and secrete
Igs) 4) the plasma cells secrete IgE which arms
the mast cells lining the respiratory tract to
respond to antigen 5) an activated mast cell
releases histamine along with leukotrienes which
cause contraction of bronchial smooth muscle,
arteriole smooth muscle, increased vascular
permeability, and cytochemotaxis
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PATHOPHYSIOLOGY OF ASTHMA INFLAMATORY CELLS mast
cells/eosinophils/ ? macrophages/platelets I
NFLAMATORY MEDIATOR histamine/leukotrienes/ ?
prostaglandins/tryptase INFLAMATORY
RESPONSE bronchoconstriction/ endothelial
leak/increase mucus
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AVOIDANCE OF TRIGGERS IS A CORNERSTONE OF
TREATMENT REGIME
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The primary sensitization requires reasonably
abundant and sustained allergen contact.
Subsequent allergen exposures of minute
quantities can cause substantial reaction.
25
Examples of allergens pollen food dust
mites insect particles and feces animal
dander molds Which of the above might be
perennial? Which of the above might be seasonal?
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ASTHMA CAN BE PRECIPITATED AND/OR EXACERBATED BY
NON-ALLERGENS, SUCH AS OZONE, SMOKE, COLD AIR,
PERFUMES AND PSYCHOGENIC FACTORS these are
associated with non-IgE mediated inflammations of
unknown mechanism
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Viral induced vs. Allergen induced

• Virus Infections behind 80 of severe asthma
  attacks
• These patients need a flu shot yearly
• Viral induced asthma attack releases interleukin
  10 chemical messenger
• New drugs can block IL-10

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Outgrowing Asthma

• Study in New Zealand showed 35 reoccurrence rate
  by age 26
• Cohort was asymptomatic at age 18
• Clinical implications?
• IE taking a good history

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• The Four Key Components
• For Long-Term Asthma Control
• Assessment and monitoring
• Pharmacologic therapy
• Control of factors contributing to asthma
  severity
• Patient education for a partnership

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These components are achieved by I) Diagnosing
asthma and initiating a partnership with
patient II) Reducing inflammation, symptoms and
exacerbations III) Monitoring and managing
asthma over time
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I) Diagnosing asthma and initiating a
partnership with patient
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I) Diagnose asthma and initiate partnership
Diagnose asthma by establishing a history of
recurrent symptoms reversible airflow
obstruction using spirometry the exclusion of
alternative diagnoses Establish patient-clinician
partnership address the patients
concerns agree upon the goals of asthma
therapy agree upon a written action plan for
patient self- management
33
https//www.asthmafoundation.org.nz/for_health_pro
fessionals_1.php
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• I) Diagnose asthma and initiate partnership
• Findings that increase the probability of asthma
• Medical History of
• episodic wheeze, chest tightness, shortness of
  breath, or cough
• symptoms worsen in the presence of aeroallergens,
  irritants or exercise
• symptoms occur or worsen at night, awakening the
  patient
• patient has allergic rhinitis or atopic
  dermatitis
• close relatives have asthma, allergy, sinusitis,
  or rhinitis

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I) Diagnose asthma and initiate
partnership Physical Examination
reveals Hyperexpansion of the thorax Wheezing
during normal breathing or a prolonged phase of
forced exhalation Increased nasal secretions,
mucosal swelling, sinusitis, rhinitis or nasal
polyps Atopic dermatitis/eczema or other signs of
allergic skin problems
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I) Diagnose asthma and initiate partnership 1)
Positive Medical History 2) Airflow obstruction
that is at least partially reversible as shown
by first testing FEV, giving short acting
?-2 agonist, retesting FEV and seeing a gt12
increase in FEV 3) Alternative diagnoses are
excluded 4) In children lt 5 yo, spirometry is
not possible so empiric therapy is recommended,
all other diagnostic steps are taken
37

• I) Diagnose asthma and initiate partnership
• If asthma is suspected and the spirometry is
  normal or coexisting conditions are suspected you
  may need to do further testing
• a. Assess diurnal variation of peak flow over 1
  to 2 weeks
• b. Refer to specialist for bronchoprovocation
• c. CXR
• d. CT chest
• e. Allergy testing
• f. GERD testing

38
Spirometry better than peak flow meters but only
in clinician office Peak flow meters have
variable reference values. To be used as
monitoring device not diagnostic Spirometry
recommended initially, at stabilization and every
1-2 years Peak flow readings help manage
exacerbations and step therapy Green zone,
yellow and red zones
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Spirometry / PFTs FEV Forced Expiratory
Volume FVC- Forced Vital Capacity FEV/FVC ratio
( reduced equals obstruction) FVC reduced with
normal ratio equals restrictive pattern
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I) Diagnose asthma and initiate partnership Set
agreed upon goals such as prevention of chronic
asthma symptoms and asthma exacerbations
during the day and night maintaining/increasing
normal activity levels having normal or
near-normal lung function being satisfied with
the asthma care few or no side effects while
receiving optimal medications
41
II) Reduce inflammation, symptoms, and
exacerbations Prescribe anti-inflammatory
medications to patients with mild, moderate, or
severe persistent asthma (IE, inhaled steroids,
cromolyn or nedocromil) Reduce exposures to
precipitants of asthma symptoms Assess patients
exposure and sensitivity to individual
precipitants (IE allergens, irritants) tobacco
smoke, air pollution, reflux, viral
infections Allergy testing- dust mites, pollen,
pets, etc.
42
II) Reduce inflammation, symptoms, and
exacerbations Provide written and verbal
instructions on how to avoid or reduce factors
that make the patients asthma worse.
43
III) Monitor and manage asthma over time Train
all patients to monitor their asthma All
patients should monitor symptoms Patients with
moderate-to-severe persistent asthma should
also monitor their peak flow See patients at
least every 1 to 6 months Assess attainment of
goals of asthma therapy and patients
concerns Adjust treatment, if needed Review the
action plan with patient Check patients inhaler
and peak flow technique
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III) Monitor and manage asthma over
time Patients should keep an asthma diary Look
for indicators of poor asthma control
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• III) Monitor and manage asthma over time
• Indicators of Poor Asthma Control
• Awakened at night with symptoms
• An urgent care visit
• Patient has increased need for short-acting
  inhaled ?-2 agonists (except in the presence of
  a URI or in exercise induced asthma)

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• III) Monitor and manage asthma over time
• Effective Asthma Therapy
• No sleep disruptions
• No missed school or work
• No or minimal need for ER or hospital care
• Normal activity and exercise levels
• Normal or near normal lung function
• Patient satisfaction
• No or minimal side effects from therapy

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III) Monitor and manage asthma over time
ASSESS ICE Inhaler technique Compliance Enviro
nment And Alternative diagnosis
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III) Monitor and manage asthma over time
Ongoing Asthma Therapy Establish
control Gradually step down until lowest doses
required to maintain control are reached Step
up therapy if you begin to see indicators of poor
control
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Classifications for Asthma Severity for 12 years
and up
I

• I Intermittent
• Symptoms lt 2 times a week
• Night time awakenings 2 or less per month
• FEV/FVC normal between episodes
• With exacerbations gtthan 80
• Use SABA 2 times or less per week

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Classifications for Asthma Severity

• II Mild Persistent
• Symptoms gt2 times a week
• Nighttime 3-4 episodes a month
• Minor limitation on activity
• Use of SABA more than 2 days a week but not on
  the same day
• FEV gt80 with episode
• FEV, FVV normal

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Classifications for Asthma Severity

• III Moderate Persistent
• Daily symptoms
• More than 1 per week, not nightly
• Daily use of SABA medication
• Some limitation on activity
• FEV gt60 but lt80 with episode
• FEV/FVC reduced 5

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Classifications for Asthma Severity

• VI Severe Persistent
• Continual symptoms
• Night time awakenings often 7x
• Extremely limited activity
• Frequent exacerbations
• FEV lt60 predicted with episode
• REV/FVC reduced gt5

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OTHER Types of Asthma

• Nocturnal asthma
• Difficult to treat asthma
• Irreversible airway flow obstruction
• Cough variant asthma

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• GENERAL GUIDELINES FOR REFERRAL TO AN ASTHMA
  SPECIALIST
• differential diagnosis is not clear
• specialized treatment required
• patient not meeting goals after 3 to 6 months
• life threatening attack has occurred
• patient requires Step 4 care
• children under 3 years of age
• patients with significant psychiatric,
  psychosocial, or family problems

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Management for Asthma

• Step 1 Intermittent Asthma
• Controller
• Daily medications needed
• None
• Relievers
• Short acting bronchodilator (beta-2-agonist) used
  less than once a week
• Intensity of treatment will depend on severity of
  episode
• Before exercise or allergen exposure
• Inhaled beta-2 agonist or cromolyn

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Management for Asthma

• Step 2 Mild Persistent Asthma
• Controller
• Daily medications
• Either inhaled corticosteroid (Flovent 44 or
  110), nedocromil (Tilade Inhaler) or
  cromoglycate (Intal), or sustained-released
  theophylline
• Leukotriene receptor antagonist (Singulair)
• If needed increase inhaled steroids, or add
  long-acting bronchodilator-esp... for night time
  symptoms (long-acting inhaled beta-2 agonist like
  Serevent, or theophylline, or long acting oral
  beta-2 agonist like
• Reliever
• Short acting bronchodilator (inhaled beta 2
  agonist PRN), not to exceed 3-4 x a day

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Management for Asthma

• Step 3 Moderate Persistent Asthma
• Controller
• Daily medications
• Inhaled corticosteroid and
• Long acting bronchodilator, esp for nighttime
  symptoms or
• Combination inhaled corticosteroid and long
  acting beta 2 agonist (Advair)
• Reliever
• Short acting bronchodilator, not to exceed 3-4
  time in 1 day

58
Management for Asthma

• Step 4 Severe Persistent Asthma
• Controller
• Daily medications
• Combination inhaled corticosteroid and long
  acting beta2 agonist (Advair) or
• Inhaled corticosteroid and long acting
  bronchodilator
• Reliever
• Short acting bronchodilator

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A Stepwise Treatment Approach- overview for
exacerbations

• Step One
• Preferred
• SABA PRN
• Step Two
• Preferred
• Lose dose ICS
• Alternative
• Cromolyn
• LTRA
• Theophylline or zileuton

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A Stepwise Treatment Approach- overview for
exacerbations

• Step Three
• Preferred
• Medium dose ICS and LABA
• Alternative
• Medium dose ICS and either
• LTRA
• Theophylline
• Zileuton

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A Stepwise Treatment Approach- overview for
exacerbations

• Step Four
• Preferred
• Medium dose ICS and LSBA
• Alternative
• Medium dose ICS
• and either
• LTRA
• Theophylline
• Zileuton

62
A Stepwise Treatment Approach- overview for
exacerbations

• Step Five
• Preferred
• High hose ICS
• LABA
• And consider
• Omalizumab for allergy patients
• (Xolair) Monoclonal Anti IgE

63
A Stepwise Treatment Approach- overview for
exacerbations

• Step Six
• Preferred
• High dose ICS
• LABA
• Oral steroid
• And
• Consider Omalizumab for patients with allergies
• (Xolair) Monoclonal Anti IgE

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STEPPING UP THERAPY Start with intensive therapy
to establish control One or more indicators of
poor asthma control suggest a need to step up
therapy 3 to 10 day courses of oral steroids may
be needed to reestablish control during a period
of gradual decline or moderate to severe
exacerbation
65
STEPPING DOWN THERAPY Gradually reduce
long-term-control medications after several weeks
or months of good control (2-4 months) Last
medication added is usually the first
reduced Inhaled steroids may be reduced about 25
every 2 to 3 months until the lowest dose
required for control is reached
66
MISCELLANEOUS ASTHMA TIPS Rinse mouth after using
steroid inhalers Use spacers- for ALL AGES Use
good judgment when prescribing, such as consider
adding a long acting ß-2 agonist to a low to
medium dose inhaled steroid rather than changing
to a higher dose steroid If patients require
frequent oral steroids, monitor for side
effects Use of high dose inhaled steroids is
generally preferable to daily use of oral
steroids With seasonal asthma, use Step Therapy
for control, begin before anticipated onset of
season The only reliable way to know that
canisters are empty is to count the number of
puffs Consider Pneumococcal and Influenza vaccine
for your asthmatic patients Treat allergic
rhinitis symptoms Beta blockers should not be
used in patients with asthma
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Common Medications

• B2 agonists
• (long acting vs short acting)
• Inhaled corticosteroids
• Systemic corticosteroids
• Leukotriene modifiers
• Nedocromil (Tilade Inhaler)
• Anticholinergics

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Beta 2 agonist
Short acting Albuterol (Proventil),
Levalbuterol (Xopenex), Pirbuterol
(Maxair), Terbutaline(Brethine)
Metaproterenol (Alupent) Long acting
Salmeterol (Serevent) Formoterol
(Foradil) FYI albuterol and terbutaline are
also both available in oral forms
69
Inhaled Corticosteroids
Fluticasone salmeterol (Advair Diskus)
Flunisolide (AeroBid) Triamcinolone
(Azmacort) Mometasone (Asmanex) Fluticasone
(Flovent) Budesonide (Pulmicort) Ciclesonide
(Alvesco) Beclomethasone (Qvar)
)
70
Systemic corticosteroids
Methylprednisolone (Medrol dose pack)
(Deltasone) Prednisolone (Orapred sol' n)

71
Leukotriene modifiers
Montelukast (Singulair) OK for kids Zafirlukast
(Accolate)
5-liposygenase inhibitor Zileuton oral (Zyflo)
watch the liver
72
Anticholinergics
Ipratropium albuterol together (DuoNeb,
Combivent) Ipratropium (Atrovent)
73
Miscellaneous Meds
Antiinflammatory MDI Nedocromil (Tilade) Mast
cell stabilizer Cromolyn (Intal) Xanthines Theophy
lline oral (Uniphyl, Theo-24) Monoclonal Anti
IgE Omalizumab (Xolair) injectable
74
Signs of an asthma exacerbation

• First rule DO NOT UNDERESTIMATE
• Patient will be breathless at rest, hunched over,
  speaking in words and not sentences, may be
  agitated, drowsy or confused, respiratory rate
  over 30 (may be 60)
• Has an O2 requirement per pulse ox
• Bradycardic or with HR over 120 in adults (160
  in children)
• May be exhausted
• Wheezes will be loud or absent!!
• Does not respond to bronchodilators promptly
• Does not respond to steroid therapy in first 2-6
  hours
• Condition is deteriorating

75
Managing an Exacerbation

• 2-4 puffs of B2 agonists every 20 minutes for the
  first hour then 6-10 puffs every 1-2 hours
• PO steroids 1-2mg/Kg now and every 24 hours for
  5 days
• I use 2mg/kg
• O2 if pulse ox less than 95
• I use 93
• DO NOT GIVE
• Sedatives, mucolytic drugs, chest PT, large
  volume hydration

76
MANAGING ASTHMA IN PREGNANT WOMEN Management of
pregnant women is generally the same as other
women. Good control of asthma is important
because poorly controlled asthma is associated
with low birth weight, perinatal mortality,
increase premature birth Keep in mind drugs that
are potentially harmful to mother and fetus such
as TCN, Cipro, live virus vaccines, decongestants
(aside from pseudoephedrine)
77
PREDICTORS OF DEATH FROM ASTHMA Past history of
severe attacks, intubation and ICU stay Frequent
hospital stays Use of more than 2 canisters of
SAß-2 agonist per month Use or withdrawal of oral
steroids Comorbidity with CV disease,
COPD Psychiatric disease such as depression,
schizophrenia Illicit drug use Low SES, urban
residence
78
MANAGING ASTHMA IN OLDER PEOPLE Make adjustments
or avoid medications that can aggravate other
conditions Inhaled steroids give supplement of
Ca with Vit D, HRT Oral steroids watch for
hyperglycemia, confusion, agitation Theophylline
and epinephrine may exacerbate underlying heart
conditions Warn patients about other medications
and interactions ASA and NSAIDS given for pain
relief and arthritis Nonselective ß blockers
given for HTN ß blockers in eye drops given for
glaucoma
79
Considerations for Adults and Older People Some
asthma shows up late in life The elderly do not
have as brisk a reaction to skin testing It is
important to not under diagnose asthma as COPD,
since asthma is treated differently and has a
better response to treatment Sometimes a trial of
steroids to test for reversibility is a better
test than inhaled SAß-2 agonists Patients with
COPD may need ipratropium (Atrovent) on a chronic
basis and antibiotics with exacerbations
80
HOW DO YOU KNOW ITS NOT COPD? COPD is more
likely to have cyanosis, lower extremity edema,
distended neck veins, weight loss, pursed-lip
breathing, quiet chest, clubbing of the fingers
and DOE than asthma
81
HOW DO YOU KNOW ITS NOT CONGESTIVE HEART
FAILURE? CHF is more likely to have the an
exaggerated SOB, LE edema, large PMI, inspiratory
crackles, cardiomegaly, vascular congestion on
CXR and daytime DOE not relieved by SAß-2 agonists
82
HOW DO YOU KNOW ITS NOT AN UPPER AIRWAY
TUMOR? Upper airway obstruction is more likely to
be characterized by inspiratory difficulty,
stridor and the wheeze is best heard over the
large airways
83
HOW DO YOU KNOW ITS NOT A LOWER AIRWAY
TUMOR? Lower airway obstruction is more likely to
be characterized by a unilateral or localized
wheeze and a PMH of smoking
84
HOW DO YOU KNOW ITS NOT A PULMONARY
EMBOLISM? Pulmonary embolism is associated by
chest pain and may have risk factors for PE or a
demonstrable source of the embolism
85
HOW DO YOU KNOW ITS NOT ASPIRATION? Elderly with
aspiration will have impaired dysarthria,
dysphagia, choking, poor gag reflex, PMH CVA,
exposure to ETOH or sedating drugs
86
CASE Ms. Anne Chovi, 71 years old, has a history
of asthma. Lately, she complains of awakening
with nocturnal dyspnea. What is the differential?
How do you work up the differential? How would
you put the Step Treatment Recommendations in
practice?
87
NSAID USE Dyspepsia, abdominal pain, GI
discomfort, and GI bleeding may be reduced by
combining the NSAID with a proton pump inhibitor
(PPI) or histamine H2 blocker. Despite the
cardioprotective qualities of aspirin, other
NSAIDs may have adverse cardiac effects,
including worsening of congestive heart failure,
increase in blood pressure, myocardial
infarction, and ischemia. The risk for myocardial
infarction is increased with COX-2 inhibitors,
although celecoxib, which is the only COX-2
inhibitor still available in the United States,
is somewhat safer regarding cardiovascular
effects. NSAIDs should not be used in patients
with cirrhotic liver diseases because such
patients are at greater risk of bleeding and for
kidney failure. However, NSAIDs rarely cause
hepatic damage, and any hepatic effects are
usually reversible. NSAIDs with more potential
for hepatic problems include sulindac and
diclofenac. Caution is advised when NSAIDs are
prescribed in the setting of anticoagulant
therapy, platelet dysfunction, or immediately
before surgery. Central nervous system adverse
effects of NSAIDs may include aseptic meningitis,
psychosis, and tinnitus. NSAIDs may also trigger
or exacerbate asthma. In patients with asthma,
especially those with nasal polyps or recurrent
sinusitis, NSAIDs and aspirin should be avoided.
88
Management calculator
http//www.empr.com/asthma-management-calculator-1
2-years-of-age-and-older/article/170225/