Asthma Guidelines: Overview

Suzette T. Gjonaj, MD

Introduction

•Asthma is a chronic disease of the airways that includes chronic inflammation, which leads to bronchial hyperresponsiveness, airflow obstruction and limitation, respiratory symptoms, and chronicity of the illness.

•Asthma is one of the most common childhood chronic illnesses, affecting more than 7 million children in the United States.

•In 1991, the first National Asthma Education and Prevention Program clinical practice guidelines were released, which were updated in 1997.

•Since then, despite the increasing prevalence of asthma, the number of asthma-related deaths has declined.

The 2007 Third Expert Panel Report

Goals of the Guidelines

•The National Heart, Lung, and Blood Institute Third Expert Panel Report (EPR-3) guidelines were published in 2007.

•The EPR-3 guidelines assist practitioners in improving and standardizing the quality of asthma care, thereby achieving better quality of life and decreasing asthma burden.

•The guidelines address long-term asthma management and management of exacerbations.

•Effective management of asthma includes the following 4 components of care:

—Assessment and monitoring

—Patient education

—Control of factors that contribute to asthma severity

—Pharmacological treatment

Assessment and Monitoring

•Assessment and monitoring are closely linked to asthma severity, control, and responsiveness.

•Severity refers to the intensity of the disease process. It must be accurately assessed prior to initiating therapy.

•Responsiveness means the degree to which control is obtained with treatment.

•Severity and control are defined according to the measure of impairment previously and currently experienced, the risk of exacerbations, the decline in lung function, and the adverse effects of medications.

•Measures such as patient history, physical examination, and spirometry are used to diagnose and assess the severity of illness and to monitor whether control is achieved and maintained.

•Children ≥5 years of age should undergo spirometry to help assess disease severity and quantify the risk of exacerbations.

•Level of severity, whether intermittent or persistent, and degree of severity of persistent asthma (mild, moderate, or severe) determine the type and amount of therapy instituted.

•Intermittent asthma is classified as experiencing symptoms <2 days per week, experiencing nocturnal symptoms <2 times per month, symptoms not interfering with normal activities, and normal spirometry values and/ or peak flow.

•Periodic monitoring is necessary to determine whether the goals of management are being achieved and whether the asthma is well controlled.

Patient Education

•Successful education enables patients and parents to understand and institute complicated pharmacological regimens, optimize environmental control measures, detect and manage exacerbations, and communicate with health care providers effectively.

•The patient and parents must be educated in self-management skills to control asthma and improve outcomes.

•Education should be initiated at the time of diagnosis, with consistent and constant reinforcement and repetition at follow-up visits.

•At every opportunity, education should include basic facts about asthma, roles in preventive management and in the event of an exacerbation, identification and reduction of environmental allergens and irritants, differences between various medications, and review of patient skills (proper use of inhalers, spacers, and peak flow meters).

•All health care team members should be included in education efforts. This involvement can occur in clinics, office visits, emergency department visits or hospital visits, pharmacies, and the community.

•It is important that an asthma action plan be created and reviewed at every visit. It should include daily management strategies and how to recognize and treat worsening asthma.

•Regular follow-up is necessary to review the status of asthma control, continue patient and parent education, develop a relationship with the patient and parents, and encourage treatment adherence.

Control of Environmental Factors and Comorbid Factors

•To achieve success in the long-term management of asthma, it is crucial to identify and decrease exposure to allergens and irritants that can trigger exacerbations or increase asthma symptoms.

•These factors include inhalant allergens, irritants, occupational exposure, and comorbid conditions, among others.

•Inhalant allergens include indoor allergens (animal dander, dust mites, cockroaches, mice, and mold) and outdoor allergens (tree, grass and weed pollens, and mold).

•Food allergies are unlikely to trigger asthma symptoms and exacerbations.

•Irritants include tobacco (environmental tobacco smoke) and smoke from fireplaces and wood-burning stoves.

•In patients who have difficulty achieving asthma control, evaluation for comorbid factors should be undertaken.

•Comorbid factors include gastroesophageal reflux disease, obesity, obstructive sleep apnea syndrome, allergic bronchopulmonary aspergillosis, sinusitis, rhinitis, chronic stress, and depression.

•Other factors include viral (respiratory syncytial virus, rhinovirus, and influenza) and atypical (Mycoplasma and chlamydia) infections.

Medications

•Pharmacotherapy is used to prevent and control asthma symptoms, improve quality of life, decrease the frequency and severity of exacerbations, and reverse airflow obstruction.

•Long-term controller medications are used to achieve and maintain control of persistent asthma.

•Quick-relief medications treat acute symptoms and exacerbations by promptly reversing airflow obstruction and relieving bronchoconstriction.

Long-term Controllers

•Patients with persistent asthma require long-term controller medication.

•Because inflammation is part of the pathophysiology of asthma, the most effective long-term controller attenuates inflammation.

Inhaled Corticosteroids