Am Fam Physician. 2003;68(1):169-170
In collaboration with the Centers for Disease Control and Prevention (CDC), the National Asthma Education and Prevention Program (NAEPP) has published an update of their guidelines on diagnosing and managing asthma. The report identifies a set of 10 clinical activities for reducing symptoms and preventing exacerbations in patients with asthma. These key activities correspond to the four recommended-as-essential components of asthma management: assessment and monitoring, control of factors contributing to asthma severity, pharmacotherapy, and education for a partnership in care. The clinical elements are intended as long-term preventive aspects of managing asthma, not acute or hospital management. The full update is available in the November 2002 issue of the Journal of Allergy and Clinical Immunology and atwww.nhlbi.nih.gov/guidelines/asthma/index.htm.
Assessment and Monitoring
Key Clinical Activity 1. Establish Asthma Diagnosis
For symptomatic adults and children five years and older who can perform spirometry, asthma can be diagnosed after a medical history and physical examination documenting an episodic pattern of respiratory symptoms, and from spirometry that indicates partially reversible airflow obstruction. Alternative diagnoses of symptoms that suggest asthma, including conditions affecting the upper and lower airways, should be ruled out and may require additional tests.
For infants and children younger than five years, the diagnostic steps are the same except for spirometry, which is not feasible in this age group. Medical histories and physical examinations should be expanded to look for factors associated with the development of chronic persistent asthma: more than three episodes of wheezing in the past year that lasted more than one day and affected sleep, and parental history of asthma or physician-diagnosed atopic dermatitis, or two of the following: physician-diagnosed allergic rhinitis, wheezing apart from colds, or peripheral blood eosinophilia.
Key Clinical Activity 2. Classify Severity of Asthma
Signs and symptoms must be classified at the initial and all following visits because patients experience varied signs and symptoms. Initially and before treatment has been optimized, clinical signs, symptoms, and peak flow monitoring or spirometry are used to classify severity. After the condition is stable, severity is then classified according to the level of medication required to maintain treatment goals (see accompanying table).
Key Clinical Activity 3. Schedule Routine Follow-Up Care
Adjustments in therapy and regular follow-up visits are important because patients experience varying symptoms and severity, exposure to environmental allergens or irritants, or insufficient adherence to their medication regimen. Routine visits should be scheduled every one to six months, depending on the severity of asthma and the patient's ability to maintain control of the symptoms. Spirometry is recommended at the initial assessment and at least every one to two years after treatment is started and the symptoms and peak expiratory flow have stabilized. The physicians also should review the patient's medication use, management plan, and self-management skills, including the use of inhalers, spacers, and peak flow meters.
Key Clinical Activity 4. Assess for Referral to Specialty Care
The NAEPP lists several circumstances that would require referring a patient to an asthma specialist, including a single life-threatening asthma exacerbation or if the asthma does not respond to current therapy.
Identifying and Controlling Factors Contributing to Asthma Severity
Key Clinical Activity 5. Recommend Measures to Control Asthma Triggers
Environmental tobacco smoke and house dust mite, cockroach, and cat and dog allergens can worsen asthma in sensitized and exposed persons. Irritant or allergen sensitivity can be determined by the patient's exposure and symptom history and confirmed with skin or blood testing. The NAEPP recommends allergy testing for perennial indoor allergens in persons with persistent asthma who are taking daily medications. After sensitivity is determined, avoidance of the trigger is recommended.
Exercise-induced bronchoconstriction, narrowing of airways with physical exertion, may be prevented with long-term control of asthma. If the patient continues to have symptoms during exercise, specific medications can be prescribed.
Key Clinical Activity 6. Treat or Prevent All Comorbid Conditions
When asthma symptoms persist or worsen despite medication adjustments, physicians should evaluate the patient for allergic rhinitis, sinusitis, gastro-esophageal reflux, and any sensitivity to medications. Patients with persistent asthma should have annual influenza vaccinations to prevent respiratory infections that can exacerbate asthma.
| Classification | Step | Daily medication | Quick-relief medication | |
|---|---|---|---|---|
| Severe persistent | 4 | High-dose inhaled steroids and long-acting inhaled beta2-agonist; if needed, add oral steroids. | Short-acting inhaled beta2-agonist, as needed; oral steroids may be required. | |
| Moderate persistent | 3 | Low- to medium-dose inhaled steroids and long-acting beta2-agonist (preferred) | Short-acting inhaled beta2-agonist, as needed; oral steroids may be required. | |
| or | ||||
| Medium-dose inhaled steroids (another preferred option for children younger than five years) | ||||
| or | ||||
| Low- to medium-dose inhaled steroids and either leukotriene modifier or theophylline | ||||
| Mild persistent | 2 | Low-dose inhaled steroids (preferred) | Short-acting inhaled beta2-agonist, as needed; oral steroids may be required. | |
| or | ||||
| Cromolyn, leukotriene modifier, or (except for children younger than five years) nedocromil or sustained-release theophylline to serum concentration of 5 to 15 mcg per mL | ||||
| Mild intermittent | 1 | No daily medicine needed | Short-acting inhaled beta2-agonist, as needed; oral steroids may be required. | |
Pharmacotherapy
Key Clinical Activity 7. Prescribe Medications According to Severity
Current evidence indicates that daily long-term control medications are necessary to prevent exacerbations and chronic symptoms in all patients with persistent asthma, whether it is mild, moderate, or severe. Inhaled corticosteroids are the most effective anti-inflammatory medication available for treating the underlying inflammation. Other long-term medications, such as cromolyn and nedocromil, have not been demonstrated to be as effective. All patients with asthma require a short-acting bronchodilator for managing acute symptoms; severe exacerbations require the addition of oral corticosteroids to treat the increased inflammation.
Key Clinical Activity 8. Monitor Use of Beta2-Agonist Drugs
Patients may need a short-acting inhaled beta2- agonist during upper respiratory viral infections and exercise-induced bronchoconstriction. If the patient is using more than one canister per month, daily long-term control therapy should be increased as needed.
Education for Partnership in Care
Key Clinical Activity 9. Develop a Written Asthma Management Plan
In consultation with the patient or the parent or guardian of a child, the physician should develop a written plan as part of educating the patient about self-management. Writing the plan helps clarify expectations for treatment and provides patients with an easy reference for remembering how to manage their asthma. The plan should be reviewed and adjusted as needed at every follow-up visit. For children, a copy of the plan should be given to each caregiver and to the child's school.
Key Clinical Activity 10. Provide Routine Education on Patient Self-Management
Education should enlist and encourage family support, include instructions on self-management skills, and be integrated with routine ongoing care. A patient's ability to take medications is a necessary skill of self-management. Patients and parents or guardians of children with asthma need to know the rationale behind daily long-term and quick-relief medications, how to take medications correctly, and how to adjust the dosage if symptoms occur.