FAQ
New asthma guidelines
In August 2007, the National Heart, Lung, and Blood Institute's (NHLBI) National Asthma Education and Prevention Program released the third expert panel guidelines for the diagnosis and management of asthma. The new asthma guidelines are divided into 4 key areas: assessment and monitoring, education, control of environmental factors and comorbid conditions, and medications. A summary of the major changes to the guidelines since the 1997 and 2002 updates are presented below.
Assessment and monitoring
An assessment of both impairment and risk to determine asthma severity and asthma control is emphasized in the new guidelines. Impairment is defined as the frequency and intensity of symptoms and functional limitations the patient is currently experiencing or has recently experienced and risk is defined as the likelihood of either asthma exacerbations, progressive decline in lung function, or risk of adverse events from medications. Assessment of both impairment and risk is recommended to determine initial treatment and subsequent maintenance therapy. At the initial assessment visit, asthma severity should be classified, precipitating factors and comorbid conditions should be identified, and patient’s knowledge and skills for self-management should be determined. The new guidelines modified the classification of asthma severity from "mild intermittent" to "intermittent" to emphasize that all patients with intermittent asthma, regardless of severity, can have severe asthma exacerbations. The importance of follow-up care is stressed in the guidelines. Clinic visits are recommended at 2- to 6-week intervals while gaining control; at 1- to 6-month intervals to monitor if sufficient control is maintained; and at 3-month intervals if a reduction in therapy is anticipated. Additionally, spirometry is recommended at the initial assessment visit and repeated every 1 to 2 years and more frequently for patients who are not well-controlled.
Education
The guidelines discuss the importance of an effective partnership between the clinician and patient with asthma. Specifically, the guidelines state that key educational messages should be tailored to the literacy level of the patient and taught/reinforced at every opportunity. These key messages include:
- Basic facts about asthma
- The difference between the airways of a person with asthma versus one without the condition.
- The role of inflammation in asthma.
- Role of medications
- The use of quick-relief medications to provide prompt relief of symptoms and that use of these medications more than twice a week indicates the need for starting or increasing long-term control medications.
- The use of long-term control medications to prevent symptoms and not to use these medications to obtain quick relief.
- Patient skills
- Correct inhaler technique and use of devices such as spacers or nebulizers.
- Identifying and avoiding environmental exposures that worsen asthma.
- Self-monitoring by assessing daily symptoms or peak flow monitoring if patients have a difficult time perceiving symptoms.
- Using a written asthma action plan.
- Seeking medical care as appropriate.
Environmental factors and comorbidities
The guidelines emphasize the importance of controlling both environmental factors and comorbid conditions that affect asthma control. Specifically, patients with asthma should reduce their exposure to irritants to which they are sensitive such as tobacco smoke, dust mites, animal dander, cockroaches, and indoor/outdoor mold, and pollen. Subcutaneous allergen immunotherapy is recommended for patients with persistent asthma when there is clear evidence of a relationship between symptoms and exposure to an allergen. Finally, comorbid conditions such as gastroesophageal reflux, obesity, obstructive sleep apnea, and rhinitis/sinusitis should be treated appropriately, as these conditions may impair asthma control.
Medications
The guidelines continue to promote a stepwise approach to therapy, with 6 recommended treatment steps replacing the original 4. Treatment approaches are now based on 3 age groups: 0–4 years, 5–11 years, and 12 years of age or older. The addition of the 5- to 11-year-old group is a recognition that drug responses differ between children and adults. Pharmacologic therapy is initiated based on asthma severity and adjusted (stepped up or down) based on level of asthma control. A summary of the recommended stepwise approach for the long-term management of asthma is presented in table 1.
Table 1. Stepwise approach for managing asthma long-term*
| Intermittent Asthma | Persistent Asthma: Daily Medication | |||||
| Mild | Moderate | Severe | ||||
| Step 1 | Step 2 | Step 3 | Step 4 | Step 5 | Step 6 | |
Children
0-4 years of age |
SABA PRN | Low-dose ICS | Medium-dose ICS | Medium-dose ICS + LABA or Montelukast | High- dose ICS + LABA or Montelukast | High- dose ICS + Oral corticosteroids + LABA or Montelukast |
Children
5-11 years of age |
SABA PRN | Low-dose ICS | Low-dose ICS + LABA, LTRA, or Theophylline OR Medium-dose ICS | Medium-dose ICS + LABA | High-dose ICS + LABA | High- dose ICS + LABA + Oral corticosteroids |
Youths 12 years of age or greater and Adults |
SABA PRN | Low-dose ICS | Low-dose ICS + LABA OR Medium-dose ICS | Medium-dose ICS + LABA | High-dose ICS + LABA And Consider Omalizumab for patients who have allergies | High- dose ICS + LABA + Oral corticosteroids And Consider Omalizumab for patients who have allergies |
Reference
National Heart, Lung, and Blood Institute. Expert panel 3 report: guidelines for the diagnosis and management of asthma. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed December 28, 2007.