New asthma guidelines aim at control

Frequent patient monitoring, education, control of allergens and proper use of medications are vital to good asthma management.

By Susan J. Landers — Posted Sept. 24, 2007

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Asthma should not dictate how people live their lives, according to updated federal guidelines on the chronic lung disease -- the first comprehensive revamp of this document in a decade. Control is the goal, and the document offers pointers to achieve that end.

The National Asthma Education and Prevention Program released its new guidelines on Aug. 29. They were developed by an expert panel working under the auspices of the National Heart, Lung and Blood Institute.

Asthma is one of the most common health problems in the nation affecting more than 22 million people, including 6.5 million children younger than 18, according to the Centers for Disease Control and Prevention. The CDC estimates that 5,000 people die from asthma exacerbations each year.

Even when the disease is less severe, it can have a significant impact on people's lives -- "at school, at work, at play and at home," said NHLBI Director Elizabeth G. Nabel, MD. She spoke at a briefing held to release the new guidelines.

Despite its potential for disruption, there have been great gains in recent years in medications that can control the disease and prevent attacks.

"There is one truth: Asthma control is achievable for almost all patients," she said. "Health care providers and patients should accept nothing less."

Plus, the guidelines offer practical help for the primary care physician, panel members said. "What we are trying to do in this document is provide better ways within time constraints to assess as well as monitor infants, children and adults," said panel member Stuart W. Stoloff, MD, a solo practice family physician from Carson City, Nev.

First published in 1991, the guidelines are believed to have improved asthma treatment greatly, said panel member Harold Nelson, MD, professor of medicine at National Jewish Medical and Research Center in Denver. Asthma mortality has declined since the guidelines made their debut, and the use of inhaled corticosteroids has increased.

"I think they are hugely important and have had a major impact on allergy treatment," said Daniel Ein, MD, president of the American College of Allergy, Asthma and Immunology. He applauded their emphasis on the important role allergies play in triggering asthma attacks.

The new guidelines include modifications of recommendations that were made in earlier versions. Among the advice is the importance of assessing current impairment and estimating future impairment, said William Busse, MD, who headed the panel and is chair of the Dept. of Medicine at the University of Wisconsin School of Medicine and Public Health, in Madison.

Asking patients about interruptions in sleep, inability to go to work or school and how often they use "rescue" medication can determine accurately how disabling their asthma is from day to day, Dr. Busse said.

Model questionnaires are available that take just a few minutes for patients to fill out but provide assurance that the right questions have been asked, said panel member Homer A. Boushey, MD, professor of medicine at the University of California, San Francisco.

Future risk can be determined by evaluating a patient's past experiences, including unscheduled physician visits, emergency department trips, hospital admissions and their lung function, Dr. Stoloff said.

Spirometry and medications

Measuring lung function with spirometry is a relatively simple but underutilized way to predict future risk, Dr. Boushey said. "Even if a person has well-controlled symptoms, they may be at high risk, and one of the ways of identifying a person at high risk is if their lung function is poor."

The guidelines also continue to promote the stepwise approach to medication in which doses or types of medicines are stepped up as needed and stepped down when possible.

The guidelines provide a new breakout of 5- to 11-year-olds as a group that responds differently to medication than does the zero to 4 age group and the 12-year-and-older group.

They also reaffirm that inhaled corticosteroids are the most effective long-term-control medications for all age groups and add a number of other options, including the use of leukotriene receptor antagonists and cromolyn for long-term control.

Patients, and the parents of young children who are being treated, also must be persuaded of the safety of inhaled corticosteroids, which they might mistakenly equate with anabolic steroids, which can be dangerous, Dr. Boushey said.

Adherence to medication, even when symptoms abate, is crucial to adequate control of the disease, the experts stressed.

Education sessions can be held to help correct erroneous beliefs and to craft written asthma action plans for each patient, the panelists said.

Patients also should be seen on a regular basis, not just when their asthma flares up, said Robert F. Lemanske, MD, professor of pediatrics and medicine at the University of Wisconsin School of Medicine and Public Health in Madison.

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Achieving optimal control

For monitoring asthma control, guidelines emphasize asking patients the following:

  • Has your asthma awakened you at night or early morning?
  • Have you needed any urgent medical care for your asthma, such as unscheduled visits to your doctor, an urgent care clinic or the emergency department?
  • Are you participating in your usual and desired activities?
  • If you are measuring your peak flow, has it been below your personal best?

If control is not optimal, guidelines recommend that doctors:

  • Assess if the medications are being taken as prescribed.
  • Assess whether the medications are being inhaled with correct technique.
  • Assess lung function with spirometry and compare with previous measurement.
  • Adjust drugs as needed to achieve the best control with the lowest dose of medication. Either step up if control is inadequate or step down if control is maximized.

Source: "Global Initiative for Asthma: Pocket Guide for Asthma Management and Prevention," National Heart, Lung and Blood Institute, National Institutes of Health

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External links

Updated Guidelines for the Diagnosis and Management of Asthma, National Heart, Lung and Blood Institute, August (link)

National Heart Lung and Blood Institute's National Asthma Education and Prevention Program (link)

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