National Asthma Guidelines Updated

The first comprehensive update in a decade of clinical guidelines for the management of asthma have been issued by the National Asthma Education and Prevention Program (NAEPP).

The new expert panel report emphasizes the importance of asthma control and outlines the recommendations for the assessment, monitoring, pharmacologic therapy, and control of environmental factors associated with asthma; it also promotes patient education in settings beyond the physician's office (Table).

"The goal of asthma therapy is to control asthma so that patients can live active, full lives while minimizing their risk of asthma exacerbations and other problems," said the panel chairman, William Busse, MD, professor of medicine and head of the Allergy and Clinical Immunology Section at the University of Wisconsin Medical School in Madison.

Key differences between the new report and the earlier asthma guidelines issued by the NAEPP are:

• Increased emphasis on the variability of chronic inflammation
• Gene-environment interactions
• Recognition of early childhood risk factors
• The role of antiinflammatory agents in the slowing or prevention of asthma progression.

Asthma is defined as a chronic inflammatory disorder of the airways, with hyperresponsiveness, airflow limitation, and disease chronicity, in which gene expression contributes to the pathophysiology, and viral infections are a major cause of asthma development and exacerbation.

According to the panel, more than 22 million Americans have asthma, including 6.5 million children, and about 4000 patients with asthma die each year from asthma exacerbations, despite the efficacy of current treatments.

Current understanding of the pathophysiology, pathogenesis, and natural history of asthma supports the concept that airway inflammation is a primary target of asthma intervention, underscoring the variability of airway inflammation with regard to intensity, cellular-mediator interactions, and response to therapy.

Available treatments are effective in controlling asthma symptoms, reducing airflow limitations, and preventing exacerbations, although they do not appear to influence the underlying severity of asthma.

The degree of asthma control can change with time and varies among individuals and by age-groups. Regular monitoring is essential to optimize treatment.

Measures of level of impairment associated with asthma include:

• Frequency and intensity of symptoms
• Objective markers of pulmonary function
• Limitations of daily activities.

Some patients with good daily functioning may nevertheless be at high risk for frequent exacerbations. Assessing patients at high risk should include:

• Risks for exacerbations
• Progressive loss of lung function
• Adverse effects associated with asthma medications.

Teaching patients appropriate skills to self-monitor and manage their asthma is essential. The guidelines state that every patient should be given a written asthma action plan that includes instructions for daily treatment, as well as strategies to detect and manage asthma exacerbations.

Unlike previous guidelines, the new report emphasizes the need to reach beyond the medical office for educational intervention and recommends adjunct settings for patient education such as pharmacies, schools, community centers, and patients' homes.

The guidelines also mandate physician education programs and systemwide approaches to incorporate the guidelines into clinical practice.

As in previous guidelines, the new report advocates a stepwise approach to asthma control, increasing medication dosages and types as needed, and decreasing them whenever possible, based on the level of asthma control.

The stepwise management charts have been expanded to provide specific recommendations for children at different ages.

Drug Therapy

For all age-groups, inhaled corticosteroids are recommended as the most effective medications for long-term control.

New treatment options include:

• Leukotriene receptor antagonists and cromolyn (Intal) for long-term control
• Long-acting beta-agonists as adjunct therapy to inhaled corticosteroids
• Omalizumab (Xolair) for severe asthma.

For acute asthma exacerbations, albuterol (eg, Proventil, AccuNeb), levalbuterol (Xopenex), and corticosteroids are recommended.

Patients requiring urgent medical care in the emergency department should receive oxygen to relieve hypoxemia, a short-acting beta₂-agonist to relieve airflow obstruction, along with adjunctive inhaled ipratropium bromide (Spiriva) for severe exacerbations, and systemic corticosteroids to decrease airway inflammation.