The National Asthma Education and Prevention Program (NAEPP) today released the Report of the Second Expert Panel on the Guidelines for the Diagnosis and Management of Asthma. The report, based on a comprehensive review of the scientific evidence accumulated during the past 6 years, updates the first asthma clinical practice guidelines released in 1991. It was released at a press conference at an American Academy of Allergy, Asthma and Immunology meeting in San Francisco.
Among the new features and recommendations are:
- A new stepwise approach to using asthma medications that puts a heavier emphasis on early use of anti-inflammatory medication;
- Identification of new classifications of asthma severity, which are linked to treatment alternatives.
- A discussion of the possible prevention of onset of asthma and its risk factors by reducing exposures to environmental allergens and secondhand tobacco smoke;
- Expanded information about identifying specific allergens for each patient, including performing allergy testing, and recommendations for reducing exposures to these allergens;
- Heavier emphasis on teaching asthma self-management and prevention to patients;
- Recommendations for more aggressive detection and treatment of asthma in children;
Inclusion of practical tools for physicians to help ensure that the guidelines are incorporated into actual practice. These include: sample questions to help in diagnosis and ongoing assessment and criteria for referral to specialty care.
Coverage of the effects of cultural and ethnic influences on asthma management.
The NAEPP is a multidisciplinary coalition of private sector and governmental groups, coordinated by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It seeks to reduce asthma-related illness and death and to enhance the quality of life of asthma patients.
"The new NAEPP guidelines reflect the increase in the scientific knowledge about asthma during the past six years," observed NHLBI Director Dr. Claude Lenfant. "The expert panel spent nearly two years meticulously conducting a review of the scientific evidence on asthma, with an emphasis on preparing practical recommendations for clinicians, especially primary care physicians, working in diverse health care settings. This is especially important today as changes in health care delivery mandate that a chronic disease like asthma be managed in the most cost-effective way."
Dr. Shirley Murphy, professor and chair of the Department of Pediatrics at the University of New Mexico and chair of the Expert Panel, agreed, noting "The Expert Panel Report does not represent a major departure from the first guidelines, but rather an evolution. It strengthens all the themes of the first report, including the critical role of inflammation in asthma and the importance of a physician/patient partnership in managing the disease."
"But the new report also reflects our improved understanding of how to diagnose and manage this serious condition and adds important recommendations that should help clinicians and patients make appropriate decisions about asthma care," she added.
For example, the new report continues to advocate a step-wise approach to pharmacological therapy. But based on the enhanced understanding of inflammation and its contribution to abnormalities in lung function, it is emphatic that persistent asthma should be controlled with daily anti-inflammatory medications. Medications are now categorized into two general classes: long-term control medications, used to achieve and maintain control of persistent asthma, and quick-relief medications, used to treat acute symptoms and attacks. This underscores the new view of persistent asthma as a chronic disease.
The report also establishes more relevant classifications for asthma severity and links its recommendations for the amount and frequency of medication to the severity of each patient's asthma . The new classifications are mild intermittent, mild persistent, moderate persistent, and severe persistent.
The new report confirms the close relationship between allergy and asthma in most asthma patients and the importance of reducing exposures to indoor and outdoor allergens. But it expands on this by establishing that allergy testing should be used to identify perennial indoor allergens for certain asthma patients and by including recommendations for controlling other factors that can increase asthma symptoms, such as aspirin/NSAIDS and respiratory infections.
The report also makes the point that asthma onset may possibly be prevented by reducing exposures to allergens and tobacco smoke. Stating that undertreatment of asthma in young children is a problem, it also includes a new section on asthma in infants and young children, which incorporates recent studies of wheezing in early childhood and of asthma risk factors.
Since the signs of asthma vary widely from patient to patient, as well as within each patient over time, establishing an asthma diagnosis can be difficult. The new report establishes clear criteria and mechanisms for an asthma diagnosis and strongly recommends that spirometry be used in an initial diagnostic work-up. It also includes new recommendations for use of spirometry and peak flow monitoring in diagnosing and monitoring asthma. Spirometry and peak flow monitoring measure the breathing capacity of the lungs.
As in the 1991 Expert Panel Report, education for an active partnership with patients is advocated as the cornerstone of asthma management. The new report calls for starting education at the time of asthma diagnosis, integrating it into every step of clinical asthma care, and tailoring it specifically to the needs of each patient, with sensitivity to cultural beliefs and practices. Patient outcomes should be measured in terms of the patients' perceptions of improvement, especially quality of life and the ability to live a normal, active life.
The report was prepared by a 22-member panel, with representatives from the fields of allergy and immunology, family practice, internal medicine, nursing, pediatrics, pulmonary medicine, and health education and economics. It was approved by the NAEPP's Coordinating Committee, comprised of representatives of 35 member organizations.
The report will be converted into a concise practical guide for physicians and widely distributed.
Additional information on the NAEPP and other nhlbi materials on asthma are
available online at the NHLBI website: http://www.