The New Asthma Guidelines
Am Fam Physician. 2009 May 1;79(9):727-731.
In this issue of American Family Physician, Pollart and Elward present a review of the new 2007 asthma guidelines from the National Heart, Lung, and Blood Institute.1,2 As a member of the panel that developed these guidelines, here is what I consider to be their highlights. First, it is important to assess the burden of asthma severity before therapy is initiated and the degree of control after treatment.3–5 This assessment includes the frequency, intensity, and duration of symptoms during the day and at night. It is not enough to assess how often symptoms occur (e.g., two days a week). Are they intense and last for hours, or are they short-lived and come mainly after going to bed? This information guides not only medication therapy, but also the rest of the management scheme. For example, symptoms occurring shortly after going to bed may suggest gastroesophageal reflux that is aggravating the asthma, which affects control and is not treated by inhaled corticosteroids or beta agonists.
Next, it is necessary to understand the burden of those symptoms, including what activities the patient is missing or modifying because of symptoms. Patients who say they have “no problems with activities” may have already modified activities to prevent symptoms. Ask about what they cannot do that they would like to do or what they could do three to five years ago.
The asthma guidelines provide clear suggestions about assessing control with control scores that are linked to medication step therapy. The flow-sheet version is to step up therapy when symptoms are not controlled, and try stepping down if symptoms are under control for three months or longer. However, embedded within the guidelines is the art of managing asthma (i.e., recognizing what is affecting control). Why is the asthma out of control? The document has sections on adherence, triggers, and patient beliefs—the topics family physicians address every day. Perhaps the inhaled corticosteroids are not working because the patient is not taking them, or not taking them properly. It may be because of poor inhaler technique or steroid phobia. In that case, simply stepping up therapy will not solve the problems. Alternatively, the problem may be a trigger; for example, someone is smoking in the house again, or the family has just gotten a new cat. Recommendations for addressing triggers, adherence, and inhaler technique are less obvious when you first review the guidelines, but the topics are covered. Successful assessment and interventions for adherence, triggers, and inhaler technique often make the difference between good control at the lowest doses of medication possible and incomplete control no matter how much medication you prescribe.
An Asthma Action Plan is an important tool for helping patients recognize and manage asthma attacks, and it can be a guide for school personnel who monitor students with asthma. This plan provides the patient or parents with guidelines for steps to try at home and when to come to the office or go directly to the emergency department. Templates for Asthma Action Plans are available in the guidelines2 and on organization Web sites, such as the American Lung Association (http://www.lungusa.org/). The evidence to support regular use of the Action Plan is mounting. Would you send patients home to care for their diabetes without telling them how to modify medication use, how to identify a crisis, and when to come back for follow-up care? I doubt it. Asthma, like diabetes, is a chronic and variable condition.
For those concerned about evidence-based recommendations, this is the first time that each specific recommendation has been followed by a level of evidence rating.6 The levels go from A to D, and I consider this a giant step forward. Even in the print material, recommendations that are based on just the opinion of the panel members are noted as such. Not all of the evidence is based on studies done in primary care settings. However, primary care data were included whenever possible, and the data did modify some of the strength of recommendations for educational programs and were the basis for the section of the guidelines addressing adherence.
Short, pocket-sized flip card versions of the guidelines (including only the severity, control, and step therapy tables) will likely circulate widely and should be useful references, especially for those using personal digital assistants. Meanwhile, there are two inclusive online documents available. The reference and resource report released in fall 2007 is lengthy and only useful if you want to know the evidence behind the recommendations. The more recently released executive summary contains all of the pertinent resource information; it includes tables and tools that address the major educational points to go over with every patient with asthma, such as an inhaler technique guide and flow charts for the management of exacerbations (http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm).
Family physicians will find the guidelines useful, but we need more than guidelines. We need tools and programs that can help us integrate the recommendations into everyday practice. Efforts are underway to make it easier to implement the guidelines rather than continue asthma care as usual.
1. Pollart SM, Elward KS. Overview of changes to asthma guidelines. Am Fam Physician. 2009;79(9):761–767.
2. National Asthma Education and Prevention Program (National Heart, Lung, and Blood Institute). Expert panel report 3: guidelines for the diagnosis and management of asthma. NIH publication no 07-4051 Bethesda, Md: National Institutes of Health National Heart, Lung, and Blood Institute; 2007. http://www.nhlbi.nih.gov/guidelines/asthma. Accessed January 29, 2009.
3. Cabana MD, Slish KK, Nan B, Lin X, Clark NM. Asking the correct questions to assess asthma symptoms. Clin Pediatr (Phila). 2005;44(4):319–325.
4. Yawn BP, Yawn RA. Measuring asthma quality in primary care: can we develop better measures? Respir Med. 2006;100(1):26–33.
5. Stoloff SW, Boushey HA. Severity, control, and responsiveness in asthma. J Allergy Clin Immunol. 2006;117(3):544–548.
6. Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 2004;69(3):548–556.
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