he great majority of the nearly 23 million people with asthma, including 6.5 million children, can avoid serious symptoms and disability if they follow the latest guidelines to keep their disease under control. Highlights of the 2007 asthma guidelines from the National Heart, Lung and Blood Institute's National Asthma Education and Prevention Program (NAEPP) were presented during the Annual Meeting of the American College of Allergy, Asthma and Immunology (ACAAI) in an effort not only to increase awareness of the new recommendations, but to help make sure they get put into practice.
"Asthma is not an event, it is a chronic disease that can be managed so that symptoms are controlled and severe attacks are prevented," said Michael B. Foggs, M.D chief of asthma, allergy and immunology, Advocate Health Care, Chicago. "The guidelines underscore the fact that people who are diagnosed with asthma do not have to suffer breathing difficulties or cut back on their activities. We want to make this a reality for all asthma patients."
Asthma occurs when the linings of the airways become inflamed and swollen and muscle spasms constrict airflow to the lungs. An "asthma attack" is characterized by labored or restricted breathing, a tight feeling in the chest, coughing and wheezing. The condition can develop quickly and may vary in severity from mild discomfort to life-threatening attacks in which breathing stops altogether. Each year, nearly 4,000 asthma deaths occur in the United States and the disease accounts for a half million hospitalizations, most of which can be prevented with appropriate care.
According to the NAEPP report, under-diagnosis and inadequate treatment are significant contributors to poor asthma control and the worsening of asthma severity. The new guidelines, the first major update in a decade, include the latest information on the best way to manage the chronic disease. Highlights include emphasis on ongoing monitoring and management of asthma, routine use of inhaled corticosteroids as the standard of care for most patients with chronic persistent asthma, distinguishing between managing acute and chronic asthma, and the identification of new risk factors for the disease.
Ongoing Monitoring and Management
According to Dr. Foggs, the guidelines put a new emphasis on the physician-patient partnership and ongoing monitoring and management. Specific recommendations include:
-- All patients with asthma should be monitored by a doctor every one to six months, regardless of how severe their condition is and whether they are experiencing symptoms.
-- Every patient should have a written asthma action plan with instructions for daily treatment and what to do if symptoms become worse. The action plan should be developed by a doctor or nurse, with input from the patient, and shared with all those who interact with the patient such as family members, teachers and coaches.
-- Education that takes into account cultural background and literacy should be part of asthma care, and patients should play an active role in managing their condition.
-- Asthma treatment based on severity is classified in six steps, rather than four in previous guidelines. A stepwise approach to treatment is still recommended, with medication stepped up or increased when asthma symptoms increase and stepped down, if possible, when asthma is under control.
"When patients and physicians work together to follow these guidelines, asthma symptoms can be prevented and patients can participate in all activities, and not miss days of work or school because of asthma. No one should expect anything less," Dr. Foggs said.
Appropriate Medication Therapy
Anti-inflammatory medications should be routinely prescribed for long-term control of chronic persistent asthma. "Low to medium dose inhaled corticosteroids are very safe, and remain the first line of treatment for preventing asthma symptoms," said H. William Kelly, PharmD, professor emeritus, department of pediatrics, University of New Mexico Health Sciences, Albuquerque. "Unfortunately, they are not prescribed as often as they should be.
"Some people confuse these safe medications with the risky anabolic steroids used by some athletes to improve performance. When used appropriately, corticosteroids are safe and effective in controlling asthma," Dr. Kelly said.
Children ages 5 to 11 have been singled out as a separate category, based on research suggesting they may respond somewhat differently to medications than adults. For many children in this age group, disease control usually can be maintained with a low daily dose of an inhaled corticosteroid, rather than combination treatments, such as long acting beta agonists, needed by many adults. Other age groups in the new guidelines are children up to 4 years old and ages 12 to adult.
The guidelines also emphasize that patients must take their controller medications even when they do not have symptoms, and should be taught how to use inhalers properly so the medication reaches their lungs.
Managing Asthma "Attacks"
The guidelines emphasize the distinction between acute and chronic asthma management, according to Carlos Camargo, M.D., DrPH, Massachusetts General Hospital, Harvard Medical School, Boston.
"The new guidelines modify the spirometry cut points used to assign the severity of an asthma exacerbation, or flare-up," Dr. Camargo said. Spirometry is a test that measures lung function.
"The guidelines also encourage increased use of 'quick relief' medications such as albuterol and oral corticosteroids in the pre-hospital setting, and consideration of adjunctive treatments in severe exacerbations. The guidelines also recommend that emergency physicians and other acute care providers consider prescribing inhaled corticosteroids before patients are discharged from the hospital," he said.
New Risk Factors
Newly identified risk factors for asthma include obesity, use of acetaminophen and exposure to formaldehyde and other volatile organic substances, according to Harold S. Nelson, M.D., professor of medicine, National Jewish Medical and Research Center and University of Colorado Health Sciences Center, Denver.
"According to one study, exposure to new surface materials such as linoleum flooring, synthetic carpeting, particle board, wall coverings and furniture, and recent painting significantly increased the risk of asthma in children," Dr. Nelson said.
Other risk factors identified in the past include allergy to pollen, molds, animal danders and house dust mites, some occupational exposures, and exposure to tobacco smoke and to certain types of air pollution.
The guidelines emphasize the importance of specialty care when early treatment by primary care physicians is not sufficient to control asthma symptoms. For example, referral to a specialist is recommended for most patients who have tried the first three steps for asthma treatment, and have not improved. It also should be considered for those who have completed the first two treatment levels without improvement.
Patients who have had a life-threatening asthma attack and those whose disease is not well-controlled after three to six months of therapy also should be referred to a specialist.
The guidelines also recommend that immunotherapy or allergy vaccinations be considered for patients with persistent allergic asthma.
ACAAI is developing materials for patients and health care professionals about the new guidelines and asthma treatment. The materials will be available early next year on the College's Web site at http://www.acaai.org.
The American College of Allergy, Asthma and Immunology (ACAAI) is a professional medical organization headquartered in Arlington Heights, Ill., that promotes excellence in the practice of the subspecialty of allergy and immunology. The College, comprising more than 5,000 allergists-immunologists and related health care professionals, fosters a culture of collaboration and congeniality in which its members work together and with others toward the common goals of patient care, education, advocacy and research.