Guidelines for the Diagnosis and Management of Asthma

INSTANT REFERENCE FOR HEALTH PROFESSIONALS

Published by the American College of Asthma, Asthma & Immunology

Guidelines for the Diagnosis and Management of Asthma

Summary of the Expert Panel II Report National Asthma Education and Prevention Program National Heart, Lung, and Blood Institute (NHLBI) National Institutes of Health (NIH)

The guidelines for diagnosing and managing asthma are based on current science.

Four components of the Guidelines:

• Assessment. Precise measurement of lung function to determine the severity of asthma and to monitor the course of therapy.
• Contributing Factors. Avoidance or elimination of factors that prompt asthma symptoms or exacerbations.
• Pharmacotherapy. Medications for reversal and long-term prevention of airway inflammation, plus medications to manage asthma exacerbations.
• Patient Education. A knowledgeable patient and family, working in partnership with health professionals.

MEASURES OF ASSESSMENT AND MONITORING

Accurate diagnosis is critical. To establish the diagnosis of asthma, determine that:

• Episodic symptoms of airflow obstruction are present.
• Airflow obstruction is at least partially reversible.
• Alternative diagnoses are excluded – particularly COPD and vocal cord obstruction in adults, and aspiration and cystic fibrosis in children.

Spirometry. Conduct spirometry before and after inhaled bronchodilator. Significant reversibility is indicated by an increase of equal to or greater than 12% and 200 mL in FEV1.

Peak flow. When spirometry is normal but patients still have symptoms, follow up with peak flow monitoring for 1-2 weeks upon arising and in the afternoon before and after inhaled bronchodilator.

Difference of 20% between high and low readings on same day suggests asthma.

Establish patient’s personal best value and evaluate the response to changes in therapy.

Patients with moderate persistent and severe persistent asthma may benefit from having a peak flow meter at home and measuring their level upon arising each morning.

CLASSIFICATION OF ASTHMA SEVERITY
	Severity Prior to Initiation of Therapy
	Mild Intermittent	Mild Persistent	Moderate Persistent	Severe Persistent
Symptoms	< or = 2 per week	> 2 per week	daily symptoms	continual symptoms
Nighttime symptoms	< or = 2 per month	> 2 per month	> 1 per week	frequent
Lung function	< or = 80% predicted	< or = 80% predicted	> 60% - < or = 80%	< or = 60%
Peak flow variability	< 20%	20-30%	> 30%	> 30%

CONTROL OF FACTORS CONTRIBUTING TO ASTHMA SEVERITY

For successful asthma management, it is essential to:

• Identify and reduce exposure to allergens and irritants that prompt symptoms and exacerbations.
• Control other factors that influence asthma severity.

FACTORS CONTRIBUTING TO ASTHMA SEVERITY
Inhalant allergens Occupational exposures Irritants – indoor and air pollution	Other factors – rhinitis/sinusitis, gastroesophageal reflux, drugs (ASA/NSAID and sulfites in sensitive patients, beta-adrenergic blockers) Viral infection

In patients with persistent asthma:

• Determine exposures to indoor allergens, such as pets, molds, dust mites, cockroaches.
• Establish sensitivity to allergen exposures by skin or in vitro testing.
• Modify environment to reduce or eliminate exposures.
• Consider immunotherapy when symptoms are related to unavoidable exposure and symptoms are prolonged or perennial.

PHARMACOTHERAPY

Goals for pharmacotherapy:

• Control chronic and nocturnal symptoms.
• Maintain normal activity levels, including exercise.
• Maintain near-normal pulmonary function.
• Prevent acute episodes of asthma.
• Avoid adverse effects of asthma medications.

To gain control of moderate persistent to severe persistent asthma, therapy should be initiated with moderate- to high-dose inhaled or even oral corticosteroids. Once control is achieved, the treatment should be rapidly reduced to the level needed to maintain control.

STEP THERAPY BASED ON ASTHMA SEVERITY
Classification	Quick Relief	Long-Term Control
Step 1: Mild Intermittent	prn	None.
Step 2: Mild Persistent	prn	Single agent with anti-inflammatory activity.
Step 3: Moderate Persistent	prn	Inhaled corticosteroids, add long-acting bronchodilator if needed.
Step 4: Severe Persistent	prn	Multiple long-term control medications. Add oral corticosteroids if needed.

PATIENT EDUCATION

Patient education is essential. An educated patient can participate in self-management and is more likely to adhere to treatment programs. Patient should have a written action plan.

Key educational messages:

• Basic facts about asthma – inflammatory nature of the disease.
• Role of medication – importance of long-term control.
• Self-management skills – inhalers, spacers, symptoms, peak flow monitoring for early warning signs of an exacerbation.
• Environmental controls.
• When and how to take action against exacerbations.

GUIDELINES FOR REFERRAL TO AN ASTHMA SPECIALIST

Patient has had life-threatening asthma exacerbation. Patient is not meeting the goals of asthma therapy after 3-6 months of treatment. Signs and symptoms are atypical; diagnosis in question. Other conditions complicate asthma management. Patient requires additional diagnostic testing, education or guidance. Patient is being considered for immunotherapy. Patient’s asthma is Step 4 Severe Persistent (or Step 3 Moderate Persistent in children under age 3).

Harold S. Nelson, M.D., Editor National Jewish Medical Research Center Published by the American College of Allergy, Asthma & Immunology

© 1997, American College of Allergy, Asthma & Immunology