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Guidelines for the Diagnosis and Management of Asthma Clinical Practice Guideline

MedStar Health

These guideli es are pro ided to assist physi ia s a d other li i ia s i aki g decisions regarding the care

of their patients. They are not a substitute for individual judgment brought to each clinical situation by the

patie t’s pri ary are pro ider i olla oratio ith the patie t. As with all clinical reference resources, they

reflect the best understanding of the science of medicine at the time of publication, but should be used with the

lear u dersta di g that o ti ued resear h ay result i e k o ledge a d re o e datio s.

MedStar Health, MedStare Prompt Care, and MedStar Family Choice accept and endorse the clinical guidelines

set forth by the National Heart, Lung, and Blood Institute Expert Panel on Asthma, Expert Panel Report 3 (EPR-

3): Guidelines for the Diagnosis and Management of Asthma – Full Report, 2007. The pre-publication report is

available on the web at:

( http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines ) with the summary report

expected December 2007.

These guidelines provide new guidance for selecting treatment based on a patient's individual needs and level

of asthma control. The EPR-3 builds upon complete asthma guidelines issued in 1991 and 1997 and an update

on selected topics released in 2002. These recommendations are based on the results of evidence-based work

in asthma and represent both results of controlled clinical trials and expert consensus. The guidelines focus on

four components of asthma care: measures to assess and monitor asthma, patient education, control of

environmental factors and other conditions that can worsen asthma, and medications.

The guidelines emphasize that while asthma can be controlled; the condition can change over time and differs

among individuals and by age groups. Thus, it is important to monitor regularly the patient's level of asthma

control so that treatment can be adjusted as needed.

Key features and changes to these four components of asthma care include:

Assessment and Monitoring: EPR-3 takes a new approach to assessing and monitoring asthma by using

multiple measures of the patient's level of current impairment (frequency and intensity of symptoms, low

lung function, and limitations of daily activities) and future risk (risk of exacerbations, progressive loss of

lung function, or adverse side effects from medications). The guidelines stress that some patients can still

be at high risk for frequent exacerbations even if they have few day-to-day effects of asthma.

Patient Education. EPR-3 confirms the importance of teaching patients skills to self-monitor and manage

asthma and to use a written asthma action plan (asthma management plan), which should include

instructions for daily treatment and ways to recognize and handle worsening asthma. New

recommendations encourage expanding educational opportunities to reach patients in a variety of

setti gs, such as phar acies, schools, co u ity ce ters, a d patie ts’ ho es. A ew sectio addresses the need for clinician education programs to improve communications with patients and to use system-

wide approaches to integrate the guidelines into health care practice.

Control of environmental factors and other conditions that can affect asthma. EPR-3 describes new

evidence for using multiple approaches to limit exposure to allergens and other substances that can

worsen asthma; research shows that single steps are rarely sufficient. EPR-3 also expands the section on

other common conditions that asthma patients can have and notes that treating chronic problems such

as rhinitis and sinusitis, gastroesophageal reflux, overweight or obesity, obstructive sleep apnea, stress,

and depression may help improve asthma control.

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Medications. EPR-3 continues the use of a stepwise approach to control asthma, in which medication

doses or types are stepped up as needed and stepped down when possible. Treatment is adjusted based

on the level of asthma control.

The stepwise asthma management charts are revised and expanded to specify treatment for three age groups:

0-4 years, 5-11 years, and 12 years and older. The 5-11 age group was added (earlier guidelines combined this

group with adults) as a result of new evidence on medications for this age group and emerging evidence that

suggests that children may respond differently than adults to asthma medications.

The Key Components for Asthma Control

1. Reduce impairment

Prevent chronic and troublesome symptoms (e.g. coughing or breathlessness in the night, in the

early morning, or after exertion).

Require infrequent use (< 2 days per week) of SABA for quick relief of symptoms

Mai tai ear or al pul o ary fu ctio . Maintain normal activity levels including exercise and other physical activity and attendance at

work or school).

Meet patie ts’ a d fa ilies’ expectations of and satisfaction with asthma care.

2. Reduce Risk

Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations

Prevent progressive loss of lung function; for children, prevent reduced lung growth

Provide optimal pharmacotherapy with minimal or no adverse effects

Appendices:

Step Wise Approach For Managing Asthma In Children (0-4 Years Of Age)-

Step Wise Approach For Managing Asthma In Children (5-11 Years Of Age)

Medication Management for Children

Step Wise Approach For Managing Asthma In Youths > 12 And Adults

Medication Management for Youths > 12 and Adults

Product Updates Table

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References:

1. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. (1997).NIH

publication No. 97-4051. Asthma Education and Prevention Program.

2. Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. (2007).

National Institutes of Health publication number 08-4051. Retrieved September, 2007 from

http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines

.

Clinical Guidelines are reviewed every two years by a committee of experts in the field. Updates to

guidelines occur more frequently as needed when new scientific evidence or national standards are

published.

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Product Updates:

Page Item Current Change to

11 Figure 4-4B Budesonide DPI 90, 180, or 200

mcg/inhalation

Budesonide DPI 90 or 180

inhalation

14 Figure 4-4c Albuterol CFC (delete product)

14 Figure 4-4c Pibuterol CFC Autohaler Delete CFC from product

description

15 Figure 4-4c Key: CFC, chlorofluorocarbon (delete from key)

20 Figure 4-8a Cromolyn MDI (delete product)

20 Figure 4-8a Nedocromil MDI (delete product)

21 Figure 4-8b Budesonide DPI 90, 180, or 200

mcg/inhalation

Budesonide DPI 90 or 180

inhalation

21 Figure 4-8b Mometasone DPI 200 mcg/inhalation

200 mcg / 400 mcg / >400 mcg

Mometasone DPI 110 or 220

mcg/inhaler

220 mcg/440 mcg/ >440 mcg

21 Figure 4-8b Triamcinolone acetonide (delete product)

23 Figure 4-8c Albuterol CFC (delete product)

23 Figure 4-8c Pibuterol CFC Autohaler Delete CFC fro product description

Initial Approval Date and Reviews:

Effective, Revised 06/2013, 07/2015(by

Adult committee), 08/2015(by Pediatric

committee)

Most Recent Revision and Approval

Date:

July 2015 - Adults, August 2015-

Pediatrics

Next Scheduled Review Date:

July 2017 Adults, August 2017 Pediatrics

Condition: Asthma