National Heart, Lung, and Blood Institute

National Heart, Lung, and Blood Institute

National Asthma Education and Prevention Program

Expert Panel Report 3: Guidelines for the Diagnosis and

Management of Asthma

Full Report 2007

 

 

August 28, 2007 Contents

C O N T E N T S

Acknowledgements and Financial Disclosures xi Acronyms and Abbreviations………………………………………………………………………………………. xix Preface ……………………………………………………………………………………………………………………xxii Section 1, Introduction ……………………………………………………………………………………………….1 Overall Methods Used To Develop This Report …………………………………………………………….2

Background……………………………………………………………………………………………………………..2 Systematic Evidence Review Overview………………………………………………………………………..3

Inclusion/Exclusion Criteria……………………………………………………………………………………..3 Search Strategies ………………………………………………………………………………………………….3 Literature Review Process………………………………………………………………………………………3 Preparation of Evidence Tables……………………………………………………………………………….6 Ranking the Evidence…………………………………………………………………………………………….7 Panel Discussion…………………………………………………………………………………………………..8 Report Preparation ………………………………………………………………………………………………..8

References………………………………………………………………………………………………………………9

Section 2, Definition, Pathophysiology and Pathogenesis of Asthma, and Natural History of Asthma …………………………………………………………………………………………………….11

Key Points: Definition, Pathophysiology and Pathogenesis of Asthma, and Natural History of Asthma……………………………………………………………………………………………………11 Key Differences From 1997 and 2002 Expert Panel Reports …………………………………………12 Introduction ……………………………………………………………………………………………………………12 Definition of Asthma ………………………………………………………………………………………………..12 Pathophysiology and Pathogenesis of Asthma…………………………………………………………….14

Pathophysiologic Mechanisms in the Development of Airway Inflammation ………………….16 Inflammatory Cells……………………………………………………………………………………………16 Inflammatory Mediators …………………………………………………………………………………….18 Immunoglobulin E…………………………………………………………………………………………….19 Implications of Inflammation for Therapy ……………………………………………………………..19

Pathogenesis ……………………………………………………………………………………………………..20 Host Factors ……………………………………………………………………………………………………20 Environmental Factors………………………………………………………………………………………22

Natural History of Asthma ………………………………………………………………………………………..23 Natural History of Persistent Asthma ………………………………………………………………………24

Children………………………………………………………………………………………………………….24 Adults …………………………………………………………………………………………………………….25 Summary ………………………………………………………………………………………………………..27

Effect of Interventions on Natural History of Asthma………………………………………………….27 Implications of Current Information About Pathophysiology and Pathogenesis, and Natural History for Asthma Management ……………………………………………………………..28

References…………………………………………………………………………………………………………….28

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Section 3, The Four Components of Asthma Management ………………………………………….35 Introduction ……………………………………………………………………………………………………………35

Section 3, Component 1: Measures of Asthma Assessment and Monitoring………………..36 Introduction ……………………………………………………………………………………………………………36 Overview of Assessing and Monitoring Asthma Severity, Control, and Responsiveness in Managing Asthma………………………………………………………………………..36 Key Points: Overview of Measures of Asthma Assessment and Monitoring …………………….36 Key Differences From 1997 and 2002 Expert Panel Reports …………………………………………37 Diagnosis of Asthma ……………………………………………………………………………………………….40 Key Points: Diagnosis of Asthma ……………………………………………………………………………..40 Key Differences From 1997 and 2002 Expert Panel Reports …………………………………………41

Medical History……………………………………………………………………………………………………41 Physical Examination …………………………………………………………………………………………..42 Pulmonary Function Testing (Spirometry)………………………………………………………………..43 Differential Diagnosis of Asthma…………………………………………………………………………….45

Initial Assessment: Characterization of Asthma and Classification of Asthma Severity………47 Key Points: Initial Assessment of Asthma ………………………………………………………………….47 Key Differences From 1997 and 2002 Expert Panel Reports …………………………………………48

Identify Precipitating Factors …………………………………………………………………………………48 Identify Comorbid Conditions That May Aggravate Asthma ………………………………………..49 Assess the Patient’s Knowledge and Skills for Self-Management………………………………..49 Classify Asthma Severity ………………………………………………………………………………………49

Assessment of Impairment ………………………………………………………………………………..50 Assessment of Risk ………………………………………………………………………………………….51

Periodic Assessment and Monitoring of Asthma Control Essential for Asthma Management ………………………………………………………………………………………………………….52 Key Points: Periodic Assessment of Asthma Control……………………………………………………52 Key Differences From 1997 and 2002 Expert Panel Reports …………………………………………54

Goals of Therapy: Asthma Control…………………………………………………………………………55 Asthma Control………………………………………………………………………………………………..55

Measures for Periodic Assessment and Monitoring of Asthma Control …………………………56 Monitoring Signs and Symptoms of Asthma …………………………………………………………57 Monitoring Pulmonary Function ………………………………………………………………………….58

Spirometry …………………………………………………………………………………………………..58 Peak Flow Monitoring ……………………………………………………………………………………59 Peak Flow Versus Symptom-Based Monitoring Action Plan ………………………………..60

Monitoring Quality of Life …………………………………………………………………………………..61 Monitoring History of Asthma Exacerbations ………………………………………………………..63 Monitoring Pharmacotherapy for Adherence and Potential Side Effects ……………………63 Monitoring Patient–Provider Communication and Patient Satisfaction ………………………63 Monitoring Asthma Control With Minimally Invasive Markers and Pharmacogenetics……………………………………………………………………………………………64 Pharmacogenetics in Managing Asthma………………………………………………………………66

Methods for Periodic Assessment and Monitoring of Asthma Control …………………………..66 Clinician Assessment ……………………………………………………………………………………….67 Patient Self-Assessment……………………………………………………………………………………67 Population-Based Assessment …………………………………………………………………………..67

Referral to an Asthma Specialist for Consultation or Comanagement ……………………………..68 References …………………………………………………………………………………………………………82

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Section 3, Component 2: Education for a Partnership in Asthma Care ………………………..93 Key Points: Education for a Partnership in Asthma Care………………………………………………93 Key Points: Provider Education ………………………………………………………………………………..95 Key Differences From 1997 and 2002 Expert Panel Reports …………………………………………95 Introduction ……………………………………………………………………………………………………………96 Asthma Self-Management Education at Multiple Points of Care……………………………………..97

Clinic/Office-Based Education ……………………………………………………………………………….97 Adults—Teach Asthma Self-Management Skills To Promote Asthma Control ……………97

Written Asthma Action Plans, Clinician Review, and Self-Monitoring …………………….98 Patient–Provider Partnership ………………………………………………………………………….99 Health Professionals Who Teach Self-Management…………………………………………100 Education With Multiple Sessions ………………………………………………………………….101

Children—Teach Asthma Self-Management Skills To Promote Asthma Control ……….101 Emergency Department/Hospital-Based Education …………………………………………………102

Adults …………………………………………………………………………………………………………..102 Emergency Department Asthma Education …………………………………………………….103 Hospital-Based Asthma Education…………………………………………………………………104

Children………………………………………………………………………………………………………..105 Educational Interventions by Pharmacists ……………………………………………………………..106 Educational Interventions in School Settings ………………………………………………………….107 Community-Based Interventions…………………………………………………………………………..108

Asthma Education ………………………………………………………………………………………….108 Home-Based Interventions ………………………………………………………………………………….109

Home-Based Asthma Education for Caregivers…………………………………………………..109 Home-Based Allergen-Control Interventions……………………………………………………….109

Other Opportunities for Asthma Education …………………………………………………………….111 Education for Children Using Computer-Based Technology ………………………………….111 Education on Tobacco Avoidance for Women Who Are Pregnant and Members of Households With Infants and Young Children………………………………………………..112 Case Management for High-Risk Patients ………………………………………………………….113

Cost-Effectiveness …………………………………………………………………………………………….114 Tools for Asthma Self-Management …………………………………………………………………………115

Role of Written Asthma Action Plans for Patients Who Have Asthma …………………………115 Role of Peak Flow Monitoring………………………………………………………………………………120 Goals of Asthma Self-Management Education and Key Educational Messages …………..121

Establish and Maintain a Partnership ……………………………………………………………………….124 Teach Asthma Self-Management …………………………………………………………………………125 Jointly Develop Treatment Goals………………………………………………………………………….131 Assess and Encourage Adherence to Recommended Therapy …………………………………131 Tailor Education to the Needs of the Individual Patient …………………………………………….133

Knowledge and Beliefs ……………………………………………………………………………………133 Health Literacy ………………………………………………………………………………………………134 Cultural/Ethnic Considerations………………………………………………………………………….135

Maintain the Partnership……………………………………………………………………………………..135 Asthma Education Resources ……………………………………………………………………………..140

Provider Education………………………………………………………………………………………………..141 Methods of Improving Clinician Behaviors ……………………………………………………………..141

Implementing Guidelines—Recommended Practices …………………………………………..141 Communication Techniques …………………………………………………………………………….143

Methods of Improving System Supports ……………………………………………………………….. 144 Clinical Pathways …………………………………………………………………………………………..144 Clinical Decision Supports ……………………………………………………………………………….145

References…………………………………………………………………………………………………………..146

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Section 3, Component 3: Control of Environmental Factors and Comorbid Conditions That Affect Asthma………………………………………………………………………………..165

Key Points: Control of Environmental Factors and Comorbid Conditions That Affect Asthma………………………………………………………………………………………………………………..165 Key Differences From 1997 Expert Panel Report ……………………………………………………….166 Introduction ………………………………………………………………………………………………………….167 Inhalant Allergens …………………………………………………………………………………………………167

Diagnosis—Determine Relevant Inhalant Sensitivity ……………………………………………….167 Management—Reduce Exposure…………………………………………………………………………169 Immunotherapy …………………………………………………………………………………………………172 Assessment of Devices That May Modify Indoor Air ………………………………………………..174

Occupational Exposures ………………………………………………………………………………………..175 Irritants………………………………………………………………………………………………………………..175

Environmental Tobacco Smoke ……………………………………………………………………………175 Indoor/Outdoor Air Pollution and Irritants……………………………………………………………….176

Formaldehyde and Volatile Organic Compounds…………………………………………………176 Gas Stoves and Appliances……………………………………………………………………………..176

Comorbid Conditions……………………………………………………………………………………………..177 Allergic Bronchopulmonary Aspergillosis ……………………………………………………………….177 Gastroesophageal Reflux Disease ……………………………………………………………………….178 Obesity …………………………………………………………………………………………………………….179 Obstructive Sleep Apnea …………………………………………………………………………………….179 Rhinitis/Sinusitis ………………………………………………………………………………………………..180 Stress, Depression, and Psychosocial Factors in Asthma ………………………………………..180

Other Factors ……………………………………………………………………………………………………….181 Medication Sensitivities ………………………………………………………………………………………181

Aspirin ………………………………………………………………………………………………………….181 Beta-Blockers ………………………………………………………………………………………………..182

Sulfite Sensitivity ……………………………………………………………………………………………….182 Infections………………………………………………………………………………………………………….182

Viral Respiratory Infections………………………………………………………………………………182 Bacterial Infections …………………………………………………………………………………………183 Influenza Infection ………………………………………………………………………………………….183

Female Hormones and Asthma ……………………………………………………………………………183 Diet………………………………………………………………………………………………………………….184

Primary Prevention of Allergic Sensitization and Asthma …………………………………………….184 References…………………………………………………………………………………………………………..190

Section 3, Component 4: Medications……………………………………………………………………..213 Key Points: Medications ………………………………………………………………………………………..213 Key Differences From 1997 and 2002 Expert Panel Reports ……………………………………….215 Introduction ………………………………………………………………………………………………………….215 Overview of the Medications …………………………………………………………………………………..216

Long-Term Control Medications …………………………………………………………………………..216 Inhaled Corticosteroids ……………………………………………………………………………………216

Mechanism ………………………………………………………………………………………………..216 Inhaled Corticosteroid Insensitivity…………………………………………………………………217 Efficacy of Inhaled Corticosteroids as Compared to Other Long-Term Control Medications as Monotherapy ………………………………………………………………………..217 Efficacy of Inhaled Corticosteroid and Adjunctive Therapy (Combination Therapy) ……………………………………………………………………………………………………217 Dose-Response and Delivery Device …………………………………………………………….218 Variability in Response and Adjustable Dose Therapy………………………………………219 Safety of Inhaled Corticosteroids …………………………………………………………………..220

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Key Points: Safety of Inhaled Corticosteroids……………………………………………………………220 Key Points: Inhaled Corticosteroids and Linear Growth in Children ………………………………222

Oral Systemic Corticosteroids ………………………………………………………………………….224 Cromolyn Sodium and Nedocromil ……………………………………………………………………224 Immunomodulators…………………………………………………………………………………………225

Omalizumab ………………………………………………………………………………………………225 Antibiotics ………………………………………………………………………………………………….226 Others ………………………………………………………………………………………………………226

Leukotriene Modifiers ……………………………………………………………………………………..227 Inhaled Long-Acting Beta2-Agonists ………………………………………………………………….229

Safety of Long-Acting Beta2-Agonists …………………………………………………………….231 Key Points: Safety of Inhaled Long-Acting Beta2-Agonists ………………………………………….231

Methylxanthines …………………………………………………………………………………………….234 Tiotropium Bromide ………………………………………………………………………………………..235

Quick-Relief Medications …………………………………………………………………………………….235 Anticholinergics ……………………………………………………………………………………………..235 Inhaled Short-Acting Beta2-Agonists………………………………………………………………….235

Safety of Inhaled Short-Acting Beta2-Agonists …………………………………………………236 Key Points: Safety of Inhaled Short-Acting Beta2-Agonists………………………………………….236

Systemic Corticosteroids …………………………………………………………………………………237 Route of Administration ………………………………………………………………………………………238

Alternatives to CFC-Propelled MDIs ………………………………………………………………….238 Spacers and Valved Holding Chambers …………………………………………………………….239

Complementary and Alternative Medicine …………………………………………………………………240 Key Points: Complementary and Alternative Medicine ……………………………………………….240

Acupuncture ……………………………………………………………………………………………………..240 Chiropractic Therapy ………………………………………………………………………………………….241 Homeopathy and Herbal Medicine………………………………………………………………………..241 Breathing Techniques…………………………………………………………………………………………241 Relaxation Techniques ……………………………………………………………………………………….242 Yoga………………………………………………………………………………………………………………..242

References…………………………………………………………………………………………………………..252

Section 4, Managing Asthma Long Term: Overview ………………………………………………… 277 Key Points: Managing Asthma Long Term ……………………………………………………………….277 Key Differences From 1997 and 2002 Expert Panel Reports ……………………………………….278 Introduction ………………………………………………………………………………………………………….279

Section 4, Managing Asthma Long Term in Children 0–4 Years of Age and 5–11 Years of Age ………………………………………………………………………………………………………….. 281

Diagnosis and Prognosis of Asthma in Children …………………………………………………………281 Diagnosis of Asthma…………………………………………………………………………………………..281 Prognosis of Asthma ………………………………………………………………………………………….281 Prevention of Asthma Progression ……………………………………………………………………….282 Monitoring Asthma Progression……………………………………………………………………………283

Treatment: Principles of Stepwise Therapy in Children ………………………………………………284 Achieving Control of Asthma ……………………………………………………………………………….285

Selecting Initial Therapy ………………………………………………………………………………….285 Adjusting Therapy…………………………………………………………………………………………..286

Maintaining Control of Asthma……………………………………………………………………………..288 Key Points: Inhaled Corticosteroids in Children ……………………………………………………..289

Key Points: Managing Asthma in Children 0–4 Years of Age ……………………………………..289

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Treatment: Pharmacologic Issues for Children 0–4 Years of Age…………………………………290 FDA Approval ……………………………………………………………………………………………………291 Delivery Devices………………………………………………………………………………………………..291

Treatment: Pharmacologic Steps for Children 0–4 Years of Age………………………………….291 Intermittent Asthma ……………………………………………………………………………………………292

Step 1 Care, Children 0–4 Years of Age…………………………………………………………….292 Persistent Asthma ……………………………………………………………………………………………..293

Step 2 Care, Children 0–4 Years of Age…………………………………………………………….293 Step 3 Care, Children 0–4 Years of Age…………………………………………………………….294 Step 4 Care, Children 0–4 Years of Age…………………………………………………………….295 Step 5 Care, Children 0–4 Years of Age…………………………………………………………….296 Step 6 Care, Children 0–4 Years of Age…………………………………………………………….296

Key Points: Managing Asthma in Children 5–11 Years of Age…………………………………296 Treatment: Special Issues for Children 5–11 Years of Age …………………………………………297

Pharmacologic Issues ………………………………………………………………………………………..297 School Issues ……………………………………………………………………………………………………298 Sports and Exercise Issues …………………………………………………………………………………298

Treatment: Pharmacologic Steps for Children 5–11 Years of Age ………………………………..299 Intermittent Asthma ……………………………………………………………………………………………299

Step 1 Care, Children 5–11 Years of Age …………………………………………………………..299 Persistent Asthma ……………………………………………………………………………………………..300

Step 2 Care, Children 5–11 Years of Age …………………………………………………………..300 Step 3 Care, Children 5–11 Years of Age …………………………………………………………..301 Step 4 Care, Children 5–11 Years of Age …………………………………………………………..303 Step 5 Care, Children 5–11 Years of Age …………………………………………………………..303 Step 6 Care, Children 5–11 Years of Age …………………………………………………………..303

References…………………………………………………………………………………………………………..319

Section 4, Managing Asthma Long Term in Youths � 12 Years of Age and Adults ………326 Key Points: Managing Asthma Long Term in Youths � 12 Years of Age and Adults ………..326

Section 4, Stepwise Approach for Managing Asthma in Youths � 12 Years of Age and Adults ……………………………………………………………………………………………………………..328

Treatment: Principles of Stepwise Therapy in Youths � 12 Years of Age and Adults……….328 Achieving Control of Asthma ……………………………………………………………………………….329

Selecting Initial Therapy for Patients Not Currently Taking Long-Term Control Medications …………………………………………………………………………………………………..329 Adjusting Therapy…………………………………………………………………………………………..329

Impairment Domain …………………………………………………………………………………….330 Risk Domain ………………………………………………………………………………………………330

Maintaining Control of Asthma……………………………………………………………………………..331 Treatment: Pharmacologic Steps ……………………………………………………………………………333

Intermittent Asthma ……………………………………………………………………………………………333 Step 1 Care …………………………………………………………………………………………………..333

Persistent Asthma ……………………………………………………………………………………………..334 Step 2 Care, Long-Term Control Medication……………………………………………………….335 Step 3 Care, Long-Term Control Medications……………………………………………………..336 Step 4 Care, Long-Term Control Medications……………………………………………………..338 Step 5 Care, Long-Term Control Medications……………………………………………………..338 Step 6 Care, Long-Term Control Medications……………………………………………………..339

Special Issues for Adolescents …………………………………………………………………………….339 Assessment Issues…………………………………………………………………………………………339 Treatment Issues……………………………………………………………………………………………340

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School Issues ………………………………………………………………………………………………..340 Sports Issues…………………………………………………………………………………………………340

Special Issues for Older Adults…………………………………………………………………………….341 Assessment Issues…………………………………………………………………………………………341 Treatment Issues……………………………………………………………………………………………341

References…………………………………………………………………………………………………………..353

Section 4, Managing Asthma Long Term—Special Situations …………………………………… 362 Introduction ………………………………………………………………………………………………………….362 Exercise-Induced Bronchospasm…………………………………………………………………………….362

Diagnosis …………………………………………………………………………………………………………362 Management Strategies ……………………………………………………………………………………..363

Surgery and Asthma ……………………………………………………………………………………………..364 Pregnancy and Asthma ………………………………………………………………………………………….364 Racial and Ethnic Disparity in Asthma………………………………………………………………………365 References…………………………………………………………………………………………………………..367

Section 5, Managing Exacerbations of Asthma ………………………………………………………… 372 Key Points: Managing Exacerbations of Asthma ……………………………………………………….372 Key Differences From 1997 and 2002 Expert Panel Reports ……………………………………….373 Introduction ………………………………………………………………………………………………………….373 General Considerations………………………………………………………………………………………….375 Treatment Goals …………………………………………………………………………………………………..377 Home Management of Asthma Exacerbations …………………………………………………………..380 Pre-hospital Management of Asthma Exacerbations …………………………………………………..383 Emergency Department and Hospital Management of Asthma Exacerbations ………………..384

Assessment………………………………………………………………………………………………………384 Treatment…………………………………………………………………………………………………………391 Repeat Assessment …………………………………………………………………………………………..395 Hospitalization …………………………………………………………………………………………………..395 Impending Respiratory Failure……………………………………………………………………………..396 Patient Discharge ………………………………………………………………………………………………398

References…………………………………………………………………………………………………………..405

For More Information ………………………………………………………………………………………………415

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List of Boxes And Figures

FIGURE 1–1. LITERATURE RETRIEVAL AND REVIEW PROCESS: BREAKDOWN BY COMMITTEE …………………………………………………………………………………………………..4

FIGURE 1–2. LITERATURE RETRIEVAL AND REVIEW PROCESS: OVERALL SUMMARY …………………………………………………………………………………………………………..6

BOX 2–1. CHARACTERISTICS OF CLINICAL ASTHMA…………………………………………………12 FIGURE 2–1. THE INTERPLAY AND INTERACTION BETWEEN AIRWAY

INFLAMMATION AND THE CLINICAL SYMPTOMS AND PATHOPHYSIOLOGY OF ASTHMA ………………………………………………………………………………………………………13

FIGURE 2–2. FACTORS LIMITING AIRFLOW IN ACUTE AND PERSISTENT ASTHMA……..15 BOX 2–2. FEATURES OF AIRWAY REMODELING ……………………………………………………….16 FIGURE 2–3. AIRWAY INFLAMMATION………………………………………………………………………17 FIGURE 2–4. HOST FACTORS AND ENVIRONMENTAL EXPOSURES …………………………..20 FIGURE 2–5. CYTOKINE BALANCE ……………………………………………………………………………21

BOX 3–1. KEY INDICATORS FOR CONSIDERING A DIAGNOSIS OF ASTHMA……………….42 BOX 3–2. IMPORTANCE OF SPIROMETRY IN ASTHMA DIAGNOSIS …………………………….43 BOX 3–3. DIFFERENTIAL DIAGNOSTIC POSSIBILITIES FOR ASTHMA …………………………46 BOX 3–4. INSTRUMENTS FOR ASSESSING ASTHMA-SPECIFIC AND GENERIC

QUALITY OF LIFE ………………………………………………………………………………………………62 FIGURE 3–1. SUGGESTED ITEMS FOR MEDICAL HISTORY* ………………………………………69 FIGURE 3–2. SAMPLE QUESTIONS* FOR THE DIAGNOSIS AND INITIAL

ASSESSMENT OF ASTHMA ………………………………………………………………………………..70 FIGURE 3-3a. SAMPLE SPIROMETRY VOLUME TIME AND FLOW VOLUME

CURVES ……………………………………………………………………………………………………………71 FIGURE 3–3b. REPORT OF SPIROMETRY FINDINGS PRE- AND

POSTBRONCHODILATOR …………………………………………………………………………………..71 FIGURE 3–4a. CLASSIFYING ASTHMA SEVERITY IN CHILDREN 0–4 YEARS OF

AGE ………………………………………………………………………………………………………………….72 FIGURE 3–4b. CLASSIFYING ASTHMA SEVERITY IN CHILDREN 5–11 YEARS OF

AGE ………………………………………………………………………………………………………………….73 FIGURE 3–4c. CLASSIFYING ASTHMA SEVERITY IN YOUTHS �12 YEARS OF AGE

AND ADULTS……………………………………………………………………………………………………..74 FIGURE 3–5a. ASSESSING ASTHMA CONTROL IN CHILDREN 0–4 YEARS OF AGE……..75 FIGURE 3–5b. ASSESSING ASTHMA CONTROL IN CHILDREN 5–11 YEARS OF

AGE ………………………………………………………………………………………………………………….76 FIGURE 3–5c. ASSESSING ASTHMA CONTROL IN YOUTHS �12 YEARS OF AGE

AND ADULTS……………………………………………………………………………………………………..77 FIGURE 3–6. SAMPLE QUESTIONS FOR ASSESSING AND MONITORING ASTHMA

CONTROL………………………………………………………………………………………………………….78 FIGURE 3–7. COMPONENTS OF THE CLINICIAN’S FOLLOWUP ASSESSMENT:

SAMPLE ROUTINE CLINICAL ASSESSMENT QUESTIONS*……………………………………79 FIGURE 3–8. VALIDATED INSTRUMENTS FOR ASSESSMENT AND MONITORING

OF ASTHMA ………………………………………………………………………………………………………80 FIGURE 3–9. SAMPLE* PATIENT SELF-ASSESSMENT SHEET FOR FOLLOWUP

VISITS……………………………………………………………………………………………………………….81 FIGURE 3–10a. ASTHMA ACTION PLAN …………………………………………………………………..117 FIGURE 3–10b. ASTHMA ACTION PLAN …………………………………………………………………..118

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FIGURE 3–10c. ASTHMA ACTION PLAN …………………………………………………………………..119 FIGURE 3–11. HOW TO USE YOUR PEAK FLOW METER…………………………………………..122 FIGURE 3–12. KEY EDUCATIONAL MESSAGES: TEACH AND REINFORCE AT

EVERY OPPORTUNITY …………………………………………………………………………………….124 FIGURE 3–13. DELIVERY OF ASTHMA EDUCATION BY CLINICIANS DURING

PATIENT CARE VISITS ……………………………………………………………………………………..126 FIGURE 3–14. HOW TO USE YOUR METERED-DOSE INHALER…………………………………128 FIGURE 3–15. HOW TO CONTROL THINGS THAT MAKE YOUR ASTHMA WORSE ………129 FIGURE 3–16a. SCHOOL ASTHMA ACTION PLAN …………………………………………………….137 FIGURE 3–16b. SCHOOL ASTHMA ACTION PLAN …………………………………………………….139 BOX 3–5. THE STRONG ASSOCIATION BETWEEN SENSITIZATION TO

ALLERGENS AND ASTHMA: A SUMMARY OF THE EVIDENCE ……………………………168 BOX 3–6. RATIONALE FOR ALLERGY TESTING FOR PERENNIAL INDOOR

ALLERGENS…………………………………………………………………………………………………….169 FIGURE 3–17. ASSESSMENT QUESTIONS* FOR ENVIRONMENTAL AND OTHER

FACTORS THAT CAN MAKE ASTHMA WORSE …………………………………………………..186 FIGURE 3–18. COMPARISON OF SKIN TESTS WITH IN VITRO TESTS ……………………….187 FIGURE 3–19. PATIENT INTERVIEW QUESTIONS* FOR ASSESSING THE CLINICAL

SIGNIFICANCE OF POSITIVE ALLERGY TESTS ………………………………………………….187 FIGURE 3–20. SUMMARY OF MEASURES TO CONTROL ENVIRONMENTAL

FACTORS THAT CAN MAKE ASTHMA WORSE …………………………………………………..188 FIGURE 3–21. EVALUATION AND MANAGEMENT OF WORK-AGGRAVATED

ASTHMA AND OCCUPATIONAL ASTHMA …………………………………………………………..189 FIGURE 3–22. LONG-TERM CONTROL MEDICATIONS………………………………………………243 FIGURE 3–23. QUICK-RELIEF MEDICATIONS …………………………………………………………..247 FIGURE 3–24. AEROSOL DELIVERY DEVICES …………………………………………………………249

BOX 4–1. SAMPLE PATIENT RECORD. MONITORING THE RISK DOMAIN IN CHILDREN: RISK OF ASTHMA PROGRESSION (INCREASED EXACERBATIONS OR NEED FOR DAILY MEDICATION, OR LOSS OF LUNG FUNCTION), AND POTENTIAL ADVERSE EFFECTS OF CORTICOSTEROID THERAPY ………………………………………………………………………………………………………..283

FIGURE 4–1a. STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 0–4 YEARS OF AGE………………………………………………………………………………………….305

FIGURE 4–1b. STEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN 5–11 YEARS OF AGE………………………………………………………………………………………..306

FIGURE 4–2a. CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 0–4 YEARS OF AGE…………………………………………………………………………307

FIGURE 4–2b. CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN 5–11 YEARS OF AGE……………………………………………………………………….308

FIGURE 4–3a. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 0–4 YEARS OF AGE …………………………………………………………………….309

FIGURE 4–3b. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN CHILDREN 5–11 YEARS OF AGE …………………………………………………………………..310

FIGURE 4–4a. USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS IN CHILDREN* ………………………………………………………………………………………………….311

FIGURE 4–4b. ESTIMATED COMPARATIVE DAILY DOSAGES FOR INHALED CORTICOSTEROIDS IN CHILDREN ……………………………………………………………………314

FIGURE 4–4c. USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS IN CHILDREN* ……………………………………………………………………………………………………..317

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FIGURE 4–5. STEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS �12 YEARS OF AGE AND ADULTS …………………………………………………………………….343

FIGURE 4–6. CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN YOUTHS �12 YEARS OF AGE AND ADULTS……………………………………………………….344

FIGURE 4–7. ASSESSING ASTHMA CONTROL AND ADJUSTING THERAPY IN YOUTHS �12 YEARS OF AGE AND ADULTS……………………………………………………….345

FIGURE 4–8a. USUAL DOSAGES FOR LONG-TERM CONTROL MEDICATIONS FOR YOUTHS �12 YEARS OF AGE AND ADULTS……………………………………………………….346

FIGURE 4–8b. ESTIMATED COMPARATIVE DAILY DOSAGES FOR INHALED CORTICOSTEROIDS FOR YOUTHS �12 YEARS OF AGE AND ADULTS ………………..349

FIGURE 4–8c.USUAL DOSAGES FOR QUICK-RELIEF MEDICATIONS FOR YOUTHS �12 YEARS OF AGE AND ADULTS……………………………………………………….351

FIGURE 5–1. CLASSIFYING SEVERITY OF ASTHMA EXACERBATIONS IN THE URGENT OR EMERGENCY CARE SETTING ……………………………………………………….374

FIGURE 5–2a. RISK FACTORS FOR DEATH FROM ASTHMA ……………………………………..376 FIGURE 5–2b. SPECIAL CONSIDERATIONS FOR INFANTS ……………………………………….377 FIGURE 5–3. FORMAL EVALUATION OF ASTHMA EXACERBATION SEVERITY IN

THE URGENT OR EMERGENCY CARE SETTING ………………………………………………..379 FIGURE 5–4. MANAGEMENT OF ASTHMA EXACERBATIONS: HOME TREATMENT…….381 FIGURE 5–5. DOSAGES OF DRUGS FOR ASTHMA EXACERBATIONS ……………………….385 FIGURE 5–6. MANAGEMENT OF ASTHMA EXACERBATIONS: EMERGENCY

DEPARTMENT AND HOSPITAL-BASED CARE …………………………………………………….387 FIGURE 5–7a. EMERGENCY DEPARTMENT—ASTHMA DISCHARGE PLAN ………………..401 FIGURE 5–7b. EMERGENCY DEPARTMENT—ASTHMA DISCHARGE PLAN:

HOW TO USE YOUR METERED-DOSE INHALER ………………………………………………..402 FIGURE 5–8. CHECKLIST FOR HOSPITAL DISCHARGE OF PATIENTS WHO HAVE

ASTHMA ………………………………………………………………………………………………………….404

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August 28, 2007 Acknowledgements and Financial Disclosures

ACKNOWLEDGMENTS AND FINANCIAL DISCLOSURES

External Review and Comment Overview

In response to a recommendation by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee, an Expert Panel was convened by the National Heart, Lung, and Blood Institute (NHLBI) to update the asthma guidelines.

Several measures were taken in the development of these asthma guidelines to enhance transparency of the evidence review process and to better manage any potential or perceived conflict of interest. In addition to using a methodologist to guide preparation of the Evidence Tables, several layers of external content review were also embedded into the guidelines development process. Expert Panel members and consultant reviewers completed financial disclosure forms that are summarized below. In addition to review by consultants, an early draft of the guidelines was circulated to a panel of guidelines end-users (the Guidelines Implementation Panel) appointed specifically for their review and feedback on ways to enhance guidelines utilization by primary care clinicians, health care delivery organizations, and third-party payors. Finally, a draft of the guidelines was posted on the NHLBI Web Site for review and comment by the NAEPP Coordinating Committee and to allow opportunity for public review and comment before the guidelines were finalized and released.

NAEPP COORDINATING COMMITTEE

Agency for Healthcare Research and Quality

Denise Dougherty, Ph.D.

Allergy and Asthma Network Mothers of Asthmatics

Nancy Sander

American Academy of Allergy, Asthma, and Immunology

Michael Schatz, M.D., M.S.

American Academy of Family Physicians Kurtis S. Elward, M.D., M.P.H., F.A.A.F.P.

American Academy of Pediatrics Gary S. Rachelefsky, M.D.

American Academy of Physician Assistants Tera Crisalida, P.A.-C., M.P.A.S.

American Association for Respiratory Care Thomas J. Kallstrom, R.R.T., F.A.A.R.C.,

AE-C

American College of Allergy, Asthma, and Immunology

William Storms, M.D.

American College of Chest Physicians John Mitchell, M.D., F.A.C.P.

American College of Emergency Physicians Richard M. Nowak, M.D., M.B.A.,

F.A.C.E.P.

American Lung Association Noreen M. Clark, Ph.D.

American Medical Association Paul V. Williams, M.D.

American Nurses Association Karen Huss, D.N.Sc., R.N., A.P.R.N.B.C.,

F.A.A.N., F.A.A.A.A.I.

American Pharmacists Association Dennis M. Williams, Pharm.D.

American Public Health Association Pamela J. Luna, Dr.P.H., M.Ed.

American School Health Association Lani S. M. Wheeler, M.D., F.A.A.P.,

F.A.S.H.A.

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Acknowledgements and Financial Disclosures

American Society of Health-System Pharmacists

Kathryn V. Blake, Pharm.D.

American Thoracic Society Stephen C. Lazarus, M.D.

Asthma and Allergy Foundation of America Mo Mayrides

Council of State and Territorial Epidemiologists

Sarah Lyon-Callo, M.A., M.S.

National Association of School Nurses Donna Mazyck, R.N., M.S., N.C.S.N.

National Black Nurses Association, Inc. Susan B. Clark, R.N., M.N.

National Center for Chronic Disease Prevention, Centers for Disease Control and Prevention (CDC)

Sarah Merkle, M.P.H.

National Center for Environmental Health, CDC

Paul M. Garbe, M.D.

National Center for Health Statistics, CDC Lara Akinbami, M.D.

National Institute for Occupational Safety and Health, CDC

Margaret Filios, S.M., R.N.

National Heart, Lung, and Blood Institute National Institutes of Health (NIH) Elizabeth Nabel, M.D.

August 28, 2007

National Heart, Lung, and Blood Institute NIH, Ad Hoc Committee on Minority

Populations Ruth I. Quartey, Ph.D.

National Institute of Allergy and Infectious Diseases (NIAID), NIH

Peter J. Gergen, M.D., M.P.H.

National Institute of Environmental Health Sciences, NIH

Charles A. Wells, Ph.D.

National Medical Association Michael Lenoir, M.D.

National Respiratory Training Center Pamela Steele, M.S.N., C.P.N.P., AE-C

Society for Academic Emergency Medicine Rita Cydulka, M.D., M.S.

Society for Public Health Education Judith C. Taylor-Fishwick, M.Sc., AE-C

U.S. Department of Education Dana Carr

U.S. Environmental Protection Agency Indoor Environments Division

David Rowson, M.S.

U.S. Environmental Protection Agency Office of Research and Development

Hillel S. Koren, Ph.D.

U.S. Food and Drug Administration Robert J. Meyer, M.D.

THIRD EXPERT PANEL ON THE DIAGNOSIS AND MANAGEMENT OF ASTHMA

William W. Busse, M.D., Chair University of Wisconsin Medical School Madison, Wisconsin

Homer A. Boushey, M.D. University of California–San Francisco San Francisco, California

Carlos A. Camargo, Jr., M.D., Dr.P.H. Massachusetts General Hospital Boston, Massachusetts

David Evans, Ph.D., A.E.-C, Columbia University New York, New York

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August 28, 2007 Acknowledgements and Financial Disclosures

Michael B. Foggs, M.D. Advocate Health Centers Chicago, Illinois

Susan L. Janson, D.N.Sc., R.N., A.N.P., F.A.A.N.

University of California–San Francisco San Francisco, California

H. William Kelly, Pharm.D. University of New Mexico Health Sciences

Center Albuquerque, New Mexico

Robert F. Lemanske, M.D. University of Wisconsin Hospital and Clinics Madison, Wisconsin

Fernando D. Martinez, M.D. University of Arizona Medical Center Tucson, Arizona

Robert J. Meyer, M.D. U.S. Food and Drug Administration Silver Spring, Maryland

Harold S. Nelson, M.D. National Jewish Medical and Research

Center Denver, Colorado

Thomas A. E. Platts-Mills, M.D., Ph.D. University of Virginia School of Medicine Charlottesville, Virginia

Michael Schatz, M.D., M.S. Kaiser-Permanente–San Diego San Diego, California

Gail Shapiro, M.D.† University of Washington Seattle, Washington

Stuart Stoloff, M.D. University of Nevada School of Medicine Carson City, Nevada

Stanley J. Szefler, M.D. National Jewish Medical and Research

Center Denver, Colorado

Scott T. Weiss, M.D., M.S. Brigham and Women’s Hospital Boston, Massachusetts

Barbara P. Yawn, M.D., M.Sc. Olmstead Medical Center Rochester, Minnesota

†Deceased

Development of the resource document and the guidelines report was funded by the NHLBI, NIH. Expert Panel members completed financial disclosure forms, and the Expert Panel members disclosed relevant financial interests to each other prior to their discussions. Expert Panel members participated as volunteers and were compensated only for travel expenses related to the Expert Panel meetings. Financial disclosure information covering the 3-year period during which the guidelines were developed is provided for each Panel member below.

Dr. Busse has served on the Speakers’ Bureaus of GlaxoSmithKline, Merck, Novartis, and Pfizer; and on the Advisory Boards of Altana, Centocor, Dynavax, Genentech/Novartis, GlaxoSmithKline, Isis, Merck, Pfizer, Schering, and Wyeth. He has received funding/grant support for research projects from Astellas, AstraZeneca, Centocor, Dynavax, GlaxoSmithKline, Novartis, and Wyeth. Dr. Busse also has research support from the NIH.

Dr. Boushey has served as a consultant for Altana, Protein Design Lab, and Sumitomo. He has received honoraria from (Boehringer-Ingelheim, Genentech, Merck, Novartis, and Sanofi-Aventis, and funding/grant support for research projects from the NIH.

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