11/18/03 Additional recommendations for quality asthma careSummaryThe National Asthma Education and Prevention Program (NAEPP), sponsored by the NHLBI (NIH), issued an updated Expert Panel Report in 2002. Recently, the CDC in collaboration with the NAEPP, issued a companion to that report describing key clinical activities for quality asthma care. Several points were emphasized: 1) The diagnosis of asthma and its level of its severity should be made as soon as feasible. In individuals older than 5 years, this can generally be done on the basis of history, physical exam and spirometry. In children < 5 years old one cannot reliably do spirometry to confirm a diagnosis of asthma. Therefore, one may have to use the diagnosis "suspected asthma". 2) Routine follow-up is important even when asthma symptoms are intermittent because the pattern may change. A reasonable frequency of such follow-up visits is every 1-6 months depending on the severity of the asthma and symptom control in an individual patient. 3) A referral for specialty care in asthma is indicated if: a) A life-threatening acute asthma flare has occurred b) Treatment goals are not reached c) Atypical symptoms - unclear asthma diagnosis d) Environmental triggers likely e) Severe, persistent asthma f) Need for additional diagnostic testing or education of patient g) Moderate persistent asthma in children < 3 years old h) Allergy immunotherapy may be indicated i) Patient requires continuous oral or high dose inhaled corticosteroids (or more than 2 burst courses of oral steroids/year). 4) Co-morbid conditions (e.g. - allergic rhinitis, sinusitis, GERD) should be treated thoroughly 5) Medication type and use should be dictated by the degree of severity/persistence of asthma symptoms. All those with persistent asthma need controller medication, usually inhaled corticosteroids. The frequency of the rescue use of inhaled beta agonists should be monitored carefully for an indefinite time period. 6) A written asthma management plan should be developed for all patients including tips about: a) recognizing worsening asthma; b) appropriate medication use for changing asthmatic status; c) when to seek medical care; d) how to monitor responses to changes in therapy. Reference MMWR 2003;52 (RR-6) 1-8 Editor's Comments These guidelines sound quite sensible and appropriate. The parallel treatment of co-morbid conditions should be employed in face of evidence that adequate treatment of concomitant allergic rhinitis and sinusitis can help asthma management. Although written management plans are still strongly recommended, recent studies have not shown impressively better asthma control when a written (vs an oral) plan was used. This may be because the written plans are above the reading comprehension of many patients.
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