SELECTED ARTICLES FROM THE RECENT LITERATURE 2004

10/28/04

Evidence based asthma management

Summary
Background - The updated evidence -based guidelines for the diagnosis and management of asthma published in 2002 by the National Asthma Education and Prevention Program are used widely in the USA. However, there are some unresolved asthma management issues that need further investigation.

Findings - Kallstrom of the Fairview Hospital in Cleveland, OH reviewed current evidence-based management principles in asthma. 1) For persistent childhood asthma (PA), inhaled corticosteroids (ICS) are more beneficial than monotherapy with long-acting beta agonists, theophylline, nedocromil or cromolyn or any combination of the latter agents. 2) Cromolyn and nedocromil are modestly effective as controller medications for PA, but not as effective as ICS. Therefore, cromolyn and nedocromil may be considered as alternatives, but not preferred to ICS for mild, persistent asthma. However, these agents may be helpful as preventative therapy used shortly before exertion or unavoidable allergen exposure. 3) There is insufficient information about the long-term impact of ICS treatment on lung function of asthmatic children < 5 year old. 4) Low to moderate dose ICS treatment is not associated with significant adverse effects on the eyes or HPA axis. 5) Leukotriene antagonists such as montelukast are an alternative (but not preferred) to ICS treatment for PA and can be considered if there is strong indication for treatment with an oral agent. 6) Beta agonists and ICS are delivered with equal efficacy by a MDI/spacer and aerosol delivery devices. 7) There is low-level evidence that inhalation of helium/oxygen mixtures (heliox) may be of benefit in treatment during the first hour of an acute asthma exacerbation. 8) There is no indication for antibiotic therapy of asthma unless there is definite evidence of a bacterial infection. The role of sinusitis in asthma pathogenesis remains to be well-defined. 9) A written management plan should enhance asthma care. However, there is inadequate evidence to say whether the action plan should be based on symptom scores or on findings in peak flow monitoring.

Reference
Resp Care 2004;49:783-92

Editor's Comments
These conclusions are in concordance with my impression of current opinions rendered by most experts in the field. However, some other current impressions/recommendations are worth mentioning:
1) A combination of inhaled long-acting beta agonist and ICS allows effective asthma control at significantly lower doses of the ICS. This is important because the likelihood of adverse systemic effects of chronic ICS therapy is dose dependent with generally no significant adverse effect at daily doses of 400 mcg of budesonide and 200 mcg of fluticasone in children;
2) Although written management plans should enhance asthma care as compared to just verbal instructions, some written plans are written at a higher reading capacity level than many adult asthmatics possess. Therefore, it is not surprising that studies have not shown a clear-cut advantage of written management plans when compared to careful verbal instruction. My impression is that a key element of successful management is repeated close interaction between the patient and the health care team.

 

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