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Resources: Asthma Care Guidelines Q&A
What parents need to know about the
2002 NAEPP updates
Paul V. Williams, MD, FAAAAI
What is the NAEPP?
In response to the increasing prevalence of asthma, and the sickness and death
resulting from asthma, the National Heart, Lung and Blood Institute (NHLBI), one
of the National Institutes of Health, established the National Asthma Education
Program (NAEP) in 1989.
The purpose of the NAEP was to
promote the education of health care professionals, the public and patients
about the proper diagnosis and management of asthma. The NAEP coordinating
committee, which works with staff from the NHLBI, is made up of representatives
from 38 lay and professional organizations who have a particular interest in
asthma. As it evolved, the committee began focusing on prevention as well, and
became the National Asthma Education and Prevention Program (NAEPP).
One of the first actions of the
coordinating committee was to appoint a panel of experts in the field of asthma
to develop guidelines for caring for patients with asthma. The first
Guidelines for the Diagnosis and Management of Asthma: The Expert Panel Report
was released in 1991, and a completely updated report was released in 1997,
called the Expert Panel Report II (EPR II).
Since the release of the 1997
Guidelines, the NAEPP and its Science Base Committee, composed of members of the
Expert Panel and others, have changed the manner of updating the guidelines.
They now are focusing on specific questions that are the target of recent
research or are of important interest for healthcare providers caring for
patients with asthma.
The NAEPP Expert Panel Report –
2002: Guidelines for the Diagnosis and Management of Asthma – Update on Selected
Topics was released in June 2002, and presents recommendations on 5 topics
or questions, based on an extensive review of research from investigators around
the world.
Following are some highlights of the
June 2002 update:
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Question #1: |
Do inhaled
steroids work better for asthma control than other medications in children,
and are they safe to use in children? |
| Answer:
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The consistent use of inhaled
steroids improves asthma control more than other controller medications such
as cromolyn, nedocromil, theophylline or leukotriene receptor antagonists.
Furthermore, there are no clinically important, long-term, irreversible
changes in growth, bone density, eye or adrenal gland changes with their
continued use in children.
The recommendations from the
1997 EPR II have been changed to state that inhaled corticosteroids are the
preferred treatment for children with mild, persistent asthma.
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Question #2: |
Do patients
with moderate persistent asthma, who are already on inhaled steroids, do
better with the addition of a second medication? |
| Answer:
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The addition of a long-acting
inhaled beta-agonist, such as salmeterol or formoterol, improves asthma
control more than the addition of leukotriene receptor antagonists,
theophylline or even doubling the dose of inhaled steroids. The EPR II
recommendations have been changed for children over the age of five and adults,
indicating that the preferred treatment for moderate persistent asthma is
the addition of a long-acting inhaled beta-agonist to low to medium doses of
inhaled steroids.
Studies of these combinations of
medications are not as plentiful for children younger than age five, so the
Panel recommends two preferred options for moderate, persistent asthma in
children less than five years old: low dose inhaled steroids plus a long-acting
inhaled beta-agonist, or medium dose inhaled steroids alone.
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Question #3: |
Does the
addition of antibiotics to standard asthma care improve the care of asthma
attacks? |
| Answer:
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Antibiotic therapy
does not improve the treatment of acute asthma attacks when given routinely
or when the suspicion of bacterial infection is low. The current
recommendations from the 1997 EPR II document are unchanged. Antibiotics
should only be used for the treatment of conditions that accompany an acute
asthma attack when those conditions are likely to be caused by a bacterial
infection. |
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Question #4: |
Is a written
asthma management plan better than medical management alone, and are written
asthma management plans based on peak flow better than those based on
symptoms? |
| Answer:
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The studies that have been done
on these questions are not strong enough to provide a clear answer. There is
some suggestion that written asthma action plans are superior in adults with
asthma. This does not imply, however, that they are not so for children. It
is just that there is not adequate information in children to tell if they
are more effective.
There are few good studies on
the issue of peak flow-based management plans compared to symptom-based
plans. Studies that have been done indicate that the two methods are at
least equally effective, and individual patient characteristics may be
important in deciding which method to use.
The NAEPP recommendations are
unchanged from the earlier EPR II: written plans as a part of an overall
effort to educate patients in self-management are recommended, and peak flow
monitoring should be considered in patients with moderate or severe asthma.
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Question #5: |
In patients
with mild or moderate persistent asthma, does early treatment with control
therapy prevent the progression of asthma? |
| Answer:
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Current studies do not provide
evidence that the early treatment of asthma can prevent progression of the
disease. Large studies in children ages 5 to 12 years do not show that lung
function declines progressively, although symptoms, and disease, are better
controlled with inhaled steroids.
When inhaled steroid therapy is
discontinued, symptoms return. This suggests that inhaled steroids provide
superior control in this age group, but do not affect the underlying
disease. In contrast, studies in three-to-five-year-old children and adults do
suggest that changes in lung function can occur, rapidly in some adults.
However, studies on whether early treatment can prevent these declines have
not been done.
The bottom line: take inhaled
corticosteroids on a consistent basis if you have persistent asthma
(regardless of age), keep a written asthma plan and take regular peak flow
readings if you have moderate or severe asthma. |
Dr. Williams is a pediatric
allergist/immunologist in Washington and former Chair of the AAAAI Quality of
Care for Asthma Committee
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