NAEPP guidelines on asthma care - National Asthma Education and Prevention Program

Author: Carrie Morantz, Brian Torrey
Date: Sept 15, 2003

The National Asthma Education and Prevention Program (NAEPP) has issued guidelines for reducing asthma symptoms and preventing exacerbations. The recommendations are available online at www.cdc. gov/mmwr/preview/mmwrhtml/rr5206a1.htm.

The NAEPP identified four components of asthma management--assessment and monitoring, controlling factors that contribute to asthma severity, pharmacotherapy, and education for partnership in care--and developed the following 10 key clinical activities:

1. Establish diagnosis using a history and physical examination documenting an episodic pattern of respiratory symptoms and from spirometry that indicates partially reversible airflow obstruction. Infants and children younger than five years should be treated as having suspected asthma once alternative diagnoses are ruled out.

2. Classify severity. After the patient's asthma is stable, severity is classified according to the level of medication required to maintain treatment goals.

3. Schedule routine follow-up care. The first follow-up visit should be scheduled within one month after initial diagnosis, with routine visits every one to six months and spirometry at least every one or two years after treatment is initiated and the symptoms and peak expiratory flow have stabilized.

4. Assess for referral to subspecialty care. Referral is recommended in the following circumstances:

* A single life-threatening asthma exacerbation occurs or the initial diagnosis is severe, persistent asthma.

* Treatment goals for the patient's asthma are not being met.

* The diagnosis is unclear or additional diagnostic testing is indicated.

* The patient has a history suggesting that asthma is being provoked by occupational factors, an environmental inhalant, or an ingested substance.

* The patient is younger than three years with moderate or severe persistent asthma.

* The patient is a candidate for immunotherapy.

* The patient or family requires additional education or guidance in managing asthma complications or therapy, following the treatment plan, or avoiding asthma triggers.

* The patient requires continuous oral corticosteroid therapy or high-dose inhaled corticosteroids, or has required more than two courses of oral corticosteroids in one year.

5. Recommend measures to control asthma triggers such as tobacco smoke, house dust mites, cockroaches, and cat and dog allergens.

6. Treat or prevent all comorbid conditions, including allergic rhinitis, sinusitis, gastroesophageal reflux disease, and sensitivity to certain medicines such as aspirin, nonsteroidal anti-inflammatory drugs, and beta blockers can exacerbate asthma symptoms.

7. Prescribe medications according to severity. Evidence indicates that daily, long-term control medications are necessary to prevent exacerbations and chronic symptoms. Inhaled corticosteroids are preferred because they are the most effective anti-inflammatory medication available for treating the underlying inflammation of persistent asthma. All patients with asthma require a short-acting bronchodilator medication for managing acute symptoms or exacerbations when they occur; severe exacerbations require the addition of systemic (oral) corticosteroids to treat the increased inflammation.

Once therapy goals are achieved, a gradual reduction in treatment should be carefully undertaken to identify the minimum dose required to maintain control.

8. Monitor use of beta-agonist drugs. Patients whose need for a short-acting inhaled beta-agonist increases probably have inadequately controlled asthma. Such patients may need short-acting inhaled beta-agonist during upper respiratory viral infections and exercise-induced bronchoconstriction. Using more than one canister of short-acting beta-agonist per month is considered above expected use.

9. Develop a written asthma management plan. Writing an asthma management plan helps clarify expectations for treatment and provides patients with an easy reference for remembering how to manage their asthma. The action plan should include written instructions on recognizing symptoms and signs of worsening asthma; taking appropriate medicines (i.e., type, dose, frequency); recognizing when to seek medical care; and monitoring responses to medications. Symptom-based plans may be equally effective as plans based on peak flow monitoring, although some patient preferences and circumstances (e.g., inability to recognize or report signs and symptoms of worsening asthma) may warrant a choice of peak flow monitoring.

10. Provide routine education on patient self-management. Effective asthma education is developed in a patient-provider partnership, tailored to the individual patient's needs relative to cultural or ethnic beliefs and practices. At a minimum, competent asthma education enlists and encourages family support, includes instructions on self-management skills, and is integrated with routine ongoing care.

COPYRIGHT 2003 American Academy of Family PhysiciansCOPYRIGHT 2003 Gale Group

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