Guidelines for the Diagnosis and Management of Asthma Clinical Practice Guideline September 2013 MedStar Health and MedStar Family Choice accept and endorse the clinical guidelines set forth by the National Heart, Lung, and Blood Institute Expert Panel on Asthma, Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma Full Report, 2007. The pre-publication report is available on the web at: http://www.nhlbi.nih.gov/guidelines/asthma/index.htm#guidelines) with the summary report expected December 2007. These guidelines provide new guidance for selecting treatment based on a patient's individual needs and level of asthma control. The EPR-3 builds upon complete asthma guidelines issued in 1991 and 1997 and an update on selected topics released in 2002. These recommendations are based on the results of evidence-based work in asthma and represent both results of controlled clinical trials and expert consensus. The guidelines focus on four components of asthma care: measures to assess and monitor asthma, patient education, control of environmental factors and other conditions that can worsen asthma, and medications. The guidelines emphasize that while asthma can be controlled; the condition can change over time and differs among individuals and by age groups. Thus, it is important to monitor regularly the patient's level of asthma control so that treatment can be adjusted as needed. Key features and changes to these four components of asthma care include: Assessment and Monitoring: EPR-3 takes a new approach to assessing and monitoring asthma by using multiple measures of the patient's level of current impairment (frequency and intensity of symptoms, low lung function, and limitations of daily activities) and future risk (risk of exacerbations, progressive loss of lung function, or adverse side effects from medications). The guidelines stress that some patients can still be at high risk for frequent exacerbations even if they have few day-to-day effects of asthma. Patient Education. EPR-3 confirms the importance of teaching patients skills to self-monitor and manage asthma and to use a written asthma action plan, which should include instructions for daily treatment and ways to recognize and handle worsening asthma. New recommendations encourage expanding educational opportunities to reach patients in a variety of settings, such as pharmacies, schools, community centers, and patients homes. A new section addresses the need for clinician education programs to improve communications with patients and to use system-wide approaches to integrate the guidelines into health care practice. Control of environmental factors and other conditions that can affect asthma. EPR-3 describes new evidence for using multiple approaches to limit exposure to allergens and other substances that can worsen asthma; research shows that single steps are rarely sufficient. EPR-3 also expands the section on other common conditions that asthma patients can have and notes that treating chronic problems such as rhinitis and sinusitis, gastroesophageal reflux, overweight or obesity, obstructive sleep apnea, stress, and depression may help improve asthma control. Medications. EPR-3 continues the use of a stepwise approach to control asthma, in which medication doses or types are stepped up as needed and stepped down when possible. Treatment is adjusted based on the level of asthma control. Page 1 of 25 Diagnosis and Management of Asthma 2013
The stepwise asthma management charts are revised and expanded to specify treatment for three age groups: 0-4 years, 5-11 years, and 12 years and older. The 5-11 age group was added (earlier guidelines combined this group with adults) as a result of new evidence on medications for this age group and emerging evidence that suggests that children may respond differently than adults to asthma medications. The Key Components for Asthma Control 1. Reduce impairment Prevent chronic and troublesome symptoms (e.g. coughing or breathlessness in the night, in the early morning, or after exertion). Require infrequent use (< 2 days per week) of SABA for quick relief of symptoms Maintain (near) normal pulmonary function. Maintain normal activity levels including exercise and other physical activity and attendance at work or school). Meet patients and families expectations of and satisfaction with asthma care. 2. Reduce Risk Prevent recurrent exacerbations of asthma and minimize the need for ED visits or hospitalizations Prevent progressive loss of lung function; for children, prevent reduced lung growth Provide optimal pharmacotherapy with minimal or no adverse effects Appendices: Step Wise Approach For Managing Asthma In Children (0-4 Years Of Age)- Step Wise Approach For Managing Asthma In Children (5-11 Years Of Age) Medication Management for Children Step Wise Approach For Managing Asthma In Youths > 12 And Adults Medication Management for Youths > 12 and Adults Product Updates Table References:. 1. Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. (1997).NIH publication No. 97-4051. Asthma Education and Prevention Program. 2. Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. (2007). National Institutes of Health publication number 08-4051. Retrieved September, 2007 from http://www.nhlbi.nih.gov /guidelines/asthma/asthgdln.htm. Clinical Guidelines are reviewed every two years by a committee of experts in the field. Updates to guidelines occur more frequently as needed when new scientific evidence or national standards are published. Page 2 of 25 Diagnosis and Management of Asthma 2013
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Product Updates: Page Item Current Change to 11 Figure 4-4B Budesonide DPI 90, 180, or 200 mcg/inhalation Budesonide DPI 90 or 180 inhalation 14 Figure 4-4c Albuterol CFC (delete product) 14 Figure 4-4c Pibuterol CFC Autohaler Delete CFC from product description 15 Figure 4-4c Key: CFC, chlorofluorocarbon (delete from key) 20 Figure 4-8a Cromolyn MDI (delete product) 20 Figure 4-8a Nedocromil MDI (delete product) 21 Figure 4-8b Budesonide DPI 90, 180, or 200 Budesonide DPI 90 or 180 mcg/inhalation 21 Figure 4-8b Mometasone DPI 200 mcg/inhalation 200 mcg / 400 mcg / >400 mcg inhalation Mometasone DPI 110 or 220 mcg/inhaler 220 mcg/440 mcg/ >440 mcg 21 Figure 4-8b Triamcinolone acetonide (delete product) 23 Figure 4-8c Albuterol CFC (delete product) 23 Figure 4-8c Pibuterol CFC Autohaler Delete CFC from product description Page 25 of 25 Diagnosis and Management of Asthma 2013