NAEPP Releases Updated Asthma Guidelines

August 29, 2007

The National Asthma Education and Prevention Program (NAEPP) has just released the long awaited update of its Guidelines for the Diagnosis and Management of Asthma.

For the first time the guidelines, which were last updated on selected topics in 2002, are fully evidence-based, reflecting a review of more than 15,000 studies graded according to the validity of their scientific findings. For example, Category A evidence, which consists of double-blind, placebo-controlled studies involving large numbers of patients, received the most weight in the development of the guidelines, with less stringent evidence weighted accordingly.

“Respiratory therapists need to be acutely aware of these new guidelines, and they especially need to be aware of the change to an evidence-based format,” says AARC COO Tom Kallstrom, BS, RRT, AE-C, FAARC, who also serves as the AARC’s representative to the NAEPP. “We encourage all RTs to read and understand the document, and then work with their peers and physicians to incorporate the changes into their practice.”

According to the NAEPP, major changes in Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Full Report, 2007 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.  

The new guidelines also include:

• Revised and expanded stepwise asthma management charts 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. 
• Updated recommendations on medications to reflect the latest evidence on effectiveness and safety.  EPR-3 reaffirms that patients with persistent asthma (e.g., patients who have symptoms more than twice a week during the day or more than twice a month at night) need both long-term control medications to control asthma and prevent exacerbations, as well as quick relief medications for symptoms as needed.  EPR-3 also reaffirms that inhaled corticosteroids are the most effective long-term control medication across all age groups.  EPR-3 includes new recommendations on treatment options such as leukotriene receptor antagonists and cromolyn for long term control; long acting beta agonists as adjunct therapy with inhaled corticosteroids; omalizumab for severe asthma; and albuterol,  levalbuterol, and corticosteroids for acute exacerbations.  
• A description of current research to improve asthma management, such as new ways for monitoring asthma control (for example, tests using a patient’s sputum and exhaled air), and tailoring treatment based on the particular characteristics of a patient’s asthma and the patient's genetic makeup.

You can read the new guidelines in their entirety on the NAEPP web site.