NIH Asthma Guidelines and Standards  

 Airway Inflammation Plays a Central Role in Asthma and its Management

• Asthma is a chronic inflammatory disorder of the airways. Many cells and cellular elements play a role, in particular, mast cells, eosinophils, T-lymphocytes, macrophages, neutrophils and epithelial cells

• Environmental and other factors provoke the airway inflammation in people with asthma. Examples of these factors include allergens to which the patient is sensitive, some irritants and viruses. The inflammation is always present to some degree, regardless of the level of asthma severity.

• Airway inflammation causes recurrent episodes in asthma patients of wheezing, breathlessness, chest tightness and coughing, particularly at night and in the early morning.

• These episodes of asthma symptoms are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. Airflow obstruction is caused by a variety of changes in the airway, including bronchoconstriction, airway edema, chronic mucus plug formation and airway remodeling.

• Inflammation causes a associated increase in the existing airway hyper-responsiveness to a variety of stimuli, such as allergens, irritants, cold air and viruses. These stimuli or precipitants result in airflow obstruction and asthma symptoms in the patient with asthma.

Asthma Changes Over Time, Requiring Active Management
 

The condition of a patient’s asthma will change depending on the environment, patient activities, management practices and other factors. Even when patients have their asthma under control, monitoring and treatment are needed to maintain control.
 

Four Key Components for Long Term Asthma Control

• Assessment and monitoring
• Pharmacologic therapy
• Control of factors contributing to asthma severity
• Patient education to form a partnership

Yes, if:

• The patient presents with episodic wheeze, chest tightness, shortness of breath, or cough
• Recurrent coughing or wheezing episodes are the only symptom
• Asthma symptoms vary throughout the day
• Symptoms worsen at night, while exercising, or in the presence of aeroallergens or irritants
• Allergic rhinitis or atopic dermatitis are present
• The patient has relatives with asthma, allergy, sinusitis, or rhinitis
• A physical exam reveals:

-Hyperextension of the thorax
-Wheezing, or prolonged or forced exhalation
-Nasal secretions, sinusitis, rhinitis, or nasal polyps
-Atopic dermatitis or eczema, or allergic skin problems

However, the absence of symptoms at the time of a physical exam does not exclude an asthma diagnosis

To establish an asthma diagnosis:

• Perform an asthma-specific medical history and physical exam
• Document by spirometry that airflow obstruction exists and is partially reversible, i.e.:

FEV₁ is < 80% of the predicted limit

FEV₁/FVC is < 65% the lower limit of normal

FEV₁ increases > 12% and at least 200mL after use of a short-acting inhaled b₂- agonist (i.e., albuterol, terbutaline)

Older adults may need to use oral steroids for 2-3 weeks before taking the spirometry test to measure the degree of reversibility achieved. Chronic bronchitis and emphysema may coexist with asthma in adults. Children younger than 6 years may not perform appropriate spirometry.

• Exclude alternative diagnoses (e.g., vocal cord dysfunction, vascular rings, foreign bodies, other pulmonary diseases), using additional tests if necessary. 

Consider referral to a specialist if:

• A differential diagnosis is problematic , other conditions aggravate the asthma, or the effects of occupational or environmental exposures on the patient’s condition need to be confirmed
• Specialized treatment (e.g., immunotherapy) or patient education (e.g., allergen avoidance) is needed
• The patient is not meeting therapeutic goals after 3-6 months, or if the patient does to respond to therapy
• A life-threatening exacerbation occurs
• The patient requires Step 4 care or has used > bursts of oral steroids in 1 year
• The patient is younger than 3 years and requires Step 3 or Step 4 care

General Goals of Asthma Therapy:

• Prevent chronic asthma symptoms and asthma exacerbations during day and night

-No sleep disruption
-No missed school or work
-No visits to the Emergency department
-No hospitalizations

• Maintain normal or near-normal activity, including exercise and other physical activities
• Achieve normal or near-normal lung function
• Ensure patient satisfaction with the asthma care received
• Significantly reduce or eliminate attacks and enhance long-term prognosis by ensuring that the patient takes anti-inflammatory medicines regularly

Assess Asthma Severity
 

Asthma is classified in steps, and they correspond to the steps of pharmacologic therapy:
 

Classification of Severity: Clinical Features Before Treatment
 

* Percent predicted values for forced expiratory volume in 1 second (FEV₁) and percent of personal best for peak expiratory flow (PEF) (relevant for children 4 years old or older who can use these devices).

Notes:

• Patients should be assigned to the most severe step in which any feature occurs

• An individual’s classification may change over time

• Patients at any level of severity of chronic asthma have mild, moderate or severe exacerbations of asthma. Some patients with intermittent asthma experience severe and life-threatening exacerbations separated by long periods of normal lung function and no symptoms.

• Patients with 2 or more asthma exacerbations per week (i.e., progressively worsening symptoms that may last hours or days) tend to have moderate-to-severe persistent asthma

All patients need to have a short-acting inhaled b₂-agonist to take as needed for symptoms.
 

Patients with mild, moderate or severe persistent asthma require daily long-term control medication to control their asthma.
 

Gaining Control of Asthma
 

The NHLBI now recommends an aggressive approach to gain control of asthma:

• At the onset, give therapy at a higher level to achieve rapid control and then STEP DOWN to the minimum therapy needed to maintain control. A higher level of therapy can be accomplished by either adding a course of oral steroids to inhaled steroids, mast cell stabilizers (cromolyn or nedocromil), leukotriene modifiers (zafirlukast or montelukast), or using a higher dose of inhaled steroids.

• In the opinion of the Expert Panel, this aggressive approach will more rapidly suppress airway inflammation and thus gain prompt control.

Maintaining Control
 

Follow-up visits every 1-6 months are essential for monitoring asthma. Increases in medications may be needed as severity and control vary over time.
 

Patients should be instructed to monitor their symptoms (and peak flow if used) and adjust therapy according to their Asthma Action Plan.
 

STEP DOWN Therapy

• Gradually reduce or "step down" long-term control medications after several weeks or months of controlling persistent asthma ~ when goals of asthma therapy are achieved.

• Inhaled steroids may be reduced about 25% every 2-3 months until the lowest dose required to maintain control is reached.

• Continuous attempts should be made to reduce daily use of oral steroids when asthma is controlled. For patients who are taking oral steroids daily on a long-term basis, referral for consultation or care by an asthma specialist is recommended. Click here for referral guidelines.

-Maintain patients on the lowest possible dose of oral steroids (single dose daily or on alternate days)

-Use high doses of inhaled steroids to eliminate or reduce the need for oral steroids.

STEP UP Therapy

• The presence of one or more indicators of poor asthma control may suggest a need to increase or "step up" therapy. These include:

-Waking through the night with symptoms
 
-An urgent care visit

-Increased need for quick-relief inhaled b₂agonists (excludes use for upper respiratory viral infections and exercise-induced bronchospasm)

• Addition of a 3- to 10- day course of oral steroids may be needed to reestablish control during a period of gradual deterioration or a moderate-to-severe exacerbation.

-If symptoms do not recur after the course of steroids (and peak flow remains normal), the patient should continue on the same step.

-If the steroid course controls the symptoms for less than 1-2 weeks, or if courses of steroids are repeated frequently, the patient should move to t the next higher step in therapy.

For more details about medications, plus dosages for long-term control and quick relief for each step, click here.

For more specific details about managing asthma in infants and pre-school children, click here.

For more specific details about managing asthma in older adults, click here.

Or go to the Asthma Management Model System of the National Heart, Lung and Blood Institute (NHLBI).

Have each patient complete the following form to assess exposures and identify factors that may contribute to asthma severity. Then educate patients on how to reduce their exposures to these factors.

PATIENT SELF-ASSESSMENT FORM FOR ENVIRONMENTAL AND OTHER FACTORS THAT CAN MAKE ASTHMA WORSE

To reduce effects of specific allergens on a patient with persistent asthma:

• Identify specific allergens to which patient is exposed

• Determine and confirm sensitivity to the allergens

Method: skin or in vitro tests, medical history

• Obtain agreement with the patient to begin one or two simple control measures.

Go to the triggers section of this website for ways to control allergens.

• Follow-up with patient, adding control measures after the first ones are started.

Patient education should begin at the time of diagnosis and continue at every visit.
 

The physician and the patient are key partners on the health care team, which also includes nurses, office staff, parents, family members, and even the staff at child care or school if the patient is a child. The team needs to work together to build the patient’s skill and confidence. Only with this partnership can the team meet the goals of asthma control.
 

The goal of patient education is to help people with asthma take actions to control their symptoms, just as diabetics do. To be successful, the patients and parents or family members need to help manage asthma at home, at work, at play ~ every day. When asthma is diagnosed, patients and family members need to start learning about self-care. They also need to be assured that they can become effective in managing asthma. Once patients believe that they can control asthma (self-efficacy), they will be better motivated to follow the asthma action plan.

Click here to find a plan for delivery of asthma education during patient office visits. You may need to download Adobe Acrobat Reader to view it.
 

Working Together, the Health Care Team Needs to:

• Develop a written asthma action plan with equal participation of patient and family
• Fit the daily medication regimen into the patient’s and family’s routine
• Identify and address obstacles and concerns. Discuss ways to overcome problems
• Get agreement from the patient and other members of the team about action plans
• Encourage and enlist family support

Role of Doctors and Their Staff

• Provide clear training and practice on how to use medications, peak flow meters, inhalers and other equipment
• Observe how patients use their equipment
• Praise patients for what they are doing right and tell them what they need to improve
• Teach patients to recognize serious or frequent symptoms early:

-waking at night with asthma
-increased medicine use
-reduced ability for physical activity

• Encourage patients to keep a diary of symptoms and peak flow numbers
• Help patients and families to recognize signs that they need to call the doctor or seek emergency care
• Follow-up: review and discuss the action plan at each patient visit
• Provide time for patient education and questions during every office visit

Role of Patients and Family Members

• Follow directions: carry out the asthma action plan
• Identify and control factors at home, work or school that make asthma worse
• Reduce common triggers for asthma such as dust, mold, furry pets and household smoke
• Take medicine as prescribed
• Use equipment correctly - inhalers, peak flow meters, etc.
• Monitor peak flow numbers and/or symptoms. Keep these records in a diary
• Follow the written action plan when symptoms or episodes occur
• Give information: tell the doctor about symptoms, share the diary. Talk about problems and concerns
• Ask questions: write down questions before each visit with the doctor
• Tell the doctor about expectations for each visit, such as answers to questions or a change in medication
• Keep medical appointments

Physicians Should Ask the Patient

• What worries you most about having asthma?
• What concerns do you have about your asthma?

Address the Patient’s Concerns and Make at Least These Key Points

• Asthma can be managed and the patient can live a normal life
• Asthma can be controlled when the patient works together with the medical staff. The patient plays a big role in monitoring asthma, taking medications, and avoiding things that can cause asthma episodes.
• Asthma is a chronic lung disease characterized by inflammation of the airways. There may be periods when there are no symptoms, but the airways are swollen and sensitive to some degree all the time. Long-term anti-inflammatory medications are important to control airway inflammation
• Many things in the home, school, work, or elsewhere can cause asthma attacks (e.g., secondhand smoke, allergens, irritants). An asthma attack (also called episodes, flare-ups, or exacerbations) occurs when airways narrow, making it harder to breathe.
• Asthma requires long-term care and monitoring. Asthma cannot be cured, but it can be controlled. Asthma can get better or worse over time and requires treatment changes.

Teach Patients How to do Self-Monitoring

• Teach all patients to recognize symptoms and what to do when symptoms occur
• Long-term daily peak flow monitoring is recommended for those with moderate or severe exacerbations.

-Educate patients how to use the peak flow meter to monitor and manage