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The information contained herein should never be used as a substitute for clinicaljudgment.
What symptoms or elements ofclinical history are helpful indiagnosing asthma?Symptoms that should prompt cli-nicians to consider asthma arewheezing, dyspnea, cough, difficul-ty taking a deep breath, and chesttightness (1). Characteristically,asthma symptoms are intermittentand may remit spontaneously orwith use of short-acting broncho-dilators. Symptoms often vary seasonally or are associated withspecific triggers, such as cold, exer-cise, animal dander, pollen, certainfoods, aspirin or nonsteroidal anti-inflammatory drugs, or occupation-al exposures. Clinicians should alsoconsider the diagnosis of asthma inall adults with chronic cough, espe-cially if cough is nocturnal, season-al, or related to the workplace or aspecific activity.
What physical examinationfindings are suggestive of asthma?A careful history to elicit the natureand timing of symptoms is para-mount in diagnosing asthma. Thephysical examination is less helpfulunless a patient is having an activeexacerbation. The clinician shouldlisten for wheezing during tidal res-pirations or prolonged expiratoryphase of breathing and examine thechest for hyperexpansion. Studiessuggest that respiratory signs(wheezing, forced expiratory time,accessory muscle use, respiratoryrate, and pulsus paradoxus) may beuseful to predict airflow obstruction,
but clinicians often disagree aboutthe presence and absence of thesesigns (1, 2).
The physical examination is some-times most helpful in looking forevidence of alternative diagnoses.Persistent dry inspiratory crackles,focal wet crackles, or an abnormalcardiac examination all suggest di-agnoses other than asthma.
How can clinicians determinewhether asthma is the cause ofchronic cough in adults?Coughing may be the only mani-festation of asthma in some pa-tients (3). Up to 24% of patientspresenting to a specialist withchronic cough after an initial evalu-ation by a primary care providermay have asthma. Although severalprotocols are available for the diag-nosis of patients with chroniccough, it is not clear which is thebest approach. Clinicians often usea trial of empirical asthma therapy,but national guidelines recommendpulmonary function tests for patients with chronic cough of unknown etiology.
What are the indications forspirometry in a patient whoseclinical presentation is consistentwith asthma?Fair-quality evidence supports theperformance of spirometry in alladult patients and older childrensuspected of having asthma. Initialpulmonary function testing shouldinclude spirometric measurements
1. Li JT, O’Connell EJ.Clinical evaluation ofasthma. Ann AllergyAsthma Immunol.1996;76:1-13; quiz 13-5. [PMID: 8564622]
2. National Heart, Lung,and Blood Institute,National Asthma Edu-cation and Preven-tion Program. ExpertPanel Report 2:Guidelines for the di-agnosis and manage-ment of asthma.Bethesda MD: US De-partment of Healthand Human Services,National Institutes ofHealth, 1997; Publica-tion 97-4051.
3. Corrao WM, BramanSS, Irwin RS. Chroniccough as the solepresenting manifes-tation of bronchialasthma. N Engl JMed. 1979;300:633-7.[PMID: 763286]
4. McFadden ER Jr. Exer-tional dyspnea andcough as preludes toacute attacks ofbronchial asthma. NEngl J Med.1975;292:555-9.[PMID: 1110670]
5. Hankinson JL, Oden-crantz JR, Fedan KB.Spirometric referencevalues from a sampleof the general U.S.population. Am JRespir Crit Care Med.1999;159:179-87.[PMID: 9872837]
Asthma, which is characterized by airway hyperresponsiveness and in-flammation, is one of the most common respiratory illnesses. Theglobal prevalence of asthma is increasing despite the development of
new therapeutic approaches. Over the past 20 years, asthma mortality in theUnited States has declined; however, morbidity, as measured by hospitaliza-tions and emergency department visits, continues to climb. Currently, about1 in 20 Americans have asthma; in children, recent estimates suggest an inci-dence as high as 10%. In certain groups of Americans, such as persons oflower socioeconomic status and minority ethnicity, asthma morbidity andmortality are disproportionately high. Such trends are surprising, given theimprovement in air quality in the United States and the availability of newpharmacologic therapies.
Diagnosis
6. Nunn AJ, Gregg I.New regressionequations for predict-ing peak expiratoryflow in adults. BMJ.1989;298:1068-70.[PMID: 2497892]
7. McFadden ER Jr., KiserR, DeGroot WJ. Acutebronchial asthma. Re-lations between clini-cal and physiologicmanifestations. NEngl J Med.1973;288:221-5.[PMID: 4682217]
8. Shim CS, Williams MHJr. Relationship ofwheezing to theseverity of obstruc-tion in asthma. ArchIntern Med.1983;143:890-2.[PMID: 6679232]
9. Chetta A, Gerra G,Foresi A, Zaimovic A,Del Donno M, Chit-tolini B, et al. Person-ality profiles andbreathlessness per-ception in outpa-tients with differentgradings of asthma.Am J Respir Crit CareMed. 1998;157:116-22. [PMID: 9445288]
11. Swanney MP, JensenRL, Crichton DA,Beckert LE, CardnoLA, Crapo RO. FEV(6)is an acceptable sur-rogate for FVC in thespirometric diagno-sis of airway ob-struction and restric-tion. Am J Respir CritCare Med.2000;162:917-9.[PMID: 10988105]
Table 1. Laboratory and Other Studies for AsthmaTest Notes
Spirometry Abnormal spirometry (reversible obstruction) can help to confirm an asthma diagnosis, but normal spirometry does not exclude asthma.
Peak flow variability A patient with normal spirometry but marked diurnal variability (based on a peakflow diary kept for >2 weeks) may have asthma, which may warrant an empiricaltrial of asthma mediations or further testing with bronchoprovocation.
Bronchoprovocation test In a patient with a highly suggestive history of asthma and normal baselinespirometry, a low PC
20(the concentration of inhaled methacholine needed to
cause a 20% drop in the FEV1) on methacholine challenge testing supports a di-
agnosis of asthma. Cold air, exercise, and histamine are other types of provoca-tive tests used. A normal bronchoprovocation test will almost definitively ex-clude asthma.
Chest radiography Chest radiography may be needed to exclude other diagnoses but is not recom-mended as a routine test in the initial evaluation of asthma.
Complete blood count with Although mild eosinophilia is not uncommon in persons with asthma, routine differential use of a CBC with leukocyte differential is not warranted in the initial evaluation.
Sputum evaluation Routine sputum evaluation is not indicated for the initial evaluation of asthma.
IgE Although elevated levels of IgE are not uncommon for persons with asthma, routine measurement of serum IgE is not warranted in the initial evaluation
Quantitative IgE antibody assays There is a strong association between allergen sensitization, exposure, andand skin testing for immediate asthma. Allergy testing is the only reliable way to detect the presence of specifichypersensitivity to aeroallergens IgE to indoor allergens. Skin testing (or in vitro testing) may be indicated to
guide the management of asthma in selected patients, but results are not usefulin establishing the diagnosis of asthma.
of the FEV1, FVC, and the FEV
1–
FVC ratio. If these measurements
reveal airflow obstruction, then
they should be repeated after ad-
ministration of a bronchodilator to
evaluate the reversibility of airflow
obstruction. Reversibility of airflow
obstruction defines asthma. Pre-
dicted normal values for spiromet-
ric measures are population-based
and differ with age and ethnicity.
Predictive tables are available (5,
6). Postbronchodilator improve-
ment ≥ 12% of the FEV1
or FVC
indicates significant reversibility
and therefore increases the likeli-
hood of an asthma diagnosis.
Complete pulmonary function test-
ing that includes lung volumes and
diffusing capacity should be con-
sidered when there is evidence of a
lack of airflow reversibility, or re-
strictive patterns with diminutions
in the FEV1
and FVC but a normal
FEV1–FVC ratio. These findings
suggest chronic obstructive pul-
monary disease (COPD) or inter-
stitial lung disease (Table 1).
A number of studies show a poorcorrelation among the presence,severity, and timing of wheezingand the degree of airflow obstruc-tion (7, 8). Patients vary in theirdegree of sensitivity to airflow limi-tations and can acclimate to thedisability and thus become insensi-tive to airflow obstruction (9). Be-cause of the disparity between pa-tient and physician estimates of theseverity of airflow obstruction andobjective measures of obstruction,pulmonary function tests are im-portant tools to characterize airflowobstruction and the degree andseverity of asthma.
Spirometry should adhere to thestandards of the American Tho-racic Society (10). Of note, spirom-etry is effort-dependent, and manypatients have difficulty with theFVC maneuver. In these patients(younger children, older adults, orpatients with severe respiratory dis-ease), alternative approaches, suchas the FEV
6may be an acceptable
surrogate to the FVC, with a re-duction in the FEV
1–FEV
6ratio
signifying obstruction (11).
Does normal spirometry rule out adiagnosis of asthma?Abnormal spirometry (reversible obstruction) can confirm an asthmadiagnosis, but normal spirometrydoes not rule out asthma. Clini-cians should consider further stud-ies in patients with normal spirom-etry who have a clinical historysuggestive of asthma (Table 1).Bronchoprovocation with metha-choline or histamine can be helpfulin establishing a diagnosis in pa-tients who report that they onlyhave symptoms during exercise orat certain times of the year. Alter-natively, marked diurnal variabilitybased on measurements recorded ina peak flow diary kept for at least 2weeks can help to establish asthmaas the cause of symptoms. Howev-er, peak flow measurements arehighly effort-dependent and mayoffer no opportunity for quality assurance of their accuracy.
When should clinicians considerprovocative pulmonary testing?
A gold standard for diagnosis ofasthma remains elusive. However,methacholine hyperresponsivenessin the pulmonary function labora-tory has high reproducibility andaccepted standardization (12). Thetest is safe but requires sophisticat-ed instrumentation and is labor-in-tensive and expensive. In a patientwith symptoms suggestive of asth-ma who has normal baselinespirometry, a low PC
20(the concen-
tration of inhaled methacholineneeded to induce a 20% decrease inthe FEV
1) on methacholine chal-
lenge testing supports the diagno-sis. Studies of methacholine chal-lenge suggest that it is sensitive andhas a high negative predictive valuefor the diagnosis of asthma (13,14). Although cold air and exercisehave been used in research to de-fine mechanisms of bronchocon-striction, methacholine challengeremains the provocative test ofchoice in patients with normal
pulmonary function tests who havesymptoms consistent with asthma.
Spirometry before, during, or afterexercise may be the only method todocument bronchoconstriction in patients with exercise-inducedasthma. As an alternative, monitor-ing peak flow is easy and inexpen-sive, but the measurement is lessprecise and limited in reproducibil-ity and sensitivity (15). Becausespirometry and peak flow have lim-itations in sensitivity and specificity,they are probably best used as partof a diagnostic strategy in conjunc-tion with a comprehensive history,physical examination, and otherlaboratory data (16).
How should clinicians classifyasthma severity?The National Heart Lung andBlood Institute (NHLBI) ExpertPanel Report 2 (2) defines asthmaseverity according to symptoms andspirometric measurements. Asshown in Table 2, asthma severityis classified as intermittent, mild,moderate, and severe persistent.Each category is defined by the fre-quency of rescue inhaler use as wellas nocturnal symptoms in conjunc-tion with the FEV
1or PEFR meas-
urement. It is important to note thatdecrease in FEV
1correlates with
airflow obstruction and not withchanges due to restrictive lung disease.
The initial determination of asthmaseverity should be made when thepatient is receiving no medications.Asthma severity is dynamic—forexample, patients who were ini-tially diagnosed as having severepersistent asthma may have symp-toms consistent with mild persist-ent asthma while receiving med-ication. The NHLBI Expert PanelReport 2 (2) suggests annualspirometry to aid in the classifica-tion of asthma, but high-qualitystudies are not available to supportthis recommendation.
12. Crapo RO, CasaburiR, Coates AL, EnrightPL, Hankinson JL,Irvin CG, et al. Guide-lines for metha-choline and exercisechallenge testing-1999. This officialstatement of theAmerican ThoracicSociety was adoptedby the ATS Board ofDirectors, July 1999.Am J Respir Crit CareMed. 2000;161:309-29. [PMID: 10619836]
13. Cockcroft DW, KillianDN, Mellon JJ, Harg-reave FE. Bronchialreactivity to inhaledhistamine: a methodand clinical survey.Clin Allergy.1977;7:235-43.[PMID: 908121]
14. Hopp RJ, Bewtra AK,Nair NM, TownleyRG. Specificity andsensitivity of metha-choline inhalationchallenge in normaland asthmatic chil-dren. J Allergy ClinImmunol.1984;74:154-8.[PMID: 6747136]
16. Perpiñá M, Pellicer C,de Diego A, CompteL, Macián V. Diag-nostic value of thebronchial provoca-tion test withmethacholine inasthma. A Bayesiananalysis approach.Chest. 1993;104:149-54. [PMID: 8325060]
What comorbid conditions andalternative diagnoses shouldclinicians consider in patients withsuspected asthma?The differential diagnosis of asth-ma includes the following condi-tions: COPD, interstitial lung dis-ease, vocal cord dysfunction,congestive heart failure, medica-tion-induced cough, bronchiectasis,pulmonary infiltration witheosinophilia syndromes, obstructivesleep apnea, mechanical airway ob-struction, cystic fibrosis, and pul-monary hypertension. Cliniciansshould consider one of these alter-native diagnoses when asthma isdifficult to control or if the patienthas atypical signs and symptoms.These conditions can also coexist ina patient who has asthma.
An important difference betweenasthma and COPD is the history ofsmoking. Although 30% of patientswith asthma in the United Statessmoke, COPD, manifested bychronic bronchitis and emphysema,often occurs in older persons with a
substantial history of cigarettesmoking. Patients with COPD alsodo not demonstrate reversibilitywith bronchodilators on pulmonaryfunction testing.
Lung imaging with radiography orcomputed tomography is helpful inidentifying bronchiectasis or lungmasses. Echocardiography can helpto identify cardiovascular disorders,including ischemic heart disease,ventricular dysfunction, and pul-monary hypertension. Flow-volumeloops and direct visualization of thelarynx during an acute episode areuseful in evaluating patients for vocal cord paralysis.
Chronic cough and dyspnea or recurrent wheezing are commonsigns of COPD, vocal cord dys-function, cystic fibrosis, obstructivesleep apnea, Churg-Strauss syn-drome, allergic bronchopulmonaryaspergillosis, interstitial lung dis-ease, bronchiectasis, congestiveheart failure, and pulmonary hyper-tension, or may be side effects of
19. Weiss ST, Utell MJ,Samet JM. Environ-mental tobaccosmoke exposure andasthma in adults. En-viron Health Per-spect. 1999;107 Sup-pl 6:891-5.[PMID: 10592149]
20. Ostro BD, Lipsett MJ,Mann JK, Wiener MB,Selner J. Indoor airpollution and asth-ma. Results from apanel study. Am JRespir Crit Care Med.1994;149:1400-6.[PMID: 8004290]
Table 2. The Step Classification of Asthma Severity*Classification Symptoms† Nocturnal Symptoms Lung Function
Step 1: Mild Symptoms ≤2 per week 2 per month FEV1
or PEFR ≥80% predictedintermittent Asymptomatic and PEFR variability <20%
normal PEFR between exacerbations Exacerbations brief (a few hours to a few days); intensity may vary
Step 2: Mild Symptoms >2 per >2 per month FEV1
or PEFR ≥80% predictedpersistent week but <1 per day PEFR variability 20%–30%
Exacerbations may affect activity
Step 3: Moderate Daily symptoms >1 per week FEV1
or PEFR >60%–<80% predictedpersistent Daily use of inhaled PEFR variability >30%
short-acting ß2-agonist
Exacerbations may affect activityExacerbations ≥2 per week; may last days
Step 4: Severe Continual symptoms Frequent FEV1
or PEFR <60% predictedpersistent Limited physical activity PEFR variability >30%
Frequent exacerbations
* Adapted from NHLBI Expert Panel Report. The presence of one of the features of severity is sufficient to place a patient inthat category. Assign patient to the most severe grade in which any feature occurs. The characteristics noted in this Tableare general and may overlap because of the high variability of asthma and because an individual’s classification may changeover time. PEFR = peak expiratory flow rate.
† Patients at any level of severity can have mild, moderate, or severe exacerbations. Some patients with intermittentasthma experience severe, life-threatening exacerbations separated by long periods of normal lung function and no symptoms.
medications. Evidence shows thatdifficult-to-control asthma may bea result of comorbid conditions andthat standardized evaluation of patients for comorbidity was associated with improved asthmacontrol (17).
When should primary careclinicians consider referringpatients with suspected asthma to specialists for diagnosis?Consultation with a pulmonologistshould be considered before order-
ing provocative pulmonary functiontesting because testing is time- and labor-intensive, requiring skilled performance and interpretation. Patients presenting with atypicalsymptoms, who have abnormalchest radiographs or unusual mani-festations of the disease, or whodisplay suboptimal response totherapy may benefit from referral toa pulmonologist. Referral to an al-lergist may be helpful for patientswith asthma that seems to have anallergic component.
What advice about reducingallergen exposure should clinicians give patients?Avoidance of triggers is the corner-stone of nonpharmacologic therapyof asthma. Clinicians should ques-tion the patient about triggers andprovide strategies to diminish expo-sure to them (see box). Since manypatients with asthma are atopic, reducing exposure to allergens canimprove outcomes. Other commontriggers of asthma include aspirin,nonsteroidal anti-inflammatorydrugs, and sulfites in food preserv-atives. Limiting exposure to trig-gers is difficult to implement orsustain in some patients; however,in most cases such triggers aredose-dependent, so even modestremediation can be beneficial.
The NHLBI Expert Panel Reportrecognized environmental smokeexposure as a common cause ofasthma exacerbations (2), and
several studies have impugned active and passive cigarette smok-ing as a cause of decreasing lungfunction in adult asthma (18, 19).
One study considered associations be-tween indoor air pollutants and symptomsin 164 adults with asthma and found anincrease in days of restricted activity (oddsratio [OR], 1.61 [95% CI, 1.06 to 2.46]) andgreater likelihood of increased asthmasymptoms in patients exposed to a smokerat home (OR, 2.05 [CI, 1.79 to 2.40]) (20).
What evidence supports the useof indoor air-cleaning devices forpatients with asthma?Given the recognition that environ-ment plays a critical role in airwayhygiene, it may seem logical thatindoor air-cleaning devices are ben-eficial. However, there is little evi-dence to suggest that HEPA filters,air duct cleaning, or dehumidifierscontrol asthma. Humidifiers mayactually increase allergen levels andmust be cleaned often. Keeping
21. Institute of MedicineCommittee on theAssessment of Asth-ma and Indoor Air.Executive summary.In: Clearing the Air:Asthma and IndoorAir Exposures. Wash-ington, DC: NationalAcademy Pr; 2000.
22. National Heart,Lung, and Blood In-stitute, NationalAsthma Educationand Prevention Pro-gram. Expert PanelReport: Guidelinesfor the Diagnosisand Management ofAsthma—Update onSelected Topics2002. Bethesda MD:US Department ofHealth and HumanServices, National In-stitutes of Health,2002; Publication 02-5075.
23. Aronson N, Lefevre F,Piper M, Manage-ment of ChronicAsthma. Summary,EvidenceReport/TechnologyAssessment Number44. Rockville, MD:Agency for Health-care Research andQuality; 2001. AHRQPublication 01-E044.
Diagnosis... A careful history focusing on the nature and timing of symptoms(wheezing, dyspnea, cough, chest tightness) and potential triggers is essential tothe diagnosis of asthma. Moderate-quality evidence supports the use of spirome-try in assessment of all adult patients and older children suspected of havingasthma. However, normal spirometry does not definitively rule out asthma. Clini-cians should consider provocative pulmonary testing for patients with normalspirometry but characteristic symptoms and no evidence of alternative diagnoses.
CLINICAL BOTTOM LINE
Treatment
Measures to Reduce Dust Miteand Other Environmental Allergen and Irritant Exposure• Use air conditioning to maintain
such as upholstered furniture,drapes, and soft toys
• Use impermeable covers formattresses and pillows
• Launder bedding weekly in waterat least 130°F
• Ensure adequate ventilation—may be the only measure neces-sary for dust mite control in dryclimates
• Exterminate to reduce cockroaches
• Remove cats from the home• Reduce dampness in the home• Avoid wood-burning or unvented
gas fireplaces or stoves• Avoid tobacco smoke
household humidity below 50%with dehumidifiers or air condition-ers reduces dust mites and mold (21).
A multidisciplinary committee convenedby the Institute of Medicine reviewed avail-able evidence concerning the impact of ventilation and air cleaning on asthma(21). Although they concluded that particleair cleaning may reduce symptoms in cer-tain situations, evidence is inadequate to broadly recommend air cleaning forpatients with asthma.
How should clinicians select fromamong available drug therapy forasthma?Table 3 summarizes drugs availableto treat asthma. Table 4 presents astepwise approach to using thesedrugs to maximize control of symp-toms (2, 22).
Clinicians should tailor drug therapyto the severity of asthma (Table 2).Stepwise therapy consists of agentsfor acute relief of symptoms (rescuetherapy) and for long-term control.Rescue therapy is critically impor-tant regardless of asthma severity.Patients with persistent symptomsrequire long-term control in addi-tion to rescue therapy. If control ispoor, stepping up to more intensetherapy is indicated. If symptomsare well-controlled, stepping downto less intensive therapy is indicated.
Clinicians should review therapyevery 1 to 6 months, depending onasthma severity. Asthma is a chron-ic disease that often requires long-term therapy. Given the complexityof airway inflammation, multipledrugs with different actions againstthe various aspects of the inflamma-tory response are often necessary.
Rescue TherapyPatients with mild intermittentasthma may only need a quick reliefmedication (short-acting β-ago-nists) on an as-needed basis. Short-acting β-agonists are the drugs ofchoice for reversal of acute bron-chospasm and are safe and well-tolerated. Patients with persistentasthma (mild, moderate, or severe)
should also receive a short-actingβ-agonist and advice to keep themedication readily available forrelief of acute symptoms.
Long-Term Controller TherapyPatients with mild, moderate, or severe persistent asthma have ab-normal baseline pulmonary functionand require long-term controllertherapy. Patients with mild persist-ent asthma should receive 1 long-term controller medication, usually alow-dose inhaled corticosteroid.
Compared with patients with mildintermittent asthma, patients withmild persistent asthma are moreprone to underlying inflammationand disease exacerbations. Low-dose inhaled corticosteroids havebeen shown to reduce bronchialhyperresponsiveness, reduce rescueβ-agonist use, and control symp-toms. Secondary alternatives to inhaled corticosteroids areleukotriene-receptor antagonistmedications (e.g., montelukast,zafirlukast) or cromolyn.
Patients with moderate persistentasthma will probably require 1 or 2long-term controller medications inaddition to short-acting rescuetherapy. The therapy of choice inthis group includes low-dose inhaled corticosteroids and a long-acting β-agonist or a moderate doseof a single long-term controllermedication. Evidence suggeststhat patients who remain sympto-matic while taking moderate dosesof inhaled corticosteroids benefitfrom the addition of a long-actingbronchodilator such as theophylline,salmeterol, or formoterol. The additive effect of the long-actingbronchodilator improves lung phys-iology, decreases use of rescue β-agonists, and reduces symptomsbetter than doubling the dose of aninhaled corticosteroid (23–26).However, there is little evidence toguide the best choice of combina-tions. Clinicians and patients mustweigh the reduced risk for adverseeffects of steroids against the use ofmore complicated regimens. It is
24. Greening AP, Ind PW,Northfield M, ShawG. Added salmeterolversus higher-dosecorticosteroid inasthma patientswith symptoms onexisting inhaled cor-ticosteroid. Allen &Hanburys LimitedUK Study Group.Lancet.1994;344:219-24.[PMID: 7913155]
25. Ukena D, Harnest U,Sakalauskas R, Mag-yar P, Vetter N, Stef-fen H, et al. Compari-son of addition oftheophylline to in-haled steroid withdoubling of thedose of inhaledsteroid in asthma.Eur Respir J.1997;10:2754-60.[PMID: 9493656]
26. Woolcock A, Lund-back B, Ringdal N,Jacques LA. Compar-ison of addition ofsalmeterol to in-haled steroids withdoubling of thedose of inhaledsteroids. Am J RespirCrit Care Med.1996;153:1481-8.[PMID: 8630590]
Table 3. Drug Treatment for AsthmaClass/Agent Mechanism of Action Benefits Side Effects Notes
Short-acting ß-agonists: Relaxes bronchial Fastest improvement Tachycardia, Should be carried by all patients with Albuterol smooth muscle, in airflow physiology palpitations, tremors, asthma at all times. Drug class of choiceMetaproterenol improves airflow of all anti-asthma hypokalemia for acute bronchospasm. Use only asTerbutaline medications needed. Effective at preventing symptomsPirbuterol of asthma when used before exercise.
Assessment of quantity of ß-agonist use mayidentify patients who require a "step-up" in thera-py. Use of >1 canister during a 1-month periodsuggests inadequate control. Oral preparationsavailable, but inhaled is preferred due to betterside effect profile.
Inhaled corticosteroids: Anti-inflammatory, Improved airflow Local: cough, Each type of inhaled corticosteroid has aBeclomethasone blocks late reaction physiology, reduced dysphonia, and thrush. different profile in terms of dosing potencydipropionate to allergen, and need for rescue Systemic: cortisol and possible risks for any of the known
Beclomethasone reduces airway medications (short- suppression, adrenal side effects.hydrofluoroalkane hyperresponsiveness acting ß-agonists), suppression, potential Drug deposition in the lower airway and
Budesonide prevents exacerbations osteoporosis, cataracts, systemic absorption and toxicity are Flunisolide and hospitalizations glaucoma conditioned by the drug and preparation,Fluticasone propionate inhalation technique, and use of a spacingTriamcinolone acetonide chamber. There is little information onCiclesonide how to monitor effectiveness and toxicityMometasone of inhaled corticosteroids, especially
considering the varying degrees of seasonal in-flammations or following differing stimuli/exposures. Inhaled corticosteroids are the most potent andeffective anti-inflammatory medications avail-able for asthma.
Long-acting inhaled Smooth muscle Improved a.m. peak Tachycardia, skeletal Use only in conjunction with anti-ß-agonists: relaxation flow, improved muscle tremor, inflammatory therapy. Salmeterol nocturnal symptoms, prolongation of QT Protection against exercise-induced Formoterol effective in preventing interval in overdose symptoms may decrease over time.
symptoms of exercise- Salmeterol has slower onset and both have induced asthma for up longer duration of action compared withto 12 hours after a short-acting ß-agonists. May provide more single dose effective symptom control when added to stan-
dard doses of inhaled corticosteroids comparedto increasing corticosteroid dosage. The FDA haswarned that these agents may increase thechances of a severe asthma episode. Thisseems more likely in blacks.
Combined fixed-agent Anti-inflammatory Improved airflow Dysphonia, thrush, Should not be initiated in patients duringcontrollers: moiety blocks late physiology, reduced nausea, headaches rapidly deteriorating or potentially life-Fluticasone and salmeterol reaction to allergen, need for short acting threatening episodes of asthma.Budesonide and formoterol and reduces airway ß-agonists, prevents Do not use in conjunction with inhaled
hyperresponsiveness, exacerbations and long-acting ß-agonists.and long-acting hospitalizations; Combined preparations prevent the use ofß-agonist leads to improved a.m. peak long-acting ß-agonists without inhaledsmooth muscle flow, improved corticosteroids.relaxation nocturnal symptoms
Leukotriene modifiers: Work by inhibition Improvements in Transient elevation in Oral tablets may be easier to use thanMontelukast of synthesis or symptoms and liver enzymes occurs inhaled medications and may enhanceZafirlukast antagonism of pulmonary function, with Zileuton and compliance; therapeutic benefits are less Zileuton receptor site for decreased exacerbation mandates monitoring than those of inhaled corticosteroids.
cysteinyl leukotrienes rate, reduced need of liver enzymes with May be of particular benefit in patientsfor rescue ß-agonist initiation of therapy; with aspirin intolerance and/or nasal
there is controversy polyps. May allow for safe reduction inover possible link with inhaled and oral corticosteroids. May beChurg-Strauss angiitis an alternative to increasing dose of(causation has not inhaled corticosteroid.been established)
Theophylline Smooth muscle Modest improvement Dose-related acute Studies show a benefit in the addition ofrelaxation, may have in expiratory flow toxicities include theophylline to inhaled corticosteroidssecondary effects of rates tachycardia, nauseainhibiting airway vomiting, inflammation and tachyarrhythmias (SVT),enhancing diaphragm CNS stimulation,contractility headache, seizures
Sometimes adverse effects are seen at therapeutic levels
Table 3. Drug Treatment for Asthma (continued)Class/Agent Mechanism of Action Benefits Side Effects Notes
Mast cell stabilizers: Anti-inflammatory, Improved airflow Cromolyn: no The therapeutic response to this class of Cromolyn blocks early and late physiology, reduced significant side effects drugs is less predictable than to cortico-Nedocromil reaction to allergens, need for rescue Nedocromil: 15%–20% steroids, but they continue to be used due
and stabilizes mast medications (short- of users complain of to their safety profilecell membranes; acting ß-agonists), unpleasant tasteinhibits eosinophil prevents exacerbationsactivation and mediator release
Systemic corticosteroids: Anti-inflammatory, Improved airflow Short-term: increased Most effective medication for severe Prednisone blocks late reaction physiology, reduced appetite and weight exacerbations and long-term control forPrednisolone to allergen, and need for rescue gain, fluid retention, patients with severe persistent asthma Methylprednisolone reduces airway medications (short- reversible abnormalities who are otherwise uncontrolled.Triamcinolone hyperresponsiveness acting ß-agonists), in glucose metabolism, Always seek lowest possible effective dose.
prevents exacerbations mood alterations Patients on corticosteroids (either daily orand hospitalizations Long-term: dermal ≥2 corticosteroid prescriptions for 5-10
thinning, cortisol days/yr) and undergoing surgery or with suppression, adrenal acute severe illness should be assessed for suppression, hyper- adrenal reserve or treated presumptively tension, diabetes with short-term systemic corticosteroid. mellitus, osteoporosis, Studies show that it is safe to give a short avascular necrosis of course of oral corticosteroids (7-10 days) femoral head, without tapering.cataracts, glaucoma
Anticholinergic agents: Bronchodilation Improved airflow Blurred vision if Treatment of choice in ß-blocker induced Ipratropium bromide mediated by physiology contact with eyes, bronchospasm; may give added broncho-Glycopyrrolate otropium antagonism of dry mouth and dilation to ß-agonists.
muscarinic receptors respiratory symptoms Meta-analysis of the use of ipratropium of airway smooth bromide in the treatment for acute severe muscle asthma shows that there is a modest
physiologic benefit in the addition of ipratropium to albuterol, with negligible risk ofadverse side effects. Tiotropium has been suggested as an alternativeto long-acting ß-agonists, but suitable effective-ness studies are lacking.
Intravenous Smooth muscle Bronchodilatation Minor effects; magnesium sulfate relaxation in acute severe flushing, lethargy,
asthma failing to nausea, or local respond to reaction at thenebulized IV sitebronchodilators-
Omalizumab A monoclonal Reduction in The main danger is Anaphylaxis may occur after any dose of antibody that binds exacerbations in anaphylaxis. Injections omalizumab (including the first dose), even to IgE used in patients with severe should be administered if there was no adverse reaction to the firstpatients aged 12 persistent asthma by trained personnel, dose. The symptoms and signs of years or older with on the best and patients should anaphylaxis include bronchospasm,moderate to severe available therapy be observed for 2 hours hypotension, syncope, urticaria, and persistent asthma, after every injection. angioedema of the throat or tongue. In proven IgE-mediated Anaphylaxis has been the major trials, there was a small increase sensitivity to perennial reported up to 24 hours in new or recurrent cancer compared to aeroallergens, and after injection, and the control grouppoor response to patients receiving standard treatment. omalizumab treatment Binding of IgE by should be fully preparedmonoclonal antibody to begin treatment forinhibits binding to anaphylaxis with an high-affinity IgE epinephrine autoinjectorreceptors on mast cells and basophils
*Readers can access detailed information on dosing in PIER at http://pier.acponline.org/physicians/diseases/d146/drug.tx/d146-s7.html. CNS = centralnervous system; FDA = Food and Drug Administration
unclear whether controlling the disease with high-dose inhaled corti-costeroids or moderate-dose inhaledcorticosteroids plus a long-actingbronchodilator results in a betterlong-term outcome.
In a 12-week, randomized, controlled trial of447 patients who remained symptomatic ontreatment with inhaled corticosteroids, adry-powder inhaler containing salmeteroland fluticasone was more effective in im-proving physiologic endpoints, reducing res-cue therapy use, and reducing exacerbations
27. Nelson HS, BusseWW, Kerwin E,Church N, EmmettA, Rickard K, et al.Fluticasone propi-onate/salmeterolcombination pro-vides more effectiveasthma control thanlow-dose inhaledcorticosteroid plusmontelukast. J Aller-gy Clin Immunol.2000;106:1088-95.[PMID: 11112891]
Table 4. Stepwise Approach for Managing Asthma in AdultsSTEP Classification Long-Term Control Quick Relief Education
Step 1: Mild No daily medication needed Short acting bronchodilator: Teach basic facts about asthma;intermittent inhaled ß
2-agonists* as needed teach inhaler/spacer/holding chamber
for symptoms technique; discuss roles of medications;develop self-management plan; developaction plan for when to take rescue medications, especially for patients with a history of severe exacerbations; discuss appropriate environmental con-trol measures to avoid exposure toknown allergens and irritants
Step 2: Mild One daily medication: Short-acting bronchodilator: Step 1 actions, plus teachpersistent • Anti-inflammatory*: either inhaled corticosteroid inhaled ß
2-agonists* as needed self-monitoring; refer to
(low doses) or cromolyn* or nedocromil* (children for symptoms group education ifusually begin with a trial of cromolyn or nedocromil) available; review and update
• Sustained-release theophylline to serum self-management planconcentration of 5-15 µg/mL is an alternative, but not preferred, therapy.
• Montelukast, zafirlukast, or zileuton may also be considered for patients age 12 and older, although their position in therapy is not fully established
Step 3: Moderate Preferred treatment: Short acting bronchodilator: Step 1 actions, plus teachpersistent • Low-to-medium dose inhaled corticosteroids and inhaled ß
2-agonists* as needed self-monitoring; refer to
long-acting inhaled ß2-agonists. for symptoms group education if
Alternative treatment: available; review and update Increase inhaled corticosteroids within medium- self-management plandose range
OR• Low-to-medium dose inhaled corticosteroids and
either leukotriene modifier or theophylline.OR• If needed (particularly in patients with recurring
severe exacerbations): Increase inhaled corticosteroids within medium-dose range, and add long-acting inhaled ß
2-agonists.
Alternative treatment:Increase inhaled corticosteroids to medium-dose range, and add either leukotriene modifier or theophylline
Step 4: Severe Preferred treatment: Short-acting bronchodilator: Step 2 and 3, plus refer to persistent High-dose inhaled corticosteroids inhaled ß
2-agonists* as needed individual education/
AND for symptoms. counselingLong-acting inhaled ß
2-agonists
AND, if needed, Corticosteroid tablets or syrup long-term (2 mg/kg/d,generally do not exceed 60 mg/d). (Make repeated attempts to reduce systemic corticosteroids and maintaincontrol with high-dose inhaled corticosteroids.)
*Intensity of treatment depends on severity of exacerbation. Use of short-acting inhaled ß2-agonists on a daily basis, or increasing use, indicates the need for additional long-
term control therapy
than was the addition of montelukast tothe inhaled corticosteroid fluticasone (27).
Long-acting β-agonists may helpimprove asthma symptoms, but theymay also increase risks for adverseoutcomes. Patients started on thesemedications should be followedclosely.
A meta-analysis of 19 randomized, con-trolled trials found that, compared withplacebo, long-acting ß-agonists in-creased severe exacerbations requiring
hospitalization (OR, 2.6 [CI, 1.6 to 4.3]), life-threatening exacerbations (OR, 1.8 [CI, 1.1to 2.9]), and asthma-related deaths (OR,3.5 [CI, 1.3 to 9.3]; risk difference, 0.07%)(28). Risks were similar for salmeterol andformoterol and in children and adults. Sev-eral trials did not report information aboutpotential harms, and the number of re-ported deaths was small. Black patientsand patients not using inhaled corticos-teroids seemed to be at high risk for theseoutcomes. These results suggest that long-acting ß-agonists should not be usedalone in asthma (28).
Patients with severe persistent asth-ma may require 3 controller med-ications to adequately controlsymptoms. Patients with this levelof disease are extremely prone toexacerbations and have profoundunderlying inflammation. Directcomparisons of high-dose inhaledcorticosteroids to leukotriene-receptor modifiers (such as monte-lukast) revealed that the inhaledcorticosteroids were more effective.The addition of montelukast to theregimen of a patient requiringhigh-dose inhaled corticosteroids,however, allowed a significant reduc-tion in the dose of the inhaledcorticosteroid while maintainingasthma control (29).
In a randomized, controlled study of pa-tients with inadequate symptom controldespite low- to moderate-dose inhaled cor-ticosteroid, the addition of montelukastimproved FEV
1daytime symptoms and
nocturnal awakenings (30).
A systematic review of trials comparing theaddition of daily leukotriene-receptor an-tagonists or long-acting ß-agonists to in-haled corticosteroids in patients with se-vere asthma concluded that long-actingß-agonists were better than leukotrieneantagonists in preventing the need forrescue therapy and systemic steroids andimproved lung function and symptoms(31, 32)
Omalizumab is a monoclonal anti-body that binds to IgE that hasbeen shown to reduce exacerbationsin patients with severe persistentasthma despite best available therapy(33). However, severe anaphylaxishas been reported up to 24 hoursafter injection. Clinicians shouldview the drug as an option only incarefully selected cases of severepersistent asthma in patients withproven IgE-mediated sensitivity toperennial aeroallergens, and failureof other therapeutic options.
What therapeutic options areeffective for patients withexercise-induced asthma?In some patients, exercise exacer-bates asthma. Symptoms often oc-cur with vigorous exercise in cold,dry air. Patients who have morethan 2 episodes of exercise-induced
asthma per week are candidates forintervention. Patients who havenormal baseline pulmonary func-tion but experience exercise-in-duced symptoms can be treated ef-fectively with albuterol, cromolynsodium, or nedocromil 15 to 30minutes before exercise.
If exercise-induced symptoms per-sist, addition of long-acting bron-chodilators or leukotriene antago-nists may be helpful. Recentevidence suggesting that mono-therapy with long-acting broncho-dilators may cause adverse out-comes in asthma cautions againstusing these agents as monotherapyin exercise-induced asthma (28, 34).Despite these concerns, evidenceclearly suggests that formoterol orsalmeterol is more effective thanplacebo in preventing exercise-induced bronchoconstriction (35, 36).In a study of patients with mildstable asthma, once-daily treatmentwith montelukast protected againstexercise-induced bronchospasm (37).
The clinician should consider exercise-induced asthma in thecontext of the patient’s overall therapy. Many patients who pres-ent with putative exercise-inducedasthma may have abnormal pul-monary function tests at baseline.Such patients should be treated according to the NHLBI ExpertPanel Report 2 regimen (2).
When should primary careclinicians refer patients withasthma to a specialist fortreatment?Although definitive evidence aboutthe effect of specialty care on asthmaoutcomes is not available, accordingto consensus recommendations re-ferral to a specialist may be useful inthe following clinical situations:
• History of life-threatening exacerbations
• Atypical signs and symptoms• Severe persistent asthma• Need for continuous oral corti-
costeroids or high-dose inhaledsteroids or more than 2 coursesof oral steroids in a 1-year period
28. Salpeter SR, BuckleyNS, Ormiston TM,Salpeter EE. Meta-analysis: effect oflong-acting beta-ag-onists on severeasthma exacerba-tions and asthma-re-lated deaths. Ann In-tern Med.2006;144:904-12.[PMID: 16754916]
29. Löfdahl CG, Reiss TF,Leff JA, Israel E, Noo-nan MJ, Finn AF, etal. Randomised,placebo controlledtrial of effect of aleukotriene receptorantagonist, mon-telukast, on taperinginhaled corticos-teroids in asthmaticpatients. BMJ.1999;319:87-90.[PMID: 10398629]
30. Laviolette M, Malm-strom K, Lu S,Chervinsky P, PujetJC, Peszek I, et al.Montelukast addedto inhaled be-clomethasone intreatment of asthma.Montelukast/Be-clomethasone Addi-tivity Group. Am JRespir Crit Care Med.1999;160:1862-8.[PMID: 10588598]
31. Coté J, Cartier A, Ro-bichaud P, Boutin H,Malo JL, Rouleau M,et al. Influence onasthma morbidity ofasthma educationprograms based onself-managementplans followingtreatment optimiza-tion. Am J Respir CritCare Med.1997;155:1509-14.[PMID: 9154850]
agonists versus anti-leukotrienes as add-on therapy toinhaled corticos-teroids for chronicasthma. Cochranedatabase Syst Rev.2006:CD003137.[PMID: 17054161].
33. Humbert M, BeasleyR, Ayres J, Slavin R,Hebert J, Bousquet J,et al. Benefits ofomalizumab as add-on therapy in pa-tients with severepersistent asthmawho are inadequate-ly controlled despitebest available thera-py (GINA 2002 step4 treatment): INNO-VATE. Allergy.2005;60:309-16.[PMID: 15679715]
• Comorbid conditions that com-plicate asthma diagnosis or treatment
• Need for provocative testing orimmunotherapy
• Problems with adherence or allergen avoidance
• Unusual occupational or other exposures.
Whether to consult an allergist orpulmonologist should reflect localavailability and consideration of thepredominant co-morbid conditionsand complicatingfeatures in asthma.For example, a patient with sleepapnea and asthmamay benefit froma pulmonary con-sultation, whereasthe patient whohas asthma withan atopic compo-nent may benefitfrom referral to an allergist.
When ishospitalization indicated for apatient with asthma?Patients who have a sustained re-sponse to treatment in outpatientsettings do not need to be hospital-ized if they understand the impor-tance of continued anti-inflamma-tory therapy and close follow-up.The decision to hospitalize a pa-tient with asthma should considerpatient characteristics, severity ofdisease, and initial response toshort-term therapy. Patients withan incomplete response to therapyduring an exacerbation (PEFR>50% but <70% than patient’s bestor of the predicted value) may needhospitalization. When posttreat-ment PEFR remains <50% of thepredicted value, intensive care unitadmission may be warranted. How-ever, data are insufficient to sup-port the idea that adequate oxygensaturation and PEFR at the time ofemergency department dischargepredict a good outcome.
In a prospective cohort study of adults pre-senting with asthma to urban emergencydepartments in the United States, the PEFR
of those who had a relapse did not signifi-cantly differ from those who did not have arelapse after discharge from the emer-gency department. However, such histori-cal features as emergency department orurgent care visits (OR, 1.3 per 5 visits), useof a home nebulizer (OR, 2.2), multipletriggers (OR, 1.1 per trigger), and longerduration of symptoms (OR, 2.5 for 1 to 7days) did predict relapse (38).
What factors identify patientswith asthma at high risk for fatalor near-fatal events during an
exacerbation?Historical factorsreflect the risk forfatal and near-fatalasthma-relatedevents and shouldlower the thresholdfor hospitalizationof a person whenthese factors arepresent. Such factorsinclude asthma his-tory, socioeconomiccharacteristics, andcomorbid conditions(see Box).
How often should clinicians seepatients with asthma for routinefollow-up?No definitive studies are availableto guide the frequency of asthmafollow-up, but consensus suggeststhat for patients with newly diag-nosed asthma, 2 to 4 visits duringthe 6 months after diagnosis canhelp to establish and reinforce thepatient’s basic knowledge and man-agement skills. For patients withasthma who have shown maximumimprovement in pulmonary func-tion and have minimal to no relat-ed symptoms, the NHLBI ExpertPanel Guide suggests routine fol-low-up every 1 to 6 months withannual pulmonary function tests(2); however, evidence document-ing the benefit of this strategy islimited. The Report also suggestsfollow-up within 7 days for patientsdischarged from the hospital andwithin 10 days for patients treatedas outpatients for an exacerbation.Studies have shown that relapseoccurs in about 1% of patients perday until the follow-up visit(38–40).
34. SMART Study Group.The Salmeterol Mul-ticenter Asthma Re-search Trial: a com-parison of usualpharmacotherapyfor asthma or usualpharmacotherapyplus salmeterol.Chest. 2006;129:15-26. [PMID: 16424409]
35. Nelson JA, Strauss L,Skowronski M, CiufoR, Novak R, McFad-den ER Jr. Effect oflong-term salme-terol treatment onexercise-inducedasthma. N Engl JMed. 1998;339:141-6. [PMID: 9664089]
36. Nightingale JA,Rogers DF, Barnes PJ.Comparison of theeffects of salmeteroland formoterol inpatients with severeasthma. Chest.2002;121:1401-6.[PMID: 12006420]
37. Leff JA, Busse WW,Pearlman D, BronskyEA, Kemp J, Hende-les L, et al. Mon-telukast, aleukotriene-receptorantagonist, for thetreatment of mildasthma and exer-cise-induced bron-choconstriction. NEngl J Med.1998;339:147-52.[PMID: 9664090]
38. Emerman CL,Woodruff PG, Cydul-ka RK, Gibbs MA,Pollack CV Jr., Camar-go CA Jr. Prospectivemulticenter study ofrelapse followingtreatment for acuteasthma amongadults presenting tothe emergency de-partment. MARC in-vestigators. Multi-center AsthmaResearch Collabora-tion. Chest.1999;115:919-27.[PMID: 10208187]
Factors Associated with PoorOutcomes of Asthma Exacerbations• Prior intubation• Multiple asthma-related exacer-
bations• Emergency room visits for asthma
in the previous year• Nonuse or low adherence to in-
haled corticosteroids• History of depression, substance
abuse, personality disorder, unem-ployment, or recent bereavement
What do professionalorganizations recommendregarding the care of patientswith asthma?Many of the recommendationsprovided in this overview are froma guideline developed by theNHLBI that was most recently up-dated in 2002 (22). The guidelineswere approved by the 40 organiza-tions that comprise the NationalAsthma Education and PreventionProgram. The document coverspathogenesis, medications, moni-toring, and prevention and is avail-able free at www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.
Numerous other organizations havedeveloped recommendations relatedto the care of patients with asthma,including the American Academyof Asthma, Allergy and Immunolo-gy (www.aaaai.org); the AmericanLung Association (www.lungusa.org); and the Asthma and AllergyFoundation of America (www.aafa.org). These organizations also pro-vide demographically and culturallysensitive educational programs andteaching tools.
What is the role of patienteducation in optimizing theoutcome of asthma care?Asthma is a paradigm illness forpatient self-management because ofits intermittent and unpredictablenature. Patients and family mem-bers can recognize changes and ini-tiate specific actions to minimize
exacerbations. Clinicians should in-clude asthma education as part ofeach office visit, and formal asthmaeducation programs may be particu-larly helpful for patients who havehad asthma hospitalizations, emer-gency department visits, or frequentexacerbations. Important elementsof asthma education include basicinformation, the role of medica-tions, inhaler and peak flow meterskills, environmental control meas-ures, and appropriate use of rescuemedications. Demographically andculturally appropriate educational materials can be used as an adjunctto one-on-one asthma education.Because many patients use metered-dose inhalers improperly, all pa-tients should receive instruction on proper use.
Clinicians should develop individu-alized self-management plans forall patients, taking into considera-tion underlying disease severity andthe patient’s willingness and abilityto manage the illness. For patientswith mild disease, clinicians shouldconsider providing a simple self-management plan that provides in-formation on how to handle exac-erbations, including health carecontacts in case of emergency. Forpatients with moderate-to-severedisease, provide a self-managementplan that incorporates a daily diaryand a detailed written action planwith specific objective and subjective
39. McCarren M, McDer-mott MF, Zalenski RJ,Jovanovic B, MarderD, Murphy DG, et al.Prediction of relapsewithin eight weeksafter an acute asth-ma exacerbation inadults. J Clin Epi-demiol. 1998;51:107-18. [PMID: 9474071]
40. Rowe BH, Bota GW,Fabris L, Therrien SA,Milner RA, Jacono J.Inhaled budesonidein addition to oralcorticosteroids toprevent asthma re-lapse following dis-charge from theemergency depart-ment: a randomizedcontrolled trial.JAMA.1999;281:2119-26.[PMID: 10367823]
41. Effectiveness of rou-tine self monitoringof peak flow in pa-tients with asthma.Grampian AsthmaStudy of IntegratedCare (GRASSIC). BMJ.1994;308:564-7.[PMID: 8148679]
42. Charlton I, CharltonG, Broomfield J,Mullee MA. Evalua-tion of peak flowand symptoms onlyself managementplans for control ofasthma in generalpractice. BMJ.1990;301:1355-9.[PMID: 2148702]
Treatment... Patients should avoid asthma triggers. While air conditioners or de-humidifiers may be helpful, indoor air-cleaning devices are of unclear utility. Allpatients with asthma should have short-acting β-agonists available for relief ofacute symptoms. For patients with persistent asthma, treatment with long-termcontroller medications should begin with low-dose inhaled corticosteroids and bestepped up to higher doses and/or additional agents according to asthma severity.Patients with severe persistent asthma may need as many as 3 long-term con-troller medications.
Should all patients with asthmareceive peak flow meters?The precision of patients and physi-cians in estimating the degree of air-flow obstruction based on symptomsalone varies greatly, so objectivemeasurement of expiratory flowrates could in theory be useful toguide therapeutic strategies. How-ever, studies that have randomly as-signed patients to action plans thatincorporate PEFR have not shown major improvements comparedwith action plans based on symp-toms alone (41, 42).
Clinicians should ensure that all
patients with persistent moderate-
to-severe asthma have a peak flow
meter at home and know how to
use it. If patients are unwilling to
measure peak flow, provide instruc-
tion in symptom-based monitoring.
Do U.S. stakeholders considerasthma care when evaluating the quality of care a physiciandelivers?In April 2005, The AmbulatoryCare Quality Alliance (AQA) re-leased a set of 26 health care qualityindicators for clinicians, consumers,and health care purchasers to use inquality improvement efforts, publicreporting, and pay-for-performanceprograms (www.ahrq.gov/qual/aqastart.htm ). In May 2005, theCenters for Medicare & MedicaidServices (CMS) endorsed the de-velopment of these indicators. Ofthe 26 AQA indicators, 2 focus onasthma care (see the Box).
As part of CMS’s Physician Quali-ty Reporting Initiative, physicianswho successfully report a designat-ed set of quality measures on claimsfor services provided July 1 to December 31, 2007, may earn abonus payment. See the Box for the2 CMS measures related to asthma(www.cms.hhs.gov/specifications_2007-02-04.pdf).
Tool Kitin the clinic
Asthma
http://PIER.acponline.orgAsthma module of PIER, an electronic deci-
sion support resource designed for rapid access
to information at the point of care.
http://pennhealth.com/ency/presentations/100200_1.htmTutorial on proper use of metered dose
inhalers.
http://pier.acponline.org/qualitym/asm.htmlTool to assist clinicians in developing strate-
gies to improve adherence to the AQA asthma
performance measures.
www.annals/intheclinic/toolsDownload copies of the patient information
sheet that appears on the following page for
duplication and distribution to your patients.
Ambulatory Care Quality Alliance Performance Measures for Asthma• Percentage of individuals who were
identified as having persistent asthmaduring the 1 year before the measure-ment year and who were appropri-ately prescribed asthma medications(e.g., inhaled corticosteroids) duringthe measurement year.
• Percentage of individuals with mild,moderate, or severe persistent asthmawho were prescribed either the pre-ferred long-term control medication(inhaled corticosteroid) or an acceptable alternative treatment.
Center for Medicare &
Medicaid Services (CMS) Asthma Quality Measures• Percentage of patients aged 5 to 40
years with a diagnosis of mild,moderate, or severe persistent asthma who were prescribed eitherinhaled corticosteroid or an accept-able alternative.
• Percentage of patients aged 5 to 40years with a diagnosis of asthmawho were evaluated during at leastone office visit within 12 monthsfor the frequency (numeric) of day-time nocturnal asthma symptoms.
THINGS PEOPLE SHOULD KNOW ABOUT ASTHMA
HEALTH TiPS*WHAT YOU CAN DOHere’s what you can do to feel better.
Stay away from what makes your asthma worse:
• Dust• Smoke• Animals• Cold or dry air
Don’t smoke and stay away from people who do
Asthma-proof your home:
• Get special mattress and pillow covers• Get rid of old carpets and drapes• Use air conditioners and dehumidifiers
Use your medicines the right way:
• Take medicines that prevent attacks everyday
• Take medicines that stop attacks when youneed them
• Learn the right way to use your inhalers
Call your doctor or go to the hospital if it ishard to breathe and your medicines are nothelping
Things to ask your doctor:
Which medicines are to keep attacks fromhappening?
Which medicines are to stop attacks when theycome on?
Can you show me the right way to use my inhaler?
Can I use my inhalers more often if I need to?
What are the side effects of my inhalers andmy other medicines?
Do I need a special meter to check my breath-ing at home? How do I use it?
How long should I wait to call the doctor or goto the hospital if I am having trouble breathing?
In the ClinicAnnals of Internal Medicine
*HEALTH TiPS are developed by the American College of Physicians Foundation and PIER Pati
A 46-year-old woman with persistent asth-ma is evaluated in the clinic for a scheduledfollow-up visit. Since her most recent visit 6months ago, her disease has been stable ona regimen of high-dose inhaled corticos-teroids plus a long-acting β-agonist and as-needed albuterol, which she uses approx-imately once every 1 to 2 weeks. The patientis pleased with the current therapy, and theas-needed albuterol is continued.
Which of the following would be the bestapproach to this patient’s therapy?
A. Continue inhaled corticosteroids andthe long-acting β-agonist at currentdoses
B. Discontinue inhaled corticosteroids andthe long-acting β-agonist
C. Continue the long-acting β-agonistand reduce the dose of inhaled corticosteroids
D. Discontinue the long-acting β-agonistand reduce the dose of inhaled corticosteroids
A 75-year-old woman with a long-standinghistory of asthma is evaluated for increasednocturnal asthma symptoms and frequentneed to use an albuterol inhaler. Her treat-ment regimen now consists of daily moder-ate-dose inhaled corticosteroids.
On physical examination she has occasionalwheezing; the examination is otherwise un-remarkable. Office spirometry shows an FEV
1
of 2.2 L (75% of predicted).
Which of the following is the most appropri-ate adjustment to this patient’s therapy?
A. Double the inhaled corticosteroid doseB. Add theophyllineC. Add a leukotriene-receptor antagonistD. Add a long-acting β-agonistE. Add anti-IgE antibody
A 38-year-old woman is evaluated for wors-ening control of mild persistent asthma. Herdisease had been under good control ontherapy with moderate-dose inhaled corti-costeroids plus as-needed albuterol until 6weeks ago when she had an acute respirato-ry tract infection. Since then she has hadsignificant worsening of her symptoms, withnightly cough and wheezing. She uses an al-buterol rescue inhaler 6 to 8 times per day.
Which of the following is the most appropri-ate therapy for this patient?
A. A 7-day course of a fluoroquinoloneantibiotic
B. Nebulized albuterol–ipratropium bromide at home
C. A short course of oral corticosteroidtherapy
D. A leukotriene-receptor antagonist
A 28-year-old man is evaluated for a 6-month history of episodic dyspnea, cough,and wheezing. He had asthma as a child buthas been asymptomatic since his early teens.The recent symptoms, which began after anupper respiratory tract infection, are oftentriggered by exercise or exposure to cold airand awaken him from sleep 3 or 4 times permonth.
On physical examination, vital signs are nor-mal. There is scattered wheezing in bothlung fields. Office spirometry shows an FEV
1
75% of predicted with a 15% improvement(370 mL) after inhaled albuterol. Chest radi-ographs are normal.
Which of the following is the most appropri-ate therapy for this patient?
A. Albuterol by metered-dose inhaler as needed
B. Long-acting β-agonist plus as-neededalbuterol
C. Long-acting β-agonistD. Inhaled corticosteroids plus as-needed
albuterolE. Long-term antibiotic therapy
A 19-year-old woman is evaluated for possi-ble asthma. She has known seasonal aller-gies that manifest as hay fever in fall andspring. Symptoms are restricted to her noseand eyes, and she has no history of wheez-ing or chest tightness. The patient had amethacholine test as part of a researchstudy, which showed borderline response.
Which of the following would be the mostappropriate management for this patient?
A. Inhaled corticosteroids and a long-acting β-agonist
B. Seasonal nasal corticosteroids and antihistamine
C. Albuterol inhaler as neededD. Repeat methacholine challenge
A 37-year-old man with asthma is evaluatedbecause he continues to have frequent at-tacks and now believes that his short-actingβ-agonist is not providing relief. Other med-ications he reportedly uses include a long-acting β-agonist inhaler, inhaled high-dosecorticosteroids, and a short-acting β-agonistinhaler as rescue medication. He has symp-toms daily and nocturnal symptoms abouttwice per week.
On physical examination, he is in mild respi-ratory distress. Temperature is 37°C (98.6°F),blood pressure is 140/85 mm Hg, pulse rateis 90 beats/min, and respiration rate is 18breaths/min. He has bilateral wheezing andoral thrush. Office spirometry shows FEV
1
65% of predicted, which improves withbronchodilators to 85% of predicted. He hasno history of recent viral upper respiratoryinfections, rhinitis, or symptoms of gastroe-sophageal reflux disease.
Which of the following is the best next stepin this patient’s management?
A. Add a leukotriene inhibitorB. Observe the patient using the metered-
dose inhalerC. Start oral prednisone therapy and have
the patient return for a pill countD. Have the patient return with a symp-
tom and treatment log
Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/ to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.
