guidelines for the diagnosis and management of asthma · 2015-04-14 · expert panel report 2:...
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Page 1 of 25 Diagnosis and Management of Asthma 2013 © Copyright MedStar Health, 2013
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.
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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.
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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
mcg/inhalation
Budesonide DPI 90 or 180
inhalation
21 Figure 4-8b Mometasone DPI 200
mcg/inhalation
200 mcg / 400 mcg / >400 mcg
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