Allercy and Asthma Health
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Improving Asthma Control

Diagnosis and Treatment of Asthma in Elderly Patients

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Time to Reinvent the Wheel

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The Official Publication of AAN - MA

Time to Reinvent the Wheel

This particular article contains a lot of advanced knowledge about asthma. Respiratory therapists continue to study and learn about the science and techniques for managing asthma so that they can help you breath better. If you are a long-time asthma sufferer and have studied about your disease, you may find this discussion of categorizing asthma control as important information in your arsenal of knowledge. Again, this article appeared earlier this year in AARC Times.
Editor

Advances in the management of asthma

Asthma is the most common chronic condition of childhood and affects more than 6.3 million children in the United States alone. The National Health Interview Survey (2002) reports a prevalence rate of 12% of children aged 0–17 have been told by a physician that they have asthma. The focus of asthma disease management has drifted from one of disease severity to one of asthma disease control.

Severity versus control
Since publication of the asthma guidelines by the National Asthma Education and Prevention Program (NAEPP) in 1991,1 the disease management focus of the guidelines has revolved around categorizing disease severity (mild, moderate, and severe). Even the release of the second edition of the guidelines by the Expert Panel (EPR-2) in 1997 and the Global Initiative for Asthma (GINA) guidelines focused on a more definitive system for classifying asthma severity (mild intermittent; and mild, moderate, and severe persistent).2,3

The problem with classifying disease severity is that by its very nature, the classification implies a fixed component of asthma. Asthma is a disease that can change over weeks, months, or years with treatment or without treatment. Asthma severity not only encompassed the underlying severity of the asthma, but its responsiveness (or lack thereof) to an appropriate treatment regimen.

The key, of course, to stratifying disease severity based on patient symptoms was that once the disease severity was identified, a medication regimen could be established based on the severity level. The medication regimen then could be increased, decreased, or left alone on subsequent follow-up visits based on the patient’s self-report of asthma symptoms and spirometry (if patients were above the age of seven).

The difficulty with the focusing of asthma disease management on disease severity, of course, comes with long-term follow-up of these patients. For example, the patient who is identified as having moderate persistent asthma is prescribed inhaled corticosteroids (and possible adjuncts) for daily maintenance and beta agonists for symptom relief. Twelve months later, the patient reports no symptoms (mild intermittent), and the question becomes how to adjust or should you adjust the medication regimen by stepping the patient down in therapy. The answer may lie not in the severity of the disease but in the control of asthma. The newly released GINA guidelines stress the importance of disease control in asthma management (see Table 1 and Figure 1).4 It is also expected that the third edition of the NAEPP guidelines to be released in 2007 will focus heavily on asthma control as well.

Another major difference between control and severity is the duration of the assessment period: Severity is assessed over the preceding six months to one year, whereas control refers to the preceding weeks (one week to three months). Thus, while the level of control has to be evaluated at each visit and may change from one visit to another, reclassification of severity should be envisaged only when a stable level of control has been obtained and maintained during several (e.g., at least three) months, allowing to decrease the “therapeutic pressure.”5

Asthma control
Implementation and utilization of the asthma severity classifications to manage the disease have been called into question for almost a decade.6,7 Asthma control has become an increasingly important focus of asthma disease management. Effective medical care and asthma management depends on improving patient outcomes and condition. Disease control can be defined to indicate disease prevention or cure; but in asthma, where neither of these are realistic options, it refers to control of the manifestations of the disease.8

Table 1. Levels of Asthma Control in New GINA Guidelines
Characteristic Controlled
(All of the following)
Partly Controlled
(Any measure present in any week)
Uncontrolled
Daytime symptoms None (twice or less/week) More than twice/week Three or more features of partly controlled asthma present in any week
Limitations of activities None Any
Nocturnal symptoms/awakening None Any
Need for reliever/rescue treatment None (twice or less/week) More than twice/week
Lung function (PEF or FEV1)‡ Normal < 80% predicted or personal best (if known)
Exacerbations None One or more/year* One in any week†
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequate.
† By definition, an exacerbation in any week makes that an uncontrolled asthma week.
‡ Lung function is not a reliable test for children 5 years and younger.
SOURCE: Global Initiative for Asthma web site. Global strategy for asthma management and prevention, 2006 revision. Available at: www.ginasthma.org/Guidelineitem.asp??l1=2&l2=1&intId=60 Accessed Feb. 16, 2007

The question becomes how to measure asthma control. The Joint Task Force on Practice Parameters for Allergy & Immunology suggested a multifactorial approach for clinicians to judge asthma control on daytime and nocturnal symptoms, use of rescue medication, limitations of daily activity, patient and physician assessment, and spirometry.9

While there is no comprehensive measurement tool to identify and define asthma control, several instruments have been developed, tested, and validated over the last several years for their reliability and reproducibility to measure asthma control. The Asthma Control Test,10 the Asthma Quality of Life Questionnaire,11 the Asthma Therapy Assessment Questionnaire,12 and the Asthma Control Scoring System13 are four of those survey instruments currently available.

These validated tools all take a slightly different approach to determining or assessing asthma control. For example, the Asthma Control Tests are either five- or seven-item question assessments of asthma control completed by the asthmatic (12 years of age or greater) or the child and parent/caregiver (four to 11 years of age), respectively.10 It is designed to identify patients whose asthma is inadequately controlled and is available on the Web in both English and Spanish (www.asthmacontrol.com). The most recent instrument in the literature, the Asthma Control Scoring System,13 assesses three types of parameters:

  • Clinical (diurnal and nocturnal symptoms, rescue beta agonist use, activities)
  • Physiological (FEV1 and/or peak expiratory flows [PEF] and/or PEF circadian variations)
  • Lower airway inflammation (induced sputum eosinophilia).

To date, there has been no definitive study contrasting or comparing these two disease management principles of severity versus control, and it is possible that a mixture of control and severity may improve asthma management. The ability to measure and quantify asthma control appears easier to operationalize in real world, clinical practice. The variability of asthma over prolonged periods of time makes disease management and treatment regimens based on disease severity difficult. Monitoring asthma control with validated instruments may better assess disease outcomes and medication regimens for both short- and long-term management. •

References

  1. National Heart, Lung, and Blood Institute. National Asthma Education Program. Expert Panel Report. Guidelines for the diagnosis and management of asthma. J Allergy Clin Immunol 1991; 88(3 Pt 2):425-534.
  2. National Institutes of Health, National Asthma Education and Prevention Program. Expert panel report II: guidelines for the diagnosis and management of asthma. Bethesda MD; 2002.
  3. Global Initiative for Asthma. Management segment, chapter 7. In: Global strategy for asthma management and prevention. NIH Publication No. 02-3659, 1995.
  4. Global Initiative for Asthma web site. Global strategy for asthma management and prevention, 2006 revision. Available at: www.ginasthma.org/Guidelineitem.asp??l1=2&l2=1&intId=60 Accessed Feb. 16, 2007
  5. Roche N, Godard P. Control and severity: complementary approaches to asthma management. Allergy 2007; 62(2):116-119.
  6. Cockcroft DW, Swystun VA. Asthma control versus asthma severity. J Allergy Clin Immunol 1996; 98(6 Pt 1): 1016-1018.
  7. Sawyer G, Miles J, Lewis S, et al. Classification of asthma severity: should the international guidelines be changed? Clin Exp Allergy 1998; 28(12):1565-1570.
  8. Humbert M, Holgate S, Boulet LP, Bousquet J. Asthma control or severity: that is the question. Allergy 2007; 62(2):95-101.
  9. Joint Task Force on Practice Parameters, et al. Attaining optimal asthma control: a practice parameter. J Allergy Clin Immunol 2005; 116:S3-S11.
  10. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol 2004; 113(1):59-65.
  11. Juniper EF, O’Byrne PM, Guyatt GH, et al. Development and validation of a questionnaire to measure asthma control. Eur Respir J 1999; 14(4):902-907.
  12. Vollmer WM. Assessment of asthma control and severity. Ann Allergy Asthma Immunol 2004; 93(5):409-416, 492.
  13. LeBlanc A, Robichaud P, Lacasse Y, Boulet LP. Quantification of asthma control: validation of the Asthma Control Scoring System. Allergy 2007; 62(2):120-125.

 

About the Author
Timothy R. Myers, BS, RRT-NPS, is director of the asthma and diagnostic centers and respiratory care at Rainbow Babies & Children’s Hospital, and assistant professor of pediatrics at Case Western Reserve University in Cleveland, OH. He also serves on the AARC Board of Directors.

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