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10 Important Things You Should Know about the New Asthma Guidelines
It may be hard to believe, but it’s been 17 years since the National Heart, Lung, and Blood Institute’s National Asthma Education and Prevention Program (NAEPP) first published guidelines on the diagnosis and management of asthma. Since then, there was a major update in 1997 and a minor update in 2002. In August 2007, the NAEPP released its Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3) — the latest revision and the first major update in 10 years.
Thomas Kallstrom, BS, RRT, AE-C, FAARC, chief operating officer of the American Association for Respiratory Care, has represented the AARC on the NAEPP coordinating committee since 1991, bringing the respiratory therapist’s knowledge to the committee. Here he shares what he believes are the most important things everyone should know about the 2007 asthma guidelines.
1. The guidelines are evidence-based.
The new guidelines are based on a review of more than 15,000 medical studies when compiling these guidelines. The NAEPP’s Expert Panel, made up of asthma care experts, performed an extensive review of these documents and attests to their validity.
2. Classification is tied to control, severity, and responsiveness, and the steps have changed.
Joint Commission Supports the New NAEPP Guidelines The National Asthma Education and Prevention Program (NAEPP) isn’t the only group supporting greater adherence to proven methods of asthma control. The Joint Commission, an organization that oversees and rates health care institutions nationwide on the quality of patient care they provide, recently introduced a new initiative of its own for asthma care.
In April 2007, The Joint Commission came out with some quality measures directed to asthma patients, primarily in pediatric hospitals. The move was spurred by questions pertaining to children’s health care outcome measures in general; and with asthma being the most common chronic disease of childhood and the most common discharge diagnosis, it made sense that they focus on asthma care. Those outcome measures, which were developed to improve asthma care, include:
- Making sure reliever medications are used with patients in hospitals.Using systemic corticosteroids for patients in the emergency department who are not responding.
- Providing patients with a home management plan upon discharge so they will know how to better manage their asthma.
3. The pharmacology section has been expanded.
It would be a good idea to ask your doctor or respiratory therapist about how this could affect you and your asthma. Control is defined as the degree to which asthma symptoms are minimized. Severity is the intensity of the disease process. Responsiveness is the ease with which control of asthma is achieved. Both severity and control include areas of current impairment and future risk, with impairment defined as the frequency and intensity of symptoms, low lung function, and limitations on daily activities. Risk is defined as the likelihood of asthma exacerbation (or flare up), progressive decline in lung function, or adverse side effects from medications.
The guidelines stress that even asthmatics who are experiencing few day-to-day effects of asthma can be at high risk for frequent exacerbations.
4. Some things just don’t work in controlling asthma.
This is the biggest section of the new guidelines, and the reason lies in the explosion in new medications available for asthma. The stepwise approach to medication management also has been expanded to simplify the actions within each step.
With all these new medications, new delivery devices have been introduced, and the guidelines emphasize the importance of your knowing exactly how to use them, whether it’s a dry powder inhaler, a metered-dose inhaler (MDI), a nebulizer, or a spacer. As an asthma patient, consider asking your doctor to prescribe a similar type of device for the majority of the medications you take. That way, you won’t get confused as easily, especially if you have several devices to master. Your asthma educator should also be making sure you can use all the devices accurately by having you demonstrate the way you use them.
Complementary or alternative medications are also mentioned in the updated new asthma guidelines, but little evidence was found on their effectiveness. Acupuncture is not recommended at all, and neither are herbal remedies. The guidelines suggest there is insufficient evidence to show breathing exercises, relaxation techniques, or even yoga make any significant change in the asthmatic condition either. This is not to say that you should not try these methods — but they certainly should not be considered as first-line treatments.
5. Self-management is key.
6. Adherence is strongly encouraged.
A major focus of the new document is the need for patient self-management. Strong evidence supports the value of your asthma care provider offering regular monitoring of your condition and your achievement of goals to reduce impairment and risk. You should be taught recognize symptom patterns that may indicate inadequate control.
It is also very important for you and your family to develop a strong partnership with your asthma care provider. Self-management should be reinforced in all your service interactions, whether they be in the clinic, emergency room, acute care facility, home, or out in the community. Everyone involved in your asthma care needs to follow the same guidelines, and if it gets confusing, ask questions.
As respiratory therapists, we know how important it is to get our patients to do what we tell them they should do to be able to self-manage asthma. Regularly review your successes and failures in managing your asthma with your asthma care provider and then make adjustments accordingly.
7. Your environment must be controlled to keep asthma under control.
Your environment causes many of the problems you have with managing your asthma. The new guidelines include strong evidence for the role of indoor allergens and the improvements that can be gained by reducing exposure. You cannot do just one thing — you must do a combination of things. Some people think that just having a semi-impermeable cover on pillows and bedding might be enough to control dust mites. In reality, it is also important to wash the bedding in water over 120 degrees at least once a week. So it’s a combination of things you do in your home to reduce triggers that really makes the difference.
8. Control your weight, stress, sleep habits, and other health issues to help keep asthma under control.
The NAEPP document also includes more discussion on the roles that obesity, sleep apnea, and stress play in asthma management. It also it covers other things such as rhinitis, sinusitis, and gastroesophageal reflux disease and the importance of treating these conditions since you have asthma.
9. Your education about asthma should span the spectrum.
10. Implementation of the updated guidelines must be enhanced.
The guidelines include strong evidence that health care providers need to educate you about your asthma in all points of care, even outside of the clinical setting. Your asthma educator should help you develop an asthma plan — even if you are not severe-asthma patient. Work with them to be sure your asthma plan fits your specific cultural, ethnic, and health literacy requirements.
Your asthma educators should be making sure you are understanding the information presented, and if not, adjusting the message to your individual situation. It’s all about you and helping you better manage your asthma.
As a patient, you can help in your own cause by asking your physician or asthma educator, “Do you have a copy of the 2007 NAEPP asthma guidelines in your office, and do you use these guidelines?” The document is available on the National Heart, Lung and Blood Institute web site.
When the asthma guidelines came out in 1991 and 1997, they were not always used by all health care providers. More providers know about the guidelines today, and this has had a positive impact on the use of asthma plans and asthma disease management programs.
NAEPP working groups are delivering key take-home messages to their individual disciplines, including physicians, respiratory therapists, nurses, support staff, hospital administrators, policymakers, purchasers, payors, and educators. They are working to ensure that everyone in the health care system who encounters asthma patients understands the importance of using the guidelines to help patients at every turn.