The verdit is in: The revision of the 1991 guidelines is lengthy, but user-friendly, as it presents important new information.
In 1991, the National Asthma Education and Prevention Program (NAEPP) guidelines revolutionized asthma care. The expert panel’s recommendations brought research advances within the reach of everyday practitioners and provided a consistent framework for treating asthma patients. The report created a broad consensus about the most effective management techniques.
The 1997 update of the Guidelines for the Diagnosis and Management of Asthma, published by the National Institutes of Health (NIH), rests squarely on the foundation laid down in 1991, says Rochelle Goldberg, MD, FACP, assistant professor of internal medicine and neurology at Allegheny University of the Health Sciences, in Philadelphia. Although most of the basic concepts are the same, some important additions have been made.
"It’s a thick document," Goldberg says of the update, but points out that it is more "user-friendly" than the original. A box at the beginning of each section neatly summarizes the expert panel’s recommendations while another box outlines how the update differs from the original1 (see Table 1, page 46).
The original guidelines
The 1991 guidelines held that effective asthma management should consist of objective measures of lung function, environmental control, pharmacotherapy directed at airway inflammation, and patient education.
The 1991 expert panel:
- recommended patients monitor peak expiratory flow on a daily basis. They also urged clinicians to work with patients to identify specific factors in the environment that may have triggered asthma attacks in the past and to eliminate or reduce factors suspected of producing daily symptoms.
- recommended that pharmacotherapy focus on controlling airway inflammation, particularly through the use of inhaled steroids.
- included stepwise protocols for adjusting pharmacotherapy to changes in the severity of the patient’s condition.
- recommended that clinicians invest time in asthma education with patients and their families so a working partnership could be established.2
According to Allan Luskin, MD, of Dean Medical Center in Sun Prairie, Wis, and a member of the NAEPP guideline coordinating committee, the update implements several important changes in the area of pharmacotherapy.3 In a presentation to the 1997 scientific session of the American College of Allergy, Asthma and Immunology in San Diego, Luskin explained that asthma drugs are now classified in two groups: short-acting and long-acting agents. In the first category are short-acting bronchodilators and oral steroids used in short bursts to provide quick relief and control exacerbations. In the second category are long-acting beta-agonists as well as theophylline, cromolyn, nedocromil, the leukotriene modifiers, and-the mainstay of long-term therapy-inhaled corticosteroids. The new guidelines recommend trying the addition of a long-acting inhaled beta-agonist before increasing inhaled steroids to high levels for the long term.
The new guidelines also recommend the recognition of four levels of asthma severity, rather than three:
- Mild, intermittent asthma, which involves symptoms no more than twice a week with normal spirometry in between.
- Mild, persistent asthma, meaning more frequent symptoms, even if pulmonary function tests are still normal.
- Moderate, persistent asthma involving daily symptoms and abnormal pulmonary function test results.
- Severe asthma, equalling poorly controlled symptoms.
According to Luskin, the new guidelines present two approaches to using this classification. As in the 1991 version, medications can be prescribed for the patient’s current level of severity and then intensified if symptoms worsen. A "big guns" approach can also be used. The new guidelines favor this strategy, which involves using short courses of oral steroids or high-dose inhaled steroids to achieve rapid control, and then tapering off the medications based on symptoms and results of pulmonary function testing.
In its discussion of pathogenesis, the 1997 expert panel emphasizes the role of airway inflammation even more strongly than it did in 1991. In a summary of recent research findings, the panel states: "Evidence indicates that sub-basement membrane fibrosis may occur in some patients and that these changes contribute to persistent abnormalities in lung function. The importance of airway remodeling and the development of persistent airflow limitation need further exploration and may have significant implications for the treatment of asthma."2
The report expands criteria for specialist referral and advocates allergy testing- either skin or in vitro-for all patients with persistent asthma exposed to perennial indoor allergens. The most significant change, Luskin says, involves the patient’s role in management. The recommendations for patient education have been expanded, and the expert panel explicitly states that patients should receive two written action plans-one for making changes within daily management, and the other for what to do during an exacerbation. As part of periodic assessment and monitoring, the guidelines now require the clinician to assess patient and family satisfaction with treatment and determine whether their expectations are being met.
Luskin believes the new focus on patient-supplied observations constitutes "research in a natural setting." With large numbers of patients monitoring themselves in a standardized manner, periodic assessment and monitoring of asthma treatment become "continuous data collection," with "patient-derived information providing the bulk of the data on which reasonable decisions can be made," he says.
According to the guidelines, "Changes in therapy are made on the basis of this data, and the information is monitored continuously over time. When this is done as part of the routine delivery of health care, it can improve individual patients’ health at the same time that data are continuously acquired in order to improve health care delivery by the caregiver and the system for large populations."3
A doctor-patient partnership
Fostering a working partnership between the clinician and the patient may also be the document’s most practical feature. According to Reynold Panettieri, MD, associate professor of medicine and director of the asthma program at the Hospital of the University of Pennsylvania in Philadelphia, the 1991 guidelines were effective in creating consensus, but many physicians had difficulty implementing them. Although the 1991 report provided a thoroughly researched rationale-supported by a comprehensive list of references-for its recommendations, many practitioners felt that the information was difficult to digest or translate into action, particularly for nonspecialists.
"The 1991 guidelines were actually aimed as a teaching tool to educate primary care physicians. But they came at a time when primary [care] doctors were receiving what seemed like a thousand new sets of guidelines every year," Panettieri says. "What was needed was a very practical approach, but the first NAEPP panel did not take that tack."
The 1997 report differs strongly in this respect. According to Stuart Stoloff, MD, clinical associate professor of family and community medicine at the University of Nevada and a private family practitioner in Carson City, the update has been designed to provide more practical information and tools. "These guidelines can be put directly into practice, whether in a clinic setting, a private practice, or any other setting. They are real-world based," says Stoloff, a member of the expert panel that developed the new recommendations. In addition to the chapter summaries, the guidelines include a complete guide to drug therapy, including dosing information based on age, for doctors less familiar with some of the newer pharmacologic agents.
Recently, the panel also published a short practical guide that summarizes the recommendations and includes samples of patient education materials and other handouts that can be photocopied for free.4 The guide includes samples of questionnaires and comment sheets that can be used to follow patients’ quality of life and determine whether patients’ and families’ expectations of treatment have been met, Stoloff says.
Stoloff says many physicians have mixed feelings about the guidelines. According to Charles Homer, MD, MPH, director of the clinical effectiveness program at Children’s Hospital Medical Center in Boston and assistant professor of pediatrics at Harvard Medical School, physicians often face systematic barriers that can make it very difficult for the individual doctor to carry out specific recommendations contained in guidelines. This is particularly true in asthma, where the barriers are largely organizational and social. For example, Homer points out that although the NAEPP guidelines recommend the use of office spirometry for the diagnosis and periodic assessment of asthma, many physicians no longer control the budgets for the purchase of equipment. "As physicians are pressured to meet productivity goals, the time allotted for patient education may vanish. There may be no funds for nurse-educators. Families may be unable to change their home environments-for example, by removing carpets-because of the costs involved or the policies of their landlords."
Because physicians have less control over such factors, Homer believes they may have been resentful about being held to the guidelines. "Some perceive them as convenient sources of up-to-date information; others view them as prescriptive and inflexible," Homer says.
Furthermore, the 1997 NAEPP guidelines have been introduced on the heels of asthma disease management, which Homer defines as "a more global approach that seeks to improve clinical results and reduce costs by integrating the various components of the health care delivery system." According to Homer,5 by 1994, more than half of large managed care organizations had launched, or were preparing to launch, asthma disease management programs. These programs generally adopt NAEPP guidelines and use large information systems to identify patients with asthma, coordinate care, and collect outcomes data. Asthma disease management programs often provide home visits by RCPs for assessment and asthma education, introduce new policies that encourage specialist referrals for more severely ill patients, and assign a nurse to follow patients and coordinate care. Although physicians may feel their patients will benefit from such added services, they may also feel their own role is being subtly downgraded, as Homer says, "from the director to the deliverer of care."
Physicians who feel this way should take a second look at the new guidelines, Stoloff says. He emphasizes that the update spells out the crucial role of the primary care physician in patient education. Although a good part of this process can be assigned to nurse-educators or RCPs, the 1997 guidelines strongly recommend that the primary care physician conduct the initial information session with the patient. "The initial conversation and the discussion of what the patient wants from the therapy are addressed in the guidelines. The primary care physician, be it a pulmonologist, an allergist, a family doctor, or a pediatrician, has to discuss that with the patient," Stoloff says. In other words, the primary care physician must explain the diagnosis to the patient and negotiate the therapeutic contract. "When patients are diagnosed as having asthma, it is the primary care doctor they want to hear say, ‘You really have to look at this information. Here is what you need to do,’ " Stoloff says. As to whether other clinicians should be assigned to provide continuing patient education is the decision of the primary care physician.
"I think the difference between this document and the previous guidelines is that we don’t make assumptions about what a physician has to do; we make recommendations based on evidence, and the recommendations are practical," Stoloff says.
A source of unity
"When we are in our own little world, even in an academic institution, it is difficult to know whether the rest of the world does things the same way we do," Goldberg says. She believes the guidelines are a source of unity for asthma clinicians. She also welcomes the fact that some of the newer anti-inflammatory agents are now included in the guidelines. "A lot has changed since the first set of guidelines came out…particularly with regard to the use of anti-inflammatory medications," Goldberg says. "With new anti-inflammatory agents becoming available-and being heavily advertised-it is good to have guidelines as to how the newer agents fit in," she says.
From a training standpoint, she considers the guidelines a great advantage. "In an academic setting, when you are responsible for fellows and residents, you want to make sure that what you pass on is consistent and accepted by the expert community-not just founded on your own view," Goldberg says.
She sees important implications in the way the new guidelines emphasize patient education and self-monitoring. "One of the questions raised before the last guidelines were published involved this dichotomy: Why, with greater attention to asthma in general by the medical community, and with a larger armamentarium of medications, is asthma mortality going in the wrong direction? And a key theme that ran through the tome-like a list of why that might be [happening]-was inadequate education, particularly inadequate awareness of symptoms and how to recognize and respond to exacerbations," Goldberg says. "By emphasizing patient education and written action plans, I think the new guidelines give clinicians a more effective way to approach patients; the patient is a dynamic component of management in any chronic disorder," Goldberg says.
Goldberg also believes the new asthma guidelines may be a testing ground for new management strategies for other chronic diseases. "People don’t necessarily think of lifestyle and prevention in connection with asthma the way they do with something like heart disease. It doesn’t seem to have much in common with ‘heart healthy’ programs directed at reducing risk factors such as elevated cholesterol, or promoting exercise," she says. "But lifestyle changes and self-management by the patient-those are definitely an important piece of addressing asthma."
India Smith is a contributing writer forRT.
1. National Asthma Education and Prevention Program. Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: NIH no. 97-4051; 1997.
2. National Asthma Education and Prevention Program. Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: National Institutes of Health; 1991.
3. Luskin A. The National Asthma Education and Prevention Program Newly Revised Guidelines for the Diagnosis and Management of Asthma: What Impact on Asthma Treatment? November 1997 scientific session. American College of Allergy, Asthma and Immunology. San Diego, Calif.
4. National Asthma Education and Prevention Program. Practical Guide to the 1997 Expert Panel Report II. Bethesda, MD: National Institutes of Health; 1998.
5. Homer C. Asthma disease management. New Engl J Med. 1998;337:1461-1463.