Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Summary Report 2007

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Highlights of the National Asthma Education and Prevention Program's Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Full Report 2007 are presented in this EPR-3 summary report. The updated guidelines emphasize the importance of asthma control. Asthma control is the degree to which the manifestations of asthma are minimized by therapeutic intervention and the goals of therapy are met. Because asthma is highly variable, the level of control must be monitored on a periodic basis to determine whether therapy should be maintained or adjusted (stepped up if necessary, stepped down if possible). On the other hand, asthma severity is the intrinsic intensity of the disease process, most easily and directly measured in a patient not receiving long-term control therapy. For managing asthma, the recommendation is to assess severity to initiate therapy and assess control to adjust therapy.

Recommendations for managing asthma include an expanded section on childhood asthma with addition of an age group 5 to 11 years old (earlier guidelines combined this group with adults). The guidelines provide new recommendations on patient education in settings beyond the physician's office, and new advice for controlling environmental factors that can cause asthma symptoms.

The concepts of current impairment (frequency and intensity of symptoms, low lung function, and limitations of daily activities) and future risk (likelihood of exacerbations, progressive loss of lung function, or adverse side effects from medications) support a new approach to assessing and monitoring the patient's level of asthma control through use of multiple measures. 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.

Moreover, 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 communication with patients and to use system-wide approaches to integrate the guidelines into health care practice.

The guidelines describe 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 common conditions that can affect asthma and notes that management of these conditions may help to improve asthma control.

Expert Panel Report 3 continues the use of a stepwise approach to control asthma. When assessing the level of asthma control to determine the need for adjusting therapy, EPR-3 reconfirms the importance of assessing patient adherence to medication, inhaler technique, and environmental control measures before making a step up in therapy.

The stepwise approach expands from 4 steps to 6 steps of care. Medications have been repositioned within these 6 steps. Recommendations on medications are updated to reflect the latest evidence on effectiveness and safety. EPR-3 reaffirms that patients with persistent asthma need both long-term control medications to control asthma and prevent exacerbations and quick-relief medication for symptoms, as needed. EPR-3 also reaffirms that inhaled corticosteroids are the most effective long-term control medication across all age groups. New recommendations on treatment options such as leukotriene receptor antagonists and cromolyn for long-term control; long-acting β-agonists as adjunct therapy with inhaled corticosteroids; omalizumab for severe asthma; and albuterol, levalbuterol, and corticosteroids for acute exacerbations are included.

Introduction

More than 22 million Americans have asthma, and it is one of the most common chronic diseases of childhood, affecting an estimated 6 million children. The burden of asthma affects the patients, their families, and society in terms of lost work and school, lessened quality of life, and avoidable emergency department (ED) visits, hospitalizations, and deaths. Improved scientific understanding of asthma has led to significant improvements in asthma care, and the National Asthma Education and Prevention Program (NAEPP) has been dedicated to translating these research findings into clinical practice through publication and dissemination of clinical practice guidelines. The first NAEPP guidelines were published in 1991, and updates were made in 1997, 2002, and now with the current report. Important gains have been made in reducing morbidity and mortality rates caused by asthma; however, challenges remain. The NAEPP hopes that the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma–Full Report 2007 will support the efforts of those who already incorporate best practices and will help enlist even greater numbers of primary care clinicians, asthma specialists, health care systems and providers, and communities to join together in making quality asthma care available to all people who have asthma. The goal, simply stated, is to help people with asthma control their asthma so that they can be active all day and sleep well at night.

EPR-3 Summary Report 2007 is a summary of the key recommendations in EPR-3 Full Report 2007. EPR-3 Summary Report 2007 does not include selected references for these recommendations. Rather, EPR-3 Full Report 2007 is considered the resource document, and it contains references and full discussion of the rationale for the recommendations. Accompanying EPR-3 Full Report 2007 are Evidence Tables on topics selected by the expert panel. Both EPR-3 Full Report 2007 and Evidence Tables are available at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm. Detailed recommendations, the levels of scientific evidence on which they are based, citations from the published scientific literature, discussion of the Expert Panel's rationale for the recommendations, and description of methods used to develop the report are included in that resource document. Because EPR-3 Full Report 2007 is an update of previous NAEPP guidelines, highlights of major changes in the update are presented here, and Fig 1 presents a summary of recommended key clinical activities.

Section snippets

Definition and pathophysiology

Asthma is a complex disorder characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness, and an underlying inflammation. The interaction of these features determines the clinical manifestations and severity of asthma (Fig 2) and the response to treatment. The working definition of asthma is as follows:

Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role: in particular, mast cells, eosinophils,

Diagnosis of asthma

To establish a diagnosis of asthma, the clinician should determine that:

  • Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present.

    Key symptom indicators for considering a diagnosis of asthma

    The presence of multiple key indicators increases the probability of asthma, but spirometry is needed to establish a diagnosis.
      Wheezing—high-pitched whistling sounds when breathing out—especially in children. A lack of wheezing and a normal chest examination do not exclude asthma.
      

Managing asthma long-term

Goal of therapy: control of asthma

Reduce impairment
  Prevent chronic and troublesome symptoms (eg, coughing or breathlessness in the daytime, in the night, or after exertion).
  Require infrequent use (≤2 days a week) of inhaled SABA for quick relief of symptoms (not including prevention of exercise-induced bronchospasm [EIB]).
  Maintain (near) normal pulmonary function.
  Maintain normal activity levels (including exercise and other physical activity and attendance at school or work).
  Meet patients'

Managing exacerbations

Asthma exacerbations are acute or subacute episodes of progressively worsening shortness of breath, cough, wheezing, and chest tightness, or some combination of these symptoms. Exacerbations are characterized by decreases in expiratory airflow; objective measures of lung function (spirometry or PEF) are more reliable indicators of severity than symptoms are. Individuals whose asthma is well controlled with ICSs have decreased risk of exacerbations. However, these patients can still be

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