National Institutes of Health (NIH) NAEPP 2007 Asthma Guideline UPDATE

1. National Institutes of Health (NIH) NAEPP 2007 Asthma GuidelineUPDATE Susan K. Ross RN, AE-C MDH Asthma Program 651-201-5629 Susan.Ross@health.state.mn.us

2. http://www.nhlbi.nih.gov/guidelines/asthma/index.htm National Institutes of HealthNational Asthma Education Prevention Program(NAEPP) 2007 Guidelines for the Diagnosis and Management of Asthma (EPR-3) National Asthma Education and Prevention Program

3. School Nurses “School nurses are an important component of the health care system for children and play a critical role in identifying solutions to the health problems faced by today’s children and families”. The Journal of School Nursing, June 2007, Vol.23, Num. 3

4. What Is Asthma? “Asthma is a common chronic disorder of the airways that involves a complex interaction of airflow obstruction, bronchial hyperresponsiveness and an underlying inflammation. This interaction can be highly variable among patients and within patients over time”. 2007 NAEPP Guidelines, EPR 3- Section 2, p 12.

5. Airway Inflammation Airway Obstruction (reversible) Hyperresponsiveness (irritability of airways) Characteristics of Asthma

6. Normal & Asthmatic Bronchiole

7. Why Do We Need Asthma Guidelines?

8. Asthma: • Accounts for 12.8 million lost school days annually 1(2003) • 67% of US children with asthma have had at least one attack in the past year 1(2005) • Is the 3rd leading cause of hospitalizations among children under 15 2 • Close to 1 in 11 (8.9%) children have asthma 1 (2005) • 6.5 million children under 18 have asthma 1 1 National Health Interview Survey; Asthma Prevalence, Health Care Use, and Mortality, 2000-01, National Center for Health Statistics, CDC 2 National Hospital Discharge Survey, 2002; American Lung Association Asthma and Children Fact Sheet, August 2006

9. Asthma Prevalence Adapted from Akinbami L. Advance Data 2006

10. This means.. In a class of 30 children, you can expect 2 to 3 students WILL have asthma This number will vary depending on age and geographical location

11. “Children & Asthma In America” Survey - 2004 • The Children and Asthma in America survey focused on children 4 to 18 years of age with asthma, which represents about 5.8 million children in the country based on figures from the 2002 National Health Interview Survey. • A survey of a national probability sample of 801 children 4 to 18 years of age who currently have asthma, conducted from February to May 2004. • The survey found that nearly 1 out of 10 (9.2%) American children 18 years of age and younger currently suffer from asthma. • The Children and Asthma in America survey concludes that a significant number of children with asthma do not have their condition under control, falling far short of national treatment goals. Excerpts taken from www.asthmainamerica.com, “Children & Asthma in America”, 2004 Glaxo-SmithKline

12. 2007 - Guidelines For The Diagnosis & Management Of Asthma Expert Review Panel (EPR-3)

13. Asthma Guidelines: History and Context • Initial guidelines released in 1991 and updated in 1997 • Updated again in 2002 (EPR-2) with a focus on several key questions about medications, monitoring and prevention. • Long-term management of asthma in children • Combination therapy • Antibiotic use • Written asthma action plans (AAP) and peak flow meters (PFM) • Effects of early treatment on the progression of asthma

14. Old and New Asthma Guidelines:What Has NOT Changed • Initial asthma therapy is determined by assessment of asthma severity. • Ideally, before the patient is on a long-term controller. • Stepping therapy up or down is based on how well asthma is controlled or not controlled . • Inhaled corticosteroids (ICS) are the preferred first-line therapy for asthma. • Systemic steroids can still be used to treat asthma exacerbations. • Peak flows and written asthma action plans are recommended for asthma self management . • Especially in moderate and severe persistent asthma, or those with a history of severe exacerbations or poorly controlled asthma.

15. Asthma Therapy Goals “The goal of asthma therapy is to control asthma so patients can live active, full lives while minimizing their risk of asthma exacerbations and other problems” Dr. William Busse, MD., chairman of the NAEPP EPR -3

16. 2007 - Guidelines For The Diagnosis & Management of Asthma (EPR-3) • (Almost) no new medications. • Restructuring into “severity” and “control” . • Domains of “impairment” and “risk”. • Six treatment steps (step-up/step-down). • More careful thought into ongoing management issues. • Summarizes extensively-validated scientific evidence that the guidelines, when followed, lead to a significant reduction in the frequency and severity of asthma symptoms and improve quality of life.

17. New Strategies of the EPR-3Summary EPR-3, Page 36-38

18. Key Points: Definition, Pathophysiology & Pathogenesis • Asthma is a chronic inflammatory disorder of the airways. • The immunohistopathologic features of asthma include inflammatory cell infiltration. • Airway inflammation contributes to airway hyperresponsiveness, airflow limitation, respiratory symptoms, and disease chronicity. • In some patients, persistent changes in airway structure occur, including sub-basement fibrosis, mucus hypersecretion, injury to epithelial cells, smooth muscle hypertrophy, and angiogenesis. (remodeling)

19. Key Points: Continued.. • Gene-by-environment interactions are important to the expression of asthma. • Atopy, the genetic predisposition for the development of an immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma. • Viral respiratory infections are one of the most important causes of asthma exacerbation and may also contribute to the development of asthma. EPR 3, Section 2: Page 11

20. Key Differences from 1997 & 2002 Reports • The critical role of inflammation is validated - there is considerable variability in the pattern of inflammation indicating phenotypic differences that may influence treatment responses. (in other words – genetics) • Gene-by-environmental interactions are affect the development of asthma. Of the environmental factors, allergic reactions are important. Viral respiratory infections are key and have an expanding role in these processes. • The onset of asthma for most patients begins early in life with the pattern of disease persistence determined by early, recognizable risk factors including atopic disease, recurrent wheezing, and a parental history of asthma. • Current asthma treatment with anti-inflammatory therapy does not appear to prevent progression of the underlying disease severity. EPR 3 – section 2, p. 12

21. Causes – We Don’t Know…Yet! • Asthma has dramatically risen worldwide over the past decades, particularly in developed countries, and experts are puzzled over the cause of this increase. • Not all people with allergies have asthma, and not all cases of asthma can be explained by allergic response. • Asthma is most likely caused by a convergence of factors that can include genes (probably several) and various environmental and biologic triggers (e.g., infections, dietary patterns, hormonal changes in women, and allergens).

22. The 4 Components Of Asthma Management - (Section 3) • Component 1: Measures of Asthma Assessment and Monitoring • Component 2: Education for a Partnership in Asthma Care • Component 3: Control of Environmental Factors and Comorbid Conditions That Affect Asthma • Component 4: Medications

23. Component 1 Measures of Asthma Assessment & Monitoring

24. Key Points -Overview: Measures Of Asthma Assessment & Monitoring Assessment and monitoring are closely linked to the concepts of severity, control, and responsiveness to treatment: • Severity - intensity of the disease process. Severity is measured most easily and directly in a patient not receiving long-term-control therapy. • Control - degree to which asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met. • Responsiveness - the ease with which asthma control is achieved by therapy. EPR -3 , Pg. 36, Section 3, Component 1: Measures of Asthma Assessment and Monitoring

25. Key Points – Cont. 2Severity & Control Are Assessed Based On 2 Domains • Impairment (Present): • Frequency and intensity of symptoms • Functional limitations (quality of life) • Risk (Future): • Likelihood of asthma exacerbations or • Progressive loss of lung function (reduced lung growth) • Risk of adverse effects from medication EPR -3, Pg. 38-80, 277-345

26. Key Points - Cont. 3Severity & Control are used as follows for managing asthma: • If the patient is not currently on a long-term controller at the first visit: • Assess asthma severity to determine the appropriate medication & treatment plan. • Once therapy is initiated, the emphasis is changed to the assessment of asthma control. • The level of asthma control will guide decisions either to maintain or adjust therapy.

27. Key Differences: Component 1 - Overview • The key elements of assessment and monitoring include the concepts of severity, control, and responsiveness to treatment: • Classifying severity for initiating therapy. • Assessing control for monitoring and adjusting therapy. • Asthma severity and control are defined under domains of impairment and risk. • The distinction between the domains of impairment and risk for assessing severity and control emphasizes the need to consider separately asthma’s effects on quality of life and functional capacity on an ongoing basis and the risks it presents for adverse events in the future, such as exacerbations and progressive loss of pulmonary function.

28. Assessing Impairment (Present) Domain • Assess by taking a careful, directed history and lung function measurement. • Assess Quality of Life using standardized questionnaires • Asthma Control Test (ACT) • Childhood Asthma Control Test • Asthma Control Questionnaire • Asthma Therapy Assessment Questionnaire (ATAQ) control index. • Some patients, appear to perceive the severity of airflow obstruction poorly.

29. Assessing Risk (Future)Domain • Of adverse events in the future, especially of exacerbations and of progressive, irreversible loss of pulmonary function—is more problematic (airway remodeling). • The test most used for assessing the risk of future adverse events is spirometry.

30. Measures of Assessment & Monitoring Diagnosis

31. Key Points – Diagnosis of Asthma To establish a diagnosis of asthma the clinician should determine that: • Episodic symptoms of airflow obstruction or airway hyperresponsiveness are present. • Airflow obstruction is at least partially reversible. • Alternative diagnoses are excluded. Recommended methods to establish the diagnosis are: • Detailed medical history. • Physical exam focusing on the upper respiratory tract, chest, and skin. • Spirometry to demonstrate obstruction and assess reversibility, including in children 5 years of age or older. • Additional studies to exclude alternate diagnoses.

32. Key Differences – Diagnosis • Discussions added on use of spirometry, especially in children and on criteria for reversibility. • Information added on vocal cord dysfunction and cough variant asthma as alternative diagnosis. • References added about conditions that complicate diagnosis and treatment. EPR -3, Sec.3, Pg. 41

33. Key Indicators:Diagnosis of Asthma • Wheezing – high-pitched whistling sounds when breathing out. • History of (any): • Cough, worse particularly at night • Recurrent wheeze • Recurrent difficulty in breathing • Recurrent chest tightness • Symptoms occur or worsen in the presence of known triggers. • Symptoms occur or worsen at night awakening patient.

34. Characterization & Classification of Asthma SEVERITY

35. Key Points - Initial Assessment: Severity • Once diagnosis is established: • Identify precipitating factors (triggers). • Identify comorbidities that aggravate asthma • Assess patient’s knowledge & skills for self-management. • Classify severity using impairment & risk domains. • Pulmonary function testing (spirometry) to assess severity. EPR -3, Sec. 3, pg. 47

36. Key Differences – Initial Assessment & Severity • Severity class for asthma changed mildintermittent to intermittent. • Severity class is defined in terms of 2 domains – impairment & risk . • New emphasis on using FEV1 /FVC is added to classify severity in children because it may be a more sensitive measure than FEV1. EPR-3 Sec.3, Pg. 48

37. Previous Guidelines Frequency of daytime symptoms Frequency of nighttime symptoms Lung function 2007 Guidelines Impairment Frequency of daytime /nighttime symptoms Quality of life assessments Frequency of SABA use Interference with normal activity Lung function (FEV1/FVC) Risk Exacerbations (frequency and severity) Assessment of Asthma Severity

38. Classification of Asthma Severity: Clinical Features Before Treatment – 2002 “Old” Guidelines Days With Nights With PEF or PEF Symptoms Symptoms FEV1 Variability Step 4Continuous Frequent 60% 30% Severe Persistent Step 3Daily >1night/week 60%-<80% 30% Moderate Persistent Step 2>2/week, <1x/day >2 nights/month 80% 20-30% Mild Persistent Step 12 days/week 2/month 80% 20% Mild Intermittent Footnote: The patient’s step is determined by the most severe feature.

39. NOT Currently Taking Controllers Level of severity is determined by both impairment a & risk. Assess impairment by caregivers recall of previous 2-4 weeks.

40. NOT Currently Taking Controllers

41. NOT Currently Taking Controllers

42. Classifying Severity AFTER Control is Achieved – All Ages (already on controller)

43. Periodic Assessment & Monitoring Asthma Control

44. Key Points – Asthma Control (Goals of Therapy) Reducing impairment • Prevent chronic & troublesome symptoms. • Prevent frequent use (< 2 days /wk) of inhaled SABA for symptoms. • Maintain (near) “normal” pulmonary function. • Maintain normal activity levels (including exercise & other physical activity & attendance at work or school). • Meet patients’ and families’ expectations of and satisfaction with asthma care. EPR- 3, p. 50

45. Key Points – Cont. Reducing Risk • Prevent recurrent exacerbations of asthma and minimize the need for ER visits and hospitalizations. • Prevent progressive loss of lung function - for children, prevent reduced lung growth. • Provide optimal pharmacotherapy with minimal or no adverse effects. • Periodic assessments at 1-6 month intervals. • Patient self-assessment (w/clinician). • Spirometry testing. NAEPP 2007 guidelines, sec. 3, p. 53

46. Key Points Cont. - Written AAP’s & PFM • Provide to all patients a written AAP based on signs and symptoms and/or PEF. • Written AAPs are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations or poorly controlled asthma”. • “Whether PF monitoring, symptoms monitoring (available data show similar benefits for each), or a combo of approaches is used, self- monitoring is important to the effective self-management of asthma” . EPR -3 Sec. 3, P.53

47. Peak Flow Monitoring Long-term daily PF monitoring can be helpful to: Detect early changes in asthma control that require adjustments in treatment: • Evaluate responses to changes in treatment • Provide a quantitative measure of impairment NAEPP 2007 guidelines Sec. 3, P.54

48. Key Differences – Assessing/ Monitoring Control • Periodic assessment of asthma control is emphasized. • A stronger distinction between classifying asthma severity and assessing asthma control. EPR-3 clarifies the issue: • For initiating treatment, asthma severity should be classified, and the initial treatment should correspond to the appropriate severity category. • Once treatment is established, the emphasis is on assessing asthma control to determine if the goals for therapy have been met and if adjustments in therapy (step up or step down) would be appropriate. EPR-3, Sec.3 Pg.54

49. Key Differences Cont. • Assessment of asthma control includes the two domains of impairment and risk. • Peak flow monitoring: • Assessing diurnal variation was deleted. • Patients are most likely to benefit from routine peak flow monitoring. • Evidence suggests equal benefits to either peak flow or symptom-based monitoring; the important issue continues to be having a monitoring plan in place. • Parameters for lung function, specifically FEV1/FVC, were added as measures of asthma control for children.

50. Asthma Control = Asthma Goals • Definition of asthma control is the same as asthma goals(slides #44 & 45) reducing impairment and risk. • Monitoring quality of life, any: • work or school missed because of asthma? • reduction in usual activities? • disturbances in sleep due to asthma? • Change in caregivers activities due to a child's asthma? There are quality of life assessment tools listed (p.62)