Quality Rounds
Breathing Easier
Interview by Scott D. Smith
A Rochester physician weighs in on new guidelines for asthma control.
In October, the National Asthma Education and Prevention Program updated its clinical practice guidelines for managing asthma for the first time in a decade. Barbara Yawn, M.D., director of research at the Olmsted Medical Center in Rochester, served on the expert panel that spent more than three years reviewing thousands of articles to create its 400-plus-page report, the executive summary of which is expected to be released in the next few months. Yawn, an expert in asthma care, shared her insights about the changes recommended by the new guidelines.
Why update the guidelines now?
The last full update was in 1997, and a lot of things have changed since then. We now have new medications and lots of new research on asthma, so we needed the guidelines to reflect that.
What is the most important change?
The concept of control is probably the most important change. Before, we always just talked about asthma severity and never really made the point that controlling symptoms is the important part.
What percentage of patients currently have their asthma controlled?
Probably 30 or 40 percent.
What kind of outcomes are possible if the guidelines are followed?
The literature says somewhere between 80 and 90 percent of patients can have their asthma controlled.
Were there changes to the guidelines regarding children with asthma?
Before, there had been very little for the birth to 4-year-old group. But there’s new research identifying very young children with asthma and how we should approach them.
What is the guidance around spirometry?
We are encouraging the use of spirometry for making a diagnosis. It’s always been there, but we’re trying to encourage it more—certainly use it with children older than 7 years of age who are not responding to treatment and with older patients where you need to separate asthma from COPD.
How have the recommendations for short-term management changed?
The short-term guideline more clearly tells you where to start and what to try next. We also emphasize stepping up and stepping down medication doses because it is clear that people have not been stepping down the doses. If the patient is doing well for, say, three months, then you want to step down to the lowest possible dose.
What has changed regarding long-term management?
This is the control concept, which I mentioned earlier. It’s a concept that helps patients understand that the disease is just like diabetes. We can’t cure asthma, but we can prevent symptoms or attacks.
We also stressed adherence a lot more because that is a major reason for asthma not being under control. We want to find out why the patient isn’t taking the medication. Is it because they can’t afford it? They’re afraid of it? You told them to take it four times a day, which no one can do?
How often should patients see their doctor?
There is not a great deal of evidence, but the opinion of the panel is at least one annual visit, preferably two, when patients are not having an attack.
Which asthma patients should have a written action plan?
We are recommending that every patient have a written asthma action plan. The previous recommendation was just for patients prone to attacks. But the research shows that plans patients can take home and refer to improve overall outcomes.
Do the new guidelines address environmental factors?
There are no new environmental triggers to be aware of. However, we’ve put more emphasis on the fact that you really have to deal with environmental factors to get someone’s asthma under control. For example, if someone is smoking in the house, you’re not going to get that person’s asthma under control.
What are the recommendations regarding medications?
There is even more evidence now that inhaled corticosteroids are still the first line of therapy. They are the preferred treatment that everyone should be started on. There are some alternative anti-inflammatory therapies, the major one being the leukotriene modifier Montelukast. It is a pill you might use if the patient is afraid of steroids or doesn’t want to use an inhaler. But it is not preferred.
If someone is not responding well to a low or medium dose of inhaled corticosteroids, then you add long-acting beta2-agonists, especially for patients 12 years and older. The evidence is very strong that this improves outcomes.
We discussed several new medications that may be used for severe asthma attacks, such as heliox, magnesium, and the racemic albuterols. We also discussed anticholinergics such as ipratropium bromide and the fact that they don’t have a place in emergency management of asthma.
Do corticosteroids prevent lung damage known as remodeling?
The idea of remodeling is still very confusing and completely unclear. Some people with asthma do have progressive loss of lung function beyond the normal loss, but we don’t know which patients those are or how to prevent it. We had hoped using corticosteroids early in the disease would prevent it, but that didn’t prove to be true.
Were any practices dropped or de-emphasized?
We dropped the emphasis on peak flow meters. The peak flow meter can be helpful for patients who have highly variable asthma, trouble recognizing early signs of an attack, or severe asthma. But they are not that helpful for most patients who won’t use them anyway. So why push it?
What do the guidelines say about the patient’s role in controlling their asthma?
We are trying to heavily stress self-management. We have to teach patients to recognize when they’re in good control, when their control is starting to slip, and if there is something that is aggravating their asthma, how to identify it and how to avoid it.
We also need to convince patients that it is worth it for them to come for visits and take their medication. They shouldn’t accept poor control. Some patients think if they only miss a day or two of work a month or if they only change their activities once or twice a week, they’re doing fine. Well, that’s not fine. That’s not good control. We’d like patients to have much higher expectations. MM
Scott D. Smith is a staff writer for the Minnesota Medical Association.