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Brief Summary

GUIDELINE TITLE

Managing asthma long term-special situations: Expert panel report 3: guidelines for the diagnosis and management of asthma.

BIBLIOGRAPHIC SOURCE(S)

  • Managing asthma long term-special situations. In: National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug. p. 363-72. [55 references]

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: National Asthma Education and Prevention Program Expert Panel Report: guidelines for the diagnosis and management of asthma update on selected topics-2002. J Allergy Clin Immunol 2002 Nov;110(5 pt 2):S141-219.

BRIEF SUMMARY CONTENT

 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Definitions of the levels of the evidence (A, B, C, D) and strength of recommendations ("is recommended" and "should or may, be considered") are presented at the end of the "Major Recommendations" field.

Note from the National Asthma Education and Prevention Program (NAEPP): Panel members only included ranking of evidence for recommendations they made based on the scientific literature in the current evidence review. They did not assign evidence rankings to recommendations pulled through from the Expert Panel Report (EPR)—2 1997 on topics that are still important to the diagnosis and management of asthma but for which there was little new published literature. These "pull through" recommendations are designated by EPR—2 1997 in parentheses following the first mention of the recommendation.

Note from the NAEPP and the National Guideline Clearinghouse (NGC): The Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma have been divided into individual summaries covering assessment, education, medications, and management. In addition to the current summary, the following are available:

Exercise-Induced Bronchospasm (EIB)

The Expert Panel concludes that exercise may be the only precipitant of asthma symptoms for some patients. These patients should be monitored regularly to ensure that they have no symptoms of asthma or reductions in peak expiratory flow (PEF) in the absence of exercise, because EIB is often a marker of inadequate asthma management and responds well to regular anti-inflammatory therapy (EPR—2 1997).

Diagnosis

The Expert Panel recommends that a history of cough, shortness of breath, chest pain or tightness, wheezing, or endurance problems during exercise suggests EIB. An exercise challenge can be used to establish the diagnosis (EPR—2 1997).

Management Strategies

The Expert Panel recommends that an important dimension of adequate asthma control is a patient's ability to participate in any activity he or she chooses without experiencing asthma symptoms. EIB should not limit either participation or success in vigorous activities. Recommended treatments include:

  • Long-term control therapy, if appropriate (Evidence A).
  • Pretreatment before exercise:
    • Inhaled beta2-agonists will prevent EIB in more than 80 percent of patients (Evidence A).
      • Short-acting beta2-agonist(s) inhaled (SABAs) used shortly before exercise (or as close to exercise as possible) may be helpful for 2 to 3 hours.
      • Long-acting beta2-agonist(s) (LABAs) can be protective up to 12 hours (Ferrari et al., 2002; Newnham et al., 1993; Richter et al., 2002; Shapiro et al., 2002). When LABAs are administered on a daily basis, however, there is some shortening of the duration of protection, even in patients using inhaled corticosteroids (ICSs) (Simons, Gerstner, & Cheang, 1997). Frequent and chronic use of LABAs for EIB should be discouraged. Such use may disguise poorly controlled persistent asthma, which should be managed with daily anti-inflammatory therapy.
    • Leukotriene receptor antagonist (LTRAs) can attenuate EIB in up to 50 percent of patients (Evidence B).
    • Cromolyn or nedocromil taken shortly before exercise is an alternative treatment to prevent EIB, but it is not as effective as SABAs (Spooner, Spooner, & Rowe, 2003) (Evidence B). The addition of cromolyn to a SABA is helpful in some individuals who have EIB (Spooner, Spooner, & Rowe, 2003). These studies (Spooner, Spooner, & Rowe, 2003) indicate that anticholinergics may also attenuate EIB, but they are less likely to be protective than either mast cell stabilizers or SABAs.
    • A warmup period before exercise may reduce the degree of EIB (de Bisschop et al. 1999) (Evidence C).
    • A mask or scarf over the mouth may attenuate cold-induced EIB (Beuther & Martin 2006) (Evidence C).

The Expert Panel recommends that teachers and coaches be notified that a child has EIB, that the child should be able to participate in activities, and that the child may need inhaled medication before activity (Evidence D).

Surgery and Asthma

The Expert Panel recommends consideration that patients who have asthma are at risk for specific complications during and after surgery (EPR—2 1997).

The Expert Panel recommends the following actions to reduce risk of complications during surgery (EPR—2 1997):

  • Patients who have asthma should have an evaluation before surgery that includes a review of symptoms, medication use (particularly the use of oral systemic corticosteroids for longer than 2 weeks in the past 6 months), and measurement of pulmonary function.
  • If possible, attempts should be made to improve lung function preoperatively (forced expiratory volume in 1 second [FEV1] or peak expiratory flow rate [PEFR]) to either their predicted values or their personal best level. A short course of oral systemic corticosteroids may be necessary to optimize lung function.
  • For patients who have received oral systemic corticosteroids during the past 6 months and for selected patients on a long-term high dose of an ICS, give 100 mg hydrocortisone every 8 hours intravenously during the surgical period and reduce the dose rapidly within 24 hours after surgery. Stress doses of corticosteroids may be considered for select patients treated with prior high-dose ICS therapy as well, because clinically important adrenal suppression has been reported in such patients, particularly children (Todd et al., "Acute adrenal crisis," 2002, "Survey of adrenal crisis," 2002).

Pregnancy and Asthma

The National Asthma Education and Prevention Program (NAEPP) "Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment—Update 2004" (NAEPP, 2005) emphasizes that maintaining adequate control of asthma during pregnancy is important for the health and well-being of both the mother and her baby.

The following is a summary of the recommendations made in the 2004 update. See that report for evidence reviews.

  • Monitoring of asthma status during prenatal visits is encouraged.
  • Albuterol is the preferred SABA
  • ICSs are the preferred treatment for long-term control medication. Budesonide is the preferred ICS because more data are available on using budesonide in pregnant women than are available on other ICSs, and the data are reassuring.
  • For the treatment of comorbid conditions, intranasal corticosteroids are recommended for treatment of allergic rhinitis because they have a low risk of systemic effect. LTRAs can also be used, but minimal data are available on their use during pregnancy. The current second-generation antihistamines of choice are loratadine or cetirizine.

For more information, see the NAEPP "Working Group Report on Managing Asthma During Pregnancy: Recommendations for Pharmacologic Treatment—Update 2004" (NAEPP, 2005).

Racial and Ethnic Disparity in Asthma

The Expert Panel recommends heightened awareness of cultural barriers between the clinician and patient that may influence asthma management as well as modification of educational/communication strategies to address these barriers (Evidence D) (See the NGC summary of the NAEPP guideline, Education for a Partnership in Asthma Care).

Definitions:

Levels of Evidence

The system* used to describe the level of evidence is as follows:

Evidence Category A: Randomized controlled trials (RCTs), rich body of data.
Evidence is from end points of well-designed RCTs that provide a consistent pattern of findings in the population for which the recommendation is made. Category A requires substantial numbers of studies involving substantial numbers of participants.

Evidence Category B: RCTs, limited body of data.
Evidence is from end points of intervention studies that include only a limited number of patients, post hoc or subgroup analysis of RCTs, or meta-analysis of RCTs. In general, category B pertains when few randomized trials exist; they are small in size, they were undertaken in a population that differs from the target population of the recommendation, or the results are somewhat inconsistent.

Evidence Category C: Nonrandomized trials and observational studies.
Evidence is from outcomes of uncontrolled or nonrandomized trials or from observational studies.

Evidence Category D: Panel consensus judgment.
This category is used only in cases where the provision of some guidance was deemed valuable, but the clinical literature addressing the subject was insufficient to justify placement in one of the other categories. The Panel consensus is based on clinical experience or knowledge that does not meet the criteria for categories A through C.

*Source: Jadad AR, Moher M, Browman GP, Booker L, Sigouin C, Fuentes M, Stevens R. Systematic reviews and meta-analyses on treatment of asthma: critical evaluation. BMJ 2000;320(7234):537-40.

Strength of Recommendations

In addition to specifying the level of evidence supporting a recommendation, the Expert Panel agreed to indicate the strength of the recommendation. When a certain clinical practice "is recommended," this indicates a strong recommendation by the panel. When a certain clinical practice "should, or may, be considered," this indicates that the recommendation is less strong.

This distinction is an effort to address nuances of using evidence ranking systems. For example, a recommendation for which clinical RCT data are not available (e.g., conducting a medical history for symptoms suggestive of asthma) may still be strongly supported by the Panel. Furthermore, the range of evidence that qualifies a definition of "B" or "C" is wide, and the Expert Panel considered this range and the potential implications of a recommendation as they decided how strongly the recommendation should be presented.

CLINICAL ALGORITHM(S)

None provided

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EVIDENCE SUPPORTING THE RECOMMENDATIONS

REFERENCES SUPPORTING THE RECOMMENDATIONS

References open in a new window

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

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IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • Managing asthma long term-special situations. In: National Asthma Education and Prevention Program (NAEPP). Expert panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007 Aug. p. 363-72. [55 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

1997 (revised 2007 Aug)

GUIDELINE DEVELOPER(S)

National Asthma Education and Prevention Program - Federal Government Agency [U.S.]
National Heart, Lung, and Blood Institute (U.S.) - Federal Government Agency [U.S.]

GUIDELINE DEVELOPER COMMENT

The National Asthma Education and Prevention Program Science Base Committee is a multidisciplinary group of clinicians and scientists with expertise in asthma management. The group includes health professionals in the areas of general medicine, family practice, pediatrics, emergency and critical care, allergy, pulmonary medicine, pharmacy, and health education.

SOURCE(S) OF FUNDING

The development of this report was entirely funded by the National Heart, Lung, and Blood Institute, National Institutes of Health.

GUIDELINE COMMITTEE

National Asthma Education and Prevention Program (NAEPP) Coordinating Committee
Third Expert Panel on the Diagnosis and Management of Asthma

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Third Expert Panel on the Diagnosis and Management of Asthma Members: William W. Busse, MD (Chair), University of Wisconsin Medical School, Madison, WI; Homer A. Boushey, MD, University of California at San Francisco, San Francisco, CA; Carlos A. Camargo, MD, DrPH, Massachusetts General Hospital, Boston, MA; David Evans, PhD, AE-C., Columbia University, New York, NY; Michael B. Foggs, MD, Advocate Health Care, Chicago, IL; Susan Janson, DNSc, RN, University of California, San Francisco, California; H. William Kelly, PharmD, University of New Mexico Health Sciences Center, Albuquerque, NM; Robert F. Lemanske, MD, University of Wisconsin Hospital and Clinics, Madison, WI; Fernando D. Martinez, MD, University of Arizona Medical Center, Tucson, AZ; Robert J. Meyer, MD, U.S. Food and Drug Administration, Rockville, MD; Harold S. Nelson, MD, National Jewish Medical and Research Center, Denver, CO; Thomas A.E. Platts-Mills, MD, PhD, University of Virginia School of Medicine, Charlottesville, VA; Michael Schatz, MD, MS, Kaiser-Permanente Medical Center, San Diego, CA; Gail Shapiro, MD (deceased), Northwest Asthma and Allergy Center, Seattle, WA; Stuart Stoloff, MD, University of Nevada School of Medicine, Carson City, NV; Stanley Szefler, MD, National Jewish Medical and Research Center, Denver, CO; Scott T. Weiss, MD, MS, Brigham and Women's Hospital, Boston, MA; Barbara P. Yawn, MD, MSc, Olmstead Medical Center, Rochester, MN

See the original guideline document for members of the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee, a list of consultant reviewers, and members of the National Heart, Lung, and Blood Institute and American Institutes for Research staffs.

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Development of the resource document and the guidelines report was funded by the National Heart, Lung, and Blood Institute (NHLBI), and National Institutes of Health (NIH). Expert Panel members completed financial disclosure forms, and the Expert Panel members disclosed relevant financial interests to each other prior to their discussions. Expert Panel members participated as volunteers and were compensated only for travel expenses related to the Expert Panel meetings. Financial disclosure information covering the 3-year period during which the guidelines were developed is provided for each Panel member below.

Dr. Busse has served on the Speakers' Bureaus of GlaxoSmithKline, Merck, Novartis, and Pfizer; and on the Advisory Boards of Altana, Centocor, Dynavax, Genentech/Novartis, GlaxoSmithKline, Isis, Merck, Pfizer, Schering, and Wyeth. He has received funding/grant support for research projects from Astellas, AstraZeneca, Centocor, Dynavax, GlaxoSmithKline, Novartis, and Wyeth. Dr. Busse also has research support from the NIH.

Dr. Boushey has served as a consultant for Altana, Protein Design Lab, and Sumitomo. He has received honoraria from (Boehringer-Ingelheim, Genentech, Merck, Novartis, and Sanofi-Aventis, and funding/grant support for research projects from the NIH.

Dr. Camargo has served on the Speakers' Bureaus of AstraZeneca, GlaxoSmithKline, Merck, and Schering-Plough; and as a consultant for AstraZeneca, Critical Therapeutics, Dey Laboratories, GlaxoSmithKline, MedImmune, Merck, Norvartis, Praxair, Respironics, Schering-Plough, Sepracor, and TEVA. He has received funding/grant support for research projects from a variety of Government agencies and not-for-profit foundations, as well as AstraZeneca, Dey Laboratories, GlaxoSmithKline, MedImmune, Merck, Novartis, and Respironics.

Dr. Evans has received funding/grant support for research projects from the NHLBI.

Dr. Foggs has served on the Speakers' Bureaus of GlaxoSmithKline, Merck, Pfizer, Sepracor, and UCB Pharma; on the Advisory Boards of Alcon, Altana, AstraZeneca, Critical Therapeutics, Genentech, GlaxoSmithKline, and IVAX; and as consultant for Merck and Sepracor. He has received funding/grant support for research projects from GlaxoSmithKline.

Dr. Janson has served on the Advisory Board of Altana, and as a consultant for Merck. She has received funding/grant support for research projects from the NHLBI.

Dr. Kelly has served on the Speakers' Bureaus of AstraZeneca and GlaxoSmithKline; and on the Advisory Boards of AstraZeneca, MAP Pharmaceuticals, Merck, Novartis, and Sepracor.

Dr. Lemanske has served on the Speakers' Bureaus of GlaxoSmithKline and Merck, and as a consultant for AstraZeneca, Aventis, GlaxoSmithKline, Merck, and Novartis. He has received honoraria from Altana, and funding/grant support for research projects from the NHLBI and NIAID.

Dr. Martinez has served on the Advisory Board of Merck and as a consultant for Genentech, GlaxoSmithKline, and Pfizer. He has received honoraria from Merck.

Dr. Meyer has no relevant financial interests.

Dr. Nelson has served on the Speakers' Bureaus of AstraZeneca, GlaxoSmithKline, Pfizer, and Schering-Plough; and as a consultant for Abbott Laboratories, Air Pharma, Altana Pharma US, Astellas, AstraZeneca, Curalogic, Dey Laboratories, Dynavax Technologies, Genentech/Novartis, GlaxoSmithKline, Inflazyme Pharmaceuticals, MediciNova, Protein Design Laboratories, Sanofi-Aventis, Schering-Plough, and Wyeth Pharmaceuticals. He has received funding/grant support for research projects from Altana, Astellas, AstraZeneca, Behringer, Critical Therapeutics, Dey Laboratories, Epigenesis, Genentech, GlaxoSmithKline, Hoffman LaRoche, IVAX, Medicinova, Novartis, Sanofi-Aventis, Schering-Plough, Sepracor, TEVA, and Wyeth.

Dr. Platts-Mills has served on the Advisory Committee of Indoor Biotechnologies. He has received funding/grant support for a research project from Pharmacia Diagnostics.

Dr. Schatz has served on the Speakers' Bureaus of AstraZeneca, Genentech, GlaxoSmithKline, and Merck; and as a consultant for GlaxoSmithKline on an unbranded asthma initiative. He has received honoraria from AstraZeneca, Genentech, GlaxoSmithKline and Merck. He has received funding/grant support for research projects from GlaxoSmithKline and Merck and Sanofi-Adventis.

Dr. Shapiro (deceased) served on the Speakers' Bureaus of AstraZeneca, Genentech, GlaxoSmithKline, IVAX Laboratories, Key Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Schering Corporation, UCB Pharma, and 3M; and as a consultant for Altana, AstraZeneca, Dey Laboratories, Genentech/Novartis, GlaxoSmithKline, ICOS, IVAX Laboratories, Merck, Sanofi-Aventis, and Sepracor. She received funding/grant support for research projects from Abbott, AstraZeneca, Boehringer Ingelheim, Bristol-Myers-Squibb, Dey Laboratories, Fujisawa Pharmaceuticals, Genentech, GlaxoSmithKline, Immunex, Key, Lederle, Lilly Research, MedPointe Pharmaceuticals, Medtronic Emergency Response Systems, Merck, Novartis, Pfizer, Pharmaxis, Purdue Frederick, Sanofi-Aventis, Schering, Sepracor, 3M Pharmaceuticals, UCB Pharma, and Upjohn Laboratories.

Dr. Stoloff has served on the Speakers' Bureaus of Alcon, Altana, AstraZeneca, Genentech, GlaxoSmithKline, Novartis, Pfizer, Sanofi-Aventis, and Schering; and as a consultant for Alcon, Altana, AstraZeneca, Dey, Genentech, GlaxoSmithKline, Merck, Novartis, Pfizer, Sanofi-Aventis, and Schering.

Dr. Szefler has served on the Advisory Boards of Altana, AstraZeneca, Genentech, GlaxoSmithKline, Merck, Novartis, and Sanofi-Aventis; and as a consultant for Altana, AstraZeneca, Genentech, GlaxoSmithKline, Merck, Novartis, and Sanofi-Aventis. He has received funding/grant support for a research project from Ross.

Dr. Weiss has served on the Advisory Board of Genentech, and as a consultant for Genentech and GlaxoSmithKline. He has received funding/grant support for research projects from GlaxoSmithKline.

Dr. Yawn has served on the Advisory Boards of Altana, AstraZeneca, Merck, Sanofi-Aventis, and Schering-Plough. She has received honoraria from Pfizer and Schering-Plough, and funding/grant support for research projects from the Agency for Healthcare Research and Quality, the CDC, the NHLBI, Merck, and Schering-Plough.

Financial disclosure information covering a 12 month period prior to the review of the guidelines is provided in the original guideline document for each consultant reviewer.

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: National Asthma Education and Prevention Program Expert Panel Report: guidelines for the diagnosis and management of asthma update on selected topics-2002. J Allergy Clin Immunol 2002 Nov;110(5 pt 2):S141-219.

GUIDELINE AVAILABILITY

Electronic copies: Available from the National Heart, Lung, and Blood Institute Web site.

Print copies: Available from NHLBI Information Center, P.O. Box 30105, Bethesda, MD 20824-0105; e-mail: nhlbiic@dgsys.com.

AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

Print copies: Available from NHLBI Information Center, P.O. Box 30105, Bethesda, MD 20824-0105; e-mail: nhlbiic@dgsys.com.

PATIENT RESOURCES

The following is available:

  • Lung diseases information. Information for patients and the public.

Electronic copies: Available from the National Heart, Lung and Blood Institute Web site.

Print copies: Available from NHLBI Information Center, P.O. Box 30105, Bethesda, MD 20824-0105; e-mail: nhlbiic@dgsys.com.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC STATUS

This summary was completed by ECRI on January 5, 1999. The information was verified by the guideline developer on April 30, 1999. This summary was updated by ECRI on January 31, 2003. This information was not verified by the guideline developer. This summary was updated by ECRI on December 5, 2005 following the U.S. Food and Drug Administration (FDA) advisory on long-acting beta2-adrenergic agonists (LABA). This NGC summary was updated by ECRI Institute on January 16, 2008.

COPYRIGHT STATEMENT

No copyright restrictions apply.

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NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.
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