• Measures of asthma assessment and monitoring.
• Education for a partnership in asthma care.
• Medications.
• Managing asthma long term in children 0-4 years of age and 5-11 years of age.
• Managing asthma long term in youths >12 years of age and adults.
• Managing asthma long term—special situations
• Managing exacerbations of asthma.

Key Points: Control of Environmental Factors and Comorbid Conditions That Affect Asthma

• Exposure of patients who have asthma to allergens (Evidence A) or irritants (EPR—2 1997) to which they are sensitive has been shown to increase asthma symptoms and precipitate asthma exacerbations.
• For at least those patients who have persistent asthma, the clinician should evaluate the potential role of allergens, particularly indoor inhalant allergens (Evidence A):
  • Use the patient's medical history to identify allergen exposures that may worsen the patient's asthma.
  • Use skin testing or in vitro testing to reliably determine sensitivity to perennial indoor inhalant allergens to which the patient is exposed.
  • Assess the significance of positive tests in the context of the patient's medical history.
  • Use the patient's history to assess sensitivity to seasonal allergens.
• Patients who have asthma at any level of severity should:
  • Reduce, if possible, exposure to allergens to which the patient is sensitized and exposed.
  • Know that effective allergen avoidance requires a multifaceted, comprehensive approach; individual steps alone are generally ineffective (Evidence A).
  • Avoid exposure to environmental tobacco smoke and other respiratory irritants, including smoke from wood-burning stoves and fireplaces and, if possible, substances with strong odors (Evidence C).
  • Avoid exertion outdoors when levels of air pollution are high (Evidence C).
  • Avoid use of nonselective beta-blockers (Evidence C).
  • Avoid sulfite-containing and other foods to which they are sensitive (Evidence C).
  • Consider allergen immunotherapy when there is clear evidence of a relationship between symptoms and exposure to an allergen to which the patient is sensitive (Evidence B). If use of allergen immunotherapy is elected, it should be administered only in a physician's office where facilities and trained personnel are available to treat any life-threatening reaction that can, but rarely does, occur.
• Adult patients who have severe persistent asthma, nasal polyps, or a history of sensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) should be counseled regarding the risk of severe and even fatal exacerbations from using these drugs (Evidence C).
• Clinicians should evaluate a patient for the presence of a chronic comorbid condition when the patient's asthma cannot be well controlled. Treating the conditions may improve asthma management: allergic bronchopulmonary aspergillosis (ABPA) (Evidence A), gastroesophageal reflux (Evidence B), obesity (Evidence B, limited studies), obstructive sleep apnea (OSA) (Evidence D), rhinitis/sinusitis (Evidence B), chronic stress/depression (Evidence D).
• Consider inactivated influenza vaccination for patients who have asthma. It is safe for administration to children more than 6 months of age and adults (Evidence A).The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) recommends vaccination for persons who have asthma, because they are considered to be at risk for complications from influenza. However, the vaccine should not be given with the expectation that it will reduce either the frequency or severity of asthma exacerbations during the influenza season (Evidence B).
• Use of humidifiers and evaporative (swamp) coolers is not generally recommended in homes of patients who have asthma and are sensitive to house-dust mites or mold (Evidence C).
• Employed persons who have asthma should be queried about possible occupational exposures, particularly those who have new-onset disease (EPR—2 1997).
• There is insufficient evidence to recommend any specific environmental strategies to prevent the development of asthma.

Key Differences from the 1997 Expert Panel Report

• Evidence strengthens recommendations that reducing exposure to inhalant indoor allergens can improve asthma control and notes that a multifaceted approach is required; single steps to reduce exposure are generally ineffective.
• Formaldehyde and volatile organic compounds (VOCs) have been implicated as potential risk factors for asthma and wheezing.
• Evidence shows that influenza vaccine, while having other benefits, does not appear to reduce either the frequency or severity of asthma exacerbations during the influenza season.
• The section has been expanded to include discussion of ABPA, obesity, OSA, and stress as chronic comorbid conditions, in addition to rhinitis, sinusitis, and gastroesophageal reflux, that may interfere with asthma management.

Inhalant Allergens

The Expert Panel recommends that patients who have asthma at any level of severity should be queried about exposures to inhalant allergens, particularly indoor inhalant allergens, and their potential effect on the patient's asthma (Evidence A).

Diagnosis—Determine Relevant Inhalant Sensitivity

The Expert Panel recommends that, given the importance of allergens and their control to asthma morbidity and asthma management, patients who have persistent asthma should be evaluated for the role of allergens as possible contributing factors as follows (EPR—2 1997):

• Determine the patient's exposure to allergens, especially indoor inhalant allergens. (See relevant questions in figure 3–17 in the original guideline document.)
• Assess sensitivity to the allergens to which the patient is exposed.
  • Use the patient's medical history, which is usually sufficient, to determine sensitivity to seasonal allergens.
  • Use skin testing or in vitro testing to determine the presence of specific immunoglobulin E (IgE) antibodies to the indoor allergens to which the patient is exposed year round. (See figure 3–18 in the original guideline document for a comparison of skin and in vitro tests.) Allergy testing is the only reliable way to determine sensitivity to perennial indoor allergens (See box 3–6 in the original guideline document for further explanation.).
  • For selected patients who have asthma at any level of severity, detection of specific IgE sensitivity to seasonal or perennial allergens may be indicated as a basis for education about the role of allergens for avoidance and for immunotherapy.
• Assess the clinical significance of positive allergy tests in the context of the patient's medical history (See figure 3–19 in the original guideline document).

Management—Reduce Exposure

The Expert Panel recommends that patients should reduce exposure, as much as possible, to allergens to which the patient is sensitized and exposed:

• The first and most important step in controlling allergen-induced asthma is to advise patients to reduce exposure to relevant indoor and outdoor allergens to which the patient is sensitive (Evidence A)
• Effective allergen avoidance requires a multifaceted, comprehensive approach; individual steps alone are generally ineffective (Evidence A).
• Consider multifaceted allergen-control education interventions provided in the home setting that have been proven effective for reducing exposures to cockroach, dustmite, and rodent allergens for patients sensitive to those allergens (Evidence A). Further research to evaluate the feasibility of widespread implementation of such programs will be helpful (See the NGC summary of the NAEPP guideline Education for a Partnership in Asthma Care).

Animal Allergens

The Expert Panel recommends the following actions to control animal antigens (Evidence D):

• If the patient is sensitive to an animal, the treatment of choice is removal of the exposure from the home.
• If removal of the animal is not acceptable:
  • Keep the pet out of the patient's bedroom.
  • Keep the patient's bedroom door closed.
  • Remove upholstered furniture and carpets from the home, or isolate the pet from these items to the extent possible.
  • Mouse allergen exposure can be reduced by a combination of blocking access, low-toxicity pesticides, traps, and vacuuming and cleaning.

House-Dust Mite Allergen

The Expert Panel recommends the following mite-control measures; effective allergen avoidance requires a multifaceted approach (Evidence A).

• Recommended actions to control mites include:
  • Encase the mattress in an allergen-impermeable cover.
  • Encase the pillow in an allergen-impermeable cover or wash it weekly.
  • Wash the sheets and blankets on the patient's bed weekly in hot water.
  • A temperature of >130 degrees F is necessary for killing house-dust mites. Prolonged exposure to dry heat or freezing can also kill mites but does not remove allergen. If high temperature water is not available, a considerable reduction in live mites and mite allergens can still be achieved with cooler water and using detergent and bleach.
• Actions to consider to control mites include:
  • Reduce indoor humidity to or below 60 percent, ideally between 30 and 50 percent.
  • Remove carpets from the bedroom.
  • Avoid sleeping or lying on upholstered furniture.
  • Remove from the home carpets that are laid on concrete.
  • In children's beds, minimize the number of stuffed toys, and wash them weekly.

Cockroach Allergen

The Expert Panel recommends that cockroach control measures should be instituted if the patient is sensitive to cockroaches and infestation is present in the home (Evidence B).

Indoor Fungi (Molds)

The Expert Panel recommends consideration of measures to control indoor mold (Evidence C).

Outdoor Allergens (Tree, Grass, and Weed Pollen; Seasonal Mold Spores)

The Expert Panel recommends that patients who are sensitive to seasonal outdoor allergens consider staying indoors, if possible, during peak pollen times—particularly midday and afternoon (EPR—2 1997).

Immunotherapy

The Expert Panel recommends that allergen immunotherapy be considered for patients who have persistent asthma if evidence is clear of a relationship between symptoms and exposure to an allergen to which the patient is sensitive (Evidence B).

Assessment of Devices that May Modify Indoor Air

The Expert Panel recommends the following actions to modify indoor air:

• Vacuuming carpets once or twice a week to reduce accumulation of house dust. Patients sensitive to components of house dust should avoid using conventional vacuum cleaners, and these patients should stay out of rooms where a vacuum cleaner is being or has just been used (EPR—2 1997; Murray et al., 1983).
• Air conditioning during warm weather, if possible, for patients who have asthma and are allergic to outdoor allergens (Evidence C).
• Use of a dehumidifier to reduce house-dust mite levels in areas where the humidity of the outside air remains high for most of the year (EPR—2 1997).
• There is insufficient evidence to recommend indoor air cleaning devices. They may reduce some, but not all airborne allergens, but evidence is limited regarding their impact on asthma control.
• There is insufficient evidence to recommend cleaning air ducts of heating/ventilation/air conditioning systems (Evidence D).

The Expert Panel does not generally recommend use of humidifiers and evaporative (swamp) coolers for use in the homes of house-dust mite-sensitive patients who have asthma (Evidence C).

Occupational Exposure

The Expert Panel recommends that clinicians query patients who are employed and have asthma about possible occupational exposures, particularly those who have new-onset disease (EPR—2 1997).

Irritants

The Expert Panel recommends that clinicians query patients who have asthma at any level of severity about exposures to irritants that may cause their asthma to worsen, and advise them accordingly about reducing relevant exposures (EPR—2 1997). (See sample assessment questions in figure 3–17 in the original guideline document.)

Environmental Tobacco Smoke (ETS)

The Expert Panel recommends that clinicians advise persons who have asthma not to smoke or be exposed to environmental tobacco smoke (ETS) (Evidence C). Query patients about their smoking status and specifically consider referring to smoking cessation programs adults who smoke and have young children who have asthma in the household (Evidence B).

Indoor/Outdoor Air Pollution and Irritants

The Expert Panel recommends that clinicians advise patients to avoid, to the extent possible, exertion or exercise outside when levels of air pollution are high (Evidence C).

Gas Stoves and Appliances

The Expert Panel recommends that clinicians advise patients to avoid, if possible, exposure to gas stoves and appliances that are not vented to the outside, fumes from wood-burning appliances or fireplaces, sprays, or strong odors (Evidence C).

Comorbid Conditions

The Expert Panel recommends that clinicians evaluate a patient for presence of a chronic comorbid condition when the patient's asthma cannot be well controlled. Treating the following conditions may improve asthma management: ABPA (Evidence A), gastroesophageal reflux (Evidence B), obesity (Evidence B, limited studies), OSA (Evidence D), rhinitis/sinusitis (Evidence B), chronic stress/depression (Evidence D).

Allergic Bronchopulmonary Aspergillosis (ABPA)

The Expert Panel recommends that ABPA should be suspected in patients who have asthma and have the presence or a history of pulmonary infiltrates. It should also be specifically considered in patients who have evidence of IgE sensitization to Aspergillus (positive prick skin test or in vitro tests) and in corticosteroid-dependent patients who have asthma (Evidence A).

Gastroesophageal Reflux Disease (GERD)

The Expert Panel recommends that medical management of GERD be instituted for patients who have asthma and complain of frequent heartburn or pyrosis, particularly those who have frequent episodes of nocturnal asthma (Evidence B).

Obesity

The Expert Panel recommends that clinicians consider advising asthma patients who are overweight or obese that weight loss, in addition to improving overall health, might also improve their asthma control (Evidence B, limited studies).

Obstructive Sleep Apnea (OSA)

The Expert Panel recommends that clinicians consider evaluating patients who have unstable, not-well-controlled asthma, particularly those who are overweight or obese, to ascertain whether they have symptoms that suggest OSA (Evidence D).

Rhinitis/Sinusitis

The Expert Panel recommends that clinicians evaluate patients who have asthma regarding the presence of rhinitis/sinusitis diagnosis or symptoms (Evidence B). It is important for clinicians to appreciate the connection between upper and lower airway conditions and the part the connection plays in asthma management.

Stress, Depression, and Psychological Factors in Asthma

The Expert Panel recommends that clinicians consider inquiring about the potential role of chronic stress or depression in complicating asthma management for patients whose asthma is not well controlled (Evidence C); additional patient education may be helpful (Evidence D).

Other Factors

Medication Sensitivities

Aspirin

The Expert Panel recommends that clinicians query adult patients who have asthma regarding precipitation of bronchoconstriction by aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) (Evidence C). If patients have experienced a reaction to any of these drugs, they should be informed of the potential for all of these drugs to precipitate severe and even fatal exacerbations. Adult patients who have severe persistent asthma or nasal polyps should be counseled regarding the risk of using these drugs (Evidence C).

Beta-Blockers

The Expert Panel recommends that clinicians advise asthma patients to avoid nonselective beta-blockers, including those in ophthalmological preparations (Evidence B).

Sulfite Sensitivity

The Expert Panel recommends that clinicians advise patients who have asthma symptoms associated with eating processed potatoes, shrimp, or dried fruit or with drinking beer or wine to avoid these products (Evidence C).

Influenza Infection

The Expert Panel recommends that clinicians consider inactivated influenza vaccination for patients who have asthma. It is safe to administer in children over 6 months and adults who have asthma (Evidence A), and the Advisory Committee on Immunization Practices of the CDC recommends the vaccine for persons who have asthma because they may be at increased risk for complications from influenza. However, the vaccine should not be given with the expectation that it will reduce either the frequency or severity of asthma exacerbations during the influenza season (Evidence B).

Female Hormones and Asthma

In the opinion of the Expert Panel, no recommendation can be made at this time regarding female hormones and asthma.

Diet

In the opinion of the Expert Panel, there is insufficient evidence to make specific recommendations with regard to dietary constituents that should be consumed or avoided to affect asthma.

Primary Prevention of Allergic Sensitization and Asthma

In the opinion of the Expert Panel, there is insufficient evidence to recommend any specific strategies to prevent the development of asthma.

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.

References open in a new window

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.

• Guidelines for the diagnosis and management of asthma. Summary report 2007. Bethesda (MD): National Heart, Lung, and Blood Institute; 2007. Available from the National Heart, Lung, and Blood Institute Web site.
• Overall methods used to develop this report. Electronic copies: Available from the National Heart, Lung, and Blood Institute Web site.
• Search strategies. Electronic copies: Available from the National Heart, Lung, and Blood Institute Web site.
• Evidence tables. Electronic copies: Available from the National Heart, Lung, and Blood Institute Web site.
• Lung diseases information. Information for health professionals. 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.

Additional tools, including sample assessment questions, can be found in the original guideline document.

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.

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