• 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]

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.

• Asthma
• Special situations requiring adjustment to asthma management, including exercise-induced bronchospasm, pregnancy, and surgery

Diagnosis
Evaluation
Management
Risk Assessment
Treatment

Allergy and Immunology
Emergency Medicine
Family Practice
Internal Medicine
Obstetrics and Gynecology
Pediatrics
Preventive Medicine
Pulmonary Medicine
Sports Medicine
Surgery

Advanced Practice Nurses
Allied Health Personnel
Health Plans
Nurses
Physician Assistants
Physicians
Respiratory Care Practitioners

• To present recommendations for the diagnosis and management of asthma that will help clinicians and patients make appropriate decisions about asthma care
• To develop clinical practice tools and educational materials for patients and the public
• To revise the National Asthma Education and Prevention Program Expert Panel Report-2 Stepwise Approach for Managing Asthma in order to incorporate findings from the review of the scientific evidence
• To present recommendations for managing asthma long term in special situations, including exercise-induced bronchospasm, pregnancy, and surgery, and asthma in racial and ethnic minorities

Infants, children, adolescents, and adults with asthma

Exercise Induced Bronchospasm

Diagnosis

1. Medical history
2. Exercise challenge testing

Management

1. Long-term control medications
2. Pretreatment before exercise
   • Inhaled short-acting or long-acting beta₂ agonists
   • Leukotriene receptor antagonists
   • Cromolyn sodium and nedocromil
   • Warm up period
   • Use of a mask or scarf over the mouth

Surgery

1. Pre-surgery evaluation, including review of symptoms and medication use
2. Measurement of pulmonary function
3. Short course of oral corticosteroids
4. Intravenous hydrocortisone

Pregnancy

1. Monitoring of asthma status during prenatal visits
2. Use of albuterol as preferred short-acting beta₂ agonists
3. Use of inhaled corticosteroids for long-term control
4. Use of intranasal corticosteroids and  antihistamines for allergic rhinitis

Racial and Ethnic Disparity in Asthma

Heightened awareness of cultural barriers

• Lung function measurements
  • Forced expiratory volume in one second (FEV₁)
  • Peak expiratory flow (PEF)
• Symptom control as indicated by:
  • Symptom scores
  • Symptom frequency
  • Use of acute bronchodilator medication
  • Exacerbations
  • Use of oral corticosteroids

Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases

In October 2004, the Expert Panel assembled for its first meeting. Using the Expert Panel Report (EPR)—2 1997 and EPR—Update 2002 as the framework, the Expert Panel organized the literature searches and subsequent report around the four essential components of asthma care, namely: (1) assessment and monitoring, (2) patient education, (3) control of factors contributing to asthma severity, and (4) pharmacologic treatment. Subtopics were developed for each of these four broad categories.

Inclusion/Exclusion Criteria

The literature review was conducted in three cycles over an 18-month period (September 2004 to March 2006). Search strategies for the literature review initially were designed to cast a wide net but later were refined by using publication type limits and additional terms to produce results that more closely matched the framework of topics and subtopics selected by the Expert Panel. The searches included human studies with abstracts that were published in English in peer-reviewed medical journals in the MEDLINE database. Two timeframes were used for the searches, dependent on topic: January 1, 2001, through March 15, 2006, for pharmacotherapy (medications), peak flow monitoring, and written action plans, because these topics were recently reviewed in the EPR—Update 2002; and January 1, 1997, through March 15, 2006, for all other topics, because these topics were last reviewed in the EPR—2 1997.

Search Strategies

Panel members identified, with input from a librarian, key text words for each of the four components of care. A separate search strategy was developed for each of the four components and various key subtopics when deemed appropriate. The key text words and Medical Subject Headings (MeSH) terms that were used to develop each search string are found in an appendix posted on the National Heart, Lung, and Blood Institute (NHLBI) Web site.

Literature Review Process

The systematic review covered a wide range of topics. Although the overarching framework for the review was based on the four essential components of asthma care, multiple subtopics were associated with each component. To organize a review of such an expanse, the Panel was divided into 10 committees, with about 4 to 7 reviewers in each (all reviewers were assigned to 2 or more committees). Within each committee, teams of two ("topic teams") were assigned as leads to cover specific topics. A system of independent review and vote by each of the two team reviewers was used at each step of the literature review process to identify studies to include in the guidelines update. The initial step in the literature review process was to screen titles from the searches for relevancy in updating content of the guidelines, followed by reviews of abstracts of the relevant titles to identify those studies meriting full-text review based on relevance to the guidelines and study quality.

The combined number of titles screened from cycles 1, 2, and 3 was 15,444. The number of abstracts and articles reviewed for all three cycles was 4,747. Of these, 2,863 were voted to the abstract Keep list following the abstract-review step. A database of these abstracts is posted on the NHLBI Web site. Of these abstracts, 2,122 were advanced for full-text review, which resulted in 1,654 articles serving as a bibliography of references used to update the guidelines, available on the NHLBI Web site. Articles were selected from this bibliography for evidence tables and/or citation in the text. In addition, articles reporting new and particularly relevant findings and published after March 2006 were identified by Panel members during the writing period (March 2006–December 2006) and by comments received from the public review in February 2007.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

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.

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Preparation of Evidence Tables

Evidence tables were prepared for selected topics. It was not feasible to generate evidence tables for every topic in the guidelines. Furthermore, many topics did not have a sufficient body of evidence or a sufficient number of high-quality studies to warrant the preparation of a table. The Panel decided to prepare evidence tables on those topics for which an evidence table would be particularly useful to assess the weight of the evidence—e.g., topics with numerous articles, conflicting evidence, or which addressed questions raised frequently by clinicians. Summary findings on topics without evidence tables, however, also are included in the updated guidelines text. Evidence tables were prepared with the assistance of a methodologist who served as a consultant to the Expert Panel. Within their respective committees, Expert Panel members selected the topics and articles for evidence tables. The evidence tables included all articles that received a "yes" vote from both the primary and secondary reviewer during the systematic literature review process. The methodologist abstracted the articles to the tables, using a template developed by the Expert Panel. The Expert Panel subsequently reviewed and approved the final evidence tables. A total of 20 tables, comprising 316 articles are included in the current update. Evidence tables are posted on the National Heart, Lung, and Blood Institute (NHLBI) Web site.

Ranking the Evidence

The Expert Panel agreed to specify the level of evidence used to justify the recommendations being made. 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. For recommendations that have been either revised or further substantiated on the basis of the evidence review conducted for the EPR—3: Full Report 2007, the level of evidence is indicated in the text in parentheses following first mention of the recommendation. Refer to the "Rating Scheme for the Strength of the Evidence" for the system used to describe the level of evidence.

Expert Consensus

The steps used to develop this report include: (1) completing a comprehensive search of the literature; (2) conducting an in-depth review of relevant abstracts and articles; (3) preparing evidence tables to assess the weight of current evidence with respect to past recommendations and new and unresolved issues; (4) conducting thoughtful discussion and interpretation of findings; (5) ranking strength of evidence underlying the current recommendations that are made; (6) updating text, tables, figures, and references of the existing guidelines with new findings from the evidence review; (7) circulating a draft of the updated guidelines through several layers of external review, as well as posting it on the National Heart, Lung, and Blood Institute (NHLBI) Web site for review and comment by the public and the National Asthma Education and Prevention Program Coordinating Committee (NAEPP CC), and (8) preparing a final-report based on consideration of comments raised in the review cycle.

Panel Discussion

The first opportunity for discussion of findings occurred within the "topic teams." Teams then presented a summary of their findings during a conference call to all members of their respective committee. A full discussion ensued on each topic, and the committee arrived at a consensus position. Teams then presented their findings and the committee position to the full Expert Panel at an in-person meeting, thereby engaging all Panel members in critical analysis of the evidence and interpretation of the data. A series of conference calls for each of the 10 committees as well as four in-person Expert Panel meetings (held in October 2004, April 2005, December 2005, and May 2006) were scheduled to facilitate discussion of findings and to dovetail with the three cycles of literature review that occurred over the 18-month period. Potential conflicts of interest were disclosed at the initial meeting.

Report Preparation

Development of the Expert Panel Report (EPR)—3: Full Report 2007 was an iterative process of interpreting the evidence, drafting summary statements, and reviewing comments from the various external reviews before completing the final report. In the summer and fall of 2005, the various topic teams, through conference calls and subsequent electronic mail, began drafting their assigned sections of the report. Members of the respective committees reviewed and revised team drafts, also by using conference calls and electronic mail. During the calls, votes were taken to ensure agreement with final conclusions and recommendations.

During the December 2005 meeting, Panel members reviewed and discussed all committee drafts. During the May 2006 meeting, the Panel conducted a thorough review and discussion of the report and reached consensus on the recommendations. For controversial topics, votes were taken to ensure that each individual's opinion was considered.

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 randomized controlled trial 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.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

In July, using conference calls and electronic mail, the Panel completed a draft of the Expert Panel Report (EPR)—3: Full Report 2007 for submission in July/August to a panel of expert consultants for their review and comments. In response to their comments, a revised draft of the EPR—3: Full Report 2007 was developed and circulated in November to the National Asthma Education and Prevention Program (NAEPP) Guidelines Implementation Panel (GIP) for their comment. This draft was also posted on the National Heart Lung and Blood Institute (NHLBI) Web site for public comment in February 2007. The Expert Panel considered 721 comments from 140 reviewers. Edits were made to the documents, as appropriate, before the full EPR—3: Full Report 2007 was finalized and published.

None provided

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

• Appropriate long-term management of exercise-induced bronchospasm, asthma during pregnancy, and asthma complications during and after surgery
• Improved awareness of cultural barriers between clinicians and patients that may influence asthma management in racial and ethnic minorities

Adverse effects of medications used to control asthma symptoms

These guidelines are intended to inform, not replace, clinical judgment. Of course, the clinician and patient need to develop individual treatment plans that are tailored to the specific needs and circumstances of the patient.

An implementation strategy was not provided.

Living with Illness
Staying Healthy

Effectiveness
Patient-centeredness

• 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]

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

1997 (revised 2007 Aug)

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

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.

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

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

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.

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.

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.

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.

No copyright restrictions apply.