• Measures of asthma assessment and monitoring.
• Control of environmental factors and comorbid conditions that affect asthma.
• 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: Education for a Partnership in Asthma Care

• Asthma self-management education is essential to provide patients with the skills necessary to control asthma and improve outcomes (Evidence A).
• Asthma self-management education should be integrated into all aspects of asthma care, and it requires repetition and reinforcement. It should:
  • Begin at the time of diagnosis and continue through followup care (Evidence B).
  • Involve all members of the health care team (Evidence B).
  • Introduce the key educational messages by the principal clinician, and negotiate agreements about the goals of treatment, specific medications, and the actions patients will take to reach the agreed-upon goals to control asthma (Evidence B).
  • Reinforce and expand key messages (e.g., the patient's level of asthma control, inhaler techniques, self-monitoring, and use of a written asthma action plan) by all members of the health care team (Evidence B).
  • Occur at all points of care where health professionals interact with patients who have asthma, including clinics, medical offices, emergency departments (EDs) and hospitals, pharmacies, homes, and community sites (e.g., schools, community centers) (Evidence A or B, depending on point of care).
    • Strong evidence supports self-management education in the clinic setting (Evidence A).
    • Observational studies and limited clinical trials support consideration of focused, targeted patient education in the ED setting (e.g., teaching inhaler technique and providing an ED asthma discharge plan with instructions for discharge medications and for increasing medication or seeking medical care if asthma should worsen). Studies demonstrate the benefits of education in the hospital setting (Evidence B).
    • Studies of pharmacy-based education directed toward understanding medications and teaching inhaler and self-monitoring skills show the potential of using community pharmacies as a point of care for self-management education. Studies report difficulties in implementation, but they also demonstrate benefits in improving asthma self-management skills and asthma outcomes (Evidence B).
    • Studies demonstrate the benefits of programs provided in the patient's home for multifaceted allergen control, although further evaluation of cost-effectiveness and feasibility for widespread implementation will be helpful (Evidence A).
    • Some, but not all, school-based programs have demonstrated success in reducing symptoms and urgent health care use and in improving school attendance and performance. Proven school-based programs should be considered for implementation because of their potential to reach large numbers of children who have asthma and provide an "asthma-friendly" learning environment for students who have asthma (Evidence B).
    • Emerging evidence suggests the potential for using computer and Internet programs incorporated into asthma care (Evidence B).
• Provide all patients with a written asthma action plan that includes two aspects: (1) daily management and (2) how to recognize and handle worsening asthma. Written action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B).
• Regular review, by an informed clinician, of the status of the patient's asthma control is an essential part of asthma self-management education (Evidence B). Teach and reinforce at every opportunity (EPR - 2 1997):
  • Basic facts about asthma
  • What defines well-controlled asthma and the patient's current level of control
  • Roles of medications
  • Skills: e.g., inhaler technique, use of a valved holding chamber (VHC) or spacer, and self-monitoring
  • When and how to handle signs and symptoms of worsening asthma
  • When and where to seek care
  • Environmental exposure control measures
• Develop an active partnership with the patient and family by (EPR - 2 1997):
  • Establishing open communications.
  • Identifying and addressing patient and family concerns about asthma and asthma treatment.
  • Identifying patient/parent/child treatment preferences regarding treatment and barriers to its implementation.
  • Developing treatment goals together with patient and family.
  • Encouraging active self-assessment and self-management of asthma.
• Encourage adherence by:
  • Choosing a treatment regimen that achieves outcomes and addresses preferences that are important to the patient/caregiver (Evidence B).
  • Reviewing the success of the treatment plan with the patient/caregiver at each visit and making adjustments as needed (Evidence B).
• Tailor the asthma self-management teaching approach to the needs of each patient. Maintain sensitivity to cultural beliefs and ethnocultural practices (Evidence C).
• Encourage development and evaluation of community-based interventions that provide opportunities to reach a wide population of patients and their families, particularly those patients at high risk of asthma morbidity and mortality (Evidence D).
• Asthma self-management education that is provided by trained health professionals should be considered for policies and reimbursements as an integral part of effective asthma care; the education improves patient outcomes (Evidence A) and can be cost-effective in improving patient outcomes (Evidence B).

Key Points: Provider Education

• Implement multidimensional, interactive clinician education in asthma care including, for example, case discussions involving active participation by the learners (Evidence B).
• Consider participation in programs to enhance skills in communicating with patients (Evidence B).
• Encourage development and use of clinical pathways for management of acute asthma (Evidence B).
• Develop, implement, and evaluate system-based interventions to support clinical decision making and to support quality care for asthma (Evidence B).

Key Differences from 1997 and 2002 Expert Panel Reports

Patient Education

• Emphasis on the many potential points of care and sites available in which to provide asthma education, including review of new evidence regarding the efficacy of asthma self management education outside the usual office setting.
• Greater emphasis on the two aspects of the written asthma action plan—(1) daily management, and (2) how to recognize and handle worsening asthma. Use of the terminology "written asthma action plan" encompasses both aspects. This change addresses confusion over the previous guidelines' use of different terms. One term is now used for the written asthma action plan, although in some studies cited, investigators may have used a variation of this term.
• New sections on the impact of cultural and ethnic factors and health literacy that affect delivery of asthma self-management education.

Provider Education

• New section with review of system-based interventions to improve the quality of asthma care, to support clinical decision making, and to enhance clinical information systems
• Review of tested programs that use effective strategies to provide clinician education in asthma care, e.g., multidimensional approaches, interactive formats, and practice-based case studies

Asthma Self-Management Education at Multiple Points of Care

The Expert Panel recommends that patients be educated at multiple points of care where health professionals and health educators may interact with patients who have asthma (Evidence A or B, depending on point of care).

Clinic/Office Based Education

Adults—Teach Asthma Self-Management Skills To Promote Asthma Control

The Expert Panel recommends that:

• Clinicians provide to patients asthma self-management education that includes the following essential items: asthma information and training in asthma management skills (Evidence A), self-monitoring (either symptom– or peak flow–based) (Evidence A), written asthma action plan (Evidence B), and regular assessment by a consistent clinician (Evidence B).
• Clinicians involve patients in decisions about the type of self-monitoring of asthma control that they will do (Evidence B)
• Clinicians provide all patients with a written asthma action plan that includes instructions for (1) daily management, and (2) recognizing and handling worsening asthma, including self-adjustment of medications in response to acute symptoms or changes in peak expiratory flow (PEF) measures. Written asthma action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B).
• Clinicians involve adult patients in the treatment decisionmaking within the context of a therapeutic partnership (Evidence B).
• Health professionals and others trained in asthma self-management education be used to implement and teach asthma self-management programs (Evidence B).
• Because poor attendance at multiple sessions may be a problem in some populations, consider introducing key messages and essential skills of self management in the first session and adjusting subsequent sessions to the needs of the patients in the groups (Evidence D). Research comparing lengthy versus condensed or shorter sessions is encouraged.

Children—Teach Asthma Self-Management Skills To Promote Asthma Control

The Expert Panel recommends that asthma self-management education be incorporated into routine care for children who have asthma (Evidence A).

Emergency Department/Hospital-Based Education

Adults

The Expert Panel recommends that:

• At the time of discharge from the ED, clinicians offer brief and focused asthma education (Evidence D) and provide patients with an ED asthma discharge plan with instructions to the patients and family for how to use it (Evidence B).
• Before patients are discharged home, assess inhaler techniques for all prescribed medications and reinforce correct technique (Evidence B).
• At the time of discharge from the ED, patients be referred for followup asthma care appointment (either primary care provider [PCP] or asthma specialist) within 1 to 4 weeks(Evidence B). If appropriate, consider referral to an asthma self-management education program (Evidence B).
• Before patients are discharged from a hospitalization for asthma exacerbations, give them asthma self-management education (Evidence B).

Children

The Expert Panel recommends that asthma education programs that have been shown to be effective be delivered to children during or following discharge from the ED or the hospital (Evidence B). More research is needed to understand how to make education maximally effective at this point of care.

The Expert Panel recommends that:

• At the time of discharge from the ED, clinicians offer brief and focused asthma education (Evidence D) and provide patients with an ED asthma discharge plan with instructions to the patients and family for how to use it (Evidence B).
• Before patients are discharged home, assess inhaler techniques for all prescribed medications and reinforce correct technique (Evidence B).
• At the time of discharge from the ED, patients be referred for followup asthma care appointment (either PCP or asthma specialist) within 1 to 4 weeks (Evidence B). If appropriate, consider referral to an asthma self-management education program (Evidence B).
• Before patients are discharged from a hospitalization for asthma exacerbations, give them asthma self-management education (Evidence B).

Educational Interventions by Pharmacists

The Expert Panel recommends that use of interventions provided by pharmacists be considered; such programs are feasible, and they merit further studies of effectiveness (Evidence B).

Educational Interventions in School Settings

The Expert Panel recommends that implementation of school-based asthma education programs proven to be effective be considered to provide to as many children who have asthma as possible the opportunity to learn asthma self-management skills and to help provide an "asthma-friendly" learning environment for students who have asthma (Evidence B).

Community-Based Interventions

Asthma Education

It is the opinion of the Expert Panel that, although studies of community-based asthma education do not demonstrate benefits in health status, they do show that asthma education programs delivered by trained community residents are feasible, can result in behavior change and improved quality of life, and deserve further research (Evidence C).

Home-Based Interventions

Home-Based Asthma Education for Caregivers

The Expert Panel recommends that asthma education delivered in the homes of caregivers of young children be considered and that this area needs more research (Evidence C).

Home-Based Allergen-Control Interventions

The Expert Panel recommends that multifaceted allergen education and control interventions delivered in the home setting and that have been shown to be effective in reducing exposures to cockroach, rodent, and dust-mite allergen and associated asthma morbidity be considered for asthma patients sensitive to those allergens (Evidence A). Further research to evaluate the cost-effectiveness and the feasibility of widespread implementation of those programs will be helpful.

Other Opportunities for Asthma Education

Education for Children Using Computer-Based Technology

The Expert Panel recommends that computer-based programs that are incorporated into asthma care be considered for adolescents and children (Evidence B).

Education on Tobacco Avoidance for Women Who Are Pregnant and Members of Households With Infants and Young Children

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

Case Management for High-Risk Patients

The Expert Panel recommends that case or care management by trained health professionals be considered for patients who have poorly controlled asthma and have recurrent visits to the ED or hospital (Evidence B).

Cost-Effectiveness

The Expert Panel recommends that asthma self-management education that is provided by trained health professionals be considered for policies and reimbursements as an integral part of effective asthma care; the education improves patient outcomes (Evidence A) and can be cost-effective (Evidence B).

Tools for Asthma Self-Management

Role of the Written Asthma Action Plans for Patients who Have Asthma

The Expert Panel recommends that clinicians provide to all patients who have asthma a written asthma action plan that includes instructions for (1) daily management and (2) recognizing and handling worsening asthma, including adjustment of dose of medications. Written action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B). Written asthma action plans may be based on PEF measurements or symptoms or both, depending on the preference of the patient and clinician (Evidence B). A peak-flow-based plan may be particularly useful for patients who have difficulty perceiving signs of worsening asthma (Evidence D).

Role of Peak Flow Monitoring

The Expert Panel recommends that:

• Written asthma action plans can be based on either symptoms or peak flow measurements (Evidence B).
• Long-term daily peak flow monitoring be considered for patients who have moderate or severe persistent asthma (Evidence B), poor perception of airflow obstruction or worsening asthma, unexplained response to environmental or occupational exposures, and others at the discretion of the clinician and the patient (EPR—2 1997).

Establish and Maintain a Partnership

The Expert Panel recommends that a partnership between patient and clinician be established to promote effective asthma management (Evidence A).

The Expert Panel recommends that when nurses, pharmacists, respiratory therapists, and other health care professionals are available to provide and support patient self-management education, a team approach through multiple points of care should be used (National Heart, Lung, and Blood Institute [NHLBI], "Nurses," 1995; NHLBI, "The role of the pharmacist," 1995).

It is the opinion of the Expert Panel that the health professional team members should consider documenting in the patient's record the key educational points (See table below), patient concerns, and actions the patient agrees to take (Evidence C).

Teach Asthma Self-Management

The Expert Panel recommends that:

• Clinicians teach patients and families the basic facts about asthma (especially the role of inflammation), medication skills, and self-monitoring techniques (Evidence A).
• Provide all patients with a written asthma action plan that includes daily management and how to recognize and handle worsening asthma. Written action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B).
• Clinicians teach patients environmental control measures (See NGC summary of the NAEPP guideline Control of Environmental Factors and Comorbid Conditions That Affect Asthma for evidence ranking on different control measures).

Jointly Develop Treatment Goals

The Expert Panel recommends that clinicians determine the patient's personal treatment goals and preferences for treatment; review the general goals of asthma treatment; and agree on the goals of treatments (Evidence B).

• Determine the patient's personal treatment goals and preferences for treatment.
• Share the general goals of asthma treatment with the patient and family.
• Agree on the goals of treatment.
• Provide a written asthma action plan that reflects the agreed upon goals for treatment. See discussion in the original guideline document: "The Role of Written Asthma Action Plans for Patients Who Have Asthma."

Assess and Encourage Adherence to Recommended Therapy

The Expert Panel recommends that clinicians assess and encourage adherence during all asthma visits (Evidence C).

Tailor Education Needs to the Individual Patient

The Expert Panel recommends that:

• Asthma education interventions be tailored as much as possible to an individual's underlying knowledge and beliefs about the disease (Evidence C).
• Health care professionals who develop asthma education programs consider the needs of patients who have limited literacy (Evidence C).
• Clinicians consider assessing cultural or ethnic beliefs or practices that may influence self-management activities, and modify educational approaches as needed (Evidence C).

Maintain the Partnership

The Expert Panel recommends that clinicians demonstrate, review, evaluate, and correct inhaler technique and, if appropriate, the use of a VHC or spacer at each visit, because these skills can deteriorate rapidly (Evidence C).

The Expert Panel recommends that clinicians continue to promote open communication with the patient and family by addressing, as much as possible, the following elements in each followup visit (Evidence B unless otherwise noted) (See also figure 3–13 in the original guideline document):

• Continue asking patients early in each visit what concerns they have about their asthma and what they especially want addressed during the visit.
• Review the short-term goals agreed on in the initial visit.
• Review the written asthma action plan and the steps the patient is to take. Adjust the plan as needed.
• Either encourage parents to take a copy of the child's written asthma action plan to the child's school or childcare setting, or obtain parental permission and send a copy to the school nurse or designee (Evidence C) (See figures 3–16a, b in the original guideline document).
• Continue teaching and reinforcing key educational messages (See table above, "Key Educational Messages: Teach and Reinforce at Every Opportunity").
• Give patients simple, brief, written materials that reinforce the actions recommended and skills taught (Gibson et al., 2000). (See "Asthma Education Resources" in the original guideline document for a list of organizations that distribute patient education materials.)

Provider Education

Methods of Improving Clinician Behaviors

Implementing Guidelines—Recommended Practices

The Expert Panel recommends the use of multifaceted, clinician education programs that reinforce guidelines-based asthma care and are based on interactive learning strategies (Evidence B).

Communication Techniques

The Expert Panel recommends that:

• Clinicians consider participating in programs designed to enhance their skills in communicating with patients (Evidence B).
• Clinicians consider documenting communication and negotiated agreements between patients and clinicians during medical encounters and that the level of asthma control be documented in the medical record of a patient at every visit to facilitate communication with patients during subsequent visits (Evidence C).
• Communication skills-building programs include strategies to increase competence in caring for multicultural populations (Evidence D).

Methods for Improving System Supports

Clinical Pathways

The Expert Panel recommends that clinical pathways be considered for the inpatient setting for patients who are admitted to hospital with asthma exacerbations (Evidence B).

Clinical Decision Supports

The Expert Panel recommends that:

• Prompts encouraging guideline-based care be integrated into system-based interventions focused on improving the overall quality of care rather than used as a single intervention strategy (Evidence B).
• System-based interventions that address multiple dimensions of the organization and delivery of care and clinical decision support be considered to improve and maintain quality of care for patients who have asthma (Evidence B and C).

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 action plans 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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