International consensus report on diagnosis and management of asthma

Asthma is a chronic, persistent inflammatory disease of the airways characterized by exacerbations of coughing, wheezing, chest tightness, and difficult breathing that are usually reversible, but that can be severe and sometimes fatal. The major factors contributing to asthma morbidity and mortality are underdiagnosis and inappropriate treatments. Most exacerbations reflect a treatment failure because they can be prevented if treatment of the disease is comprehensive and ongoing. The goals of asthma therapy are to improve the patient's quality of live by achieving and maintaining control of syptoms; preventing exacerbations; attaining normal lung function; maintaining normal activity levels, including exercise; and avoiding adverse effects from asthma medications. Recent studies have revealed thet inflammation is a critical feature in the pathogenesis of asthma, and therefore asthma therapy is predicated on medications to reverse and prevent this abnormality. Anti-inflammatory medications such as inhaled corticosteroids, sodium cromoglycate, and nedocromil are the primary therapy for the chronic care of all but mild, intermittent asthma. Further, early introduction or an increase in the dose of corticosteroids is an important component of treating severe exacerbations in order to speed resolutio of the exacerbation and prevent rucurrence. A six-part asthma management program is recommended for effective treatment: 1. Educate patients to develop a partnership in asthma management. Open communication, joint development of a treatment plan by the clinician and patient (guided self-management strategies), and encouragement of th efamily's efforts to improve asthma management will help patients gain the motivation, skill, and confidence to control their asthma. 2. Assess and monitor asthma severity with measures of lung function. Spirometry is recommended for the initial and scheduled periodic assessements of all asthma patients.A period of home peak flow monitoring may be useful for the initial assessement. Spirometry or peak expiratory flow monitoring is essential in hospital-based management of exacerbations. Home peak expiratory flow monitoring should be considered for patients who take medications daily. 3. Avoid or control asthma triggers. Environmental control measures are an important prevention strategy: Appropriate avoidance of triggers may reduce symptoms, the need for medication, and levels of nonspecific airway hyperresponsiveness. The role of specific immunotherapy in asthma management is under continual investigation. Currently available asthma management strategies with patient education, avoidance measures, and pharmacologic treatment usually provide good control of asthma. Immunotherapy may be considered when avoiding allergens is not possible, when appropriate medications fail to control symptoms, and where an effective specific immunotherapy is available. 4. Establish medication plans for chronic management. Because asthma is a dynamic as well as a chronic conditio, medication plans need to accomodate variability among patients as well as within individual patients over time. A stepwise approach to pharmacology therapy, in which the number and frequency of medications are increased with increasing classification of asthma severity, permits this flexibility. Once control of asthma is sustained for several weeks or months, a reduction in therapy - a step down - can be carefully considered and is needed to identify the minimum therapy required to maintain control. The four steps to achieve and maintain control of asthma emphasize that anything more than mild occasional asthma requires daily therapy with anti-inflammatory agents and that patients should not rely on frequent use of bronchodilator agents to control their asthma. Figure 4 in Chapter 2 summarizes the treatment recommended in the stepwise approach. A color-coded asthma zone management system for patients has been developed to help patients understand and monitor the variable nature of this chronic disease. and take appropriate actions to maintain control of asthma. The forst (Green Zone) reflects therapy required to achieve the goals of therapy, i.e., maintaint control of symptoms and prevent exacerbations. The stepwise approach described above is used to identify the minimum amount of medication required to maintain control of the patient's asthma. The second (Yellow Zone) reflects a deterioration in asthma control and indicates a need to temporarily increase treatments as well as a need to review the Green Zone plan. The third (Red ZOne) signals a medical alert, and immediate steps to amnage the exacerbation are required, with subsequent adjustment of the Green Zone plan. Written plans for each zone are essential to improve patient adherence. 5. Establish plans for managing exacerbations. Exacerbations usually reflect either a failure of chronic management or exposure to a noxious agent. Severe exacerbations often reflect inadequate action at the onset of the exacerbation. Therapy for exacerbations emphasizes the early introduction of corticosteroids as well as frequent administration of inhaled beta2-agonists. Patients need a written plan for recognizing signs that asthma is worsening, for when, how, and for how long to increase treatment, and for reaching medical care. 6. Provide regular followup care. Patients need regular supervision and support by a clinician who is knowledgeable about asthma. Continual monitoring is essential to assure that therapeutic goals are met. The following report elaborates upon each of these six parts of effective asthma management. It provides more detailed recommendations and documentation from the scientific literature