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New Asthma Guidelines

The guidelines include new sections for asthma management in children ages 0 to 4 and 5 to 11 years.

The NIH has released the third version of the Guidelines for the Diagnosis and Management of Asthma. The 416-page report is well organized and includes important new sections on the management of asthma in children from birth through age 4 and from age 5 through 11 years, boxes delineating the key differences from the 1997 and 2002 reports, and evidence ratings for many recommendations. The amount of material is overwhelming, however, making it difficult to decide what information to highlight. The following list represents topics that I believe are critically important, provide new information, or are controversial.

• The differential diagnosis of asthma in infants and children includes allergic rhinitis and sinusitis, as well as vocal cord dysfunction.
  
• The severity classification "mild intermittent" has been changed to "intermittent," emphasizing that periodic wheeze can be severe.
  
• FEV₁/FVC is a better measure of asthma severity in children than FEV₁ alone.
  
• Clinical pathways may improve management of acute asthma and should be encouraged.
  
• Written action plans are effective and should be based on symptoms or peak flow measurements and emphasize both daily management and recognition and management of worsening symptoms.
  
• Emergency departments should provide patients with a written discharge plan.
  
• Ipratropium bromide provides additional benefit in moderate or severe asthma exacerbations and should be added to short-acting ß-agonist therapy in the emergency department.
  
• Early intervention with inhaled corticosteroids (ICSs) does not modify the severity or progression of asthma.
  
• Because of safety issues associated with long-acting ß-agonists (LABAs; 13 vs. 3 deaths among about 26,000 patients treated for 28 weeks with salmeterol vs. placebo, respectively), LABAs should not be used as monotherapy for long-term control. However, for patients aged 5 years and older on low-dose ICSs, the options of increasing the ICS dose or adding LABAs are given equal weight.
  
• LABAs are preferred to leukotriene modifiers in patients aged 5 years and older whose asthma is not controlled by low-dose ICSs.
  
• In children up to age 4 years, increasing the ICS dose to a medium dose is recommended before adding adjunctive therapy.
  
• Initiation of long-term control therapy in children up to age 4 is recommended if they have had four or more episodes of wheezing during the past year that lasted more than 1 day and affected sleep and they have risk factors for developing persistent asthma (parental history, physician-diagnosed atopic dermatitis, sensitization to aeroallegens or food, 4% peripheral blood eosinophilia, or wheezing apart from colds).
  
• Initiation of long-term control therapy in children aged 5 through 11 years is recommended if they have persistent asthma.
  
• ICS is the preferred long-term treatment in children of all ages. At low and medium doses, ICSs are safe and reduce linear growth by only about 1 cm during the first year of treatment.
  
• Short-acting ß-agonists are recommended for intermittent asthma in children of all ages.
  
• The major difference in treating children aged 0 through 4 and those aged 5 through 11 occurs when low-dose ICS is not sufficient for asthma control. For younger children, medium-dose ICS is recommended as the next step. In older children, either medium-dose ICS or low-dose ICS plus a LABA, leukotriene modifier, or theophylline is recommended.
  

Comment: This report confirms that ICS remains the mainstay of asthma treatment, that therapy must be stepped up and down as symptoms wax and wane, and that additional treatments might be necessary at times to improve symptoms. The report also emphasizes that communicating with patients in writing is important, as is monitoring symptoms using either objective measures or checklists. Because integrating the new recommendations from this lengthy and detailed report into practice will be challenging, I recommend that clinicians read all the synopses of this guideline that likely will appear in various publications. Also, if possible, pediatricians in group practices might consider designating one "asthma expert" for the group.

— Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine October 31, 2007

Citation(s):

National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma; 2007 Aug 28. (http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf)