The Evolving Guideline

Abstract

Colice1 has expressed concern that the current asthma management guidelines used in the United States of America, United Kingdom, Australia, and Canada are symptom oriented and do not include measures of airway inflammation as a guide to the management of asthma. Over the past decade increasing attention has been given to clinical practice guidelines to promote more effective diagnosis and treatment of many common problems.2,3,4 The development of a guideline should be based on a critical analysis of the diagnostic and/or therapeutic options available for a particular problem. Ideally, the risks and benefits of the diagnostic and/or therapeutic alternatives should be tested and their efficacy demonstrated. The information required to utilize a guideline should be easily acquired without unusual cost or risk to the patient. Guidelines should be developed for a specific group of users. Those that are appropriate for the clinician may not be suitable for the patient. Guidelines may give general recommendations and should not be interpreted as standards of care. Guidelines should be concise and be based on readily available clinical information. The “Guidelines for the Diagnosis and Management of Asthma,”5 Expert Panel Report 2, prepared by the National Asthma Education and Prevention Program (National Institutes of Health) are based on symptoms and spirometry. The American Thoracic Society has recently published “Guidelines for Assessing and Managing Asthma Risk at Work, School and Recreation”6 making recommendations primarily based on environmental factors. Measurements of inflammation were considered to be the subject of clinical investigation at the time of publication of the “Guidelines for the Diagnosis and Management of Asthma.”5 There is a role for both clinician and patient oriented guidelines in the management of asthma. As studies of airway inflammatory responses progress there is likely to be a place for a measure of airway inflammation in a future guideline. Sputum eosinophil counts may also be useful. Bronchoprovocation testing with methacholine or exercise is only indicated in patients when lung function studies are normal. Bronchoscopic procedures for airway biopsy or bronchoalveolar lavage are unlikely to be incorporated in a guideline in view of the cost and risk to the patient. As developers of guidelines study the clinical utility of their recommendations, new and more precise guidelines will evolve. As asthma is an inflammatory process, incorporation of a measure of inflammation deserves consideration as a component of an asthma management guideline. Additional research is required to determine which measure of airway inflammation is the best one for inclusion in a new version of an asthma management guideline.