National Asthma Education And Prevention Program Guidelines Research Articles

Continuous Noninvasive Measurement of Pulsus Paradoxus Complements Medical Decision Making in Assessment of Acute Asthma Severity

Pulsus paradoxus (PP) is a pathophysiologic parameter that is indicative of asthma severity. The ability of PP to categorize acutely asthmatic patients in accordance with the earlier National Asthma Education and Prevention Program (NAEPP) expert panel report 1 guidelines was determined. An arterial tonometric BP monitor, which was interfaced to an analog-digital converter, executed a periodic amplitude analysis algorithm, which computed PP in real time. The PP measurement was compared to the criterion standard of emergency physicians in determining the hospital admission vs hospital discharge disposition following the NAEPP standardized treatment. Receiver operating characteristics (ROCs) were calculated, and the PP threshold, which maximized sensitivity and specificity, was identified. In a separate laboratory investigation, PP was induced in a healthy volunteer by inspiration through a fixed resistance. Plethysmographic waveform changes, induced by PP, were measured by a second analog-to-digital converter that was connected to a pulse oximeter. A total of 79 patients were enrolled in the study, of whom 63 met a priori inclusion criteria and had uninterrupted data acquisition. The mean PP for patients who were appropriately discharged from the hospital was 9.1 mm Hg (95% confidence interval [CI], 7.3 to 10.9 mm Hg) and differed from the PP of 17.6 mm Hg (95% CI, 13.5 to 21.8; p < 0.001) for patients admitted to the hospital/relapsed. The sensitivity and specificity for physician disposition were 0.83 and 0.89, respectively, and for PP values were 0.78 and 0.78, respectively. The Wilcoxon area under the ROC curve was 0.82 (95% CI, 0.64 to 0.99) following treatment. The risk ratio was 5.32 for hospital admission among patients with a PP of > 11.3 mm Hg. Changes in the photoplethysmography peak height were correlated to PP from the BP monitor by a regression line with a slope of 0.01 V/mm Hg. Continuous PP can aid in determining disposition among emergency department (ED) patients with acute asthma. ED physicians equipped with a PP monitor would be able to objectify the work of breathing and would more closely adhere to NAEPP guidelines. The possibility that a PP detection algorithm could reside in a pulse oximeter warrants further investigation.

Use of asthma guidelines by primary care providers to reduce hospitalizations and emergency department visits in poor, minority, urban children

To determine whether an organized, citywide asthma management program delivered by primary care providers (PCPs) increases adherence to the National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines and whether adherence to the guidelines by PCPs decreases medical services utilization in low-income, minority children. Analysis of the utilization of medical services for a cohort of 3748 children with asthma who presented for care at one of six primary care urban clinics in Hartford, Connecticut, and who were enrolled in a disease management program (Easy Breathing) between June 1, 1998 and August 31, 2002. Of the 3748 children with physician-confirmed asthma, 48% had persistent disease. Paid claims for inhaled corticosteroids increased 25% ( P <.0001) after enrollment in Easy Breathing. Provider adherence to the NAEPP guidelines for anti-inflammatory therapy increased from 38% to 96%. Easy Breathing children with asthma experienced a 35% decrease in overall hospitalization rates ( P <.006), a 27% decrease in asthma emergency department (ED) visits ( P <.01), and a 19% decrease in outpatient visits ( P <.0001). An organized, disease management program increased adherence to the NAEPP guidelines for anti-inflammatory use by PCPs in urban clinics. Adherence to this element of the guidelines by PCPs reduced hospitalizations, ED visits, and outpatient visits for children with asthma.

Asthma Update

Asthma Update

Sub-optimal asthma treatment and symptom control in senior citizens with a diagnosis of asthma

Rationale As the U.S. population ages, asthma in the elderly is an increasing problem. Several studies suggest that asthma is under-diagnosed and under-treated in elderly populations. Our study assesses asthma treatment and symptom control using National Asthma Education and Prevention Program (NAEPP) guidelines in a population of asthmatics 60 years and older. Methods A 75 question asthma specific survey was mailed to participants in the Aging Research Registry of Northwestern University's Buehler Center on Aging. Results Surveys were mailed to 171 registry members ages 60 and older who identified themselves as having asthma or allergies. One hundred and twelve (65%) responded to the survey, of which 35 (31%) reported a diagnosis of asthma. Only participants with a diagnosis of asthma were included in the study. The mean age of the respondents was 76 years of age. Eighty-three percent of the respondents were women, 17% were men, 89% were white, and 11% were black. Using NAEPP guidelines, 15 (43%) of the respondents had poorly controlled asthma based on nocturnal symptoms or frequent albuterol use. Of those with poor symptom control, 6 (40%) were not on an inhaled corticosteroid and 8 (53%) were not on a long acting beta agonist. Conclusions Our results suggest that 40% of senior citizens with asthma have poor symptom control. In addition, nearly half of seniors with poor symptom control do not appear to meet NAEEP treatment guidelines. These data are consistent with findings in children and younger adults who frequently have less than recommended treatment.

Pediatric Asthma Care, Polypharmacy

Pediatric Asthma Care, Polypharmacy

Documenting Asthma Severity: Do We Get It Right?

Background. The 1997 National Asthma Education and Prevention Program (NAEPP) recommends a severity classification scheme to optimize the use of anti-inflammatory therapy for persistent asthma. Physician documentation of asthma severity is often used as a quality assurance measure. Objective. To test the hypothesis that physician documentation of asthma severity is associated with appropriate use of anti-inflammatory therapy. Design/Methods. Setting: inner-city academic health center. First, we reviewed a consecutive sample of charts of scheduled pediatric patients. Then, we administered a structured parent survey regarding the child's asthma symptoms and current asthma therapy. We used NAEPP guidelines to classify patients' severity of asthma. The main outcome measure was appropriate use of anti-inflammatory therapy. Appropriate therapy was defined as: (1) mild persistent asthmatics using anti-inflammatory therapy, and (2) moderate-severe persistent asthmatics using inhaled steroids. Chart classification of asthma severity was compared with the NAEPP-applied classification. Results. Of 784 charts, 214 (27%) were asthmatic. Of these, 176 (82%) were surveyed. The mean age was 7.4 years; 61% were males. Severity classification was documented in 77% of charts. Chart documentation differed significantly from survey classification for the same patients: (mild intermittent 54% vs. 40%, mild persistent 21% vs. 14%, moderate persistent 24% vs. 36%, severe persistent 1% vs. 10%; all p<.001). Correctly classified patients were more likely to be on appropriate therapy. Conclusions. Physicians underestimated the severity classification of asthmatic patients. Incorrect classification was associated with inappropriate asthma therapy. These findings have implications for the institution of asthma quality improvement programs.

Asthma Symptoms, Morbidity, and Antiinflammatory Use in Inner-City Children

Asthma is a major cause of morbidity that disproportionately affects inner-city children. For children with persistent asthma, defined as having asthma symptoms 3 or more days per week or 3 or more nights per month, national guidelines recommend the use of daily antiinflammatory agents. Despite these recommendations, antiinflammatory agents remain underused, particularly in inner-city children with high asthma morbidity. The objectives of our study were to determine: 1) whether persistent asthma symptoms in inner-city children are related to acute care utilization and to the frequency of acute exacerbations; 2) whether children with persistent asthma are receiving recommended daily antiinflammatory agents; and 3) whether antiinflammatory medication use relates to sociodemographic factors, caretaker self-efficacy, the frequency of primary care visits, and/or measures of quality asthma care. A 64-item telephone survey was administered between July 1996 and June 1997 to 219 parental caretakers of 2- to 12-year-old children who had been hospitalized with asthma at an inner-city medical center between January 1995 and February 1996. Persistent asthma symptoms were assessed by inquiring about the frequency of daily and nocturnal asthma symptoms over the last 4 weeks. Children's asthma severity was classified by applying the 1997 National Asthma Education and Prevention Program (NAEPP) Asthma Guidelines' severity classification scheme based on the frequency of asthma symptoms. Asthma morbidity was defined as the frequency of acute asthma exacerbations, emergency department visits and hospitalizations. Daily antiinflammatory medication use was compared by sociodemographic factors, caretaker self-efficacy, frequency of primary care visits, and measures of quality asthma home management. In this sample, quantifying persistent asthma symptoms and applying the NAEPP symptom criteria identified 17% of the children with mild intermittent asthma, 27% with mild persistent asthma and 56% with moderate to severe persistent asthma. There were no differences in the age of the children in the 3 groups (mean age: 6 years). Asthma morbidity, as measured by the number of asthma exacerbations in the last 6 months, was significantly higher in the children with moderate to severe persistent asthma compared with children with mild intermittent asthma (9.8 vs 3.5) or mild persistent asthma (9.8 vs 4.5). In addition, there were significantly more emergency department visits in the moderate to severe group than in the mild persistent (3.05 vs 1.69) or mild intermittent group (3.05 vs 1.76). Lastly, as asthma symptom frequency increased, there were trends toward more hospitalizations and more days hospitalized. Overall, 35% of the 219 families reported giving daily antiinflammatory medications to their child (mostly cromolyn sodium). Of the 181 children (83%) who met NAEPP symptom criteria for persistent asthma, only 39% were receiving daily antiinflammatory treatment. Of the children with symptoms of moderate to severe asthma, only 15% were receiving inhaled steroids in contrast to the guidelines' recommendations. Use of antiinflammatory agents was not related to caretaker sociodemographic factors or self-efficacy scores. Measures of quality asthma home management, which included use of mattress covers, written plans, and peak flow meters, correlated positively with use of antiinflammatory agents. Children whose families reported using daily antiinflammatory medications had more primary care visits in the last 6 months than those children not receiving antiinflammatory medications. Questioning parents about the frequency of their child's asthma symptoms is an important, inexpensive, and readily accessible bedside and office tool that may aid in the detection of persistent symptoms and help direct therapy. Our study suggests that classifying asthma severity by quantifying persistent asthma symptoms, as defined in the NAEPP Guidelines, is a clinically useful tool that relates to asthma morbidity. In our sample of previously hospitalized children with asthma, 83% met 1997 NAEPP symptom criteria for persistent asthma, and yet only 35% were receiving daily antiinflammatory agents. Use of antiinflammatory agents correlated positively with other indicators of quality asthma home management. Additional work is necessary to increase appropriate use of antiinflammatory agents in this population, and in particular, to increase inhaled steroid use for children with moderate or severe symptoms.

Adherence to asthma treatment guidelines among children in the maryland medicaid program

Background: Asthma is the most common chronic illness in children. However, adherence to asthma treatment guidelines in children is poor. The factors associated with this nonadherence are not well understood. Objectives: The purpose of this study was to assess adherence to national asthma treatment guidelines in pediatric Medicaid enrollees in Maryland. Factors associated with nonadherence and with short-term persistence in nonadherence were studied. Methods: Adherence was assessed by applying 7 criteria to Maryland Medicaid claims data for children with asthma between the ages of 5 and 18 years. These criteria were based on the National Heart, Lung, and Blood Institute's National Asthma Education and Prevention Program (NAEPP). To examine patterns of nonadherence to guidelines, each patient's asthma medication use was compared over 2 consecutive 6-month periods. Results: The most frequently failed treatment criterion was lack of use of anti-inflammatory inhalers in persistent asthma (20.2%). Compared with younger children (5–8 years) older children (9–18 years) were at higher risk of failing several of the criteria, including overuse of beta 2-agonist inhalers, inappropriate use of salmeterol, and lack of use of inhaled anti-inflammatory drugs. Prevalence of nonadherence was significantly different during the 2 periods (31.2% vs 18.9%; P <0.001), with adherence in 1 period having poor agreement with adherence in the second (κ = 0.26). Conclusions: Based on this study of Maryland Medicaid claims data, approximately one third of children with asthma are not being treated in accordance with current treatment guidelines. Older children are at higher risk than younger children for nonadherence to NAEPP guidelines. Adherence to asthma treatment guidelines varies over time, suggesting that patients' regimens should be monitored frequently.

Prevalence of Cocaine Use and Its Impact on Asthma Exacerbation in an Urban Population

To assess the prevalence of cocaine use, and its impact on severity of presentation, among adults presenting to the emergency department (ED) with asthma. A secondary aim was to assess the use of various asthma treatment modalities, with reference to the 1997 National Asthma Education and Prevention Program (NAEPP) guidelines. All adults aged 18 to 55 years who presented to the ED of this institution with an asthma attack, were approached about participating in the study, which required giving informed consent, answering a facilitated questionnaire, and giving a urine sample for drug screening. Patients were enrolled during a 7-month period. A total of 163 patients were approached to enter the study; 116 patients consented to participate in the study, with 103 submitting complete urine samples. Thirty-seven patients refused to participate, and 10 were excluded. Sixty-eight percent of the patients were women, with a mean age of 33 years. African-Americans made up 89% of the total group. Thirty-five percent were cigarette smokers. Urine cocaine tests were positive in 13 of 103 (13%); 6 of 103 (5.8%) were positive for opiates. In the cocaine-positive group, 5 of 13 patients (38%) were admitted to the hospital, including two patients requiring intubation and mechanical ventilation. Of the total group, 23 of 103 patients (22%) were admitted, and 5 of those 23 admitted patients (22%) were cocaine-positive. Length of stay was significantly longer (5 vs 2.5 days, p < 0.05) in the cocaine-positive admitted patients. Forty-six percent of all patients reported using inhaled corticosteroids (ICS), with 39% of admitted patients using them. Thirty-two percent of all patients had obtained three or more refills of their beta(2)-agonist inhaler in the previous month. The prevalence of cocaine use may be much higher than the 13% shown in this study, because of patients' refusal to participate in the study. Second, the severity of exacerbation appears to be worse in the cocaine-positive group. Finally, the majority of patients presenting did not use ICS in accordance with the NAEPP guidelines.

PHARMACOLOGY OF INHALED GLUCOCORTICOIDS

The inhaled glucocorticoids are the most effective drugs currently available for the long-term control of persistent asthma and offer the broadest array of anti-inflammatory activity. 7 The inhaled glucocorticoids were developed to provide the beneficial effects of glucocorticoids without the unwanted adverse effects. To achieve improved local or topical selectivity, physicochemical modifications of the basic steroid structure were made that result in both enhanced topical potency and diminished systemic activity. The structural changes have also produced differences in pharmacokinetics and potency among the various products. 7,14,20,37 As a result, the recently published National Asthma Education and Prevention Program (NAEPP) guidelines for asthma treatment provide a dosage table of approximately comparative clinical dosages for the available inhaled glucocorticoids (Table 1). 44 This table assumes that, aside from potency differences, only minimal differences in topical selectivity exist among products. Since the NAEPP guidelines were published, a number of comparative clinical trials have confirmed the existence of clinically significant differences in potency among the inhaled glucocorticoids. 37,48 There is some suggestion that significant differences in topical selectivity may also exist. This article evaluates how the clinical pharmacologic differences among the inhaled glucocorticoid products might translate into significant differences in their clinical effectiveness. The clinical trials that concurrently evaluate safety and efficacy are reviewed to confirm clinically important differences among products.

Asthma Care Practices, Perceptions, and Beliefs of Chicago-Area Primary-Care Physicians

Although primary-care physicians were a principal target audience for the National Asthma Education and Prevention Program (NAEPP), there is little published information describing the postguideline asthma care practices of these physicians or their willingness to embrace the NAEPP guidelines. This study examines asthma care practices of Chicago-area primary-care physicians and assesses these practitioners' perceptions and beliefs about several aspects of the NAEPP guidelines. In 1997, a self-administered survey was mailed to a randomly selected 10% sample of Chicago-area general pediatricians, internists, and family practitioners. Surveys were returned by 244 of the 405 eligible Chicago-area primary-care physicians (60.2%) in the sample. Of these, 66 (27.6%) were pediatricians, 83 (34.7%) were general internists, and 90 (37.7%) were family practitioners. Physicians reported that 54.6 +/- 2.7% (mean +/- SE) of patients with newly diagnosed asthma have spirometry performed as part of their initial evaluation. For patients with moderate persistent asthma, prescribing of inhaled corticosteroids varied by patient age, with 60.5% of physicians routinely prescribing them for patients < 5 years, compared with 95.7% of physicians prescribing them for patients > or = 5 years. Awareness of the NAEPP guide-lines among these physicians was high, with 88.5% reporting that they have heard of the guidelines, and 73.6% reporting having read them. Of patients with moderate or severe persistent asthma, physicians estimated that 47.7 +/- 2.7% were given written treatment plans. Several aspects of the NAEPP guidelines appear to have been incorporated into clinical practice by Chicago-area primary-care physicians, whereas other recommendations do not appear to have been readily adopted. This information suggests areas for interventions to improve primary care for asthma in the Chicago area.

How the Discrepancy between Symptoms and Peak Expiratory Flow Rate Influences Evaluation of Asthma Severity

Recent asthma guidelines recommend the assessment of severity levels based on the most severe symptoms and peak expiratory flow rate (PEFR). Discrepancies are frequently encountered in the use of these variables in determining the severity levels of asthmatics. The objective of this study was to determine the difference in asthma severity levels as assessed by either symptoms alone or by PEFR alone, as compared with the assessment by the asthma guidelines. Severity levels that were determined by recent asthma guidelines for 60 asthmatic patients were reassessed, based on symptoms alone and PEFR alone. They were compared for any significant differences to the asthma guidelines. Asthmatics were aged between 15 and 70 (mean 34) years, and 63.8% were females. Severity levels by symptoms alone were different from the guidelines in 27 cases (45%). Of these, 89% showed a tendency toward higher severity levels. Severity levels by PEFR alone were different in only three cases (5%). In both comparisons, differences of severity levels were significant (P<0.0001), but assessment by symptoms alone showed more deviation (x(2) =162.1) than PEFR alone (x(2) =73.1). The study documented significant discrepancies in asthma severity assessed by symptoms alone and PEFR alone, when compared to the recent asthma guidelines. Severity assessed by symptoms alone showed lower levels, and the use of PEFR tended to categorize some asthmatics into a more severe level.

Survey of Asthma Practice Among Emergency Physicians

The National Asthma Education and Prevention Program (NAEPP) published guidelines for asthma management in 1991. The purpose of this study is to assess the concordance between emergency physicians' practice and the guidelines. Survey mailed to emergency physicians. Non-respondents were mailed a second copy of the survey. Eight hundred randomly selected active members of the American College of Emergency Physicians. None. Participants were asked questions regarding training, current asthma practices, and sources of information on asthma management. Eight hundred questionnaires were mailed, of which 416 (52%) were returned. Sixty-four percent of respondents administer beta-agonists consistent with the NAEPP guidelines. Seventy-five percent of respondents administer corticosteroids in similar accord, while 75% prescribed outpatient corticosteroids in concordance with those recommendations. Forty-seven percent report measuring pretreatment pulmonary function more than half the time and only 38% report checking pulmonary function prior to disposition more than half the time. Most emergency physicians surveyed use beta-agonists and steroids at least as often as recommended. A minority of emergency physicians reported utilizing pulmonary function testing in the manner recommended by the NAEPP.