Recommendations For Asthma Management Research Articles

Maintenance Therapy for Children and Adolescents with Asthma: Guidelines and Recommendations from the Emilia-Romagna Asthma (ERA) Study Group.

Asthma is the most frequent chronic disease of childhood, affecting up to 20% of children worldwide. The main guidelines on asthma maintenance therapy in pediatrics suggest different approaches and describe different stages of asthma to determine the most appropriate treatment. This project aims to summarize the most recent evidence regarding maintenance therapy for asthma in children and adolescents. A multidisciplinary panel of experts was asked clinical questions regarding the treatment of children and adolescents with asthma. Overall, 10 clinical questions were addressed, and the search strategy included accessing electronic databases and a manual search of gray literature published in the last 25 years. After data extraction and narrative synthesis of results, recommendations were developed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology. Results showed that the choice of medication depends on the severity of the child's asthma, phenotype, age, preference, and individual factors. In addition to medications, the identification of comorbidities and modifiable factors is crucial to obtaining good control. Asthma in children is heterogeneous, and its evolution varies over time. Since most recommendations for asthma management in childhood are extrapolated from clinical studies performed in adults, more clinical trials specifically designed for young children should be conducted.

Short-Acting Beta-2-Agonist Exposure and Severe Asthma Exacerbations: SABINA Findings From Europe and North America

Expert national/global asthma management recommendations raise the issue whether a safe threshold of short-acting beta-2 agonist (SABA) use without concomitant inhaled corticosteroids (ICS) exists. To examine SABA and maintenance therapy associations with severe asthma exacerbations across North America and Europe. Observational analyses of 10 SABa use IN Asthma (SABINA) datasets involving 1,033,564 patients (≥12 y) from Canada, France, the Netherlands, Poland, Spain, the United Kingdom, and the United States. Negative binomial models (incidence rate ratio [IRR] [95% CI adjusted for prespecified-covariates]) evaluated associations between SABA and exacerbations. Across severities, 40.2% of patients were prescribed/possessed 3 or more SABA canisters/y. Per the Global Initiative for Asthma (GINA) 2018 definitions, steps 3 to 5-treated patients prescribed/possessing 3 or more versus 1 or 2 SABAs experienced more severe exacerbations (IRR 1.08 [95% CI 1.04‒1.13], U.S. Medicare; IRR 2.11 [95% CI 1.96‒2.27], Poland). This association was not observed in all step 1 or 2-treated patients (the Netherlands, IRR 1.25 [95% CI 0.91‒1.71]; U.S. commercial, IRR 0.92 [95% CI 0.91‒0.93]; U.S. Medicare, IRR 0.74 [95% CI 0.71‒0.76]). We hypothesize that this inverse association between SABA and severe exacerbations in the U.S. datasets was attributable to the large patient population possessing fewer than 3 SABA and no maintenance therapy and receiving oral corticosteroid bursts without face-to-face health care provider encounters. In U.S. SABA monotherapy-treated patients, 3 or more SABAs were associated with more emergency/outpatient visits and hospitalizations (IRR 1.31 [95% CI 1.29‒1.34]). Most GINA 2 to 5-treated study patients (60.6%) did not have maintenance therapy for up to 50% of the time; however, the association of 3 or more SABAs and severe exacerbations persisted (IRR 1.32 [95% CI 1.18‒1.49]) after excluding these patients and the independent effect was further confirmed when U.K. SABA data were analyzed as a continuous variable in patients with up to 100% annual coverage for ICS-containing medications. Increasing SABA exposure is associated with severe exacerbation risk, independent of maintenance therapy. As addressed by GINA, based on studies across asthma severities where as-needed fast-acting bronchodilators with concomitant ICS decrease severe exacerbations compared with SABA, our findings highlight the importance of avoiding a rescue/reliever paradigm utilizing SABA monotherapy.

Are pregnant women with asthma receiving guideline-recommended antenatal asthma management? A survey of pregnant women receiving usual care in Australia

BackgroundAsthma affects 12.7% of pregnant women in Australia. Key recommendations for asthma management during pregnancy include: 4–6 weekly review of lung function, medications, written asthma action plan, inhaler device technique, current asthma control and triggers; smoking cessation and vaccination advice. It is unknown if these key recommendations are provided to pregnant women with asthma in Australia. AimTo explore usual antenatal asthma management (usual care) in Australia and the inclusion of key recommendations. MethodPregnant women with asthma were invited to complete an online survey distributed in 2 antenatal clinics and via social media platforms from July 2017-Jan 2019. ResultsThe survey was completed by 142 pregnant women with asthma. 87(61%) were enrolled in an asthma management clinical trial and were therefore not receiving ‘usual’ care. Data presented is from 55(39%) women receiving usual care at survey completion. Of these women, 36% did not have their asthma reviewed during their pregnancy, 31% had a written asthma action plan, 11% had lung function assessed, 38% had an asthma medication review and 35% had their inhaler technique reviewed. 65% were not questioned about their asthma symptoms, 85% were not asked about asthma triggers, 96% were not given information about vaccinations and 95% did not receive smoking cessation information. ConclusionsOverall, the key recommendations for antenatal asthma management were not always provided for this sample of pregnant women receiving usual care. Improved knowledge and implementation of these key recommendations by health professionals may alter this situation and improve maternal and infant outcomes.

Antenatal asthma management by midwives in Australia — Self-reported knowledge, confidence and guideline use

BackgroundAsthma affects approximately 12.7% of pregnant women in Australia. Increased maternal and infant morbidity is closely associated with poorly controlled asthma during pregnancy. Midwives are well placed to provide antenatal asthma management but data on current asthma management during pregnancy is not available, nor is the use of guidelines for clinical practice by this health professional group. AimTo explore self-reported antenatal asthma management provided by midwives across Australia and how this reflects guideline recommendations. MethodAn online survey was developed and distributed throughout Australia via the Australian College of Midwives, social media and healthcare facilities. ResultsResponses from 371 midwives were obtained. Ten percent of midwives rated their knowledge as ‘good’ and 1% as ‘very good’, with 39% ‘poor’ or ‘very poor’. Being ‘somewhat’ or ‘not at all’ confident to provide antenatal asthma management was noted by 87% of midwives. Clinical guidelines were referred to by 50% of midwives and 40% stated that their main role was to refer women to other healthcare professionals. Only 54% reported that a clear referral pathway existed. Most respondents (>90%) recognised key recommendations for asthma management such as smoking cessation, appropriate vaccinations, and the continuation of prescribed asthma medications. ConclusionAlthough midwives appear aware of key clinical recommendations for optimal antenatal asthma management, low referral to clinical practice guidelines and lack of knowledge and confidence was evident. Further research is required to determine what care pregnant women with asthma are actually receiving and identify strategies to improve antenatal asthma management by midwives.

Treating Pediatric Asthma According Guidelines.

Asthma is a common chronic inflammatory disorder of the lower respiratory airways in childhood. The management of asthma exacerbations and the disease control are major concerns for clinical practice. The Global Strategy for Asthma Management and Prevention, published by GINA, updated in 2017, the British Thoracic Society/Scottish Intercollegiate Guideline Network, revised in 2016, the National Institute for Health and Care Excellence asthma guideline consultation, available in 2017, are widely accepted documents, frequently implemented, with conflicting advices, and different conclusion on asthma definition and treatment. An International Consensus on Pediatric Asthma was carried out in 2012 by a Committee with expertise in the field, to critically review differences on current guidelines. In addition, the specific issue of treating severe and difficult asthma has been recently highlighted throughout the International European Respiratory Society/American Thoracic Society guidelines on severe asthma. The aim of this paper is to describe conventional treatments and some new therapeutic approaches to pediatric asthma according to guidelines, highlighting key aspects, and differences on proposed clinical recommendations for asthma management. Age specific therapy are proposed in steps, according to clinical severity and the level of disease control. If control is not achieved within 3 months, stepping-up should be considered; otherwise, if control is achieved after 3 months, stepping down may be considered. The most used drug classes of asthma medications are beta-2 adrenergic agonists, corticosteroids, and leukotriene modifiers. Intramuscolar triamcinolone has been used for severe asthma treatment. Chromones and xanthines have been extensively used in the past, but they have shown limits related to their efficacy and safety profile. Omalizumab, a monoclonal antibody against IgE, is an immunomodulatory biological agent, used as new drug in patients with confirmed IgE-mediated allergic asthma, only for patient's specific range of total IgE level. There are low evidences in the efficacy of metotrexate, as well as macrolide antibiotics in children with asthma. Antifungal agents are also not recommended in asthmatic patients. Non-pharmacological measures that may improve patient's quality of life should also be attempted. We conclude that treatment decisions on childhood asthma management should be critically made, pondering the differences suggested by agreed international consensus documents.

Asthma treatment in children: A pragmatic approach

Background. Asthma is a heterogeneous condition characterised by chronic inflammation and variable expiratory airflow limitation, with airway reversibility. Management of chronic inflammation with anti-asthma medication improves asthma control and quality of life. Objectives. To provide an evidence-based approach for chronic asthma management in young children and adolescents and provide guidance on the use of new asthma drugs in children. Methods. The South African Childhood Asthma Working Group (SACAWG) convened in January 2017. The asthma treatment task group reviewed the available scientific literature and international asthma treatment guidelines. The evidence was then graded according to the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system and recommendations were made based on scientific evidence and local context. Asthma management recommendations were made for children ˂6 years of age and older children and adolescents, as well as for stepping up and stepping down of therapy. This review does not include biologics or novel asthma drugs, which are covered in another CME article in this edition of SAMJ . Conclusions. To ensure good response, treatment and adherence, type of medication, device and checking of technique are all critical. Stepping up of therapy should be done only after ensuring good adherence and technique. Once therapeutic response is achieved, medication administration has to be stepped down to improve ease of use and avoid unnecessary side-effects.

The Implementation of Global Asthma Management Guidelines in Two General Respiratory Outpatient Clinics in Greece

BACKGROUND: The implementation of global guidelines for asthma management aims at asthma control. The aim of this study was to investigate the implementation of asthma management guidelines by both patients and physicians in two general pulmonary outpatient clinics in Greece. METHODS: Two questionnaires were administered to pulmonologists (n=43) and patients (n=181) separately. Asthma control was assessed by Asthma Control Test. RESULTS: All physicians informed their patients about asthma and suggested regular visits. The vast majority educated their patients to recognize symptom deterioration (n=42, 97.7%) and asthma triggers (n=41, 95.3%), to readjust treatment (n=41, 95.3%) and use correctly the inhaler devices (n=40, 93%). Greek pulmonologists suggested physical activity (n=40, 93%), peak flow meter use (n=13, 30.2%) and asthma physiotherapy (n=10, 23.3%), while 13 (30.2%) provided a written action plan. Among 181 participants with asthma, 41 (22.7%) had hyperventilation, while 117 (64.6%), mostly young men, had controlled asthma with high FEV1% predicted and without hyperventilation. Only 21 (11.6%) visited the emergency room in the past 6 months, while 98 (54.1%) had regular follow-up. They had developed a partnership with their physician (n=151, 83.4%) and confirmed their response to education on asthma triggers (n=156, 86.2%), symptom deterioration (n=171, 94.5%), inhaler medication technique (n=168, 92.8%) and peak flow meter use (n=40, 22.1%). Moreover, 118 (65.2%) patients recognized medication categories and 34 (18.8%) had a written action plan. They complied with physical activity suggestion (n=141, 77.9%), while 11 (6.1%) have performed breathing exercises. CONCLUSION: The recommendations for asthma management are significantly integrated into clinical practice in Greece, leading to high prevalence of asthma control.

Knowledge, attitude and adherence of Spanish healthcare professionals to asthma management recommendations during pregnancy

BackgroundThe aim of the present study was to evaluate the knowledge, attitude and adherence to asthma management recommendations during pregnancy of Spanish health care professionals. MethodsA multiple choice survey with 14 questions was designed. Items assessed opinion about asthma guidelines and attitudes towards treatment, spirometry, specific immunotherapy and labour in pregnant asthmatic patients. Test completion was voluntary, individual, and anonymous. ResultsA total of 1000 questionnaires were fulfilled: respiratory medicine specialists (19.8%); allergy specialists (17.2%); primary care physicians (46.1%); and gynaecologists/obstetricians (16.9%). Guidelines were considered useful by 96.5% although 64% admitted that they followed them seldom or never. Most physicians (55.9%) answered that they would maintain asthma therapy in clinically stable patients. Almost 30% of physicians would not perform spirometry in pregnant asthma patients. 19% declared they would interrupt specific immunotherapy which had proven safe and effective. Univariate analysis revealed low adherence to be associated with the following variables: age, primary care or gynaecology/obstetrician specialisation, number of asthmatics attended per month, and declared use of guidelines for pregnant asthmatic patients. Multivariate analysis showed that being a primary care physician and a gynaecologist/obstetrician, attending a low number of asthma patients per month, and poor use of spirometry during pregnancy are associated to low adherence to asthma guidelines. ConclusionEven though the majority of Spanish physicians surveyed seem to consider guidelines useful, their adherence to those is very low if translated to managing pregnant asthmatic patients. Educational strategies seem unavoidable and should be targetted mainly to primary care and gynaecology/obstetrician physicians.

Asthma management and control in the United States: Results of the 2009 Asthma Insight and Management survey

Past asthma surveys have shown suboptimal management and control of asthma in the United States. No major survey of asthma management has been conducted since the Third Expert Panel Report for the National Asthma Education and Prevention Program (NAEPP) guidelines on diagnosis and treatment of asthma (August 2007). This study was designed to report asthma management and control results from the Asthma Insight and Management survey of U.S. patients and physicians. A telephone-based survey was conducted during 2009 in 2500 patients with asthma, aged ≥12 years, and 309 physicians (104 allergists, 54 pulmonologists, 101 family practitioners, and 50 internists). Patients' asthma control perceptions (71% "completely controlled" or "well controlled") were inconsistent with their NAEPP control level as determined by self-reported symptoms (29% well controlled). Patients and physicians had low expectations for effective asthma management; patients considered asthma well managed if rescue medication was used three times per week (46%), urgent care visits occurred twice per year (67%), or emergency department visits occurred once per year (60%). Asthma-related syncope, seizure, intensive care unit admission, and intubation were associated with uncontrolled asthma based on NAEPP guidelines. Respiratory specialists (allergists/pulmonologists) implemented asthma management recommendations more than other physicians surveyed. However, only 22% of patients visited a specialist for usual asthma care and 48% had never visited a specialist. Despite detailed NAEPP guidance, asthma management and control in U.S. patients is unsatisfactory. Improved asthma control assessment (impairment and risk) and implementation of NAEPP management recommendations are needed to improve asthma control and outcomes.

Behind the NAEPP Asthma Guidelines

An estimated 22.9 million adults and 6.8 million children in the United States have asthma. Historically, high asthma prevalence and alarming morbidity trends continue to be a major cause of disability, placing a huge burden on children, adults, and their families. Research demonstrates that the use of clinical guidelines for the management of asthma improves patient outcomes. The National Asthma Education and Prevention Program (NAEPP) first developed clinical practice guidelines offering specific advice for the management and treatment of asthma in 1991. Despite the availability of these evidence-based guidelines for 19 years, their recommendations for asthma management are underutilized in practice. This integrative literature review chronicles the development of NAEPP guidelines and their utilization in current practice. Database searches included MEDLINE, PubMed, OVID, and CINAHL.

Asthma management in the developing world: achievements and challenges

Asthma is a serious global health problem that affects people of all ages. The best strategy to reduce the mortality and morbidty of asthma is evidence-based management based on guidelines. National and international guidelines are available worldwide but they are not being implemented. The main barriers to implementation include difficulties in implementing a structured-care approach, advocated by guidelines in different healthcare systems, and patient noncompliance. Additional barriers in developing countries include poverty, inadequate resources and poor infrastructure. Many of these barriers are potentially correctable or ameliorable, and the goal of guideline implementation is to translate evidence-based asthma-management recommendations into real-life practice to improve patient health and reduce healthcare cost. This article reviews the challenges and current status of asthma management and highlights the new global initiatives for bringing optimal asthma care to asthma sufferers in resource-poor countries.

New recommendations for asthma management in pregnancy

New recommendations for asthma management in pregnancy

A Multisite Randomized Trial of the Effects of Physician Education and Organizational Change in Chronic Asthma Care: Cost-effectiveness Analysis of the Pediatric Asthma Care Patient Outcomes Research Team II (PAC-PORT II)

Purpose of the Study. To estimate the cost-effectiveness of 2 different asthma care interventions: a peer leader–based physician behavior-change intervention (PLE) and a practice-based redesign called the planned asthma care intervention (PACI). Study Population. Participants were 638 children (aged 3–17 years) with mild-to-moderate asthma. More than half of the subjects were on maintenance medication. Methods. This was a 3-arm cluster-randomized trial conducted in 42 primary care practices. These practices were randomly assigned to PLE (n = 226), PACI (n = 213), or usual care (n = 199). The PLE strategy involved training a pediatrician at each of the practice sites as an asthma expert and champion. This leader provided support, education, and feedback to the other members of the practice with regard to asthma management. The PACI strategy included all the components of the PLE arm and also included scheduled asthma care visits with an asthma nurse, who provided standardized assessments, care planning, coordination with the primary care physician, and self-management tools. Practices in the usual-care arm received copies of the National Asthma Education and Prevention Program Expert Panel Report 2 and patient-information handouts 12 months into the study. The subjects were followed for 2 years. The primary outcome was symptom-free days (SFDs). Costs included asthma-related health care utilization and intervention. Results. Patients in the usual-care arm of the study had in increase in SFDs of 14.8 per year. Patients in the PLE and PACI arms had an additional gain of 6.5 and 13.3 SFDs per year, respectively, compared with the usual-care arm. When the costs of development were excluded, the cost for SFDs gained compared with usual care was $18 for PLE and $68 for PACI. Conclusions. It is possible to increase SFDs in children and to move organizations toward guideline recommendations for asthma management. However, the improvements were associated with an increase in the costs associated with asthma care. Reviewer Comments. This trial was designed to provide cost analyses to both health care providers and health maintenance organizations. It is difficult, however, to establish a threshold for cost-effectiveness. The authors cite other trials to provide a context for this question. For example, the cost-effectiveness of inhaled corticosteroids in the treatment of children ranges from $7 to $12 per SFD gained. A social worker–based intervention had a cost-effectiveness ratio of $9 per SFD gained. What is it worth to patients, their families, and their health care providers to have an extra SFD?

Management Considerations for Chronic Asthma

Asthma is a common chronic disease affecting millions of individuals in the United States. Appropriate management and prevention of asthma symptoms is essential in order to maintain quality of life and reduce healthcare costs. Published consensus guidelines provide recommendations for asthma management and emphasize pharmacologic and nonpharmacologic components for long-term management. Major components of asthma management include environmental control measures, patient education and self-management, pharmacotherapy and periodic assessment. Since publication of the guidelines in 1997, there has been additional research and advances in our knowledge and understanding of asthma. Ongoing research focuses on issues such as regular versus as needed use of short-acting bronchodilators, early initiation of inhaled corticosteroids, safety of inhaled corticosteroids in children with asthma, combination therapy with inhaled corticosteroids and other long-term control agents, and reduction of inhaled corticosteroid doses. Advances in therapy and new knowledge about appropriate management strategies should be incorporated into clinical management strategies.

Asthma education programme in Russia: educating patients

To address the recent rise in asthma morbidity and mortality in Russia, an intervention study was conducted to improve asthma diagnosis, treatment and prevention. US recommendations for asthma management were adapted for use in educating Moscow families with children with asthma. Two hundred and fifty-two children with asthma aged 4–14 years receiving health care in eight Moscow public health clinics together with their parents were enrolled in the study to see whether US teaching manuals for asthma management would be acceptable and effective in Russia. Children at four of the clinics with recent asthma attacks were randomly assigned to either the education or control group to test if patient education and guided asthma care would improve outcomes for patients. Modern medications were made available to both groups to see if training in the US guidelines was necessary to get physicians to use the medications. Children with recent asthma attacks at the other four clinics were defined as comparison group 1 to control for the possible effect of medication availability. All children at the eight clinics who had no asthma attacks composed comparison group 2 to see if the outcomes for these children would change over time. One-year follow-up results showed significant improvement in asthma self-management skills of children and parents, in terms of asthma treatment, only among those in the education group. Significant increases were observed in the subgroup of children in the education group using anti-inflammatory drugs for asthma control. Children in the education group had markedly increased peak flow rates and reduced daily peak flow variability as compared to control and comparison groups. There was a significantly greater reduction in doctor visits by the education group of children compared to control. Presumably, changes in parents' and children's behaviour in terms of asthma treatment and prevention skills, proper treatment of the disease and access to medications could be responsible for reducing asthma morbidity in children.