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Attaining optimal asthma control: A practice parameter

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These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology; the American College of Allergy, Asthma and Immunology; and the Joint Council of Allergy, Asthma and Immunology.

The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing “Attaining optimal asthma control: A practice parameter.” This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or the ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion.

Section snippets

Contributors

The Joint Task Force has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded inadvertently, the Task Force will ensure that appropriate recognition of such contributions is made subsequently.

Chief Editors

James T. Li MD, PhD

Division of Allergic Diseases and Internal Medicine

Mayo Clinic

Rochester, Minn

John Oppenheimer, MD

Department of Internal Medicine

New Jersey Medical School

Pulmonary and Allergy Associates

Morristown, NJ

I. Leonard Bernstein, MD

Department of Medicine and Environmental Health

University of Cincinnati College of Medicine

Cincinnati, Ohio

Richard A. Nicklas, MD

Clinical Professor of Medicine

George Washington Medical Center

Washington, DC

Joint Task Force Reviewers

David A. Khan, MD

Department of Internal Medicine

University of Texas Southwestern Medical Center

Dallas, Tex

Joann Blessing-Moore, MD

Departments of Medicine and Pediatrics

Stanford University Medical Center

Department of Immunology

Palo Alto, Calif

David M. Lang, MD

Allergy/Immunology Section

Division of Medicine

Director, Allergy and Immunology Fellowship Training Program

Cleveland Clinic Foundation

Cleveland, Ohio

Jay M. Portnoy, MD

Section of Allergy, Asthma & Immunology

The Children's Mercy Hospital

Reviewers

John Cohn, MD, Philadelphia, Pa

A. Gilbert, MD, Dallas, Tex

Andy Nish, MD, Gainesville, Ga

Bruce Prenner, MD, San Diego, Calif

David Stempel, MD, Bellevue, Wash

Steven Weinstein, MD, Huntington Beach, Calif

Brock Williams, MD

Category of Evidence

  • Ia

    Evidence from meta-analysis of randomized controlled trials

  • Ib

    Evidence from at least one randomized controlled trial

  • IIa

    Evidence from at least one controlled study without randomization

  • IIb

    Evidence from at least one other type of quasiexperimental study

  • III

    Evidence from nonexperimental descriptive studies, such as comparative studies, correlation studies, and case-control studies

  • IV

    Evidence from expert committee reports, opinions or clinical experiences of respected authorities, or both

Strength of Recommendation

  • A

    Directly based on category

Preface

The Joint Task Force on Practice Parameters developed “Practice parameters for the diagnosis and treatment of asthma” in 1995.1 The first focused update was published in 1998.2 This publication, “Attaining optimal asthma control: a practice parameter,” represents the second focused update.

  • Preface S4

  • Summary statements S5

  • Asthma severity and asthma control S5

  • Assessment of asthma control S7

  • Step care based on asthma control S8

  • Physician's role in attaining asthma control S9

In 1991, the National Heart,

Summary Statements

  • Summary Statement 1. Asthma symptoms do not always correlate with asthma severity. There are limitations to classifying asthma severity in patients already being treated. (B)

  • Summary Statement 2. Management on the basis of asthma control encompasses the principles of chronic disease management, including periodic assessment, goal (outcome) orientation, and individualization of therapy. (B)

  • Summary Statement 3. Asthma control can be expected to change over time. Asthma control should be assessed

Summary Statement 1. Asthma symptoms do not always correlate with asthma severity. There are limitations to classifying asthma severity in patients already being treated. (B)

In 1991, the NHLBI published its first set of guidelines for the diagnosis and management of asthma.3 This publication introduced the concept of classification of asthma by asthma severity (mild, moderate, and severe) and linked asthma severity to a stepwise guide to pharmacotherapy of asthma. Because the criteria of classification of asthma severity included asthma symptoms and objective measures of airway obstruction, this scheme highlighted the importance of a detailed asthma history (eg,

Summary Statement 3. Asthma control can be expected to change over time. Asthma control should be assessed at every clinical encounter for asthma, and management decisions should be based on the level of asthma control. (B)

Asthma control should be assessed at every clinical encounter for asthma, and management decisions should be based on the level of asthma control. The components of asthma control assessment roughly follow the NHLBI criteria for classification of asthma severity, with several additions and modifications (Table II, see below).3, 5, 22, 23

. Definition of well-controlled asthma

Asthma symptoms twice a week or less
Rescue bronchodilator use twice a week or less
No nighttime or early morning awakening
No

Summary Statement 8. A patient's asthma control for a specific clinical encounter should be determined as well controlled or not well controlled. (B)

On the basis of the criteria of asthma control as outlined above, a patient's asthma control for a specific clinical encounter can be determined as well controlled or not well controlled. This dichotomous determination then drives the clinical decision to maintain treatment unchanged or to step up or step down treatment.47 In short, asthma that is completely or well controlled generally warrants unchanged or step-down therapy, whereas asthma that is not well controlled warrants re-evaluation

Summary Statement 11. Asthma management driven by level of asthma control demands a close partnership between physician and patient. (B)

Asthma management driven by level of asthma control demands a close partnership between physician and patient. In partnership with the patient, the physician should set a realistic target for asthma control while balancing the risks and benefits of therapy. Well-controlled asthma, as defined above, is a realistic target for most, but not all, patients.22 However, both the treatment goals and the treatment program should be individualized. Some patients are not fully satisfied with

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    ∗This parameter was edited by Dr Nicklas in his private capacity and not in his capacity as a medical officer with the Food and Drug Administration. No official support or endorsement by the Food and Drug Administration is intended or should be inferred.

    Disclosure of potential conflict of interest: J. Li had consultant arrangements with Roche, Novartis, and Glaxo; has received grants from Astra Zeneca, Glaxo, and Schering; and has received honoraria from Merck, Astra Zeneca, and Glaxo. I. Bernstein has stock in Glaxo. J. Oppenheimer has consultant arrangements with Sepracor, Glaxo, Astra Zeneca, and Roche; has received grants from Sepracor, Glaxo, Astra Zeneca, Schering Sanofi, Boehringer Ingelheim, and Merck; and is on the speaker's bureau for Sepracor, Glaxo, Schering Sanofi, and Boehringer Ingelheim. R. Nicklas—none disclosed.

    Reprints requests: Joint Council of Allergy, Asthma and Immunology, 50 N Brockway St, #3-3, Palatine, IL 60067.

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