Asthma - Latest Management Guidelines

National Asthma Education and Prevention Program Updates Guidelines for Asthma Management

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

Release Date: August 30, 2007;

August 30, 2007 — The National Asthma Education and Prevention Program (NAEPP) has issued comprehensive updates to their clinical guidelines for the diagnosis and management of asthma. The revised guidelines, which update the complete asthma guidelines published in 1991 and 1997, as well as the update of selected topics issued in 2002, highlight the importance of asthma control and introduce novel strategies to monitor asthma symptoms. They also feature an expanded section on childhood asthma, including an additional age group,

The US Centers for Disease Control and Prevention (CDC) estimate that US prevalence of asthma is 22 million, including 6.5 million children younger than 18 years, and mortality from asthma exacerbations is estimated at 4000 per year.

"Asthma is one of the most common health problems in the United States — and it can significantly affect patients' lives — at school, at work, at play, and at home," NHLBI Director Elizabeth G. Nabel, MD, said in a news release. "It is essential that asthma patients benefit from the best available scientific evidence, and these guidelines bring such evidence to clinical practice."

Under the aegis of NHLBI, an expert panel of 18 unpaid experts convened by NAEPP conducted a rigorous, systematic review of the published medical literature to incorporate the best available evidence into the updated asthma guidelines.

The new recommendations offer treatment options based on a patient's specific needs and level of asthma control. Because the degree of control can change with time and varies among individuals and by age groups, regular monitoring is essential to optimize treatment.

"The goal of asthma therapy is to control asthma so that patients can live active, full lives while minimizing their risk of asthma exacerbations and other problems," said Expert Panel Chair William W. Busse, MD, from the University of Wisconsin in Madison.

The new guidelines for asthma management focus on 4 main areas: measures to evaluate and monitor asthma control, patient education outside the healthcare provider's office, control of environmental exposures known to trigger or exacerbate asthma symptoms, and pharmacotherapy.

"Overall, these components have stood the test of time, and many of the earlier recommendations have been solidly confirmed by additional research throughout the years," said Busse. "For instance, inhaled corticosteroids are still the best long-term control treatment for asthma patients of all ages because we have even stronger evidence that they are generally safe and are the most effective medication at reducing inflammation, a key component of asthma. Our review of the recent scientific evidence helps us incorporate these four components even more effectively to provide quality asthma care."

Specific recommendations in these 4 areas of asthma management are as follows:

• Assessment and Monitoring: Multiple measures of the current level of impairment include frequency and intensity of symptoms, markers of lung function, and limitations of daily activities. Determination of future risk should consider risk for exacerbations, progressive loss of lung function, or adverse effects associated with antiasthma medications. Some patients with good daily functioning when evaluated may still be at high risk for frequent exacerbations, according to the EPR-3.
  
  
• Patient Education: It is essential to teach patients appropriate skills to self-monitor and manage their asthma. A written asthma action plan is needed for each patient, which should include instructions for daily treatment as well as strategies to detect and manage asthma exacerbations.
  
  Unlike previous guidelines, the EPR-3 emphasizes reaching beyond the medical office for educational opportunities, with new settings for teaching to include pharmacies, schools, community centers, and patients' homes. An additional section of the EPR mandates clinician education programs to improve patient communications and to implement system-wide approaches that will incorporate the guidelines into healthcare practice.
  
  
• Control of Environmental Factors and Other Asthma Triggers: Isolated measures to limit exposure to allergens and other triggers are seldom sufficient, so the EPR-3 reviews recent evidence for using a combination of several strategies.
  
  A newly expanded section of the guidelines describes comorbid conditions commonly present in asthma patients. Asthma control is often improved by treating chronic diseases including rhinitis and sinusitis, gastroesophageal reflux, overweight or obesity, obstructive sleep apnea, stress, and/or depression.
  
  
• Pharmacotherapy: As in previous asthma guidelines, the EPR-3 advocates a stepwise approach to control asthma, increasing medication dosages and types as needed, and decreasing them whenever possible, based on the level of asthma control. The EPR-3 includes revised stepwise asthma management charts that are expanded to guide treatment for 3 age groups: 0 to 4 years, 5 to 11 years, and 12 years or older.
  
  Although earlier guidelines combined the 5- to 11-year age group with adults, the EPR-3 added this group because of new data concerning pharmacotherapy in this age group, as well as emerging evidence supporting differences in response to anti-asthma drugs between children and adults.
  
  The EPR-3 has updated pharmacotherapy recommendations based on recent efficacy and safety data. As in previous guidelines, the EPR-3 reiterates that patients with persistent asthma, defined as daytime symptoms more than twice weekly or nighttime symptoms more than twice monthly, should have a 2-pronged approach to asthma control. This includes medications to control asthma and prevent exacerbations during the long-term, as well as fast-acting medications to control acute symptoms on an as-needed basis.

For all age groups, the EPR-3 recommends inhaled corticosteroids as the most effective medication for long-term control. New treatment options covered in EPR-3 include leukotriene receptor antagonists and cromolyn for long-term control, long-acting β-agonists as adjunct therapy with inhaled corticosteroids, and omalizumab for severe asthma.

For acute asthma exacerbations, albuterol, levalbuterol, and corticosteroids are recommended. Urgent medical care in the emergency department should include oxygen to relieve hypoxemia; a short-acting β₂-agonist (SABA) to relieve airflow obstruction, with inhaled ipratropium bromide added for severe exacerbations; systemic corticosteroids to decrease airway inflammation in moderate or severe exacerbations, or for patients who do not respond promptly and completely to a SABA; and adjunct therapy in some cases, such as intravenous magnesium sulfate or heliox, for patients refractory to the aforementioned measures.

Additional strategies being tested to improve asthma management include new strategies to monitor asthma control by testing sputum and exhaled air and treatment options tailored to patient-specific clinical characteristics and genetic profile makeup.

"Research is beginning to help us identify genes that influence how well certain patients respond to certain asthma medications," said James Kiley, PhD, director of the NHLBI Division of Lung Diseases. "This information is helping us move toward providing personalized treatment for asthma based on a patient's individual characteristics."

National Heart, Lung, and Blood Institute. Published online August 29, 2007.

http://www.nhlbi.nih.gov/guidelines/asthma/index.htm

Limit Influenza Spread in Family

Influenza is transmitted predominantly from person to person through infectious respiratory droplets Although more than 70 years have passed since influenza A was discovered, debate continues over its mode of transmission; specifically, whether influenza is transmitted via airborne contact, respiratory droplets, or direct contact, or via a combination of these routes. Possible modes of respiratory virus transmission include the following (Brankston, 2007): Direct physical contact between an infected individual and a susceptible host, resulting in the transfer of microorganisms Indirect contact via an intermediate object that is touched by the infected individual and is not cleaned prior to coming in contact with a susceptible host Droplet transmission (drops ≥ 5 mcm in diameter) via sneezing, coughing, or speaking; these droplets are propelled < 1 m through the air and come in contact with the oral, nasal, or conjunctival mucosa of a susceptible host (ie, they do not remain suspended in the air) Airborne transmission via aerosolization (airborne particles ≤ 5 mcm in diameter); organisms are contained in droplets or in dust particles and remain suspended in the air for long periods of time

Some basic principles to help prevent the spread of influenza include:
1) avoid close contact with people who are sick;
2) stay home when you are sick;
3) cover mouth and nose when sneezing;
4) wash hands frequently;
5) avoid touching eyes, nose, or mouth while you are sick; and
6) get plenty of sleep, be physically active, manage your stress, drink plenty of fluids, and eat nutritious food.

Influenza virus survives on the hands for < 5 minutes but regular hand washing is a commonsense action that should be widely followed (Inglesby, 2006).

The impact of influenza can vary from year to year and be influenced by the circulating strains and protective antibody levels in the population. However, the efficacy of influenza vaccine among children in preventing laboratory-confirmed influenza is estimated to be 80%

School-age children and young adults who are completely susceptible experience the highest incidence of infection and contribute most of the spread of infection during an epidemic.

source: Medscape's Medpulse CME
Limiting the Spread of Influenza in a Family Setting to Reduce Secondary Infections

meningococcal vaccine

Prevention and control of meningococcal disease. Recommendations of the Advisory Committee on Immunization Practices (ACIP).

Bilukha OO, Rosenstein N; National Center for Infectious Diseases, Centers for Disease Control and Prevention (CDC).

Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC, 1600 Clifton Road NE, MS C-09, Atlanta, GA 30333, USA. OBB0@cdc.gov

In January 2005, a tetravalent meningococcal polysaccharide-protein conjugate vaccine ([MCV4] Menactra, manufactured by Sanofi Pasteur, Inc., Swiftwater, Pennsylvania) was licensed for use among persons aged 11-55 years. CDCns Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of young adolescents (defined in this report as persons aged 11-12 years) with MCV4 at the preadolescent health-care visit (at age 11-12 years). Introducing a recommendation for MCV4 vaccination among young adolescents might strengthen the role of the preadolescent visit and have a positive effect on vaccine coverage among adolescents. For those persons who have not previously received MCV4, ACIP recommends vaccination before high-school entry (at approximately age 15 years) as an effective strategy to reduce meningococcal disease incidence among adolescents and young adults. By 2008, the goal will be routine vaccination with MCV4 of all adolescents beginning at age 11 years. Routine vaccination with meningococcal vaccine also is recommended for college freshmen living in dormitories and for other populations at increased risk (i.e., military recruits, travelers to areas in which meningococcal disease is hyperendemic or epidemic, microbiologists who are routinely exposed to isolates of Neisseria meningitidis, patients with anatomic or functional asplenia, and patients with terminal complement deficiency). Other adolescents, college students, and persons infected with human immunodeficiency virus who wish to decrease their risk for meningococcal disease may elect to receive vaccine. This report updates previous reports from ACIP concerning prevention and control of meningococcal disease. It also provides updated recommendations regarding use of the tetravalent meningococcal polysaccharide vaccine (MPSV4) and on antimicrobial chemoprophylaxis.

pneumococcal vaccine reduce pneumonia morbidity

Routine Pneumococcal Vaccination Linked to Fewer Medical Visits in Kids Under 2

Healthcare visits and expenditures due to pneumonia in children under age 2 have declined markedly since routine pneumococcal vaccination was implemented in that age group, reports Archives of Pediatric and Adolescent Medicine.

Researchers reviewed health records from a large database of self-insured employers across the U.S. Data on approximately 77,000 children younger than 2 years were available each year from 1997 through 2004. Among the findings:

• From the prevaccination period (1997–1999) to 2004, hospitalization of children for all-cause pneumonia and pneumococcal pneumonia dropped by 52% and 58%, respectively.
• Ambulatory visits for all-cause pneumonia fell by 41%, while visits for pneumococcal pneumonia decreased by 47%.
• Estimated national annual medical expenditures for all-cause pneumonia and pneumococcal pneumonia dropped by 45% and 27%, respectively.

The authors conclude: "The decline in disease ... highlights the further health and economic benefits of [the 7-valent pneumococcal conjugate vaccine] in young children in the United States."

Archives of Pediatrics and Adolescent Medicine article (Free)

ACIP recommendations on preventing pneumococcal disease in kids (2000) (Free)

Meningococal Vaccine for 2-10yrs

ACIP Recommends Meningococcal Vaccine in Children at Increased Risk

Children between the ages of 2 and 10 and at increased risk for invasive meningococcal disease should receive quadrivalent meningococcal conjugate vaccine (MCV4), the Advisory Committee on Immunization Practices recommends.

Previously, the MCV4 vaccine was only approved for people aged 11 to 55 years.

As detailed in MMWR, children may be considered to be at increased risk if they:

• travel to or live in nations with hyperendemic or epidemic meningococcal disease;
• have terminal complement component deficiencies;
• suffer anatomic or functional asplenia;
• are infected with HIV (MCV4's efficacy among these children is not known);
• received the MPSV4 (polysaccharide) vaccine at least 3 years ago and are still at increased risk.

The vaccine may also be used to control outbreaks of meningococcal disease in children.

Physician's First Watch for December 7, 2007
David G. Fairchild, MD, MPH, Editor-in-Chief

Reducing Pain from Injections

• Members of a university-based pediatric pain relief program hosted a consensus conference to review the existing literature and generate expert recommendations regarding best practices for reduction of injection pain.
• The pain associated with immunizations can create anxiety and distress for the children receiving the immunizations, their parents, and healthcare providers. Dread evoked by painful immunization procedures may create feelings of persistent tension in future clinical encounters, thereby interfering with optimal delivery of healthcare.
• The injection process can be divided into 2 periods: before the injection and during the injection.
• Before the injection, preparation of a child older than 2 years reduces anxiety and subsequent pain. Children younger than 4 years should be prepared shortly before the injection itself.
• Intramuscular immunizations should be administered in the vastus lateralis (anterolateral thigh) for infants and toddlers younger than 18 months and in the deltoid (upper arm) for children older than 36 months. The ventrogluteal area may be the most appropriate site for all age groups.
• Despite the common belief that the shortest needle with the thinnest gauge would produce the least trauma and pain, this does not seem to be the case. Several studies suggest that longer needles, which are more likely to penetrate muscle than shorter ones, cause less pain, fewer adverse effects, and less local reaction.
• During the injection, parental attitudes affect the child's pain behaviors. Excessive parental reassurance, criticism, or apology tends to increase distress, whereas humor and distraction may reduce distress.
• The child's age, temperament, and interests and parent's personal style will aid in selecting effective distraction techniques. These may include storytelling, reading to the child, deep breathing, and blowing.
• During injection to children younger than 6 months, sucrose solution should be routinely given directly into the mouth or on a pacifier. This decreases evidence of distress and is relatively inexpensive.
• Because of the high cost and time needed for administration, routine local anesthetic administration is not indicated, but selective use is recommended for children who are especially fearful, who have had previous negative experiences, or who will require multiple procedures in the future.
• Pressure at the immunization site decreases pain, whether applied with a device or finger, and this strategy is noninvasive, inexpensive, and without adverse effects. Properties of the injectate itself can exacerbate pain, but there has been little research in this area.
• Parents often prefer that multiple injections be given simultaneously, rather than sequentially, if there are sufficient personnel.

Pearls for Practice

• Before the injection, important aspects of the immunization process that may reduce pain include preparing the child and family, site selection for the injection, selection of needle length and gauge, and specific properties of the injectate.
• During the injection itself, key elements of the immunization process that may reduce pain include parental demeanor, use of sucrose, use of topical anesthetic agents, nonpharmacologic and physical strategies, and specific aspects of administration technique.

Source: Medscape Medical News May 07

Teen Weight Loss

Safe steps to a healthy weight

from http://www.mayoclinic.com/health/teen-weight-loss/WT00012

Healthy habits are the key to teen weight loss. Show your teen the way with this practical plan for success.

Teenage obesity is a dangerous — and growing — problem. There's no magic bullet for teen weight loss, but there's plenty you can do to help. Start by encouraging your teen to adopt healthy habits that can last a lifetime.

Have a heart-to-heart

If your teen is overweight, he or she is probably concerned about the excess weight, too. Aside from lifelong health risks such as high blood pressure and diabetes, the social and emotional fallout of being overweight can be devastating for a teenager. It can also be frustrating to attempt weight loss and have poor results. Offer support and gentle understanding — and a willingness to help your teen take control of the problem.

You might say, "I can't change your weight. That's up to you. But I can help you make the right decisions."

Dispute unrealistic images

Weight and body image can be delicate issues, especially for teenage girls. When it comes to teen weight loss, remind your teen that there's no single ideal and no perfect body. The right weight for one person might not be the right weight for another.

Rather than talking about "fat" and "thin," encourage your teen to focus on practicing the behaviors that promote a healthy weight. Your family doctor can help set realistic goals for body mass index and weight based on your teen's age, height and general health.

Resist quick fixes

Help your teen understand that losing weight — and keeping it off — is a lifetime commitment. Fad diets may rob your growing teen of iron, calcium and other essential nutrients. Weight-loss pills and other quick fixes don't address the root of the problem. And the effects are often short-lived. Without a permanent change in habits, any lost weight is likely to return — and then some.

Promote activity

Like adults, teens need about 60 minutes of physical activity a day. But that doesn't necessarily mean 60 solid minutes at a stretch. Shorter, repeated bursts of activity during the day can help burn calories, too. In fact, any physical activity counts.

Team sports through school or community programs are great ways to get active. If your teen isn't an athlete or is hesitant to participate in certain sports, that's OK. Encourage him or her to walk, bike or in-line skate to school, or to walk a few laps through the halls before class. Suggest trading one hour of after-school channel surfing for shooting baskets in the driveway, jumping rope or walking the dog. Even household chores such as vacuuming and washing the car have aerobic benefits.

MORE ON THIS TOPIC

• Fitness for kids: Getting your children off the couch
• Children and sports: Choices for all ages

Suggest breakfast

If your teen fights the alarm clock the way it is, getting up even earlier to eat breakfast may be a tough sell — but it's important. A nutritious breakfast will jump-start your teen's metabolism and give him or her energy to face the day ahead. Even better, it may keep your teen from eating too much during the rest of the day.

If your teen resists high-fiber cereal or whole-wheat toast, suggest last night's leftovers. Even a piece of string cheese or a small handful of nuts and a piece or two of fruit can do the job.

MORE ON THIS TOPIC

• Breakfast: Why is it so important?

Encourage smart snacking

It can be tough to make healthy choices when school halls are lined with vending machines, but it's possible. Encourage your teen to replace even one bag of chips a day with a healthier grab-and-go option from home:

• Frozen grapes
• Oranges, strawberries or other fresh fruit
• Sliced red, orange or yellow peppers
• Cherry tomatoes
• Baby carrots
• Low-fat yogurt or pudding
• Pretzels
• Graham crackers
• String cheese

MORE ON THIS TOPIC

• Snacks: How they fit into a healthy diet

Watch portion sizes

When it comes to portions, size matters. Encourage your teen to scale back and stop eating when he or she is full. It might take just one slice of pizza or half the pasta on the plate to feel full — and there's no shame in sharing a meal, ordering a smaller portion or taking home leftovers.

MORE ON THIS TOPIC

• Lose weight with proper portion control

Count liquid calories

The average 12-ounce can of soda has more than 100 calories and 10 teaspoons of sugar. The calories and sugar in fruit juice, specialty coffees and other drinks can add up quickly as well. Drinking water instead of soda and other sugary drinks may spare your teen hundreds of calories and a day's worth of sugar — or even more. For variety, suggest flavored water, seltzer water or unsalted club soda.

Allow occasional treats

Late-night pizza with friends or nachos at the mall don't need to derail your teen's healthy-eating plan. Suggest a breadstick and marinara sauce instead of garlic bread dripping in butter and cheese, or a shared snack rather than a full-size order. Let your teen know that he or she is in control — and an occasional indulgence is OK. A trend toward healthier habits is what really matters.

Make it a family affair

Rather than singling out your teen, adopt healthier habits as a family. After all, eating healthier foods and getting more exercise is good for everybody.

• Encourage the entire family to eat more fruits, veggies and whole grains, such as whole-wheat bread, brown rice and oatmeal. Be sure to set a good example yourself.
• Leave junk food at the grocery store. Healthy foods sometimes cost more, but it's an important investment.
• Try new recipes or healthier alternatives to family favorites.
• Banish food from the couch to curb mindless munching.
• Plan active family outings, such as evening walks or weekend visits to a local recreation center.

Be positive

Being overweight doesn't inevitably lead to a lifetime of low self-esteem, but your acceptance is critical. Listen to your teen's concerns. Comment on his or her efforts, skills and accomplishments. Make it clear that your love is unconditional — not dependent on weight loss. Help your teen learn healthy ways to express his or her feelings, such as writing in a journal.

If your teen is struggling with low self-esteem or isn't able to cope with his or her weight in a healthy manner, consider a support group, formal weight-control program or professional counseling. Additional support may give your teen the tools to counter social pressure, cultivate more positive self-esteem and take control of his or her weight. The benefits will last a lifetime.

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