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Asthma control

Note: Not all the tables cited in this report are included in the text below. A PDF version (36KB) of all the tables is available for download.

This report  represents the medical/scientific literature on this subject as of June 1998. Also see the CSA's 2002 report Childhood Asthma: Emerging Patterns and Prospects for Novel Therapies.

Full text

This report, written in response to Resolution 422 (A-97), examines the recent evolution of guidelines on the diagnosis and treatment of asthma, particularly those released in 1997 by the National Heart, Lung and Blood Institute (NHLBI) in conjunction with the National Asthma Education and Prevention Program (Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma) (EPR-2).1 The key performance elements of this report and other recent comprehensive guidelines are examined in light of asthma mortality trends. An important component of contemporary approaches to management of this disease is informed self-management. Attention is focused on the recurring problems experienced by inner city ethnic minorities with asthma and to environmental and occupational triggers for asthma that persist in other segments of the United States population. This report concludes with recommendations on how the American Medical Association (AMA) can assist in educating physicians and consumers about asthma and how the AMA can contribute to efforts aimed at decreasing the morbidity and mortality of this disease.

Methodology

Articles for this report were selected from a MEDLINE search of the literature from 1975 to 1997 using the key word asthma, cross indexed with the terms self care, patient education, pediatric, mortality, occupational exposure or diseases, air pollution, and urban population. In addition, the bibliographies of selected articles and of EPR-2 were reviewed.

Definition of asthma

The current working consensus definition2 of asthma recognizes it as a chronic inflammatory disorder of the airways perpetuated by the interplay of many cells and cellular elements, particularly mast cells, eosinophils, T cells, macrophages, neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing which tend to worsen at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is usually reversible either spontaneously or with treatment. Inflammation also increases existing bronchial hyperresponsiveness to a variety of stimuli, including inhaled substances and irritants, exposure to cold air, and exercise.

The immunohistologic features of asthma (inflammatory cell infiltration comprising eosinophils, lymphocytes, and rarely neutrophils) and the pathophysiologic aspects of airflow obstruction (ie, airway smooth muscle spasm, mucosal edema, chronic mucus plugging of smaller airways) can result in airway remodeling. In some patients this leads to airflow limitations that are only partially reversible. Atopy, the genetic predisposition for the development of an IgE-mediated response to common aeroallergens, is the most reliable risk factor for subsequent development of asthma.1 A positive family history, particularly in the mother, also is predictive. Overall, the inheritance pattern of asthma is complex and the participation of environmental factors is required for disease expression.3 The age of onset of the disease and its course and severity are often variable and unpredictable.

Current activities of the AMA related to asthma

The Journal of the American Medical Association (JAMA) maintains an Asthma Information Center on the AMA Web site that is funded by an unrestricted educational grant from Zeneca Pharmaceuticals. This site is produced and maintained by JAMA editors and staff under the direction of an editorial review board of leading asthma authorities. The Asthma Information Center collects recent news reports on asthma and maintains a current bibliography of relevant articles from the medical literature. It also contains links to treatment guidelines and clinical resources on asthma diagnosis and treatment and maintains a list of national asthma support and information groups, as well as resources on patient education. A Continuing Medical Education program originating from this site is under development.

General trends in asthma mortality and morbidity

In the United States, asthma affects an estimated 14 to 15 million people, nearly one third of whom are less than 18 years of age, making asthma the most common chronic disease of childhood.4 In the past 30 years, asthma-related death rates have varied from 0.8 to 8.5 per 100,000 persons in industrialized nations, with rates in the United States being among the lowest.2,5,6 In 1991, more than 5000 deaths in this country were attributable to asthma.7

Although the total number of deaths from asthma has remained low, asthma mortality has apparently increased over the last two decades. Most reports on asthma mortality in the United States have been based on studies of death certificates listing asthma as an underlying cause of death. Epidemiological studies of asthma-associated mortality have focused on young patients because death in childhood is unusual, deaths due to asthma are unexpected, and the citation of asthma as an underlying cause of death on death certificates is believed to be most accurate in the group from 5 to 34 years of age.8,9 Over the last half century, asthma mortality rates in patients aged 5 to 34 years gradually increased in nonwhites from 1941 to 1965, then declined in all populations from 1965 to 1977.10 Since then, the case fatality rate more than doubled from 0.8 to 2.0 per 100,000 in 1990.6,7,10 Several studies have confirmed the apparent steady increase in asthma mortality from the period of 1978-1982 through 1993 among most age groups and population subgroups analyzed.6,11-13 Asthma prevalence, as well as emergency room visits and hospitalizations caused by the disease, also increased over this period.14-18

Some of the increase in asthma morbidity detected in 1979 and subsequently has been attributed to transition from the International Classification of Diseases, Eighth Revision, Clinical Modification (ICD-8-CM) to the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) on January 1, 1979. In the latter, certain respiratory conditions with the mention of asthma were reclassified as such rather than as bronchitis. Thus, a diagnostic shift from acute bronchitis may have contributed to apparent increases in asthma mortality.14,19 However, the shift in coding from bronchitis to asthma cannot account for the long-term trends observed.6,20

The most recent analysis suggests that asthma-related mortality has stabilized in the United States, but at rates more than 50 percent higher than those of 1979.21

Guidelines on the diagnosis and management of asthma

Because of the global rise in asthma morbidity and mortality, national and international expert panels have been convened within the last decade to formulate guidelines on the diagnosis and treatment of asthma based on the belief that asthma morbidity and mortality are largely preventable occurrences.

EPR-2 is the most recent entry into this field, completing a revision of the original Expert Panel Report issued in February 1991. EPR-2 retains recommendations of the first report that remain valid and incorporates elements of the International Consensus Report on the Diagnosis and Treatment of Asthma (ICR) released in 1992 and the Global Initiative for Asthma (GINA) guidelines released in 1995.2,22 Several other comprehensive guidelines have been offered to the international community and updated within this time frame, in addition to guidelines targeting selected aspects of asthma management.23-34

Prior to the release of EPR-2 in 1997, the British Thoracic Society (BTS) revised its guidelines in 1995, and a Joint Task Force (JTR) of the American Academy of Allergy and Immunology and the American College of Allergy and Immunology released its comprehensive practice parameters in the same year.26,35 EPR-2 and BTS were formulated, in part, to aid primary care physicians. Although JTR was formulated by the specialty of allergy and clinical immunology, it is intended for use by anyone interested in the care of patients with asthma.

For comparison purposes, Table 1 summarizes the approach taken by EPR-2, BTS, and JTR in classifying asthma severity. [NOTE: Table 1 available in PDF format only.] In EPR-2 this classification is ultimately linked with general treatment recommendations. Classification of asthma is divided into three (JTR), four (EPR-2), or five (BTS) categories or steps. JTR uses the terms mild, moderate, and severe to define asthma severity, with an inclusive description of several elements that could be used to help classify the level of disease severity. The requirement for long-term corticosteroid treatment is one criterion to indicate the presence of severe asthma. EPR-2 uses pretreatment measures and symptoms to establish disease severity. Daily use of short-acting beta2 agonists is used as one criterion to define the presence of moderate, persistent asthma. Because the BTS guidelines are based on pharmacotherapy requirements and not pretreatment measures, they incorporate outcome targets into their severity classification. Outcome targets advocated by EPR-2 (page 5) are not linked to a specific level of disease severity. JTR offers a similar range of outcome targets or measures.

Key elements of EPR-2

EPR-2 includes a discussion of asthma pathogenesis and definition followed by four components: (1) Measures of Assessment and Monitoring; (2) Control of Factors Contributing to Asthma Severity; (3) Pharmacologic Therapy; and (4) Education for a Partnership in Asthma Care. This report further substantiates the critical role of airway inflammation and incorporates evidence that subbasement membrane fibrosis occurs in some patients causing persistent and partially irreversible changes.

Key messages of EPR-2 are that: (1) asthma is a chronic inflammatory disease, and pharmacologic treatment for persistent asthma is aimed at suppressing and reversing inflammation; (2) objective measures should be used to monitor the degree of airflow limitation, course of the disease, and response to therapy; (3) environmental triggers need to be identified and controlled; and (4) optimal management is based on a partnership between the patient and health care providers, with education the critical link. The following sections highlight some important elements of EPR-2 and note changes incorporated in its evolution.

Assessment and monitoring

Significant changes occurred in the classification of asthma from three categories (mild, moderate and severe) to the categories of intermittent (mild) and persistent (mild, moderate, or severe). Sample questions to use for diagnosis and initial assessment of asthma were added, and information on wheezing in infancy and vocal cord dysfunction was expanded in the differential diagnosis section. General guidelines for referral to an asthma specialist were refined (Table 2), and more specific recommendations for measuring peak expiratory flow (PEF) diurnal variation were made.

Table 2. Indications1 for referrala to an asthma specialistb

  • Occurrence of life-threatening episode
  • Inability to achieve treatment goals
  • Atypical signs and symptoms
  • Presence of other complicating conditions
  • Additional diagnostic testing required
  • Additional education necessary
  • Immunotherapy is being considered
  • Patient (adult) has severe, persistent asthma (Step 4 )
  • Patient requires continuous oral steroids, high
  • Patient is younger than 3 years and has dose ICS, or >2 bursts of oral steroids in 1 year moderate or severe asthma (Step 3)
  • Patient’s history suggests contribution of occupational component

aReferral may be considered for adults with moderate (step 3) or young children with mild (step 2) persistent asthma
bEPR-2 defines a specialist in asthma care as a fellowship-trained allergist or pulmonologist or physicians with expertise in asthma management developed through additional training and experience

Objective assessments of pulmonary function are necessary to establish a diagnosis of asthma. This assessment in the physician’s office should be accomplished through use of a spirometer rather than with a less accurate peak flow meter. These tests are recommended at the time of initial assessment, after treatment is initiated and symptoms and PEF have stabilized, and at least every 1 to 2 years, or at more frequent intervals as necessary to monitor progress and therapeutic needs.

Periodic clinician assessment and ongoing patient self-assessment can maximize achievement of the goals of therapy. Control of asthma is defined as:

  • Preventing chronic and troublesome symptoms
  • Maintaining (near) "normal" pulmonary function
  • Maintaining normal activity levels
  • Preventing exacerbations and the need for ER visits or hospitalizations
  • Providing optimal pharmacotherapy
  • Meeting patients’ and families’ expectations of, and satisfaction with, asthma care

Specific domains that should be assessed by the clinician are: (1) the patient’s signs and symptoms; (2) pulmonary function; (3) quality of life; (4) exacerbation history; (5) medication use and management plan, including effective use of a metered-dose-inhaler and peak flow meter; and (6) patient-provider communication and satisfaction. In the latter, both the patient’s and family’s satisfaction with asthma control and the quality of care should be assessed.

Patients at all severity levels should be taught to recognize signs and symptoms that indicate deterioration or inadequate control and should be given a written action plan based on signs and symptoms and/or PEF (see section on Principles of Self-Management).1

Control of factors contributing to asthma severity

Inhalant allergen exposure is a common precipitant of asthmatic symptoms in both children and adults and perpetuates asthma severity. Regardless of the efficiency of clinician assessment and patient self-monitoring, if the patient’s exposure to irritants or allergens to which he or she is sensitive is not reduced or eliminated, symptom control and exacerbation rate may not improve. Formerly entitled "Environmental Control," the key points in this area logically include efforts by clinicians to pinpoint causative agents and to provide specific advice on how to avoid or reduce exposure to environmental or dietary triggers and drugs that may provoke or exacerbate symptoms. Relevant environmental agents include specific indoor and outdoor allergens, tobacco smoke,36-39 a wide variety of occupational triggers, and air pollution. In addition to exacerbating symptoms in patients with asthma, it is estimated that exposure to environmental tobacco smoke is responsible for the induction of 8,000 to 26,000 new cases of asthma per year.40 In addition to environmental tobacco smoke, other possible indoor pollutants include NO2 from gas stoves and fireplaces, fumes from kerosene heaters, and volatile organic compounds from carpeting, cabinetry, plywood, particle board and fumes from household cleaning products.

Skin or in vitro testing is recommended at least for those patients with persistent asthma exposed to perennial indoor allergens (ie, animal antigens, dust mite and cockroach allergens, fungi). Patients also should receive prophylaxis (eg, influenza vaccine) or prompt treatment for medical conditions (eg, rhinitis/sinusitis, gastroesophageal reflux, viral infections) that can exacerbate their asthma. Although allergen injection immunotherapy has a long history of use in the United States, opinions differ among experts on its use in asthma.41-48 In recent years, the general consensus has been to consider targeted allergen immunotherapy appropriate for asthma patients with persistent symptoms in whom evidence of a relationship between symptoms and allergen exposures is documented and for whom the goals of asthma management are not being achieved on a program of avoidance measures combined with regular medication.1

Because asthma is characterized by both nonspecific bronchial hyperresponsiveness and airway inflammation, persons with asthma are generally considered to have increased susceptibility to the respiratory health effects of inhaled air pollutants. There is considerable evidence that: (1) persons with asthma are at increased risk of exacerbations with exposure to ozone, SO2, NO2 and particulate matter; and (2) fluctuations in the levels of air pollution correlate with asthma symptoms and hospital admissions.1,49 While annual rates of death from asthma have increased in the United States in recent years, concentrations of major ambient pollutants have declined.50 This occurrence minimizes the importance of atmospheric pollution as an explanation for recent asthma mortality trends. The contribution of air pollution as a cause of asthma remains unresolved. There is little evidence to support a causal relationship between air pollution and increases in asthma prevalence over the past 20 years.51-55 Nevertheless, the possible causative role of particulates in the pathogenesis of asthma is receiving renewed attention.56,57

The focus on the most relevant indoor allergen has varied over time depending on the locale and population studied. All commonly recognized sources have been implicated including dust mites, animals, and for inner city children, cockroaches.58-65 Indeed, the recommendations in EPR-2 focus on the home environment and offer specific discussion on reducing exposure to animal allergens, house dust mites, cockroach allergens, indoor fungi, and indoor irritants.

Pharmacologic therapy

Anti-asthma drugs can be divided into two categories: quick relief and long-term control (Table 3).1 [NOTE: Table 3 available in PDF format only.] Drugs in each class are not interchangeable, thus rational use of anti-asthma medications is predicated on selecting the appropriate drugs and route of administration, applying their use in a stepwise fashion, and integrating their use into protocols for managing exacerbations. Although anti-inflammatory medications are "those that cause a reduction in the markers of airway inflammation in airway tissues or airway secretion," there are marked differences in the intensity of their anti-inflammatory effects.1

In JTR, the discussion on pharmacotherapy is organized according to individual medications and how they may be used in individual patients. The views of the JTR on medication use are similar to those expressed in EPR-2.

Long-term management of asthma

Persistent asthma is most effectively controlled with daily long-term control medication, specifically anti-inflammatory therapy, using a stepwise approach to gain and maintain control of asthma (Table 4).  [NOTE: Table 4 available in PDF format only.] Dosage regimens target airway inflammation and are predicated on the severity of disease. Prompt control should be an immediate goal, with aggressive treatment of symptoms employed when necessary to gain control of the disease. In some patients this can best be achieved by initiating therapy at a higher step or administering a short course of systemic (oral) corticosteroids.1 Once control is achieved and sustained for several weeks, a "step-down" approach can be used to maintain adequate control with the smallest amount and number of medications.1,2,26,35

The stepwise approach incorporates general guidelines to assist clinical decision-making, but is not intended to be a specific prescription. Asthma is highly variable; clinicians should tailor specific medication plans to the needs and circumstances of individual patients. Each step should include educational measures appropriate for the level of disease severity. A rescue course of systemic steroids may be needed during exacerbation at any step of care.

The pharmacotherapy approach recommended by EPR-2 is compared with that of ICR, GINA, and BTS in Table 4 [NOTE: Table 4 available in PDF format only.] All guidelines agree that daily therapy, preferably with inhaled corticosteroids (ICS) is required for patients with persistent asthma (Step 2) although they do not agree on the maximal doses. EPR-2 and BTS specify low, medium, or high doses of ICS. Importantly, they also provide corresponding equivalent doses among preparations because absolute dosage amounts vary depending on the preparation. Alternatives to ICS are offered in EPR-2 and GINA for treating mild persistent asthma.

These guidelines vary in the threshold for beta2 agonist use that must be exceeded to indicate a need to step-up or increase therapy, from more than once/week (GINA) to more than once/day (BTS). The guidelines agree that the next step is to increase the dose of ICS or to combine a lower dose of ICS with a long-acting bronchodilator (inhaled beta2 agonist, sustained released theophylline, oral beta2 agonist). Severe asthma requires the addition of oral corticosteroids. In patients requiring daily high doses of ICS and an inhaled long-acting beta2 agonist, BTS suggests an additional intermediate step comprised of sequential trials of one or more of the other available agents prior to adding oral corticosteroids.

Education for a partnership in asthma care - Principles of self-management

Health care professionals and patients are partners in asthma management. Patient education should begin at the time of diagnosis and be integrated into every step of asthma care.1 Where possible, this should involve a team approach including nurses, pharmacists, respiratory therapists, and other health care professionals, in addition to the principal clinician.1 Patient education also should be delivered in other clinical settings (eg, emergency room visits and hospitalizations). Educational efforts should be continuous and should reinforce or revise essential elements as necessary in each follow-up visit.

A variety of formal asthma education programs offered by organizations intended for use in outpatient medical facilities, schools, and the community have been validated in the literature.66-74 Several narrative reviews of these and other self-management educational programs have been conducted.75-80 When these programs are available or can be implemented, they can supplement office-based efforts. In general, educational programs improve knowledge, compliance, self-management behavior, family coping, and school attendance or performance.81 A recent meta-analysis failed to support the notion that educational programs per se significantly reduce morbidity in pediatric patients, although studies that had different educational objectives and methods were combined.82 Several controlled studies have shown educational programs are effective¾ these interventions have reduced utilization of health care services (ie, urgent care or emergency room visits, hospitalizations), especially in those whose asthma is labeled severe in both pediatric and adult patients.80

Managing asthma at home is a complex problem for many families, one that requires not only appropriate responses in the face of an episode, but also efforts to prevent the onset of attacks and attempts to reduce the psychologic and social burdens that asthma imposes on the patient and family. Considerable independent decision-making is required. Self-management education provides the patient (or child and parent) with the technical knowledge and skills to promote changes in behavior that will improve health status and enhance quality of life. To the extent possible, educational approaches should be modified according to cultural or ethnic beliefs or practices that may influence self-management practices and should be provided in the patient’s native language. Because the context of patient, disease, and environment is highly variable, home management must be adapted to individual patient’s lifestyle.

In addition to teaching basic facts about asthma so that the patient and family understand the rationale for needed actions, the clinician works with the patient to jointly develop treatment goals. To achieve these goals, clinicians should develop a written individualized, daily self-management plan, and a written "action plan" outlining the management of exacerbations, especially for patients with moderate-to-severe persistent asthma and for those with a history of severe exacerbation.

Specific self-management tasks or domains can be divided into three categories.81

Attack prevention: This includes: (1) teaching the patient that asthma is a chronic disease characterized by acute exacerbations; and (2) fostering behaviors and actions that help the patient avoid an asthma episode or reduce its potential severity. Relevant tasks and behaviors are:

  • identify, control, and avoid environmental triggers
  • use preventive medicines correctly (ie, correct use of inhaler and spacer/holding chamber) and continuously
  • monitor symptoms to recognize early signs of deterioration and act on early signs to ward off exacerbation

Every patient with asthma should be taught to recognize symptom patterns that indicate inadequate control.1 Maintaining a daily diary that includes symptom monitoring (ie, shortness of breath, cough, wheeze, chest tightness) and/or peak flow measurements, medication use, and notes of restricted activity can help determine the need for interventions in the context of a written asthma action plan for patients with persistent asthma.

EPR-2 recommends the use of daily peak flow monitoring for patients with moderate-to-severe persistent asthma. Results of one small uncontrolled sample of adults with moderate-to-severe asthma and three randomized controlled trials suggest that asthma interventions with educational self-management plans that emphasize peak flow monitoring can decrease symptoms, improve medication use and lung function, reduce hospitalizations, and improve work attendance.83-86 Controlled studies comparing the relative effectiveness of peak flow monitoring with symptom monitoring in general practice were unable to demonstrate significant differences between the two approaches.87-89 Until further definitive information is available on the value of long-term daily peak flow monitoring, this method should be used primarily in patients with moderate-to-severe persistent asthma (as well as any patient with a history of severe, life-threatening exacerbation) to help determine the severity of exacerbations and guide therapeutic decisions.1 Daily monitoring may be helpful in detecting early changes that require treatment, especially in those patients who have difficulty perceiving the extent of airflow obstruction, and to evaluate responses to changes in therapy.

In patients who require peak flow monitoring, the recommendation was changed in EPR-2 from twice daily to morning (on waking from sleep before taking a bronchodilator). Failure to achieve at least 80 percent of the patient’s personal best PEF is recommended for use as the reference point for more frequent monitoring and institution of self-management measures.1

Attack management: This domain involves teaching the patient to treat an exacerbation aggressively, but to recognize when assistance is needed and how to obtain it. This is best achieved by providing a written action plan. Relevant skills and behaviors include:

  • using quick relief medicines correctly
  • following other recommendations of the physician
  • resting and staying calm
  • monitoring the progress of therapy
  • seeking assistance as necessary

Social support: Family, friends, and clinicians all play important roles in encouraging adherence and promoting effective management. Important aspects include:

  • open and effective communication with the clinician based on friendly and reassuring prompts, including efforts to elicit the patient’s concerns about his or her asthma and perceptions of disease severity
  • assessing the level of social support and handling related problems at school, work, home, and with friends

Compliance: Studies have shown poor compliance with regular drug therapy in asthmatic patients of all ages.90-98 Several variables are related to medication noncompliance in asthma including: (1) the patient (eg, failure to fill prescription, failure to take as directed or when needed); (2) inadequate interactions between medical staff and patients or parents (eg, poor instruction or communication, inadequate monitoring or follow-up); (3) medication characteristics (eg, taste, expense, schedule, side effects, need for chronic use in the absence of symptoms); and (4) intermittent, reversible, variable nature of asthma. Because long-term compliance is important for the favorable control of asthma, additional research on enhancing compliance from the patient’s perspective is needed.

Disparities in asthma morbidity and mortality

Although overall mortality rates from asthma have increased within the last 20 years, the geographic and racial/ethnic distribution of deaths remains uneven. In the United States, the increase has been most marked in population groups of lower socioeconomic status. Asthma prevalence, severity, and mortality are highest among urban blacks and Hispanics.7,10,12,13,17,50,99-106 Deaths from asthma occur predominately in residents of large cities and may be highest in census tracts with larger percentages of low-income and minority residents, particularly blacks.13,50,107 Increases in asthma mortality have been paralleled by increases in asthma hospitalizations, emergency room visits, and other measures of morbidity.13-16,108-110 These trends in hospitalization of pediatric asthma patients have been recently confirmed by examining state hospital discharge data.111 Hospitalizations have increased primarily in children ages <5 years.12,16

In the 1990s, the hospitalization and mortality rates of black asthmatic patients were 3 to 4 times higher than those of whites.12 Greater severity (rates of mortality and hospitalization) and prevalence of asthma have been associated with low socioeconomic status and other measures of poverty, such as lower income, crowding, and living in inner city neighborhoods.102,104,108,109,112,113 Greater asthma prevalence, adverse outcomes, and severity also have been associated with black or Hispanic ethnicity.10,101,102,104,106,114-116 The prevalence of undiagnosed asthma among urban school children also may be even higher than is generally acknowledged.117, 118

Factors affecting the severity of inner city asthma

While the findings linking poverty and race with increased asthma morbidity and mortality would seem to lend themselves to straightforward analysis, confounders exist. Although elevated death rates from asthma occur in large cities, they are not evident in states with low per capita income.119 Furthermore, urban minorities are likely exposed to different patterns and levels of allergens and pollutants and second-hand cigarette smoking than their rural or suburban counterparts.64,113,120 Lower socioeconomic status may reduce timely access to care, as well as impair the continuity of medical care, which means that more patients will obtain asthma care episodically in an emergency department.109,121 Indeed, black youths receiving Medicaid and black adults in managed care are more likely to require emergency department care and less likely to pursue regular outpatient care.122 Although asthma hospitalization rates have been directly correlated with measures of poverty and inversely correlated with income levels and educational attainment, underuse of inhaled anti-inflammatory medications may explain these trends.123

These types of studies that attempt to link poverty or race per se, or to assign relative magnitudes to their effects based on linear regression analysis, have a "broad risk of ecologic bias and are more properly viewed as exploratory exercises."124 Barriers to effective outpatient use of asthma services exist among poor inner city residents.109,121 Because asthma is an ambulatory care-sensitive condition, poor access and quality of care are associated with higher morbidity.110,126 Nevertheless, differential utilization of health care services cannot be fully explained by poverty or lack of access; consideration must be given to the sociocultural factors that underlie these health care behaviors. The combination of urban environment, race/ethnicity, and poverty appears to constitute the key interaction for asthma mortality in the United States. Thus race or poverty, as such, are "not biologic risk factors for asthma, but rather are proxy measures for underlying environmental and health-care related factors associated with high asthma hospitalization rates."116 They persist as markers for a population that is not optimally accessing and utilizing the health care system.

To address concerns about asthma in the inner city, the National Institute of Allergy and Infectious Diseases launched the National Cooperative Inner-City Asthma Study (NCICAS) in 1991.127 NCICAS is being conducted by 8 groups from 7 large cities throughout the United States. Phase I identified factors associated with severity of asthma in more than 1500 children ages 4 to 11 living in inner cities, 73 percent of whom were African American, 20 percent Hispanic, and 7 percent Caucasian. Evaluation of both asthma-specific and nonspecific psychosocial variables as well as results of broad-based epidemiological investigation confirmed that a wide variety of factors are responsible for asthma morbidity in inner city children. These include limited asthma problem-solving skills, multiple family members guiding self-management, adjustment problems involving both the child and adult caretakers, and high levels of life stress.128 Additionally, participants suffered from high levels of exposure to indoor allergens (especially cockroach allergen), second-hand tobacco smoke, and the respiratory irritant nitrogen dioxide produced by inadequately vented stoves and heating appliances.65,129

The recent focus on cockroaches as a major contributor to inner city asthma extends findings reported nearly 30 years ago.130-132 Cockroach-specific IgE antibody levels are markedly elevated in the sera of these patients, and the presence of skin sensitivity to cockroach antigen is linked to allergic bronchial asthma.133, 134 Cockroach sensitization is a risk factor for acute severe exacerbations in patients visiting emergency departments, and chronicity of disease been linked to poverty as a mitigating factor.135, 136 In children with atopic asthma, African-American race and poverty have been linked with cockroach allergen sensitization and asthma severity.137-139 In the NCICAS, the combination of cockroach allergy and exposure to high levels of allergen predicted asthma-related health problems in inner-city children.65

Interventions targeting inner city patients with asthma

Although inner city residents shoulder a disproportionate burden of asthma morbidity and mortality, the comparative number of educational self-management programs designed with this group in mind has been disproportionately small. Nevertheless, some educational programs based in schools and outpatient or inpatient settings have improved knowledge of asthma and self-management skills; reduced symptoms, exacerbations, and emergency room visits; improved school performance; and reduced recurrent hospitalizations in this group.66-68, 139 Targeted training of clinic staff has increased the frequency and apparent efficiency by which asthma education is delivered in public health clinics resulting in greater continuity and quality of care for minority children attending pediatric clinics.140 Recurrent utilization of health services by adult inner city residents can be reduced by specialized asthma clinics offering a broad-based educational program, and other hospital or outpatient-based educational and management programs.141-143

Optimism about the potential effectiveness of interventions that target high-risk, inner city children has been renewed by preliminary results of the second phase of the NCICAS in which more than 1000 children and their families were assisted by an asthma care counselor (most were social workers) who provided individualized asthma care counseling.144 The counselor’s primary role was to teach and monitor asthma self-management skills, including the institution of environmental controls based on the specific triggers identified for each child. Preliminary analysis shows that children in the intervention group had a 30 percent decrease in urgent care visits and hospitalizations.

Occupational asthma

Another unique niche in asthma, especially regarding adult-onset cases, is occupational asthma (OA). It is recommended that patients with this variant be referred to an asthma specialist. OA is a disease characterized by "variable airflow limitation and/or airway hyperresponsiveness due to causes and conditions attributable to a particular occupational environment and not to stimuli encountered outside the workplace."145 OA is differentiated from work-aggravated asthma, which is defined as concurrent asthma worsened by workplace exposure.146 Because management of OA (short of removal from exposure) is difficult, primary preventive measures are critical. Depending on the offending agent and industry, several methods can be employed in workplace management to reduce the level of exposure such as process changes, use of less volatile or sensitizing chemicals, local exhaust ventilation, and personal protective devices.

Estimates of the risk of asthma attributable to workplace exposures in adults range from 2 percent to 20 percent.147-151 Although OA is a relatively common illness, little is known about quantitative exposure-response relationships. Actual risks are based on employment in specific industries and poorly defined elements of exposure.

Improvement in symptoms away from work is suggestive of OA, but failure to improve away from work does not exclude the diagnosis. OA may appear after a latency period of several months to several years, or can appear within several minutes to hours after a single high-level inhalation exposure to a toxic, respiratory irritant, causing the so-called reactive airways dysfunction syndrome (RADS).152 RADS is considered a subset of irritant-induced asthma.153, 154 Asthma-like symptoms are absent in patients prior to the exposure. Onset of respiratory symptoms is abrupt, requiring medical care. Airflow obstruction on pulmonary function testing is apparent. Nonspecific bronchial hyperresponsiveness may persist for years or permanently. More than 100 case reports have appeared since 1985 detailing the occurrence of RADS after exposure to a wide variety of respiratory toxins.155

Many different allergens from plant and animal sources and synthetic reactive chemicals have been associated with occupational asthma (Table 5). Animal and plant sources (high-molecular-weight agents) and some low-molecular-weight compounds that can act as haptens (acid anhydrides, platinum salts) cause OA after a variable latent period in association with specific IgE-mediated mechanisms. Atopy and cigarette smoking increase the risk of OA from these sources, but subclinical nonspecific airway hyperresponsiveness apparently does not.145, 149, 155, 156 Most-low-molecular weight compounds cause immune activation through poorly understood mechanisms or may induce asthmatic symptoms via irritant effects.157, 158 Diisocyanates are the leading cause of OA.159

Table 5. Animal and plant allergens and reactive chemicals that cause occupational asthma159

High-molecular-weight compounds

Examples

Animal proteins

Insects

Enzymes

Plant proteins

Legumes

Seeds

Vegetable gums

Laboratory animals, egg white, seafood

Mites, silk, mealworms, cockroaches

Subtilisin, Asperigillus-derived, trypsin, pancreatin, papain, bromelin, cellulase; alpha amylase

Cereal grains, flour, gluten, latex, garlic, tobacco leaf, psyllium

Green coffee beans, soybeans, castor beans

Cottonseeds, linseed, flaxseed

Acacia, guar

Low-molecular-weight compounds

  

Anhydrides

Precious metal

Dyes

Diisocyanates

Pharmaceuticals

Wood dust

Miscellaneous

Phthalic-, trimellitic-, and himic anhydrides

Platinum salts

Quinones, methyl blue

Toluene-, methylene diphenyl-, and hexamethylene diisocyanates

Antibiotics, piperazine hydrochloride, phenylglycine acid Cl

Western red cedar (plicatic acid), African maple, ramin wood

Chloramine T, gluteraldehyde/formaldehyde, persulfate salts, ethylenediamine, acrylics

Comprehensive guidelines for the clinical investigation of OA, exposure assessment, challenge testing, indications for PEF monitoring, and the role of nonspecific bronchial hyperresponsiveness have been developed.153, 160 It is crucial to confirm the cause-effect relationship between occupational exposure and asthma.161, 162 Skin tests or serum-specific IgE analysis (if available) and specific inhalation challenge tests either in the laboratory or in the workplace and/or peak expiratory flow monitoring are used to confirm this relationship.161-163 The National Institute for Occupational Safety and Health has developed a case definition for OA, requiring two major criteria (physician diagnosis of asthma AND association between symptoms of asthma and work) plus any one of the following:

  • workplace exposure to an agent or process previously associated with occupational asthma
  • significant work-related changes in forced expiratory volume in one second (FEV1) or peak expiratory flow rate (PEFR)
  • significant work-related changes in airway responsiveness as measured by nonspecific inhalation challenge
  • positive response to inhalation provocation testing with an agent to which the patient is exposed at work

The primary treatment for OA is removal from exposure. Symptoms of nonspecific bronchial hyperresponsiveness (NSBH) may persist after cessation of occupational exposure in up to 50 percent of subjects.164 Although NSBH parallels symptoms of OA at their onset, NSBH may become independent of symptoms and of sensitivity to the specific agent, suggesting that different mechanisms may be involved after the disease is fully developed.156 In asthma induced by both low- and high-molecular-weight compounds, prognosis is related to the duration of exposure, symptom duration, and severity of disease.165 In some patients, asthma can persist for years after exposure has ended.166 On the other hand, asthma symptoms resolve completely in up to 50 percent of affected individuals if the implicated exposures are recognized early and controlled. Thus, early detection of OA is particularly important, and clinicians should maintain a high index of suspicion for occupational causes among adults with new onset asthma.

Conclusion

Recent trends in US asthma mortality underscore the need to achieve progress in asthma management through: (1) improved therapeutic compliance; (2) expanded use of culturally and linguistically appropriate patient education programs; and (3) improved access to, and optimal utilization of, asthma care services. Several comprehensive guidelines on the diagnosis and management of asthma have been developed in recent years to assist clinicians, including the most recent issue in 1997 by the National Heart, Lung and Blood Institute in conjunction with the National Asthma Education and Prevention Program (Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma) (EPR-2).1 These guidelines are intended to educate physicians, particularly primary care physicians, about medical advances in the treatment of asthma. The AMA is contributing to dissemination of asthma treatment guidelines and principles as well as patient information via the JAMA Asthma Information Center on the AMA website. Education for physicians also was provided through publication of articles in JAMA’s Primer on Allergic and Immunologic Diseases.167, 168 However, the mere availability of comprehensive guidelines is inadequate, in and of itself, to change physician behavior.126, 169, 170

Public health efforts directed at reducing asthma morbidity and mortality need to address the fact that asthma prevalence is higher within inner cities and that a large number of children with asthma may be inadequately diagnosed and treated. More specific data are needed on the natural history of asthma in minority populations, hospital admission practices, access to medical care, and compliance with asthma therapy. Various innovative demonstration and education research programs supported by the National Institutes of Health are important efforts in this regard.

Recommendations

The following statements, recommended by the Council on Scientific Affairs, were adopted as AMA Policy at the 1998 AMA Annual Meeting:

  1. The AMA encourages physicians to make appropriate use of guidelines, including those contained in Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma released by the National Heart, Lung and Blood Institute. Furthermore, the AMA believes practice guidelines should be evidence-based and urges that all future guidelines for the diagnosis and management of chronic diseases such as asthma be evidence-based.
  2. The AMA will continue to maintain the JAMA Asthma Information Center as a source of educational material for clinicians and patients.
  3. The AMA encourages physicians to provide education to patients about asthma and the principles of asthma self-management as follows: The AMA (a) insists that patient education be based on evaluated models using appropriate behavioral theory and emphasizing the core asthma information and skills associated with effective self-management; (b) encourages physicians to participate in training based on evaluated physician education models that can enhance their teaching and communication skills enabling them to provide patient education that engenders positive change in patients; and (c) encourages physicians to augment their own patient education whenever possible by referring patients to comprehensive asthma education programs based on evaluated models.
  4. The AMA encourages physicians to monitor outcomes of their asthma treatment through instruments such as the Asthma Outcomes Monitoring System (AOMS) developed by the Joint Council of Allergy, Asthma and Immunology.
  5. In regard to Diabetes Self-Management Programs: The AMA (a) will work with invited medical groups to promote the physician-led team approach to disease-specific patient care as providing the highest quality of patient care; (b) insists that evidence-based disease-specific (eg, diabetes and asthma) education services and self-management training be initiated and continued under the direction of a physician; (c) believes all changes of care or medications by members of the team should be supervised by a physician; (d) will seek to have physician-directed benefits of evidence-based disease-specific education and self-management training provided to the beneficiaries of Medicare, Medicaid, other publicly supported programs, and all other payors.; and (e) believes that status reports and all changes made by the disease-specific self-management team be transmitted in a timely fashion to the primary care physician, if the primary care physician is not the supervisor of the management team.
  6. The AMA will work collaboratively with national specialty societies and other physician directed organizations to coordinate efforts to provide evidence-based disease-specific management education to both physicians and patients.

Reports by topic

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Resolution 422 (A-97)

Resolution 422, introduced by the California delegation and referred to the Board of Trustees at the 1997 Annual Meeting, asks:

That the American Medical Association (AMA) promote the distribution of nationally approved and accepted guidelines for the diagnosis and management of asthma; and

That the AMA use existing publications to educate physicians, other health care providers, consumers, employers, legislators, health plans, media and other appropriate groups about asthma self-management principles; and

That the AMA support legislative and regulatory efforts to (1) ensure access for asthma care education, and (2) support reduction of environmental and occupational triggers of asthma.

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Last updated: Sep 24, 2007
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