The new asthma guidelines: a patient-centred approach to asthma

Asthma is chronic disabling condition that causes high levels of morbidity and mortality. New asthma guidelines provide evidence to guide clinical decisions about asthma management and advocate self-management programmes that involve the use of written personalized asthma action plan. Nurses have a vital role to play in improving outcomes for people with asthma.     

National guidelines for the management of asthma in adults.

Asthma is now considered primarily an inflammatory disease in which bronchospasm occurs secondary to airway inflammation. Management strategies include the use of inhaled anti-inflammatory agents, notably inhaled corticosteroids and cromolyn. Mild intermittent asthma may be treated with inhaled bronchodilators. Moderate asthma should be treated with an inhaled anti-inflammatory agent in addition to an inhaled beta agonist. If symptoms persist, an oral bronchodilator (either a beta-adrenergic agonist or theophylline) should be added. Therapy for severe asthma includes combinations of the foregoing medications, with the possible addition of oral corticosteroids. Other aspects of management include the use of a spacer device with inhaler therapy, control of concomitant allergies and triggering factors such as chronic sinusitis, tobacco smoke and gastroesophageal reflux, and home use of a portable peak flow meter to monitor the disease.     

An overview of the new resuscitation guidelines

New resuscitation guidelines contain significant changes intended to improve resuscitation practice and survival from cardiac arrest. The guidelines also include helpful new sections with guidance on in-hospital resuscitation. This article provides an overview of the key changes and discusses their practice implications for nurses.     

New asthma guidelines emphasize control, regular monitoring

Updated asthma care guidelines have recently been released. This review will focus on several elements in the third Expert Panel Report (EPR3) guidelines that reflect substantial differences from recommendations of the second EPR (EPR2) guidelines, issued in 1997 and updated in 2002. A major difference is the emphasis on asthma control. Asthma control can be assessed serially by the use of validated instruments. The goal of asthma therapy is to achieve asthma control by reducing current impairment and future risk. Recommendations for asthma pharmacotherapy have also been revised since the release of the updated EPR2 guidelines. The revisions in asthma management proposed in these guidelines offer the potential for improved asthma care outcomes in the United States.     

Categorizing asthma severity: an overview of national guidelines

Asthma is an inflammatory disease of the airways associated with intermittent episodes of bronchospasm. Corticosteroids are the most effective anti-inflammatory class of medication currently available for the treatment of asthma. However, as higher doses of inhaled corticosteroids are used the risks of systemic exposure and side effects will correspondingly increase. Justification of the benefits from higher doses of inhaled corticosteroids can only be made if patients with more severe asthma can be identified. Methods to categorize asthma severity have been introduced in various national asthma management guidelines. Unfortunately, there are substantial conceptual and practical differences among these recommended approaches to asthma severity categorization. Furthermore, these recommended approaches suffer from a focus on features of asthma control, such as symptoms, short-acting beta-agonist use, and lung function rather than actual measures of asthma severity that would encompass markers of airway inflammation. Without the endpoints necessary to assess airway inflammation, current recommendations for asthma severity categorization may lead to systematic under dosing of appropriate anti-inflammatory therapy with subsequent perpetuation of the asthma exacerbation cycle.     

Review and evaluation of the Dutch guidelines for osteoporosis

RATIONALE: At the request of a Dutch governmental organization, a multidisciplinary group of osteoporosis experts in the Netherlands published in 2002 a guideline on case finding, diagnosis, prevention and treatment of osteoporosis. These guidelines were evaluated for their validity and applicability. METHODS: Analysis by 5 external osteoporosis experts using the 'Appraisal of Guidelines for Research & Evaluation' ('AGREE') instrument. RESULTS: The score for the 6 domains of AGREE was 88% for the scope and purpose domain, 76% for stakeholder involvement, 81% for rigour of development, 84% for clarity and presentation, 77% for applicability and 73% for editorial independence. For single components of the domains of AGREE, highest scores were found for systematic methods used to search for evidence (100%), inclusion of individuals from all the relevant professional groups (95%) and ease of identifying key recommendations (95%). Lowest scores to single components of the several domains were given for piloting among target users (44%). All experts recommended the guidelines for use in practice. CONCLUSIONS: The AGREE instrument scored high for development, clarity and presentation but low for piloting among target users and implementation. Based on the guideline, algorithms from case finding to treatment were constructed that could be tested for piloting among target users and for implementation of the guideline.     

Some new guidelines for the diagnosis of urolithiasis

The purpose of the study was to develop diagnostic and prognostic criteria for the development of urolithiasis (UL), by using the chromatographic mass spectrometric and aggregatometric techniques, in order to determine the type of a metabolic disturbance and the type of stone formation, as well as to create an algorithm of pathogenetically grounded prevention of the disease. According to the type of a metabolic disorder, all the patients were divided into 4 groups: (1) 47 (43.1%) patients with uric acid UL; (2) 26 (23.9%) with calcium oxalate UL; (3) 25 (22.9%) with calcium phosphate UL; (4) 11 (10.1%) with mixed UL. The specific feature of Group 4 was a preponderance of patients with calcium phosphate and calcium oxalate stones. Analysis of the findings has led to the conclusion that the new guidelines for the diagnosis and pathogenesis of UL, by applying the current chromatographic mass spectrometric techniques make it possible to detect the type of metabolic disturbances, to assess a risk for stone formation with the elevated urinary levels of lithogenic substances, to simulate a stone formation process by aggregatometry, which is of no importance in developing an algorithm of the pathogenetic treatment and prevention of stone formation in UL patients mainly at the early stage of the pathological process.     

Effect of practitioner education on adherence to asthma treatment guidelines

OBJECTIVE: To determine whether a letter-based intervention program submitted to prescribers and pharmacists would improve drug therapy in users of high-dose beta(2)-agonists (HDBs). STUDY DESIGN: Retrospective drug utilization review. PATIENTS AND METHODS: The intervention group consisted of 135 asthmatic patients (identified through ICD-9-CM codes) in the Connecticut Medicaid Program who submitted >1 claim per month for short-acting beta(2)-agonists (over a 6-mo period). Patient-specific intervention packets were mailed to the patients' prescribers and pharmacists, and their use of long-term control agents and healthcare utilization was evaluated over 6 months. These variables were compared with a comparison group (n = 510) of asthmatics drawn from the same Medicaid program who were not considered to be high-dose users of short-acting beta(2)-agonists at baseline. RESULTS: Prior to the intervention, the intervention group used fewer long-term asthma control agents as compared with the comparison group (58% vs. 96%; p < 0.001); there was no significant difference after the intervention program (65% vs. 71%; p = 0.169). The acquisition of spacers was greater in the intervention group than in the control group after the intervention (7% vs. 2%; p = 0.007). At the end of the 6-month intervention period, 46% of patients in the intervention group were no longer HDB users (p < 0.001). The higher frequency of prescriber office visits in the intervention group than the comparison group before the intervention (0.46 +/- 0.82 vs. 0.25 +/- 0.66; p < 0.001) was not evident after the intervention program (0.24 +/- 0.63 vs. 0.18 +/- 0.60; p = 0.283). CONCLUSIONS: This intervention program had modest impact on improving the use of long-term control agents and reducing prescriber office visits.     

Review of current guidelines on the care of postherpetic neuralgia

An unfortunate minority of patients with acute herpes zoster (AHZ) experience pain beyond the typical 4-week duration, and roughly 10% develop the distressing complication of postherpetic neuralgia (PHN), often defined as pain persisting for > 4 months after the onset of the rash. Elderly patients are at increased risk of PHN. The pathophysiology of PHN is complex, likely involving both peripheral and central processes. This complexity may create opportunities for pharmacologic interventions with multiple differing mechanisms of action. Consequently, complementary combinations of pharmacologic agents are frequently more effective than any monotherapy. Current US and international guidelines on the care of patients with PHN are reviewed and interpreted here to facilitate their effective incorporation into the practice of primary care physicians, acknowledging the contrasts that often exist between the clinical trial populations analyzed to craft so-called evidence-based medicine and the individual patients seen in daily practice, many of whom may not have been candidates for those clinical trials. First-line treatments for PHN include tricyclic antidepressants, gabapentin and pregabalin, and the topical lidocaine 5% patch. Opioids, tramadol, capsaicin cream, and the capsaicin 8% patch are recommended as either second- or third-line therapies in different guidelines. Therapies that have demonstrated effectiveness for other types of neuropathic pain are discussed, such as serotonin-norepinephrine reuptake inhibitors, the anticonvulsants carbamazepine and valproic acid, and botulinum toxin. Invasive procedures such as sympathetic blockade, intrathecal steroids, and implantable spinal cord stimulators have been studied for relief of PHN, mainly in patients refractory to noninvasive pharmacologic interventions. The main guidelines considered here are those issued by the American Academy of Neurology for the treatment of postherpetic neuralgia (2004) and general guidelines for the treatment of neuropathic pain issued by the Special Interest Group on Neuropathic Pain of the International Association for the Study of Pain (2007) and the European Federation of Neurological Societies (2010).     

Implementing new guidelines on epilepsy management

New guidance has been released by the National Institute for Clinical Excellence on the diagnosis and management of epilepsies in adults, children and young people. Appropriate treatment and management can result in up to 70 per cent of people with epilepsy living seizure free. However, there are concerns regarding the shortage of specialists to implement the new guidance.     

The new NICE guidelines on COPD

The National Institute of Clinical Excellence guidelines on chronic obstructive pulmonary disease, published in March this year, provide a new way of thinking about the management of the disease. This article highlights the key areas and recommendations made by the guidelines.