National Asthma Education and Prevention Program guidelines: what is new?

New guidelines for the diagnosis and management of asthma were released in 2007. Separate recommendations are presented for three separate age groups (ages 0–4, 5–11 and ≥ 12). Six pharmacologic steps of therapy are defined for each age group. Severity is assessed in patients not on long-term control medication as a guide to initiating therapy. Control is assessed in patients on long-term control therapy to determine whether a step up, no change or a step down in therapy is indicated. Before increasing pharmacologic therapy in patients with uncontrolled asthma, adverse environmental exposure, poor adherence and inadequately treated comorbidities should be considered as targets of therapy. Guidelines for the management of asthma exacerbations are also presented.     

Work-related asthma: a case-based approach to management

The management of work-related asthma has some differences from management of other asthma. Components of management include not only making as accurate a diagnosis as possible, identifying the causative agent or triggers at work, and managing the asthma with pharmacologic treatment as for other patients with asthma, but also advising on the appropriate work changes that may be needed, assisting the worker with appropriate compensation claims, and supporting protective measures for?coworkers. This article discusses the approaches that may be taken for patients with different forms of work-related asthma.     

EAACI position statement on asthma exacerbations and severe asthma

Asthma exacerbations and severe asthma are linked with high morbidity, significant mortality and high treatment costs. Recurrent asthma exacerbations cause a decline in lung function and, in childhood, are linked to development of persistent asthma. This position paper, from the European Academy of Allergy and Clinical Immunology, highlights the shortcomings of current treatment guidelines for patients suffering from frequent asthma exacerbations and those with difficult‐to‐treat asthma and severe treatment‐resistant asthma. It reviews current evidence that supports a call for increased awareness of (i) the seriousness of asthma exacerbations and (ii) the need for novel treatment strategies in specific forms of severe treatment‐resistant asthma. There is strong evidence linking asthma exacerbations with viral airway infection and underlying deficiencies in innate immunity and evidence of a synergism between viral infection and allergic mechanisms in increasing risk of exacerbations. Nonadherence to prescribed medication has been identified as a common clinical problem amongst adults and children with difficult‐to‐control asthma. Appropriate diagnosis, assessment of adherence and other potentially modifiable factors (such as passive or active smoking, ongoing allergen exposure, psychosocial factors) have to be a priority in clinical assessment of all patients with difficult‐to‐control asthma. Further studies with improved designs and new diagnostic tools are needed to properly characterize (i) the pathophysiology and risk of asthma exacerbations, and (ii) the clinical and pathophysiological heterogeneity of severe asthma.     

Asthma diagnosis and treatment: filling in the information gaps

Current approaches to the diagnosis and management of asthma are based on guideline recommendations, which have provided a framework for the efforts. Asthma, however, is emerging as a heterogeneous disease, and these features need to be considered in both the diagnosis and management of this disease in individual patients. These diverse or phenotypic features add complexity to the diagnosis of asthma, as well as attempts to achieve control with treatment. Although the diagnosis of asthma is often based on clinical information, it is important to pursue objective criteria as well, including an evaluation for reversibility of airflow obstruction and bronchial hyperresponsiveness, an area with new diagnostic approaches. Furthermore, there exist a number of treatment gaps (ie, exacerbations, step-down care, use of antibiotics, and severe disease) in which new direction is needed to improve care. A?major morbidity in asthmatic patients occurs with exacerbations and in patients with severe disease. Novel approaches to treatment for these conditions will be an important advance to reduce the morbidity associated with asthma.     

Quantification of asthma control: validation of the Asthma Control Scoring System

BACKGROUND: We developed an instrument for quantifying asthma control, the Asthma Control Scoring System (ACSS), based on the criteria proposed by the Canadian Asthma Consensus Guidelines. OBJECTIVE: To assess the measurement properties of the ACSS. METHODS: The ACSS and two other questionnaires were completed by 44 asthmatic patients on a first visit and 2 weeks later. The ACSS evaluates three types of parameters: clinical, physiologic, and inflammatory. These parameters are each quantified to obtain a maximal score of 100% and a global score is calculated as the mean of these scores. RESULTS: The analysis showed sufficient internal consistency for every section of the ACSS (Cronbach's-alpha ranging from 0.72 to 0.88). Pearson's correlations indicated good test-retest reliability for the clinical score (r = 0.59, P = 0.005), the physiologic score (r = 0.86, P < 0.0001), the inflammatory score (r = 0.71, P = 0.049), and the global score (r = 0.65, P = 0.001). Cross-sectional and longitudinal construct validity were supported by moderate correlations between the ACSS scores and corresponding instruments. CONCLUSIONS: The ACSS is a valid tool for quantifying asthma control parameters, using a percent score. Further research should determine the usefulness of such an instrument as a means to improve asthma management and reduce related morbidity.     

Advancing asthma care: the glass is only half full!

Over the past 20 years, there has been a concerted effort in the United States to reduce morbidity related to chronic disease, including asthma. Attention was initially directed toward asthma in response to the recognition that asthma mortality was increasing and that the burden of disease was significant. These efforts to address asthma mortality led to many new initiatives to develop clinical practice guidelines, implement the asthma guidelines into clinical practice, conduct research to fill the gaps in the guidelines, and continuously revise the asthma guidelines as more information became available. An assessment of our progress shows significant accomplishments in relation to reducing asthma mortality and hospitalizations. Consequently, we are now at a crossroads in asthma care. Although we have recognized some remarkable accomplishments in reducing asthma mortality and morbidity, the availability of new tools to monitor disease activity, including biomarkers and epigenetic markers, along with information technology systems to monitor asthma control hold some promise in identifying gaps in disease management. These advances should prompt the evolution of new strategies and new treatments to further reduce disease burden. It now becomes imperative to continue a focus on ways to further reduce the burden of asthma and prevent its onset.     

Agents causing occupational asthma in Finland in 1986–2002: Cow epithelium bypassed by moulds from moisture-damaged buildings

BACKGROUND: Occupational asthma is an avoidable form of asthma. In Finland, the diagnosis of occupational asthma entitles substantial compensation to the employee. The diagnostics are based on symptoms, exposure assessment, allergologic investigations, follow-up of peak expiratory flow (PEF) at work and at home and, in many cases, specific challenge tests. OBJECTIVE: To study the causative agents of occupational asthma in Finland. METHODS: The causative agents and the numbers of new occupational asthma cases notified to the Finnish Register of Occupational Diseases (FROD) during 1986-2002 are reported. RESULTS: The number of occupational asthma cases increased from 1986 until 1995, after which a downward trend, stabilizing during the last few years, has been observed. The majority of the cases (59%) in the beginning of the period (1986-1990) were associated with agriculture, but the percentage has fallen thereafter (42% of the cases in 1998-2002) along with the fall in the total number of cases. Since 1995, indoor moulds from water-damaged buildings have caused an increasing number of cases and have become the most important causative agents (0.5% cases, in 1986-1990 and 18% of the cases in 1998-2002). Chemicals have caused 10-30% of the cases, a decreasing number since 1990. The most important chemicals causing occupational asthma have been diisocyanates and welding fumes, followed by hairdressing chemicals and formaldehyde. CONCLUSIONS: The number of occupational asthma cases in Finland reached its height in the mid-1990s. The decrease in the number of total cases is because of the decrease in agriculture-associated cases, reflecting the number of employees in agriculture-associated occupations, which has greatly decreased since Finland joined the EU in 1995. An epidemic of mould-induced asthma, affecting mostly white-collar employees working in moisture-damaged buildings, has taken place since 1995.     

Trends in hospital admissions for childhood asthma in Oslo, Norway, 1980-95

BACKGROUND: The prevalence of asthma and quality of asthma care both influence hospital admission rates for childhood asthma. Therefore, we aimed to assess possible changes in the hospital admission rate for acute asthma in Oslo, Norway, from 1980 to 1995, as well as evaluate the possible effect of changes in asthma treatment upon hospitalization for acute asthma in this period. METHODS: All pediatric patient records from the two municipal hospitals in Oslo from 1980 through 1995 with the discharge diagnoses (ICD-9) acute asthma, acute bronchitis/bronchiolitis, pneumonia, and/or atelectasis were thoroughly reviewed. RESULTS: Of the 3,538 children admitted for acute asthma, 66% were boys and 75% were younger than 4 years, and the admittance rate increased significantly among children aged 0-3 years. First admissions increased throughout the study, whereas readmissions, as well as the mean duration of hospital stay, decreased significantly. Prophylactic treatment with inhaled steroids prior to admission increased over 1980-89, but stabilized thereafter. The use of a short course of systemic steroids during admission increased markedly from 1991. CONCLUSIONS: The findings of increasing first admission rate as well as overall admission rate for acute asthma in children under 4 years of age, but decreasing readmissions as well as number of treatment days in hospital, probably reflect changes in the management of the disease, as well as an increasing prevalence of childhood asthma.     

Reproducibility of Exercise-Induced Asthma in Children

The reproducibility of exercise-induced asthma (EIA) was studied in children with perennial asthma, using treadmill exercise challenge tests repeated at mean intervals of 1 week (Group I, n = 20), 1 month (Group II, n = 20) and 1 year (group III, n = 18). The protocol was standardized with respect to intensity and duration of exercise, time of last medication prior to exercise, air humidity, use of corticosteroids, asthma attacks, and 6) pollen season. The mean percentage fall in peak expiratory flow (PEF) following exercise remained significantly unchanged in the three groups. The reproducibility of EIA was improved compared with previous studies. Although the random variation of EIA tended to be greater in Group III, the individual severity of EIA was remarkably stable whatever the interval between tests. Improvements in baseline airway function between tests were not followed by a simultaneous decrease in EIA. In conclusion, the severity of EIA is reproducible in children with perennial asthma, when the exercise protocol is standardized for factors known to influence bronchial reactivity.