asthma management pocket reference 2008

Review article

Asthma management pocket reference 2008*

Asthma is one of the most common chronic airways diseases worldwide, and itsprevalence is increasing. Family doctors (sometimes called �primary care physi-cians� or �general practitioners�) are frequently an asthma patient�s first point ofcontact with healthcare systems. Disease management that follows evidence-based practice guidelines yields better patient results, but such guidelines areoften complicated and may recommend the use of resources not available in thefamily practice setting. A joint expert panel of the World Organization of FamilyDoctors (Wonca), International Primary Care Airways Group (IPAG) and theInternational Primary Care Respiratory Group (IPCRG) offers support tofamily doctors worldwide by distilling the globally accepted, evidence-basedrecommendations from the Global Initiative for Asthma (GINA) into this briefreference guide.This guide provides tools intended to supplement a thoroughhistory taking and the clinician�s professional judgment in order to provide thebest possible care for patients with asthma. Diagnostic Questionnaires developedfor children and adults specifically focus the physician�s attention on keysymptoms and markers of asthma. When questionnaire responses suggest adiagnosis of asthma, Diagnosis Guides then lead the clinician through a series ofinvestigations commonly available in primary care to support the diagnosis. Inpatients >40 years who smoke, COPD is an important alternative diagnosis,and some key aspects of differential diagnosis are illuminated.According toGINA, the goal of asthma treatment is to achieve and maintain control of thedisease symptoms long-term. The physician must first assess the patient�s currentlevel of asthma control, then treat asthma in a stepwise manner to achieve andmaintain symptom control. Both of these aspects are summarized in figuresincluded in this guide. Finally, the guide also presents a flow chart summarizingmanagement of asthma exacerbations in the acute care setting, and a glossary ofasthma medications to assist the clinician in making medication choices for eachindividual patient. Finally, many patients with asthma also have concomitantallergic rhinitis, and this must be checked.The World Organization of FamilyDoctors has been delegated by WHO as the group that will be taking primaryresponsibility for education about chronic respiratory diseases among primarycare physicians globally. This document will be a major resource in this edu-cational program.

C. van Weel1, E. D. Bateman2,J. Bousquet3,**, J. Reid4, L. Grouse5,T. Schermer6, E. Valovirta7,**,N. Zhong8

1Department of General Practice, UniversityMedical Centre Nijmegen, Nijmegen, theNetherlands; 2Department of RespiratoryMedicine, University of Cape Town LungInstitute, Cape Town, South Africa; 3AllergicRhinitis and its Impact on Asthma, Service desMaladies Respiratoires, H�pital Arnaud deVilleneuve, Montpellier C�dex 5, France;4Dunedin School of Medicine, University ofOtago, Dunedin, New Zealand; 5School ofMedicine, University of Washington, WA, USA;6COPD & Asthma Research Co-ordinator,Department of General Practice/FamilyMedicine, University Medical Centre Nijmegen,Nijmegen, the Netherlands; 7Pediatrician, PediatricAllergist, Turku Allergy Center, Turku, Finland;8First Affiliated Hospital, Guanghzou Canton,China

*Global Primary Care educationWorld Organization of Family Doctors (Wonca)International Primary Care Respiratory Group(IPCRG)European Federation of Allergy and AirwayDiseases Patients Association (EFA)Based on the 2007 GINA report update and theIPAG handbook

**GA2LEN is supported by EU frameworkprogramme for research, contract number FOOD-CT-2004-506378.

Key words: asthma; GINA; management; primary care.

Prof. C. van WeelDepartment of General PracticeUniversity Medical Centre NijmegenNijmegenthe Netherlands

Accepted for publication 17 January 2008

Allergy 2008: 63: 997–1004 � 2008 The AuthorsJournal compilation � 2008 Blackwell Munksgaard

DOI: 10.1111/j.1398-9995.2008.01643.x

997

The purpose of this guide

Management that follows evidence-based practiceguidelines yields better patient results. However, globalevidence-based practice guidelines are often complicatedand recommend the use of resources often not availablein the family practice setting worldwide. The prevalenceof asthma in family practice is high. In some groups ofpatients, such as smokers over 40 years, COPD may bemore prevalent than asthma. This raises the issues ofdifferential diagnosis, as treatment strategies for asthmaand COPD are different. The joint Wonca/GARDexpert panel offers support to family doctors� world-wide by distilling the Global Initiative for Asthma(GINA) and International Primary Care AirwaysGroup (IPAG) recommendations into this brief refer-ence guide. The guide lists diagnostic and therapeuticmeasures, which can be carried out in the familymedicine environment and in this way it is intended toimprove the quality of care for patients with asthma inprimary care. This document was prepared by theWonca Expert Panel including C. van Weel, E. D.Bateman, J. Bousquet, J. Reid, L. Grouse, T. Schermer,E. Valovirta, N. Zhong, and was edited by DmitryNonikov. The authors acknowledge the contributionof International Primary Care Respiratory Group(IPCRG), the European Federation of Allergy andAirways Diseases Patients Associations (EFA), and theGINA, who supported the development with theirreview and input.

Diagnosing asthma

The questionnaires and diagnosis guides supplied belowhave been specially adapted to facilitate the diagnosisof asthma in primary care. History taking of patientswith respiratory and allergy-related problems should bebased on the general principles of history taking inprimary care. Family doctors should first and foremostapply active listening and then invite patients to expresstheir symptoms, worries and concerns. This will oftenpresent a full picture. Validated questionnaires are notintended to replace history taking, but identify keysymptoms and elements of the medical history toexplore with patients. The investigations presented inthe diagnosis guides may not be available in all areas;in most cases, the combination of those diagnosticinvestigations that are available and the individualhealthcare professional�s clinical judgment will lead toan accurate clinical diagnosis. The guides are intendedto supplement, not replace, a complete physical exam-ination and thorough medical history. For patients

diagnosed with asthma, it is important to assesswhether they also have allergic rhinitis, a commoncomorbidity.

Childhood asthma questionnaire (1)

Interpretation

In children aged 6–14 years, a positive response to any ofthe questions above suggests an increased likelihood ofasthma, and suggests that the patient should undergofurther diagnostic assessment. Positive responses to threeor more of the questions in bold suggest a >90%likelihood of asthma. If responses suggest asthma,proceed to the Childhood Asthma Diagnosis Guidebelow. If responses suggest that asthma is unlikely,consider alternative diagnoses and/or referral to aspecialist.

Childhood asthma diagnosis guide (1)

�In different healthcare systems, the terms �primary care physicians�or �general practitioners� may be used.

van Weel et al.

� 2008 The Authors998 Journal compilation � 2008 Blackwell Munksgaard Allergy 2008: 63: 997–1004

Adult asthma questionnaire (1)

Interpretation

A positive response to any of the questions 1–6,particularly questions one or two in bold, suggests anincreased likelihood of asthma. The more the numberof positive answers, the greater the likelihood ofasthma. If in your judgment, the patient�s responsessuggest asthma, proceed to the Adult Asthma Diagno-sis Guide below. A positive response to question 7suggests an occupational association. Referral of thepatient to a specialist for further objective testing andassessment is recommended. If answers suggest thatasthma is unlikely, consider other diagnoses or special-ist referral.

Adult asthma diagnosis guide (1)

Differential diagnosis with COPD

Among adult patients, it is important to excludethe diagnosis of COPD in making the diagnosis ofasthma.

Treating to achieve control

Once asthma is diagnosed, it is important to providetreatment that will control patient symptoms.

Key points:

• Effective and safe pharmacological regimens areavailable for asthma. Pharmacological treatment isthe primary component of asthma management.

• Education is essential for the patients to increasecompliance with therapy.

• Allergen avoidance may be indicated in specificpatients.

Each patient is assigned to one of five treatment �steps�.These detail the treatments at each step for adults andchildren age 5 and over.

At each treatment step, reliever medication should beprovided for quick relief of symptoms as needed (how-ever, be aware of how much reliever medication thepatient is using – regular or increased use indicates thatasthma is not well controlled). At steps 2 through 5,patients also require one or more regular controllermedications, which keep symptoms and attacks fromstarting. Controller medications include inhaled andsystemic glucocorticosteroids, leukotriene modifiers,long-acting inhaled beta-2-agonists in combination withinhaled glucocorticosteroids, sustained-release theophyl-line, anti-IgE, and other systemic steroid-sparing thera-pies. Inhaled glucocorticosteroids are currently the mosteffective anti-inflammatory medications for the treatmentof persistent asthma. Their therapeutic index is alwaysmore favorable than long-term systemic glucocortico-steroids in asthma. Long-term oral glucocorticosteroidtherapy may be required for severe uncontrolled asthma,but its use is limited by the risk of significant adverseeffects.

The available literature on treatment of asthma inchildren 5 years and younger precludes detailed treatment

Asthma management pocket reference 2008

� 2008 The AuthorsJournal compilation � 2008 Blackwell Munksgaard Allergy 2008: 63: 997–1004 999

recommendations. The best documented treatment tocontrol asthma in these age groups is inhaled glucocort-icosteroids and at step 2, a low-dose inhaled glucocort-icosteroid is recommended as the initial controllertreatment.

Assessing asthma control

Each patient should be assessed to establish his or hercurrent treatment regimen, adherence to the currentregimen, and level of asthma control. The need for rescuemedication (addressed by questions such as �How oftendo you have to puff on your blue canister?�) is animportant factor for assessing asthma control in familymedicine. A simplified scheme for recognizing controlled,partly controlled, and uncontrolled asthma is provided inthe figure below.

Management approach based on control

Total dose of topical steroids should be considered ifintranasal steroids are used for concomitant allergicrhinitis.

van Weel et al.


Management of asthma exacerbations in acute care setting



Glossary of asthma medications – controllers

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Glossary of asthma medications – relievers



Acknowledgements

GINA materials have been used with permission from the GlobalInitiative for Asthma (http://www.ginasthma.org). Material fromthe IPAG Handbook has been used with permission from theInternational Primary Care Airways Group.

This document was developed with an unrestricted educationalgrant from Nycomed-Altana.

The Global Initiative for Asthma (GINA) has been supported byeducational grants from: AstraZeneca, Boehringer Ingelheim,Chiesi Group, GlaxoSmithKline, Meda Pharma, Merck, Sharp &Dohme, Mitsubishi Tanabe Pharma Corporation, Novartis, Ny-comed-Altana, Pharmaxis and Schering-Plough.

Reference

1. Bateman ED, Hurd SS, Barnes PJ,Bousquet J, Drazen JM, Firzgerald Met al. Global strategy for asthmamanagement and prevention: GINAexecutive summary. Eur Respir J2008;31:143–178.

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asthma management pocket reference 2008

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