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Guidelines for Asthma Management: A Reviewand Comparison of 5 Current Guidelines

Timothy R Myers RRT-NPS

IntroductionHistory of Asthma Guidelines

New Zealand and Australian GuidelinesCanadian GuidelinesBritish GuidelinesGlobal Initiative for Asthma GuidelinesNational Asthma Education and Prevention Program Guidelines

Currently Available GuidelinesComparison of Selected Topics in the NAEPP, GINA, Canadian,

Australian, and British GuidelinesEvidence-Based Grading SystemIntroduction, Diagnosis, and Natural HistoryEnvironmental ControlPharmacologic ManagementOther Materials in the Pharmacology Sections

Patient EducationSpecial CircumstancesTarget AudienceProvision for Frequent UpdatingSummary

The first clinical practice guidelines for the assessment and management of asthma were publishedover 20 years ago in New Zealand and Australia. During the same period, British and Scottishgroups were collaborating on a United Kingdom version of asthma guidelines. Shortly after theintroduction of the New Zealand and Canadian guidelines, the National Heart, Lung, and BloodInstitute of the United States National Institutes of Health participated in 2 additional asthmaguideline endeavors, which were published in the early 1990s. The National Heart, Lung, and BloodInstitute formed the National Asthma Education and Prevention Program to develop asthma guide-lines for the United States, and participated with an international task force to develop guidelinesfor the treatment of asthma in all countries, which resulted in the formation of the Global Initiativefor Asthma in the mid-1990s. The asthma guidelines issued by professional societies and othergroups prior to the late 1990s were primarily based on consensus or expert opinion in each guidelinecommittee, though those opinions were based on the available studies. The early guidelines playeda vital role in bridging the gap between various treatment options and recent discoveries in basicscience, and served as the vehicle to implementation into daily clinical practice. Asthma guidelineshave been published and revised in dozens of countries around the world and have become repu-table directives or “road maps” in asthma diagnosis, treatment, and management for patients of allages. The guidelines have similar formats. The dissemination and implementation of the earlyguidelines was inconsistent, and they were criticized for not being evidence-based. As the knowledgeof asthma pathophysiology continues to expand, along with basic science research on asthmadiagnosis, treatment, and management, as well as education of the asthma patient, it is essential that

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the asthma guidelines be frequently updated and based on evidence-based-medicine processes. Keywords: asthma, practice guidelines, spirometry, severity, control, management, bronchodilators, corti-costeroids, education. [Respir Care 2008;53(6):751–767. © 2008 Daedalus Enterprises]

Introduction

Asthma is a chronic inflammatory disease, with epi-sodic occurrences of airflow obstruction and hypersensi-tivity and responsiveness to various stimuli. Asthma is oneof the most common chronic conditions today. The globalburden of asthma occurs in approximately 300 millionpeople of all ages and ethnic backgrounds worldwide,1 andhas a prevalence of approximately 21 million citizens ofthe United States, according to the Centers for DiseaseControl and Prevention.2

Clinical practice guidelines are systematically developedstatements designed to help practitioners and patients makeappropriate health care decisions in specific circumstances.3

The first opinion-based asthma guidelines were published inthe mid-1980s in Australia and New Zealand. The overallgoal of these guidelines and others that followed was to re-duce asthma deaths and morbidity as disease prevalence, mor-bidity and mortality were increasing in all age groups. Ex-pert-opinion-based asthma guidelines were produced over thenext 2 decades in many different countries.

With the change from opinion-based to evidence-basedpractice, the principles of evidence-based medicine becameessential in thepreparationofguidelines.Evidence-basedmed-icine attempts to present a rational and suitable structure ofproblem-solving from which the quality and importance ofclinical studies can be analyzed in an unbiased manner. Andwhen there is uncertainty in the research, systematic reviewsmay offer a resolution. Evidence-based clinical practice guide-lines offer both evidence and instructional components, andrepresent the present ideal for bringing current scientificknowledge to the clinic and bedside.4

In this paper I will review the history of clinical practiceguidelines for managing asthma. I will compare the cur-rent guidelines from the Global Initiative for Asthma(GINA), the (United States) National Asthma Educationand Prevention Program (NAEPP), Canada, Australia, andthe United Kingdom on selected topics in asthma diagno-sis and management, and discuss the degree to which theseguidelines are evidence-based, accessible to potential us-ers, and applicable in different practice contexts. All 5 ofthese guidelines address exacerbation management, includ-ing mechanical ventilation and other aspects of criticalcare, but as those issues are covered in other articles in thisJournal Conference, I will focus primarily on assessmentand management of clinically stable patients.

History of Asthma Guidelines

A standardized template for asthma guideline develop-ment would theoretically consist of 4 basic components.First, practical asthma guidelines should be constructed ona strong foundation from scientific or evidenced-based ther-apies or discoveries. Second, they should be widely dis-seminated and implemented throughout the health carecommunity. Third, they should ultimately benefit patientoutcomes. Fourth, to ensure that they remain current andbased on knowledge and evidence, they should have amechanism for regular scheduled update.

Asthma guidelines are approaching their third decade ofexistence, and each set of guidelines has attempted to buildon the earlier guidelines and consensus documents. The first(opinion-based) asthma guidelines were published in the late1980s by groups in Australia and New Zealand5 and Cana-da,6 with the primary goal to reduce asthma deaths and mor-bidity, which was increasing in all age groups. Upon inves-tigation, many of these deaths were believed to have beenpreventable, because there had been suboptimal long-termcare and patient delays in seeking medical assistance duringasthma attacks. Since those initial guidelines, an assortmentof other asthma guidelines have been produced for specificcountries,5-7 a global initiative,8 specific patient populations,9

and specific clinicians.10 All the current versions of the guide-lines reviewed below are evidence-based.

Asthma is generally managed in general-practice set-tings, throughout most nations, and the organization ofdirectives or guidelines for asthma care affects how thiscare can be delivered. Differential diagnosis and manage-ment practices differ according to location, traditions, andavailability of resources and medications. To facilitate gen-

Timothy R Myers RRT-NPS is affiliated with Pediatric Diagnostics andRespiratory Care, Rainbow Babies and Children’s Hospital, and Depart-ment of Pediatrics, Case Western Reserve University School of Medi-cine, Cleveland, Ohio.

Mr Myers has served on the advisory board of Cardinal Health and beena member of the speaker’s bureau for Sepracor. He reports no otherconflicts of interest in the content of this paper.

Timothy R Myers RRT-NPS presented a version of this paper at the 41stRESPIRATORY CARE Journal Conference, “Meeting the Challenges ofAsthma,” held September 28-30, 2007, in Scottsdale, Arizona.

Correspondence: Timothy R Myers RRT-NPS, Pediatric Diagnostics andRespiratory Care, Rainbow Babies and Children’s Hospital, 11100 Eu-clid Avenue, Room 684, Cleveland OH 44106. E-mail: [email protected].

COMPARISON OF ASTHMA GUIDELINES

752 RESPIRATORY CARE • JUNE 2008 VOL 53 NO 6

eral practitioners’ understanding of asthma management,guidelines for asthma assessment and treatment have beencompiled in the United States,11,12 United Kingdom,13 Can-ada,14 Australia,5 and many other countries. These guide-lines have similar goals: reduce asthma morbidity and mor-tality; minimize airflow obstruction; and increase properasthma diagnosis. Common methods for achieving thesegoals include encouraging greater long-term use of pre-ventive medications (inhaled anti-inflammatories), objec-tive monitoring by clinicians and self-monitoring by pa-tients, and increased self-management of asthma.

All of the original guidelines produced in the late 1980sand early 1990s were based on expert opinion, with ref-erences from the scientific literature to support the “stan-dards of care” established by the published guidelines. Themajority of those early guidelines had commonalities in 4main categories: epidemiology, pathophysiology, and di-agnosis of asthma; pharmacologic therapies for acute andchronic asthma management; nonpharmacologic interven-tions; and asthma education and self-management prac-tices. I will make a brief historical review of the 5 mostfrequently cited early guidelines.

New Zealand and Australian Guidelines

During the 1980s, asthma mortality data from Australiaand New Zealand indicated that those countries were ex-periencing more asthma deaths than any other countries.After investigating fatal and near-fatal asthma attacks, someinvestigators concluded that inadequate asthma manage-ment and treatment, poor medical care, poor patient ad-herence to therapy, and delays in seeking and receivingcare were all preventable factors involved in the fatalities.

Though the Australian guidelines were only 4 pageslong, the first breakthrough in Australia for improvingasthma management was the development of the 6-StepAsthma Management Plan by the Thoracic Society of Aus-tralia and New Zealand in 1989.5 The plan used a system-atic approach to asthma management; it recommended thatphysicians assess asthma severity on a regular basis in aneffort to attain and maintain the best possible lung functionstatus. The guidelines listed objectives to achieve in everyperson with asthma (Table 1).

After publication of the Asthma Management Plan, stud-ies on the application of asthma management plans dem-

onstrated improved health outcomes for people with asth-ma.15-17 A study by Adams et al, in South Australia, foundthat the percentage of adults who had a written asthmaaction plan almost doubled between 1992 and 1995.18 How-ever, not all the news in asthma management was positive;there was increasing evidence that asthma managementwas not ideal.19-21 A study by Robertson et al19 indicatedthat almost 45% of those who suffered an asthma-relateddeath in the Australian state of Victoria had been assessedas having mild-to-moderate asthma. A separate study byRubinfeld et al,20 in Victoria, assessed asthma patients’knowledge, and the median score was less than 50%. Thisled to 2 separate studies by Bauman and colleagues, whichboth seriously questioned practitioners’ ability to imple-ment effective asthma management plans in Australia21

and indicated that the overall treatment and managementof asthma in Australia and New Zealand was suboptimal.22

There was increasing evidence of and mounting concernabout various problems in the 2 countries’ asthma treat-ment and management, as well as an increasing acknowl-edgment of inadequate general awareness of new treat-ment recommendations and inadequate dissemination andimplementation of asthma guidelines. These discoveriesled to the establishment of the National Asthma Cam-paign,23 a collaboration of the Thoracic Society of Aus-tralia and New Zealand, the Royal Australian College ofGeneral Practitioners, the Pharmaceutical Society of Aus-tralia, and the Asthma Foundations of Australia.

The National Asthma Campaign goal was to implementbetter asthma management according to the publishedguidelines and to promote community awareness of theasthma problem. This is believed to be the first nationalpublic education campaign through radio and televisionmedia to promote and enhance the general population’sasthma knowledge. Within Australia the Asthma Manage-ment Plan was widely disseminated to doctors and alliedhealth professionals by the National Asthma Campaign, inthe Asthma Management Handbook, which has undergonemultiple revisions, the latest in 2002. Any major publichealth initiative should be rigorously evaluated before itsrecommendations become established practice, and the Na-tional Asthma Campaign has been monitoring asthma man-agement practices and outcomes since 1990.24

Canadian Guidelines

In 1998 the Canadian Thoracic Society’s Asthma Com-mittee and other Canadian asthma specialists reviewedrecommendations for optimal asthma management, and pub-lished their consensus guidelines in 1999.14 The recommen-dations to be published in the 1999 guidelines were debatedat regional meetings throughout Canada and compared andcontrasted to the recommendations of similar guidelines fromother countries. The goal was to provide the health care com-

Table 1. The 6-Step Australian Asthma Management Plan

Frequent regular assessment of asthma severityOptimal use of asthma medicationsHelp patient to avoid asthma triggersDevelop and instruct patient about individualized asthma action planEducate patient about his or her asthmaRegular review and assessment of asthma status by a physician



munity with current guidelines for the diagnosis and optimalmanagement of asthma in all patient populations and in var-ious ambulatory and in-patient settings.

The guideline development committee established core val-ues and key points for consideration in asthma prevention,achieving and maintaining optimal asthma control and avoid-ing environmental triggers, thorough patient education withnecessary measures of self-maintenance and pharmacologicasthma management and control at the lowest dose that ef-fectively controls symptoms and minimizes morbidity andthe risk of exacerbation. The consensus group also consid-ered the roles of a diversified pharmacotherapy regimen andthe importance of appropriate use of asthma-medication de-livery devices and an evidence-based approach to emergencyand in-hospital asthma management.

The 1999 Canadian guidelines also gave the world a lookat some essential staples for future asthma guidelines: anevidence-based system for asthma guideline development andproduction, and guideline-based outcomes to evaluate effec-tiveness. Guideline adherence should significantly reducesymptoms, morbidity, mortality, emergency and hospital ad-missions, and adverse effects from medications, improve pa-tient quality of life, and reduce the overall cost of care. Thekey diagnostic and therapeutic recommendations were basedon the 1995 Canadian guidelines25 and received a thoroughand critical literature review by small groups prior to going tothe full group at the consensus meeting. All the recommen-dations were graded according to 5 levels of evidence. Whenevidence was lacking or scientifically weak, recommenda-tions were based on consensus opinion following discussion.Effectiveness of outcomes was based on the stipulation ofoptimal asthma management by confirmation of diagnosis,using objective measures, rapid attainment, and continualmaintenance of asthma control with interventions, treatment,and regular follow-up.

The 1999 Canadian guidelines included recommendationsin each section of the report. A summary of these recommen-dations would suggest that after the diagnosis of asthma ismade based on clinical evaluation, including demonstrationof variable airflow obstruction, and contributing factors areidentified, a treatment plan should be established to obtainand maintain optimal asthma control. The main componentsof the guidelines are patient education, environmental con-trol, individualized pharmacotherapy, and regular follow-upat recommended intervals. The Canadian consensus groupalso recognized that dissemination and implementation wouldbe key to the overall success and effectiveness of the guide-lines, and an implementation committee was established todevelop a strategy for disseminating the guidelines to varioushealth professionals and patients, and to create tools and re-sources to integrate the recommendations into current asthmacare practice.

British Guidelines

In 1989 a group of physicians and researchers from theBritish Thoracic Society, Asthma United Kingdom, andthe Royal College of Physicians in London began draftingthe first British asthma management guidelines, which werepublished in the British Medical Journal in 2 papers: onedirected at chronic asthma management26 and one at ex-acerbation management.27 The British guidelines were pro-duced about the same time as asthma guidelines were be-ing developed in Australia and Canada. The first Britishguidelines26 endorsed a stepwise approach to asthma man-agement and recommended inhaled anti-inflammatories ifa bronchodilator was required more than occasionally. Ifsymptoms were not relieved, then inhaled corticosteroidswould be increased. These guidelines also promoted mon-itoring asthma with a peak flow meter, the avoidance ofasthma triggers, and stressed the importance of patientself-management.

The British guidelines also stressed the need to increaseinhaled corticosteroids and add bronchodilators at step 4.The guidelines briefly touched on ipratropium bromide,oral � agonists, xanthines, and high-dose bronchodilators.As well as introducing a plan for incremental increases inmedication for lack of asthma control, these guidelinesdiscussed the need for periodic review and the potential todecrease medication when asthma control was achieved.Other treatment options that had not proven beneficialwere briefly mentioned but not encouraged.

The second publication27 of the 2-part British guidelinesfocused on asthma exacerbation management and empha-sized the importance of objective measurements. This partof the guidelines provided recommendations for treatingacute asthma in the home, the emergency department, andthe hospital setting, and stressed the importance of recog-nizing objective symptoms and signs of asthma exacerba-tion, and identifying features that were classified as im-minently life-threatening. Arterial blood gas values andpeak flow readings were identified as objective measure-ments that could be useful in exacerbation management.

Similar to other guidelines at that time (and even to theircurrent editions), the British guidelines’ recommendationsfor immediate asthma exacerbation management includedoxygen as necessary, high doses of both inhaled broncho-dilators and systemic corticosteroids, and possibly intra-venous bronchodilators if necessary. They recommendedfrequent patient reassessment and provided guidelines forcontinuing or stopping asthma treatment. The British guide-lines even included a generic treatment algorithm to illus-trate the flow of assessment and treatment. The documentconcluded with brief sections on criteria for admission tothe intensive care setting, monitoring of treatment, addi-tional tests that might be necessary, discharge planning,and the need for physician follow-up.



Global Initiative for Asthma Guidelines

A different perspective and approach to asthma guide-lines was also formulated in the late 1980s that did nottake a local, regional, or national approach. In 1989 theGINA program was started to raise international aware-ness among public health and government officials, healthcare workers, and the general public that the prevalence ofasthma was on the increase. The GINA program’s missionwas to develop recommendations on asthma care and man-agement that would be based on the best available scien-tific evidence so that it could be customized or adapted tomeet the needs and resources of local health care systems.

The GINA program was launched as a collaboration of theWorld Health Organization and the National Heart, Lung,and Blood Institute of the United States National Institutes ofHealth. The initial phase of the GINA program was to pro-duce a report that reflected the most up-to-date clinical prac-tice28 and provided an overview of asthma epidemiology,pathogenesis, and prevention, and the more traditional com-ponents on treatment and education.

Because the GINA guidelines focused on internationalasthma, the different financial statuses of various countriesled the GINA panel to produce a comprehensive documentthat highlighted preferred treatment categories for acuteand chronic asthma but did not focus on specific medica-tions. However, the report documented acceptable thera-pies and included a well-referenced review of complemen-tary therapies. The document concluded with sections onhealth economics, guideline implementation, and organi-zation of care. The second phase of the GINA project wasto produce a variety of reference materials to assist withthe delivery of asthma care.

National Asthma Education and Prevention ProgramGuidelines

In 1989 the National Heart, Lung, and Blood Institute es-tablished the NAEPP Expert Panel to begin the process ofdeveloping consensus, science-based guidelines for the diag-nosis and management of asthma. The panel’s original ob-jectives were simple, yet comprehensive (Table 2). The panelconsisted of a coordinating committee with representativesfrom 36 major medical associations, voluntary health orga-nizations, and federal agencies with an interest in asthma.

In 1991 the NAEPP published a set of practical, compre-hensive asthma guidelines, “Guidelines for the Diagnosis andManagement of Asthma,” to assist clinicians in bridging thegap between advances in basic science and treatment optionsand clinical practice.7 These consensus-based guidelines weredeveloped from the panel’s comprehensive review and inter-pretation of the available literature at that time.

The 1991 NAEPP guidelines stated that effective asthmamanagement consisted of objective measurements of lung

function, environmental control, pharmacotherapy directed atairway inflammation, and patient education. They recom-mended that patients self-monitor peak expiratory flow daily,and that clinicians assist patients to identify, eliminate, reme-diate, and/or avoid asthma triggers. Inhaled steroids were therecommended drugs for controlling airway inflammation, andthere was a stepwise protocol for adjusting pharmacotherapy,based on 3 asthma severity categories: mild, moderate, andsevere. Finally, the 1991 NAEPP guidelines suggested thatclinicians devote time to asthma education partnership withpatients and their families.

This landmark document established the foundation fornationwide improvements in clinical asthma management.The guidelines reversed the clinical practice from focus ontreating asthma exacerbations to long-term disease manage-ment that emphasized the role of airways inflammation, theimportance of objective measurement of lung function, andthe need to establish education partnerships between patientsand providers. Over 300,000 copies of the 1991 NAEPPguidelines were printed and distributed to physicians, healthprofessionals, and medical schools. To further support exten-sive use of the guidelines, the NAEPP developed supplemen-tal documents for nurses, emergency department personnel,pharmacists, and school personnel.

One of the major benefits of the original NAEPP guide-lines was that they stimulated additional and new researchto bridge the gaps in the evidence. This academic researchdrastically increased knowledge and evidence about asthmaand asthma care.

The second Expert Panel was convened in 1995, torevise and update the 1991 NAEPP guidelines. The secondExpert Panel (1) reviewed the asthma literature publishedsince the previous guidelines, (2) prepared practical man-agement and treatment recommendations for use by clini-cians, and (3) developed specific aids to assist in imple-menting the recommendations. The second edition of theNAEPP guidelines (Expert Panel Report 2) was publishedin July 1997.29 One major change in the dissemination ofthe 1997 guidelines was that they were initially releasedover the Internet, in early 1997, but these revised guide-lines shared the program’s initial goals (Table 3).

Table 2. Guiding Principles of the NAEPP Asthma Guidelines

To raise awareness among patients, health professionals, and thepublic that asthma is a serious chronic disease.

To ensure that asthma symptoms are recognized by patients, families,and the public, and that appropriate diagnosis is made by healthprofessionals.

To ensure effective asthma control by encouraging a partnershipamong patients, physicians, and other health professionals, usingmodern treatment and education programs.

NAEPP � National Asthma Education and Prevention Program7



The 1995 Expert Panel used new methods in their lit-erature review and guideline development process. Theyinitiated an evidence-based approach, though they chosenot to use a specific evidence-ranking system, opting in-stead to simply cite and reference relevant studies. Onrecommendations that had robust evidence (eg, peak flowmeasurement), comprehensive reviews were reported.When evidence was nonexistent, controversial, or vaguethe panel acknowledged their recommendations as “basedon the opinion of” or “recommended by the Expert Panel.”

The 1997 NAEPP guidelines classified asthma severity on2 variables: symptom frequency and objective measurementof airflow obstruction, assessed via peak expiratory flow orspirometry. The 1997 NAEPP guidelines classified patientsinto 4 levels of asthma severity: mild intermittent, and mild,moderate, or severe persistent asthma. These guidelines alsoadopted a new scheme for a modified home-managementstrategy (“asthma action plan”), and new peak-flow value“cutoffs” to direct care. They classified asthma medicationsaseither“long-termcontrollers”or“quick-reliefmedications,”and added newly approved controller medications for long-term therapy (eg, leukotriene modifiers), and new approachesin acute asthma care (eg, anticholinergics, aggressive use ofinhaled � agonists, and prompt emergency-medical-servicesintervention in the acute setting). New patient education ma-terials were also included.

Overall, the 1997 NAEPP guidelines could be summa-rized as follows:

1. A new appreciation for the major role of airwayinflammation in the pathogenesis of asthma

2. A focused effort to emphasize anti-inflammatory main-tenance therapy

3. A center of attention to establish important risk fac-tors for the development of asthma and identifying suit-able programs for control and prevention

To facilitate these new goals, the NAEPP outlined sev-eral key management components. First, self-managementskills and patient education (disease knowledge, correctmedication use, proper metered-dose-inhaler technique, andwritten action plans for managing exacerbations) are vitalto overall success. Second, patients with moderate or se-vere disease should use a home peak-flow meter to mon-itor disease severity, but only once a day, in the morning,

before inhaling bronchodilator. Third, such patients shouldminimize or avoid exposure to known asthma triggers,both in the home and outdoors. Fourth, such patients shoulduse pharmacotherapy, with a special emphasis on “step-down” therapy after a period of good control. The 1997NAEPP guidelines were disseminated nationwide, and weremodified into a practical guide, a best-practices pediatricguide, and a pocket guideline.

An update to the 1997 NAEPP guidelines was publishedin 2002,30 and it serves as a companion to the 1997 NAEPPguidelines. The “Quick Reference” section provided a con-cise review of timely information on 10 selected priorityasthma topics essential for ensuring the prevention aspectof asthma care and addresses the components of care rec-ommended in the guidelines. The action steps listed foreach key clinical activity suggest specific ways to accom-plish each activity. The 2002 update added several evi-denced-based points (Table 4). The 1997 NAEPP guide-lines and their 2002 update represented the establishedscience-based consensus concerning accurate informationfor health-care providers regarding asthma diagnosis andmanagement.

However, although those asthma care principles havebeen widely endorsed, numerous studies have highlightedthat publication of guidelines does not guarantee appro-priate dissemination or guideline adoption throughout themedical community. For instance, Hartert et al31 foundthat under-assessment and under-treatment remained a com-mon problem. Legorreta et al32 found that adherence tonational guideline management principles was low in Cal-ifornia health-maintenance organizations, which had poorpractices in prescribing preventive medication and routinemeasurement of peak flow. Meng et al33 documented thatadherence to the national guidelines was consistently lowin various regions in the United States, and they called fortargeted interventions to increase guideline adherenceamong both providers and patients.

The NAEPP guidelines have provided an excellent ve-hicle for translating research findings into clinical recom-mendations. As with guidelines from other countries and

Table 3. Main Goals of the 1997 NAEPP Asthma Guidelines

Prevent asthma symptomsMaintain (near) “normal” pulmonary function and activity levelPrevent exacerbationsMinimize emergency department visits and hospitalizationsProvide optimal pharmacologic therapy, with minimal or no adverse

effects


Table 4. Key Evidence-Based Points in the 2002 Update of theNAEPP Asthma Guidelines

Strong emphasis on inhaled corticosteroids as the recommended long-term controller medications for children with mild to moderatepersistent asthma

Recommend adding long-acting � agonists (for patients � 5 y old)with moderate persistent asthma that is poorly or inadequatelycontrolled by inhaled corticosteroids

Do not add antibiotics during asthma exacerbationDe-emphasize written action plans, because they have not shown

benefit over medical management alone




organizations, a body of scientific evidence suggests thatwhen the guidelines are followed there is a significantreduction in the severity and frequency of exacerbations,and patients are better able to maintain normal, activelives.34-40 Education programs that focus on communityoutreach and self-management and target high-risk popu-lations are an indispensable part of the effort to ensure fullguideline utilization. Creative interventions that assist ac-cess to medical care, and suitable financial support forasthma-management components (medication, monitoringaids, and environmental control measures) reduce the bur-den of asthma.

Currently Available Guidelines

Since the initial development of asthma guidelines inthe late 1980s and early 1990s, dozens of different ver-sions of asthma management guidelines have been devel-oped and produced worldwide. Regardless of the contentof these guidelines or when they were produced, advancesin their content have been made, and most of them are nowevidence-based.

The systematic development of guidelines through anevidence-based process is currently regarded as the mostrigorous and accurate means to develop clinical practiceguidelines.41 Developing evidence-based consensus guide-lines is an enormous undertaking in a field such as asthma;it involves a major literature search, consideration of thou-sands of papers, and a large time commitment by numer-ous individuals in the respiratory medical community.42

Since the initial guidelines were published in the late1980s, asthma guidelines have taken on both more specificapproaches (local, regional, national, specific patient pop-ulations, and specific clinicians) and a generalized ap-

proach (the global initiative). I will compare the currentasthma guidelines from the NAEPP,11 GINA,12 UnitedKingdom (British and Scottish),13 Canada,43 and Austra-lia.44 These guidelines have a similar structure and format,but each offers unique perspectives and sections, and somecover certain components in much more detail. Table 5identifies the major content sections of each of these 5guidelines.

Comparison of Selected Topics in the NAEPP, GINA,Canadian, Australian, and British Guidelines

Evidence-Based Grading System

The 5 guidelines take slightly different approaches ingrading the evidence, but they share the common hierar-chal component that randomized controlled trials (RCTs)are always graded as the highest level of evidence, andexpert-opinion is graded the lowest. The GINA guidelinesand 2007 NAEPP guidelines follow a similar approach45

and grade the levels of evidence in an A (highest) throughD (lowest) hierarchy. The general format of evidence-grading systems is a descending-order alphabetical or nu-merical hierarchy (eg, A-B-C, 1-2-3, or I-II-III). Table 6compares the evidence grading scales in the 5 guidelines.

There are some limitations to evidence-based guidelines.RCTs are typically designed to maximize internal validityand to minimize confounding variables in a controlled pop-ulation and setting. RCTs are not primarily concerned withthe external validity or generalizability of the findings towhole populations, and differences between the homogeneityof the trial population and the heterogeneity of the generalpopulation may limit the generalizability of RCT findings.46

So, though the evidence from RCTs is strong, many question

Table 5. Comparison of the Major Content Sections of the Asthma Guidelines From Canada, Britain, Australia, GINA, and NAEPP

Section Canada43 Britain13 Australia44 GINA12 2007NAEPP11

Diagnosis and evaluation Yes Yes Yes Yes YesProvocative factors Yes No No No NoAsthma education and patient monitoring Yes Yes Yes Yes YesAvoidance of environmental allergens Yes Yes Yes Yes YesImmunotherapy Yes No Yes No YesPharmacology Yes Yes Yes Yes YesInhalation devices Yes Yes Yes No YesSpecial considerations Yes Yes Yes Yes YesExacerbation management Yes Yes Yes Yes YesImplementation Yes Yes Yes Yes NoOrganization and delivery No Yes No No NoOutcomes No Yes Yes No No

GINA � Global Initiative for AsthmaNAEPP � National Asthma Education and Prevention Program



the “real-world” practicality of certain recommendations thatare based on RCTs, in certain situations.

Two recent peer-reviewed papers compared the results ofRCTs and observational studies and determined that whenyou review similar studies that are RCTs or lower level ev-idence trials, the results are the same.47,48 Knowledge ac-quired from realistic trials and observational studies can be avaluable adjunct to that gained from RCTs. Realistic trials,which may be blinded or open-label, are designed to moreclosely replicate conditions in clinical practice, including dif-ferences in patient characteristics and the use of a manage-ment protocol rather than a predetermined assigned treat-ment.49

Another criticism of evidence-based guidelines arises fromthe amount of time and effort required for their development,resulting in delayed implementation of best practice. Theprocess of reviewing the literature, arriving at a consensus,and writing and publishing the guidelines can take severalyears and therefore might inadvertently exclude recent pub-lications, and always excludes potentially important researchpublished soon after the guidelines. The Australian guide-lines include a brief section that recognizes the potential gapsbetween the evidence and current practice.44

Introduction, Diagnosis, and Natural History

All 5 asthma guidelines open with an introduction andthen discuss the epidemiology, pathophysiology, and di-agnosis of asthma. Most include an explanation of theevidence-grading system. All 5 guidelines also include asummary of the current version and describe the differ-ences between the current version and its predecessor.

Both the 2007 NAEPP guidelines11 and the GINA guide-lines12 provide much more detail on the pathophysiologyand pathogenesis of asthma then do the recent versions ofthe British, Canadian, and Australian guidelines. The 2007

NAEPP and GINA guidelines also look at the genetic andenvironmental factors that may play a vital role in thedevelopment of asthma and that hinder disease control.The 2007 NAEPP guidelines extensively review the def-inition of asthma, the inflammation aspects of asthma, andboth acute and chronic asthma’s impact on the airways.

All 5 guidelines spend a sizeable amount of space dis-cussing the diagnosis of asthma. Unlike the original se-verity-based asthma guidelines, asthma assessment nowdepends on 2 concepts: control and severity. Signs andsymptoms are systematically identified and quantified toassist the clinician in determining disease severity (duringdiagnosis) and assessing asthma control (during follow-upcare and management). The control and severity assess-ments are both based on symptoms, exacerbations, impacton daily life, use of rescue medications, lung function, andvariations in lung function.50 All the guidelines provide anoverview of the main components of assessment and mon-itoring, and they cover physical examination, medical-his-tory-taking, and objective measurements as the primarycomponents in making a diagnosis.

Also covered in great detail in each of these guidelinesare the relevant (eg, spirometry, skin testing) and optional(eg, radiology and laboratory testing) diagnostic tests, andsome new tests and factors to consider (eg, exhaled nitricoxide, quality of life). The topic that receives the greatestattention is the hallmark measurement for diagnosing asth-ma: pulmonary function testing, specifically spirometry.Some of the guidelines provide very detailed explanationsof the role of spirometry,11-13 whereas the others provideonly a summary and citations for relevant articles or re-sources for more specific information.

In all the guidelines the sections on asthma severity,asthma control, and pulmonary function are similar inthat they all establish the basis for the treatment rec-ommendations. In a stepwise pharmacologic approach

Table 6. Evidence Levels and Grades Used in the Asthma Guidelines From Canada, Britain, Australia, GINA, and NAEPP

Canada43 Britain13 Australia44 GINA12 2007 NAEPP11

Evidence Levels Level I 1�� 2� 1�� 2� A ALevel II 1� 2– 1� 2– B BLevel III 1– 3 1– 3 C CLevel IV 2�� 4 2�� 4 D DLevel V NA NA NA NA

Evidence Grades Level I A A A ALevel II B B B BLevel III C C C CLevel IV D D D DLevel V NA NA NA NA

GINA � Global Initiative for AsthmaNAEPP � National Asthma Education and Prevention ProgramNA � not applicable because this guideline has only 4 evidences levels/grades.



to asthma management, medications and regimen areadjusted based on information obtained from the sever-ity and control assessment variables and pulmonary func-tion measurements (Fig. 1). Table 7 compares the sim-ilarities and differences.

Environmental Control

Allergies and asthma go hand in hand in many patients. Asmany as 85% of individuals diagnosed with asthma also havea positive skin test to one or more of the common aeroaller-

Table 7. Comparison of the Sections on Asthma Severity, Control, and Pharmacology in the Asthma Guidelines From Canada, Britain, Australia,GINA, and NAEPP

Canada43 Britain13 Australia44 GINA12 2007 NAEPP11

Pharmacology steps 5 5 6 5 6

Severity levels 5 Follows treatmentsteps

3 4 4

Asthma control Present, with specificdefinitions

Present, withrecommendationson step-treatment

Present, with measurementtools



GINA � Global Initiative for AsthmaNAEPP � National Asthma Education and Prevention Program

Fig. 1. Stepwise approach to asthma management in children 5–11 years old. (Based on a figure in Reference 11.)



gens. For good long-term asthma control it is necessary toidentify and reduce exposure to allergens, irritants, and otherfactors that increase asthma symptoms or precipitate asthmaexacerbations. These environment factors can be classifiedinto 5 categories: inhaled allergens, irritants, occupationalexposures, comorbid conditions, and other factors.

All 5 guidelines comprehensively overview and analyzethe importance of environmental aspects of asthma man-agement. There is a strong correlation between sensitiza-tion to aeroallergens and the subsequent development ofasthma, and a strong association between early exposureand sensitization to aeroallergens. Some of the guidelinesdivide environmental control into 2 parts: primary, pre-ventive measures, and secondary measures to reduce oravoid exposures. Though there are certainly different strat-egies between the primary and secondary measures, thereis also some overlap.

The primary prophylaxis strategies focus on interveningon risk factors and exposures prior to the onset of asthma.Most of the data in this category come from research onyoung children, and it is a subject that is growing in in-terest and evidence. The primary topics being investigatedare inhaled allergens, genetics, natural and immunother-apy strategies, outdoor and indoor environments, irritants,comorbid conditions, and occupational exposures.

Secondary prophylaxis strategies focus on environmen-tal interventions after the onset and development of asthma.The cause/effect relationship is much stronger in this areaand the data receive much higher evidence scores in all 5guidelines. Some of the strongest evidence of cause/effectand intervention studies exists on aeroallergens in the in-door environment. These environmental factors fall into 4categories: pests (eg, roaches, mice), pets (eg, cats, dogs),irritants (eg, tobacco smoke, chemicals), and airborne par-ticulate matter (eg, from dust mites, molds, mildew).

Though the GINA (4 pages), British (4 pages), and Ca-nadian (7 pages) guidelines12,13,43 cover environmental as-pects of asthma adequately, the most through examinationof environmental factors is in the 2007 NAEPP guide-lines11 (47 pages, including references), where the focus is

much the same, but the level of detail is much greater andincludes discussion of comorbid conditions, infections,medications, and diet. Though all the guidelines discussthe cause/effect relationship in an evidence-based fashion,the 2007 NAEPP guidelines have a large section that de-tails evidence-based interventions for reducing exposuresand remediating environmental conditions.

Pharmacologic Management

As one might expect, the most extensively covered topicin all 5 guidelines is pharmacologic management of asthma.The primary goal of asthma management is to achieve andmaintain control of symptoms. The efficacy of pharmaco-logic management has been well established for many de-cades, and pharmacologic management remains the foun-dation of both chronic and acute asthma management. All5 guidelines address pharmacologic asthma managementin the chronic and acute domains, specifically, as control-ler and reliever medications.

Chronic Asthma Management: Controller Medications.All 5 guidelines stress the importance of daily preventive(controller) medications for patients with persistent symp-toms or inadequate asthma control. All 5 guidelines alsoprovide a stepwise approach or rationale for recommend-ing controller medications, and the dose can be escalatedor reduced based on how well the asthma is controlled (seeFig. 1). Each set of guidelines takes a slightly differentapproach to how they document and explain the stepwiseapproach to pharmacologic asthma management. Thereare differences in terminology and number of steps in thetreatment hierarchies (Table 8), but each of the guidelinesclearly points out that robust clinical trial evidence sup-ports the use of inhaled corticosteroids for asthma controlin patients with persistent asthma, who are above the bot-tom tier (step 1). All 5 guidelines devote considerablespace to the nuances of dosing difference between corti-costeroid types and patient populations (eg, adults vs chil-dren), in a very similar fashion. All 5 guidelines discussthe potential adverse effects of inhaled corticosteroids. The2007 NAEPP guidelines11 and Canadian guidelines43 pro-vide the most thorough explanations of the local and sys-temic adverse effects. The most distinct difference be-tween the guidelines is the medications mentioned. As onemight expect, medication availability differs markedlycountry-to-country, which causes less of a consensus onmedications from guideline-to-guideline.

For patients who fail to achieve adequate asthma controlin the lower steps/tiers of asthma treatment with inhaledcorticosteroids, all 5 guidelines promote escalating the phar-macologic treatment with an increase in inhaled cortico-steroid dose or addition of another class of controller med-ication. The guidelines take slightly different approaches

Table 8. Example of How the 2007 NAEPP Asthma GuidelinesClassify Asthma Severity After the Asthma Becomes WellControlled, by Lowest Level of Treatment Required toMaintain Control

Classification of Asthma Severity

Intermittent Persistent

Mild Moderate Severe

Step 1 Step 2 Step 3 or 4 Step 5 or 6

NAEPP � National Asthma Education and Prevention Program(Adapted from Reference 11.)



to escalation of inhaled corticosteroid dose versus addingother medications. Because asthma is a nonhomogenousdisease that has great variability from person to person,and possibly in the same person over time, one mightexpect these differences among the guidelines.

Though there are slightly different approaches to med-ications and pharmacology with lack of asthma controland a need to escalate asthma medications, all 5 guidelinesprovide a detailed explanation of the various classes ofmedications (leukotriene modifiers, nonsteroidal anti-in-flammatories, anticholinergics, long-acting � agonists, oralcorticosteroids, methylxanthines, and anti-immunoglobu-lin E human monoclonal antibodies).

Acute Asthma Management: Reliever Medications. All5 guidelines highlight the importance of as-needed relievermedication for patients at all asthma severity levels, tomanage acute symptoms and exacerbations. There is gen-eral consensus among the 5 guidelines that the preferredreliever medications are the short-acting � agonists (formsof albuterol). Though the primary purpose of the short-acting � agonists is rapid relief of acute bronchoconstric-tion, all 5 guidelines provide evidence of their benefits asa maintenance or preventive medication in patients withdocumented exercise-induced asthma.

The sections on reliever medications are relatively brief(compared to the sections on controller medications) in all5 guidelines, which is understandable, based on the step-wise approach to the pharmacologic asthma managementand the role assigned to the reliever medications. As withthe sections on the controller medications, the sections onreliever medications all discuss other classes of medica-tion (anticholinergics, long-acting � agonists, oral corti-costeroids, and methylxanthines) that might be consideredoptional reliever medications, based on regional or na-tional opinions, in the absence of solid evidence.

Other Materials in the Pharmacology Sections

Though the 5 guidelines are all consistent in their ap-proach to providing adequate materials and resources oncontroller and reliever medications, the pharmacology sec-tions also contain other materials and resources. I willbriefly summarize the pharmacology sections and provideexamples of the types of materials therein.

Australian. The Australian guidelines44 provide an algo-rithm-based approach for managing asthma exacerbations,at the beginning of the pharmacology section. This algo-rithm branches into various management approaches basedon exacerbation severity. This section also provides crite-ria for hospital admission, general recommendations forhospital management of prolonged asthma treatment, anda brief review of the various medication-delivery devices

used in both chronic and acute asthma. A different sectionprovides materials on nonpharmaceutical and complemen-tary asthma-management therapies, in an evidence-basedformat, and therapies and approaches that do not havesufficient or any evidence are grouped together withoutany evidence-based analysis.

Canadian. The Canadian guidelines43 provide an evi-dence-based review of other drugs for severe asthma, andunconventional therapies. Most of these other drugs fallinto the level 3 (of 5) category of evidence. They includedrugs such methotrexate, cyclosporin A, gold salts, andintravenous immunoglobulins. The Canadian guidelinesstate that there is no objective evidence of any benefit,apart from placebo effect, from the more frequently usedunconventional therapies such as acupuncture, chiroprac-tic, homeopathy, naturopathy, osteopathy, and herbal rem-edies (level 1 or 3, depending on the therapy). The Cana-dian guidelines complete their coverage of pharmacologywith a 10-page section on medication-delivery devices, forboth adults and children, and provide 10 evidence-basedrecommendations and some suggestions for future research.

British. The British guidelines13 pharmacology sectionaddresses specific management problems, including asthmaexacerbations, exercise-induced asthma, rhinitis, allergicbronchopulmonary aspergillosis, aspirin-intolerant asthma,and anti-immunoglobulin E monoclonal antibodies. Thesection that addresses aerosol-delivery devices starts withthe comment that, though “studies of inhaler devices aremore suitable for an evidence-based approach than manyother aspects of asthma management, a number of meth-odological issues complicate evidence review in this area.”This section also provides some information on spacersand valved holding chambers. Section 6 of the Britishguidelines comprehensively reviews (14 pages, or 14% ofthe document) strategies, approaches, and recommenda-tions on asthma exacerbations, including specific criteriato determine exacerbation severity, assessment recommen-dations, hospital admission criteria, recommendations forintensive care admission, and adjunctive therapies (eg, he-liox and noninvasive ventilation).

GINA. The GINA guidelines12 pharmacology sectionsticks to controller and reliever medications, but also de-votes a portion of this section to specific needs in andrecommendations on asthma pharmacology in children.The section after the pharmacology section deals withasthma management and prevention. The asthma-manage-ment portion of this section comprehensively reviews as-sessment, exacerbation severity, and treatment recommen-dations. One highlight of this section is an intricate chartwith which to determine asthma exacerbation severity,



based on both subjective and objective measures. The ex-acerbation-treatment algorithm later in the section is basedon the exacerbation-severity assessment. The section wrapsup with discharge criteria for both the emergency depart-ment and hospital setting.

2007 NAEPP Guidelines. The 2007 NAEPP guidelines11

are similar in many aspects to the GINA guidelines,12 inthat the pharmacology section includes specific recom-mendations and components that address pharmacologicapproaches to asthma in children. The section immediatelyafter the pharmacology section deals with a more detailedapproached to medications and treatment. Section 4 pro-vides a comprehensive (95 pages) system for managing

asthma long-term, which is divided into 4 components,based on either age (0–4 y, 5–11 y, or � 12 y) or specialcircumstances of asthma. This section devotes a great dealof space to discussing the new (to the NAEPP guidelines)components of impairment and risk and how they relate toasthma management and control (Table 9). To oversim-plify these concepts, impairment refers to functional mor-bidity or daily symptoms, and risk refers to exacerbations,medication adverse effects, and long-term decline in func-tion from asthma.

Section 5 thoroughly reviews the concepts of assessingand treating asthma exacerbations. As in the GINA guide-lines,12 there is an intricate chart with which to determine

Table 9. Classifying Asthma Severity in Patients � 12 Years Old and Who Are Not Currently Taking Long-Term Asthma-Control Medications*

Components of SeverityAsthma Severity Classification (children � 12 y old and adults)

Intermittent Persistent

Symptoms Mild Moderate Severe

Nighttimeawakenings

� 2 d/wk � 2 d/wk but not daily Daily Throughout the day

� twice a month 3–4 times a month � once a weekbut not nightly

Often 7 times aweek

Short-acting �2 � 2 d/wk � 2 d/wk but not Daily Several times a dayagonists for � once a daysymptom control (notprevention ofexercise-inducedbronchospasm)

Interference withnormal activity

None Minor limitation Some limitation Extreme limitation

Impairment Lung function Normal FEV1

betweenexacerbationsFEV1 � 80% ofpredictedFEV1/FVC normal

FEV1 � 80% ofpredictedFEV1/FVC normal

FEV1 � 60%but � 80% ofpredictedFEV1/FVCreduced 5%

FEV1 � 60% ofpredictedFEV1/FVC reduced� 5%

Risk Exacerbation that 0–1 time a year† � twice a year† � twice a year† � twice a year†

requires oralsystemic

Consider severity and interval since last exacerbation.Frequency and severity may fluctuate for patients in any severity category.

corticosteroids Relative annual risk of exacerbation may be related to FEV1.

FEV1/ FVC:8–19 yr 85%20–39 yr 80%40–59 yr 75%60–80 yr 70%* Severity level is determined by assessment of both impairment and risk. Assess impairment domain by patient’s/caregiver’s recall of previous 2–4 weeks and spirometry. Assign severity to themost severe category in which any feature occurs.† There are inadequate data to correspond frequency of exacerbation to asthma severity level. In general, more frequent and intense exacerbations (eg, that require urgent, unscheduled care,hospitalization, or admission to the intensive care unit) indicate greater underlying asthma severity. For treatment purposes, patients who had � 2 exacerbations that required oral systemiccorticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment consistent with the diagnosis of persistent asthma.FEV1/FVC � ratio of forced expiratory volume in the first second to forced vital capacity(Adapted from Reference 11.)



asthma-exacerbation severity, based on both subjectiveand objective measurements (Table 10), and the exac-erbation-treatment algorithm is based on the exacerba-tion-severity assessment. This section also highlightsrisk factors for fatal asthma. There is an algorithm-based exacerbation-management approach for both thehome and acute care (emergency department and hos-pital) settings (Fig. 2). There is even a section on pre-hospital (emergency medical services) managementstrategies.

The 2007 NAEPP guidelines also review treatments thatare not recommended for exacerbations (eg, methylxan-thines, hydration, chest physiotherapy) and discuss adjunc-tive therapies (eg, magnesium sulfate, heliox, noninvasiveventilation) that need more investigation in order to pro-vide evidence-based recommendations. This section finisheswith some criteria for discharge from acute settings and rec-ommendations for specific documentation for the patient.

Patient Education

The primary objective of asthma care and patient self-management is to decrease asthma morbidity and asthma’seffects on activities of daily living and overall quality of life.There is now sufficient evidence that asthma self-manage-ment education improves long-term asthma outcomes. Be-havioral modification through specific training in various self-management skills is essential to produce positive outcomesin chronic conditions such as asthma. Equally important isclinician education, to facilitate educating patients on self-management skills and to support guideline implementation.

All 5 asthma guidelines extensively cover and stress theimportance of asthma education for patients, caregivers,clinicians, and the general public. Each of the 5 guidelinesaddress this important topic, with slightly different ap-proaches, but all share some common viewpoints. They allstress the importance of a partnership between patients andclinicians to achieve optimal asthma outcomes. This part-nership and formalized education should be initiated onthe confirmation of the asthma diagnosis, and reviewedand reinforced at each subsequent visit.

All the guidelines stress the importance of self-manage-ment skill training and review. This can include a multitudeof behavior-based skills, but also includes items such as writ-ten asthma education and action plans, peak flow and med-ication-delivery-device education and technique reviews, andthe ability to recognize signs and symptoms of worseningasthma control. Most of the guidelines also stress the impor-tance of assessing the patient for adherence to the writtentreatment plan and medication regimen. The 2007 NAEPPguidelines11 and the Canadian guidelines43 include detailedinformation on providing asthma education in various set-tings (eg, clinician’s office, patient’s home, acute care setting,

school), which provides some insight into the necessity of amulti-dimensional approach to education.

Education of the nonasthmatic is equally important tothe success of asthma education. The GINA guidelines12

truly take a global approach to education and address therole of asthma guidelines in providing information to thegeneral public. The Canadian guidelines43 focus on theimportance of appropriate training of asthma educators.This is not surprising, because education programs forasthma educators have been developed in various regionsin Canada, and national certification for asthma educatorshas been available for over a decade. The 2007 NAEPPguidelines11 provide specific information on methods forimproving clinician behavior, starting with recommendedpractices for implementing the vast amount of informationin the guidelines, then they discuss how to improve com-munication techniques. This section concludes with a re-view of methods for improving system supports and de-tails on asthma clinical pathways and clinical decision-support systems.

Special Circumstances

Patients with asthma frequently encounter situations thatrequire adjustments to their management regimen to keeptheir asthma under control. All of the guidelines provide somereview of some common and uncommon occurrences or co-morbid conditions that can necessitate a change in asthmamanagement or that call for additional patient education. Spe-cial situations described in the 2007 NAEPP guidelines11

include exercise-induced bronchospasm, pregnancy, and sur-gery. The NAEPP guidelines also review the problems thatracial and ethnic differences can pose in asthma management.

The Canadian guidelines43 review 2 specific subjects ingreat detail: asthma in the elderly, and asthma during preg-nancy. In both these conditions, specific treatment and man-agement recommendations are provided in an evidence-basedformat. The British guidelines similarly address asthma andpregnancy, and offer a unique approach in their review ofoccupational asthma, which does not exist in the NAEPPguidelines11 or Canadian guidelines43 as a separate entity.The GINA guidelines12 provide the most diverse outlook onspecial circumstances in asthma, including pregnancy, sur-gery, occupational exposure, respiratory infection, gastro-esophageal reflux, aspirin-induced asthma, rhinitis, sinusitis,nasal polyps, and anaphylaxis.

Target Audience

All 5 guidelines contain materials and resources for healthprofessionals of all disciplines, patients, and the general pub-lic, and are easily accessible via the Internet. The documentsand resources for health care professionals differ somewhatin structure and comprehensiveness, but are presented in amanner appropriate for all care providers, regardless of spe-



Table 10. Classification System for Asthma Exacerbation Severity in the Urgent or Emergency Department Setting

Mild Moderate SevereSubset of Severe: Respiratory

Arrest Imminent

Symptoms*Breathlessness While walking

Can lie downWhile at rest (infant:softer, shorter cry,difficulty feeding)Prefers sitting

While at rest (infantstops feeding)Sits upright

NA

Talks in Sentences Phrases Words NA

Alertness May be agitated Usually agitated Usually agitated Drowsy or confused

SignsRespiratory rate

Guide to respiratory rate inawake children:Age Rate (breaths/min)� 2 mo � 602–12 mo � 501–5 y � 406–8 y � 30

Increased Increased Often � 30 breaths/min NA

Use of accessory muscles:suprasternal retractions

Usually not Commonly Usually Paradoxical thoracoabdominalmovement

Wheeze Moderate, often onlyend-expiratory

Loud: throughoutexhalation

Usually loud:throughout inhalationand exhalation

Absence of wheeze

Heart rate (beats/min)Guide to normal heart rate inchildren:Age Rate (beats/min)2–12 mo � 1601–2 y � 1202–8 y � 110

� 100 100–200 � 120 Bradycardia

Pulsus paradoxus (mm Hg) Absent � 10 May be present10–25

Often presentAdult: � 25Child: 20–40

Absence suggests respiratorymuscle fatigue

Functional AssessmentPEF (% of predicted or %of personal best)

� 70 Approximately 40–69 orresponse lasts � 2 h

� 40 � 25PEF test may not be neededduring a very severe attack.

PaO2(mm Hg) on air Normal

Test not usuallynecessary

� 60Test not usuallynecessary

� 60Possible cyanosis

NA

and/or PCO2(mm Hg) � 42

Test not usuallynecessary

� 42Test not usuallynecessary

� 42Possible respiratoryfailure

NA

SaO2(%) on air, at sea level � 95

Test not usuallynecessary†

90–95Test not usuallynecessary†

� 90† NA

* The presence of several (but not necessarily all) signs/symptoms indicates the general classification of the exacerbation. Many of these variables have not been systematically studied, especially asthey correlate to each other, so they serve only as general guides. The emotional impact of asthma symptoms on the patient and family is variable but must be recognized and addressed, and canaffect approaches to treatment and follow-up.† Hypercapnia (hypoventilation) develops more readily in young children than in adolescents or adults.NA � not applicable or data not availablePEF � peak expiratory flowSaO2 � arterial oxygen saturation(Adapted from Reference 11.)



Fig. 2. Asthma exacerbation-management algorithm for the emergency department and hospital settings. (Adapted from Reference 11.)



cialty or area of care within the continuum of asthma man-agement. The summary documents of the NAEPP guide-lines11 and Canadian guidelines43 are the most useful andaccessible resource from the point of view of the respiratorytherapist. The British13 and Australian44 guidelines are di-rected more at primary care physicians in those countries, butalso provide valuable information not necessarily found inthe other guidelines. The GINA guidelines12 offer a true globalperspective in their recommendations and can be generalizedto many different countries and care providers.

Provision for Frequent Updating

The previous generations of asthma guidelines were pre-pared by their respective professional groups for publica-tion on a particular date, with no specific plan or formatfor updating. Many of the updates came only when therespective group thought that a sufficient amount of infor-mation or treatment changes had developed to merit pub-lishing a revision. The NAEPP group had empirically se-lected a revision frequency of 5–6 years. The latest changewas that all the groups developed evidence-based guide-lines, which take much longer to update. Some of theguideline groups now publish annual or biannual updateson the Web, in an abbreviated format from the originaldocuments. This Web-based strategy may assure the timelyposting of updated information and resources for all groups.

Summary

Asthma guidelines are approaching their 25th anniver-sary in the literature and have positively influenced thequality and outcomes of asthma care worldwide. TheNAEPP guidelines11 and the GINA guidelines12 are themost frequently cited and solicited by American clinicians,and are now evidence-based and have similar frameworks,because both originated from the National Institutes ofHealth. Though the 5 guidelines are formatted in vastlydifferent frameworks, they take a relatively consistent ap-proach to diagnosis, environmental control, pharmacologicmanagement, exacerbation management, and patient edu-cation, compared to the expert-opinion-based guidelines ofthe 1990s. The convenience of access to these guidelinesvia the Internet, and their inclusion of potentially helpfulinformation for patients, should promote wider awarenessand implementation across the continuum of asthma care.

With the emergence of the electronic age and the Inter-net, guideline availability and retrieval is nearly instanta-neous, and access to information is nearly unlimited. Guide-lines and guideline updates continue to be needed, becausemany patients still have uncontrolled asthma and new stud-ies frequently produce either a new treatment or a betterunderstanding of the current treatments.

Though asthma guidelines may not be perfect, they arethe best vehicle to assist primary care physicians to pro-vide the best possible asthma care.

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Discussion

Enright: Probably the weakest as-pect of the guidelines for asthma andCOPD [chronic obstructive pulmonarydisease] is that the diagnosis recom-mendations are not evidence-based.The ATS/ERS [American ThoracicSociety and European Respiratory So-ciety] 2005 pulmonary function group,

which worked for 3 years, did not evenattempt to assign evidence grades fortheir diagnosis scheme, so I resignedfrom the committee and asked that myname be taken off of the Italian schemefor interpreting lung function.

The NAEPP asthma guidelines andGINA guidelines do grade the evidence,and that’s certainly a massive step for-ward, but another step needs to be taken

for both COPD and asthma guidelines,and it is well-stated in the ATS evi-dence-grading recommendations.1

After grading the evidence, weshould consider the cost, the inconve-nience, and temporary and permanentadverse effects of the recommendations.That will take a lot of time, expertise,and dedication. For example, there isgrade A evidence that prednisone



treats asthma wonderfully, butshould everyone who has asthma betaking prednisone? No. Another ex-ample is bronchial thermoplasty.Maybe 5 years from now there’ll begrade B evidence that it works won-derfully for a small subset of pa-tients with asthma, but it’s going tobe very expensive and the adverseeffects will probably be severe. Thisis an additional layer of consideringevidence that has not yet been un-dertaken by the NAEPP group.

1. Schunemann HJ, Jaeschke R, Cook DJ, BriaWF, El-Solh AA, Ernst A, et al. ATS Doc-uments Development and ImplementationCommittee. An official ATS statement:grading the quality of evidence and strengthof recommendations in ATS guidelines andrecommendations. Am J Respir Crit CareMed 2006;174(5):605-614.

Myers: I think the take-home mes-sage is that grading the evidence isjust the first step. We shouldn’t bediscouraged by evidence grades of Cor D; they just identify gaps in theevidence and questions on which weneed randomized controlled trials. Idon’t look at a low evidence grade asa detriment to or a negative compo-nent of the guidelines, but as a spur tothought and research to support or re-fute the recommendations and perhapstake a different approach. The problemis that it’s kind of a “surgeon-based”approach to evidence-based medicine,in that we are not going to do some-thing that is detrimental or even that wedon’t think is beneficial to the patientjust to get the level of evidence up.

Enright: You are a bit more opti-mistic than I am, because identifyingand recognizing important gaps in theevidence doesn’t mean the research isgoing to get funded. The professionalsocieties are not set up to fill thoseevidence gaps, and the NHLBI [Na-tional Heart, Lung, and Blood Insti-tute] is very slow to do so.

Rubin:* Tim mentioned the superb1999 Canadian guidelines,1 which werecertainly well in advance of others. Thatwas during the time that the MedicalResearchCouncilwasbeingreorganizedinto the Canadian Institutes of HealthResearch (CIHR), which is similar tothe NIH [National Institutes of Health].One of the things the guidelines com-mittee was charged with was specifi-cally developing recommendations forfurther studies and further funding, tohelp guide the CIHR. The CIHR lis-tened and were responsive to thoseguidelines, and used them to considerstudy proposals. So it was a nice inter-action. Perhaps we should be thinkingthe same way, just as optimistically, ifwe can identify in these papers, in meet-ings like this, and in guidelines wheredata are lacking and why it’s importantthat we develop it. I think we might beable to influence some of the fundingagencies. The voice will be loud enough.

1. Becker A, Lemiere C, Berube D, BouletLP, Ducharme FM, FitzGerald M, KovesiT; Asthma guidelines working group of theCanadian Network for Asthma Care. Sum-mary of recommendations from the Cana-dian Asthma Consensus guidelines, 2003.CMAJ 2005;173(6 Suppl):S3-S11.

Stoloff:† The 1997 NAEPP asthmaguidelines, which we started develop-ing in late 1994, were as evidence-based as possible. It was the first timewe had used Jadad’s process to eval-uate and grade the evidence. We madeour recommendations based on theavailable studies, and knowing that inthe future there would be more robustdata. The robust data comes out ofevidence reports—Canadian, British,American, GINA—where questionsare raised within the documents thatresearchers both in translational and

basic sciences have identified as in-teresting and worth studying.

Clearly, in all these guidelines whatyou find when you start making a newone is the amount of literature that hascome forth as a result of questionsraised in the guidelines, which is oneof the major reasons it’s done. Tim,what to you were the striking changesbetween the latest version of the GINAguidelines and the NAEPP guidelines?

Myers: They are very similar. Thebiggest differences is that the GINAguidelines are for a global audience,because their mission is to improveasthma care all over the world, whereasthe NAEPP guidelines are more spe-cific to the United States style ofasthma management, though they didincorporate recommendations and ev-idence from the other guidelines andfrom other patients. But they are sim-ilar, as are the 1999 Canadian guide-lines. One difference is that theygrade the evidence a little differently,which sometimes makes it difficult tocompare the evidence grades betweenthe guidelines. They are all similarwith regard to the layout, the way theyprovide recommendations, the waythey drive home key points, and wherethey found that the evidence wasn’tstrong and needed more work.

Stoloff: On the NAEPP guidelinespanel we wanted to do cost/benefit anal-yses of all the different interests, in ad-dition to pharmacotherapy, but theNHLBI told us very clearly that we werenot allowed to comment on that. Thatwas not the panel’s purview. In the fu-ture there will be ways they approachthat, but the NHLBI was appropriatelyconcerned about how that would comeout, because they are a federal agency.

Kercsmar: You mentioned that 70%of asthma care is rendered in a pri-mary care setting. With the 1997NAEPP guidelines the implementationdidn’t match the dissemination. I sus-pect the same thing will happen withthe 2007 NAEPP guidelines. It’s a very

* Bruce K Rubin MD MEngr MBA FAARC,Department of Pediatrics, Wake Forest Univer-sity School of Medicine, Winston Salem, NorthCarolina.† Stuart W Stoloff MD, Department of Familyand Community Medicine, University of Ne-vada, Reno, Nevada, representing Monaghan/Trudell Medical.



different paradigm; there’s more em-phasis on monitoring and control.There is a call for doing things thatare probably beyond what can be doneeasily in most primary care settings.

As we’ve seen from the ACE[Asthma Control Evaluation] trial1

data, asthma care and management inthe hands of specialists is much moreeffective, even in difficult populations,where we can do this kind of care.There probably aren’t enough special-ists to provide that care. We have theinterface with RTs, who we would liketo be an adjunct to providing specialtycare, and they may be a group that hasthe knowledge and tools to do someof this asthma management. However,how are we going to resolve this ten-sion between evidence-based guide-lines that we’d like to not only dis-seminate but implement in settings thatmay be ill-equipped to do so?

1. Inner-City Asthma Consortium. Evaluationof an asthma treatment strategy based onexhaled nitric oxide measurements in ado-lescents: the Asthma Control and Evalua-tion (ACE) trial. http://clinicaltrials.gov.Accessed March 20, 2008.

Myers: The 2007 NAEPP asthmaguidelines are very outcomes-focused.A separate committee was spun off tolook at implementing the guidelines,building on past successes, and ad-dressing past failures.

Kallstrom: Yes, the implementationcommittee is a multidisciplinary group.They’re trying to avoid mistakes madewith the previous versions of the guide-lines and to put the document in thehands of people who can really use it.It’s been 10 years since we updated theNAEPP guidelines, Stuart, how do yousee the next version coming forth?

Stoloff: The next? You mean afterwhat we just did? Some individuals inthe present group said that they won’tbe in the next group; the work load ofthis project is very heavy. You do thisbecause you love it, but the workloadover the three and a half years was farmore than any of us anticipated. We did

not want to rewrite the report; we wantedto do a rapid—“rapid” in federal gov-ernment terms—update, similar to the2002 update of the NAEPP guidelines,and address a few questions that are im-portant to certain audiences, but in amuch shorter period. This piece of workwas enormous. Few people in theNHLBI participated in facilitating thisprocess; it was really the clinicians onthe committee who wrote the report anddid the grunt work.

I am for more concerned about im-plementation, because there are enor-mous differences between the GINAguidelines and the 2007 NAEPP guide-lines. The 2007 NAEPP guidelines isthe most evidence-based report ever pro-duced on asthma. The Lancet,1 on Sep-tember 8th, 2007, said the 2007 NA-EPP guidelines are “brilliant,” anddescribed the 1997 version as averageor less. To have The Lancet—the Brit-ish group—say that these guidelines arerigorous and meet the standards of ev-idenced-based medicine in an editoriallisted on the cover is an enormous pos-itive for the members of the NAEPPcommittee, the NHLBI, and for all ofyou here who contributed their hardwork in basic science, translational sci-ence, and clinical science, as well as forthe networks that Chris [Sorkness] ispart of. The networks are a crucial meansof answering important questions.

So I think that GINA pales in com-parison. GINA deals with countrieswhere the major asthma medicinesmight be theophylline, oral steroids,and oral bronchodilators—which noneof us would use any more. GINA ad-dresses the needs of less developedcountries and does it exceedingly well,but there are important differences inhow we see asthma therapy, in whatrole we see therapy. There’s no men-tion of immunotherapy in GINA,whereas we considered it, or of$12,000 medications such as Xolair.So there are enormous differences. Butthe concern we all have is identical:dissemination to and implementationby clinicians, and facilitating asthmaco-management between specialists

and their primary-care colleagues. Ithink developing those “bridges” ismandatory for this document to “live.”

What a guideline is: you get in yourcar, you turn it on. Neither the car noryou is a guideline. You drive downthe road; still not a guideline. A signsays Tucson, Phoenix, Peoria; that’sthe guideline; you get to choose. Youchoose your direction based on yoursituation and the best evidence. That’swhat our guideline is. Our hope is tofacilitate this communication. Thoughit’s 417 pages, I think this documentis actually simple. It talks about achronic disease model, about impair-ment and risk, and about followingpatients carefully, no differently thanwe should do in diabetes, hypertension,hyperlipidemia, and other chronic dis-eases. That’s the education we need todisseminate, whether you’re a subspe-cialist or a primary-care clinician withspecial interest in it. RTs have a role,pharmacists have a role, medical assis-tants, nurses—everyone needs to be en-gaged in this, because so far we haven’tdone it well enough.

1. New guidelines for better asthma control.Lancet 2007;370(9590):802.

Moores: I don’t think any of us havethe answer for guideline implementa-tion. That’s probably a conference inand of itself. My bias, coming fromthe ACCP [American College of ChestPhysicians], where I think we do a lotof good guidelines on other subjects—maybe one thing that’s changed in theenvironment that— good or bad—might help is in the area of patientsafety and looking at pay-for-perfor-mance initiatives. Perhaps more im-portantly, maintenance of certificationand licensure—all of those forces area little different than they were whenwe first started putting out guidelines,and they’re going to force us to lookat some of these measures that aredone. We are going to have to startsaying that if you’re not following theevidence-based guidelines, you’re notmeeting the standard of care.



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