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The ABCs of Asthma Control
CONCISE ATTAINING ASTHMA REVIEW CONTROL FOR IN 4 EASY CLINICIANS STEPS
The ABCs of Asthma Control BJORG THORSTEINSDOTTIR, MD; GERALD W. VOLCHECK, MD; BO ENEMARK MADSEN, MD; ASHOKAKUMAR M. PATEL, MD; JAMES T. C. LI, MD, PhD; AND KAISER G. LIM, MD On completion of this article, you should be able to: (1) properly assess impairment using the new asthma guidelines, (2) integrate the Asthma Control Test questionnaire in routine asthma office visits, and (3) facilitate review of confounding factors and comorbidities of uncontrolled asthma using the mnemonic AIRESMOG. The new asthma guidelines have introduced impairment and risk assessments into the management of asthma. Impairment assessment is based on symptom frequency and pulmonary function, whereas risk assessment is based on exacerbation frequency and severity. These 2 measures determine the initial severity of asthma in the untreated patient as well as the degree of control in asthma once treatment has been initiated. The focus on asthma control is important because the attainment of control correlates with a better quality of life and reduction in health care use. We describe 4 easy steps to achieving asthma control in the ambulatory practice setting: (1) a standardized assessment of asthma symptoms using a 5-question assessment tool called the Asthma Control Test, (2) a simple mnemonic that provides a systematic review of the comorbidities and clinical variables that contribute to uncontrolled asthma, (3) directed patient education, and (4) a schedule for ongoing care. Most if not all patients can achieve good control of their asthma with optimal care through an active partnership with their health care professionals.
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ACT = Asthma Control Test; GINA = Global Initiative for Asthma; NAEPP = National Asthma Education and Prevention Program
T
he concept of asthma control has assumed center stage in both the new Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) guidelines.1,2 The NAEPP introduced the term impairment (Figure 1) to refer to the assessment of lung function and of the intensity and frequency of asthma symptoms.2 The term risk refers to exacerbation frequency and severity. These 2 parameters determine whether a patient’s disease burden from asthma is under clinical control. Asthma control, which is an assessment of symptom frequency and lung function once treatment has been From the Division of Primary Care Internal Medicine (B.T.), Division of Allergic Diseases (G.W.V., J.T.C.L., K.G.L.), Department of Emergency Medicine (B.E.M.), and Division of Pulmonary and Critical Care Medicine (A.M.P., K.G.L.), Mayo Clinic, Rochester, MN. Dr Thorsteinsdottir is now with Harvard Medical School, Boston, MA. Dr Madsen is now with Beth Israel Deaconess Medical Center, Boston, MA. Individual reprints of this article are not available. Address correspondence to Kaiser G. Lim, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 ([email protected]). © 2008 Mayo Foundation for Medical Education and Research
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started, must be differentiated from asthma severity, which is an assessment of disease intensity before the start of therapy.3 Separating the 2 concepts dispels the common misperception that well-controlled asthma is synonymous with mild asthma and that poorly controlled asthma is synonymous with severe asthma.3 More importantly, the degree of asthma control can be used as a clinical outcome measure for titrating anti-inflammatory medications.4 In the new NAEPP guideline, asthma severity categorization is still used but has more relevance when initiating therapy in treatment-naive patients or in those with newly diagnosed asthma. The new stepwise treatment recommends that adjustments in controller therapy now be based on the level of asthma control and risk reduction for asthma exacerbation.1,2 Minimizing impairment and risk is the goal of therapy for all levels of asthma severity.1,2 The attainment of asthma control correlates with improved quality of life and reduced health care use.5,6 Asthma control has emerged as an aggregate outcome measure of disease severity, confounding comorbidities, pharmacologic and nonpharmacologic interventions, and adherence totherapy.1,5-7 This review focuses on how to assess impairment and achieve asthma control. ATTAINING ASTHMA CONTROL STEP 1: USE A STANDARDIZED QUESTIONNAIRE TO ASSESS ASTHMA CONTROL Asthma is one of the most common chronic diseases in children and in adults in the reproductive age range. Despite expert guidelines and medications with demonstrated efficacy, asthma continues to be undertreated because patients and health care professionals underestimate disease severity.8,9 Clinicians frequently fail to ask and/or document longitudinally the basic set of clinical information required to assess whether asthma is under control.10,11 Their failure to do so inevitably leads to inconsistency and variability in clinical decision making and practice. Each clinical encounter in primary care, even those that are unrelated to asthma, should be considered an opportunity to assess asthma control. Assessment can be facilitated by
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ATTAINING ASTHMA CONTROL IN 4 EASY STEPS
Classification of asthma severity ≥12 y
Components of severity
Persistent Intermittent ≤2 d /wk
Symptoms
Impairment Normal FEV1/FVC: 8-19 y 85% 20-39 y 80% 40-59 y 75% 60-80 y 70%
Nighttime awakenings
≤2 times /mo
Short-acting β2-agonist use for symptom control (not prevention of EIB)
≤2 d /wk
Interference with normal activity
Mild
Moderate
>2 d/wk but not daily
Daily
Throughout the day
>1 time/wk but not nightly
Often 7 times/wk
Daily
Several times/d
3-4 times/mo >2 d/wk but not daily, and not more than 1 time on any day
None
Minor limitation
Extremely limited
Normal FEV1 between exacerbations Lung function
F EV1 >80% predicted
F EV1 >80% predicted
F EV1 >60% but <80% predicted
F EV1 <60% predicted
F EV1/FVC normal
F EV1/FVC normal
F EV1/FVC reduced 5%
F EV1/FVC reduced >5%
≥2/y
0-1/y
Risk
Some limitation
Severe
Exacerbations requiring oral systemic corticosteroids
Consider severity and interval since last exacerbation Frequency and severity may fluctuate over time for patients in any severity category Relative annual risk of exacerbations may be related to FEV1 Step 3
Recommended step for initiating t reatment
Step 1
Step 2
Step 4 or 5
and consider short course of oral systemic corticosteroids
In 2-6 wk, evaluate level of asthma control that is achieved and adjust therapy accordingly
(See Figure 3 for treatment steps)
FIGURE 1. National Asthma Education and Prevention Program (NAEPP) Expert Panel 3 categorization of asthma control and stepwise approach to adjusting asthma treatment in patients aged 12 years and older. EIB = exercise-induced bronchoconstriction; FEV1= forced expiratory volume in the first second of expiration; FVC = forced vital capacity. Adapted from reference 2.
using the Asthma Control Test (ACT) (QualityMetric Incorporated, Lincoln, RI), a one-page asthma control questionnaire (Figure 2) that is validated for use in the primary care setting as well as in specialty clinics.12-17 The developers of the questionnaire started with 22 questions to catalog the frequency and intensity of asthma symptoms, use of asthma medications, and the effect of asthma on daily activities. By stepwise logistic regression, these 22 questions were trimmed to the 5 items that have the greatest agreement with a specialist’s assessment. The ACT score was then subjected to prospective validation by comparison with the specialist’s rating of asthma control, the patient’s lung function, and the influence on the specialist’s decision to change therapy. Designed for self-administration, this simple questionnaire can be completed while patients are waiting in the lobby for their appointment. The 5 items on the ACT questionnaire (Figure 2) cover the 4 weeks14 before the visit and include an assessment of the number of work Mayo Clin Proc.
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days lost or school days missed, dyspnea frequency, rescue medication requirement, nocturnal awakenings, and selfassessment of asthma control. These parameters are known sources of patient dissatisfaction with asthma care.18 Each answer corresponds to a numeric score; these scores are totaled to arrive at the ACT score. The ACT questionnaire is available in Spanish and in a version intended for children (http://www.asthmacontrol.com). By serving as an educational tool for patients (ie, symptom monitoring), the questionnaire can simplify the clinician’s job. The NAEPP uses the ACT score to categorize degree of control: an ACT score of 20 or more indicates that asthma is well controlled; 16 through 19, that it is not well controlled; and 15 or lower, that it is poorly controlled.2 On the basis of these categorizations, recommendations to step up or step down asthma treatment can be made (Figure 3). The ACT may help overcome some of the problems regarding symptom perception in asthma, including differing
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Asthma Control Test This survey was designed to help you describe your asthma and how your asthma affects how you feel in the one box that best describes your and what you are able to do. To complete it, please mark an answer. 1. I n the past 4 w eeks, how much of the time did your asthma keep you from getting as much done at w ork, school or at home? All of the time
Most of the time
1
2.
2
None of the time
4
3
5
Not at all
4
5
During the past 4 w eeks, how often did your asthma symptoms ( w heezing, coughing, shortness of breath, chest tightness or pain) w ake you up at night or earlier than usual in the morning? 4 or more 2 to 3 nights a week nights a week Once a week Once or Twice Not at all
2
3
4
5
During the past 4 w eeks, how often have you used your rescue inhaler or nebulizer medication ( such as Albuterol, Ventolin , Proventil , Maxair or Primatene Mist ) ? 3 or more times per day
1 or 2 times per day
1
5.
3
2
1
4.
A little of the time
During the past 4 w eeks, how often have you had shortness of breath? More than 3 to 6 Once or twice once a day Once a day times a week a week
1
3.
Some of the time
2 or 3 times per week
2
Once a week or less
3
4
How w ould you rate your asthma control during the past 4 w eeks? Not Controlled Poorly Somewhat Well at all Controlled Controlled Controlled
1
2
3
4
Not at all
5
Completely Controlled
5
FIGURE 2. The Asthma Control Test. Copyright 2002, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated.
sensitivity in symptom perception, discrimination between intensity of symptoms, and reliability of clinical symptoms.19 The ACT has been shown to be reliable, valid, and responsive to changes in asthma control over time.14 Review of the questionnaire also helps physicians foster a partnership with patients and engage them in their own asthma management. STEP 2: TROUBLESHOOT IF ASTHMA IS NOT UNDER CONTROL If asthma is not under control (ACT score, <20), it is helpful to quickly run through a list of common factors affecting control. We offer an easy mnemonic to help the clinician quickly review potential causes of poor asthma 816
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control and determine which aspect of asthma treatment requires intensification or whether further diagnostic evaluation is necessary (Table).2,20-47 STEP 3: EDUCATE THE PATIENT Clinicians often underestimate the severity of their patients’ disease state and overestimate their patients’ knowledge of disease management.48 They assume that their patients are aware of the differences between reliever and maintenance medications and overestimate the number of patients with a current written action plan. If consistently used as a symptom checklist in the physician’s office and at home, the ACT can be a helpful tool for teaching patients about
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ATTAINING ASTHMA CONTROL IN 4 EASY STEPS
Persistent asthma: daily medication
Intermittent asthma
Consult with asthma specialist if step 4 care or higher is required Consider consultation at step 3
Step 6 Step 5 Preferred:
Step 4 Step 3 Step 2 Low-dose ICS
Low-dose ICS + LABA OR Medium-dose ICS
Alternative:
Alternative:
Cromolyn, LTRA, nedocromil, or theophylline
Low-dose ICS + either LTRA, theophylline, or zileuton
Preferred:
Step 1 Preferred: SABA, as needed
Preferred:
High-dose ICS + LABA
Preferred: Medium-dose ICS + LABA
Alternative: Mediium-dose ICS + either LTRA, theophylline, or zileuton
Preferred: High-dose ICS + LABA + oral corticosteroid
AND
AND
Consider omalizumab for patients who have allergies
Consider omalizumab for patients who have allergies
Step up if needed (first, check adherence, environmental control, and comorbid conditions)
Assess control Step down if possible
Each step: Patient education, environmental control, and management of comorbidities Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
(and asthma is well controlled at least 3 months)
Quick-relief medication for all patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed. Use of SABA >2 d/wk for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment
FIGURE 3. National Asthma Education and Prevention Program Expert Panel 3 Stepwise Approach for Asthma Control. EIB = exercise-induced bronchoconstriction; ICS = inhaled corticosteroid; LABA = long-acting β-agonist; LTRA = leukotriene receptor antagonist; SABA = short-acting βagonist. Adapted from reference 2.
asthma control. The patient can use a peak flow meter as an objective measure of lung f unction; however, the patient must be instructed on the proper use of the peak flow meter because it is very effort dependent. The patient’s personal best should be used to avoid overtreatment based on predicted values.49 Because the other goal in the management of asthma is to minimize the severity and duration of asthma exacerbations, any self-management TABLE. AIRESMOG Mnemonic for Contributors to Asthma A I R E S M O G
Allergy2,20-22 and Adherence to therapy23-26 Infection20 and Inflammation27,28 Rhinitis29,30 and Rhinosinusitis31-33 Exercise34,35 and Error in diagnosis Smoking36-38 and pSychogenic factors31 Medications (β-blockers, angiotensin-converting enzyme inhibitor, aspirin) Occupational exposures,39 Obesity,40-42 and Obstructive sleep apnea31,43 Gastroesophageal reflux disease44-47
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plan must be geared toward early recognition of an asthma attack50 and should include behavioral skills to adjust medications primarily through the use of a written asthma action plan. The written asthma action plan serves as a contingency prescription to be activated when there is worsening of asthma control.2 The ideal written asthma action plan should be simple and readable and should incorporate monitoring of symptoms and lung function with contingency instructions regarding medication changes.51-53 Patients should be instructed (1) how to monitor symptoms with the ACT, (2) how to monitor lung function with a peak flow meter, and (3) how to use a written asthma action plan. The last item will put asthma triggers, medication use, and inhaler technique in context. Patients should participate actively in the management of their disease,2 and health care professionals can engage patients in a dialogue regarding the role of long-term control medications and quick-relief medications, inhaler technique, confounding factors, and a
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self-management plan.3,54 A recent systematic review of randomized controlled trials of asthma self-management and education confirmed their efficacy in reducing hospitalizations, emergency department visits, and nocturnal symptoms.55 STEP 4: BRING THE PATIENT BACK FOR MONITORING Patients with uncontrolled asthma must have scheduled follow-up visits to ensure adequate response to intensification of therapy. Overtreatment and undertreatment occur because of inadequate follow-up.56 The NAEPP and GINA have excellent stepwise care plans to achieve control (Figure 3).1,2 For maintenance of control, inhaled corticosteroids are the preferred anti-inflammatory therapy for all patients with persistent asthma and for those who have frequent exacerbations. A stepwise intensification of therapy is advised for any patient who has uncontrolled or poorly controlled asthma (Figure 3). Patients should be seen 2 to 6 weeks after treatment intensification to assess for response. If results at baseline or at time of therapy intensification are abnormal, lung function tests, particularly spirometry, should be repeated. After confounding AIRESMOG factors have been reviewed, asthma medication should be intensified to achieve control. Once control has been attained, stepping down the medication intensity should be considered. After 3 months of stability on the current dose of controller medication,57 a step down in medication intensity should be attempted because little incremental benefit can be expected thereafter.28 Objective measurement of pulmonary function as well as exhaled nitric oxide can help guide clinicians in stepping down treatment.58 After discontinuation of inhaled corticosteroids, re sidual anti-in flammatory effects can still be observed for 2 weeks58,59 and airway inflammation can take a few weeks to increase, causing a substantial lag between stepping down of treatment and worsening of asthma symptoms.60 To maintain asthma control, the patient should be seen for a scheduled followup evaluation 12 weeks (or earlier if symptoms occur) after each decremental change in asthma medications.2,61 In any practice, only a few atients p will have frequent and severe exacerbations. These patients ay m require closer follow-up (every 3 to 6 months) to maximize opportunities to intervene and monitor and minimize impairment and risk. PUTTING IT ALL TOGETHER Patients should be taught to assess asthma control with the ACT monthly. Clinicians can then assess the ACT score at every clinical encounter and, if asthma is not under control, review the clinical history with the mnemonic AIRESMOG. On the basis of the review, they should 818
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consider whether referral to a specialist is appropriate or whether further diagnostic testing is needed to confirm diagnosis and/or rule out other diseases that confound or mimic asthma. To reassess asthma control, clinicians should schedule asthma follow-up within 2 to 6 weeks after each change in medication during treatment intensification (earlier if necessary owing to further deterioration). Patients whose medication is being stepped down should be followed up in 12 weeks (or earlier if symptoms recur). Scheduled follow-up is the key to a successful step-up or step-down approach to controlling asthma. Clinicians should empower patients to be active participants in managing their disease through education and a written asthma action plan. CONCLUSION Through an active partnership with their health care professionals, most patients can achieve good control of their asthma with symptom monitoring, optimal pharmacotherapy, and control of confounding factors.
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CME Questions About Attaining Asthma Control 1. Which one of the following is not used to assess impairment from asthma? a. Symptoms b. Nighttime awakenings c. Interference with normal activity d. Acute bronchodilator use e. Exacerbations 2. Which one of the following statements about the Asthma Control Test (ACT) is false? a. Lung function testing is required to obtain a score b. Asthma symptoms during the previous 4 weeks are used to help determine the ACT score c. An ACT score of less than 20 means uncontrolled asthma d. An ACT score of less than 16 means very poorly controlled asthma e. The ACT score can be used to adjust asthma medications 3. Which one of the following statements regarding comorbidities is false? a. Severe chronic rhinosinusitis has an adjusted odds ratio of 5.5 for frequent exacerbations b. Psychological dysfunction has an adjusted odds ratio of 11.7 for frequent exacerbations
c. Gastroesophageal reflux disease has an adjusted odds ratio of 4.9 for frequent exacerbations d. Patients with asthma who smoke have the same response to inhaled corticosteroids as those who do not smoke e. Nonadherence to medication is a serious cause of poor asthma control 4. Which one of the following is not used in the assessment of asthma risk? a. Progressive lung function decline b. Frequency and severity of exacerbations c. Adverse reaction to treatment d. Nonadherence to therapy e. Frequency of oral corticosteroid use 5. Which one of the following statements regarding asthma treatment is true? a. Lung function and symptoms continue to improve more than 3 months after intensification of therapy b. Residual effects of anti-inflammatory therapy disappear in a few days after dose reduction or discontinuation c. Medication should be adjusted only on the basis of results of lung function tests (eg, spirometry) d. Medication should be adjusted to reduce frequent exacerbations e. Asthma control can be attained only in mild to moderate persistent asthma
This activity was designated for 1 AMA PRA Category 1 Credit(s).™
The Concise Review for Clinicians contributions are a CME activity, and answers to the questions are not published in the print journal. For CME credit and the answers, see the onlink our Web site at mayoclinicproceedings.com.
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The ABCs of Asthma Control BJORG THORSTEINSDOTTIR, MD; GERALD W. VOLCHECK, MD; BO ENEMARK MADSEN, MD; ASHOKAKUMAR M. PATEL, MD; JAMES T. C. LI, MD, PhD; AND KAISER G. LIM, MD On completion of this article, you should be able to: (1) properly assess impairment using the new asthma guidelines, (2) integrate the Asthma Control Test questionnaire in routine asthma office visits, and (3) facilitate review of confounding factors and comorbidities of uncontrolled asthma using the mnemonic AIRESMOG. The new asthma guidelines have introduced impairment and risk assessments into the management of asthma. Impairment assessment is based on symptom frequency and pulmonary function, whereas risk assessment is based on exacerbation frequency and severity. These 2 measures determine the initial severity of asthma in the untreated patient as well as the degree of control in asthma once treatment has been initiated. The focus on asthma control is important because the attainment of control correlates with a better quality of life and reduction in health care use. We describe 4 easy steps to achieving asthma control in the ambulatory practice setting: (1) a standardized assessment of asthma symptoms using a 5-question assessment tool called the Asthma Control Test, (2) a simple mnemonic that provides a systematic review of the comorbidities and clinical variables that contribute to uncontrolled asthma, (3) directed patient education, and (4) a schedule for ongoing care. Most if not all patients can achieve good control of their asthma with optimal care through an active partnership with their health care professionals.
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ACT = Asthma Control Test; GINA = Global Initiative for Asthma; NAEPP = National Asthma Education and Prevention Program
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he concept of asthma control has assumed center stage in both the new Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) guidelines.1,2 The NAEPP introduced the term impairment (Figure 1) to refer to the assessment of lung function and of the intensity and frequency of asthma symptoms.2 The term risk refers to exacerbation frequency and severity. These 2 parameters determine whether a patient’s disease burden from asthma is under clinical control. Asthma control, which is an assessment of symptom frequency and lung function once treatment has been From the Division of Primary Care Internal Medicine (B.T.), Division of Allergic Diseases (G.W.V., J.T.C.L., K.G.L.), Department of Emergency Medicine (B.E.M.), and Division of Pulmonary and Critical Care Medicine (A.M.P., K.G.L.), Mayo Clinic, Rochester, MN. Dr Thorsteinsdottir is now with Harvard Medical School, Boston, MA. Dr Madsen is now with Beth Israel Deaconess Medical Center, Boston, MA. Individual reprints of this article are not available. Address correspondence to Kaiser G. Lim, MD, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905 ([email protected]). © 2008 Mayo Foundation for Medical Education and Research
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started, must be differentiated from asthma severity, which is an assessment of disease intensity before the start of therapy.3 Separating the 2 concepts dispels the common misperception that well-controlled asthma is synonymous with mild asthma and that poorly controlled asthma is synonymous with severe asthma.3 More importantly, the degree of asthma control can be used as a clinical outcome measure for titrating anti-inflammatory medications.4 In the new NAEPP guideline, asthma severity categorization is still used but has more relevance when initiating therapy in treatment-naive patients or in those with newly diagnosed asthma. The new stepwise treatment recommends that adjustments in controller therapy now be based on the level of asthma control and risk reduction for asthma exacerbation.1,2 Minimizing impairment and risk is the goal of therapy for all levels of asthma severity.1,2 The attainment of asthma control correlates with improved quality of life and reduced health care use.5,6 Asthma control has emerged as an aggregate outcome measure of disease severity, confounding comorbidities, pharmacologic and nonpharmacologic interventions, and adherence totherapy.1,5-7 This review focuses on how to assess impairment and achieve asthma control. ATTAINING ASTHMA CONTROL STEP 1: USE A STANDARDIZED QUESTIONNAIRE TO ASSESS ASTHMA CONTROL Asthma is one of the most common chronic diseases in children and in adults in the reproductive age range. Despite expert guidelines and medications with demonstrated efficacy, asthma continues to be undertreated because patients and health care professionals underestimate disease severity.8,9 Clinicians frequently fail to ask and/or document longitudinally the basic set of clinical information required to assess whether asthma is under control.10,11 Their failure to do so inevitably leads to inconsistency and variability in clinical decision making and practice. Each clinical encounter in primary care, even those that are unrelated to asthma, should be considered an opportunity to assess asthma control. Assessment can be facilitated by
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ATTAINING ASTHMA CONTROL IN 4 EASY STEPS
Classification of asthma severity ≥12 y
Components of severity
Persistent Intermittent ≤2 d /wk
Symptoms
Impairment Normal FEV1/FVC: 8-19 y 85% 20-39 y 80% 40-59 y 75% 60-80 y 70%
Nighttime awakenings
≤2 times /mo
Short-acting β2-agonist use for symptom control (not prevention of EIB)
≤2 d /wk
Interference with normal activity
Mild
Moderate
>2 d/wk but not daily
Daily
Throughout the day
>1 time/wk but not nightly
Often 7 times/wk
Daily
Several times/d
3-4 times/mo >2 d/wk but not daily, and not more than 1 time on any day
None
Minor limitation
Extremely limited
Normal FEV1 between exacerbations Lung function
F EV1 >80% predicted
F EV1 >80% predicted
F EV1 >60% but <80% predicted
F EV1 <60% predicted
F EV1/FVC normal
F EV1/FVC normal
F EV1/FVC reduced 5%
F EV1/FVC reduced >5%
≥2/y
0-1/y
Risk
Some limitation
Severe
Exacerbations requiring oral systemic corticosteroids
Consider severity and interval since last exacerbation Frequency and severity may fluctuate over time for patients in any severity category Relative annual risk of exacerbations may be related to FEV1 Step 3
Recommended step for initiating t reatment
Step 1
Step 2
Step 4 or 5
and consider short course of oral systemic corticosteroids
In 2-6 wk, evaluate level of asthma control that is achieved and adjust therapy accordingly
(See Figure 3 for treatment steps)
FIGURE 1. National Asthma Education and Prevention Program (NAEPP) Expert Panel 3 categorization of asthma control and stepwise approach to adjusting asthma treatment in patients aged 12 years and older. EIB = exercise-induced bronchoconstriction; FEV1= forced expiratory volume in the first second of expiration; FVC = forced vital capacity. Adapted from reference 2.
using the Asthma Control Test (ACT) (QualityMetric Incorporated, Lincoln, RI), a one-page asthma control questionnaire (Figure 2) that is validated for use in the primary care setting as well as in specialty clinics.12-17 The developers of the questionnaire started with 22 questions to catalog the frequency and intensity of asthma symptoms, use of asthma medications, and the effect of asthma on daily activities. By stepwise logistic regression, these 22 questions were trimmed to the 5 items that have the greatest agreement with a specialist’s assessment. The ACT score was then subjected to prospective validation by comparison with the specialist’s rating of asthma control, the patient’s lung function, and the influence on the specialist’s decision to change therapy. Designed for self-administration, this simple questionnaire can be completed while patients are waiting in the lobby for their appointment. The 5 items on the ACT questionnaire (Figure 2) cover the 4 weeks14 before the visit and include an assessment of the number of work Mayo Clin Proc.
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days lost or school days missed, dyspnea frequency, rescue medication requirement, nocturnal awakenings, and selfassessment of asthma control. These parameters are known sources of patient dissatisfaction with asthma care.18 Each answer corresponds to a numeric score; these scores are totaled to arrive at the ACT score. The ACT questionnaire is available in Spanish and in a version intended for children (http://www.asthmacontrol.com). By serving as an educational tool for patients (ie, symptom monitoring), the questionnaire can simplify the clinician’s job. The NAEPP uses the ACT score to categorize degree of control: an ACT score of 20 or more indicates that asthma is well controlled; 16 through 19, that it is not well controlled; and 15 or lower, that it is poorly controlled.2 On the basis of these categorizations, recommendations to step up or step down asthma treatment can be made (Figure 3). The ACT may help overcome some of the problems regarding symptom perception in asthma, including differing
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Asthma Control Test This survey was designed to help you describe your asthma and how your asthma affects how you feel in the one box that best describes your and what you are able to do. To complete it, please mark an answer. 1. I n the past 4 w eeks, how much of the time did your asthma keep you from getting as much done at w ork, school or at home? All of the time
Most of the time
1
2.
2
None of the time
4
3
5
Not at all
4
5
During the past 4 w eeks, how often did your asthma symptoms ( w heezing, coughing, shortness of breath, chest tightness or pain) w ake you up at night or earlier than usual in the morning? 4 or more 2 to 3 nights a week nights a week Once a week Once or Twice Not at all
2
3
4
5
During the past 4 w eeks, how often have you used your rescue inhaler or nebulizer medication ( such as Albuterol, Ventolin , Proventil , Maxair or Primatene Mist ) ? 3 or more times per day
1 or 2 times per day
1
5.
3
2
1
4.
A little of the time
During the past 4 w eeks, how often have you had shortness of breath? More than 3 to 6 Once or twice once a day Once a day times a week a week
1
3.
Some of the time
2 or 3 times per week
2
Once a week or less
3
4
How w ould you rate your asthma control during the past 4 w eeks? Not Controlled Poorly Somewhat Well at all Controlled Controlled Controlled
1
2
3
4
Not at all
5
Completely Controlled
5
FIGURE 2. The Asthma Control Test. Copyright 2002, by QualityMetric Incorporated. Asthma Control Test is a trademark of QualityMetric Incorporated.
sensitivity in symptom perception, discrimination between intensity of symptoms, and reliability of clinical symptoms.19 The ACT has been shown to be reliable, valid, and responsive to changes in asthma control over time.14 Review of the questionnaire also helps physicians foster a partnership with patients and engage them in their own asthma management. STEP 2: TROUBLESHOOT IF ASTHMA IS NOT UNDER CONTROL If asthma is not under control (ACT score, <20), it is helpful to quickly run through a list of common factors affecting control. We offer an easy mnemonic to help the clinician quickly review potential causes of poor asthma 816
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control and determine which aspect of asthma treatment requires intensification or whether further diagnostic evaluation is necessary (Table).2,20-47 STEP 3: EDUCATE THE PATIENT Clinicians often underestimate the severity of their patients’ disease state and overestimate their patients’ knowledge of disease management.48 They assume that their patients are aware of the differences between reliever and maintenance medications and overestimate the number of patients with a current written action plan. If consistently used as a symptom checklist in the physician’s office and at home, the ACT can be a helpful tool for teaching patients about
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ATTAINING ASTHMA CONTROL IN 4 EASY STEPS
Persistent asthma: daily medication
Intermittent asthma
Consult with asthma specialist if step 4 care or higher is required Consider consultation at step 3
Step 6 Step 5 Preferred:
Step 4 Step 3 Step 2 Low-dose ICS
Low-dose ICS + LABA OR Medium-dose ICS
Alternative:
Alternative:
Cromolyn, LTRA, nedocromil, or theophylline
Low-dose ICS + either LTRA, theophylline, or zileuton
Preferred:
Step 1 Preferred: SABA, as needed
Preferred:
High-dose ICS + LABA
Preferred: Medium-dose ICS + LABA
Alternative: Mediium-dose ICS + either LTRA, theophylline, or zileuton
Preferred: High-dose ICS + LABA + oral corticosteroid
AND
AND
Consider omalizumab for patients who have allergies
Consider omalizumab for patients who have allergies
Step up if needed (first, check adherence, environmental control, and comorbid conditions)
Assess control Step down if possible
Each step: Patient education, environmental control, and management of comorbidities Steps 2-4: Consider subcutaneous allergen immunotherapy for patients who have allergic asthma
(and asthma is well controlled at least 3 months)
Quick-relief medication for all patients SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of oral systemic corticosteroids may be needed. Use of SABA >2 d/wk for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment
FIGURE 3. National Asthma Education and Prevention Program Expert Panel 3 Stepwise Approach for Asthma Control. EIB = exercise-induced bronchoconstriction; ICS = inhaled corticosteroid; LABA = long-acting β-agonist; LTRA = leukotriene receptor antagonist; SABA = short-acting βagonist. Adapted from reference 2.
asthma control. The patient can use a peak flow meter as an objective measure of lung f unction; however, the patient must be instructed on the proper use of the peak flow meter because it is very effort dependent. The patient’s personal best should be used to avoid overtreatment based on predicted values.49 Because the other goal in the management of asthma is to minimize the severity and duration of asthma exacerbations, any self-management TABLE. AIRESMOG Mnemonic for Contributors to Asthma A I R E S M O G
Allergy2,20-22 and Adherence to therapy23-26 Infection20 and Inflammation27,28 Rhinitis29,30 and Rhinosinusitis31-33 Exercise34,35 and Error in diagnosis Smoking36-38 and pSychogenic factors31 Medications (β-blockers, angiotensin-converting enzyme inhibitor, aspirin) Occupational exposures,39 Obesity,40-42 and Obstructive sleep apnea31,43 Gastroesophageal reflux disease44-47
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plan must be geared toward early recognition of an asthma attack50 and should include behavioral skills to adjust medications primarily through the use of a written asthma action plan. The written asthma action plan serves as a contingency prescription to be activated when there is worsening of asthma control.2 The ideal written asthma action plan should be simple and readable and should incorporate monitoring of symptoms and lung function with contingency instructions regarding medication changes.51-53 Patients should be instructed (1) how to monitor symptoms with the ACT, (2) how to monitor lung function with a peak flow meter, and (3) how to use a written asthma action plan. The last item will put asthma triggers, medication use, and inhaler technique in context. Patients should participate actively in the management of their disease,2 and health care professionals can engage patients in a dialogue regarding the role of long-term control medications and quick-relief medications, inhaler technique, confounding factors, and a
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self-management plan.3,54 A recent systematic review of randomized controlled trials of asthma self-management and education confirmed their efficacy in reducing hospitalizations, emergency department visits, and nocturnal symptoms.55 STEP 4: BRING THE PATIENT BACK FOR MONITORING Patients with uncontrolled asthma must have scheduled follow-up visits to ensure adequate response to intensification of therapy. Overtreatment and undertreatment occur because of inadequate follow-up.56 The NAEPP and GINA have excellent stepwise care plans to achieve control (Figure 3).1,2 For maintenance of control, inhaled corticosteroids are the preferred anti-inflammatory therapy for all patients with persistent asthma and for those who have frequent exacerbations. A stepwise intensification of therapy is advised for any patient who has uncontrolled or poorly controlled asthma (Figure 3). Patients should be seen 2 to 6 weeks after treatment intensification to assess for response. If results at baseline or at time of therapy intensification are abnormal, lung function tests, particularly spirometry, should be repeated. After confounding AIRESMOG factors have been reviewed, asthma medication should be intensified to achieve control. Once control has been attained, stepping down the medication intensity should be considered. After 3 months of stability on the current dose of controller medication,57 a step down in medication intensity should be attempted because little incremental benefit can be expected thereafter.28 Objective measurement of pulmonary function as well as exhaled nitric oxide can help guide clinicians in stepping down treatment.58 After discontinuation of inhaled corticosteroids, re sidual anti-in flammatory effects can still be observed for 2 weeks58,59 and airway inflammation can take a few weeks to increase, causing a substantial lag between stepping down of treatment and worsening of asthma symptoms.60 To maintain asthma control, the patient should be seen for a scheduled followup evaluation 12 weeks (or earlier if symptoms occur) after each decremental change in asthma medications.2,61 In any practice, only a few atients p will have frequent and severe exacerbations. These patients ay m require closer follow-up (every 3 to 6 months) to maximize opportunities to intervene and monitor and minimize impairment and risk. PUTTING IT ALL TOGETHER Patients should be taught to assess asthma control with the ACT monthly. Clinicians can then assess the ACT score at every clinical encounter and, if asthma is not under control, review the clinical history with the mnemonic AIRESMOG. On the basis of the review, they should 818
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consider whether referral to a specialist is appropriate or whether further diagnostic testing is needed to confirm diagnosis and/or rule out other diseases that confound or mimic asthma. To reassess asthma control, clinicians should schedule asthma follow-up within 2 to 6 weeks after each change in medication during treatment intensification (earlier if necessary owing to further deterioration). Patients whose medication is being stepped down should be followed up in 12 weeks (or earlier if symptoms recur). Scheduled follow-up is the key to a successful step-up or step-down approach to controlling asthma. Clinicians should empower patients to be active participants in managing their disease through education and a written asthma action plan. CONCLUSION Through an active partnership with their health care professionals, most patients can achieve good control of their asthma with symptom monitoring, optimal pharmacotherapy, and control of confounding factors.
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13. Juniper EF, Bousquet J, Abetz L, Bateman ED GOAL Committee. Identifying ‘well-controlled’ and ‘not well-controlled’ asthma using the Asthma Control Questionnaire. Respir Med. 2006 Apr;100(4):616-621. Epub 2005 Oct 13. 14. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the Asthma Control Test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;113(1):59-65. 15. Skinner EA, Diette GB, Algatt-Bergstrom PJ, et al. The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents. Dis Manag. 2004 Winter;7(4):305-313. 16. Laforest L, Van Ganse E, Devouassoux G, et al. Management of asthma in patients supervised by primary care physicians or by specialists. Eur Respir J. 2006;27(1):42-50. 17. Schatz M, Sorkness CA, Li JT, et al. Asthma Control Test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol. 2006;117(3):549-556. 18. Markson LE, Vollmer WM, Fitterman L, et al. Insight into patient dissatisfaction with asthma treatment. Arch Intern Med. 2001;161(3):379384. 19. Banzett RB, Dempsey JA, O’Donnell DE, Wamboldt MZ. Symptom perception and respiratory sensation in asthma. Am J Respir Crit Care Med. 2000;162(3, pt 1):1178-1182. 20. Lemanske RF Jr, Robert F., Busse WW. Asthma: factors underlying inception, exacerbation, and disease progression. J Allergy Clin Immunol. 2006; 117(2 suppl Mini-Primer):S456-S461. 21. Rank MA, Li JT. Allergen immunotherapy. Mayo Clin Proc. 2007;82 (9):1119-1123. 22. D’Amato G. Role of anti-IgE monoclonal antibody (omalizumab) in the treatment of bronchial asthma and allergic respiratory diseases. Eur J Pharmacol. 2006 Mar 8;533(1-3):302-307. Epub 2006 Feb 7. 23. Schaffer SD, Tian L. Promoting adherence: effects of theory-based asthma education. Clin Nurs Res. 2004;13(1):69-89. 24. Allen SC, Ragab S. Ability to learn inhaler technique in relation to cognitive scores and tests of praxis in old age. Postgrad Med J. 2002;78 (915):37-39. 25. Katsara M, Donnelly D, Iqbal S, Elliot T, Everard ML. Relationship between exhaled nitric oxide levels and compliance with inhaled corticosteroids in asthmatic children. Respir Med. 2006 Sep;100(9):1512-1517. Epub 2006 Feb 28. 26. Beck-Ripp J, Griese M, Arenz S, Koring C, Pasqualoni B, Bufler P. Changes of exhaled nitric oxide during steroid treatment of childhood asthma. Eur Respir J. 2002;19(6):1015-1019. 27. O’Byrne PM, Parameswaran K. Pharmacological management of mild or moderate persistent asthma. Lancet. 2006;368(9537):794-803. 28. Sin DD, Man J, Sharpe H, Gan WQ, Man SF. Pharmacological management to reduce exacerbations in adults with asthma: a systematic review and meta-analysis. JAMA. 2004;292(3):367-376. 29. Rolla G, Guida G, Heffler E, et al. Diagnostic classification of persistent rhinitis and its relationship to exhaled nitric oxide and asthma: a clinical study of a consecutive series of patients. Chest. 2007 May;131(5):1345-1352. Epub 2007 Feb 22. 30. Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003;129(3 suppl):S1-S32. 31. ten Brinke A, Sterk PJ, Masclee AA, et al. Risk factors of frequent exacerbations in difficult-to-treat asthma. Eur Respir J. 2005;26(5):812-818. 32. Bousquet J, van Cauwenberge P, Khaltaev N. Allergic rhinitis and its impact on asthma. J Allergy Clin Immunol. 2001;108(5)(suppl):S147-S334. 33. Aggarwal R, Cardozo A, Homer JJ. The assessment of topical nasal drug distribution. Clin Otolaryngol Allied Sci. 2004;29(3):201-205. 34. Anderson SD, Daviskas E. The mechanism of exercise-induced asthma is .... J Allergy Clin Immunol. 2000;106(3):453-459. 35. Greiling AK, Boss LP, Wheeler LS. A preliminary investigation of asthma mortality in schools. J Sch Health. 2005;75(8):286-290. 36. Chaudhuri R, McSharry C, McCoard A, et al. Role of symptoms and lung function in determining asthma control in smokers with asthma. Allergy. 2008;63(1):132-135. 37. Chaudhuri R, Livingston E, McMahon AD, et al. Effects of smoking cessation on lung function and airway inflammation in smokers with asthma. Am J Respir Crit Care Med. 2006 Jul 15;174(2):127-133. Epub 2006 Apr 27. 38. Lazarus SC, Chinchilli VM, Rollings NJ, et al, National Heart, Lung, and Blood Institute’s Asthma Clinical Research Network. Smoking affects response to inhaled corticosteroids or leukotriene receptor antagonists in
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asthma. Am J Respir Crit Care Med. 2007Apr 15;175(8):783-790. Epub 2007 Jan 4. 39. Banks D, Jalloul A. Occupational asthma, work-related asthma and reactive airways dysfunction syndrome. Curr Opin Pulm Med. 2007;13 (2):131-136. 40. Beuther DA, Sutherland ER. Overweight, obesity, and incident asthma: a meta-analysis of prospective epidemiologic studies. Am J Respir Crit Care Med. 2007 Apr 1;175(7):661-666. Epub 2007 Jan 18. 41. Rodrigo GJ, Plaza V. Body mass index and response to emergency department treatment in adults with severe asthma exacerbations: a prospective cohort study. Chest. 2007 Nov;132(5):1513-1519. Epub 2007 Sep 21. 42. McLachlan C, Poulton R, Car G, et al. Adiposity, asthma, and airway inflammation. J Allergy Clin Immunol. 2007 Mar;119(3):634-639. Epub 2006 Dec 4. 43. Ciftci TU, Ciftci B, Guven SF, Kokturk O, Turktas H. Effect of nasal continuous positive airway pressure in uncontrolled nocturnal asthmatic patients with obstructive sleep apnea syndrome. Respir Med. 2005 May;99 (5):529-534. Epub 2004 Nov 23. 44. Havemann B, Henderson CA, El-Serag HB. The association between gastro-oesophageal reflux disease and asthma: a systematic review. Gut. 2007 Dec;56(12):1654-1664. Epub 2007 Aug 6. 45. Littner MR, Leung FW, Ballard ED II, Huang B, Samra NK, Lansoprazole Asthma Study Group. Effects of 24 weeks of lansoprazole therapy on asthma symptoms, exacerbations, quality of life, and pulmonary function in adult asthmatic patients with acid reflux symptoms. Chest. 2005;128(3):1128-1135. 46. Harding SM, Guzzo MR, Richter JE. 24-h esophageal pH testing in asthmatics: respiratory symptom correlation with esophageal acid events. Chest. 1999;115(3):654-659. 47. Kiljander TO, Harding SM, Field SK, et al. Effects of esomeprazole 40 mg twice daily on asthma: a randomized placebo-controlled trial. Am J Respir Crit Care Med. 2006 May 15;173(10):1091-1097. Epub 2005 Dec 15. 48. van den Berg NJ, Hagmolen of ten Have W, Nagelkerke AF, Bindels PJE, van der Palen J, van Aalderen WMC. What general practitioners and paediatricians think about their patients’ asthma. Patient Educ Couns. 2005 Nov; 59(2):182-185. Epub 2004 Dec 16. 49. Douma WR, Kerstjens HA, Rooyackers JM, Koëter GH, Postma DS, Dutch CNSLD Study Group. Risk of overtreatment with current peak flow criteria in self-management plans. Eur Respir J. 1998;12(4):848-852. 50. Reddel HK, Barnes DJ Exacerbation Advisory Panel. Pharmacological strategies for self-management of asthma exacerbations. Eur Respir J. 2006;28(1):182-199. 51. Gibson PG, Powell H. Written action plans for asthma: an evidencebased review of the key components. Thorax. 2004;59(2):94-99. 52. Reddel HK, Marks GB, Jenkins CR. When can personal best peak flow be determined for asthma action plans? Thorax. 2004;59(11):922-924. 53. Lefevre F, Piper M, Weiss K, Mark D, Clark N, Aronson N. Do written action plans improve patient outcomes in asthma? an evidence-based analysis. J Fam Pract. 2002;51(10):842-848. 54. Clark NM, Gong M. Management of chronic disease by practitioners and patients: are we teaching the wrong things? BMJ. 2000;320(7234):572575. 55. Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev. 2002;3:CDC001117. 56. Yawn BP, Wollan PC, Bertram SL, et al. Asthma treatment in a population-based cohort: putting step-up and step-down treatment changes in context. Mayo Clin Proc. 2007;82(4):414-421. 57. Bacharier LB. “Step-down” therapy for asthma: why, when, and how [editorial]? J Allergy Clin Immunol. 2002;109(6):916-919. 58. Smith AD, Cowan JO, Brassett KP, Herbison GP, Taylor DR. Use of exhaled nitric oxide measurements to guide treatment in chronic asthma. N Engl J Med. 2005 May 26;352(21):2163-2173. Epub 2005 May 24. 59. Tonelli M, Bacci E, Dente FL, et al. Predictors of symptom recurrence after low-dose inhaled corticosteroid cessation in mild persistent asthma. Respir Med. 2006 Apr;100(4):622-629. Epub 2005 Oct 25. 60. Giannini D, Di Franco A, Cianchetti S, et al. Analysis of induced sputum before and after withdrawal of treatment with inhaled corticosteroids in asthmatic patients. Clin Exp Allergy. 2000;30(12):1777-1784. 61. American Lung Association Asthma Clinical Research Centers. Randomized comparison of strategies for reducing treatment in mild persistent asthma [published correction appears in N Engl J Med. 2007;357(7):728]. N Engl J Med. 2007;356(20):2027-2039.
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ATTAINING ASTHMA CONTROL IN 4 EASY STEPS
CME Questions About Attaining Asthma Control 1. Which one of the following is not used to assess impairment from asthma? a. Symptoms b. Nighttime awakenings c. Interference with normal activity d. Acute bronchodilator use e. Exacerbations 2. Which one of the following statements about the Asthma Control Test (ACT) is false? a. Lung function testing is required to obtain a score b. Asthma symptoms during the previous 4 weeks are used to help determine the ACT score c. An ACT score of less than 20 means uncontrolled asthma d. An ACT score of less than 16 means very poorly controlled asthma e. The ACT score can be used to adjust asthma medications 3. Which one of the following statements regarding comorbidities is false? a. Severe chronic rhinosinusitis has an adjusted odds ratio of 5.5 for frequent exacerbations b. Psychological dysfunction has an adjusted odds ratio of 11.7 for frequent exacerbations
c. Gastroesophageal reflux disease has an adjusted odds ratio of 4.9 for frequent exacerbations d. Patients with asthma who smoke have the same response to inhaled corticosteroids as those who do not smoke e. Nonadherence to medication is a serious cause of poor asthma control 4. Which one of the following is not used in the assessment of asthma risk? a. Progressive lung function decline b. Frequency and severity of exacerbations c. Adverse reaction to treatment d. Nonadherence to therapy e. Frequency of oral corticosteroid use 5. Which one of the following statements regarding asthma treatment is true? a. Lung function and symptoms continue to improve more than 3 months after intensification of therapy b. Residual effects of anti-inflammatory therapy disappear in a few days after dose reduction or discontinuation c. Medication should be adjusted only on the basis of results of lung function tests (eg, spirometry) d. Medication should be adjusted to reduce frequent exacerbations e. Asthma control can be attained only in mild to moderate persistent asthma
This activity was designated for 1 AMA PRA Category 1 Credit(s).™
The Concise Review for Clinicians contributions are a CME activity, and answers to the questions are not published in the print journal. For CME credit and the answers, see the onlink our Web site at mayoclinicproceedings.com.
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Mayo Clin Proc.
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July 2008;83(7):814-820
•
www.mayoclinicproceedings.com
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.