How can one accurately predict a patient’s future risk of asthma attacks? What information should be gathered and measures taken to assess asthma severity? Asthma control? What are the appropriate discharge medications? How should one follow up with discharged patients?
These are not the only questions health care providers may have when it comes to caring for patients with asthma, and unfortunately, not all of them can be answered at this time. However, two sets of guidelines issued within the past year have attempted to close some of the existing gaps in the knowledge and best practices regarding asthma control and management.
An Official American Thoracic Society (ATS)/European Respiratory Society (ERS) Statement1 was published in the American Journal of Respiratory and Critical Care Medicine. The document addresses the confusion in the literature resulting from the lack of standardized measurements and terminology and offers recommendations for avoiding this data jumble in the future so that true best practices can be discerned.
In the emergency department, asthma can also be confusing, in part because emergency care physicians cannot devote a lot of time to studying any one disease. In 2006, there were 119.2 million visits to emergency departments in the United States, according to the Centers for Disease Control and Prevention (CDC). Asthma patients represent a small portion.
“One doesn’t have time in that setting to do a primary literature review of what’s new in the field. So one really does have to have guidelines that hopefully are specific and targeted to that setting to help the providers give the best care they can,” says Michael Schatz, MD, MS, chief of the Department of Allergy at Kaiser Permanente Medical Center in San Diego.
To that end, the American Academy of Allergy, Asthma, and Immunology (AAAAI), the American Academy of Emergency Medicine (AAEM), and the ATS collaborated to develop the “Joint Task Force Report: Supplemental Recommendations for the Management and Follow-up of Asthma Exacerbations.”2
As a result of the collaborative efforts, both documents are specific, interdisciplinary, and valuable. “The [ATS/ERS] report has been accessed about 14,000 times in 6 months over the Web. So that tells us there is a lot of interest in this subject,” says Helen Reddel, MBBS [MD equivalent], PhD, FRACP, research leader of the clinical management group at the Woolcock Institute of Medical Research in Australia, and an ATS/ERS task force member.
ELIMINATING CONFUSION
Over the past few years, the emphasis in guidelines has transitioned from a focus on asthma severity to one of asthma control. As a result, clinical trials have increasingly been using asthma control as an outcome measure. Yet, these measures have been inconsistent.
“We found large numbers of variables that had been used in clinical trials to describe asthma control and large numbers used to describe asthma severity. [Both] were basically the same list of variables and referred to the same guidelines as justification. So the terminology in the literature was completely confusing,” Reddel says.
The 24-person task force—made up of asthma experts from around the world—sought to standardize the variables and terminology to eliminate the confusion in three primary areas: asthma control, asthma severity, and asthma exacerbations. The definitions of all three were updated to enable collection of clinically useful data.
One of the key differences in the new document regarding asthma control is the incorporation of future risk alongside current clinical control. “The addition of future risk is important for three reasons: first, because some medications can improve symptoms while not treating the underlying disease; second, because some patients are at increased risk of asthma attacks despite having few symptoms; and third, because the potential for medication side effects should be taken into account when deciding a patient’s need for treatment,” Reddel says.
For instance, a person taking a long-acting beta-agonist, but no controller medication, may not display any symptoms or need any quick-acting relief medication; lung function looks normal. However, many studies have indicated that the patient will have uncontrolled inflammation and be at high risk for the future.
Unfortunately, there are patients who are prescribed both types of medication and who fall into this situation, often dropping one of the prescriptions due to cost. In the past, these patients were identified inconsistently, if at all, in part because the data gathered did not provide the whole story.
The new guidelines review and recommend the measurements that can avoid such discrepancies, finding the most robust predictors of future risk to be the frequency of asthma exacerbations, measures of lung function, and treatment side effects.1 If time does not permit the accurate collection of exacerbation data (for instance, a study time frame is too short), surrogate markers, such as sputum analysis or bronchial challenges, can be used. The ATS/ERS guidelines also provide standardized endpoints for assessment of the patient’s current clinical control for use in clinical practice and clinical trials.
So, rather than vague notes in the patient’s medical record to refer to (eg, “well,” “stable,” “no problems,” etc) when the patient returns, there are objective numbers against which to compare current status. “Respiratory therapists, as well as any other health care provider, should document specific outcomes—one of the validated asthma scores or [information such as] how many days a week the patient has symptoms, how often they use their reliever, whether they ever wake at night due to asthma, some brief documentation of their actual status,” says Reddel.
The guidelines were not able, however, to address every question, particularly those dealing with long-term improved outcomes. “There were some areas that we really felt we couldn’t make strong recommendations about because there simply weren’t enough good data,” Reddel says.
The two challenges now, according to Reddel, are to obtain research to fill these gaps while encouraging widespread adoption of the existing guidelines. “In order to have a big impact, they need to be adopted by guidelines bodies, pharmaceutical companies, and managed care organizations,” Reddel says.
ATS and ERS have already thrown their support behind the new recommendations, a process that took roughly 5 years. The inspiration originated at a 2003 symposium in Vienna, where attendees decided to produce solutions for some of their concerns and applied to the ERS to create a task force. That group subsequently expanded with the involvement of the ATS. “The two societies have existing procedures to collaborate on issues they regard as being important at an international level,” Reddel says.
The asthma control and exacerbations guidelines were completed in 2008 and then underwent a “very long review process through the two societies,” Reddel recalls, noting the approval mechanism has since been streamlined. Similarly, it may take a few years for the field to catch up, particularly research studies.
“Health professionals reading the literature need to be aware that the terminology in previous studies—and probably even over the next few years as existing studies are published—will remain difficult to interpret in some cases. The task force report will provide some tools to help understand the outcome measures that have been used in studies and where they fit into this new model of assessing asthma control,” Reddel says.
Based on the interest shown in the document, however, adoption may already be occurring. In addition to the document being accessed during many Web visits, task force members have been inundated with speaking requests, pharmaceutical companies have initiated discussions about the implications for their future research, and the National Institutes of Health (NIH) organized a workshop to develop recommendations for assessment measures in NIH asthma studies.
“The NIH will move beyond where the task force ended, because we certainly don’t think we’ve solved all the problems. At the end of each section, we put a list of research questions, and we very much hope that people will take those and run with them,” Reddel says.
GETTING SPECIFIC
It is also hoped that the guidelines produced by the AAAAI, AAEM, and ATS inspire further research. Many of the new recommendations for the management and follow-up of patients presenting with asthma in the emergency department are based on Evidence Category D, which relied on task force consensus judgment based on clinical experience and other nonsystematic clinical observations. The document’s introduction concludes with recognition of this fact and a call for data: “Because many of the recommendations are based on only Evidence Category D, we also hope that this report will stimulate additional needed research.”2
The knowledge gaps the task force aimed to fill included four of 11 that have been identified: use of noninvasive ventilation, use of intubation and mechanical ventilation, appropriate discharge medications, and techniques for ensuring proper follow-up after an ED visit. These areas were selected to complement, and avoid duplicating, the efforts of the Expert Panel Report 3 (EPR3), which updated the National Asthma Education and Prevention Program guidelines and addressed the remaining seven areas.
“An important aspect we felt needed to be elaborated on included not only how to treat the episode as it’s occurring, but what to do at that time to prevent other episodes,” Schatz says. The emergentologists consulted for the study often said they lacked experience in the treatment and management of asthma patients because most of their patients do not require intubation and ventilation. They do, however, often present quite ill and require immediate care.
In 2005, there were nearly 1.8 million patients treated for asthma in US emergency departments. “Asthma is a common clinical presentation in our emergency departments. Our clinicians manage asthmatic patients every day in all our EDs,” says A. Antoine Kazzi, MD, FAAEM, associate professor of emergency medicine in the Department of Emergency Medicine at the American University of Beirut and past president of AAEM.
Asthma patients represent only a small portion of all emergency department visits, though. “The emergency department, in particular, is a challenging environment in which to work. There are some specific structural issues with providing best care,” says Jerry A. Krishnan, MD, PhD, associate professor of medicine and epidemiology and director of the Asthma and COPD Center, Section of Pulmonary and Critical Care Medicine, University of Chicago. He cites examples such as multiple emergencies and overcrowding.
The guidelines, therefore, address best practices under different scenarios. “[These] recommendations will be helpful to all clinicians and providers who work in the ED, including nurses and inhalation therapists. The clarity and best practice standards should help reduce errors and delays,” Kazzi says.
Ideally, the document will find its way into the hands of emergency practitioners and others, who may not see the recommendations any other way. “We’re hopefully getting the information to a broader range of stakeholders,” Schatz says.
By making the effort interdisciplinary, the three-association group tripled its accessibility beyond what each organization could have achieved on its own. The effort represents the first time the three groups have worked together. “This was an opportunity for three different professional societies that interact with the management of asthma to come together to supplement and provide additional guidelines to clinicians over and beyond what was already available in the national guidelines,” Krishnan says.
The initiative began with a discussion in 2004 between Kazzi and Schatz (who were then serving as officers for AAEM and AAAAI, respectively), which took place during a conference and addressed how the two organizations might work together. “Education and development of such clinical recommendations are core elements of the mission of our societies. And asthma is the most common of the two main medical conditions managed daily by AAAAI and AAEM providers—anaphylaxis being the second,” Kazzi says.
A decision to focus on asthma then necessitated outreach to the ATS. “We thought it would be essential to invite our pulmonary colleagues and their society to contribute to this project,” Kazzi says.
The process involved a few years and many steps, including creation of the process itself. “We learned a lot about working together across societies and the complexities that you can get into when you’re trying to work at the intersection of three groups that for years have worked independently of one another, at least with respect to writing guidelines like this,” Krishnan says.
The committee decided on a systematic review of the literature to synthesize best practices in the form of recommendations based on evidence. The group stayed in touch with the Expert Panel 3 to coordinate content and delayed finalization of their document until after the EPR3 was released. Then came review. “There were three different sets of reviewers, each with their own criteria and recommendations or revisions to address,” Kazzi says.
All agree that the effort was worth it. “I think one of the things we all felt happened as a result of working together was that we developed a better product than if we had worked independently. I can imagine similar such efforts coming together in the future,” Krishnan says. More minds can be expected to help answer more questions regarding asthma control and management.
Renee Diiulio is a contributing writer for RT. For further information, contact [email protected].
References
- Reddel HK, Taylor DR, Bateman ED, et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med. 2009;180:59-99.
- Schatz M, Kazzi AAN, Brenner B, et al. Joint Task Force Report: Supplemental Recommendations for the Management and Follow-up of Asthma Exacerbations. Co-published: Am J Respir Crit Care Med. 2009;6:353-356. J Allergy Clin Immunol. 2009;124:S1-S4. J Emerg Med. 2009;37(2S):S1-S5.
