Asthma management pocket reference 2008*
Global Primary Care education World Organization of Family Doctors (Wonca) International Primary Care Respiratory Group (IPCRG)
European Federation of Allergy and Airway Diseases Patients Association (EFA)
Based on the 2007 GINA report update and the IPAG handbook
In different healthcare systems, the terms ‘primary care physicians’ or ‘general practitioners’ may be used.
Prof. C. van Weel
Department of General Practice
University Medical Centre Nijmegen
Asthma is one of the most common chronic airways diseases worldwide, and its prevalence is increasing. Family doctors (sometimes called ‘primary care physicians’ or ‘general practitioners’) are frequently an asthma patient’s first point of contact with healthcare systems. Disease management that follows evidence-based practice guidelines yields better patient results, but such guidelines are often complicated and may recommend the use of resources not available in the family practice setting. A joint expert panel of the World Organization of Family Doctors (Wonca), International Primary Care Airways Group (IPAG) and the International Primary Care Respiratory Group (IPCRG) offers support to family doctors worldwide by distilling the globally accepted, evidence-based recommendations from the Global Initiative for Asthma (GINA) into this brief reference guide.
This guide provides tools intended to supplement a thorough history taking and the clinician’s professional judgment in order to provide the best possible care for patients with asthma. Diagnostic Questionnaires developed for children and adults specifically focus the physician’s attention on key symptoms and markers of asthma. When questionnaire responses suggest a diagnosis of asthma, Diagnosis Guides then lead the clinician through a series of investigations commonly available in primary care to support the diagnosis. In patients >40 years who smoke, COPD is an important alternative diagnosis, and some key aspects of differential diagnosis are illuminated.
According to GINA, the goal of asthma treatment is to achieve and maintain control of the disease symptoms long-term. The physician must first assess the patient’s current level of asthma control, then treat asthma in a stepwise manner to achieve and maintain symptom control. Both of these aspects are summarized in figures included in this guide. Finally, the guide also presents a flow chart summarizing management of asthma exacerbations in the acute care setting, and a glossary of asthma medications to assist the clinician in making medication choices for each individual patient. Finally, many patients with asthma also have concomitant allergic rhinitis, and this must be checked.
The World Organization of Family Doctors has been delegated by WHO as the group that will be taking primary responsibility for education about chronic respiratory diseases among primary care physicians globally. This document will be a major resource in this educational program.
The purpose of this guide
Management that follows evidence-based practice guidelines yields better patient results. However, global evidence-based practice guidelines are often complicated and recommend the use of resources often not available in the family practice setting worldwide. The prevalence of asthma in family practice is high. In some groups of patients, such as smokers over 40 years, COPD may be more prevalent than asthma. This raises the issues of differential diagnosis, as treatment strategies for asthma and COPD are different. The joint Wonca/GARD expert panel offers support to family doctors† worldwide by distilling the Global Initiative for Asthma (GINA) and International Primary Care Airways Group (IPAG) recommendations into this brief reference guide. The guide lists diagnostic and therapeutic measures, which can be carried out in the family medicine environment and in this way it is intended to improve the quality of care for patients with asthma in primary care. This document was prepared by the Wonca Expert Panel including C. van Weel, E. D. Bateman, J. Bousquet, J. Reid, L. Grouse, T. Schermer, E. Valovirta, N. Zhong, and was edited by Dmitry Nonikov. The authors acknowledge the contribution of International Primary Care Respiratory Group (IPCRG), the European Federation of Allergy and Airways Diseases Patients Associations (EFA), and the GINA, who supported the development with their review and input.
The questionnaires and diagnosis guides supplied below have been specially adapted to facilitate the diagnosis of asthma in primary care. History taking of patients with respiratory and allergy-related problems should be based on the general principles of history taking in primary care. Family doctors should first and foremost apply active listening and then invite patients to express their symptoms, worries and concerns. This will often present a full picture. Validated questionnaires are not intended to replace history taking, but identify key symptoms and elements of the medical history to explore with patients. The investigations presented in the diagnosis guides may not be available in all areas; in most cases, the combination of those diagnostic investigations that are available and the individual healthcare professional’s clinical judgment will lead to an accurate clinical diagnosis. The guides are intended to supplement, not replace, a complete physical examination and thorough medical history. For patients diagnosed with asthma, it is important to assess whether they also have allergic rhinitis, a common comorbidity.
Childhood asthma questionnaire (1)
In children aged 6–14 years, a positive response to any of the questions above suggests an increased likelihood of asthma, and suggests that the patient should undergo further diagnostic assessment. Positive responses to three or more of the questions in bold suggest a >90% likelihood of asthma. If responses suggest asthma, proceed to the Childhood Asthma Diagnosis Guide below. If responses suggest that asthma is unlikely, consider alternative diagnoses and/or referral to a specialist.
Childhood asthma diagnosis guide (1)
Adult asthma questionnaire (1)
A positive response to any of the questions 1–6, particularly questions one or two in bold, suggests an increased likelihood of asthma. The more the number of positive answers, the greater the likelihood of asthma. If in your judgment, the patient’s responses suggest asthma, proceed to the Adult Asthma Diagnosis Guide below. A positive response to question 7 suggests an occupational association. Referral of the patient to a specialist for further objective testing and assessment is recommended. If answers suggest that asthma is unlikely, consider other diagnoses or specialist referral.
Adult asthma diagnosis guide (1)
Differential diagnosis with COPD
Among adult patients, it is important to exclude the diagnosis of COPD in making the diagnosis of asthma.
Treating to achieve control
Once asthma is diagnosed, it is important to provide treatment that will control patient symptoms.
- • Effective and safe pharmacological regimens are available for asthma. Pharmacological treatment is the primary component of asthma management.
- • Education is essential for the patients to increase compliance with therapy.
- • Allergen avoidance may be indicated in specific patients.
Each patient is assigned to one of five treatment ‘steps’. These detail the treatments at each step for adults and children age 5 and over.
At each treatment step, reliever medication should be provided for quick relief of symptoms as needed (however, be aware of how much reliever medication the patient is using – regular or increased use indicates that asthma is not well controlled). At steps 2 through 5, patients also require one or more regular controller medications, which keep symptoms and attacks from starting. Controller medications include inhaled and systemic glucocorticosteroids, leukotriene modifiers, long-acting inhaled beta-2-agonists in combination with inhaled glucocorticosteroids, sustained-release theophylline, anti-IgE, and other systemic steroid-sparing therapies. Inhaled glucocorticosteroids are currently the most effective anti-inflammatory medications for the treatment of persistent asthma. Their therapeutic index is always more favorable than long-term systemic glucocorticosteroids in asthma. Long-term oral glucocorticosteroid therapy may be required for severe uncontrolled asthma, but its use is limited by the risk of significant adverse effects.
The available literature on treatment of asthma in children 5 years and younger precludes detailed treatment recommendations. The best documented treatment to control asthma in these age groups is inhaled glucocorticosteroids and at step 2, a low-dose inhaled glucocorticosteroid is recommended as the initial controller treatment.
Assessing asthma control
Each patient should be assessed to establish his or her current treatment regimen, adherence to the current regimen, and level of asthma control. The need for rescue medication (addressed by questions such as ‘How often do you have to puff on your blue canister?’) is an important factor for assessing asthma control in family medicine. A simplified scheme for recognizing controlled, partly controlled, and uncontrolled asthma is provided in the figure below.
Management approach based on control
Total dose of topical steroids should be considered if intranasal steroids are used for concomitant allergic rhinitis.
Management of asthma exacerbations in acute care setting
Glossary of asthma medications – controllers
Glossary of asthma medications – relievers
GINA materials have been used with permission from the Global Initiative for Asthma (http://www.ginasthma.org). Material from the IPAG Handbook has been used with permission from the International Primary Care Airways Group.
This document was developed with an unrestricted educational grant from Nycomed-Altana.
The Global Initiative for Asthma (GINA) has been supported by educational grants from: AstraZeneca, Boehringer Ingelheim, Chiesi Group, GlaxoSmithKline, Meda Pharma, Merck, Sharp & Dohme, Mitsubishi Tanabe Pharma Corporation, Novartis, Nycomed-Altana, Pharmaxis and Schering-Plough.