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Education Program Improves Asthma Outcomes in Children

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By Karla Gale

NEW YORK (Reuters Health) Nov 10 - A one-to-one asthma education program for pediatric patients and their

families can prevent severe exacerbations, reduce medical costs and improve school and work attendance,

investigators reported at the annual scientific meeting of the American College of Allergy, Asthma and

Immunology underway in Miami Beach, Florida.

"Our asthma education and self-management training program provides what patients and families want and

when they want it while making sure that we give messages that are compatible with what providers hope to

accomplish in the office," Dr. Laura Blaisdell told Reuters Health

The education/self-management training sessions last 1 to 2 hours for 1 or 2 sessions. The goals are to help

patients understand "that asthma is a chronic disease and why the medications are used and how to use them,

how to avoid triggers and what to do in case of a flare," the researcher explained.

In addition, she said, "We often need to dispel the myths that exist around asthma; written asthma plans need

to be reviewed; patients need to be checked on their ability to actually use the medications prescribed (e.g.,

nebulizers vs. dry powder inhaler vs. metered dose inhaler with spacer). Sometimes we actually have to help

patients find resources to help with the cost of medications."

Dr. Blaisdell and associates from the Maine Medical Center in Portland evaluated their AH! Asthma Health

Program in an observational study that spanned the period from 1999 to 2008 and involved 1096 children.

The program achieved consistent reductions in a variety of endpoints. Over the 9 years of the study, for

example, emergency department visits averaged 25 percentage points lower after participation, falling to less

than 10%. The percentage of children who required hospitalization declined on average from 30% prior to the

program to 1% afterward. The average proportions of patients who missed school or work were 58% during the

6 months prior to participation compared to only 12% afterward.

Dr. Blaisdell's advice to clinicians: "Partner with certified asthma educators to support the prescribing and

diagnosing that goes on in the office. Identify someone in the office who can become expert in device training

and trouble shooting. And refer to a specialist who can help the patient figure out their triggers and help to

decide on best management strategies."

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First, let's look at the EPR-3 guideline information on assessing asthma severity at the initial visit, shown in

Figure 1 (children, ages 0-4), Figure 2 (children, ages 5-11), and Figure 3 (youths, age 12 and adults).


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(Enlarge Image)

Figure 1.

Classifying asthma severity in children 0-4 years of age. Reprinted with Permission from USDepartment of Health and Human Services, NIH, NHLBI.

(Enlarge Image)

Figure 2.

Classifying asthma severity in children 5-11 years of age. Reprinted with Permission from USDepartment of Health and Human Services, NIH, NHLBI.

(Enlarge Image)

Figure 3.

Classifying asthma severity in youths 12 years of age and adults. Reprinted with Permission

from US Department of Health and Human Services, NIH, NHLBI.

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Next, let's look at the EPR-3 guidelines regarding assessing asthma control in follow-up visits in Figure 4

(children, ages 0-4); Figure 5 (children, ages 5-11), and Figure 6 (youths, age 12 and adults).

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Figure 5.

Assessing asthma control in children 6-11 years of age. Reprinted with permission from USDepartment of Health and Human Services, NIH, NHLBI.

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For example, research has shown that a general question posed to a patient with asthma such as "How are

you doing with your asthma?" is not very helpful at determining how well controlled a patient's asthma is at that

particular time. More specific questions, such as asking them how many times they're needing their albuterol

inhaler in a week, or whether shortness of breath is limiting exercise or waking them up from sleep at night, is

much more helpful at assessing asthma control. In addition, measured pulmonary function provides an

objective assessment that can be followed over time. Using these particular questions and measurements can

be much more accurate than asking general questions regarding a patient's perception of their disease control.

Unfortunately, patients will accommodate to their level of airway obstruction and it will become "normal" to

them. This underscores the need for objective data in following their disease, much as we use serial blood

pressure measurements for patients with hypertension or hemoglobin A1C for diabetics. I think that one of the

barriers to more widespread use of the NIH Guidelines in general practice is a perception that it will add more

work and "hassle factor" to caring for these patients. In fact, I think it is just the opposite. Use of the NIH


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asthma treatment guidelines is very straightforward and, in my view, actually speeds your treatment decisions

regarding management of patients with asthma. Let's examine the stepwise approach for managing each age

group according to the EPR-3 guidelines: Figure 7 for children ages 0 to 4; Figure 8 for children ages 5 to 11;

and, Figure 9 for youths 12 years old and older and adults.

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There are also simple helpful hints in the guidelines. For example, once you obtain adequate asthma control,

your patient should not be using their albuterol more than twice per week to control spontaneous asthma

symptoms In other words, if somebody spontaneously needs albuterol for shortness of breath (not counting

pre-treatment for exercise) more than twice a week, then your level of asthma control is probably not adequate.

Medscape: The guidelines place a strong emphasis on spirometry. Should clinicians be monitoring

spirometry regularly in an office setting, and, if so, how do you obtain this without adversely affectingthe flow of patient care?


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Dr. O'Hollaren: Spirometry is a very important metric that we use to see if what we're using to treat patients

with asthma is actually working or not. Office spirometry is sometimes not used because clinicians feel that it

will disrupt the flow of patient care. In addition, some clinicians may have forgotten some of the skills used in

interpretation of office spirometry. The latter can be addressed with a brief lecture or refresher course regarding

the meaning of values obtained using office spirometry.

What we do in our office is check spirometry in patients prior to placing them in the examination room. It isbasically a vital sign that is taken for our patients with asthma to help the clinician decide how that patient is

doing at the time of the office visit. You would not think of having someone come in for a hypertension check up

without having the blood pressure checked prior to seeing the patient, and the same should be true for

checking spirometry in patients with asthma. We use it to help guide our decisions regarding therapy.

The way not to disrupt patient care is to have it done before the patient is put in the examination room. Others

will bring a small portable spirometer into the examination room and perform the test there. It is very clear that

reliance on symptoms alone to follow patients with asthma is totally inadequate and cannot be the basis for

clinical decision-making. If you go into a room with an asthmatic patient and ask them how they're doing, and

try to make treatment decisions based on history alone, you will be more often wrong than right. It is no more

accurate to guess a patient's blood pressure than it is to guess their pulmonary function and so spirometry

simply needs to be checked.

Medscape: You discussed the importance of a patient-clinician relationship with regard to medication

compliance. How do you handle steroid phobia in patients with asthma and how about steroid phobia

on the part of parents of pediatric asthma patients?

Dr. O'Hollaren: This is a very common problem. I think the fundamental way to address steroid phobia in both

patients and parents is to explain the physiology of asthma to the patient and the parents. I find that anatomical

models that show airway swelling and inflammation speak a thousand words about why we need an anti-

inflammatory component to our asthma treatment programs. When we show the how smooth muscle

constriction is only a small part of the physiology that produces symptoms, then we have the patients' attention

and they have a conceptual framework to understand why they need to take inhaled anti-inflammatorymedications.

It is also important to point out that the data are very strong that the use of inhaled corticosteroids reduces the

risk of dying from asthma and reduces the risk of needing emergent care or hospitalization. In contrast, the

data show that increasing use of albuterol inhalers is associated with an increased risk of hospitalization and

an increased risk of dying from asthma. There is a misunderstanding in the eyes of many patients that albuterol

is harmless and steroids are harmful. In the case of asthma, appropriately dosed inhaled corticosteroids can be

lifesaving, and excessive reliance on short-acting bronchodilators can be life-threatening. So, the relationship

between inhaled steroid use and dying from asthma, which is an inverse relationship, is very helpful to bring

parents on board if they think that the use of steroids will be too harmful for their child.

I also discuss the results of the CAMP Study, published in The New England Journal of Medicineseveral years

ago, in which the data showed that inhaled corticosteroids could be safely taken in children with asthma without

significant effects on growth, bone density, ocular side effects, or psychological parameters. I think the data are

abundantly clear and very clearly outlined in the NIH Guidelines that the cornerstone of management for

persistent asthma is inhaled corticosteroids. Symptomatic use of short-acting beta-agonists should be used

only on an as needed basis, and hopefully less than or equal to twice per week, so that we know we have good

foundational baseline control of breathing. Frequently parents also have misconceptions about the fact that

asthma is going to prevent their children from participating in sports or athletics. I find that sometimes parents

will subconsciously discourage their children from relying on asthma inhalers because it means that they're

weak or that they're not working hard enough to "get into shape." In fact, I point out that over 10% of the US

Olympic team has asthma, and they are incredibly compliant with their medications to ensure optimalperformance. In summary, I think it's important to point out that inhaled corticosteroids are lifesaving

medications, that they decrease the risk for death from asthma, they decrease the risk of hospitalization and


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urgent care for asthma, they improve quality of life, sleep quality, and overall will allow patients with asthma to

lead a much more productive and active life.

Medscape: Well thank you so much, Dr. O'Hollaren, for sharing these practical insights into the clinical

management of asthma. We thank you for this 2-part series.

Guidelines Issued for Sublingual ImmunotherapyLaurie Barclay, MDAuthors and Disclosures

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December 21, 2009 Evidence-based guidelines for use of sublingual Immunotherapy (SLIT) are issued in

the World Allergy Organization Position Paper 2009, reported in the November issue of the World Allergy

Organization Journal. This article is co-published as a supplement to the December 2009 issue of Allergy.

"...SLIT has gained wide acceptance in many European countries and has raised the level of interest in

immunotherapy among practicing allergists and primary care physicians," write World Allergy Organization

(WAO) chair G. Walter Canonica, MD, from the University of Genoa in Genoa, Italy, and colleagues.

"Large pivotal double-blind, placebo-controlled, randomized clinical trials have confirmed the efficacy and

safety of SLIT, although some negative trials have also been published. In 2008, the...[WAO] Board Of

Directors decided that it was important and timely to advise our global constituents on the current State of theArt on SLIT, to offer consensus on its use based on currently available evidence and expert opinion, and to

develop practice parameters."

On January 22-23, 2009, WAO convened a global consensus meeting on SLIT in Paris, France. Regional,

national, and affiliate WAO member societies were represented, as were nongovernmental organizations

working in the field of allergy, as well as Allergic Rhinitis and its Impact on Asthma, the European Federation of

Allergy and Airway Diseases Patients Association, the International Primary Care Respiratory Group, the

International Association of Asthmology, the Global Allergy and Asthma European Network, and others. The

meeting and position statement were totally independent from funding or other influence of the pharmaceutical

or the allergen extract/vaccine industries.

Topics in the Position Statement

In addition to offering guidelines for clinical practice using SLIT, the meeting aimed to identify unmet needs by

analyzing recent and ongoing SLIT clinical trials and by recommending additional studies needed and

appropriate methodology.

Topics included in the SLIT position statement are the following:

Introduction and historical background regarding SLIT.

Allergen-specific immunotherapy.

Mechanisms of SLIT.

Clinical efficacy of SLIT.

Safety of SLIT.

Effect of SLIT on the natural history of respiratory allergy.
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Use of SLIT in children.

Guidelines and recommendations concerning SLIT.

Definition of patient selection for SLIT.

The future of immunotherapy in the community care setting.

Methodology of clinical trials evaluating SLIT.

In determining their recommendations for SLIT, the WAO noted that there have been several adequatelypowered, well-designed, randomized clinical trials. Findings from these studies suggest that high-dose,

sublingual, specific immunotherapy is effective in carefully selected patients.

Appropriate indications for use of SLIT include rhinitis, conjunctivitis, and/or asthma caused by pollen and/or

house dust mite (HDM) allergy. Although the safety of SLIT has been confirmed in randomized clinical trials,

many patients report local adverse effects. Systemic reactions have been reported only rarely.

In appropriate patients, SLIT may be considered as initial treatment; failure of pharmacologic treatment is not

required before starting therapy. Special SLIT indications exist in patients whose allergies are uncontrolled with

optimal pharmacotherapy, patients in whom pharmacotherapy induces undesirable adverse effects, patients

refusing injections, and patients who do not want to be receiving constant or long-term pharmacotherapy.

Immunotherapy Recommendations

To reduce risk and improve efficacy of SLIT, the WAO recommends the following considerations for starting

immunotherapy:

There should be the presence of a demonstrated immunoglobulin E (IgE)mediated disease, with

positive skin test results and serum-specific IgE to an allergen concordant with clinical symptoms.

There should be documentation that the symptoms can be explained by specific sensitivity, based on

appearance of symptoms related to exposure to the allergen(s) identified by allergy testing. Optional

confirmation may include allergen challenge with the relevant allergen(s).

Severity and duration of symptoms should warrant use of SLIT, with confirmation from objective

parameters such as missing time from work or school. For rhinoconjunctivitis, patients should have

subjective symptoms of sufficient severity and duration. For asthma, the control questionnaire should

not show uncontrolled asthma, and pulmonary function testing is required to exclude patients with

severe asthma. Pulmonary function should be monitored during therapy.

SLIT therapy should only be started in settings where standardized or high-quality vaccines are

available. Only specialists should prescribe specific immunotherapy. Subcutaneous immunotherapy

should be administered only by physicians trained to manage systemic reactions if anaphylaxis occurs.

Although SLIT is administered at home, patients should be educated regarding possible risks and how

to control adverse effects that may develop.

Patients with a single allergen sensitivity are more likely to benefit from specific immunotherapy vs

patients sensitive to multiple allergens, but more data are needed in this area.

Specific immunotherapy will not benefit patients with nonallergic triggers.

For safety reasons, asthmatic patients must be asymptomatic when receiving SLIT injections.

Asthmatic patients with severe airways obstruction are more likely to have lethal adverse reactions.

To maximize the efficacy and safety of SLIT in asthmatic patients, forced expiratory volume in 1

second with pharmacologic treatment should reach at least 70% of predicted values.

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Asthma Us Guide