Helping patients attain and maintain asthma control: reviewing the role of the nurse practitioner

Figures & data

Figure 1 Methods of classifying asthma severity and initiating treatment in patients 12 years of age and older.

Notes: Level of severity is determined by assessment of both impairment and risk. Assess impairment domain by patient’s/caregiver’s recall of previous 2–4 weeks and spirometry. Assign severity to the most severe category in which any feature occurs. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma. Reproduced from the National Heart Lung and Blood Institute.⁷
Abbreviations: EIB, exercise-induced bronchospasm; FEV₁, forced expiratory volume in 1 second; FVC, forced vital capacity; ICU, intensive care unit.

Figure 2 Methods of classifying asthma control and adjusting treatment in patients 12 years of age and older.

Notes: *ACQ values of 0.76 to 1.4 are indeterminate for well-controlled asthma. Minimal Important Difference: 1.0 for the ATAQ; 0.5 for the ACQ; not determined for the ACT. The level of control is based on the most severe impairment or risk category. Assess impairment domain by patient’s recall of previous 2–4 weeks and by spirometry or peak flow measures. Symptom assessment for longer periods should reflect a global assessment, such as inquiring whether the patient’s asthma is better or worse since the last visit. At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma. Before step-up in therapy: (1) Review adherence to medication, inhaler technique, environmental control, and comorbid conditions. (2) If an alternative treatment option was used in a step, discontinue and use the preferred treatment for that step. Reproduced from the National Heart Lung and Blood Institute.⁷
Abbreviations: FEV₁, forced expiratory volume in 1 second; EIB, exercise-induced bronchospasm; N/A, not applicable; ATAQ, Asthma Therapy Assessment Questionnaire; ACQ, Asthma Control Questionnaire; ACT, Asthma Control Test.

Figure 3 Stepwise approach for managing asthma in patients aged ≥12 years.

Note: Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. Reproduced from the National Heart Lung and Blood Institute.⁷
Abbreviations: ICS, inhaled corticosteroid; LABA, long-acting inhaled beta₂-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta₂-agonist.

Figure 4 Sample patient self-assessment sheet for follow-up visits.

Table 1 Classification of well-controlled asthma

Components of control	Value
The “Rule of 2s”
Asthma symptoms	≤2 days per week
Nighttime awakenings	≤2 times per month
SABA use for symptom control (not prevention of EIB)	≤2 days per week
Other measurements
Interference with normal activity	None
FEV1 or PEF	>80% predicted/personal best

Abbreviations: EIB, exercise-induced bronchoconstriction; FEV₁, forced expiratory volume in 1 second; PEF, peak expiratory flow; SABA, short-acting β₂-agonist

Note: Reproduced from the National Heart Lung and Blood Institute.⁷

Table 2 Validated instruments for assessing asthma control^25–27,29

Instrument	Assessments	Number of questions/items	Score interpretation
Asthma control questionnaire (ACQ)^Citation25,Citation26	Adequacy of asthma control Change in asthma control	7	0 = totally controlled 6 = severely uncontrolled
Asthma therapy assessment questionnaire (ATAQ)^Citation27	Self-perceived asthma control Missed school, work, or daily activities Nighttime awakenings due to asthma symptoms Use of quick-relief inhaler medications	4	0 = no control issues 4 = 4 control issues
Asthma control test (ACT)^Citation29	Productivity at work/school Shortness of breath Nighttime/early morning awakenings due to symptoms Use of rescue medications Self-rating of asthma control	5	Not specified – up to discretion of physician

Figure 5 Overview of the allergic cascade. IgE (immunoglobulin E) is produced by the plasma cells, which are derived from B lymphocytes. The IgE moves through the extracellular fluid and vasculature until it binds to a high-affinity receptor, primarily found on mast cells and basophils. Cross-linking of the membrane IgE results in degranulation of the cell with mediator release and the resultant symptoms of asthma.

Ledford DK. Expert Opin Biol Ther. 2009;9:933–943. Copyright © 2009. Informa Healthcare. Reproduced with permission of Informa Healthcare.⁴⁹

Table 3 Classes of asthma medications^7,36–38,40

How used	Class	Example(s) of approved agents	Mechanism of action
Long-term controllers	ICSs	beclomethasone	Anti-inflammatory effects
		budesonide
		fluticasone
		mometasone
	Immunomodulators	omalizumab	Anti-inflammatory effects
	Leukotriene modifiers	montelukast	Anti-inflammatory effects
		zileuton
	LABAs	salmeterol	Bronchodilation
		formoterol
	Methylxanthines	theophylline	Mild/moderate bronchodilation
			Mild anti-inflammatory effects
	Combined ICS/LABA	fluticasone/salmeterol	Anti-inflammatory effects
		budesonide/formoterol	Bronchodilation
Quick-relief/exacerbations	Anticholinergics	ipratropium bromide	Bronchodilation
	SABAs	albuterol	Bronchodilation
		levalbuterol
	Oral corticosteroids	prednisone/prednisolone	Anti-inflammatory effects

Abbreviations: ICSs, inhaled corticosteroids; LABAs, long-acting β₂-agonists; SABAs, short-acting β₂-agonists.

Table 4 Criteria for referring a patient with difficult-to-treat asthma to a specialist

Patients should be referred if they meet ANY of the criteria below: below: Asthma is difficult to control or is persistent >2 oral corticosteroid bursts per year are needed Exacerbations have required hospitalization Therapy at step 4 or higher is required to achieve adequate asthma control Immunotherapy or therapy with omalizumab is being considered Additional testing is needed

Note: Reproduced from the National Heart Lung and Blood Institute.⁷

National Heart Lung and Blood InstituteExpert Panel Report 3: guidelines for the Diagnosis and Management of Asthma Summary Report 20072007174

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