NHLBI issues new asthma care guidelines

Document stresses early education

For the first time since 1991, the National Heart, Lung and Blood Institute in Washington, DC, has updated its guidelines for dealing with acute attacks of asthma and chronic management of the disease. The report, prepared by a panel of allergists, immunologists, pulmonologists, and representatives from other fields, strongly links asthma attacks to allergens and blames childhood exposure to tobacco smoke, among other things, for the development of asthma later in life.

One of the biggest problems with asthma, the panel concluded, is diagnosing it properly, because symptoms vary so much among asthmatics. To clarify a diagnosis, the panel recommends spirometry always be used in the initial diagnostic work-up. In addition, a few symptoms may be highly suggestive of undiagnosed asthma: interminable chest colds; dermatitis or eczema; and increased nasal secretions and wheezing, coughing, or shortness of breath after exercise.

As in 1991, the panel recommends that patient education form a cornerstone of asthma care but that it be conducted with more vigor and at earlier stages of the disease. The panel urges patient educators and clinicians to adopt written strategy plans for patient self-management of acute exacerbations with instructions for patients on how to recognize early signs of the disease worsening.

Beta-2 agonists are the preferred treatment for acute exacerbations, with systemic corticosteroids and oxygen as backups in severe attacks. However, the following therapies should be avoided, the panel says:

• Theophylline/aminophylline. They don’t help with an acute attack and they cause numerous side effects, some of which — increased heart rate, for example — could be harmful during an acute attack.

• Unless there’s evidence of pneumonia or a sinus infection, avoid antibiotics.

• Hydration doesn’t relieve acute asthma attacks in adults and older children, as high respiratory rates contribute to dehydration. Younger children might benefit from hydration therapy, however.

• Chest physical therapy is too stressful for asthma patients and should be avoided.

• Mucolytics such as N-acetylcysteine or SSKI can further clog the airways and worsen coughs.

• No sedatives or hypnotics. Those depress the respiratory system.