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Asthma is one of the most common chronic diseases in primary care. It affects more than 25 million people in the United States with a prevalence of 7.8% among adults and children. 1 The range of evidence-based treatments has become better defined, although nuances and differences between guidelines exist. This article reviews common questions about outpatient asthma treatment and provides evidence-based answers.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
BEST PRACTICES IN PULMONOLOGY
Recommendations From Choosing Wisely
| Recommendation | Sponsoring organization |
|---|---|
| Do not diagnose or manage asthma without spirometry. | American Academy of Allergy, Asthma & Immunology |
| Do not use long-acting beta2 agonist/corticosteroid combination drugs as initial therapy for intermittent or mild persistent asthma in children. | American Academy of Pediatrics |
| Avoid stepping up asthma therapy (i.e., adding new drugs or going to higher doses) before assessing adherence, appropriateness of device, and technique with current asthma medications. | American Academy of Pediatrics |
Source: For more information on Choosing Wisely, see https://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https://www.aafp.org/afp/recommendations/search.htm.
How Should Clinicians Assess Asthma Severity to Guide a Stepwise Approach to Treatment?
Asthma severity and control should be assessed at diagnosis and at subsequent visits by analyzing the level of impairment and the risk of future exacerbations. Once a diagnosis and treatment plan has been made, several validated tools may be used to assess control, including the Asthma Control Test and the asthma APGAR (activities, persistent, triggers, asthma medications, response to therapy) tools. Spirometry should be performed in all patients at diagnosis. There is weak evidence for repeating spirometry in patients with worsening symptom control. 2,3 Evidence is limited for the use of adjuncts such as fractional excretion of nitric oxide and sputum eosinophils.
EVIDENCE SUMMARY
The regular assessment of asthma control is crucial because 62% of adults with the disease do not have adequately controlled asthma. 4 The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report recommends classifying asthma severity based on reported symptoms at diagnosis to determine initial therapy (Table 1)