Acupuncture

Recommendation

· Patients with asthma should not be treated solely with acupuncture (A)

Evidence for statement

Statement: acupuncture has not been shown to have any therapeutic benefit in patients with asthma (I)—Tashkin et al studied 25 patients who received classic Chinese acupuncture or placebo acupuncture in random order within a crossover design.⁽¹²⁵⁾ Each treatment period was for four weeks. There was no effect, in either arm of the study, on lung function, symptoms, or use of medication. There was no power calculation. (This was the highest scoring study in the systematic review by Kleijnen et al.⁽¹²⁶⁾)

In a qualitative systematic review of trials of acupuncture Kleijnen et al reviewed 13 trials with explicit methodological criteria that resulted in an overall score for each trial.⁽¹²⁶⁾ The quality of the studies was not high and the results from the better studies were contradictory.

In a meta-analysis to evaluate the effectiveness of acupuncture for the treatment of bronchial asthma Linde et al studied seven trials of acupuncture for the treatment of asthma or asthma-like symptoms.⁽¹²⁷⁾ None of the trials were directly comparable. Two suggested that the acupuncture strategies investigated were superior to dummy acupuncture. Five showed no significant difference between treatment and sham groups. However, some studies used sham points, which can be used for the treatment of asthma according to the principles of traditional Chinese medicine, and only one used individualised treatment strategies. They concluded that it is not yet possible to make any recommendations to patients, their physicians, or acupuncturists about the practice of acupuncture in the treatment of asthma on the basis of the data currently reported. Given the increasing use of acupuncture by the public, there is an urgent need for quality research which should take into account the complex nature of acupuncture as a treatment.

Yoga

Recommendation

· Patients should not be treated solely with yoga (A)

Evidence for statement

Statement: yoga has not been shown to have any therapeutic benefit in patients with asthma (I)—Singh et al studied 22 patients with mild asthma in a randomised, double blind, placebo controlled crossover trial.⁽¹²⁸⁾ For two week periods the patients breathed either through a device called the pink city lung, which imposes slowing of breathing equivalent to the pranayama breathing method, or through a matched placebo device. There were no significant changes in FEV₁, PEFR, symptoms, or use of inhalers. There was a significant improvement in airway reactivity during the yoga period compared with the placebo placebo. We identified only one study of yoga. While spirometry did not change, bronchial reactivity decreased, suggesting some effect from the intervention. This merits further study.

Homoeopathy

Recommendation

· Patients should not be treated solely with homoeopathy(A)

Evidence for statement

Statement: homoeopathy has not been shown to have any therapeutic benefit in patients with asthma (I)—In a systematic review to evaluate the evidence for the effectiveness of homoeopathic remedies for the treatment of patients with stable chronic asthma Linde and Jobst examined three trials of homoeopathic remedies for the treatment of asthma.⁽¹²⁹⁾ All were placebo controlled, randomised, and double blind, but they differed considerably regarding patients included, interventions used (three different homoeopathic remedies), and methodological quality, thus precluding quantitative meta-analysis. Two trials reported significant positive outcomes from the tested homoeopathic remedies compared with placebo, and in the other trial no significant differences were observed. The review concluded that the currently available evidence is insufficiently reliable to assess the possible role of homoeopathy in the treatment of asthma.

Research question

What is the place of complementary medicine in the treatment of asthma?

Exacerbations of asthma

Recommendations

· Patients with an exacerbation of asthma should be treated with oral corticosteroids; there is currently no good evidence to suggest use of high dose inhaled corticosteroids as an alternative (A)

· Prednisolone should be given at dosages of 30-40 mg daily and continued until the episode has resolved, symptoms are controlled, and lung function has returned to previous best levels. While seven days’ treatment will often be sufficient, it may need to be continued for up to 21 days (B)

· Use of oral corticosteroids does not need to be tapered; they can be stopped from full dosages. In patients on maintenance oral steroids reduction should be to their pre-exacerbation dose rather than stopping (D)

· Depending on the severity of the episode patients may need an inhaled short acting b₂ agonist via either a nebuliser or a large volume spacer device (A)

· Inhaled treatment should be used in preference to intravenous b₂ agonists for the treatment of exacerbations of asthma in primary care (A)

· Inhaled treatment can be as effectively delivered by spacer as by nebuliser (A)

· In patients given inhaled short acting b₂ agonist via a spacer device clinicians should consider repeat doses at 30-60 minutes; reassessment of such patients is important (A)

Statements

· Oral corticosteroids are effective in the treatment of exacerbations of asthma; oral administration is as effective as intravenous or intramuscular administration (I)

· Used in short courses oral corticosteroids are safe; they produce low rates of gastrointestinal bleeding. The greatest risk is in patients with a history of gastrointestinal bleeding or who are taking anticoagulants (III)

· Intravenous aminophylline offers little benefit over inhaled b₂ agonists in the treatment of acute asthma (I)

· Nebulised salbutamol is more effective than intravenous salbutamol in the treatment of acute asthma (I)

· Spacer devices can be as effective as nebulisers in delivering drugs for the treatment of acute asthma (I)

· Adding ipratropium to salbutamol produces little additional benefit (I)

· In patients given a short acting b₂ agonist via a spacer their short term FEV₁ improves more if the initial dose is repeated after 30-60 minutes (I)

The British Thoracic Society guidelines suggest the need for rescue courses of corticosteroids if symptoms and PEFR get progressively worse day by day; PEFR falls below 60% of patient’s best; sleep is disturbed by asthma; morning symptoms persist until midday; there is diminishing response to inhaled bronchodilators; and emergency use is made of nebulised or injected bronchodilators.

Evidence for statements

Statement: oral corticosteroids are effective in the treatment of exacerbations of asthma; oral administration is as effective as intravenous or intramuscular administration (I)—Rowe et al carried out a meta-analysis of 30 relevant randomised controlled trials looking at the effectiveness of corticosteroid treatment in acute exacerbations of asthma.⁽¹³⁰⁾ They concluded that the use of corticosteroids early in the treatment of asthmatic exacerbations reduces subsequent admissions to hospital in adults (odds ratio 0.47, 95% confidence interval 0.27 to 0.79); corticosteroids are effective in preventing relapse in the outpatient treatment of asthmatic exacerbations (0.15, 0.05 to 0.44); and oral and intravenous corticosteroids seem to have equivalent effects on pulmonary function in acute exacerbations (effect size -0.07, -0.39 to 0.25).⁽¹³⁰⁾ They could not produce any summary conclusions about dose and dosing, though "low" doses were not as effective as "medium and high doses."

In 1998 Rowe et al published a further meta-analysis of seven trials.⁽¹³¹⁾ Two studies used intramuscular corticosteroids, five studies used oral corticosteroids. Significantly fewer patients in the corticosteroid group needed additional care in the first week (0.35, 0.17 to 0.73). This favourable effect was maintained over the first 21 days (0.33, 0.13 to 0.82). Patients who received corticosteroids had less need for b agonists (weighted mean difference -3.3, -5.5 to -1.0, activations/day). Changes in pulmonary function tests (standardised mean difference 0.045, -0.47 to 0.56) and side effects (0.03, -0.38 to 0.44) in the first 7-10 days, while rarely reported, showed no differences between the treatment groups. Significant heterogeneity was identified for the side effect results; all other outcomes were homogeneous. Intramuscular corticosteroids are as effective as a 7-10 day tapering course of oral agents. From these results, as few as nine patients need to be treated to prevent relapse to additional care after an exacerbation of asthma. The review concluded that a short course of corticosteroids after assessment for an acute exacerbation of asthma significantly reduces the number of relapses to additional care and decreases use of b agonist without an apparent increase in side effects. Intramuscular corticosteroids seem to be as effective as oral agents.

Statement: used in short courses oral corticosteroids are safe; they produce low rates of gastrointestinal bleeding. The greatest risk is in patients with a history of gastrointestinal bleeding or who are taking anti-coagulants (III)—Carson et al reported a descriptive analysis of the records of 90 880 patients who received oral corticosteroids (for dermatitis as well as asthma).⁽¹³²⁾ They found a low incidence of gastrointestinal bleeding and concluded that prophylaxis against bleeding is not generally necessary. In subgroup analysis the biggest risk was in people who had upper gastrointestinal bleeding in the past and in those also taking oral anticoagulants but even here the incidence was low. The BNF states that "corticosteroid therapy is weakly linked with peptic ulceration; the use of soluble or enteric-coated preparations to reduce risk is speculative only."

Statement: one underpowered study showed no difference between oral steroids and high dose inhaled steroids in treating exacerbations of asthma (I)—In a UK multicentre, general practice, double blind, parallel group randomised controlled trial Levy et al studied 413 adults presenting to their GP with an acute exacerbation of asthma not severe enough to require hospital admission.⁽¹³³⁾ They were treated with high dose inhaled fluticasone propionate (1 mg twice daily via a spacer device) or oral prednisolone (reducing course starting at 40 mg reducing by 5 mg every two days) for 16 days. Treatment failure rates (peak expiratory flow <60% predicted on two consecutive occasions or symptom score of 3 on three or more consecutive days) were 27% in the inhaled fluticasone propionate group compared with 23% in the oral prednisolone group. The results were not significant, but power was reduced because of insufficient recruitment.

Statement: intravenous aminophylline offers little benefit over b₂ agonists in the treatment of acute asthma (I)—Littenberg conducted a meta-analysis on the use of aminophylline in acute asthma.⁽¹³⁴⁾ He looked at 347 papers and for various reasons rejected all but 13 of them. In five comparisons of intravenous aminophylline against parenteral b₂ agonists, the b₂ agonists did marginally better. In three papers in which b₂ agonist plus corticosteroid were compared with aminophylline plus corticosteroid there was no obvious advantage to either. In five trials of b₂ agonists compared with b₂ agonists plus aminophylline, there was a trend towards an increased effect with the addition of aminophylline but this was not significant.

Wrenn et al studied 133 patients presenting to a hospital emergency room.⁽¹³⁵⁾ Some had asthma, some chronic obstructive pulmonary disease, though the numbers are unclear. They were given inhaled b₂ agonists at 20 minute intervals, methylprednisolone 80 mg intravenously, and either aminophylline infusion or a placebo. There were no significant differences in any measures of lung function or in side effects. Significantly fewer patients were admitted from the emergency room to hospital after treatment with aminophylline (6% v 21%).

Murphy et al studied 44 patients with asthma who were treated with nebulised b₂ agonist, then, if their peak flow did not improve to above 40% predicted, treated with an infusion of aminophylline or placebo.⁽¹³⁶⁾ Treatment with nebulised b₂ agonist was continued, and they were given intravenous methylprednisolone. There was no difference in improvement between the two groups and more side effects in the aminophylline group. Serum concentrations of aminophylline were not measured.

Statement: nebulised salbutamol is more effective than intravenous salbutamol in the treatment of acute asthma (I)—Salmeron et al studied 47 patients admitted to hospital with severe acute asthma (PEFR <150 l/min and PaCO₂ ³ 40 mm Hg) in a multicentre parallel group study. ⁽¹³⁷⁾ The patients received either nebulised salbutamol 5 mg twice or an intravenous salbutamol infusion 5 mg over one hour. The increase in PEFR was greater in the nebulised group (by over 60 l/min) as was the decrease in PaCO₂. The percentage judged, by predefined criteria, to have been treated successfully at one hour was greater in the nebuliser group (86% v 40%).

Statement: spacer devices can be as effective as nebulisers in delivering drugs for the treatment of acute asthma (I)—Cates conducted a review to compare holding chambers with wet nebulisation for the delivery of b agonists in the treatment of acute asthmatic exacerbations.⁽¹⁰⁶⁾ He included randomised controlled trials of adults and/or children (from 2 years of age), in which b₂ agonists delivery was compared by using wet nebulisation and holding chambers. Outcome measures included admission to hospital, duration in the emergency department, and change in respiratory rate, blood gases, pulse rate, tremor, symptom score, and lung function. The review was restricted to 12 articles which met the inclusion criteria.

There were no significant differences in hospital admission rates in either adults or children when the two delivery methods were compared (odds ratio (95% confidence interval) 1.12 (0.45 to 2.76) for adults and 0.71 (0.23 to 2.23) for children). Significant differences were found for other outcomes, with use of holding chambers resulting in less time spent by children in the emergency department (weighted mean difference -0.62 (-0.84 to –0.40) hours). Use of holding chambers also resulted in lower pulse rates in children (-10.0%, -14.13% to -5.87% from baseline).

The review concludes that metered dose inhalers with a holding chamber produce outcomes that were at least equivalent to nebuliser delivery of b agonists in acute asthma. Uncertainty over delivery of equipotent doses from the different devices can be overcome by administering b agonists at short intervals (for example, standard dose via nebuliser or four separately inhaled actuations via a holding chamber every 15 to 20 minutes) with number of treatments titrated to the patient’s response. The side effects in children may be more pronounced with nebulisers.

In addition, within the review’s "implications for practice" section the author suggests two relevant points. Firstly, the experimental method adopted in many of the studies was to give repeated treatments at short intervals (for example, one standard dose via a nebuliser or four actuations of a metered dose inhaler via a holding chamber every 15 minutes). The number of treatments required was adjusted to the individual patient’s response, overcoming the uncertainty of dosage delivery from different devices. This method is therefore recommended for practice until further evidence becomes available. Secondly, the studies excluded patients with life threatening asthma; therefore, the results of this meta-analysis should not be extrapolated to such patients.

Statement: adding ipratropium to salbutamol produces little additional benefit in terms of FEV₁ (I)—We found three studies (table 27).

Table 27 Addition of ipratropium to salbutamol in acute asthma
 

Statement: in patients given short acting b₂ agonist via a spacer their short term FEV₁ improves more if the initial dose is repeated after 30-60 minutes (I)—We found one study ( ).
 

Table 28 Frequency of dose by spacer in acute asthma
 

Precipitants

Allergen avoidance and allergen specific immunotherapy

Recommendations

· Methods to control mites should not be routinely recommended (A)

· Allergen specific immunotherapy may be appropriate for certain patients, but it is not currently a primary care treatment (A)

Statements

· Methods aimed at reducing exposure to house dust mite allergens seem to be ineffective (I)

· Allergen specific immunotherapy significantly reduced asthma symptoms and medication requirements, but there was no consistent effect on lung function. Allergen immunotherapy reduced allergen specific bronchial hyperreactivity to a greater extent than non-specific bronchial hyperreactivity (I)

Hammarquist and colleagues conducted a Cochrane review to determine whether patients with asthma who are sensitive to house dust mites benefit from measures designed to reduce their exposure to house dust mite antigen in the home. ⁽¹⁴²⁾ A secondary objective was to determine whether such people benefit from a proved reduction of exposure to house dust mite antigen. Twenty three randomised trials were included, 13 of which exclusively studied children. The participants were diagnosed by a physician as having bronchial asthma. Their mite sensitisation was assessed by skin testing, bronchial provocation tests, or serum assay for IgE antibodies. The outcomes considered were subjective wellbeing, asthma symptom scores, use of medication, days of sick leave from school or work, number of unscheduled visits to a physician/hospital; FEV₁; PEFR; PC20 (provocative concentration that causes a 20% fall in FEV₁); and skin prick testing.

The total number of patients who improved after the experimental intervention was similar to the corresponding number in the control group (41/113 v 38/117, odds ratio 1.20, 0.66 to 2.18). Asthma symptom scores were grossly heterogeneous (P<0.0001 for test of heterogeneity), but there was no indication of an effect (standardised mean difference -0.06, -0.54 to 0.41). There was no significant difference overall for use of medication (-0.14, -0.43 to 0.15). Peak flow in the morning was the most commonly reported variable (-0.03, -0.25 to 0.19). For chemical methods there was a significant difference, which favoured the control group (-0.50, -0.98 to -0.01); this study had a baseline difference which favoured the control group. For physical methods the difference was 0.06 (-0.26 to 0.37) for the five crossover studies and 0.33 (-0.28 to 0.94) for the only group comparative trial. For combination methods the difference was 0.02 (-0.46 to 0.50). There was no effect on FEV₁ (0.09, -0.16 to 0.33). There was no difference between the treatments for PC20 (-0.04, -0.32 to 0.23). One study reported that none of the 12 participants missed school during treatment, as opposed to three during the control period. There was, however, no mention of reasons for missing school. None of the studies reported on number of unscheduled visits to a physician/hospital or results of skin prick testing after the treatment. The authors conclude that current chemical and physical methods aimed at reducing exposure to house dust mite allergens seem to be ineffective and cannot be recommended as prophylaxis for asthmatic people who are sensitive to dust mites.

Abramson et al conducted a review to estimate the overall efficacy of allergen specific immunotherapy on asthmatic symptoms, medication requirements, lung function, non-specific bronchial hyperreactivity (BHR), and allergen specific BHR.⁽¹⁴³⁾ The review was restricted to randomised controlled trials. Only studies that focused on asthma were included. Allergen specific immunotherapy was defined as the subcutaneous administration of extracts of house dust mites, pollens, animal danders or moulds, chemically modified allergoids, and antigen-antibody complexes. Although placebo controlled trials were methodologically stronger, studies that administered house dust or other relatively antigenically inactive preparations to the control group were also considered. Double blinded trials were preferred, but single blind and open studies were also reviewed for possible inclusion. At least one of the following clinical outcomes had to be reported: asthmatic symptoms, asthma medication requirements, lung function, non-specific BHR, or allergen specific BHR. The comparisons were allergen immunotherapy versus placebo, allergen immunotherapy versus antigenically inactive control, house dust versus placebo, and allergen immunotherapy versus untreated control. These comparisons were performed separately for each outcome, whenever these results were reported. Fifty four randomised controlled trials published between 1954 and 1997 satisfied the inclusion criteria.

There were 25 studies reporting immunotherapy for mite allergy, 13 studies of pollen allergy, eight studies of animal dander allergy, two studies of allergy to the mould Cladosporium, and six studies that attempted simultaneous immunotherapy for multiple aeroallergens. Concealment of allocation was assessed as clearly adequate in only 11 studies. The adequacy or otherwise of 40 studies could not be determined from the details published in the papers. Only three studies used a clearly inadequate method for concealment of allocation.

There was a significant overall improvement in asthma symptom scores after immunotherapy (combined standardised mean difference -0.52, -0.70 to -0.35). Patients randomised to immunotherapy were also significantly less likely to report a deterioration in symptoms of asthma than those randomised to placebo (odds ratio 0.27, 0.21 to 0.35). Requirements for asthma medication were significantly reduced (standardised mean difference -0.51, -0.74 to -0.28). Patients randomised to immunotherapy were also significantly less likely to require medication than those randomised to placebo (odds ratio 0.28, 0.19 to 0.42). There was no overall improvement in lung function after immunotherapy and marked heterogeneity between studies. There was a modest reduction in non-specific BHR after immunotherapy (standardised mean difference -0.32, -0.55 to -0.1). Non-specific BHR was also significantly more likely to improve among patients randomised to immunotherapy than those randomised to placebo (odds ratio 0.13, 0.05 to 0.34). There was a significant reduction in allergen specific BHR after immunotherapy (standardised mean difference -0.69, -0.46 to -0.91). Patients randomised to immunotherapy were also significantly less likely to develop increased allergen specific BHR (odds ratio 0.28, 0.19 to 0.41).

The authors conclude that allergen specific immunotherapy significantly reduced asthma symptoms and requirements for medication, but there was no consistent effect on lung function. Allergen immunotherapy reduced allergen specific bronchial hyperreactivity to a greater extent than non-specific bronchial hyperreactivity. On the basis of the data in this review, we cannot compare the size of improvement with immunotherapy with that obtained with other treatments for asthma. In particular, we cannot assess the effect of concurrent treatment with inhaled cortocosteroids on the benefits to be derived from immunotherapy. Immunotherapy may be considered when asthma is extrinsic and an unavoidable clinically relevant allergen can be identified. A specific effective extract should be used. When this treatment is used, the question of side effects must be fully discussed with the patient. After an immunotherapy treatment the patient must be observed long enough to deal with any major systemic reactions, and adequate resuscitation measures must be available because of the possibility of anaphylaxis.

Research questions (from the review authors)

Specific to immunotherapy

What are the most important determinants of the clinical relevance of an allergen?

Which patients respond best?

Is the result better when only a few skin tests yield positive results or is it just as effective in pan-reactors?

Is immunotherapy with a single component better than the use of a cocktail of allergens to which the patient reacted?

What is the optimal length of treatment and the best duration of effect?

Immunotherapy in relation to other asthma therapies

What is the size of effect compared with other treatments?

What is the effect of concurrent steroid treatment?

What is the isk:benefit profile?
 

Smoking and smoking cessation

Recommendations

· The current smoking status of all patients should be known (D)

· While there is no one strategy that is effective for all patients, strategies should be centred around advice and support from a health professional and nicotine replacement therapy in those who are motivated to quit (A)

· Advice and strategies should be tailored to individual circumstances (D)

· Patients should avoid passive smoking (D)

Evidence for statement

Statement: brief advice from a health professional and nicotine replacement therapy can both help patients to stop smoking (I)—The tobacco addiction module of the Cochrane Database of Systematic Reviews draws together evidence of the effectiveness of smoking cessation interventions.⁽¹⁴⁴⁾ These reviews and supporting information have been summarised in the NHS Centre for Reviews and Dissemination publication Effectiveness Matters, in a paper entitled Smoking cessation: what the health service can do, which reviews the effectiveness of smoking cessation interventions.⁽¹⁴⁵⁾ Both sources conclude that there is good evidence of effectiveness for brief advice from a health professional, nicotine replacement therapy with advice, and advice and support for pregnant women. There is insufficient evidence of effectiveness for antidepressants/anxiolytics, aversive conditioning, acupuncture, hypnosis, mecamylamine, and self help materials, booklets, pamphlets, and manuals. There was some supportive evidence for the effectiveness of clonidine but doubts about its usefulness. The publication examines weight gain after smoking cessation and states that "smokers should be informed that weight gain is common but that the associated health risks are far outweighed by the benefits of stopping smoking. Nicotine replacement therapy can delay weight gain until smokers feel ready to follow a weight control strategy."

Patient education and self management

Recommendations

· Patients should be offered education about their condition and its management (A)

· Education about self management, which involves a written action plan, self monitoring, and regular medical review, should be offered to adults with asthma (B)

· The routine home use of peak flow meters for self management is not mandatory (A)

Statements

· Patient education can improve knowledge and morbidity and beneficially alter behaviour (I).

· A self management package incorporating regular review, self monitoring, and individualised written action plans may be more effective than limited education in reducing morbidity and resource use (I)

The Cochrane Airways group has carried out two reviews of patient self management and education in adults with asthma which applied a post hoc categorisation to the elements of a self management package. The first considers limited (information only) education programmes in which the education programme is delivered to a person or group of people with asthma, including interactive sessions. The second looks at more intensive self management and practitioner review, regular medical review, self monitoring (either peak flow or symptoms), and individualised written action plans. Both are primarily interested in morbidity as outcome. The findings of the limited education review showed little or no impact on morbidity from this type of intervention. The exception to this was patients attending emergency departments, where limited asthma education did reduce attendance. The review of self management and regular practitioner review found clinically and statistically significant improvements in morbidity resulting from these interventions. There were reductions in admissions to hospital and emergency room visits, unscheduled visits to a doctor, days lost from work, and episodes of nocturnal asthma. Contamination of the control groups meant that if anything these studies underestimate the effect of these interventions. Asthma education that allowed patients to adjust their medications on the basis of a written action plan was more effective than education on self management of asthma without such a plan.

However, while this has considerable face validity, it is not clear if it should be applied to all patients or only some; and the resource consequences of this strategy are considerable. In addition, the analysis resulted from a post hoc categorisation that was devised by the authors of the review and not the authors of the original trials, and there is still uncertainty about the elements of such packages. For these reasons such a strategy should be tested in a prospective trial containing a cost effectiveness analysis.

Gibson and colleagues conducted a systematic overview of the literature to identify whether limited asthma education (information only) leads to improved health outcomes in adults with asthma.⁽¹⁴⁶⁾ Two reviewers independently assessed full text articles for inclusion on the basis of the following criteria: randomised controlled trials or controlled clinical trials; adults ( >16 years old) with asthma (defined by doctors diagnosis or objective criteria); asthma education that was delivered to person (or group of people) with asthma (and not their doctors) and that was limited to information transfer only (interventions involving self monitoring, enhanced medical management, and written action plans were excluded); and outcomes of admissions for asthma, emergency room visits, visits to a doctor, use of rescue b agonists, quality of life, lung function, and symptom scores.

Limited asthma education was studied in 11 randomised controlled trials conducted over a period of 20 years and with results reported of variable quality. Limited asthma education did not reduce admissions to hospital for asthma and unscheduled doctor visits and did not improve lung function. The effects on asthma symptoms were variable. There was no reduction in days lost from normal activity but perceived asthma symptoms did improve after limited asthma education. In the emergency department setting, where adults have severe asthma and a high rate of reattendance, limited asthma education did reduce emergency room attendance. Health outcomes in adults with asthma are unlikely to be improved by the widespread use of limited asthma education as it has been practised. Selective application of this intervention in the emergency department setting looks promising.

Gibson and colleagues conducted a second review to identify whether education in self management and regular review by a health practitioner improved health outcomes in adults with asthma.⁽¹⁴⁷⁾ Randomised controlled trials which studied the effects of education about self management on health outcomes in adults with asthma were included. Studies were subgrouped and analysed according to whether the asthma education intervention involved regular medical review (as a part of the programme or advised by the programme), self monitoring (peak expiratory flow or symptoms), an individualised written action plan that indicated when and how to adjust medications according to asthma severity, and optimal self management that involved all of the above.

Education about self management of asthma was studied in 24 randomised controlled trials. Twenty two studies compared education on self management with usual care. Self management reduced admissions to hospital (odds ratio 0.57), emergency room visits (0.72), unscheduled visits to the doctor (0.57), days off work or school (0.55), and nocturnal asthma (0.53). Improvements in peak flow were marginal (8.4 l/min). Non-significant improvements were seen in FEV₁. Subgroup analyses showed that optimal self management yielded larger and more clinically significant effect sizes compared with treatments that did not include a written action plan. Three studies which compared self management of peak expiratory flow with self management of symptoms showed no differences between these two forms of treatment in admissions to hospital and unscheduled visits to the doctor. In one study the number of emergency room visits was significantly reduced by plans based on peak flow, while in another significantly fewer participants in the symptom based group required a course of oral corticosteroids. In five studies that compared people who managed their asthma by self adjustment of medications according to an individualised written plan with those whose medications were adjusted by the doctor, lung function data (FEV₁ and PEF) were significantly higher in the self managed group.

Education on self management that includes self monitoring by either PEF or symptoms, together with regular medical review and a written action plan, improves health outcomes for adults with asthma. There are major reductions in resource use and improvements in morbidity. Asthma education that allows patients to adjust their medications on the basis of a written action plan is more effective than self management education without such a plan.

Research question

The cost effectiveness of different self management plans needs to be evaluated in a pragmatic, community based, randomised controlled trial.

Referral

We found no evidence concerning the referral of patients with asthma, either from primary to secondary care or between healthcare professionals within primary care. These recommendations are taken from the British Thoracic Society guidelines.

Referral to a chest physician

Recommendations

· Referral to a respiratory physician is appropriate for:

The guideline development group made additional points of clarification.

Recommendations

· Suspected occupational asthma should be referred for the confirmation of the diagnosis, the management of avoidance of sensitisers, and the management of other workers in the workplace (D) (while this could be managed by general practitioners the low prevalence of such patients in the population means that any one general practitioner will have only limited experience in their management)

· Patients for whom a general practitioner is considering long term oral corticosteroids or home use of a nebuliser should be referred to a respiratory physician for assessment (D)

· Patients who have recently been discharged from hospital should have their treatment reviewed; this does not need hospital review if the primary healthcare professional possesses the relevant skills and resources (D)

· Patient preference should be accommodated in the decision to refer (D)

· Primary healthcare professionals should be aware of the range of skills and facilities available within their practice and should, when appropriate, refer within the practice (D)

Research questions

Short acting b₂ agonists

What is the relative place of regular and as required dosing with short acting b₂ agonists?

Inhaled corticosteroids

What is the lowest doses of inhaled corticosteroids at which patients benefit from the addition of long acting b₂ agonists?

When and how quickly should the dose of inhaled corticosteroids be decreased?

Is it effective to increase the dose of inhaled corticosteroids during intercurrent illnesses?

How safe are inhaled corticosteroids and what is the relevance of changes in serum cortisol concentrations?

Is there a role for using inhaled corticosteroids as first line treatment?

Leukotriene antagonists

What is the appropriate place of leukotriene antagonists in a therapeutic sequence?

Complementary therapy

What is the appropriate role of complementary therapies in the treatment of asthma?

Allergen avoidance and allergen specific immunotherapy (from the review authors)—specific to immunotherapy

What are the most important determinants of the clinical relevance of an allergen ?

Which patients respond best ?

Is the result better when only a few skin tests yield positive results or is it just as effective in pan-reactors?

Is immunotherapy with a single component better than the use of a cocktail of allergens to which the patient reacted?

What is the optimal length of treatment and the best duration of effect ?

Immunotherapy in relation to other asthma treatments

What is the size of effect compared with other treatments?

What is the effect of concurrent steroid treatment?

What is the risk:benefit profile?

Patient education and self management

The cost effectiveness of different self management plans needs to be evaluated in a pragmatic community based randomised controlled trial.

Is there a learning effect from the use of peak flow meters on symptom perception and control?

What is the role of peak flow in predicting outcome in acute situations in UK primary care?

Which patients should be monitored with regular peak expiratory flow rate measurements and when?

• Brad Cheek: last updated Dec 2006
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