NAEPP Expert Panel Report 3 (EPR-3) Guidelines for the Diagnosis and Management of Asthma - 2007

Issued by the National Asthma Education and Prevention Program (NAEPP) under the aegis of the National Heart, Lung and Blood Institute at NIH, the updated guidelines build upon complete asthma guidelines issued in 1991 and 1997 and an update on selected topics released in 2002. The guidelines focus on four components of asthma care: measures to assess and monitor asthma, patient education, control of environmental factors and other conditions that can worsen asthma, and medications.

Key features and changes to these four components of asthma care include:

• Assessment and Monitoring:  EPR-3 takes a new approach to assessing and monitoring asthma by using multiple measures of the patient's level of current impairment (frequency and intensity of symptoms, low lung function, and limitations of daily activities) and future risk (risk of exacerbations, progressive loss of lung function, or adverse side effects from medications).  The guidelines stress that some patients can still be at high risk for frequent exacerbations even if they have few day-to-day effects of asthma.
• Patient Education. EPR-3 confirms the importance of teaching patients skills to self-monitor and manage asthma and to use a written asthma action plan, which should include instructions for daily treatment and ways to recognize and handle worsening asthma.  New recommendations encourage expanding educational opportunities to reach patients in a variety of settings, such as pharmacies, schools, community centers, and patients’ homes. A new section addresses the need for clinician education programs to improve communications with patients and to use system-wide approaches to integrate the guidelines into health care practice. 
• Control of environmental factors and other conditions that can affect asthma.  EPR-3 describes new evidence for using multiple approaches to limit exposure to allergens and other substances that can worsen asthma; research shows that single steps are rarely sufficient. EPR-3 also expands the section on other common conditions that asthma patients can have and notes that treating chronic problems such as rhinitis and sinusitis, gastroesophageal reflux, overweight or obesity, obstructive sleep apnea, stress, and depression may help improve asthma control. 
• Medications.  EPR-3 continues the use of a stepwise approach to control asthma, in which medication doses or types are stepped up as needed and stepped down when possible. Treatment is adjusted based on the level of asthma control.  

The stepwise asthma management charts are revised and expanded to specify treatment for three age groups: 0-4 years, 5-11 years, and 12 years and older.  The 5-11 age group was added (earlier guidelines combined this group with adults) as a result of new evidence on medications for this age group and emerging evidence that suggests that children may respond differently than adults to asthma medications.

Recommendations on medications are updated to reflect the latest evidence on effectiveness and safety.  EPR-3 reaffirms that patients with persistent asthma (e.g., patients who have symptoms more than twice a week during the day or more than twice a month at night) need both long-term control medications to control asthma and prevent exacerbations, as well as quick relief medications for symptoms as needed.  EPR-3 also reaffirms that inhaled corticosteroids are the most effective long-term control medication across all age groups.  EPR-3 includes new recommendations on treatment options such as leukotriene receptor antagonists and cromolyn for long term control; long acting beta agonists as adjunct therapy with inhaled corticosteroids; omalizumab for severe asthma; and albuterol,  levalbuterol, and corticosteroids for acute exacerbations.

EPR-3 also describes areas of current research to improve asthma management, such as new ways for monitoring asthma control (for example, tests using a patient’s sputum and exhaled air), and tailoring treatment based on the particular characteristics of a patient’s asthma and the patient's genetic makeup.