1. Introduction to Asthma

Brief definition

“Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. In susceptible individuals, this inflammation causes recurrent episodes of coughing (particularly at night or early in the morning), wheezing, breathlessness, and chest tightness. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment.”- EPR3/4

“Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation.”- GINA

Guidelines for asthma care

There are national and global guidelines available for asthma. The two most widely accepted are reviewed and summarized in this reference guide.

National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC) Expert Panel Report (EPR). These reports are produced by expert panels on an as needed basis and update recommendations on asthma care and management. The EPR1 published in 1991, EPR2 was published in 1997, and EPR3 produced in 2007. The EPR4 are working group most recently published their report in 2020 updating 6 priority topics. It is a published report from a committee functioning under the United State’s National Heart Lung and Blood Institute. In this reference guide, we will mainly focus on the differences between the EPR3 and EPR4.

Global Initiative for Asthma (GINA) Report: The GINA report is published annually and is used globally with many different countries using it as their national reference.

A table is provided to compare major similarities and differences between the EPR3, EPR4, and GINA 2020.

	EPR3 (2007)	EPR4 (2020)	GINA (2020)
Goals of guideline	To provide quality care to those with asthma Defined asthma control and severity Focused on long term management of reducing impairment & reducing risk Modified stepwise approach	Appropriate diagnosis, management of asthma, improving outcomes for individuals with asthma, reducing morbidity, mortality and improving quality of life. Goal: Updating EPR3 with data on 6 priority topics	Does not consider themselves a guideline but rather an “integrated evidence-based strategy focusing on translation into clinical practice” Goal: to prevent deaths, exacerbations, symptom control. Information is targeted towards PCPs
Step therapy	Refer to Steps Diagram for differences and comparisons between different guidelines/reports for recommendations on pharmacotherapy for asthma based on severity and on follow up visits. We have elected to keep all 6 steps as per EPR and embedded recommendations from GINA within 6 steps.
Age groups: 0-4 years of age 5-11 years of age >12 years of age 6 total steps for all age groups	Same as EPR 3	Age groups: 0-5 years of age 6-11 years of age >12 years of age 4 steps for 0-5 years old 5 steps for 6-11 years old 5 steps for >12 years old
Inhaled Corticosteroid (ICS) Highlights of recommendation changes, for full comparison refer to steps diagram.	0-4 years of age: with mild symptoms or recurrent wheezing: treat with SABA q 4-6 hrs for 24 hrs, for more than 24 hrs, need MD evaluation with mod/severe exacerbation: treat with OCS >12 years of age: Recommendation for daily ICS for persistent asthmatics with low/med/high dosing based on severity with use of SABA prn for all steps. Recommendation for consideration of medium dose ICS/LABA at Step 4 (mod/severe)	0-4 years of age: with recurrent wheezing with NO symptoms in between exacerbations: conditional recommendation of short course of ICS + PRN SABA at onset of respiratory illness > 4 + years of age: *mild/moderate persistent asthma who are likely adherent* to therapy: conditional recommendation against short term increase in ICS dose mod/severe persistent asthma: strong recommendation for low or moderate dose ICS/formoterol as daily and quick relief therapy compared to ICS/LABA + PRN SABA or high dose ICS + PRN SABA >12+ years of age: with mild persistent asthma:** conditional recommendation of daily low dose ICS +	ICS is preferred daily controller should be considered at any age from Step 2 onward At age 6 onward, addition of ICS whenever SABA is taken as an alternative therapy in Step 1 and step 2 Emphasis on low, medium, and high dose ICS varying with age. (Please see ICS dosing charts)

EPR3 (2007)

EPR4 (2020)

GINA (2020)

Goals of guideline

To provide quality care to those with asthma

Defined asthma control and severity
Focused on long term management of reducing impairment & reducing risk
Modified stepwise approach

Appropriate diagnosis, management of asthma, improving outcomes for individuals with asthma, reducing morbidity, mortality and improving quality of life.

Goal: Updating EPR3 with data on 6 priority topics

Does not consider themselves a guideline but rather an “integrated evidence-based strategy focusing on translation into clinical practice”

Goal: to prevent deaths, exacerbations, symptom control.

Information is targeted towards PCPs

Step therapy

Refer to Steps Diagram for differences and comparisons between different guidelines/reports for recommendations on pharmacotherapy for asthma based on severity and on follow up visits. We have elected to keep all 6 steps as per EPR and embedded recommendations from GINA within 6 steps.

Age groups:

0-4 years of age

5-11 years of age

>12 years of age

6 total steps for all age groups

Same as EPR 3

Age groups:

0-5 years of age

6-11 years of age

>12 years of age

4 steps for 0-5 years old

5 steps for 6-11 years old

5 steps for >12 years old

Inhaled Corticosteroid (ICS)

Highlights of recommendation changes, for full comparison refer to steps diagram.

0-4 years of age:

with mild symptoms or recurrent wheezing: treat with SABA q 4-6 hrs for 24 hrs, for more than 24 hrs, need MD evaluation
with mod/severe exacerbation: treat with OCS

>12 years of age:

Recommendation for daily ICS for persistent asthmatics with low/med/high dosing based on severity with use of SABA prn for all steps.
Recommendation for consideration of medium dose ICS/LABA at Step 4 (mod/severe)

0-4 years of age:

with recurrent wheezing with NO symptoms in between exacerbations: conditional recommendation of short course of ICS + PRN SABA at onset of respiratory illness

> 4 + years of age:

mild/moderate persistent asthma who are likely adherent to therapy: conditional recommendation against short term increase in ICS dose
mod/severe persistent asthma: strong recommendation for low or moderate dose ICS/formoterol as daily and quick relief therapy compared to ICS/LABA + PRN SABA or high dose ICS + PRN SABA

>12+ years of age:

with mild persistent asthma: conditional recommendation of daily low dose ICS +

ICS is preferred daily controller should be considered at any age from Step 2 onward

At age 6 onward, addition of ICS whenever SABA is taken as an alternative therapy in Step 1 and step 2

Emphasis on low, medium, and high dose ICS varying with age. (Please see ICS dosing charts)

1. Introduction to Asthma

Brief definition

Guidelines for asthma care

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