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Proceedings From an ACCP International Roundtable Conference FREE TO VIEW

Sidney S. Braman, MD, FCCP
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*From the Division of Pulmonary and Critical Care Medicine, Brown University, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903.

Correspondence to: Sidney S. Braman, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Brown University, Rhode Island Hospital, Providence, RI.

Chest. 2006;130(1_suppl):1S-3S. doi:10.1378/chest.130.1_suppl.1S
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Many groups have met over the years to discuss the shortcomings in asthma management and to look at new treatments and strategies to overcome them. However, despite widely publicized guidelines and extensive educational programs, asthma continues to impact negatively on many patients’ lives, and mortality from this condition is still excessive based on the treatments that are available. The burden of disease due to asthma is likely to continue to increase, particularly in developing countries where a more westernized lifestyle is adopted.

This Supplement is the proceedings of a meeting conducted by the American College of Chest Physicians to develop strategies for closing the loop between developments in our understanding of asthma, the needs of asthma patients, and the challenges of providing appropriate therapy and management for this condition. A multinational, multidisciplinary panel examined the key issues in asthma, including some of the more neglected questions, and looked widely into other areas of medicine for strategies to better manage asthma as a chronic disease. Above all else, the participants focused on the practical needs of physicians managing asthma on a day-to-day basis. The main findings of this meeting are outlined below but are expanded more thoroughly in the articles. The articles cover only the presented material. For other, relevant information, readers are directed to the current literature. Following each article, there is also a summary of participants’ feedback on that particular topic. Feedback was obtained during workshop discussions that were an open forum for participants to provide the panel with their own experiences, insights, and views. The workshops were recorded by the meeting organizers, with the key points published here confirmed by participants as being representative of their input.

The panel acknowledged the fact that the first challenge in asthma is diagnosis. As this topic was not covered in detail, readers are directed to the updated Global Initiative for Asthma report1 for further information. A clinical diagnosis of asthma is unreliable, and compatible objective testing, as well as a favorable response to asthma therapy, need to be incorporated into our diagnostic algorithm. Poor diagnosis of asthma can lead to undertreatment or overtreatment, although asthma is generally undertreated. Diagnosis should always be reexamined in patients who do not respond to asthma therapy.

Asthma is an inflammatory disease, and therapy should address the underlying inflammatory process. Consequently, inhaled corticosteroids remain the cornerstone of asthma therapy. In children, early treatment with inhaled corticosteroids has been shown to delay the decline in lung function.2However, it is unclear whether the potential benefits of early treatment with inhaled corticosteroids in slowing disease progression are, in fact, translated into improved long-term clinical outcomes. The World Health Organization3 includes inhaled corticosteroids in the Essential Medicines Library for the nonsystemic corticosteroid prophylaxis of asthma, stating that inhaled steroids are more effective than theophylline, cromoglycate, or long-acting β-agonists. It is important that all countries embrace this recommendation and that access to inhaled corticosteroids is improved. However, even in more affluent countries, reimbursement and cost issues will have a large influence on the choice of efficacious agents. In addition, physicians must remain cognizant of the risk of local and systemic adverse events with currently available inhaled corticosteroids, particularly at higher doses. Physicians should also be conscious of patient histories of adverse events with inhaled corticosteroids, as well as their beliefs and possible concerns that may negatively affect adherence to therapy. An ideal inhaled corticosteroid would have a larger therapeutic ratio than currently available agents, allowing doses to be increased but without greatly increasing the frequency or severity of adverse events. Safer inhaled corticosteroid therapy has the potential to increase patient adherence, enhance the use of inhaled corticosteroid monotherapy in the primary care setting, and increase the range of patients for whom inhaled corticosteroid monotherapy would be appropriate. However, these potential benefits would have to be demonstrated clinically for any new agent.

In addition to cost and safety issues, barriers to prescribing inhaled corticosteroids include, but are not limited to, “steroid phobia” and a lack of differentiation with anabolics, a failure to acknowledge asthma as a chronic illness requiring long-term therapy, insufficient patient empowerment/education, and a lack of resources to provide support for primary care physicians for asthma management. Despite the availability of additional therapeutic options, continued inadequate control of asthma in terms of symptoms, exacerbations, hospitalizations, and mortality demonstrates a need for improved approaches to asthma management.

Current clinical guidelines for asthma provide a good starting point in regard to setting out the objectives of stepwise care, and in defining the hierarchy of asthma medications: from no therapy, through the use of inhaled corticosteroids, to oral corticosteroids in patients in whom control is not achieved. However, the use of a severity classification to drive treatment choice is impractical and complex to apply in clinical practice, leading to large inconsistencies in patient categorization, even between asthma experts. Moreover, the use of a baseline severity classification (without therapy) does not allow the effect of asthma treatment to be assessed and is often difficult to use in patients with continuing asthma and therapy over many years. There are two main alternatives to this approach. First, we can continue to look for more objective markers of severity, such as nitric oxide production, that would provide an accurate picture of a patient’s ongoing inflammatory status (with or without medication). Although attractive, at present this approach is impractical outside clinical trials. As an alternative, a focus on achieving relief of patient symptoms, or other agreed-upon outcomes between the clinician and patient, such as the ability to take exercise, and use the minimal level of medication required to achieve these outcome objectives may be preferable. This is a more pragmatic approach to asthma management, giving only those medications necessary in order to meet the patient’s need for symptom control with a built-in flexibility to modify treatment based on step-up or step-down as symptoms change. Also, guidance on when to refer for specialist care could be based on the failure to meet the agreed-upon therapy outcomes. Rather than using the more “theoretical” concept of asthma severity, focusing on outcomes also provides a shared language for patients and clinicians.

A patient-focused approach to asthma care can be abbreviated to the “three Cs”: communication, continuity of care, and concordance (ie, finding common ground). Physicians should not underestimate the importance of these three factors in influencing therapy adherence, clinical outcomes, and future health service use in asthma. In particular, adherence may be difficult to assess in asthma, and patient report is considered unreliable as the sole measure of compliance. Maximizing adherence is an important consideration when choosing the asthma treatment and delivery device. Information on local adverse events should be proactively sought from the patient, as they may adversely affect therapy adherence. Education of health-care providers on easy-to-use, adherence-promoting techniques is required, as very few clinicians will have received support or training in this area. Where physician extenders, such as specialist nurses and health visitors, are available, time pressure on primary care providers and specialists can be reduced, with enhanced patient education, communication, and provision of information. However, it must also be recognized that these additional resources may often be unavailable. In such cases, time spent developing patient self-care programs earlier in asthma management may be rewarded with better outcomes and reduced service use in the medium-to-longer term. Ideally, the asthma care model should be interdisciplinary to facilitate communication, education, patient empowerment, a referral paradigm, and treatment protocols. However, this model must also encompass a patient-focused approach and reflect the needs of all the components in the interdisciplinary group (ie, it must be accepted and relevant to all parties), or else it will fail to deliver coordinated care. The physician/patient relationship is an often overlooked but critical element to asthma management.

A new dialogue in asthma needs to be opened: one that promotes practical solutions, is focused on patient needs, and that encompasses learning from diverse areas. On behalf of the faculty and participants, I would like to thank all those that took part in this meeting.

Program Chair

Sidney S. Braman, MD, FCCP, Division of Pulmonary and Critical Care Medicine, Brown University, Rhode Island Hospital, Providence, RI.

Program Faculty

Giorgio W. Canonica, MD, Allergy and Respiratory Diseases, Pad Maragliano, Genoa, Italy; Franklin Cerasoli Jr, PhD, ALTANA Pharma, Florham Park, NJ; LeRoy M. Graham, MD, FCCP, Morehouse School of Medicine, GA Pediatric Pulmonary Associates, Atlanta, GA; Rob Horne, PhD, MRPharmS, Centre for Health Care Research, Brighton and Sussex Medical School, University of Brighton, Brighton, UK; Marc Humbert, MD, PhD, Service de Pneumologie et Réanimation Respiratoire, Hôpital Antoine Béclère, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Clamart, France; Richard S. Irwin, MD, FCCP, Pulmonary, Allergy and Critical Care Medicine Division, University of Massachusetts Medical School, Worcester, MA.

Program Participants

Martin B. Allen, MBChB, FCCP, Department of Respiratory Medicine, City General Hospital, Stoke-on-Trent, UK; Meyer S. Balter, MD, FCCP, Department of Medicine, University of Toronto, Toronto, ON, Canada; Thomas Brack, MD, FCCP, University Hospital Zurich, Weesen, Switzerland; Peter Bremner, Mount Medical Centre, Perth, WA, Australia; Nunzio Crimi, MD, FCCP, Pulmonary Division, Ascoli-Tomaselli Hospital, Catania, Italy; Alberto Cukier, MD, Pulmonary Division, University of São Paulo Medical School, São Paulo, Brazil; Ryszarda Chazan, MD, FCCP, Pneumonology Department, Warsaw University Medical School, Warsaw, Poland; Giusepe U. Di Maria, MD, FCCP, Institute of Respiratory Diseases, University of Catania, Catania, Italy; James F. Donohue, MD, FCCP, Department of Medicine, University of North Carolina, Chapel Hill, NC; Charles Feldman, MBBCh, FCCP, Medical School, Hillbrow Hospital and University of the Witwatersrand, Johannesburg, South Africa; Giuseppe Girbino, MD, FCCP, Institute of Respiratory Diseases, Policlinico University, Messina, Italy; Philippe Godard, MD, PhD, Respiratory Illness Clinic, Hôpital Arnaud deVilleneuve, Montpellier, France; David Honeybourne, MD, FCCP, Department of Respiratory Medicine, Birmingham Heartlands Hospital, Birmingham, UK; Claus Kroegel, MD, FCCP, Medical Clinic IV, Pneumology and Allergy and Immunology, Friedrich-Schiller-University, Jena, Germany; Lindsay Lawson, MD, FCCP, University of British Columbia, St Paul’s Hospital, Vancouver, BC, Canada; Ewa Nizankowska, MD, FCCP, Division of Pulmonary Medicine, Jagellonian University School of Medicine, Kraków, Poland; Jill A. Ohar, MD, FCCP, Pulmonology/Critical Care Medicine Section, Wake Forest University School of Medicine, Winston-Salem, NC; Richard Ruffin, MBBS, FCCP, Department of Medicine, Queen Elizabeth Hospital, Woodville, SA, Australia; Satyendea Sharma, MBBS, FCCP, Section of Respiratory Diseases, University of Manitoba, Winnipeg, MB, Canada; José Manuel Tunon de Lara, MD, PhD, Hôpital du Haut Lévêque, Pessac, France; Mauro M. Zamboni, MD, FCCP, Pneumology Service, University Hospital Clementino Fraga Filho, State University of Rio de Janeiro, Rio de Janeiro, Brazil.

Proceedings of a meeting held in July 16–17, 2004, Stresa, Lake Maggiori, Italy.

The meeting and publication were supported by Altana Pharma AG.

The author has no conflict of interest or financial investment that would pertain to this article. He has however, been a consultant and on the speakers’ Bureau of GlaxoSmithKline, Altana Pharma, Bland Schering Plough, Inc.


Global Initiative for Asthma (GINA). Global strategy for asthma prevention and management. Available at: www.ginasthma.com. Accessed January 26, 2006.
Agertoft, L, Pedersen, S Effects of long-term treatment with an inhaled corticosteroid on growth and pulmonary function in asthmatic children.Respir Med1994;88,373-381. [PubMed] [CrossRef]
World Health Organization. Essential medicines library. Available at: http://mednet3.who.int/eml/. Accessed July 22, 2004.




Global Initiative for Asthma (GINA). Global strategy for asthma prevention and management. Available at: www.ginasthma.com. Accessed January 26, 2006.
Agertoft, L, Pedersen, S Effects of long-term treatment with an inhaled corticosteroid on growth and pulmonary function in asthmatic children.Respir Med1994;88,373-381. [PubMed] [CrossRef]
World Health Organization. Essential medicines library. Available at: http://mednet3.who.int/eml/. Accessed July 22, 2004.
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