GLOBAL INITIATIVE FOR ASTHMA GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION DISTRIBUTE NHLBI/WHO WORKSHOP REPORT (Based on a March 1993 Meeting) OR COPY NOT DO - MATERIAL NATIONAL INSTITUTES OF HEALTH National Heart, Lung, and Blood Institute Publication Number 95-3659 COPYRIGHTED January 1995 Reprinted May 1996 i TABLE OF CONTENTS INTRODUCTION............................................................xiii RESEARCH RECOMMENDATIONS.............................18 REFERENCES...............................................................22 CHAPTER 1 DEFINITION...............................................1 KEY POINTS....................................................................2 CHAPTER 3 RISK FACTORS......................................25 AIRWAY PATHOLOGY IN ASTHMA...............................2 KEY POINTS .................................................................26 RELATIONSHIP OF AIRWAY PATHOLOGY TO RISK FACTORS INVOLVED IN THE DEVELOPMENTDISTRIBUTE DISORDERED LUNG FUNCTION ..............................3 OF ASTHMA..............................................................26 Airway Hyperresponsiveness ......................................3 Predisposing Factors .................................................26 Airflow Limitation..........................................................4 Atopy and Inheritance of Asthma .........................26 Genetic Control of IgEOR Synthesis.....................28 DEFINITION OF ASTHMA...............................................6 Genetic Control of the Immune Response ......28 Gender and Asthma .............................................28 RESEARCH RECOMMENDATIONS...............................7 Race and Asthma .................................................28 Causal Factors...........................................................28 REFERENCES.................................................................7 Indoor AllergensCOPY....................................................29 Domestic Mites ................................................29 Animal Allergens..............................................30 CHAPTER 2 EPIDEMIOLOGY .......................................9 Cockroach Allergen .........................................30 NOTFungi................................................................30 KEY POINTS..................................................................10 Outdoor Allergens.................................................30 Pollens.............................................................30 Fungi................................................................30 DEFINITIONS.................................................................10 DO Occupational Sensitizers ......................................32 Defining Populations..................................................10- Drugs and Food Additives ....................................32 Defining Countries .....................................................11 Contributing Factors ..................................................32 Defining Asthma for Epidemiological Studies............11 Smoking................................................................32 Questionnaires .....................................................11 Passive Smoking .............................................32 Objective Measurements of Airway Active Smoking................................................32 Hyperresponsiveness .......................................11 Air Pollution...........................................................32 Evaluation of Etiologic Factors .............................11 Outdoor Pollutants...........................................32 Indoor Pollutants..............................................33 PREVALENCE OF ASTHMA .........................................11 Viral Respiratory Infections...................................33 MATERIAL Small Size at Birth ................................................34 MORTALITY OF ASTHMA.............................................13 Diet .......................................................................34 Parasitic Infections................................................34 MORBIDITY ...................................................................16 Quality of Life .............................................................16 RISK FACTORS THAT CAUSE ASTHMA Hospital Admissions ..................................................16 EXACERBATIONS: TRIGGERS ...............................34 Allergens..........................................................34 NATURAL HISTORY OF ASTHMA ...............................17 Air Pollutants....................................................34 Infancy .......................................................................17 Respiratory Infections......................................35 Childhood...................................................................17 Exercise and Hyperventilation.........................35 Adulthood...................................................................17 Weather Changes............................................35 Sulfur Dioxide ..................................................35 ASSESSING THE NATIONAL/LOCAL ASTHMA Foods, Additives, Drugs ..................................35 COPYRIGHTEDPROBLEM .................................................................18 Extreme Emotional Expression .......................35 Other Factors That May Exacerbate Asthma ..35 ix RESEARCH RECOMMENDATIONS.............................36 DIFFERENTIAL DIAGNOSIS.........................................57 REFERENCES...............................................................36 CLASSIFICATION OF ASTHMA....................................57 Etiology ......................................................................57 Severity ......................................................................59 CHAPTER 4 MECHANISMS OF ASTHMA..................39 Time Trends of Airflow Limitation ..............................59 KEY POINTS..................................................................40 ASTHMA SCREENING..................................................59 AIRWAY INFLAMMATION IN ASTHMA ........................40 RESEARCH RECOMMENDATIONS.............................59 Immunologic Mechanisms .........................................40 Inflammatory Mediators .............................................40 REFERENCES...............................................................60 IgE-Dependent, T-Lymphocyte-Dependent Mechanisms...........................................................41 DISTRIBUTE IgE-Independent, T-Lymphocyte-Dependent CHAPTER 6 PREVENTION .........................................63 Mechanisms...........................................................41 Adhesion Molecules...................................................42 KEY POINTS..................................................................64OR Constitutive Cells .......................................................42 PRIMARY PREVENTION STRATEGIES ......................64 NEURAL CONTROL OF AIRWAYS ..............................42 Indoor Environments..................................................65 Tobacco Smoking ......................................................65 ASTHMA SYMPTOMS...................................................43 Outdoor Environments...............................................65COPY Workplace Environments...........................................65 AIRFLOW LIMITATION IN ASTHMA .............................43 Small Size at Birth......................................................65 Reversible Airflow Limitation and Airway Infections....................................................................65 Hyperresponsiveness ............................................44 NutritionNOT and Diet .......................................................66 Irreversible Airflow Limitation.....................................44 Other Areas for Consideration and Research ...........66 BLOOD GAS ABNORMALITIES IN ASTHMA ...............44 DOSUGGESTIONS FOR A PRIMARY PREVENTION PROGRAM ................................................................66 NOCTURNAL ASTHMA.................................................45- REFERENCES...............................................................66 RESEARCH RECOMMENDATIONS.............................45 REFERENCES...............................................................45 CHAPTER 7 A SIX-PART ASTHMA MANAGEMENT PROGRAM.....................................................................69 CHAPTER 5 DIAGNOSIS AND CLASSIFICATION ....47 KEY POINTS..................................................................70 KEY POINTS..................................................................48MATERIAL PART 1: EDUCATE PATIENTS TO DEVELOP A PARTNERSHIP IN ASTHMA MANAGEMENT .........71 CLINICAL DIAGNOSIS ..................................................48 History and Measurements of Symptoms..................48 PART 2: ASSESS AND MONITOR ASTHMA SEVERITY Physical Examination.................................................48 WITH MEASUREMENTS OF SYMPTOMS AND Measurements of Lung Function ...............................49 MEASUREMENTS OF LUNG FUNCTION ...............71 Measurements of Allergic Status ...............................52 Measurements of Symptoms.....................................71 Measurements of Lung Function ...............................72 PARTICULARLY DIFFICULT DIAGNOSTIC Measurement of PEF............................................72 GROUPS ...................................................................52