DEPARTMENT OF HEALTH & HUMAN SERVICES 
Health Care Financing Administration 
Center for Medicaid and State Operations 
7500 Security Boulevard 
Baltimore, MD 21244-1850 
SMDL #01-011 
January 19, 2001 
Dear State Medicaid Director: 
I am writing to advise you of recent developments in the care of asthma and to stress the importance 
of State action to assure that Medicaid beneficiaries with asthma, particularly children, receive 
appropriate care.  This issue is particularly important because of the increasing incidence of asthma 
and its prevalence among low-income populations.  This letter also clarifies mandated and optional 
Medicaid coverage for asthma items and services. 
Medicaid covers asthma-related medical services under various categories, including prescription 
drugs, home health services, physician services, and other licensed practitioners.  Some State 
Medicaid programs are using disease management programs as an effective means of improving 
outcomes for asthma patients and reducing costs.  Medicaid programs can also improve service 
delivery by coordinating asthma-related initiatives with other programs and addressing utilization 
limits with Medicaid managed care organizations and pharmacy benefit managers. 
In General 
To underscore the importance of the asthma epidemic, President Clinton signed an Executive Order 
in 1997, which created the Task Force on Environmental Health Risks and Safety Risks to 
Children.  This task force is co-chaired by the Secretary of the Department of Health and Human 
Services (DHHS), Donna Shalala, and the Commissioner of the Environmental Protection Agency 
(EPA), Carol Browner, and seeks to reduce the incidence of pediatric asthma and associated 
medical costs by promoting additional research, programs to lessen exposure to environmental 
irritants, better data collection, and provider education. 
The Department of Health and Human Services also recently issued Action Against Asthma: A 
Strategic Plan for the Department of Health and Human Services, which is available on the 
Internet at http://aspe.hhs.gov/sp/asthma/.  This action plan outlines four priority areas for 
investment in asthma management over the next five years: determining the cause of asthma and 
interventions to prevent its onset, decreasing the burden of asthma for people with the disease, 
eliminating the disproportionate burden of asthma in minority populations and those living in 
poverty, and tracking the disease and assessing the effectiveness of asthma programs.  We 
encourage you to review this plan and help achieve progress in these priority areas.  Page 2  State Medicaid Director 
Epidemiological Trends 
Asthma is a chronic and episodic inflammatory disease of the airways, which is often exacerbated 
by exposure to indoor allergens (such as tobacco smoke, pet dander, house dust mites, cockroaches, 
and mold), outdoor air pollutants, and upper respiratory infections.  The number of Americans 
afflicted with asthma nearly doubled between 1980 and 1996, and the condition now affects nearly 
15 million Americans, including nearly 5 million children.  It is the most common chronic disease 
of childhood. 
The illness is responsible for over 1.8 million emergency room visits, 460,000 hospitalizations and 
5,000 deaths each year.  Children with asthma lose an extra 10 million school days each year, and 
this results in an estimated $1 billion in lost productivity from their working parents.  Claims data 
reveal that Medicaid-eligible children under age 18 in 28 States had more than 36,000 
hospitalizations costing over $101.7 million and more than 765,000 outpatient visits costing over 
$55.67 million for a primary diagnosis of asthma in 1995. 
While asthma affects Americans of all ages, races, and ethnic groups, low-income and minority 
populations are disproportionately affected.  For example, while African-Americans have only 
slightly higher rates of asthma than whites, they are twice as likely to die from their asthma. 
African-American children are four times more likely to die from asthma than white children. 
Pediatric asthma hospitalizations are five times higher for children in lower income families than 
for other children.  In addition, research has indicated that low-income and minority children are 
less likely to have access to quality care, and are less likely to receive optimal medical therapy. 
Management of Asthma Symptoms: NIH Guidelines 
Asthma can be managed most effectively by avoiding or controlling environmental and 
occupational factors that exacerbate the condition, taking appropriate medications, objective 
monitoring of the disease, and actively involving the patient and family in self-care and disease 
management.  Effective asthma management reduces the need for hospitalizations and urgent care 
visits, and leads to a more full and active life. 
In 1997, the National Asthma Education and Prevention Program (NAEPP), sponsored by the 
National Heart, Lung, and Blood Institute (NHLBI), updated Guidelines for the Diagnosis and 
Management of Asthma (Introduction including overview enclosed).  The Guidelines translate 
research findings into recommendations for management by health care providers and for patient 
self-management.  Although the Guidelines were widely disseminated and are recommended as 
standards of care, studies indicate that many professionals and affected families are not using the 
Guidelines.  The Departments Asthma Action Plan specifically directs HCFA to work 
with...State health officials to accelerate widespread adoption of the Guidelines.  We encourage 
you to make your providers and beneficiaries aware of these Guidelines.  The Guidelines can be 
accessed at http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.  Page 3  State Medicaid Director 
Medicaids Role in Improving Asthma Management 
Access to Medicaid Services: It has come to our attention that certain State Medicaid prescription 
drug and medical equipment policies could be barriers to appropriate asthma management and 
violate Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service requirements.  To 
avoid such barriers and violations and to contribute to the goals of the DHHS Asthma Action Plan, 
each State should review Medicaid utilization controls and other policies in its program that could 
present such obstacles.  For example, State Medicaid utilization limits may prevent a child from 
having an inhaler whenever and wherever he or she needs it (e.g., school, caretakers home). 
Coverage policies that permit only replacement of nebulizers (used to convert medication to steam), 
disposable tubing, and other parts used with a nebulizer at specified time intervals may not 
accommodate situations in which a child requires replacement of such items more frequently. 
Utilization limits on asthma-related medical equipment, including nebulizers and integral parts, 
peak flow meters (used to monitor degree of airflow obstruction) and spacers (used to assist in 
proper delivery of inhaled medication to the lungs in young children), can also be problematic.  For 
example, limits of one peak flow meter or spacer per lifetime may prevent a child from replacing a 
lost or broken piece of equipment, or graduating from a child to an adult sized meter. 
We remind you that the requirements of the EPSDT service do not allow such arbitrary restrictions 
on services provided to individuals under the age of 21.  Section 1905(r)(5) requires the State 
Medicaid agency to provide EPSDT-eligible individuals with all medically necessary services 
coverable under Section 1905(a) regardless of whether the item or service is specified in the State 
plan or whether the State has established utilization limits for Medicaid beneficiaries generally.  If a 
State requires prior authorization of asthma-related drugs, supplies, or equipment under EPSDT, the 
State must assure that these items are provided in a timely manner to Medicaid children who need 
them.  Each State should review its prescription and medical equipment policies and make changes 
to assure that its policies are consistent with EPSDT requirements. 
Medicaid Coverage of Asthma-Related Services:  Individuals with asthma typically need a variety 
of services to manage their condition.  Medicaid covers a comprehensive array of medical services 
required by a person with asthma, including prescription drugs and equipment to deliver those 
drugs, diagnostic tests and monitoring equipment, and encounters with physicians and other 
licensed practitioners.  If a State elects to provide a drug benefit, coverage of all FDA-approved 
drugs, including asthma-related drugs, produced by manufacturers participating in the Medicaid 
drug rebate program is mandatory.  Items such as inhalers are covered under the Medicaid 
pharmacy benefit and are also subject to the drug rebate requirements. 
Asthma-related supplies and equipment, such as spacers, peak flow meters, and nebulizers, are not 
considered drugs and should not be covered under the prescription drug benefit, even though some 
of these items have a National Drug Code number and are sold through pharmacies.  Neither can 
they be covered as durable medical equipment (DME) because, unlike Medicare, Medicaid law 
does not recognize DME as a separate coverable service.  Page 4  State Medicaid Director 
Medicaid reimbursement is available for asthma-related supplies and equipment through the home 
health benefit, which allows coverage for medical supplies, equipment, and appliances that are 
suitable for use in the home (42 CFR 440.70(B)(3)).  In accordance with these regulations, a 
physician must review a beneficiarys need for such supplies, equipment, or appliances annually. 
Although expenditures for these items should be reported to HCFA as home health services, the 
items can be provided by home health agencies, pharmacies, medical equipment suppliers, or other 
providers. 
States must cover home health services for individuals entitled to nursing facility services under the 
State Medicaid plan.  Regardless of whether they are entitled to nursing facility services, States 
must also cover medically necessary home health services for any EPSDT-eligible individual. 
It has come to our attention that some pharmacies which do not sell medical supplies and equipment 
in large volume find it difficult to obtain Medicaid reimbursement for these items.  To improve 
access for beneficiaries with asthma, you should establish procedures that allow pharmacies to be 
providers of medical  supplies and equipment under the Medicaid home health benefit. 
Disease Management Programs:  In some Medicaid populations, nearly one-third of prescriptions 
for asthma medications are never filled. Covered by Medicaid under 42 CFR 440.60, disease 
management programs seek to address such compliance problems and improve outcomes for high-
incidence or high-cost diseases by stressing state-ofthe-art clinical approaches, intensive 
monitoring and examination of patients at frequent intervals, and patient education.  Pharmacists 
and other non-physician practitioners are generally responsible for coordinating these programs. 
States are beginning to track the effects of disease management programs on clinical outcomes and 
costs.  A 1997 study found that total medical costs for patients with asthma and other conditions, 
who participated in a community pharmacy-based disease management program in the Richmond, 
Virginia area, were 29 percent lower than total medical costs for patients in a control group 
(Clinical Therapeutics, Vol. 19, No. 1, 1997) 
Medicaid programs in the States of Arkansas, Delaware, Florida, Georgia, Mississippi, and Virginia 
have planned or implemented disease management programs for asthma.  To claim Medicaid 
Federal financial participation for these services, you should submit a State Plan Amendment, 
providing a detailed description of the services to be covered and indicating which other licensed 
practitioners (e.g., pharmacists) will furnish those services.  If your State practice act for 
pharmacists or other licensed practitioners does not encompass services provided under disease 
management programs, State laws must be amended if these professionals are to be reimbursed for 
these services under Medicaid.  Practitioners planning to participate in these programs may need 
special training in disease management. 
Collaboration with Other Organizations:  Because beneficiaries with asthma obtain services in 
various settings and through different delivery systems, it is essential that you work with other 
organizations that serve this population to eliminate barriers to care.  We encourage you to discuss  Page 5  State Medicaid Director 
use of asthma medications in the school setting with State or local boards of education.  We also 
urge you to review utilization limits with Medicaid managed care organizations and pharmacy 
benefit managers to determine whether they pose barriers to effective prevention and treatment of 
asthma. 
By addressing the strategies discussed in this letter, you can serve in a leadership role to reduce 
morbidity, mortality, and the need for acute care associated with asthma, as you improve the daily 
lives of individuals and families who are affected by this serious health problem.  We encourage 
you to provide us with information about your innovative approaches to addressing asthma that we 
can share with other States.  Please contact David Greenberg by phone at (410) 786-2637 or e-mail 
(dgreenberg@hcfa.gov) to furnish information about your approaches or any concerns regarding 
Medicaid and asthma. 
Sincerely, 
Timothy M. Westmoreland 
Director 
Enclosure 
cc: 
HCFA Regional Administrators

HCFA Associate Regional Administrators

for Medicaid and State Operations

Lee Partridge

Director, Health Policy Unit

American Public Human Services Association

Joy Wilson

Director, Health Committee

National Conference of State Legislatures

Matt Salo

Director of Health Legislation

National Governors Association

Brent Ewig

National Association for State and

Territorial Health Officials
 Guidelines for the Diagnosis and 
Management of Asthma 
NATIONAL INSTITUTES OF HEALTH

National Heart, Lung, and Blood Institute

JULY 1997 
I N T R O D U C T I O N 
Asthma is a chronic inflammatory disease of the airways. In the United States, asthma affects 

14 million to 15 million persons. It is the most common chronic disease of childhood, affecting 

an estimated 4.8 million children (Adams and Marano 1995; Centers

for Disease Control and Prevention 1995).  People with asthma collectively have more than 100 

million days of restricted activity and 470,000 hospitalizations annually. More than 5,000 people 

die of asthma annually. Asthma hospitalization rates have been highest among blacks and 

children, while death rates for asthma were consistently highest among blacks aged 15 to 24 

years (Centers for Disease Control and Prevention 1996). These rates have increased or 

remained stable over the past decade. This report describes the appropriate use of the available 

therapies in the management of asthma.

To help health care professionals bridge the gap between current knowledge and practice, the 

National Heart, Lung, and Blood Institutes (NHLBI) National Asthma Education and Prevention 

Program (NAEPP) has convened two Expert Panels to prepare guidelines for the diagnosis and 

management of asthma. The NAEPP Coordinating Committee, under the leadership of Claude 

Lenfant, M.D., director of the NHLBI, con-vened the first Expert Panel in 1989. The charge to 

this Panel was to develop a report that would provide a general approach to diagnosing and 

managing asthma based on current science. The Expert Panel Report: Guidelines for the 

Diagnosis and Management of Asthma (NAEPP 1991) was published in 1991, and the 

recommendations for the treatment of asthma were organized around four components of 

effective asthma management:

Use of objective measures of lung function to assess the severity of asthma and to monitor the 

 
course of therapy

Environmental control measures to avoid or eliminate factors that precipitate asthma 

 
symptoms or exacerbations

Comprehensive pharmacologic therapy for long-term management designed to reverse and 

 
prevent the airway inflammation characteristic of asthma as well as pharmacologic therapy to 

manage asthma exacerbations

Patient education that fosters a partnership among the patient, his or her family, and clinicians 
 
The principles addressed within these four components of asthma management served as the 
starting point for the development of two additional reports prepared by asthma experts from 
many countries in cooperation with the NHLBI: the International Consensus Report on 
Diagnosis and Management of Asthma (NHLBI 1992) and the Global Initiative for Asthma 
(NHLBI/WHO 1995). The Expert Panel Report 2: Guidelines for the Diagnosis and Management 
of Asthma (EPR-2) is the latest report from the National Asthma Education and Prevention 
Program and updates the 1991 Expert Panel Report. The second Expert Panel critically 
reviewed and built upon the reports listed above.  This report presents basic recommendations for the diagnosis and management of asthma that 
will help clinicians and patients make appropriate decisions about asthma care. Of course, the 
clinician and patient need to develop individual treatment plans that are tailored to the specific 
needs and circumstances of the patient. The NAEPP, and all who participated in the 
development of this latest report, hope that the patient with asthma will be the beneficiary of the 
recommendations in this document. This report is not an official regulatory document of any 
Government agency. 
METHODS USED TO DEVELOP THIS REPORT 
The NAEPP Coordinating Committee established a Science Base Committee of U.S. asthma 

experts who began work in early 1994 to monitor the scientific literature and advise the 

Coordinating Committee when an update of the 1991 Expert Panel Report: Guidelines for the 

Diagnosis and Management of Asthma was needed. The Science

Base Committee, along with international members of the Global Initiative for Asthma, examined 

all the relevant literature on asthma in human subjects published in English between 1991 and 

mid-1995, obtained through a series of MEDLINE database searches. More than 5,000 

abstracts were reviewed. In 1995, the Science Base Committee recommended to the NAEPP 

Coordinating Committee that sufficient new information had been published since 1991 to 

convene a panel of experts to update the first Expert Panel Report. 

The second Expert Panel is a multidisciplinary group of clinicians and scientists with expertise in 

asthma management. The Panel includes health professionals in the areas of general medicine, 

family practice, pediatrics, emergency medicine, allergy, pulmonary medicine, nursing, 

pharmacy, and health education. Among the Panel members are individuals who served on 

either the Science Base Committee or the 1991 Expert Panel. Other members were chosen 

based on names submitted by NAEPP Coordinating Committee member organizations. Several 

Expert Panel members are themselves members of the Coordinating Committee. 

Representatives from several Federal agencies also have participated. 

The charge to the Panel was to prepare recommendations for use by clinicians working in 

diverse health care settings that address the practical decisionmaking issues in the diagnosis 

and management of asthma. The Panel also was requested to develop specific aids to facilitate 

implementation of the recommendations. 

Panel members were asked to base their recommendations on their review of the scientific 

literature and to cite studies that support the recommendations. When a clear recommendation 

could not be extracted from the studies (e.g., studies were not available, were conflicting, or 

were equivocal), the Panel was asked to label the recommendation as based on the opinion of 

the Expert Panel, recommended by the Expert Panel, or similar terminology. When a whole 

section was based on the opinion of the Expert Panel, this was indicated at the beginning of 

the section (e.g., see component 1-Initial Assessment and Diagnosis). 

This report was prepared in a systematic and iterative process. In addition to the Science Base 

Committee review of the scientific literature, the Panel conducted in-depth reviews of the 

literature in selected areas it considered controversial. In interpreting the literature, the Panel 

considered the nature and quality of the study designs and analyses. Given the complexities of 

several issues, the Panel chose not to use the strict evidence ranking system used in the 

guidelines development procedures of the U.S. Preventive Services Task Force. However, this 

procedure was applied in the area of peak flow monitoring. The Panel submitted their 

interpretation of the literature and related recommendations for multiple reviews by their fellow 

Expert Panel members and outside reviewers. 
 The development of EPR-2 was directed by an Executive Committee; each member of the 
Executive Committee headed a subcommittee assigned to prepare a specific chapter. Each 
member of the Panel was assigned to one of the subcommittees. The sub-committees were 
responsible for reviewing the pertinent literature and drafting the recommendations with the 
supporting evidence for the full Panel to review. Once the subcommittee reports were prepared, 
the full Panel critically reviewed the evidence and rationale for each recommendation, discussed 
revisions, and reached final agreement on each recommendation.  A vote was taken to confirm 
the consensus of the Panel. The final report was approved by the NAEPP Coordinating 
Committee via mail. Box 1 summarizes the draft, review, and consensus-building process. 
The development of this report was entirely funded by the National Heart, Lung, and Blood 
Institute, National Institutes of Health. Panel members and reviewers participated as volunteers 
and were compensated only for travel expenses related to the two Expert Panel meetings and 
the Executive Committee meetings. 
B O X 1. M A J O R  E V E N T S I N T H E D E V E L O P M E N T O F  T H E E X P E R T P A N E L R E P O R T -
First Expert Panel meeting June 1995

Executive Committee meeting November 1995

Executive Committee meeting (by phone) February 1996

Second Expert Panel meeting and review by outside experts May 1996

Review by NAEPP Coordinating Committee member organizations August 1996

Executive Committee meeting October 1996

Mail Review, Expert Panel December 1996

Mail Review and Approval, NAEPP Coordinating Committee January 1997

The goal of the Expert Panel Report 2: Guidelines for the Diagnosis and Management of 
Asthma is to serve as a comprehensive guide to diagnosing and managing asthma. 
Implementation of EPR-2 recommendations is likely to increase some costs of asthma care by 
increasing the number of primary care visits for asthma and the use of asthma medications, 
environmental control products and services, and equipment (e.g., spacer/holding chamber 
devices). However, asthma diagnosis and management are expected to improve, which should 
reduce the numbers of lost school and work days, hospitalizations and emergency department 
visits, and deaths due to asthma. A net reduction in total health care costs should result. The 
NAEPP encourages research to evaluate the impact of implementing the recommendations in 
this report. 
OVERVIEW OF THE REPORT 
Each section of EPR-2 begins with a list of Key Points and Differences From 1991 Expert 
Panel Report. A brief overview of each section is provided below. 
Pathogenesis and Definition 
In the 1991 Expert Panel Report, the role of inflammation in the pathogenesis of asthma was 
emphasized although the scientific evidence for the involvement of inflammation in asthma was 
just emerging. Now in 1997, although the role of inflammation is still evolving as a concept, a 
much firmer scientific basis exists to indicate that asthma results from complex interactions 
among inflammatory cells, mediators, and the cells and tissues resident in the airways. 
Thus, asthma is now defined as a chronic inflammatory disorder of the airways in which many 
cells and cellular elements play a role, in particular, mast cells, eosinophils,  T lymphocytes, neutrophils, and epithelial cells. In susceptible individuals, this inflammation 
causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly 
at night and in the early morning. These episodes are usually associated with widespread but 
variable airflow obstruction that is often reversible either spontaneously or with treatment. The 
inflammation also causes an associated increase in the existing bronchial hyperresponsiveness 
to a variety of stimuli. 
C O M P O N E N T 1 : 
Measures of Assessment and Monitoring 
Initial Assessment and Diagnosis of Asthma 
Making the correct diagnosis of asthma is extremely important. Clinical judgment is required 
because signs and symptoms vary widely from patient to patient as well as within each patient 
over time. To establish the diagnosis of asthma, the clinician must determine that: 
Episodic symptoms of airflow obstruction are present. 
 
Airflow obstruction is at least partially reversible. 
 
Alternative diagnoses are excluded. 
 
This section differs from the 1991 Expert Panel Report in several ways. Asthma severity 
classifications have been changed from mild, moderate, and severe to mild intermittent, mild 
persistent, moderate persistent, and severe persistent to more accurately reflect the clinical 
manifestations of asthma. The Panel emphasizes that patients at any level of severity can have 
mild, moderate, or severe exacerbations. In addition, information on wheezing in infancy and 
vocal cord dysfunction has been expanded in the differential diagnosis section in component 1. 
Situations that may warrant referral to an asthma specialist have been refined with input from 
specialty and primary care physicians. 
Periodic Assessment and Monitoring 
To establish whether the goals of asthma therapy have been achieved, ongoing monitoring and 
periodic assessment are needed. The goals of asthma therapy are to: 
Prevent chronic and troublesome symptoms 
 
Maintain (near) normal pulmonary function 
 
Maintain normal activity levels (including exercise and other physical activity) 
 
Prevent recurrent exacerbations of asthma and minimize the need for emergency department 
 
visits or hospitalizations 
Provide optimal pharmacotherapy with minimal or no adverse effects 
 
Meet patients and families expectations of and satisfaction with asthma care 
 
Several types of monitoring are recommended: signs and symptoms, pulmonary function, 
quality of life/functional status, history of asthma exacerbations, pharmacotherapy, and patient-
provider communication and patient satisfaction. 
The Panel recommends that patients, especially those with moderate-to-severe persistent 
asthma or a history of severe exacerbations, be given a written action plan based on signs and 
symptoms and/or peak expiratory flow. As in the 1991 report, daily peak flow monitoring is  recommended for patients with moderate-to-severe persistent asthma. In addition, the Panel 
states that any patient who develops severe exacerbations may benefit from peak flow 
monitoring. A complete review of the literature on peak flow monitoring was conducted, 
evidence tables were prepared, and the results of this analysis are summarized in the report. 
C O M P O N E N T 2 : 
Control of Factors Contributing 
to Asthma Severity 
Exposure of sensitive patients to inhalant allergens has been shown to increase airway 
inflammation, airway hyperresponsiveness, asthma symptoms, need for medication, and death 
due to asthma. Substantially reducing exposures significantly reduces these outcomes. 
Environmental tobacco smoke is a major precipitant of asthma symptoms in children, increases 
symptoms and the need for medications, and reduces lung function in adults.  Increased air 
pollution levels of respirable particulates, ozone, SO 2 , and NO 2 have been reported to 
precipitate asthma symptoms and increase emergency department visits and hospitalizations 
for asthma. Other factors that can contribute to asthma severity include rhinitis and sinusitis, 
gastroesophageal reflux, some medications, and viral respiratory infections. EPR-2 discusses 
environmental control and other measures to reduce the effects of these factors. 
C O M P O N E N T 3 : 
Pharmacologic Therapy 
EPR-2 offers an extensive discussion of the pharmacologic management of patients at all levels 

of asthma severity. It is noted that asthma pharmacotherapy should be instituted in conjunction 

with environmental control measures that reduce exposure to factors known to increase the 

patients asthma symptoms. 

As in the 1991 report, a stepwise approach to pharmacologic therapy is recommended, with the 

type and amount of medication dictated by asthma severity. EPR-2 continues to emphasize that 

persistent asthma requires daily long-term therapy in addition to appropriate medications to 

manage asthma exacerbations. To clarify this concept, the EPR-2 now categorizes medications 

into two general classes: long-term-control medications to achieve and maintain control of 

persistent asthma and quick-relief medications to treat symptoms and exacerbations.

Observations into the basic mechanisms of asthma have had a tremendous influence on 

therapy. Because inflammation is considered an early and persistent component of asthma, 

therapy for persistent asthma must be directed toward long-term suppression of the 

inflammation. Thus, EPR-2 continues to emphasize that the most effective medications for long-

term control are those shown to have anti-inflammatory effects. For example, early intervention 

with inhaled corticosteroids can improve asthma control and normalize lung function, and 

preliminary studies suggest that it may prevent irreversible airway injury.

An important addition to EPR-2 is a discussion of the management of asthma in infants and 

young children that incorporates recent studies on wheezing in early childhood. Another addition 

is discussions of long-term-control medications that have become available since 1991long-

acting inhaled beta 2 -agonists, nedocromil, zafirlukast,

and zileuton.

Recommendations for managing asthma exacerbations are similar to those in the 1991 Expert 

Panel Report. However, the treatment recommendations are now on a much firmer scientific 

basis because of the number of studies addressing the treatment of asthma exacerbations in 

children and adults in the past 6 years.
 C O M P O N E N T 4 : 
Education for a Partnership in Asthma Care 
As in the 1991 Expert Panel Report, education for an active partnership with patients remains 
the cornerstone of asthma management and should be carried out by health care providers 
delivering asthma care. Education should start at the time of asthma diagnosis and be 
integrated into every step of clinical asthma care. Asthma self-management education should 
be tailored to the needs of each patient, maintaining a sensitivity to cultural beliefs and 
practices. New emphasis is placed on evaluating outcomes in terms of patient perceptions of 
improvement, especially quality of life and the ability to engage in usual activities. Health care 
providers need to systematically teach and frequently review with patients how to manage and 
control their asthma. Patients also should be provided with and taught to use a written daily self-
management plan and an action plan for exacerbations. It is especially important to give a 
written action plan to patients with moderate-to-severe persistent asthma or a history of severe 
exacerbations. Appropriate patients should also receive a daily asthma diary. Adherence should 
be encouraged by promoting open communication; individualizing, reviewing, and adjusting 
plans as needed; emphasizing goals and outcomes; and encouraging family involvement. 
In summary, the 1997 Expert Panel Report 2: Guidelines for the Diagnosis and Management of 
Asthma reflects the experience of the past 6 years as well as the increasing scientific base of 
published articles on asthma. The Expert Panel hopes this new report will assist the clinician in 
forming a valuable partnership with patients to achieve excellent asthma control and outcomes. 
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Adams PF, Marano MA. Current estimates from the National Health Interview Survey, 1994. Vital Health Stat 
1995;10:94. 
Centers for Disease Control and Prevention. Asthma mortality and hospitalization among children and young adults  
United States, 1990-1993. MMWR 1996;45:350-353. 
Centers for Disease Control and Prevention. Asthma-United States, 1989-1992. MMWR 1995;43:952-5. 
National Asthma Education and Prevention Program. Expert Panel Report: Guidelines for the Diagnosis and 
Management of Asthma. National Institutes of Health pub no 91-3642. Bethesda, MD, 1991. 
National Heart, Lung, and Blood Institute. International Consensus Report on Diagnosis and Management of Asthma. 
National Institutes of Health pub no 92-3091. Bethesda, MD, 1992. 
National Heart, Lung, and Blood Institute and World Health Organization. Global Initiative for Asthma. National 
Institutes of Health pub no 95-3659. Bethesda, MD, 1995. 
U.S. Preventive Services Task Force. Guide to Clinical Preventive Health Services. Baltimore: Williams and Wilkins, 
1989.