ASTHMA GUIDELINE
PICO QUESTIONS v3
12-5-07
a. Control of Symptoms:
— Nighttime awakenings
— Need for SABA for quick relief of symptoms
— Work/school days missed
— Ability to engage in normal daily activities or in desired activities
b. Optimize (normal) lung function
— (FEV1 pp; FEV1/FVC; peak flow)
c. Reduce risk of exacerbation
d. Minimize adverse effect
e. Utilization of health care
—Emergency room visits (exacerbations)
—Hospital admissions
f. Increase working knowledge of asthma action plan
g. Improve patient satisfaction
------------------------------------------------------------------------------------------------------Diagnosis
1.
In patients with asthma, does consultation or referral to a subspecialist
(pulmonologist/allergist) at the time of diagnosis, when admitted to the ER with
exacerbation, or early in treatment vs no consultation/referral improve
symptom control, patient satisfaction and increase patient knowledge? ([A&P]18)
2.
In patients with asthma does routine allergy testing (e.g., skin prick testing,
aeroallergens, immunotherapy) vs. no testing or testing HIGH RISK (Severe
uncontrolled Asthma, family Hx of allergies) improve outcomes in terms of QOL
through allergen avoidance or immunotherapy, patient knowledge and adherence?
([A&P]19)
3.
In adults with exercise-related symptoms of asthma only and non-diagnostic
spirometry, is formal exercise testing with pre- and post-PFTs compared to
informal exercise testing (methacholine challenge test, broncho provocation test)
better for establishing the diagnosis of EIB or exercise induced asthma? ([A]29)
4.
Does the routine use of office-based Spirometry compared to history and
physical for both asthma diagnosis and monitoring improve outcomes? (Peds 5)
5.
In adults with exercise-related symptoms asthma, is peak flow monitoring to
assess variability of airway obstruction compared to Spirometry a comparable way
for diagnosing of EIB or exercise induced asthma? ([A] 30)
6.
Do biomarkers of inflammation (e.g., total and differential cell count and
mediator assays) in sputum, blood, urine, and exhaled air aid in the diagnosis and
assessment of asthma in the primary care setting? ([A&P]7)
7.
Is a thorough history and physical, followed by a therapeutic challenge sufficient to
identify comorbid GERD compared to a diagnostic test in children with asthma?
([P]3)
PICO Questions – page 1
8.
In pregnant women who were not previously diagnosed with asthma, but who
develop symptoms consistent with asthma, does assessing PFT compared to a
presumptive diagnosis (no PFT) improve patient outcome with no harm? (33)
Prognosis
9.
In adults with asthma who present with an acute exacerbation, what clinical
predictors are best at predicting successful outpatient management? ([A] 22)
10.
In patients with difficult to control asthma (adults & children), how frequently does
the management of coexisting sinusitis or GERD compared to no management
improve the control of asthma? ([A&P] 23)
11.
In patients with asthma who are obese, does weight loss and exercise
compared to no weight loss/exercise improve the control of asthma symptoms?
([A&P]41)
Medications
12.
In children with under controlled asthma while on low dose ICS, what is the best
step up treatment / add on therapy to gain asthma control (search in age
groups 1-5, 5-12, 12-17)? (P 9)
13.
In active duty personnel with asthma in operational environments, is one
controller compared to other controllers better apt to control asthma symptoms?
([A] 31)
14.
In patients with mild persistent asthma and no evidence of allergies as triggers
(adults & children), does ICS compared to Montelukast or Tilade, Intal, or
other pulmonary antiinflammatories lead to better outcome and minimimize
harm? (9,15)
15.
In patients with moderate or severe uncontrolled asthma who are taking ICS
(adults & children), does increasing the dose of ICS compared to adjunctive
therapy (LABA, Singulair, Leukotriene) lead to better control of symptoms with no
harm? ([A] 17)
16.
In adult patients with asthma, does tiotropium (Spiriva) compared to long
acting inhaled bronchodilators lead to comparable improvement in PFT, peak
flow measures, and safety? ([A])
17.
In patients with exercise-induced asthma (bronchospasm) (adults & children), does
taking a preventive medication before exercise compared to continuous daily
medication improve symptom control? (40) [A&P]
18.
In patients older than 65 years with asthma, does the use of long acting beta
adrenergic drugs compared to not using the drug reduce adverse cardiovascular
events (e.g., sudden death, acute MI, arrhythmias)? ([A >65] 36)
19.
In patients older than 65 years who require long term systemic corticosteroids,
does a reduced dose of corticosteroids compared to the regular dose reduce
the risk for adverse complications (osteoporosis, DM, Vavascular necrosis of the
femoral head, cataracts)? ([A >65]37)
20.
In patients with asthma how effective is aerosol delivery of asthma medications by
pMDI + VHC compared to nebulization for quick relief aerosols? [A&P]
PICO Questions – page 2
21.
Do studies show there is an effective pharmacotherapy (PRN SABA, ICS
Leukotrine) for the <5 year old child with recurrent wheeze, but no asthma
diagnosis? ([P] 4)
22.
Do studies show an optimal systemic steroid preparation, dosage, and duration
of treatment for managing asthma in pediatrics? ([P] 6)
23.
Do studies show that routine initiating LTC ICS children with persistent asthma at
discharge from the Emergency Department is more effective? [NHLBI p.400]
([P] 11)
Management
24.
Does the use of a home peak flow meter based Asthma Action Plan compared
to a symptom based Asthma Action Plan result in better outcomes in patients with
asthma ([A&P])?
Patient Education
25.
Which strategy in the outpatient setting leads to better outcomes in terms of
decreased frequency of exacerbations, ER visits, or hospitalization in patients with
asthma (A&P)?
a. Implementation of comprehensive asthma care (pt. education, action
plans and asthma educators) compared to usual care (27)
b. Implementation of group visits compared to individual patients
appointments
c. Written action plans compared to not using a written action plan in
usual care (28)
d. Providing patient education in modality other than written (e.g.,
media, computer based, internet) (26)
PICO Questions – page 3