In this Issue August 2004

Evidence suggests that allergens play a role in developing asthma, as well as the current functioning of asthma. Many intervention trials have attempted to prevent asthma through avoidance of allergens, or minimise allergen effect on asthma by reducing exposure to environmental allergens. Allergen levels vary widely by area (as a function of humidity), so locally-based research is a better basis for local allergen reduction strategies.

It has been proposed that asthma’s increased prevalence in developed countries in the past 30 years may be related to dietary changes, such as decreased consumption of fruit and vegetables, fish and meat.

There is strong consensus on the deleterious effect exposure to tobacco smoke has on infant, child and adult asthma. There is little evidence of interventions specific to people with asthma for preventing initiation of smoking, other than the findings regarding environmental tobacco smoke (ETS) reduction.

Workplace exposure to irritants accounts for approximately one in ten cases of adult onset asthma. There is evidence that occupational agents (>250) affect the development of asthma, and aggravation of current asthma.

Evidence suggests that most childhood asthma begins early. Early detection and intervention is important as impaired lung function is related to the length of the asthma disease process (for both adults and children), and severe asthma is associated with a significant loss of lung function soon after onset. The question remains whether screening can change asthma morbidity or reach undiagnosed people in the population

Asthma self-management education provides individuals with the skills and resources to effectively manage their illness. These programs include information on preventing asthma exacerbations, communicating with health care professionals, and acute asthma management. While a core goal of asthma education may be to increase adherence to treatment recommendations, asthma education will vary in length and intensity.

One strategy to increase patient adherence and self-management is providing written instructions to patients, to increase the likelihood they will adhere to prescribed management actions. Written asthma management plans document the actions required for regular asthma management and the actions to take in the event of an asthma exacerbation (based on symptoms and peak flow readings).

Self-management involves a written action plan for the use and adjustment of medications, education for self-monitoring (via symptoms or airflow), or regular review by a medical practitioner of these activities. Optimal self-management includes all of these components.

Psychological factors have long been regarded as significant for asthma and its control. A number of psychotherapeutic interventions have been employed in addition to medical management, for patients in whom medical management alone is not effecting desired change and where there are psychological aspects implicated in poor management. These include family therapy, behavioural therapy, cognitive therapies, and psychodynamic therapy.

Various emergency department-based strategies have been suggested to enhance linkages with primary care, such as booking appointments for patients prior to emergency department discharge.

Clinical guidelines are important in ensuring the delivery of care, according to latest evidence. However, doctors experience barriers to implementation. Good quality provider–patient relationships are important to patient adherence and provide a foundation for clinical guideline adherence.

While the evidence demonstrates optimal self-management is the ‘gold standard’ in asthma management, the intensity of the intervention, the emphasis on each component and the setting in which it is delivered will vary. Putting the pieces together in a service delivery package is the point where interventions can become most creative, to target specific populations.