Yes, several alternative classifications have recently been developed. They all acknowledge the fact that NAEPP classifications have been extremely useful in guiding asthma care and treatment over the years and have been widely used by practicing physicians in daily patient care. In May 2006, a task force sponsored by the National Heart, Lung, and Blood Institute; the American Thoracic Society; and the American Academy of Allergy, Asthma, and Immunology unveiled a classification designed specifically for purposes of asthma research.
The joint effort divides all asthma into four categories (or phenotypes): infection-induced asthma, allergic asthma, nonallergic asthma, and aspirin-sensitive asthma. Of the four classes, allergic asthma tends to begin early in life and is undoubtedly the most common, affecting up to 88% of all persons with asthma. Infection-induced asthma occurs in children and adults. Nonallergic asthma is more common in adults and occurs more often in women.
Aspirin-sensitive asthma phenotype, a more unusual variant of asthma, affects no more than 5% of children with asthma and is more of a concern in adult age groups. The American Thoracic Society believes that the four-phenotype asthma classification system will “enhance interpretation of study findings, promote appropriate comparisons among studies, and facilitate genetics research.” Time will tell how useful the tool will be.
In 2006, the Global Initiative for Asthma, or GINA, announced the release of its Global Strategy for Asthma Management and Prevention. GINA, formed in 1993, works with healthcare professionals worldwide to reduce asthma prevalence, morbidity, and mortality. GINA is committed to presenting recommendations for asthma management based on the best scientific information available, worldwide. It began as a collaborative effort between the U.S. National Heart, Lung, and Blood Institute (NHLBI) and the World Health Organization (WHO). GINA comprises networks of individuals and organizations committed to asthma care.
If you are familiar with World Asthma Day, held on the first Tuesday in May yearly since 1998, you may already know that GINA is its sponsor. The 2006 GINA guide-lines supplanted earlier GINA statements and presented a new, easy-to-implement classification of asthma (Table 16). Previous guidelines (including the 1991, 1997, and 2002 NAEPP) had introduced asthma management strategies based solely on disease severity.
The GINA guidelines also take the patient’s response to therapy into account and accordingly create a classification based on how effectively the patient’s asthma is controlled. The 2006 GINA report thus defines asthma control and bases treatment recommendations directly on its classification of three levels of control: controlled, partly controlled, and uncontrolled asthma (Table 15). GINA recommends that the previous asthma classification of intermittent; mild persistent; moderate persistent; and severe persistent not be entirely abandoned, and that it be used for research purposes rather than direct patient care.
GINA has pledged to update the Global Strategy for Asthma Management and Prevention on a regular basis. The GINA experts have accordingly reviewed the impact of scientific asthma publications every 12 months and have published updates annually via the GINA Web site. The 2007 and 2008 updates to the 2006 Global Strategy for Asthma Management and Prevention researched publications from July 1, 2006, to June 30, 2007, and from July 1, 2007, to June 30, 2008, respectively, and issued updates in December 2007 and again in 2008.
The most recent edition continues to highlight the importance of asthma control and states. there is now good evidence that the clinical manifestations of asthma, symptoms, sleep disturbances, limitations of daily activity, impairment of lung function, and use of rescue medications—can be controlled with appropriate treatment. The ongoing NAEPP and GINA efforts to draft pragmatic guidelines and to revise them as our medical sophistication continues to grow ultimately benefits all persons with asthma. Physicians caring for persons with asthma (both children and adults) should be familiar with the documents.