Guidelines for the Diagnosis and Management of Asthma (EPR-3)
Published Aug 2007
DownloadPDF 4 MB

The EPR 3 Guidelines on Asthma was developed by an expert panel commissioned by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee (CC), coordinated by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. Using the 1997 EPR 2 guidelines and the 2004 update of EPR 2 as the framework, the expert panel organized the literature review and final guidelines report around four essential components of asthma care, namely: assessment and monitoring, patient education, control of factors contributing to asthma severity, and pharmacologic treatment. Subtopics were developed for each of these four broad categories.

Version History:

  • EPR-2 Update on Selected Topic in 2002
  • EPR-2 published in 1997
  • EPR-1 published in 1991 

The EPR 3 Guidelines on Asthma was developed by an expert panel commissioned by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee (CC), coordinated by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. Using the 1997 EPR 2 guidelines and the 2004 update of EPR 2 as the framework, the expert panel organized the literature review and final guidelines report around four essential components of asthma care, namely: assessment and monitoring, patient education, control of factors contributing to asthma severity, and pharmacologic treatment. Subtopics were developed for each of these four broad categories.

Version History:

  • EPR-2 Update on Selected Topic in 2002
  • EPR-2 published in 1997
  • EPR-1 published in 1991 

Overall Methods Used To Develop This Report

Background

In June 2004, the Science Base Committee of the NAEPP recommended to the NAEPP CC that its clinical practice guidelines for the diagnosis and management of asthma be updated. In September, under the leadership of Dr. Barbara Alving, M.D. (Chair of the NAEPP CC, and Acting Director of the NHLBI), a panel of experts was selected to update the clinical practice guidelines by using a systematic review of the scientific evidence for the treatment of asthma and consideration of literature on implementing the guidelines.

In October 2004, the Expert Panel assembled for its first meeting. Using EPR-2 1997 and EPR-Update 2002 as the framework, the Expert Panel organized the literature searches and subsequent report around the four essential components of asthma care, namely: (1) assessment and monitoring, (2) patient education, (3) control of factors contributing to asthma severity, and (4) pharmacologic treatment. Subtopics were developed for each of these four broad categories.

The steps used to develop this report include: (1) completing a comprehensive search of the literature; (2) conducting an indepth review of relevant abstracts and articles; (3) preparing evidence tables to assess the weight of current evidence with respect to past recommendations and new and unresolved issues; (4) conducting thoughtful discussion and interpretation of findings; (5) ranking strength of evidence underlying the current recommendations that are made; (6) updating text, tables, figures, and references of the existing guidelines with new findings from the evidence review; (7) circulating a draft of the updated guidelines through several layers of external review, as well as posting it on the NHLBI website for review and comment by the public and the NAEPP CC, and (8) preparing a final-report based on consideration of comments raised in the review cycle.

    Expert Panel Members

    Chair

    William W. Busse, M.D.
    University of Wisconsin Medical School
    Madison, WI

    Members

    Homer A. Boushey, M.D.
    University of California at San Francisco
    San Francisco, CA

    Carlos A. Camargo, M.D., Dr. P.H.
    Massachusetts General Hospital
    Boston, MA

    David Evans, Ph.D., A.E.-C.
    Columbia University
    New York, NY

    Michael B. Foggs, M.D.
    Advocate Health Care
    Chicago, IL

    Susan Janson, D.N.Sc., R.N.
    University of California
    San Francisco, California

    H. William Kelly, Pharm.D.
    University of New Mexico Health Sciences Center
    Albuquerque, NM

    Robert F. Lemanske, M.D.
    University of Wisconsin Hospital and Clinics
    Madison, WI

    Fernando D. Martinez, M.D.
    University of Arizona Medical Center
    Tucson, AZ

    Robert J. Meyer, M.D.
    U.S. Food and Drug Administration
    Rockville, MD

    Harold S. Nelson, M.D.
    National Jewish Medical and Research Center
    Denver, CO

    Thomas A.E. Platts-Mills, MD, PhD
    University of Virginia School of Medicine
    Charlottesville, VA

    Michael Schatz, M.D., M.S.
    Kaiser-Permanente Medical Center
    San Diego, CA 92111

    Gail Shapiro, M.D.†
    Northwest Asthma and Allergy Center
    Seattle, WA

    Stuart Stoloff, M.D.
    University of Nevada School of Medicine
    Carson City, NV

    Stanley Szefler, M.D.
    National Jewish Medical and Research Center
    Denver, CO

    Scott T. Weiss, M.D., M.S.
    Brigham and Women's Hospital
    Boston, MA

    Barbara P. Yawn, M.D., M.Sc.
    Olmstead Medical Center
    Rochester, MN

    †Deceased

    Financial and Other Disclosures

    Development of the resource document and the guidelines report was funded by the NHLBI, NIH. Expert Panel members completed financial disclosure forms, and the Expert Panel members disclosed relevant financial interests to each other prior to their discussions. Expert Panel members participated as volunteers and were compensated only for travel expenses related to the Expert Panel meetings. Financial disclosure information covering the 3 year period during which the guidelines were developed is provided for each Panel member below.

    • Dr. Busse has served on the Speakers' Bureaus of GlaxoSmithKline, Merck, Novartis, and Pfizer; and on the Advisory Boards of Altana, Centocor, Dynavax, Genentech/Novartis, GlaxoSmithKline, Isis, Merck, Pfizer, Schering, and Wyeth. He has received funding/grant support for research projects from Astellas, AstraZeneca, Centocor, Dynavax, GlaxoSmithKline, Novartis, and Wyeth. Dr. Busse also has research support from the NIH.

    • Dr. Boushey has served as a consultant for Altana, Protein Design Lab, and Sumitomo. He has received honoraria from (Boehringer-Ingelheim, Genentech, Merck, Novartis, and Sanofi Aventis, and funding/grant support for research projects from the NIH.

    • Dr. Camargo has served on the Speakers' Bureaus of AstraZeneca, GlaxoSmithKline, Merck, and Schering Plough; and as a consultant for AstraZeneca, Critical Therapeutics, Dey Laboratories, GlaxoSmithKline, MedImmune, Merck, Norvartis, Praxair, Respironics, Schering Plough, Sepracor, and TEVA. He has received funding/grant support for research projects from a variety of Government agencies and not-for-profit foundations, as well as AstraZeneca, Dey Laboratories, GlaxoSmithKline, MedImmune, Merck, Novartis, and Respironics.

    • Dr. Evans has received funding/grant support for research projects from the NHLBI.

    • Dr. Foggs has served on the Speakers' Bureaus of GlaxoSmithKline, Merck, Pfizer, Sepracor, and UCB Pharma; on the Advisory Boards of Alcon, Altana, AstraZeneca, Critical Therapeutics, Genentech, GlaxoSmithKline, and IVAX; and as consultant for Merck and Sepracor. He has received funding/grant support for research projects from GlaxoSmithKline.

    • Dr. Janson has served on the Advisory Board of Altana, and as a consultant for Merck. She has received funding/grant support for research projects from the NHLBI.

    • Dr. Kelly has served on the Speakers' Bureaus of AstraZeneca and GlaxoSmithKline; and on the Advisory Boards of AstraZeneca, MAP Pharmaceuticals, Merck, Novartis, and Sepracor.

    • Dr. Lemanske has served on the Speakers' Bureaus of GlaxoSmithKline and Merck, and as a consultant for AstraZeneca, Aventis, GlaxoSmithKline, Merck, and Novartis. He has received honoraria from Altana, and funding/grant support for research projects from the NHLBI and NIAID.

    • Dr. Martinez has served on the Advisory Board of Merck and as a consultant for Genentech, GlaxaSmithKline, and Pfizer. He has received honoraria from Merck.

    • Dr. Meyer has no relevant financial interests.

    • Dr. Nelson has served on the Speakers' Bureaus of AstraZeneca, GlaxoSmithKline, Pfizer, and Schering Plough; and as a consultant for Abbott Laboratories, Air Pharma, Altana Pharma US, Astellas, AstraZeneca, Curalogic, Dey Laboratories, Dynavax Technologies, Genentech/Novartis, GlaxoSmithKline, Inflazyme Pharmaceuticals, MediciNova, Protein Design Laboratories, Sanofi-Aventis, Schering Plough, and Wyeth Pharmaceuticals. He has received funding/grant support for research projects from Altana, Astellas, AstraZeneca, Behringer, Critical Therapeutics, Dey Laboratories, Epigenesis, Genentech, GlaxoSmithKline, Hoffman LaRoche, IVAX, Medicinova, Novartis, Sanofi-Aventis, Schering Plough, Sepracor, TEVA, and Wyeth.

    • Dr. Platts-Mills has served on the Advisory Committee of Indoor Biotechnologies. He has received funding/grant support for a research project from Pharmacia Diagnostics.

    • Dr. Schatz has served on the Speakers' Bureaus of AstraZeneca, Genentech, GlaxoSmithKline, and Merck; and as a consultant for GlaxoSmithKline on an unbranded asthma initiative. He has received honoraria from AstraZeneca, Genentech, GlaxoSmithKline and Merck. He has received funding/grant support for research projects from GlaxoSmithKline and Merck and Sanofi-Adventis.

    • Dr. Shapiro† served on the Speakers' Bureaus of AstraZeneca, Genentech, GlaxoSmithKline, IVAX Laboratories, Key Pharmaceuticals, Merck, Pfizer Pharmaceuticals, Schering Corporation, UCB Pharma, and 3M; and as a consultant for Altana, AstraZeneca, Dey Laboratories, Genentech/Novartis, GlaxoSmithKline, ICOS, IVAX Laboratories, Merck, Sanofi-Aventis, and Sepracor. She received funding/grant support for research projects from Abbott, AstraZeneca, Boehringer Ingelheim, Bristol-Myers-Squibb, Dey Laboratories, Fujisawa Pharmaceuticals, Genentech, GlaxoSmithKline, Immunex, Key, Lederle, Lilly Research, MedPointe Pharmaceuticals, Medtronic Emergency Response Systems, Merck, Novartis, Pfizer, Pharmaxis, Purdue Frederick, Sanofi-Aventis, Schering, Sepracor, 3M Pharmaceuticals, UCB Pharma, and Upjohn Laboratories.

    • Dr. Stoloff has served on the Speakers' Bureaus of Alcon, Altana, AstraZeneca, Genentech, GlaxoSmithKline, Novartis, Pfizer, Sanofi Aventis, and Schering; and as a consultant for Alcon, Altana, AstraZeneca, Dey, Genentech, GlaxoSmithKline, Merck, Novartis, Pfizer, Sanofi Aventis, and Schering.

    • Dr. Szefler has served on the Advisory Boards of Altana, AstraZeneca, Genentech, GlaxoSmithKline, Merck, Novartis, and Sanofi Aventis; and as a consultant for Altana, AstraZeneca, Genentech, GlaxoSmithKline, Merck, Novartis, and Sanofi Aventis. He has received funding/grant support for a research project from Ross.

    • Dr. Weiss has served on the Advisory Board of Genentech, and as a consultant for Genentech and GlaxoSmithKline. He has received funding/grant support for research projects from GlaxoSmithKline.

    • Dr. Yawn has served on the Advisory Boards of Altana, AstraZeneca, Merck, Sanofi Aventis, and Schering Plough. She has received honoraria from Pfizer and Schering Plough, and funding/grant support for research projects from the Agency for Healthcare Research and Quality, the CDC, the NHLBI, Merck, and Schering Plough.

    †Deceased

    Evidence Tables

    Evidence tables were prepared for a wide range of topics in this comprehensive review.

    You may download the evidence tables below in PDF format. You need the Acrobat Reader to open the files

    Information for visitors using screen readers
    Information about PDF

    1. Assessment and Monitoring: Predictors of Exacerbation
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 144 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 340 K

    2. Assessment and Monitoring: Usefulness of Peak Flow Measurement
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 72 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 180 K

    3. Patient/Provider Education: Asthma Self-Management Education for Adults
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, xxx K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 340 K

    4. Patient/Provider Education: Asthma Self-Management Education for Children
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, xxx K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 432 K

    5. Patient/Provider Education: Asthma Self-Management Education in Community Settings
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, xxx K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 452 K

    6. Patient/Provider Education: Cost-Effectiveness of Asthma Self-Management Education
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, xxx K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 232 K

    7. Patient/Provider Education: Methods for Improving Clinical Behaviors -- Implementing Guidelines
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, xxx K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 136 K

    8. Patient/Provider Education: Methods for Improving Systems Support
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, xxx K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 108 K

    9. Control of Factors Affecting Asthma: Allergen Avoidance
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, xxx K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 240 K

    10. Control of Factors Affecting Asthma: Immunotherapy
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, xxx K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 228 K

    11. Pharmacologic Therapy: Inhaled Corticosteroids -- Combination Therapy
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 164 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 700 K

    12. Pharmacologic Therapy: Inhaled Corticosteroids -- Dosing Strategies
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 216 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 788 K

    13. Pharmacologic Therapy: Immunomodulators -- Anti-Immunoglobulin E
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 108 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 432 K

    14. Pharmacologic Therapy: Leukotriene Receptor Antagonist Monotherapy/Effectiveness Studies
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 140 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 592 K

    15. Pharmacologic Therapy: Bronchodilators -- Safety of Long-Acting Beta2-Agonists
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 116 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 280 K

    16. Pharmacologic Therapy: Bronchodilators -- Levalbuterol
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 48 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 180 K

    17. Managing Exacerbations: Increasing the Dose of Inhaled Corticosteroids
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 40 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 120 K

    18. Managing Exacerbations: IV Aminophylline
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 24 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 56 K

    19. Managing Exacerbations: Magnesium Sulfate
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 72 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 172 K

    20. Managing Exacerbations: Heliox
      [[nid:819 view_mode=custom_size width=20 height=16]] Printer-friendly version, PDF file, 40 K
      [[nid:819 view_mode=custom_size width=20 height=16]] Screen reader-friendly version, PDF file, 172 K

    Changes to the Guidelines

    The EPR-3 was initially posted to the NHLBI website in August 2007. Periodically edits are made to this document and these edits are logged onto this change page.

    As of August 5, 2008 the following edits have been made (specific wording changes are indicated in bold):

    Page Figure or Table Changes
    75 Figure 3-5a: Assessing Asthma Control in Children 0 - 4 Years of Age Under the heading Well Controlled, Nighttime awakenings - change to read:
    "one time or less per month"
    311 Figure 4-4a: Usual Dosages for Long-Term Control Medications in Children Under the heading, Systemic Corticosteroids, ages 0 to 4 years - change to read:
    Short-course "burst": 1 - 2 mg/kg/day, maximum 60 mg/day for 3 - 10 days.
    315 Figure 4-4b: Estimated Comparative Daily Dosages for Inhaled Corticosteroids in Children (continued) Under the first bullet, 3rd dash - replace text to read:
    The doses for budesonide and fluticasone MDI or DPI are based on recently available comparative data. These new data, including meta-analyses, show that fluticasone requires one-half the microgram dose of budesonide DPI to achieve comparable efficacy (Adams et al. 2005; Barnes et al. 1998; Nielsen and Dahl 2000).
    318 Figure 4-4c: Usual Dosages for Quick-Relief Medications in Children (continued) Under the heading, Systemic Corticosteroids, ages 5 - 11 years - change to read:
    Short-course "burst": 1-2 mg/kg/day, maximum 60 mg/day for 3 - 10 days.
    349 Figure 4-8b: Estimated Comarative Daily Dosages for Inhaled Corticosteroids for Youths 12 Years of Age or Older and Adults Under the last bullet, 3rd dash - replace text to read:
    The doses for budesonide and fluticasone MDI or DPI are based on recently available comparative data. These new data, including meta-analyses, show that fluticasone requires one-half the microgram dose of budesonide DPI to achieve comparable efficacy (Adams et al. 2005; Barnes et al. 1998; Nielsen and Dahl 2000).
    387 Figure 5-5: Dosages of Drugs for Asthma Exacerbations Under the heading, Anticholinergics, Ipratropium bromide nebulizer solution - change to read:
    0.25 - 0.5 mg every 20 minutes for 3 doses, then as needed
    387 Figure 5-5: Dosages of Drugs for Asthma Exacerbations Under the heading Anticholinergics, Iptratropium with albuterol nebulizer solution - change to read:
    1.5 - 3.0 mL every 20 minutes for 3 doses, then as needed
    387 Figure 5-5: Dosages of Drugs for Asthma Exacerbations Under the heading, Systemic Corticosteroids, Prednisone - change to read:
    1 - 2 mg/kg in 2 divided doses (maximum = 60 mg/day) until PEF is 70% of predicted or personal best

    Last updated: August 5, 2008