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Asthma as a Model for Chronic Disease Management Programs

The Interplay between Pulmonary Function and Quality of Life

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Chronic obstructive pulmonary disease (COPD) is a relatively new target for disease management programs; however, asthma has long been a focus for such programs, and can provide a template for respiratory disease management. A major difficulty when developing disease management programs in an area that has not previously been targeted is determining the outcomes that need to be monitored. In this area, experience in asthma management may provide direction for the management of other COPDs.

Healthcare providers that manage patients with chronic respiratory diseases must use a variety of outcome measures to guide therapy. No single measure provides a complete picture of an individual’s perceived well-being and future risk of pulmonary decline. Therefore, clinicians must consider outcome measures that reflect both the short- and long-term morbidity associated with the disease process. These outcome measures include both objective measures of pulmonary function and quality-of-life assessments.

Ideally, objective measures of pulmonary function would allow for direct determination of the rate of pulmonary decline. Inherent limitations mean that these measurements are instead used as a surrogate for disease control. The goal therefore is to reduce the impairment experienced by an individual and potentially slow the rate of decline in pulmonary function. The most commonly used measures of pulmonary function are pulmonary function tests, peak expiratory flows, and airway hyper-responsiveness. To use them effectively, clinicians must be aware of the information provided by these measures and the limitations with their use.

Outcome measures related to quality of life provide information about a patient’s subjective experience and ability to function in daily life. It has been recognized that these measures are important to individuals with chronic diseases and that they provide clinicians with information about the disease process that cannot be determined using measures of pulmonary function. Such measures can be broadly grouped into healthcare utilization measures, symptom scores, and measures of activity limitation. These measures are essential components of long-term asthma management, but are subject to their own limitations.

Measurements of pulmonary function and quality of life provide complementary information about respiratory disease processes. For example, asthma guidelines incorporate both types of measurements into current classification schemes to assess asthma impairment and risk of future morbidity. Further research is required to better understand the relationship between these outcome measures.

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Table I
Table II


  1. 1.

    National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma [publication no. 08-4051]. Bethesda (MD): National Institutes of Health, 2007

  2. 2.

    Moorman JE, Rudd RA, Johnson CA, et al. Centers for Disease Control and Prevention (CDC). National surveillance for asthma: United States, 1980–2004. MMWR Surveill Summ 2007 Oct 19; 56(8): 1–54

  3. 3.

    Weiss ST, Tosteson TD, Segal MR, et al. Effects of asthma on pulmonary function in children: a longitudinal population-based study. Am Rev Respir Dis 1992; 145: 58–64

  4. 4.

    Brown PJ, Greville HW, Finucane KE. Asthma and irreversible airflow obstruction. Thorax 1984; 39: 131–6

  5. 5.

    Ulrik CS, Backer V. Nonreversible airflow obstruction in life-long nonsmokers with moderate to severe asthma. Eur Respir J 1999; 14: 892–6

  6. 6.

    Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life: the Group Health Medical Associates. N Engl J Med 1995; 332(3): 133–8

  7. 7.

    Morgan WJ, Stern DA, Sherrill DL, et al. Outcome of asthma and wheezing in the first 6 years of life: follow-up through adolescence. Am J Respir Crit Care Med 2005; 172(10): 1253–8

  8. 8.

    Krawiec ME, Westcott JY, Chu HW, et al. Persistent wheezing in very young children is associated with lower respiratory inflammation. Am J Respir Crit Care Med 2001; 163(6): 1338–43

  9. 9.

    Thurlbeck WM. Lung growth and alveolar multiplication. Pathobiol Ann 1975; 5: 1–34

  10. 10.

    Childhood Asthma Management Program Research Group (CAMP). Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med 2000; 343(15): 1054–63

  11. 11.

    Covar RA, Spahn JD, Murphy JR, et al. Progression of asthma measured by lung function in the childhood asthma management program. Am J Respir Crit Care Med 2004; 170(3): 234–41

  12. 12.

    Agertoft L, Pedersen S. Effects of long-term treatment with an inhaled corticosteroid on the growth and pulmonary function in asthmatic children. Respir Med 1994; 88: 373–81

  13. 13.

    Zeiger RS, Dawson C, Weiss S. Relationships between duration of asthma and asthma severity among children in the Childhood Asthma Management Program (CAMP). J Allergy Clin Immunol 1999; 103: 376–87

  14. 14.

    Xuan W, Peat JK, Toelle BG, et al. Lung function growth and its relation to airway hyperresponsiveness and recent wheeze: results from a longitudinal population study. Am J Respir Crit Care Med 2000; 161(6): 1820–4

  15. 15.

    Sears MR, Greene JM, Willan AR, et al. A longitudinal, population-based, cohort study of childhood asthma followed to adulthood. N Engl J Med 2003; 349(15): 1414–22

  16. 16.

    Peat JK, Woolcock AJ, Cullen K. Rate of decline of lung function in subjects with asthma. Eur J Respir Dis 1987; 70(3): 171–9

  17. 17.

    Lange P, Parner J, Vestbo J, et al. A 15-year follow-up study of ventilatory function in adults with asthma. N Engl J Med 1998; 339(17): 1194–200

  18. 18.

    Ulrik CS, Lange P. Decline of lung function in adults with bronchial asthma. Am J Respir Crit Care Med 1994; 150: 629–34

  19. 19.

    James AL, Palmer LJ, Kicic E, et al. Decline in lung function in the Busselton Health Study: the effects of asthma and cigarette smoking. Am J Respir Crit Care Med 2005; 171(2): 109–14

  20. 20.

    Sherrill D, Guerra S, Bobadilla A, et al. The role of concomitant respiratory diseases on the rate of decline in FEV1 among adult asthmatics. Eur Respir J 2003; 21(1): 95–100

  21. 21.

    Griffith KA, Sherrill DL, Siegel EM, et al. Predictors of loss of lung function in the elderly: the Cardiovascular Health Study. Am J Respir Crit Care Med 2001; 163(1): 61–8

  22. 22.

    Juniper EF, Guyatt GH, Feeny DH, et al. Measuring quality of life in asthma. Am Rev Respir Dis 1993; 147: 832–8

  23. 23.

    Rowe BH, Oxman AD. Performance of an asthma quality of life questionnaire in an outpatient setting. Am Rev Respir Dis 1993; 148: 675–81

  24. 24.

    Ehrs PO, Aberg H, Larsson K. Quality of life in primary care asthma. Respir Med 2001; 95: 22–30

  25. 25.

    Shim CS, Williams MH. Relationship of wheezing to the severity of obstruction in asthma. Arch Intern Med 1983; 143: 890–2

  26. 26.

    Kerstjens HA, Brand PL, de Jong PM, et al. Influence of treatment on peak expiratory flow and its relation to airway hyperresponsiveness and symptoms: the Dutch CNSLD Study Group. Thorax 1994; 49(11): 1109–15

  27. 27.

    Leone FT, Mauger EA, Peters SP, et al. The utility of peak flow, symptom scores, and β-agonist use as outcome measures in asthma clinical research. Chest 2001; 119: 1027–33

  28. 28.

    Josephs LK, Gregg I, Mullee MA, et al. Nonspecific bronchial reactivity and its relationship to the clinical expression of asthma: a longitudinal study. Am Rev Respir Dis 1989; 140: 350–7

  29. 29.

    Stanescu DC, Frans A. Bronchial asthma without increased airway reactivity. Eur J Respir Dis 1982; 63: 5–12

  30. 30.

    Corren J, Hams AG, Aaronson D, et al. Efficacy and safety of loratidine plus pseudoephedrine in patients with seasonal allergic rhinitis and mild asthma. J Allergy Clin Immunol 1997; 100: 781–8

  31. 31.

    Noonan M, Chervinsky P, Busse WW, et al. Fluticasone Propionate reduces oral Prednisone use while it improves asthma control and quality of life. Am J Respir Crit Care Med 1995; 152: 1467–73

  32. 32.

    Okamato LJ, Noonan M, de Boisblanc BP, et al. Fluticasone Propionate improves quality of life in patients with asthma requiring oral corticosteroids. Ann Allergy Asthma Immunol 1996; 76: 455–61

  33. 33.

    Ogirala RG, Sturm TM, Aldrich TK, et al. Single, high-dose intramuscular triamcinolone acetonide versus weekly oral methotrexate in life-threatening asthma: a double-blind study. Am J Respir Crit Care Med 1995; 152: 1461–6

  34. 34.

    Otulana BA, Varma N, Bullock A, et al. High dose nebulized steroid in the treatment of chronic steroid-dependent asthma. Respir Med 1992; 86: 105–8

  35. 35.

    Li D, German D, Lulla S, et al. Prospective study of hospitalization for asthma: a preliminary risk factor model. Am J Respir Crit Care Med 1995; 151: 647–55

  36. 36.

    Fuhlbrigge AL, Kitch BT, Paltiel AD, et al. FEV1 is associated with risk of asthma attacks in a pediatric population. J Allergy Clin Immunol 2001; 107(1): 61–7

  37. 37.

    Bacharier LB, Strunk RC, Mauger D, et al. Classifying asthma severity in children: mismatch between symptoms, medication use, and lung function. Am J Respir Crit Care Med 2004; 170(4): 426–32

  38. 38.

    Pauli K, Covar R, Jain N, et al. Do NHLBI lung function criteria apply to children? A cross-sectional evaluation of childhood asthma at National Jewish Medical and Research Center, 1999–2002. Pediatr Pulmonol 2005; 39(4): 311–7

  39. 39.

    Enright PL, Johnson LR, Connett JE, et al. Spirometry in the Lung Health Study: 1. Methods and quality control. Am Rev Respir Dis 1991; 143: 1215–23

  40. 40.

    Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention: NHLBI/WHO workshop report [publication no. 95-3659]. Bethesda (MD): National Institutes of Health, National Heart, Lung and Blood Institute, 1995

  41. 41.

    Brand PLP, Postma DS, Kerstjens HA, et al. Relationship of airway hyperresponsiveness to respiratory symptoms and diurnal peak flow variation in patients with obstructive lung disease: the Dutch CNSLD Study Group. Am Rev Respir Dis 1991; 143: 916–21

  42. 42.

    Enright PL, Lebowitz MD, Cockroft DW. Physiologic measures: pulmonary function tests. Asthma outcomes. Am J Respir Crit Care Med 1994; 149 (2 Pt 2): S9–20

  43. 43.

    Quackenboss JJ, Lebowitz MD, Krzyzanowski M. The normal range of diurnal changes in peak expiratory flow rates: relationship to symptoms and respiratory disease. Am Rev Respir Dis 1991; 143: 323–30

  44. 44.

    Venables KM, Burge PS, Davison AG, et al. Peak flow records in surveys: reproducibility of observers reports. Thorax 1984; 39: 828–32

  45. 45.

    Brand PL, Duiverman EJ, Waalkens HJ, et al. Peak flow variation in childhood asthma correlation with symptoms, airways obstruction, and hypperresponsiveness during long-term treatment with inhaled corticosteroids: the Dutch CNSLD Study Group. Thorax 1999; 54(2): 103–7

  46. 46.

    Garrett J, Fenwick JM, Taylor G, et al. Peak expiratory flow meters (PEFs): who uses them and how does education affect the pattern of utilisation? Aust N Z J Med 1994; 24: 521–9

  47. 47.

    Kikuchi Y, Okabe S, Tamura G, et al. Chemosensitivity and perception of dyspnea in patients with a history of near-fatal asthma. N Engl J Med 1994; 330: 1329–34

  48. 48.

    Crapo RO, Casaburi R, Coates AL, et al. Guidelines for methacholine and exercise challenge testing: 1999. Am J Respir Crit Care Med 2000; 161: 309–29

  49. 49.

    Pattemore PK, Asher MI, Harrison AC, et al. The interrelationship among bronchial hyperresponsiveness, the diagnosis of asthma, and asthma symptoms. Am Rev Respir Dis 1990; 142: 549–54

  50. 50.

    Rijcken B, Schouten JP, Xu X, et al. Airway hyperresponsiveness to histamine associated with accelerated decline in FEV1? Am J Respir Crit Care Med 1995; 151: 1377–82

  51. 51.

    Guyatt G, Naylor CD, Juniper E, et al. Quality of life. In: Guyatt G, Rennie D, Evidence-Based Medicine Working Group, editors. Users’ guides to the medical literature: a manual for evidence-based clinical practice. Chicago (IL): AMA Press, 2002

  52. 52.

    Stevens JC, Stevens SS. Brightness function: effects of adaptation. J Opt Soc Am 1963; 53: 375–85

  53. 53.

    Burdon JG, Juniper EF, Killian KJ, et al. The perception of breathlessness in asthma. Am Rev Respir Dis 1982; 126: 825–8

  54. 54.

    Moy ML, Israel E, Weiss ST, et al. Clinical predictors of health-related quality of life depend on asthma severity. Am J Respir Crit Care Med 2001; 163: 924–9

  55. 55.

    Marks GB, Dunn SM, Woolcock AJ. A scale for the measurement of quality of life in adults with asthma. J Clin Epidemiol 1992; 45: 461–72

  56. 56.

    Juniper EF, Wisniewski ME, Cox FM, et al. Relationship between quality of life and clinical status in asthma: a factor analysis and structural equation modeling. Eur Respir J 2004; 23(2): 287–91

  57. 57.

    Bailey WC, Higgins DM, Richards BM, et al. Asthma severity: a factor analytic investigation. Am J Med 1992; 93(3): 263–9

  58. 58.

    Ware Jr J, Kosinsky M, Keller SD. A 12 item short form health survey: construction of scales and preliminary tests of reliability and validity. Med Care 1996; 34: 220–33

  59. 59.

    Juniper EF, Guyatt GH, Cox FM, et al. Development and validation of the Mini Asthma Quality of Life questionnaire. Eur Respir J 1999; 14(1): 32–8

  60. 60.

    Bayliss MS, Espindle DM, Buchner D, et al. A new tool for monitoring asthma outcomes: the ITG asthma short form. Qual Life Res 2000; 9(4): 451–66

  61. 61.

    Vollmer WM, Markson LE, O’Conner E, et al. Association of asthma control with health care utilization and quality of life. Am J Respir Crit Care Med 1999; 160: 1647–52

  62. 62.

    Schatz M, Mosen D, Apter AJ, et al. Relationships among quality of life, severity, and control measures in asthma: an evaluation using factor analysis. J Allergy Clin Immunol 2005 May; 115(5): 1049–55

  63. 63.

    Juniper EF, Norman GR, Cox FM, et al. Comparison of the standard gamble, rating scale, AQLQ and SF-36 for measuring quality of life in asthma. Eur Respir J 2001; 18: 38–44

  64. 64.

    Yurk RA, Diette GB, Skinner EA, et al. Predicting patient-reported asthma outcomes for adults in managed care. Am J Manag Care 2004; 10: 321–8

  65. 65.

    Rabe KF, Adachi M, Lai CK, et al. Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys. J Allergy Clin Immunol 2004; 114: 40–7

  66. 66.

    Yelin E, Trupin L, Earnest G, et al. The impact of managed care on health care utilization among adults with asthma. J Asthma 2004; 41: 229–42

  67. 67.

    Leidy NK, Coughlin C. Psychometric performance of the Asthma Quality of Life questionnaire in a US sample. Qual Life Res 1998; 7: 127–34

  68. 68.

    Rutten-van Mölken MP, Custers F, van Doorslaer EK, et al. Comparison of performance of four instruments in evaluating the effects of salmeterol on asthma quality of life. Eur Respir J 1995; 8: 888–98

  69. 69.

    Fuhlbrigge AL, Adams RJ, Guilbert TW, et al. The burden of asthma in the United States: level and distribution are dependent on interpretation of the national asthma education and prevention program guidelines. Am J Respir Crit Care Med 2002; 166: 1044–9

  70. 70.

    Adams RJ, Smith BJ, Ruffin RE. Factors associated with hospital admissions and repeat emergency department visits for adults with asthma. Thorax 2000; 55: 566–73

  71. 71.

    Osman LM, Calder C, Robertson R, et al. Symptoms, quality of life, and health service contact among young adults with mild asthma. Am J Respir Crit Care Med 2000; 161: 498–503

  72. 72.

    Van der Molen T, Postma DS, Schreurs AJ, et al. Discriminative aspects of two generic and two asthma-specific instruments: relation with symptoms, bronchodilator use and lung function in patients with mild asthma. Qual Life Res 1997; 6: 353–61

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Correspondence to Dr Aris C. Garro.

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Garro, A.C., Robert, B. Asthma as a Model for Chronic Disease Management Programs. Dis-Manage-Health-Outcomes 16, 297–303 (2008). https://doi.org/10.2165/0115677-200816050-00005

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  • Asthma
  • Chronic Obstructive Pulmonary Disease
  • Pulmonary Function
  • Asthma Control
  • Healthcare Utilization