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In 2007 the National Asthma Education and Prevention Program (NAEPP) published new asthma guidelines. A major emphasis of the new guidelines is a focus on asthma control. The term asthma control is meant to reflect the degree to which asthma symptoms are minimized with therapeutic interventions and goals of therapy are met. Since asthma control may vary over time, monitoring the level of control on a periodic basis can help determine whether a given therapy is effective and if asthma controller medications may need to be increased or decreased.

The Asthma Control Test (ACT) is one tool recommended by the NAEPP that is gaining acceptance in clinical practice because of its simplicity and ease of use. The ACT questionnaire comes in two forms, one for patients 12 years and older and the other for children 4-11 years of age. Both have been clinically validated and seem to be as sensitive at measuring asthma control as the gold standard physiological measurement of pulmonary function testing. The ACT can be administered in the office, taken at home or even completed free-of-charge online at www.asthmacontrol.com. The ACT is also available in Spanish.

The ACT asks asthmatic patients to recall their asthma symptoms over the previous 4 weeks. The adult ACT contains only five questions. The 4-11 year old ACT asks questions of the child and the caregiver. The sum of the responses is totaled for an overall score that ranges from 5-25 (in the adult form) and 5-27 (in the childhood form). Scores of 20-27 (green zone) are considered to be indicative of well controlled asthma. Scores of 16-19 (yellow zone) suggest that a patient’s asthma is only somewhat controlled. And scores of 5-15 (red zone) represent poorly controlled asthma. Patients in the green zone require no immediate adjustment of their asthma medications. Those in the yellow zone may need to step-up their asthma therapy. Patients in the red zone are poorly controlled and are at a higher risk for an emergency room visit or hospitalization. They should contact their medical provider promptly.

To help illustrate the utility of the ACT tool in every day practice, in Figure 1, the monthly ACT scores of an imaginary asthmatic are plotted. Overall, this patient’s asthma seems well controlled since 7/12 data points are in the green zone. However, this patient experienced a mild deterioration in his asthma in the spring and a more severe drop in the fall. This pattern suggests that this asthmatic may have seasonal allergies that could be triggering his asthma. Alternatively, if the drops in his ACT occurred in the fall and winter, it may be that viral illnesses could be a significant trigger for the patient. Though a single ACT score may be useful, the strength of this tool will be more likely realized with monthly measurements.

The use of the ACT score or other similar tools should help families, patients and medical providers more accurately assess asthma control. If paired with other NAEPP recommendations such as asthma education, a written action plan, appropriate pharmacotherapy and regular outpatient office visits, overall asthma care should improve. Use of the ACT score should better match disease activity with medical therapy and maximize the therapeutic index of the overall asthma medical regimen.

Finally, the ACT score is not some arbitrary number. Recent studies have shown that lower ACT scores directly correlate with poorer asthma outcomes such as emergency room visits and hospitalizations. This new tool has the potential to improve how asthmatic patients are managed.

References:
Expert Panel Report 3 (EPR-3): Guidelines for the diagnosis and management of asthma-summary report of 2007. J Allergy Clin Immunol 2007, 120:S93-S138.
Schatz M et al. Asthma control test: reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol 2006, 117:549-556.
Liu AH et al. Development and cross-sectional validation of the childhood asthma control test. J Allergy Clin Immunol 2007, 119:817-825.




Presented in Partnership by Nashville Medical News and Vanderbilt University Medical Center



February 2008



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