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Asthma is a common chronic disease of childhood. Providers' adherence to asthma guidelines is still less than optimal.

OBJECTIVES: To determine if an Asthma Education Program aimed at primary care practices can improve asthma care within practices and if the results vary by duration of the program.
METHODS: Ten practices were randomly assigned to an Early Asthma Education Intervention (EI) group or a Delayed Asthma Education Intervention (DI) group. The EI group received the intervention for 12 months and was monitored for 6 additional months. The DI group was observed without intervention for 12 months, then received the intervention for 6 months, and was monitored for 6 additional months. The program included training of asthma educators in each practice and then monitoring for improvement in medical record documentation of NAEPP asthma quality indicators by blinded random review of patient charts.

RESULTS: In the EI group, 6 month, 12 month and 18 month data revealed significant improvement in documentation of asthma severity, education, action plan, night time symptoms and symptoms with exercise compared to baseline and compared to DI group at baseline and at the 12 month interval. In the DI group, significant improvement in documentation in all of the above endpoints and also in documentation of NAEPP treatment guidelines was noted at 18 months and 24 months. In both groups, documentation levels remained relatively stable at 6 months after the intervention, with no significant differences between groups. While improved, guideline adherence was <80% for half of the indicators.

CONCLUSION: In-office training of non-physician asthma providers improves the quality of asthma care.

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Exhaled nitric oxide (FENO) is elevated in asthma, and a clinical practice guideline has been published with recommendations for anti-inflammatory treatment. It summarizes that a FENO at an expiratory flow rate of 50 ml s(-1) (FENO50) above 35 ppb in children indicates eosinophilic inflammation, and the most likely response is to use inhaled corticosteroids. Intermediate FENO50 between 20-35 ppb should be interpreted cautiously.

The aim of the study was to investigate this guideline in a small group of asthmatic children.

Thirty-seven asthmatic children; 23 boys and 14 girls, visited the outpatient clinic, and provided exhaled breath samples for offline NO measurement. These samples were analysed with chemiluminescence techniques. Three flow rates, namely 16, 90 and 230 ml s(-1) were used for the extended NO analysis (Högman-Meriläinen algorithm, HMA) to estimate the alveolar concentration (CANO), diffusion rate of the airway wall (DawNO) and airway wall content (CawNO). For accuracy of the HMA, the estimated value of FENO at 50 ml s(-1) (FENO50) was compared with measured FENO50.

In nine children the difference was more than 5 ppb and the data were therefore excluded. Five children with FENO50  <20 ppb had no known allergy and their FENO50 geometrical mean (25th; 75th percentile) was 11 (10;14) and CawNO was 32 (20;43) ppb. Ten children with FENO50  >  35 ppb had an allergy and had FENO50 of 56 (47;60) ppb and CawNO of 140 (121;172) ppb. Thirteen children with allergies, with intermediate FENO50, had FENO50 of 27 (25;30) ppb with a wide range of CawNO. In five of these children, values were comparable to healthy children, 44 (43;50) ppb while eight children had elevated CawNO values of 108 (95;129) ppb. Our data indicate the clinical potential use of extended NO analysis to determine the personal target value of FENO50 for monitoring the treatment outcome.

Furthermore, for children with intermediate FENO50 more than half of them could possibly benefit from an adjustment of inhaled corticosteroids if the CawNO value was considered.