An Update on Asthma & Allergy Care
For those who live with allergic rhinitis, ‘tis always the season. From the itchy, runny nose to the congestion and post-nasal drip, not to mention the watery, itchy eyes, the range of symptoms experienced by this patient population are determined by an uncontrollable range of one’s environmental factors — the patient’s seasonal milieu, if you will. And while some may become accustomed to dealing with their condition as a “normal” part of their lives, John Oppenheimer, MD, FAAAAI, chief of allergy at Atlantic Health System in New Jersey and professor of clinical medicine at Rutgers University of Medicine and Dentistry of New Jersey, says that hay fever is, pardon the pun, nothing to sneeze at, especially for the younger folks who tend to be most affected by seasonal allergies.
“Generally, I tell people that, unlike with hospice, where you’re talking about a life-threatening illness, this is a ‘quality-of-life-threatening’ illness,” said Oppenheimer, who also sits on the Joint Task Force on Practice Parameters for the American Academy of Allergy, Asthma & Immunology. “There are studies showing that, if you look at quality-of-life measures, having allergic rhinitis may be akin to having congestive heart failure with regard to impact. Imagine having a profound cold that lasts for weeks on end. For a young person, that is a big deal. And from a quality-of-life perspective, this may be the greatest encumbrance of healthcare they’ve had up until this point in their lives.”
For nurses, the challenge becomes trying to determine just how much of a negative impact the condition can cause (and is causing) their patients. That said, patients will oftentimes rely on their nurses to serve as advocates to healthier living by providing education and effective communication, especially when symptoms are not present, even if they’re not actively campaigning for that advocacy.
“Because, frequently [for patients], when it comes to seasonal allergy it’s ‘out of sight, out of mind,’ meaning that when the symptoms are improved by using medicine they wait for the next episode to occur,” Oppenheimer said. “So, it’s a matter of getting people to paradigm shift their approach to care and, instead of just dealing with things acutely, deal with them proactively.”
Much of this can be accomplished on the nursing side by, firstly, being cognizant of the different types of medications available and how each one works. For example, oral antihistamines help alleviate itching and a runny nose, but they aren’t effective for nasal stuffiness. Nasal steroids, meanwhile, are intended to treat obstruction, itching, and a runny nose, but they take time to produce their effects. This is where educating patients as to a drug’s mechanism of action can be very important, because a drug that takes longer to act may be perceived as “not working” by the patient, when in reality it is designed to be a substance that controls symptoms as opposed to treating acutely, and thus will take longer to take affect.
Pharmacological education should absolutely be a priority for nurses and other healthcare staff due to the nature of today’s pharmacy scene, where many drugs that were once exclusively available by prescription are now widely available over the counter. This has led to confusion about various drug options among patients who, with the way our healthcare system tends to function today, are often put into compromising positions from the time they walk into a pharmacy.
“When you think about allergic rhinitis treatment as a whole, you’ve got several options: You’ve got antihistamines, nasal steroids, nasal antihistamines, leukotriene modifiers, and allergy shots,” Oppenheimer said. “In the past, to be able to gain access to a lot of new-generation antihistamines and nasal steroids, you had to go to a doctor’s office to get a prescription. Today, many of these are available over the counter, and some people have no idea how or when to use them.
Pharmacists are going to be far too busy to educate everyone, so they come to our office holding a bag of medicine that [they think] has ‘failed.’ But it has ‘failed’ in many cases because people have unrealistic expectations. We are seeing people on good medicines who don’t know how to use them, when to use them, and why to use them. That’s a failure of the system, and this is where nurses and doctors can be very impactful in improving outcomes through education.”
In order to provide the appropriate education, however, healthcare personnel must ensure that there aren’t any misconceptions of their own related to allergy treatment. “I think the biggest misconception is that people think an antihistamine solves allergic rhinitis; it doesn’t,” Oppenheimer said. “If somebody’s got nasal stuffiness, you’re going to be failing them if you use an antihistamine as a monotherapy. You really need to be using something anti-inflammatory, whether it be immunotherapy, allergy shots, or nasal steroids. You’re going to need something else to help with the inflammatory component.”
Though not necessarily a misconception, Matthew Rank, MD, FAAAAI, associate professor of medicine at the Mayo Clinic in Arizona warns nurses and other healthcare providers that there are many unproven treatments being used for seasonal allergies that patients will take. “And there are many people who are not trained [to treat] allergy who provide treatment recommendations that are not based on clinical evidence,” Rank continued. “Nurses should be aware that when this is happening there may be other proven therapies available that a patient could take. “
Beyond the difficulty of prescribing the best medication and helping patients to understand appropriate usage is achieving actual adherence to medications that will actually control or treat symptoms acutely. This can be of additional concern among those who may be diagnosed for the first time with a chronic condition and have not yet become accustomed to following a strict regimen. “Allergies peak in the late teens to early 20s from a rhinitis perspective, as far as prevalence goes,” Oppenheimer said. “And, often, this is without a doubt the first illness that these young people are suffering from. And that makes it all the more difficult for people to adhere to their medicines, because they’re not used to having a chronic illness. So I think people deal in a reactive versus a proactive approach in many of these situations.”
While there’s no clinical danger per se of not taking the medication routinely as directed, Oppenheimer sees somewhat of a psychological need to address because of that impact on life quality. “The only thing that can exacerbate a sinus disease is if there is a [clinical] comorbidity, but the real point is that the system, as it stands right now, is demanding educators, and nurses are a part of that team, to help people to use the medicines that are available, and available without doctor involvement, appropriately,” he said. “I look at this as the medical team, and the nurse is a big part of the medical team who often has a lot of face-to-face contact, sometimes more with the patient than the doctor does. And this is affecting young people in the maximal productive part of their lives.”
So, how much better should nurses be at telling their patients how they should feel when determining whether or not a prescription is being followed and working to its maximal productivity? That at least is an easy answer according to Oppenheimer.
“My goal, is to encourage patients that they should be able to do everything that they want to do,” he said. “There should be no encumbrance of their quality of life if we care for them aggressively early on.”
The same also holds true for those living with asthma, he said, though the presentation of asthma in the very young can look similar to seasonal allergies, making evaluations and diagnoses a challenge. “In kids, it can be sometimes difficult to differentiate the two because cough can be a comorbidity,” Oppenheimer said. “But with anyone over the age of 5, you can do a lung function and better define. Documented lung function not only assists in determining the presence of asthma, it also lends to understanding how severe the asthma is, which can actually be near impossible for patients to pinpoint on their own.
“The truth is that there’s a subgroup of people who are poor ‘perceivers’ of their asthma and, sadly, their morbidity, that would be emergency room visits and hospitalizations, and their mortality, that would be actual death, have been shown to be worse if they’re poor perceivers of dyspnea,” Oppenheimer said. “They don’t know that they’re short of breath until they’re close to death. So that means that we have to listen to a patient’s history and make assessment, but we also want to corroborate it with an objective measure of lung function through the use of a spirometer. Because we have to put all of the information together to really ascertain the level of control.”
Much like rhinitis, it is also important to understand how asthma is affecting the patient’s life, Rank adds. “Does it interfere with sleep, exercise, work, or school,” Rank suggests. “Asthma can be difficult to diagnosis in preschoolers, as many children in this age range may have wheezing with viral infections, but then as they get older never develop asthma.” According to Rank and Oppenheimer, some of the differences to note between asthma and allergy symptoms include wheezing, shortness of breath, chest tightness, and, yes, the coughing.
Another key to helping patients achieve good health is ascertaining the type of asthma medications that they’re relying on—the rescue variety or the control variety. (With the distinction of importance being that if patients are relying on immediate rescue of their symptoms then they aren’t seeing much control of them.)
“One of the telltale signs that somebody is falling out of control or has increased potential for morbidity and mortality is their use of rescue therapy,” Oppenheimer said. “If they’re requiring frequent use of their albuterol or are seeing escalating use of their albuterol, that is an indication that trouble is around the corner and that we need to act.”
This highlights another area in which he believes nurses can make a profound impact on their patients through communication and education advocacy.
“Unlike allergic rhinitis, asthma is associated with mortality,” Oppenheimer said. “Nonadherence with asthma can translate to actual death. About 250 people die each month in the U.S. and that’s a significant number of people. And a large majority of them could be prevented if we could assess their level of control [and adherence] and act.” Much like with seasonal allergies, however, is the fact that misconceptions about drug utilization can also lead to unhealthy circumstances.
”We need people to be educated to understand onset of action,” Oppenheimer continued. “And this is, again, where nurses can really be helpful: It is not uncommon, if we don’t spend time educating patients, to see them given both a short-acting rescue medicine and a controller medicine like an anti-inflammatory.
They take the albuterol, it works right away. They take the inhaled steroid, and it doesn’t make a difference at all. Why? Because it takes weeks to work. So, people say ‘this medicine doesn’t work,’ and never take it again. That’s a really bad misconception, that ‘all medicines work with the same onset of action.’ They don’t.”
Another similarity of misconception is that “Nurses should also be aware that some patients may be misdiagnosed with asthma,” Rand said. “If patients are not doing well despite taking a lot of asthma treatment, they should go back to their healthcare provider and make sure the diagnosis is right.”