Asthma Management: A Moving Target


Vol. 16 •Issue 10 • Page 56
Asthma Management: A Moving Target

New NHLBI guidelines stress need for more asthma education

Across America, whether in open plains or dense urban areas, asthma rates continue to escalate. More than 22 million Americans have asthma, including 6.5 million children under age 18; and an estimated 4,000 Americans die from asthma exacerbations each year, according to the Centers for Disease Control and Prevention.

Given those figures, respiratory therapists and other caregivers who treat patients with asthma can always use new and improved information on how to combat such a prevalent and dangerous disease.

So it came as welcome news in August that for the first time in a decade, the National Asthma Education and Prevention Program (NAEPP) issued a comprehensive update of clinical guidelines for the diagnosis and management of asthma.

Latest scientific advances

At the behest of the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health, NAEPP convened an expert panel to review the published literature on asthma to be sure the guidelines reflected the latest scientific advances.

As a result, the new guidelines include an expanded section on childhood asthma (with an additional age group: 5- to 11-year-olds), new guidance on medications, new recommendations on patient education in settings beyond the physician’s office, and new advice for controlling environmental factors that can cause asthma symptoms.

Media coverage about the updated guidelines has pleased James Kiley, PhD, MS, director of the NHLBI’s Division of Lung Diseases.

“We have received considerable press coverage, with reach extending to over 53 million Americans, which indicates considerable public interest,” Dr. Kiley said. “Our expert panel members and staff report positive feedback regarding the emphasis on asthma control, the usefulness of thinking of control in terms of both impairment and risk, the desirability of adding the new age group, and the comprehensiveness and thoroughness of the full report.”

Asthma education stressed

Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma – Full Report, 2007 provides new guidance for selecting treatment based on a patient’s individual needs and level of asthma control.

The guidelines emphasize asthma severity can change over time and can differ among individuals and age groups, so treatment must be adjusted as needed.

EPR-3 stresses patients need the skills to self-monitor and manage asthma and to use a written asthma action plan, which should include instructions for daily treatment and ways to subdue worsening asthma.

The new recommendations call for expanding patient education to a variety of new settings, like pharmacies, schools, community centers, and patients’ homes. “As the guidelines note, patient education is a team effort,” Dr. Kiley said. “The ideal is to have every member of the health care team engaged in some level of patient education. The nurse, physician assistant/nurse practitioner, respiratory therapist, pharmacist, and asthma educator all can elaborate on the key messages and review self-management skills with the patient. Even the receptionist in the office has a role in reinforcing key messages.”

Jane Chancellor, RRT, and other therapists at Santa Barbara Cottage Hospital, Santa Barbara, Calif., saw to this need long ago. They devised a therapist-driven protocol for asthma education.

“We knew MDIs worked as well as medication nebulizers when used properly,” explained Respiratory Care Department Director Paul Sherman, MS, RRT, RPFT, RCP. “I was tired of giving asthma patients the message that when they get sick we’ll give them a med neb because that works better than an MDI. Sometimes patients would come in and their medication would be empty or they wouldn’t use a spacer and weren’t getting the meds. Now we’re showing them how to use their inhalers in a crisis, and they’re getting the message, ‘I can do this at home.'”

Stepwise approach

Regarding the actual asthma medications, EPR-3 endorses a stepwise approach to control asthma, in which medication doses or types are stepped up as needed and stepped down when possible. Treatment is adjusted based on the level of asthma control.

The new guidelines revise and expand stepwise asthma management charts to specify treatment for three age groups: 0 to 4 years, 5 to 11 years, and 12 years and older. The 5- to 11-year age group was added because new evidence indicates children may respond differently than adults to asthma medications.

“Therapy should be stepped up if a patient’s asthma is not well controlled,” Dr. Kiley said. “A step-down in therapy may be considered when the patient’s asthma is well controlled for at least three months.”

EPR-3 reaffirms that patients with persistent asthma (whose symptoms occur more than twice a week during the day or more than twice a month at night) need both long-term control medications to prevent exacerbations and quick relief medications for symptoms as needed. It also affirms inhaled corticosteroids are the most effective long-term control medication across all age groups.

However, EPR-3 makes several new recommendations on treatment options, including:

  • leukotriene receptor antagonists and cromolyn for long-term control
  • long-acting beta2-agonists as adjunct therapy with inhaled corticosteroids
  • omalizumab for severe asthma
  • albuterol, levalbuterol, and corticosteroids for acute exacerbations.

    Asthma action plan

    “A variety of educational approaches are usually necessary to improve adherence to recommended long-term control therapy,” he said. “First and foremost should be a discussion between the clinician and the patient (and parent, if the patient is a child) in which the clinician conveys that asthma treatment is a partnership effort.”

    The clinician and patient should develop a written asthma action plan together, one that balances what the patient’s goals are with the clinician’s assessment of the patient’s level of asthma severity or control. “Many patients don’t realize their asthma could be better controlled,” Dr. Kiley said.

    EPR-3 contains a chapter titled “Education for a Partnership in Care,” which outlines numerous methods to promote this partnership and to enhance adherence.

    “All of these methods stress that while it is important to give patients information about medications, it is not sufficient by itself,” Dr. Kiley said. “The patients must also learn self-management skills and must believe the treatments will make a difference in their lives.”

    Environmental control

    EPR-3 also emphasizes the importance of controlling environmental factors and other conditions that can affect asthma. It describes new evidence for using multiple approaches to limit exposure to allergens and substances that can worsen asthma.

    An expanded section focuses on other chronic conditions common to asthma patients, like rhinitis and sinusitis, gastroesophageal reflux, weight problems, obstructive sleep apnea, stress, and depression.

    “The role of stress and depression in asthma is important but not fully defined,” Dr. Kiley noted. “An increasing number of studies demonstrate an association between stress and depression and poor asthma outcomes, not only among patients but also among the children of mothers who are depressed.”

    The guidelines recommend that in cases of poorly controlled asthma, the clinician should inquire about the potential role of depression or chronic stress because it could complicate asthma management.

    Implementation challenge

    Much hard work and many long hours went into updating the NAEPP asthma guidelines. Historically though, clinicians often are slow to adopt new guidelines for asthma (and many other medical conditions), a sore point with health care leaders.

    To help encourage adoption, the NHLBI has convened a Guidelines Implementation Panel (GIP) to recommend strategies to enhance implementation of the guidelines, including ways to promote their integration into clinical practice routines. A final draft of the GIP report is slated for release within a couple months, Dr. Kiley said.

    Pressed for specifics on how to persuade clinicians to change their practices and adopt the new guidelines, he said: “As with patients, multi-pronged approaches will be necessary. It will be important to provide system-wide support for the clinician to follow the guidelines.”

    The new Guidelines for the Diagnosis and Management of Asthma can be accessed at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm.

    Michael Gibbons, is senior associate editor. He can be reached at mgibbons@merion.com.

    Do You Provide Dysfunctional Asthma Care?

    The new Guidelines for the Diagnosis and Management of Asthma cover four components of asthma management. One of these — education for a partnership in asthma care — requires especially careful attention.

    An effective professional/patient partnership is essential for achieving success. Many professionals work hard toward this goal. Others unknowingly impede the formation of such a partnership. The way many physicians’ practices approach the care of patients with asthma is dysfunctional. Poor planning and lack of consistency make good asthma outcomes less likely.

    Several provider-related factors may derail the development of a partnership in asthma care, but these suggested remedies can get you on track.

    Inconsistent practices and vocabularies

    The problem: Doctors are taught to be independent thinkers. They often misinterpret this to mean they don’t have to agree on protocols with others in their practice. As a result, patients get conflicting advice during a visit.

    Misunderstandings often occur when various staff members use the same word without agreeing on its definition. For example, two respiratory therapists may use the word “moderate” to describe signs of different severity.

    Use of several terms with the same meaning also causes confusion. Patients who hear the terms quick relief, reliever, rescue, fast-acting beta-agonist, quick-acting beta-agonist, and short-acting beta-agonist as synonyms for albuterol may think they’re different medicines. Sometimes they assume one doctor is changing the medicine that another prescribed.

    The solution: All professionals at a given site must agree on the essentials of asthma treatment and the words used to describe it. If they don’t, patients will spend their time trying to reconcile differences rather than learning new concepts.

    Patient education

    The problem: Patient educational materials are uneven in quality and often use different vocabularies. Many practices haven’t established criteria for evaluating handouts, diaries, and action plans. Their choices often are based on the cost of materials rather than their effectiveness in improving asthma outcomes and office efficiency.

    The solution: All staff and all written materials (books, diaries, action plans, and learning tools) in a practice or institution should use the same language and concepts to make asthma education more effective and efficient. Using a unified approach to language and treatment, I guided staff at four Kaiser sites (130,000 pediatric enrollee years) as they reduced hospital days for asthma, bronchitis, bronchiolitis, and pneumonia to less than 25 percent of the national rate.1

    Diaries and action plans

    The problem: A well-designed, comprehensive diary is an excellent tool for learning about asthma and managing it at home. Yet many professionals don’t ask their patients to keep an asthma diary.

    The solution: Professionals will use diaries once they see that this practice improves patients’ ability to communicate by phone, recall events during a visit, and to treat asthma at home. For patients older than age 4, diaries and action plans should be based on peak flow. For young children, they should be based on objective signs rather than subjective symptoms.

    Hierarchy

    The problem: The relationship between many asthma professionals and patients is hierarchical rather than equal. Physicians frame their recommendations as imperatives: “I want you to take…”, “I need you to take…. The tone of these statements may discourage questions from the patient and promote misunderstanding.

    The solution: Instead of using phrases such as, “You should take…”, a more helpful statement would be, “This medicine would benefit you because…”.

    Patient participation

    The problem: Physicians have low expectations of patients. Many asthma professionals don’t encourage patients to educate themselves by reading about their condition.

    The solution: Get physicians and patients on the same page. A recent study showed that staff and patients who used a free asthma learning tool improved their ability to communicate about and care for asthma.2 More information about this report can be found at www.pedipress.com/alt_main.html.

    Enlist patients’ participation in their care to promote learning and make the most effective use of office visits. Patients who are asked to write a narrative of their asthma history gain a better understanding of their asthma and are more willing to use inhaled steroids on a daily basis.3

    Equipment and medications

    The problem: When patients don’t follow directions for correct inhaler technique or use their medications improperly, asthma professionals often blame the patient for noncompliance. But they forget to look at their own office procedures and materials to find a possible source for the failure.

    The solution: Use as few brands as possible. Teaching and troubleshooting is easier when professionals only have to be familiar with one brand of each device. All equipment, including peak flow meters, holding chambers, and nebulizers, should be efficient and of good quality. For example, using an efficient nebulizer cup can reduce treatment time and increase parent compliance.

    Opportunity

    Partnership and the education it fosters often are a low priority in health care settings. I believe the dysfunctional culture of asthma care must change if asthma outcomes are to improve. Every encounter a patient has with an asthma professional — in the office, the emergency department, the hospital ward, and the school — is an opportunity to learn about asthma and build that partnership.

    For a list of references, look under the “From Print” toolbar on the left side of our home page at www.advanceweb.com/respmanager.

    Thomas F. Plaut, MD, is an ADVANCE editorial board member and creator of the Asthma Peak Flow Diary, Asthma Signs Diary, Peak Flow Based Asthma Action Plan, Signs Based Asthma Action Plan, the Asthma Emergency Guides for Schools and Preschools, and the free Asthma Learning Tool available at www.pedipress.com. Dr. Plaut retains the copyrights for this article.

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