Asthma Case Study
2.6
hours
Continuing Education
By Susan Corbridge, PhD, APN, ACNP, AE-C, and
Thomas C. Corbridge, MD, FCCP
ASTHMA in Adolescents and Adults
Guideline-based diagnosis and management.
A
24-year-old woman presents to an
NP, reporting a two-year history of episodic cough, chest tightness, and shortness of breath. (This patient is a composite of several cases we’ve encountered in our practice.) Over the past three months, episodes have become slightly more frequent, occurring on an average of once a month, with weekly nighttime episodes that awaken her from sleep. Between episodes she feels completely well. Symptoms are precipitated by stress and exposure to cigarette smoke and are slightly worse in the spring and fall.
The patient had …show more content…
childhood allergies but has no other significant medical or surgical history. She’s never smoked and uses no medications. She lives in an apartment with wall-to-wall carpeting and has a cat. She works in a smoke-free office. She says she experiences slight chest tightness during our examination but displays no acute distress. Auscultation reveals infrequent end-expiratory wheezes. The phy sical examination is otherwise normal, except for mild swelling of the nasal mucosa.
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With office spirometry, the patient demonstrates mild expiratory airflow obstruction. Repeat spirometry is normal 10 minutes after albuterol treatment.
Based on the patient’s levels of impairment and risk, the NP diagnoses her with mild persistent asthma and allergic rhinitis. She prescribes a low-dose inhaled corticosteroid and a short-acting rescue bronchodilator to address the asthma and a nasal corticosteroid to treat the allergic rhinitis. She educates the patient about basic asthma pathophysiology, proper medication use, and environmental control (suggesting, among other things, that she separate from her cat); provides written guidelines and a peak flow meter for monitoring asthma control; and schedules her for a follow-up visit in one month.
In this scenario, did the NP take the appropriate ajnonline.com Photo © Medical-on-Line / Alamy
OVERVIEW: More than 16 million U.S. adults have asthma, a condition that prompts 2 million ED visits and nearly half a million hospital admissions annually.
Management of this potentially deadly, chronic inflammatory disease depends on early diagnosis, accurate classification, appropriate treatment, and targeted patient education.
This article outlines current guideline recommendations for asthma and reviews what clinicians need to teach patients about its pathophysiology, pharmacotherapy, self monitoring, and environmental control. The authors discuss the classic clinical presentation of the disease, describe how to assess severity and control, and explain how such assessments can guide management. course of action? Were the medications she prescribed sufficient? Did she address the issues most important to asthma control? This article seeks to answer these questions. ASTHMA’S IMPACT
In the United States, more than 16 million adults and about 7 million children have asthma.1 Annually, it’s responsible for roughly 11 million outpatient visits,
2 million ED visits, nearly 500,000 hospital admissions, and close to 4,000 deaths.1-3 It’s a common reason for school absenteeism among children, and causes adults to lose more than 10 million workdays each year.1, 4 Although asthma is more common in boys than girls, it’s more common among women than men.5 Prevalence, hospitalization, and mortality rates have stabilized over the past decade or so but had been on the rise in both sexes and across all age and racial groups from 1977 through 1996.6, 7 …show more content…
Among adult patients, hospitalization and mortality rates are generally highest for blacks and women.6-8
BEHIND THE OBSTRUCTION
The chronic inflammation of asthma involves the ac tion of various types of cells, most notably eosinophils and Th2 lymphocytes.3, 9 Airway wall inflammation is associated with hypertrophy and hyperplasia of smooth muscle tissue and mucus plugging of the small and medium-sized airways.3 The bronchial epithelium is commonly disrupted and there is a thickening of the basement membrane (see Figure 1).9 Airway smooth muscle increases in mass, and airways become hyperreactive to a number of specific and nonspecific triggers. Variable combinations of inflammation, intraluminal mucus, and bronchospasm obstruct expiratory airflow. Although such obstruction is usually reversible either spontaneously or with pharmacotherapy, the precipitating structural changes can result in air way remodeling and fixed airflow obstruction.3
There is no clear single cause of asthma. Although atopy is an important identifiable risk factor, findings from epidemiologic studies differ as to whether early exposure to some allergens increases or reduces the risk of subsequent asthma.10 The effects are particularly difficult to discern when early exposure occurs in association with frequent lower respiratory infection.10 Asthma is also recognized as having an inheritable component, though the genetics of the disease are poorly understood.3, 11 More recently, obesity has been recognized as a risk factor,3, 12 although the precise relationship isn’t yet understood.
CLINICAL PRESENTATION
Asthma is characterized by breathlessness, chest tightness, wheezing, and coughing. (Nasal congestion and postnasal drip are also common.) Symptoms vary from patient to patient and can vary in the same
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atient over time. Symptoms may occur spontanep ously, or be precipitated or exacerbated by various triggers (see Selected Asthma Triggers3). Asthma is commonly worse in the early morning hours or at night,3 corresponding to circadian variations in bronchomotor tone and bronchial reactivity.
Occupational asthma is triggered by various agents in the workplace and may occur weeks to years after exposure and sensitization. Separation from the in citing agent is essential in the management of occupational asthma but doesn’t always result in clinical improvement.13 ESTABLISHING THE DIAGNOSIS
A diagnosis of asthma is based on characteristic signs and symptoms in the presence of airflow obstruction or hyperresponsiveness.3 The patient history should focus on
• symptoms.
• home and work environments.
• triggers.
• medication use.
• family history.
• social history.
• the impact of symptoms on daily life.
The hallmarks of airflow obstruction are expiratory wheezes and expiratory phase prolongation, al though wheezes may be absent or diminished between obstructive episodes and when airflow rates are critically low.14 Indeed the quiet chest with minimal air
Selected Asthma Triggers 3
• Allergen exposure (for example, pollen, mold, air pollutants, dust mites, cockroaches, pet dander, and saliva)
• Medications (for example, aspirin, nonsteroidal antiinflammatory drugs, and β-blockers) • Illicit drugs (for example, heroin and cocaine)
• Upper respiratory tract infections
• Gastroesophageal reflux disease
• Strong odors or fumes
• Rhinosinusitis
• Smoke (cigarette and wood)
• Hormone levels (such as variations in asthma related to menstruation)
• Exercise
• Foods or drinks containing histamine or sulfites (such as beer, wine, shrimp, dried fruit, processed potatoes)
• Cold air
• Laughing
• Stress
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entry is an ominous sign of an impending respiratory arrest.14 Other physical findings suggestive of asthma include nasal polyps, eczema, and atopic dermatitis.3
It’s important to point out, however, that the physical examination of a patient with asthma may be entirely normal. Spirometry is a simple, office-based test that can reveal airflow obstruction, as well as its severity and responsiveness to bronchodilator treatment (see Figure 2). The key spirometric measures are the forced vital capacity (FVC) (or total volume exhaled) and the forced expiratory volume within the first second of exhaling from total lung capacity (FEV1). An FEV1/
FVC ratio below 70% suggests airflow obstruction.
Reversible airflow obstruction is defined as an in crease of at least 200 mL and 12% above baseline in
FEV1, FVC, or both, after administration of a shortacting bronchodilator, such as albuterol (Proventil and others).3, 15
A normal spirometry doesn’t exclude asthma, par ticularly when symptoms are infrequent or cough is the only symptom. In such situations, a provocative challenge with methacholine (Provocholine) or
histamine (substances that cause airways to spasm and narrow when asthma is present) or exercise may trigger the obstructive process, demonstrating hyper reactivity, a central feature of asthma. Conversely, a negative test may help rule out the disease. Variable findings with a handheld peak flow meter also suggest asthma, particularly if flow rates are lower when symp toms are present and higher after albuterol treatment.
Although not central to the diagnosis of asthma, a chest X-ray may help exclude alternative diagnoses
(see Differential Diagnosis of Asthma 3, 16). Blood work may reveal eosinophilia and elevated immunoglobulin E levels.
ASSESSING DISEASE SEVERITY AND CONTROL
Assessing and monitoring asthma severity and control is essential. Severity is measured in part by how difficult it is to control the disease with treatment.3, 17
Current evidence-based guidelines, which outline preferred and alternative therapies in a stepwise manner, enable clinicians to select appropriate initial therapy for patients on the basis of disease severity (see Figures
33 and 43).3
Normal Bronchiole
Asthmatic Bronchiole
Mucus plug
Bronchoconstriction
Cross section
Cross section
Disrupted
epithelial layer Basement membrane thickening
Airway wall inflammation Intraluminal mucus
Figure 1. Normal and Asthmatic Bronchiole
The pathophysiologic hallmarks of asthma include airway wall inflammation, intraluminal mucus, and smooth muscle-mediated bronchospasm. Frequently the bronchial epithelium is disrupted and there is deposition of collagen beneath the basement membrane (referred to as basement membrane thickening).
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Severity categories. After evaluating impairment
(through symptom assessment and spirometry) and exacerbation risk, asthma can be classified into one of four severity categories: intermittent, mild per sistent, moderate persistent, or severe persistent.3
Patients with intermittent asthma have normal pulmonary function tests between infrequent asthma episodes. They require only as-needed treatment with a short-acting bronchodilator but no daily asthma medication. Patients whose symptoms occur more than twice weekly or awaken them more than twice monthly and those whose routine pulmonary function tests demonstrate obstruction have persistent asthma and require a daily antiinflammatory control medication as well as a short-acting bronchodilator for rescue. Patients with severe persistent disease require higher doses of control agents than do those with mild or moderate persistent disease and, possibly, combination treatment with different classes of asthma medications.
Asthma control is the degree to which signs and symptoms, risk of future episodes, and loss of lung function are reduced through treatment and environmental control. Because both patients and health care providers tend to underrecognize and underreport asthma symptoms,18, 19 control should be assessed at each visit using a validated tool such as the Asthma
Differential Diagnosis of Asthma3, 16
•
•
•
•
•
•
•
•
•
•
•
•
•
Vocal cord dysfunction
Chronic obstructive pulmonary disease
Alpha-1 antitrypsin deficiency
Allergic bronchopulmonary aspergillosis
Laryngotracheomalacia and tracheal stenosis
Foreign body aspiration
Viral or obliterative bronchiolitis
Endobronchial obstruction (benign or malignant) Cystic fibrosis
Bronchiectasis
Lymphangioleiomyomatosis
Churg-Strauss syndrome
Eosinophilic pneumonia
antiinflammatory medications (used either alone or in combination with other control agents) are the inhaled corticosteroids, which improve asthma symptoms and lung function, decrease the need for short-acting bronchodilators, and reduce the risk of hospitalization and asthma-related death.3
Clinicians should prescribe the least amount of
medication required to achieve control as assessed by a validated tool and spirometry.
Therapy Assessment Questionnaire, the Asthma Control Questionnaire, or the Asthma Control Test (see
Figure 520).3 These questionnaires are easily accessed online and can be administered quickly. Periodic lung function measurement though spirometry and pa tient monitoring of peak flow and symptoms can further help clinicians determine control and adjust medication accordingly.
PHARMACOTHERAPY
If patient education and adherence are adequate, most cases of asthma can be managed with a limited number of medications and environmental control measures. Medications are divided into short-acting drugs for rescue and long-term drugs for control (see
Table 13, 21).
All patients should receive a short-acting (quick
relief) bronchodilator to treat bronchospastic episodes. Those with persistent asthma require an additional long-term control agent to treat underlying airway wall inflammation. The most effective
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The daily use of a low-dose inhaled corticosteroid is preferred treatment for patients with mild persistent asthma.3 Moderate persistent asthma is generally treated with a medium-dose inhaled corticosteroid or a low-dose inhaled corticosteroid combined with a long-acting β2-adrenergic agonist.3 Alternatively a leukotriene receptor antagonist (also called a leukotriene modifier) or theophylline (Uniphyl and others) can be prescribed in addition to an inhaled corticosteroid to help the patient achieve adequate control. Patients with severe persistent asthma require high doses of an inhaled corticosteroid combined with a long-acting β2-adrenergic agonist, often in combination with other control medications.3 Those with refractory symptoms may require daily oral corticosteroids to achieve control.
Clinicians should prescribe the least amount of medication required to achieve control as assessed by a validated tool and spirometry, but tapering of medications shouldn’t be attempted until control has been achieved for at least three months.3 Patients
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Simple Spirometry
Volume Time Curve
7
(FEV1/FVC = 4.1/5.5 = 0.75)
6
Liters
5
FVC = 5.5 L
FEV1 = 4.1 L
4
FVC = 5.0 L
3
FEV1 = 2.3 L
2
(FEV1/FVC = 2.3/5.0 = 0.46)
1
0
0
1
2
3
4
5
6
Seconds
Figure 2. Simple Spirometry
Figure
1 spirometry the patient exhales as forcefully and completely as possible starting at full lung inflation
During
simple
(bottom left of the above curve). Exhaled volume (in liters) is plotted on the Y axis against exhalation time (in seconds) on the X axis to generate the volume-time curve. The total volume exhaled during this maneuver is the forced vital capacity (FVC), and the volume exhaled during the first second of the FVC maneuver is the forced expiratory volume in one second (FEV1). Under normal conditions (dashed line), the FVC is completed in three to four seconds (as indicated by a plateauing of the volume-time curve), and 70% to 80% of the FVC is exhaled in the first second (the
FEV1/FVC ratio is normally 0.7 to 0.8). In this case, the patient (solid line) has asthma, with an FEV1 of 2.3 L, an FVC of
5 L, and an FEV1/FVC of 0.46, meaning that only 46% of the FVC is exhaled in the first second. Because patients with asthma have narrowed airways, less volume can be exhaled, and it takes longer for them to fully empty their lungs.
An FEV1/FVC ratio of less than 0.7 suggests obstruction.
should be monitored closely after reducing medications to ensure continued control.
When choosing a pharmacologic regimen, consider adverse effects. Because of their sympathomimetic properties, β2-adrenergic agonists and theophylline should be used with caution in patients with cardiovascular disorders, particularly those with tachycardia and tachyarrhythmias.3 Long-acting β2-agonists may increase the risk of severe symptom exacerbation, hospitalization, and asthma-related death.22 For these reasons, the Food and Drug Administration recently issued a warning that long-acting β2-agonists should be used only
• for the shortest period of time required to achieve symptom control.
• in patients whose asthma symptoms are inadequately managed by a control medication.
• in combination products containing an inhaled corticosteroid, if the patient is a child or adolescent
(to ensure adherence to the inhaled corticoste roid).23 Long-acting β2-adrenergic agonists provide neither rescue therapy nor adequate treatment for airway wall inflammation. Their use is contraindicated except in conjunction with an asthma control medication, such as an inhaled corticosteroid.23
The inhaled corticosteroids are associated with oral candidiasis, the potential for suppressed or delayed
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growth, and reduced bone mineral density. Long-term use of inhaled corticosteroids has also been associated with cataracts and glaucoma. Recent reports suggest a possible link between leukotriene receptor antagonists and neuropsychiatric events, including depression and suicidal ideation.24
OTHER TREATMENT CONSIDERATIONS
Evaluating and treating comorbid conditions such as gastroesophageal reflux disease, rhinosinusitis, and nasal polyposis improve asthma symptoms, as does weight loss in obese or overweight patients. Obesity, in fact, increases a patient’s risk of obstructive sleep apnea, which may impede asthma management. Pa tients with poorly controlled asthma should also be evaluated for stress and depression.
Address preventive health care measures such as yearly influenza vaccination, optimal weight mainte nance, exercise, good handwashing techniques, avoid ing contact with those who are sick, and—for patients taking corticosteroids—bone mineral density measurement and calcium and vitamin D supplementation.
Other bone protective or restorative therapies may be considered in patients with osteopenia or osteoporosis.
PATIENT EDUCATION
Asthma education is an ongoing process that’s critical to achieving control, improving outcomes, and ajnonline.com minimizing medication use. As such, a needs assessment to identify patients’ key knowledge deficits, followed by targeted instruction, should be integrated into every patient visit. Nationally certified asthma educators are now recognized as the ideal practitioners to teach patients and their families about asthma. (Information on becoming a certified asthma educator can be found at www.naecb.org.)
Key components of an asthma education program should include essential facts about asthma patho physiology, the role of asthma medications, inhaler technique, the importance of asthma control, signs and symptoms of reduced control, measures for re ducing exposure to environmental irritants, and selfmanagement skills such as peak flow monitoring.3
Basic asthma pathophysiology, with instruction
Table 1. Medications for Short- and Long-Term Control of Asthma3, 21
Type of Medication
Comments
Examples
Long-term control medications (taken on a daily basis to treat and prevent symptoms)
Inhaled corticosteroids
Most effective
Fluticasone (Flovent)
Budesonide (Pulmicort)
Triamcinolone acetonide
(Azmacort)
Flunisolide (Aerobid)
Beclomethasone (QVAR)
Mometasone (Asmanex)
Long-acting β2-adrenergic agonists Always used with an inhaled corticosteroid Salmeterol (Serevent)
Formoterol (Foradil)
Combination treatment with an inhaled cortico steroid and a long-acting β2-adrenergic agonist
Fluticasone–salmeterol (Advair)
Budesonide–formoterol (Symbicort)
Leukotriene receptor antagonists Montelukast (Singulair)
Zafirlukast (Accolate)
Zileuton (Zyflo)
Mast cell stabilizers
May soon be unavailable
Cromolyn (Intal and others)
Nedocromil (Tilade)
Methylxanthines
Theophylline (Uniphyl and others)
Immunomodulators
Omalizumab (Xolair)
Systemic corticosteroids
(oral)
Methylprednisolone
Prednisolone
Prednisone
Short-acting rescue medications (taken on an as-needed basis to treat symptoms or prevent exercise-induced symptoms)
Short-acting β2-adrenergic agonists Albuterol (Proventil and others)
Levalbuterol (Xopenex)
Pirbuterol (Maxair)
Anticholinergics
Usually reserved for asthma exacerbations, not for routine outpatient use
Ipratropium (Atrovent)
Systemic corticosteroids
(oral, intravenous, subcutaneous, intramuscular)
Although oral systemic corticosteroids are not shortacting drugs, they are used adjunctively with short-acting β2-adrenergic agonists to hasten recovery
Methylprednisolone
Prednisolone
Prednisone
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tailored to the patient’s and the family’s learning style, motivation, cognitive level, cultural beliefs, and asthma management practice, reinforces the need for a daily, long-term antiinflammatory medication.
Teaching patients about how asthma—and asthma medications—affects their airways helps them rec ognize the importance of their medications, environmental control, and self monitoring. The pathophysiology can be explained as simply as follows: “Asthma is a chronic lung disease in which the airways become inflamed, or swollen, narrow, and sensitive to certain substances, which we call triggers. Exposure to these triggers tightens muscles surrounding the airways, causing further narrowing. Swollen, constricted airways, which are often filled with mucus, make breathing increasingly difficult, causing the symptoms of wheezing, chest tightness, shortness of breath, and coughing.” Medication education should focus on differences between control and rescue medications. Patients can be offered the following simple explanation: “Control medications are used to prevent symptoms, usually by reducing the inflammation that underlies asthma.
They must be taken every day, even when you are feeling well. They’re not for quick relief. Rescue medications, on the other hand, relax the muscles around the
airways to relieve symptoms quickly. They don’t treat asthma inflammation and, therefore, can’t provide long-term control. If you find yourself needing your rescue medication with increasing frequency, then your asthma is not well controlled.”
When discussing medication, be sure to address potential adverse effects. Patients who use inhaled corticosteroids, for example, should be instructed to rinse the mouth with water and spit after each use to prevent oral candidiasis and throat irritation. Because these drugs are usually prescribed for use twice daily, you might suggest that patients use them immediately before morning and nighttime toothbrushing.
Patients who use a metered dose inhaler might also use a spacer to reduce the amount of medication swallowed and absorbed.
Parents may express concern over the safety of inhaled corticosteroid use in children and the potential for subsequent delayed growth. It may be
helpful to inform them that current asthma guidelines from the National Heart, Lung, and Blood Institute say that the efficacy of inhaled corticosteroids for establishing asthma control outweighs concerns about growth or systemic effects.3 In addition, poorly controlled asthma delays growth in children. Explain that inhaled corticosteroids are titrated to the lowest
Figure 3. Classifying Asthma Severity 3
EIB = exercise-induced bronchospasm; FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity.
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Reducing Allergen Exposure in the Home3, 25
Ways to limit patients’ exposure to environmental irritants.
Dust mites
• Encase mattress and pillows in allergenimpermeable covers.
• Wash all sheets, bedding, and blankets once a week in hot (> 130°F) water.
• Use a dehumidifier or air conditioner to reduce indoor humidity to < 60% (ideally, between 30% and 50%).
• Remove stuffed animals from the bedroom or wash weekly (in hot water or in cooler water with soap and bleach) or place in a dryer or freeze once a week.
• Remove carpet from the bedroom.
Indoor mold
• Fix any leaky faucets or toilets.
possible dose needed to maintain control and that proper inhaler technique reduces systemic absorp tion of the drug.
Inhaler technique should be reassessed at every clinical visit. Poor asthma control in a patient who has been prescribed a control medication should raise questions about whether the patient is using proper technique and adhering to the prescribed regimen.
• Clean moldy surfaces.
• Dehumidify basements.
Animal dander
• Keep furry pets out of the home.
• If you can’t keep them outdoors, don’t allow them in the bedroom.
• Don’t allow pets on any carpet or clothcovered furniture in the home.
Cockroach allergen
• Keep food in closed containers and out of the bedroom. • Keep garbage in closed containers.
• Use traps or a professional exterminator.
patients and clinicians assess control, peak flow measurements are valuable in predicting exacerbations because values tend to drop before symptoms appear.
Peak flow meters are inexpensive and easy to use
(see How to Use a Peak Flow Meter.3) They measure how quickly and forcefully a person can exhale. The maximum expiratory flow achieved is called the peak expiratory flow rate (PEFR). Predicted normal PEFR
Review asthma symptom triggers at each visit.
Repetitive teaching with return demonstrations improves technique, medication delivery, and asthma control. The importance of asthma control and signs of reduced control must be clearly communicated to pa tients. They need to recognize that increased use of a rescue bronchodilator, nighttime awakenings, worsening symptoms, or diminishing peak flow measurements signal a decline in control.
Identifying environmental irritants and reducing exposure to them can dramatically improve asthma control and may allow medication dosages to be re duced. Review asthma symptom triggers at each visit.
Teach patients about the role of such irritants, their effect on the inflammation of asthma, and how to minimize exposure in the home (see Reducing Allergen Exposure in the Home3, 25).
Peak flow monitoring allows patients with possible occupational asthma to monitor symptoms in the workplace as well as at home. In addition to helping
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values are based on a population without asthma and vary with age, sex, and height. What’s “normal” for your patients, however, is their personal best PEFR, which is the highest peak flow measurement they record when measuring PEFR twice daily (morning and night) over a two-week period in which they are well and their asthma is controlled. Comparing predicted normal PEFR values to a patient’s personal best PEFR provides an objective measure of the patient’s airway narrowing, whereas evaluating trends in a patient’s
PEFR values over time may be useful in assessing re sponse to treatment.
THE ASTHMA ACTION PLAN
Individualized written asthma action plans, developed in collaboration with patients, have been shown to enhance patient–provider communication and im prove outcomes.3, 26 Recommended for all patients as part of an overall asthma education program, written action plans are particularly valuable to patients with
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moderate or severe persistent asthma, a history of ex acerbations, or poorly controlled asthma.3 Action plans, which provide instruction for daily management and outline how to recognize and respond to worsening asthma, can be based on either symptoms or peak flow measurements. Patients who find it difficult to assess their asthma symptoms (for example, those with a history of near fatal asthma or prior intubation) may derive the most benefit from an action plan based on peak flow.
Action plans should be simple and easy to use.
Many use a traffic light analogy, describing green, yellow, and red zones for which specific actions are prescribed. In the green (“go”) zone, patients’ PEFR is 80% to 100% of their personal best and they have no symptoms. These patients can continue using their daily medications and taking steps to limit exposure to triggers, as described in their plan. When patients’
PEFR is 50% to 80% of their personal best and they have symptoms, they’ve entered the yellow (“caution”) zone, and practitioners may consider prescribing alternative antiinflammatory medications and, possibly, a higher dose or more frequent use of the rescue medication. Patients whose PEFR drops below
50% of their personal best and whose symptoms fail to improve significantly with prescribed rescue
medications are in the red (“danger–stop”) zone. They should increase medication as indicated in their action plan and call their health care provider immediately. If unable to reach their provider, they should stop what they’re doing and go directly to the nearest ED.
Numerous sample asthma action plans are available online (for example, see http://bit.ly/hM4s0) and in the asthma guidelines.3, 10, 27 Effective plans specify the frequency and dose of all prescribed medications and provide clear instructions about when to call the health care provider. Clinicians should review action plans with their patients at every clinical visit, making updates as necessary.
FOLLOW-UP
When the patient in our opening scenario returns for follow-up in a month, the NP assesses her asthma control using the Asthma Control Test, spirometry, and physical examination. The patient isn’t in acute distress, but end-expiratory wheezing remains evident on auscultation. Again, spirometry demonstrates expiratory airflow obstruction, and the patient’s Asthma Control
Test score is 19, indicating insufficient control.
The patient reports that she’s been using her in haled corticosteroid as prescribed, and she’s able to demonstrate its proper use. She’s also taking the nasal
Figure 4. Stepwise Approach for Managing Asthma3
EIB = exercise-induced bronchospasm; ICS = inhaled corticosteroid; LABA = inhaled long-acting β2-agonist; LTRA =
leukotriene receptor antagonist; SABA = inhaled short-acting β2-agonist.
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INSTRUMENTS FOR ASSESSMENT AND MONITORING OF ASTHMA
uniper et al. 1999b) uestionnaire (Vollmer et al. 1999) (See below.) al. 2004) (See below.) al. 2002)
Figure
© 5. Asthma
ESTIONNAIRE
(ATAQ)
Control
Test
This test helps clinicians
assess work, school, or asthma normalcontrol daily in patients ages 12 and older.
1 point for YES)
A perfect test score is 25.
A score of 20 or higher suggests well-controlled asthma. Scores between
16 and 19 indicate some controlled lack in the
4 weeks? of past control, and scores below 16 suggest very poor control.20 from asthma symptoms?
If yes,
Reprinted with permisn 1 day yousion. tookAsthma of this Control inhaler?Test (1 TM
Health Survey 2003, 2004, by QualityMetric Incorporated – All rights reserved. ating more control problems Asthma Control TestTM is a trademark of QualityMetric mission fromIncorporated.
Merck and Co., Inc.
at night because of your
Co., Inc. All Rights Reserved.
steroid as prescribed and her nasal symptoms have
The NP in this scenario followed current guidelines.
which she allows on her bed. The NP prescribes a step-up in medication and reiterates that a complete separation from the cat would be advisable. She suggests, however, that if complete separation is unacceptable to the patient, she should at least keep the cat out of the bedroom. Based on guidelines, the preferred next step is to prescribe a higher (medium-dose) inhaled corticosteroid or a long-acting β2-adrenergic agonist to use in conjunction with the previously prescribed low-dose inhaled corticosteroid. (Alternatively she could consider adding a leukotriene modifier or theophylline to the initial regimen.) However, the NP chooses to keep the patient’s inhaled corticosteroid at the same low dose and prescribes a long-acting β2-adrenergic agonist to use along with it.
The NP provides additional asthma education, fo cusing on environmental control, the importance of
PEFR monitoring, and proper use of medications. She reviews and updates the asthma action plan, schedules a follow-up appointment in another month, and instructs the patient to call immediately if symptoms worsen. vided thorough patient teaching. She correctly asked the patient to return for reassessment in a month, recognized that the patient’s asthma remained poorly controlled when she returned, stepped up therapy as recommended, and reinforced patient education, which must continue at every clinical visit. t
n figure 3–8 assess only the impairment domain of asthma control and NOTassessed the riskasthma domain. Measure of improved.
She hasn’t been recording her PEFR.
She accurately severity at presenta, hospitalizations, and declines in lung function, are important elements of assessing the level of asthma
The patient acknowledges that she still has a cat, tion, initiated appropriate pharmacotherapy, and pro-
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For more than 27 additional continuing nursing education articles on respiratory topics, go to nursingcenter.com/ce. Susan Corbridge is director of the Acute Care Nurse Practitioner and Clinical Nurse Specialist programs at the University of Illinois at Chicago College of Nursing and clinical assistant professor in the Division of Pulmonary and Critical Care Medicine at the
University of Illinois at Chicago Medical Center. Thomas C.
Corbridge is professor of medicine and a member of the Division of Pulmonary and Critical Care Medicine at Northwestern
University’s Feinberg School of Medicine, Chicago. Contact author: Susan Corbridge, sjsmith@uic.edu. Thomas C. Corbridge is a former member of the speakers’ bureau for GlaxoSmithKline and Boehringer Ingelheim.
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How to Use a Peak Flow Meter3
Staying in the zone.
In acute asthma episodes, peak flow monitoring may be helpful in assessing response to treatment. Long-term monitoring provides useful information in determining the need for medication changes and dose adjustments.
In conjunction with an asthma action plan, both uses help patients stay in the zone of effective control. A patient with well-controlled asthma (one for whom medications may be tapered) will have high peak flow measurements and minimal peak flow variability from day to day and from morning to night. Because peak flow measurements are effort- and technique-dependent, however, it’s helpful for patients to review instructions for peak flow meter use regularly, bring peak flow meters to all clinic visits, and perform return demonstrations in the presence of their health care provider. 1. Stand.
2. Be sure the peak flow meter is at zero.
3. Take as deep a breath as possible.
4. Place the meter in your mouth and wrap your lips around the mouthpiece.
5. Blow out as hard and fast as possible.
6. If you cough, spit, or block the mouthpiece with your tongue, disregard the reading. 7. Repeat the procedure two more times.
8. Record the highest reading.
REFERENCES 1. National Center for Health Statistics, Centers for Disease
Control and Prevention. FastStats. Asthma. 2009. http:// www.cdc.gov/nchs/FASTATS/asthma.htm. 2. Centers for Disease Control and Prevention. Asthma. Data and surveillance. 2009. http://www.cdc.gov/asthma/ asthmadata.htm. 3. National Heart, Lung, and Blood Institute, National Asthma
Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma.
Bethesda, MD; 2007 Aug 28. http://www.nhlbi.nih.gov/ guidelines/asthma/asthgdln.pdf. 4. American Academy of Allergy, Asthma, and Immunology.
Asthma statistics. 2009. http://www.aaaai.org/media/ statistics/asthma-statistics.asp. 5. Moorman JE, et al. National surveillance for asthma—United
States, 1980-2004. MMWR Surveill Summ 2007;56(8):1-54. 6. American Lung Association, Epidemiology and Statistics
Unit. Trends in asthma morbidity and mortality. Washington,
DC; 2009 Jan. http://www.lungusa.org/assets/documents/
ASTHMA-JAN-2009.pdf.
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7. Getahun D, et al. Recent trends in asthma hospitalization and mortality in the United States. J Asthma 2005;42(5):373-8. 8. Asthma and Allergy Foundation of America. Asthma facts and figures. n.d. http://www.aafa.org/display.cfm?id=
8&sub=42.
9. Fahy JV. Eosinophilic and neutrophilic inflammation in asthma: insights from clinical studies. Proc Am Thorac Soc
2009;6(3):256-9.
10. GINA: the Global Initiative for Asthma. Global strategy for asthma management and prevention; 2008 (updated 2009). http://www.ginasthma.com/Guidelineitem.asp??l1=2&l2= 1&intId=1561. 11. Ober C. Perspectives on the past decade of asthma genetics.
J Allergy Clin Immunol 2005;116(2):274-8. 12. Beuther DA. Recent insight into obesity and asthma. Curr
Opin Pulm Med 2010;16(1):64-70. 13. Tarlo SM, et al. Diagnosis and management of work-related asthma: American College of Chest Physicians Consensus
Statement. Chest 2008;134(3 Suppl):1S-41S. 14. Corbridge T, Corbridge S. Severe asthma exacerbation. In:
Fink MP, et al., editors. Textbook of critical care. 5th ed.
Philadelphia: Elsevier Saunders; 2005. p. 587-97. 15. Pellegrino R, et al. Interpretative strategies for lung function tests. Eur Respir J 2005;26(5):948-68. 16. Tilles SA. Differential diagnosis of adult asthma. Med Clin
North Am 2006;90(1):61-76. 17. Reddel HK, et al. An official American Thoracic Society/
European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med 2009;
180(1):59-99.
18. Chapman KR, et al. Suboptimal asthma control: prevalence, detection and consequences in general practice. Eur Respir J
2008;31(2):320-5.
19. FitzGerald JM, et al. Asthma control in Canada remains suboptimal: The Reality of Asthma Control (TRAC) study.
Can Respir J 2006;13(5):253-9. 20. Kosinski M, et al. Asthma control test (ACT). QualityMetric.
2004. http://www.qualitymetric.com/WhatWeDo/
DiseasespecificHealthSurveys/AsthmaControlTestACT/tabid/
190/Default.aspx. 21. U.S. Food and Drug Administration. Drug safety and availability. Drugs to be discontinued. 2010. http://www.fda.gov/
Drugs/DrugSafety/DrugShortages/ucm050794.htm.
22. Nelson HS, et al. The Salmeterol Multicenter Asthma
Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest
2006;129(1):15-26.
23. U.S. Food and Drug Administration. FDA drug safety communication: new safety requirements for long-acting inhaled asthma medications called long-acting beta-agonists
(LABAs). 2010. http://www.fda.gov/Drugs/DrugSafety/
PostmarketDrugSafetyInformationforPatientsandProviders/
ucm200776.htm. 24. U.S. Food and Drug Administration. Safety alerts for human medical products: leukotriene inhibitors: montelukast
(marketed as Singulair), zafirlukast (marketed as Accolate), and zileuton (marketed as Zyflo and Zyflo CR). 2009. http://www.fda.gov/Safety/MedWatch/SafetyInformation/ SafetyAlertsforHumanMedicalProducts/ucm166246.htm. 25. Asthma and Allergy Foundation of America. Tips to control indoor allergens. n.d. http://www.aafa.org/display.cfm?id=
9&sub=18&cont=533.
26. Kaya Z, et al. Self-management plans for asthma control and predictors of patient compliance. J Asthma 2009;
46(3):270-5.
27. Camargo CA, Jr., et al. Managing asthma exacerbations in the emergency department: summary of the National
Asthma Education and Prevention Program Expert Panel
Report 3 guidelines for the management of asthma exacerbations. Proc Am Thorac Soc 2009;6(4):357-66.
ajnonline.com
hours
Continuing Education
By Susan Corbridge, PhD, APN, ACNP, AE-C, and
Thomas C. Corbridge, MD, FCCP
ASTHMA in Adolescents and Adults
Guideline-based diagnosis and management.
A
24-year-old woman presents to an
NP, reporting a two-year history of episodic cough, chest tightness, and shortness of breath. (This patient is a composite of several cases we’ve encountered in our practice.) Over the past three months, episodes have become slightly more frequent, occurring on an average of once a month, with weekly nighttime episodes that awaken her from sleep. Between episodes she feels completely well. Symptoms are precipitated by stress and exposure to cigarette smoke and are slightly worse in the spring and fall.
The patient had …show more content…
childhood allergies but has no other significant medical or surgical history. She’s never smoked and uses no medications. She lives in an apartment with wall-to-wall carpeting and has a cat. She works in a smoke-free office. She says she experiences slight chest tightness during our examination but displays no acute distress. Auscultation reveals infrequent end-expiratory wheezes. The phy sical examination is otherwise normal, except for mild swelling of the nasal mucosa.
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With office spirometry, the patient demonstrates mild expiratory airflow obstruction. Repeat spirometry is normal 10 minutes after albuterol treatment.
Based on the patient’s levels of impairment and risk, the NP diagnoses her with mild persistent asthma and allergic rhinitis. She prescribes a low-dose inhaled corticosteroid and a short-acting rescue bronchodilator to address the asthma and a nasal corticosteroid to treat the allergic rhinitis. She educates the patient about basic asthma pathophysiology, proper medication use, and environmental control (suggesting, among other things, that she separate from her cat); provides written guidelines and a peak flow meter for monitoring asthma control; and schedules her for a follow-up visit in one month.
In this scenario, did the NP take the appropriate ajnonline.com Photo © Medical-on-Line / Alamy
OVERVIEW: More than 16 million U.S. adults have asthma, a condition that prompts 2 million ED visits and nearly half a million hospital admissions annually.
Management of this potentially deadly, chronic inflammatory disease depends on early diagnosis, accurate classification, appropriate treatment, and targeted patient education.
This article outlines current guideline recommendations for asthma and reviews what clinicians need to teach patients about its pathophysiology, pharmacotherapy, self monitoring, and environmental control. The authors discuss the classic clinical presentation of the disease, describe how to assess severity and control, and explain how such assessments can guide management. course of action? Were the medications she prescribed sufficient? Did she address the issues most important to asthma control? This article seeks to answer these questions. ASTHMA’S IMPACT
In the United States, more than 16 million adults and about 7 million children have asthma.1 Annually, it’s responsible for roughly 11 million outpatient visits,
2 million ED visits, nearly 500,000 hospital admissions, and close to 4,000 deaths.1-3 It’s a common reason for school absenteeism among children, and causes adults to lose more than 10 million workdays each year.1, 4 Although asthma is more common in boys than girls, it’s more common among women than men.5 Prevalence, hospitalization, and mortality rates have stabilized over the past decade or so but had been on the rise in both sexes and across all age and racial groups from 1977 through 1996.6, 7 …show more content…
Among adult patients, hospitalization and mortality rates are generally highest for blacks and women.6-8
BEHIND THE OBSTRUCTION
The chronic inflammation of asthma involves the ac tion of various types of cells, most notably eosinophils and Th2 lymphocytes.3, 9 Airway wall inflammation is associated with hypertrophy and hyperplasia of smooth muscle tissue and mucus plugging of the small and medium-sized airways.3 The bronchial epithelium is commonly disrupted and there is a thickening of the basement membrane (see Figure 1).9 Airway smooth muscle increases in mass, and airways become hyperreactive to a number of specific and nonspecific triggers. Variable combinations of inflammation, intraluminal mucus, and bronchospasm obstruct expiratory airflow. Although such obstruction is usually reversible either spontaneously or with pharmacotherapy, the precipitating structural changes can result in air way remodeling and fixed airflow obstruction.3
There is no clear single cause of asthma. Although atopy is an important identifiable risk factor, findings from epidemiologic studies differ as to whether early exposure to some allergens increases or reduces the risk of subsequent asthma.10 The effects are particularly difficult to discern when early exposure occurs in association with frequent lower respiratory infection.10 Asthma is also recognized as having an inheritable component, though the genetics of the disease are poorly understood.3, 11 More recently, obesity has been recognized as a risk factor,3, 12 although the precise relationship isn’t yet understood.
CLINICAL PRESENTATION
Asthma is characterized by breathlessness, chest tightness, wheezing, and coughing. (Nasal congestion and postnasal drip are also common.) Symptoms vary from patient to patient and can vary in the same
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atient over time. Symptoms may occur spontanep ously, or be precipitated or exacerbated by various triggers (see Selected Asthma Triggers3). Asthma is commonly worse in the early morning hours or at night,3 corresponding to circadian variations in bronchomotor tone and bronchial reactivity.
Occupational asthma is triggered by various agents in the workplace and may occur weeks to years after exposure and sensitization. Separation from the in citing agent is essential in the management of occupational asthma but doesn’t always result in clinical improvement.13 ESTABLISHING THE DIAGNOSIS
A diagnosis of asthma is based on characteristic signs and symptoms in the presence of airflow obstruction or hyperresponsiveness.3 The patient history should focus on
• symptoms.
• home and work environments.
• triggers.
• medication use.
• family history.
• social history.
• the impact of symptoms on daily life.
The hallmarks of airflow obstruction are expiratory wheezes and expiratory phase prolongation, al though wheezes may be absent or diminished between obstructive episodes and when airflow rates are critically low.14 Indeed the quiet chest with minimal air
Selected Asthma Triggers 3
• Allergen exposure (for example, pollen, mold, air pollutants, dust mites, cockroaches, pet dander, and saliva)
• Medications (for example, aspirin, nonsteroidal antiinflammatory drugs, and β-blockers) • Illicit drugs (for example, heroin and cocaine)
• Upper respiratory tract infections
• Gastroesophageal reflux disease
• Strong odors or fumes
• Rhinosinusitis
• Smoke (cigarette and wood)
• Hormone levels (such as variations in asthma related to menstruation)
• Exercise
• Foods or drinks containing histamine or sulfites (such as beer, wine, shrimp, dried fruit, processed potatoes)
• Cold air
• Laughing
• Stress
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entry is an ominous sign of an impending respiratory arrest.14 Other physical findings suggestive of asthma include nasal polyps, eczema, and atopic dermatitis.3
It’s important to point out, however, that the physical examination of a patient with asthma may be entirely normal. Spirometry is a simple, office-based test that can reveal airflow obstruction, as well as its severity and responsiveness to bronchodilator treatment (see Figure 2). The key spirometric measures are the forced vital capacity (FVC) (or total volume exhaled) and the forced expiratory volume within the first second of exhaling from total lung capacity (FEV1). An FEV1/
FVC ratio below 70% suggests airflow obstruction.
Reversible airflow obstruction is defined as an in crease of at least 200 mL and 12% above baseline in
FEV1, FVC, or both, after administration of a shortacting bronchodilator, such as albuterol (Proventil and others).3, 15
A normal spirometry doesn’t exclude asthma, par ticularly when symptoms are infrequent or cough is the only symptom. In such situations, a provocative challenge with methacholine (Provocholine) or
histamine (substances that cause airways to spasm and narrow when asthma is present) or exercise may trigger the obstructive process, demonstrating hyper reactivity, a central feature of asthma. Conversely, a negative test may help rule out the disease. Variable findings with a handheld peak flow meter also suggest asthma, particularly if flow rates are lower when symp toms are present and higher after albuterol treatment.
Although not central to the diagnosis of asthma, a chest X-ray may help exclude alternative diagnoses
(see Differential Diagnosis of Asthma 3, 16). Blood work may reveal eosinophilia and elevated immunoglobulin E levels.
ASSESSING DISEASE SEVERITY AND CONTROL
Assessing and monitoring asthma severity and control is essential. Severity is measured in part by how difficult it is to control the disease with treatment.3, 17
Current evidence-based guidelines, which outline preferred and alternative therapies in a stepwise manner, enable clinicians to select appropriate initial therapy for patients on the basis of disease severity (see Figures
33 and 43).3
Normal Bronchiole
Asthmatic Bronchiole
Mucus plug
Bronchoconstriction
Cross section
Cross section
Disrupted
epithelial layer Basement membrane thickening
Airway wall inflammation Intraluminal mucus
Figure 1. Normal and Asthmatic Bronchiole
The pathophysiologic hallmarks of asthma include airway wall inflammation, intraluminal mucus, and smooth muscle-mediated bronchospasm. Frequently the bronchial epithelium is disrupted and there is deposition of collagen beneath the basement membrane (referred to as basement membrane thickening).
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Severity categories. After evaluating impairment
(through symptom assessment and spirometry) and exacerbation risk, asthma can be classified into one of four severity categories: intermittent, mild per sistent, moderate persistent, or severe persistent.3
Patients with intermittent asthma have normal pulmonary function tests between infrequent asthma episodes. They require only as-needed treatment with a short-acting bronchodilator but no daily asthma medication. Patients whose symptoms occur more than twice weekly or awaken them more than twice monthly and those whose routine pulmonary function tests demonstrate obstruction have persistent asthma and require a daily antiinflammatory control medication as well as a short-acting bronchodilator for rescue. Patients with severe persistent disease require higher doses of control agents than do those with mild or moderate persistent disease and, possibly, combination treatment with different classes of asthma medications.
Asthma control is the degree to which signs and symptoms, risk of future episodes, and loss of lung function are reduced through treatment and environmental control. Because both patients and health care providers tend to underrecognize and underreport asthma symptoms,18, 19 control should be assessed at each visit using a validated tool such as the Asthma
Differential Diagnosis of Asthma3, 16
•
•
•
•
•
•
•
•
•
•
•
•
•
Vocal cord dysfunction
Chronic obstructive pulmonary disease
Alpha-1 antitrypsin deficiency
Allergic bronchopulmonary aspergillosis
Laryngotracheomalacia and tracheal stenosis
Foreign body aspiration
Viral or obliterative bronchiolitis
Endobronchial obstruction (benign or malignant) Cystic fibrosis
Bronchiectasis
Lymphangioleiomyomatosis
Churg-Strauss syndrome
Eosinophilic pneumonia
antiinflammatory medications (used either alone or in combination with other control agents) are the inhaled corticosteroids, which improve asthma symptoms and lung function, decrease the need for short-acting bronchodilators, and reduce the risk of hospitalization and asthma-related death.3
Clinicians should prescribe the least amount of
medication required to achieve control as assessed by a validated tool and spirometry.
Therapy Assessment Questionnaire, the Asthma Control Questionnaire, or the Asthma Control Test (see
Figure 520).3 These questionnaires are easily accessed online and can be administered quickly. Periodic lung function measurement though spirometry and pa tient monitoring of peak flow and symptoms can further help clinicians determine control and adjust medication accordingly.
PHARMACOTHERAPY
If patient education and adherence are adequate, most cases of asthma can be managed with a limited number of medications and environmental control measures. Medications are divided into short-acting drugs for rescue and long-term drugs for control (see
Table 13, 21).
All patients should receive a short-acting (quick
relief) bronchodilator to treat bronchospastic episodes. Those with persistent asthma require an additional long-term control agent to treat underlying airway wall inflammation. The most effective
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The daily use of a low-dose inhaled corticosteroid is preferred treatment for patients with mild persistent asthma.3 Moderate persistent asthma is generally treated with a medium-dose inhaled corticosteroid or a low-dose inhaled corticosteroid combined with a long-acting β2-adrenergic agonist.3 Alternatively a leukotriene receptor antagonist (also called a leukotriene modifier) or theophylline (Uniphyl and others) can be prescribed in addition to an inhaled corticosteroid to help the patient achieve adequate control. Patients with severe persistent asthma require high doses of an inhaled corticosteroid combined with a long-acting β2-adrenergic agonist, often in combination with other control medications.3 Those with refractory symptoms may require daily oral corticosteroids to achieve control.
Clinicians should prescribe the least amount of medication required to achieve control as assessed by a validated tool and spirometry, but tapering of medications shouldn’t be attempted until control has been achieved for at least three months.3 Patients
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Simple Spirometry
Volume Time Curve
7
(FEV1/FVC = 4.1/5.5 = 0.75)
6
Liters
5
FVC = 5.5 L
FEV1 = 4.1 L
4
FVC = 5.0 L
3
FEV1 = 2.3 L
2
(FEV1/FVC = 2.3/5.0 = 0.46)
1
0
0
1
2
3
4
5
6
Seconds
Figure 2. Simple Spirometry
Figure
1 spirometry the patient exhales as forcefully and completely as possible starting at full lung inflation
During
simple
(bottom left of the above curve). Exhaled volume (in liters) is plotted on the Y axis against exhalation time (in seconds) on the X axis to generate the volume-time curve. The total volume exhaled during this maneuver is the forced vital capacity (FVC), and the volume exhaled during the first second of the FVC maneuver is the forced expiratory volume in one second (FEV1). Under normal conditions (dashed line), the FVC is completed in three to four seconds (as indicated by a plateauing of the volume-time curve), and 70% to 80% of the FVC is exhaled in the first second (the
FEV1/FVC ratio is normally 0.7 to 0.8). In this case, the patient (solid line) has asthma, with an FEV1 of 2.3 L, an FVC of
5 L, and an FEV1/FVC of 0.46, meaning that only 46% of the FVC is exhaled in the first second. Because patients with asthma have narrowed airways, less volume can be exhaled, and it takes longer for them to fully empty their lungs.
An FEV1/FVC ratio of less than 0.7 suggests obstruction.
should be monitored closely after reducing medications to ensure continued control.
When choosing a pharmacologic regimen, consider adverse effects. Because of their sympathomimetic properties, β2-adrenergic agonists and theophylline should be used with caution in patients with cardiovascular disorders, particularly those with tachycardia and tachyarrhythmias.3 Long-acting β2-agonists may increase the risk of severe symptom exacerbation, hospitalization, and asthma-related death.22 For these reasons, the Food and Drug Administration recently issued a warning that long-acting β2-agonists should be used only
• for the shortest period of time required to achieve symptom control.
• in patients whose asthma symptoms are inadequately managed by a control medication.
• in combination products containing an inhaled corticosteroid, if the patient is a child or adolescent
(to ensure adherence to the inhaled corticoste roid).23 Long-acting β2-adrenergic agonists provide neither rescue therapy nor adequate treatment for airway wall inflammation. Their use is contraindicated except in conjunction with an asthma control medication, such as an inhaled corticosteroid.23
The inhaled corticosteroids are associated with oral candidiasis, the potential for suppressed or delayed
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growth, and reduced bone mineral density. Long-term use of inhaled corticosteroids has also been associated with cataracts and glaucoma. Recent reports suggest a possible link between leukotriene receptor antagonists and neuropsychiatric events, including depression and suicidal ideation.24
OTHER TREATMENT CONSIDERATIONS
Evaluating and treating comorbid conditions such as gastroesophageal reflux disease, rhinosinusitis, and nasal polyposis improve asthma symptoms, as does weight loss in obese or overweight patients. Obesity, in fact, increases a patient’s risk of obstructive sleep apnea, which may impede asthma management. Pa tients with poorly controlled asthma should also be evaluated for stress and depression.
Address preventive health care measures such as yearly influenza vaccination, optimal weight mainte nance, exercise, good handwashing techniques, avoid ing contact with those who are sick, and—for patients taking corticosteroids—bone mineral density measurement and calcium and vitamin D supplementation.
Other bone protective or restorative therapies may be considered in patients with osteopenia or osteoporosis.
PATIENT EDUCATION
Asthma education is an ongoing process that’s critical to achieving control, improving outcomes, and ajnonline.com minimizing medication use. As such, a needs assessment to identify patients’ key knowledge deficits, followed by targeted instruction, should be integrated into every patient visit. Nationally certified asthma educators are now recognized as the ideal practitioners to teach patients and their families about asthma. (Information on becoming a certified asthma educator can be found at www.naecb.org.)
Key components of an asthma education program should include essential facts about asthma patho physiology, the role of asthma medications, inhaler technique, the importance of asthma control, signs and symptoms of reduced control, measures for re ducing exposure to environmental irritants, and selfmanagement skills such as peak flow monitoring.3
Basic asthma pathophysiology, with instruction
Table 1. Medications for Short- and Long-Term Control of Asthma3, 21
Type of Medication
Comments
Examples
Long-term control medications (taken on a daily basis to treat and prevent symptoms)
Inhaled corticosteroids
Most effective
Fluticasone (Flovent)
Budesonide (Pulmicort)
Triamcinolone acetonide
(Azmacort)
Flunisolide (Aerobid)
Beclomethasone (QVAR)
Mometasone (Asmanex)
Long-acting β2-adrenergic agonists Always used with an inhaled corticosteroid Salmeterol (Serevent)
Formoterol (Foradil)
Combination treatment with an inhaled cortico steroid and a long-acting β2-adrenergic agonist
Fluticasone–salmeterol (Advair)
Budesonide–formoterol (Symbicort)
Leukotriene receptor antagonists Montelukast (Singulair)
Zafirlukast (Accolate)
Zileuton (Zyflo)
Mast cell stabilizers
May soon be unavailable
Cromolyn (Intal and others)
Nedocromil (Tilade)
Methylxanthines
Theophylline (Uniphyl and others)
Immunomodulators
Omalizumab (Xolair)
Systemic corticosteroids
(oral)
Methylprednisolone
Prednisolone
Prednisone
Short-acting rescue medications (taken on an as-needed basis to treat symptoms or prevent exercise-induced symptoms)
Short-acting β2-adrenergic agonists Albuterol (Proventil and others)
Levalbuterol (Xopenex)
Pirbuterol (Maxair)
Anticholinergics
Usually reserved for asthma exacerbations, not for routine outpatient use
Ipratropium (Atrovent)
Systemic corticosteroids
(oral, intravenous, subcutaneous, intramuscular)
Although oral systemic corticosteroids are not shortacting drugs, they are used adjunctively with short-acting β2-adrenergic agonists to hasten recovery
Methylprednisolone
Prednisolone
Prednisone
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tailored to the patient’s and the family’s learning style, motivation, cognitive level, cultural beliefs, and asthma management practice, reinforces the need for a daily, long-term antiinflammatory medication.
Teaching patients about how asthma—and asthma medications—affects their airways helps them rec ognize the importance of their medications, environmental control, and self monitoring. The pathophysiology can be explained as simply as follows: “Asthma is a chronic lung disease in which the airways become inflamed, or swollen, narrow, and sensitive to certain substances, which we call triggers. Exposure to these triggers tightens muscles surrounding the airways, causing further narrowing. Swollen, constricted airways, which are often filled with mucus, make breathing increasingly difficult, causing the symptoms of wheezing, chest tightness, shortness of breath, and coughing.” Medication education should focus on differences between control and rescue medications. Patients can be offered the following simple explanation: “Control medications are used to prevent symptoms, usually by reducing the inflammation that underlies asthma.
They must be taken every day, even when you are feeling well. They’re not for quick relief. Rescue medications, on the other hand, relax the muscles around the
airways to relieve symptoms quickly. They don’t treat asthma inflammation and, therefore, can’t provide long-term control. If you find yourself needing your rescue medication with increasing frequency, then your asthma is not well controlled.”
When discussing medication, be sure to address potential adverse effects. Patients who use inhaled corticosteroids, for example, should be instructed to rinse the mouth with water and spit after each use to prevent oral candidiasis and throat irritation. Because these drugs are usually prescribed for use twice daily, you might suggest that patients use them immediately before morning and nighttime toothbrushing.
Patients who use a metered dose inhaler might also use a spacer to reduce the amount of medication swallowed and absorbed.
Parents may express concern over the safety of inhaled corticosteroid use in children and the potential for subsequent delayed growth. It may be
helpful to inform them that current asthma guidelines from the National Heart, Lung, and Blood Institute say that the efficacy of inhaled corticosteroids for establishing asthma control outweighs concerns about growth or systemic effects.3 In addition, poorly controlled asthma delays growth in children. Explain that inhaled corticosteroids are titrated to the lowest
Figure 3. Classifying Asthma Severity 3
EIB = exercise-induced bronchospasm; FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity.
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Reducing Allergen Exposure in the Home3, 25
Ways to limit patients’ exposure to environmental irritants.
Dust mites
• Encase mattress and pillows in allergenimpermeable covers.
• Wash all sheets, bedding, and blankets once a week in hot (> 130°F) water.
• Use a dehumidifier or air conditioner to reduce indoor humidity to < 60% (ideally, between 30% and 50%).
• Remove stuffed animals from the bedroom or wash weekly (in hot water or in cooler water with soap and bleach) or place in a dryer or freeze once a week.
• Remove carpet from the bedroom.
Indoor mold
• Fix any leaky faucets or toilets.
possible dose needed to maintain control and that proper inhaler technique reduces systemic absorp tion of the drug.
Inhaler technique should be reassessed at every clinical visit. Poor asthma control in a patient who has been prescribed a control medication should raise questions about whether the patient is using proper technique and adhering to the prescribed regimen.
• Clean moldy surfaces.
• Dehumidify basements.
Animal dander
• Keep furry pets out of the home.
• If you can’t keep them outdoors, don’t allow them in the bedroom.
• Don’t allow pets on any carpet or clothcovered furniture in the home.
Cockroach allergen
• Keep food in closed containers and out of the bedroom. • Keep garbage in closed containers.
• Use traps or a professional exterminator.
patients and clinicians assess control, peak flow measurements are valuable in predicting exacerbations because values tend to drop before symptoms appear.
Peak flow meters are inexpensive and easy to use
(see How to Use a Peak Flow Meter.3) They measure how quickly and forcefully a person can exhale. The maximum expiratory flow achieved is called the peak expiratory flow rate (PEFR). Predicted normal PEFR
Review asthma symptom triggers at each visit.
Repetitive teaching with return demonstrations improves technique, medication delivery, and asthma control. The importance of asthma control and signs of reduced control must be clearly communicated to pa tients. They need to recognize that increased use of a rescue bronchodilator, nighttime awakenings, worsening symptoms, or diminishing peak flow measurements signal a decline in control.
Identifying environmental irritants and reducing exposure to them can dramatically improve asthma control and may allow medication dosages to be re duced. Review asthma symptom triggers at each visit.
Teach patients about the role of such irritants, their effect on the inflammation of asthma, and how to minimize exposure in the home (see Reducing Allergen Exposure in the Home3, 25).
Peak flow monitoring allows patients with possible occupational asthma to monitor symptoms in the workplace as well as at home. In addition to helping
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values are based on a population without asthma and vary with age, sex, and height. What’s “normal” for your patients, however, is their personal best PEFR, which is the highest peak flow measurement they record when measuring PEFR twice daily (morning and night) over a two-week period in which they are well and their asthma is controlled. Comparing predicted normal PEFR values to a patient’s personal best PEFR provides an objective measure of the patient’s airway narrowing, whereas evaluating trends in a patient’s
PEFR values over time may be useful in assessing re sponse to treatment.
THE ASTHMA ACTION PLAN
Individualized written asthma action plans, developed in collaboration with patients, have been shown to enhance patient–provider communication and im prove outcomes.3, 26 Recommended for all patients as part of an overall asthma education program, written action plans are particularly valuable to patients with
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moderate or severe persistent asthma, a history of ex acerbations, or poorly controlled asthma.3 Action plans, which provide instruction for daily management and outline how to recognize and respond to worsening asthma, can be based on either symptoms or peak flow measurements. Patients who find it difficult to assess their asthma symptoms (for example, those with a history of near fatal asthma or prior intubation) may derive the most benefit from an action plan based on peak flow.
Action plans should be simple and easy to use.
Many use a traffic light analogy, describing green, yellow, and red zones for which specific actions are prescribed. In the green (“go”) zone, patients’ PEFR is 80% to 100% of their personal best and they have no symptoms. These patients can continue using their daily medications and taking steps to limit exposure to triggers, as described in their plan. When patients’
PEFR is 50% to 80% of their personal best and they have symptoms, they’ve entered the yellow (“caution”) zone, and practitioners may consider prescribing alternative antiinflammatory medications and, possibly, a higher dose or more frequent use of the rescue medication. Patients whose PEFR drops below
50% of their personal best and whose symptoms fail to improve significantly with prescribed rescue
medications are in the red (“danger–stop”) zone. They should increase medication as indicated in their action plan and call their health care provider immediately. If unable to reach their provider, they should stop what they’re doing and go directly to the nearest ED.
Numerous sample asthma action plans are available online (for example, see http://bit.ly/hM4s0) and in the asthma guidelines.3, 10, 27 Effective plans specify the frequency and dose of all prescribed medications and provide clear instructions about when to call the health care provider. Clinicians should review action plans with their patients at every clinical visit, making updates as necessary.
FOLLOW-UP
When the patient in our opening scenario returns for follow-up in a month, the NP assesses her asthma control using the Asthma Control Test, spirometry, and physical examination. The patient isn’t in acute distress, but end-expiratory wheezing remains evident on auscultation. Again, spirometry demonstrates expiratory airflow obstruction, and the patient’s Asthma Control
Test score is 19, indicating insufficient control.
The patient reports that she’s been using her in haled corticosteroid as prescribed, and she’s able to demonstrate its proper use. She’s also taking the nasal
Figure 4. Stepwise Approach for Managing Asthma3
EIB = exercise-induced bronchospasm; ICS = inhaled corticosteroid; LABA = inhaled long-acting β2-agonist; LTRA =
leukotriene receptor antagonist; SABA = inhaled short-acting β2-agonist.
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INSTRUMENTS FOR ASSESSMENT AND MONITORING OF ASTHMA
uniper et al. 1999b) uestionnaire (Vollmer et al. 1999) (See below.) al. 2004) (See below.) al. 2002)
Figure
© 5. Asthma
ESTIONNAIRE
(ATAQ)
Control
Test
This test helps clinicians
assess work, school, or asthma normalcontrol daily in patients ages 12 and older.
1 point for YES)
A perfect test score is 25.
A score of 20 or higher suggests well-controlled asthma. Scores between
16 and 19 indicate some controlled lack in the
4 weeks? of past control, and scores below 16 suggest very poor control.20 from asthma symptoms?
If yes,
Reprinted with permisn 1 day yousion. tookAsthma of this Control inhaler?Test (1 TM
Health Survey 2003, 2004, by QualityMetric Incorporated – All rights reserved. ating more control problems Asthma Control TestTM is a trademark of QualityMetric mission fromIncorporated.
Merck and Co., Inc.
at night because of your
Co., Inc. All Rights Reserved.
steroid as prescribed and her nasal symptoms have
The NP in this scenario followed current guidelines.
which she allows on her bed. The NP prescribes a step-up in medication and reiterates that a complete separation from the cat would be advisable. She suggests, however, that if complete separation is unacceptable to the patient, she should at least keep the cat out of the bedroom. Based on guidelines, the preferred next step is to prescribe a higher (medium-dose) inhaled corticosteroid or a long-acting β2-adrenergic agonist to use in conjunction with the previously prescribed low-dose inhaled corticosteroid. (Alternatively she could consider adding a leukotriene modifier or theophylline to the initial regimen.) However, the NP chooses to keep the patient’s inhaled corticosteroid at the same low dose and prescribes a long-acting β2-adrenergic agonist to use along with it.
The NP provides additional asthma education, fo cusing on environmental control, the importance of
PEFR monitoring, and proper use of medications. She reviews and updates the asthma action plan, schedules a follow-up appointment in another month, and instructs the patient to call immediately if symptoms worsen. vided thorough patient teaching. She correctly asked the patient to return for reassessment in a month, recognized that the patient’s asthma remained poorly controlled when she returned, stepped up therapy as recommended, and reinforced patient education, which must continue at every clinical visit. t
n figure 3–8 assess only the impairment domain of asthma control and NOTassessed the riskasthma domain. Measure of improved.
She hasn’t been recording her PEFR.
She accurately severity at presenta, hospitalizations, and declines in lung function, are important elements of assessing the level of asthma
The patient acknowledges that she still has a cat, tion, initiated appropriate pharmacotherapy, and pro-
ajn@wolterskluwer.com
For more than 27 additional continuing nursing education articles on respiratory topics, go to nursingcenter.com/ce. Susan Corbridge is director of the Acute Care Nurse Practitioner and Clinical Nurse Specialist programs at the University of Illinois at Chicago College of Nursing and clinical assistant professor in the Division of Pulmonary and Critical Care Medicine at the
University of Illinois at Chicago Medical Center. Thomas C.
Corbridge is professor of medicine and a member of the Division of Pulmonary and Critical Care Medicine at Northwestern
University’s Feinberg School of Medicine, Chicago. Contact author: Susan Corbridge, sjsmith@uic.edu. Thomas C. Corbridge is a former member of the speakers’ bureau for GlaxoSmithKline and Boehringer Ingelheim.
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37
How to Use a Peak Flow Meter3
Staying in the zone.
In acute asthma episodes, peak flow monitoring may be helpful in assessing response to treatment. Long-term monitoring provides useful information in determining the need for medication changes and dose adjustments.
In conjunction with an asthma action plan, both uses help patients stay in the zone of effective control. A patient with well-controlled asthma (one for whom medications may be tapered) will have high peak flow measurements and minimal peak flow variability from day to day and from morning to night. Because peak flow measurements are effort- and technique-dependent, however, it’s helpful for patients to review instructions for peak flow meter use regularly, bring peak flow meters to all clinic visits, and perform return demonstrations in the presence of their health care provider. 1. Stand.
2. Be sure the peak flow meter is at zero.
3. Take as deep a breath as possible.
4. Place the meter in your mouth and wrap your lips around the mouthpiece.
5. Blow out as hard and fast as possible.
6. If you cough, spit, or block the mouthpiece with your tongue, disregard the reading. 7. Repeat the procedure two more times.
8. Record the highest reading.
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Control and Prevention. FastStats. Asthma. 2009. http:// www.cdc.gov/nchs/FASTATS/asthma.htm. 2. Centers for Disease Control and Prevention. Asthma. Data and surveillance. 2009. http://www.cdc.gov/asthma/ asthmadata.htm. 3. National Heart, Lung, and Blood Institute, National Asthma
Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma.
Bethesda, MD; 2007 Aug 28. http://www.nhlbi.nih.gov/ guidelines/asthma/asthgdln.pdf. 4. American Academy of Allergy, Asthma, and Immunology.
Asthma statistics. 2009. http://www.aaaai.org/media/ statistics/asthma-statistics.asp. 5. Moorman JE, et al. National surveillance for asthma—United
States, 1980-2004. MMWR Surveill Summ 2007;56(8):1-54. 6. American Lung Association, Epidemiology and Statistics
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DC; 2009 Jan. http://www.lungusa.org/assets/documents/
ASTHMA-JAN-2009.pdf.
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7. Getahun D, et al. Recent trends in asthma hospitalization and mortality in the United States. J Asthma 2005;42(5):373-8. 8. Asthma and Allergy Foundation of America. Asthma facts and figures. n.d. http://www.aafa.org/display.cfm?id=
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Opin Pulm Med 2010;16(1):64-70. 13. Tarlo SM, et al. Diagnosis and management of work-related asthma: American College of Chest Physicians Consensus
Statement. Chest 2008;134(3 Suppl):1S-41S. 14. Corbridge T, Corbridge S. Severe asthma exacerbation. In:
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19. FitzGerald JM, et al. Asthma control in Canada remains suboptimal: The Reality of Asthma Control (TRAC) study.
Can Respir J 2006;13(5):253-9. 20. Kosinski M, et al. Asthma control test (ACT). QualityMetric.
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190/Default.aspx. 21. U.S. Food and Drug Administration. Drug safety and availability. Drugs to be discontinued. 2010. http://www.fda.gov/
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Research Trial: a comparison of usual pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol. Chest
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23. U.S. Food and Drug Administration. FDA drug safety communication: new safety requirements for long-acting inhaled asthma medications called long-acting beta-agonists
(LABAs). 2010. http://www.fda.gov/Drugs/DrugSafety/
PostmarketDrugSafetyInformationforPatientsandProviders/
ucm200776.htm. 24. U.S. Food and Drug Administration. Safety alerts for human medical products: leukotriene inhibitors: montelukast
(marketed as Singulair), zafirlukast (marketed as Accolate), and zileuton (marketed as Zyflo and Zyflo CR). 2009. http://www.fda.gov/Safety/MedWatch/SafetyInformation/ SafetyAlertsforHumanMedicalProducts/ucm166246.htm. 25. Asthma and Allergy Foundation of America. Tips to control indoor allergens. n.d. http://www.aafa.org/display.cfm?id=
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46(3):270-5.
27. Camargo CA, Jr., et al. Managing asthma exacerbations in the emergency department: summary of the National
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