As respiratory therapists, we regularly deal with asthma in our day-to-day practice. I am sure many of you remembers the lessons on the CBABE diseases. These are a corner stone in every respiratory education program. As much as I learned in school, I have learned even more post-graduation. Asthma care and management goes beyond the treatment of the episodic wheezing, coughing, breathlessness, and chest tightness that occurs in acute exacerbation. It includes understanding the patients cultural beliefs, economic situation, and overall goals for the patients quality of life. Asthma is the No. 1 cause of childhood hospitalization and school absenteeism. This results in more than 2 million emergency rooms visits for adults and children.
For those caring for these patients it is important to be able properly educate the patient and family. From day one of diagnosis and every point of provider contact from then on, should include reinforcement on proper self-management. We need to make sure that patients understand their illness and how to properly use their medications and adjunct equipment such as spacers.
The diagnosis of asthma is obtained by using four major components which are the medical history, physical exam, and the objective measurements, and the response to treatment. When patients have episodic airflow obstruction that is at least partially reversible the idea of possible asthma should come to mind. Proper diagnosis is the first step to achieving asthma control.
But we do have to be aware that not all that wheezes is asthma so other alternatives should be excluded such as bronchiolitis, congenital heart disease, vocal cord dysfunction, and other differential diagnosis. Remember, wheezing is a symptom, not a diagnosis. One of the best resources for understanding asthma was published by the National Heart, Lung, and Blood Institute Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. The guidelines were last updated in 2007 and currently are being reviewed for addendums.
When speaking to patients and families to obtain a history it is important build a working relationship with the family. This will be your guide identifying risks factors that may lead to the diagnosis of asthma. Care givers should ask opened questions and avoid questions that have yes or no answers. Open ended questions allow the family to give you a better description of what has been happening with their child or themselves. Below are examples of open ended questions that can be used with possible asthma patients.
- What’s your family history of asthma?
- When does your child wheeze?
- Does your child suffer from any nighttime coughing?
- How is your child’s wheezing during the changing seasons?
Understanding the patient’s medical history is important. Recurrent cough, wheeze, shortness of breath, and tachypnea are common symptoms we look for in identifying asthma. Older children and adults will at times describe chest tightness or chest pain with exercise. There are also genetic risk factors for asthma which include atpoy, family history, and having another allergic condition. Also there are environmental risk factors, which can be biological, chemical, or occupational. Patients may be able to identify triggers that cause them to have asthma like symptoms such as stress, cats, cold air, and perfumes among others. With effective questioning you and your patient may be able to attempt to identify some of the possible triggers.
When patients come into the emergency department they normally have had an exacerbation which has landed them there. The normal physical exam in this setting is tachypnea, wheezing, dyspnea, prolonged expiratory phase, cough, and possibly retractions. You should also look for eczema, nasal polyps, or frequent rhinorrhea. Although we do not normally diagnosis children under the age of five with asthma there is a tool called the Modified Asthma Predictive Index (MAPI) that is used to predict development or persistent asthma in three years and younger with more than three episodes of wheezing during the prior year. Please see figure below.
Positive MAPI Requires:
• Documented Episodes of recurrent wheezing < 3 years of age
• At Least 1 Major Criteria OR 2 Minor Criteria
A positive MAPI is 77% accurate in predicting development of asthma in this subset of children while a negative MAPI at three years of age provides a less than three percent chance of developing active asthma from ages 6-13 years.
Additionally, for children who can cooperate and adults we can use objective measurements to help us diagnosis asthma. Spirometry is helpful in assessing patient’s airflow obstruction by measuring FEV1/FVC. Pre- and post- bronchodilator and exercise studies can be done to assess impairment and reversibility. An increase of >12% in FEV1 post- bronchodilator trial on spirometry establishes patient’s reversibility. Peak flow measurements can be helpful in managing a patient’s asthma control but, does not assist in its diagnosis.
As medical professionals the goals of asthma disease management include:
- Control of symptoms
- Reduce/eliminate exacerbations
- Improve lung function and quality of life
- Decrease the number of emergency room visits
- Decrease use of quick relief medication
- Minimal adverse effects associated with the disease
To achieve these goals we must characterize the patient’s asthma, identify the patient’s severity, and control. We can use the EPR3 guidelines to determine the patient’s stepwise medication therapies. An initial asthma assessment should occur at the time of diagnosis which would include the symptoms the patient has been suffering from for the last 2-4 weeks. Asthma classification is interpreted from the following findings.
- Family, clinical, and past medical history
- Physical examination
- Quality of life questionnaire
- Vital signs
- Pulmonary Function
- Allergy testing if indicated
Classifying a patient’s asthma allows patient care providers to guide treatment options, make the distinction of intermittent or persistent, and monitor a patient’s severity as it can change over time. We can determine the patient’s current impairment when classified as persistent into three categories of mild, moderate, or severe. (See page 5 of the Asthma Care Quick Reference guide; click on the image.)
Our initial goal by doing this is to gain control and follow-up allows patients to maintain the control once achieved. Patients with asthma should see their primary care physician at least every six months if not more. During all visits providers should review medication administration techniques and verify proper use and modify therapy based on severity and clinical course. Using a stepwise approach we can determine patients treatment approach. (See page 7 of the Asthma Care Quick Reference guide, click on the image.)
How can we evaluate a patient’s control? We can use the Baylor Rule of Two. The following questions can assist in determining a patient’s control:
- Take your “quick-relief inhaler” more than two times a week?
- Awaken at night with asthma more than two times a month?
- Refill your “quick-relief inhaler” more than two times a year?
- Measure your peak flow at less than two times 10 (20%) from baseline with asthma symptoms?
Using Baylor Rule of Two, if a patient answers yes to any of these questions, it determines that the patient’s asthma is not in control and patient’s therapy regimen should be reassessed. (http://www.dcasthma.org/rules_of_two_poster.pdf)
As well, asthma control is grouped as well controlled, not well controlled, and very poorly controlled. By using NHLBI Asthma Quick Reference, we can look at the components of control. This is separated into impairment and risk.
Impairment includes the following aspects:
- Frequency of symptoms
- Interference with normal activity
- Short acting beta-agonist use for symptom control (not for the prevention of exercise induced asthma)
- Lung Function Studies when appropriate
- Validated Quality of life questionnaires
Risk looks at following aspects:
- Asthma exacerbations requiring oral systemic corticosteroids
- Reduction in lung growth/Progressive loss of lung function
- Treatment-related adverse effects
By looking at these aspects a provider can determine the next step for the patient based on their current control level. (See page 6 of the Asthma Care Quick Reference guide, click on the image.)
Asthma educators and other medical providers need to be aware of the various aspects of assessment, the stepwise approach to treatment, and control. We need to be proactive for our hospitalized patients and make meaningful recommendations and reassess the patients asthma while providing them effective education so they care self-manage their disease. Using the NHBLI EPR3 guidelines healthcare providers are able to review treatment plans and make modifications based on the patient’s condition. If managed properly patients with asthma can lead productive lives with minimal impairment or risk.
For more information on the complete EPR3 report please visit http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf and for more information on becoming a Certified Asthma Educator visit the National Asthma Educator Certification Board website at http://www.naecb.com.
Tabatha Dragonberry is a neonatal/pediatric respiratory therapist who has been working in the field since 2006. She has had various experiences in her field. Her varied exposure has allowed her the opportunity to care for various patients and expand her knowledge in the process.