Asthma Management A Moving Target


Vol. 20 •Issue 23 • Page 10
Asthma Management A Moving Target

New NHLBI Guidelines Stress Need for More Asthma Education

Jane Chancellor, RRT, has watched the respiratory care profession grow and thrive during her many years as a staff therapist at Santa Barbara Cottage Hospital in Santa Barbara, Calif.

Chancellor also has observed asthma rates in her part of the country grow exponentially during her long career. It doesn’t take a genius to see the connection: Rising asthma rates, as much if not more than any single factor, are driving the growth of her chosen field.

“Asthma is really epidemic,” the 38-year veteran said. “I recently visited a grade school in which almost every child was allergic or asthmatic and packed an emergency inhaler.”

Respiratory care had “just become a field when I started,” Chancellor added. “It was an ancillary department to nursing. Now we’re one of the biggest departments. We have high pollen counts here. We sit in a bowl.”

Across America, whether in bowls, 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 asthmatics always can 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 reflect 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, MD, 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,” Kiley told ADVANCE.

“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 that asthma severity can change over time and can differ among individuals and by 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.

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,” 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 can all 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.”

Chancellor and other therapists at Santa Barbara Cottage Hospital saw to this need a long time ago, devising a therapist-driven protocol for asthma education.

“We knew MDIs worked as well as medication nebulizers when used properly,” explained 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: 0-4 years, 5-11 years, and 12 years and older. The 5- to 11-year group was added because new evidence indicates children may respond differently from adults to asthma medications.

“Therapy should be stepped up if a patient’s asthma is not well-controlled,” Kiley summarized. “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 control asthma and 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 beta agonists as adjunct therapy with inhaled corticosteroids;
  • omalizumab for severe asthma; and
  • albuterol, levalbuterol and corticosteroids for acute exacerbations.

    Asthma Action Plan

    Convincing patients to use long-term meds and not to rely only on rescue meds when in trouble takes communication and cooperation, Kiley noted.

    “A variety of educational approaches is 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 level of the patient’s asthma severity or control,” Kiley continued. “Many patients don’t realize their asthma could be better controlled.”

    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,” 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 other 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,” 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, he said, “recommend that in cases of poorly controlled asthma, the clinician should inquire about the potential role of depression or chronic stress (for the patient and, if the patient is a child, for the parent as well) because it could complicate asthma management.

    “It may also be important to evaluate psychosocial factors in children who have repeated hospitalizations, although it is not clear from research whether these factors affect or result from the hospitalizations.”

    Implementation Challenge

    As readers can see, much hard work and long hours went into updating the NAEPP asthma guidelines. Historically though, clinicians are often 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,” Kiley said.

    A final draft of the GIP report is slated for release “within a couple months.”

    Pressed for specifics on how to persuade clinicians to change their practices and adopt the new guidelines, Kiley 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.

    “In a broad sense, this may mean considering a range of activities from clinician training, to reminders in the medical record to prompt clinicians about a patient’s asthma status, to assurance that prescribed therapies and equipment can be readily obtained by the patient, to allowing sufficient time for patient assessment and education.”

    Programs are needed, he concluded, “that can help make it easy and efficient for clinicians to incorporate the recommendations into their routine practice.”

    Additional resources on the NAEPP and asthma:

  • Guidelines for the Diagnosis and Management of Asthma, www.nhlbi.nih.gov/guidelines/asthma/index.htm
  • National Asthma Education and Prevention Program, www.nhlbi.nih.gov/about/naepp/index.htm
  • Asthma public education materials, www.nhlbi.nih.gov/health/public/lung/index.htm

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

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