Lack of Knowledge Leads to Poor Asthma Care

Lack of Knowledge Leads to Poor Asthma Care

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Asthma Guidelines

Lack of Knowledge Leads to Poor Asthma Care

By Thomas F. Plaut, MD

The major factor causing death and hospitalizations due to asthma in the United States is lack of knowledge. No, I’m not referring to patients’ lack of knowledge; I’m referring to health professionals. If clinicians don’t understand asthma, they won’t be able to teach their patients how to control it.

I make the diagnosis of uncontrolled asthma almost every time I give a talk to health professionals: A respiratory therapist coughs several times during my presentation, a nurse coughs after blowing peak flow during my hands-on demonstration, or a doctor coughs after laughing at a humorous remark.

These coughers simply don’t know that they’re living with uncontrolled asthma that could worsen unexpectedly at any time. Because competent health professionals often don’t use current practice guidelines to manage their own asthma, it’s no surprise that they don’t provide effective care for their patients.

NHLBI Guidelines
In 1997, the National Heart, Lung, and Blood Institute (NHLBI) published revised Guidelines for the Diagnosis and Management of Asthma to bring primary care physicians up to date. In the main, they codified the practices that many asthma specialists had been using for years. The guidelines describe a clear path for achieving good results in asthma care, including drug treatment, environmental control, monitoring and patient education.

However, the expert panel’s recommendations are ignored more frequently than they are followed. Most physicians I have queried fail to:

• treat patients who have symptoms more than two days a week with a controller medicine
• give specific, patient-related advice on improving the environment coupled with a clear rationale for doing so
• encourage patients with moderate or severe asthma to monitor their airflow and keep a diary
• give their patients written treatment plans and an asthma booklet that is current, comprehensive and accurate.

It’s clear that these techniques produce excellent outcomes. The year prior to the NHLBI report, I guided interventions covering all 113,000 enrollees under age 15 in two HMOs in Oregon and California. They stressed use of preventive anti-inflammatory medicines, proper delivery of inhaled medicines, peak flow monitoring and patient education. Hospital days for asthma dropped to 36 percent of the national rate. Simultaneously, hospital days for bronchitis, bronchiolitis and pneumonia fell to less than 25 percent of the national rate.

Improving Care
Why don’t all physicians take these simple steps that the guidelines outline to improve asthma care? I’ll answer from my own experience as a pediatrician.

I started treating children with asthma in the Bellevue Hospital emergency room in 1959. When I saw a child with marked retractions, wheezing loudly and breathing rapidly, I gave an injection of adrenaline. Ten minutes after receiving the shot the child was often greatly improved, smiling and breathing easily. The mother, who had been gravely concerned about her child’s health, was grateful. I was pleased to have achieved such dramatic results.

Most pediatricians have cared for hundreds of children with asthma. They’re as impressed with their ability to bring an attack under control rapidly as I was 40 years ago. However, there is much more to asthma care than treating emergencies. In fact, emergencies should rarely occur.

Many doctors are not aware that almost all patients with persistent asthma who use inhaled steroids daily will be able to prevent most attacks. The few that do occur will be less severe.

In addition, health care professionals often don’t realize their patients suffer from symptoms that limit their activities. They get only a brief “snapshot” of a patient in the office. Only a few use a comprehensive diary that would give them a continuing daily account, a “videotape,” of the patient’s status. In the absence of such a record they can’t understand that the patient’s asthma is not adequately controlled.

Asthma causes 500,000 hospitalizations and 5,000 deaths a year in the United States. These numbers will drop when health professionals understand the basics of asthma, its monitoring and treatment; expect their patients to achieve excellent control; and teach them how to manage most asthma problems at home.

Patient Scenarios
In the meantime, patients will settle for poor control unless they know they have an option. Consider three patients’ experiences:

A friend introduced me to a 45-year-old health administrator at a cocktail party saying that he had been hospitalized for asthma 12 times in the preceding 10 years and needed my help.

For the three years before we met he had symptoms every afternoon and evening in spite of taking epinephrine, theophylline, cromolyn, metaproteronol and albuterol several times each day and prednisone 5 mg to 30 mg almost daily. His allergist had labeled him as noncompliant.

At his first visit, I learned that he had daily contact with major triggers and that his inhaler technique was seriously flawed. We corrected these problems, and two weeks later his peak flow doubled and his symptoms disappeared.

A mother came in with her 7 month old, after reading that most asthma symptoms could be prevented and the rest controlled with proper treatment.

She said her son had been coughing every few minutes, day and night, since his first month of life. Over the next six months two pediatricians, an allergist, a pulmonologist and an ER doctor treated him, but his symptoms continued.

I recommended specific changes in the environment, cleared his airways with a burst of prednisone, gave him an effective nebulizer cup to deliver cromolyn and simplified his medication routine. Two weeks after his first visit, his symptoms were gone.

A 54-year-old nurse with a history of asthma since age 16 saw me because of symptoms that occurred daily despite treatment with an inhaled steroid and salmeterol, and albuterol eight to 24 puffs a day.

She lived with a cat, even though she knew she was allergic to cat dander. I pointed out that even five minutes of contact with a cat can cause inflammation of the airways that may increase her reaction to triggers for 12 weeks. I reviewed inhaler technique with her and increased her dose of inhaled steroid.

When I saw her four weeks later, she was asymptomatic but was still struggling with how to handle the cat, which was a beloved member of her family. I convinced her that her high dose of inhaled steroid would increase her risk of developing osteoporosis. A month later she placed the cat with a friend and was looking forward to reducing her dose of inhaled steroids.

These stories show that patients will seek help and will follow advice that they have reason to trust.

Dr. Plaut is the author of One Minute Asthma: What you Need to Know and several other asthma books for the public. He is the founder of Pedipress Asthma Publications, serves as an asthma consultant to HMOs and government programs nationwide and sees patients at his office in Amherst, Mass. You can read the full stories of the patients described above at www.pedipress.com.

He is also a member of the ADVANCE Editorial Board.

Reasons Why Physicians and Patients Settle for Poor Asthma Control
Many doctors don’t know or don’t believe that:

effective treatment can eliminate almost all symptoms

nearly every patient should be able to run as fast and as long as he or she wants

an asthma treatment plan is unsatisfactory if a patient has symptoms more than two days a week

low-level symptoms that occur daily may handicap a patient more than an occasional acute episode

the danger of using inhaled steroids to treat persistent asthma, measured in terms of hospitalization and death, is far less than the risk of not using them

patients will take inhaled steroids if doctors clearly describe the expected benefits and they experience these benefits during a trial period

improving a patient’s indoor environment can greatly reduce symptoms and the need for
medicines

patients will reduce triggers in their environment if they’re given specific instructions and understand the benefits of doing so

patients will monitor peak flow and keep records if they find these techniques help them manage and control their asthma

two new, effective nebulizer cups will deliver three times the respirable dose of medicine as most cups in use today.

Patients often don’t expect good results because:

their doctors have not taught them to expect excellent outcomes

their asthma control is much better than it was 10 years ago, and they don’t realize it is far from ideal

their relatives have asthma problems much worse than theirs

the media frequently runs stories of asthma emergencies and deaths. They know they are doing much better than that.

they think that having mild symptoms daily is par for the course

they don’t know that if they have symptoms more than two days a week their treatment plan is unsatisfactory

they don’t know that they should be able to participate vigorously in any sport

they see fund-raising ads that do more to scare and to depress them than to teach and encourage them. One mother, who had worked hard to manage her child’s asthma, said the slogan, “Don’t let his next breath be his last,” made her feel hopeless, and that all her work would be of no help.

—Thomas F. Plaut, MD