Editorial' Educating the Patient with Asthma Walter T. McNicholas

Department of Respiratory Medicine and the Asthma Education Centre, St. Vincent's Hospital, Dublin.

The past two decades have seen major advances in the understanding of the pathogenesis and treatment of asthma. Increasingly effective forms of therapy have been made available, and there is now a multiplicity of different pharma- ceutical agents in use, both bronchodila- tor and preventive in action. Inhaled bronchodilators, particularly beta ag- onists allow many patients almost in- stant relief from the debilitating and often frighteningsymptoms ofdyspnoea and wheeze. In recent years however an increasing emphasis has centred on the preventive therapy of asthma, the objec- tive being that patients have their symptoms sufficiently controlled using preventive agents such as inhaled corti- costeroids that bronchodilator require- ments are reduced to a minimum, and in many eases not needed at all. The in- creasing sophistication of inhalers with technical modifications to allow maxi- mal delivery of aerosol to the lower respiratory tract has allowed many pa- tients to have their asthma controlled without recourse to systemic therapy, with a consequent reduction in the total dose of medication required, and sub- stantially decreased risk of systemic side effects of therapy.

This proliferation of drug therapies however, and the increasing sophistica- tion of inhaled delivery systems pose a major problem of understanding for the unfortunate asthmatic patient. Indeed some physicians have difficulty keep- ing pace with the rapid changes in inhaler technology. Thus it is not surprising that many asthmatics become bewildered by the range of available therapies, with the result that many patients do not take their medications as prescribed. It should be obvious therefore that a patient who understands the nature, the purpose and the correct use of his therapy is likely to be more

compliant with such therapy, particu- larly if multiple agents are involved.

The above considerations indicate that education of the asthmatic patient in the nature of his condition and the ra- tionale of therapy should be an essential component of an overall asthma man- agement strategy, similar to already established education programmes for the diabetic patient. An effective educa- tion programme should have the follow- ing components :

1. Understanding the disorder A basic understanding of the patho-

genesis, trigger factors, and potential danger signs helps the patient to cope with his condition, minimise potential environmental trigger factors, and also helps to ensure that the patient knows when to seek medical help.

2. Understanding the treatment Since asthma therapy can now be

divided into two broad categories, bron- chodilator and preventive, it is esential that patients understand the different modes of action of these therapies. Otherwise a patient who is on both beta agonist and corticosteroid inhaler may be tempted to drop the steroid inhaler because of the lack of immediate symp- tomatic relief, in contrast to the beta agonistinhaler. Many patients also have the mistaken idea that inhaler therapy is as potent as the oral form, even when identical agents are being used.

3. Correct use of inhaled therapy Inhaled therapy can only be effective

if used correctly, since it is only the portion of the aerosol which reaches the tracheobronchial tree that has a thera- peutic effect. Yet previous studies have indicated that many patients do not use their inhalers correctly r Any patient therefore who is prescribed an inhaler

should first be shown how to use the device correctly. Furthermore the in- creasing complexity of inhaled devices, with a variety of different spacing de- vices, rotahalers, etc. now available, all with the highly desirable aim of improv- ing delivery of the aerosol to the lower airways, requires appropriate instruc- tion to ensure correct usage of the device in question.

Proper education of the asthmatic patient is inevitably timecon~s uming, but numerous teaching aids are available, the most useful of which is probably the asthma information booklet produced by the Asthma Society of Ireland. At a general practice level, the provision of practice nurses under the new GMS contract should make it easier for many group practices to provide appropriate instruction to their asthmatic patients. Some teaching hospitals have established asthma education centres, modelled on the Diabetic Centres.

Despite the major advances achieved in asthmapharmacotherapyover thepast twenty years, death from asthma re- mains a major problem c21. Research into the background of these deaths suggest thatdelay in seeking medical help on the part of the patient and underuse of corticosteroids represent important contributing factors to many of these deaths. Such factors may represent a poor understanding of the condition on the part of the patient. Itcan reasonably be hoped, therefore, that improved edu- cation of the asthmatic patient should result in a reduction in both mortality and morbidity.

References l. Epstein, S. W., Manning, C. P. R., Ashley, M.

J., Corey, P. N. Survey of the clinical use of pressurised aerosol inhalers. Can. Med. As- soc. J. 1979: 120, 813-816.

2. Sears, M. R., Rea, H. H., Rothwell, R. P. G. et at Asthma mortality: comparison between New Zealand and England. Brit. Med. I. 1986:

293, 1342-1345.

293