thomas c. corbridge, md, fccp asthma -...

By Susan Corbridge, PhD, APN, ACNP, AE-C, and Thomas C. Corbridge, MD, FCCP

hours

Continuing Education2.6

28 AJN ▼ May 2010 ▼ Vol. 110, No. 5 ajnonline.com

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 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 ex periences slight chest tightness during our exami-nation but displays no acute distress. Auscultation reveals infrequent end-expiratory wheezes. The phy-sical ex amination is otherwise normal, except for mild swelling of the nasal mucosa.

ASTHMA in Adolescents and AdultsGuideline-based diagnosis and management.

With office spirometry, the patient demonstrates mild expiratory airflow obstruction. Repeat spirom-etry 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 bronchodila-tor to address the asthma and a nasal corticosteroid to treat the allergic rhinitis. She educates the patient about basic asthma pathophysiology, proper medi-cation 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

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 inflam-matory disease depends on early diagnosis, accurate classification, appropriate treatment, and targeted patient education. This article outlines current guideline recommendations for asthma and reviews what clini-cians need to teach patients about its pathophysiology, pharmacotherapy, self monitoring, and environmental control. The authors discuss the classic clinical presenta-tion of the disease, describe how to assess severity and control, and explain how such assessments can guide management.

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[email protected] AJN ▼ May 2010 ▼ Vol. 110, No. 5 29

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 IMPACTIn 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 admis-sions, and close to 4,000 deaths.1-3 It’s a common rea son 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 Among adult patients, hospitalization and mortality rates are generally highest for blacks and women.6-8

BEHIND THE OBSTRUCTIONThe 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 hy-perreactive to a number of specific and nonspecific triggers.

Variable combinations of inflammation, intralu-minal mucus, and bronchospasm obstruct expiratory airflow. Although such obstruction is usually revers-ible 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 particu-larly difficult to discern when early exposure occurs in association with frequent lower respiratory infec-tion.10 Asthma is also recognized as having an inherit-able 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 pre-cise relationship isn’t yet understood.

CLINICAL PRESENTATIONAsthma is characterized by breathlessness, chest tight-ness, wheezing, and coughing. (Nasal congestion and postnasal drip are also common.) Symptoms vary from patient to patient and can vary in the same

patient over time. Symptoms may occur spontane-ously, or be precipitated or exacerbated by various triggers (see Se lected Asthma Triggers3). Asthma is commonly worse in the early morning hours or at night,3 corresponding to circadian variations in bron-chomotor tone and bron chial 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 occu-pational 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 expira-tory wheezes and expiratory phase prolongation, al-though wheezes may be absent or diminished between obstructive episodes and when airflow rates are criti-cally low.14 Indeed the quiet chest with minimal air

Allergen exposure (for example, pollen, •mold, air pollutants, dust mites, cock-roaches, pet dander, and saliva)Medications (for example, aspirin, non-•steroidal 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•

Selected Asthma Triggers3

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 Fig-ure 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 short-acting bron chodilator, 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 provoca-tive 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 neg ative test may help rule out the disease. Variable find ings with a handheld peak flow meter also sug gest asthma, particularly if flow rates are lower when symp-toms are present and higher after albuterol treat ment.

Although not central to the diagnosis of asthma, a chest X-ray may help exclude alternative diagnoses (see Differential Diagnosis of Asthma3, 16). Blood work may reveal eosinophilia and elevated immunoglobu-lin E levels.

ASSESSING DISEASE SEVERITY AND CONTROLAssessing and monitoring asthma severity and con-trol 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 pre-ferred 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


Asthmatic Bronchiole

Bronchoconstriction

Mucus plug

Cross section Cross section

Disrupted epithelial layer Airway wall

inflammation

Intraluminal mucus

Normal Bronchiole

Figure 1. Normal and Asthmatic BronchioleThe 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).

Basement membrane thickening


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 Pa tients with intermittent asthma have normal pul-monary function tests between infrequent asthma ep-isodes. 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 func-tion 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 re-quire higher doses of control agents than do those with mild or moderate persistent disease and, possi-bly, 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 environ-mental 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

Therapy Assessment Questionnaire, the Asthma Con-trol 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 epi-sodes. Those with persistent asthma require an ad ditional long-term control agent to treat underly-ing airway wall inflammation. The most effective

antiinflamma tory medications (used either alone or in combination with other control agents) are the inhaled cortico steroids, 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

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

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•

Differential Diagnosis of Asthma3, 16

Clinicians should prescribe the least amount of medication required to achieve control as assessed by a validated tool and spirometry.

should be monitored closely after reducing medica-tions 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 cardio-vascular disorders, particularly those with tachycar-dia and tachyarrhythmias.3 Long-acting β2-agonists may increase the risk of severe symptom exacerba-tion, 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 inad-•equately managed by a control medication.in combination products containing an inhaled •co rticosteroid, 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

growth, and reduced bone mineral density. Long-term use of inhaled corticosteroids has also been associ-ated 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 CONSIDERATIONSEvaluating 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 main te-nance, exercise, good handwashing techniques, avoid-ing contact with those who are sick, and—for patients taking corticosteroids—bone mineral density measure-ment and calcium and vitamin D supplementation. Other bone protective or restorative therapies may be considered in patients with osteopenia or os teoporosis.

PATIENT EDUCATIONAsthma education is an ongoing process that’s criti-cal to achieving control, improving outcomes, and


Figure 2. Simple SpirometryDuring simple spirometry the patient exhales as forcefully and completely as possible starting at full lung inflation (bottom left of the above curve). Exhaled volume (in liters) is plotted on the Y axis against exhalation time (in sec-onds) 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 vol-ume 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.

0

1

2

3

4

5

6

7

0 1 2 3 4 5 6

Seconds

Lite

rsFEV1 = 4.1 L

Simple SpirometryVolume�Time Curve

(FEV1/FVC = 4.1/5.5 = 0.75) FVC = 5.5 L

FEV1 = 2.3 L

FVC = 5.0 L

(FEV1/FVC = 2.3/5.0 = 0.46)

Figure 1

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 self-management skills such as peak flow monitoring.3

Basic asthma pathophysiology, with instruction

minimizing medication use. As such, a needs assess-ment to identify patients’ key knowledge deficits, fol-lowed by targeted instruction, should be integrated into every patient visit. Nationally certified asthma educators are now recognized as the ideal practi-tioners to teach patients and their families about asthma. (Information on becoming a certified asthma educator can be found at www.naecb.org.)

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 (Symbi-cort)

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)

MethylprednisolonePrednisolonePrednisone

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, subcuta-neous, intramuscular)

Although oral systemic cor-ticosteroids are not short-acting drugs, they are used adjunctively with short-acting β2-adrenergic agonists to has-ten recovery

MethylprednisolonePrednisolonePrednisone


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, environ-mental control, and self monitoring. The pathophys-iology can be explained as simply as follows: “Asthma is a chronic lung disease in which the airways become in flamed, or swollen, narrow, and sensitive to certain substances, which we call triggers. Exposure to these trig gers tightens muscles surrounding the airways, causing further narrowing. Swollen, constricted air-ways, which are often filled with mucus, make breath-ing 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 feel-ing well. They’re not for quick relief. Rescue medica-tions, 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 immedi-ately before morning and nighttime toothbrushing. Patients who use a metered dose inhaler might also use a spacer to reduce the amount of medication swal-lowed and absorbed.

Parents may express concern over the safety of inhaled corticosteroid use in children and the poten-tial 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 estab-lishing asthma control outweighs concerns about growth or systemic effects.3 In addition, poorly con-trolled asthma delays growth in children. Explain that in haled corticosteroids are titrated to the lowest

Figure 3. Classifying Asthma Severity3

EIB = exercise-induced bronchospasm; FEV1 = forced expiratory volume in 1 second; FVC = forced vital capacity.


pos sible dose needed to maintain control and that proper in haler technique reduces systemic absorp-tion of the drug.

Inhaler technique should be reassessed at every clini cal 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.

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 res-cue 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 Aller-gen 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

patients and clinicians assess control, peak flow mea-surements 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

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 re-cord 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 as sessing re-sponse to treatment.

THE ASTHMA ACTION PLANIndividualized 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


Reducing Allergen Exposure in the Home3, 25

Dust mitesEncase mattress and pillows in allergen-• impermeable 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 moldFix any leaky faucets or toilets.•

Clean moldy surfaces.•Dehumidify basements.•

Animal danderKeep 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 cloth-• covered furniture in the home.

Cockroach allergenKeep food in closed containers and out of the •bedroom.Keep garbage in closed containers.•Use traps or a professional exterminator.•

Review asthma symptom triggers at each visit.

Ways to limit patients’ exposure to environmental irritants.


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 worsen-ing 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, yel low, 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 (“cau-tion”) zone, and practitioners may consider prescrib-ing 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 avail-able 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-UPWhen the patient in our opening scenario returns for follow-up in a month, the NP assesses her asthma con-trol using the Asthma Control Test, spirometry, and physical examination. The patient isn’t in acute distress, but end-expiratory wheezing remains evident on aus-cultation. 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.

http://bit.ly/hM4s0


steroid as prescribed and her nasal symptoms have improved. She hasn’t been recording her PEFR.

The patient acknowledges that she still has a cat, 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 sug-gests, however, that if complete separation is unac-ceptable 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 pre-scribed 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, sched-ules a follow-up appointment in another month, and instructs the patient to call immediately if symptoms worsen.

The NP in this scenario followed current guidelines. She accurately assessed asthma severity at presenta-tion, initiated appropriate pharmacotherapy, and pro-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

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, [email protected]. Thomas C. Corbridge is a former member of the speakers’ bureau for GlaxoSmithKline and Boehringer Ingelheim.

For more than 27 additional continuing nursing education articles on respiratory topics, go to nursingcenter.com/ce.

Figure 5. Asthma Control TestThis test helps clinicians assess asthma control in patients ages 12 and older. A perfect test score is 25. A score of 20 or higher suggests well-controlled asthma. Scores between 16 and 19 indicate some lack of control, and scores below 16 suggest very poor control.20

Reprinted with permis-sion. Asthma Control TestTM Health Survey 2003, 2004, by QualityMetric Incorpo-rated – All rights reserved. Asthma Control TestTM is a trademark of QualityMetric Incorporated.

Section 3, Component 1: Measures of Asthma Assessment and Monitoring

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F I G U R E 3 – 8 . V A L I D A T E D I N S T R U M E N T S F O R A S S E S S M E N T A N D M O N I T O R I N G O F A S T H M A

Asthma Control Questionnaire (Juniper et al. 1999b) Asthma Therapy Assessment Questionnaire (Vollmer et al. 1999) (See below.) Asthma Control Test (Nathan et al. 2004) (See below.) Asthma Control score (Boulet et al. 2002)

ASTHMA THERAPY ASSESSMENT QUESTIONNAIRE© (ATAQ)

1. In the past 4 weeks did you miss any work, school, or normal daily activities because of your asthma? (1 point for YES)

2. In the past 4 weeks, did you wake up at night because of your asthma? (1 point for YES)

3. Do you believe your asthma was well controlled in the past 4 weeks? (1 point for NO)

4. Do you use an inhaler for quick relief from asthma symptoms? If yes, what is the highest number of puffs in 1 day you took of this inhaler? (1 point for more than 12)

Total points = 0–4, with more points indicating more control problems Source: Adapted and reprinted with permission from Merck and Co., Inc. Copyright 1997, 1998, 1999 Merck and Co., Inc. All Rights Reserved.

CAUTION: The sample questionnaires in figure 3–8 assess only the impairment domain of asthma control and NOT the risk domain. Measure of risk, such as exacerbations, urgent care, hospitalizations, and declines in lung function, are important elements of assessing the level of asthma control.

http://www.nursingcenter.com/ce

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.

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How to Use a Peak Flow Meter3 Staying in the zone.

In acute asthma episodes, peak flow monitor-ing 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 measure-ments 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 demon-strations in the presence of their health care provider.

Stand.1.

Be sure the peak flow meter is at zero.2.

Take as deep a breath as possible.3.

Place the meter in your mouth and wrap 4. your lips around the mouthpiece.

Blow out as hard and fast as possible.5.

If you cough, spit, or block the mouth-6. piece with your tongue, disregard the reading.

Repeat the procedure two more times.7.

Record the highest reading.8.


thomas c. corbridge, md, fccp asthma -...

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