Asthma - Case Management

• Goals of asthma management.
• General principles of asthma management.
• Four components of asthma management.

GOALS OF ASTHMA MANAGEMENT

• Maintain normal activity levels (including exercise).
• Maintain (near) normal pulmonary function rates.
• Prevent chronic and troublesome symptoms (e.g., coughing or breathlessness at night, in the early morning, or after exertion).
• Prevent recurrent episodes of asthma (e.g., no hospitalizations or emergency department visits).
• Avoid adverse effects from asthma medications.

Most asthma patients will be able to achieve the goals of asthma management with proper therapy. These goals can be used as the basis for initial and followup assessments, as will be discussed later. Goal: full participation in physical activities.

GENERAL PRINCIPLES OF ASTHMA MANAGEMENT

• Long-term, ongoing care is required to control symptoms, prevent acute asthma episodes, and reduce persistent airway inflammation caused by this chronic disease.
• Prevention of acute episodes is a key ingredient for achieving asthma control. This can be achieved by avoiding allergens or irritants and pretreating before exercise or exposure to other stimuli. In addition, patients with moderate or severe asthma can prevent episodes by taking anti-inflammatory medication daily.
• Anticipatory or early treatment of symptoms is important to reduce the likelihood of developing severe airway narrowing. Early warning signs that should be treated immediately include (1) a peak flow rate 20 percent below predicted or personal best (peak flow rates will be described in more detail later), (2) cough, (3) wheeze, (4) tightness of the chest, (5) shortness of breath, or (6) other individual signals a patient may have of an upcoming episode.
• Objective measurement of asthma severity should guide the management of asthma.
• Management activities should focus on (1) reducing airway inflammation to prevent asthma episodes and (2) relieving airway narrowing when necessary. This principle is based on the current understanding of the pathophysiology of asthma.

FOUR COMPONENTS OF ASTHMA MANAGEMENT

1. Objective measures of lung function to both assess and monitor each patient’s asthma.

2. Environmental control efforts to reduce or eliminate exposure to allergens and irritants (often called asthma triggers) that induce airway inflammation and precipitate acute asthma episodes.

3. Pharmacologic therapy to prevent, reverse, and control airway inflammation and obstruction.

4. Patient education to help patients prepare and follow their daily management plan and their action plan for dealing with symptoms.

Asthma Management Component 1: Objective Measures of Lung Function

Spirometry

• Forced expiratory volume in 1 second (FEV 1 )—the amount of air forcefully blown out in the first second. FEV 1 is one of the most useful measures because it indicates both large and small airway function.
• Peak expiratory flow rate (PEFR)—the highest flow rate that can be created by the patient forcefully blowing with fully inflated lungs. PEFR correlates well with FEV 1 although it primarily measures large airway function. PEFR measurements are made in liters per minute.
• Forced vital capacity (FVC)—the total volume of air that the patient can blow out as rapidly as possible. FVC is a good indicator of patient effort and also may help determine airway obstruction.
• Maximum midexpiratory flow rate (MMEF)— the flow measured between 25 and 75 percent of the forced expiratory volume. MMEF measurements assess small airway function.

Peak Flow Monitoring

Actions/Implications for Nurses: Objective Measures

• Ensure that patients obtain accurate spirometric readings by coaching them to use the correct technique.
• Use the handouts “How To Use Your Peak Flow Meter” and “Asthma Management Plan” to instruct patients how to use a peak flow meter, obtain their personal best, and use peak flow readings to help them manage their asthma. Help patients to be aware of other signs that indicate the need to take medications, such as coughing, wheezing, and difficulty breathing.
• Ask all patients to demonstrate their PEFR technique at each visit. Use the five steps listed in “How To Use Your Peak Flow Meter” to check off each step they complete accurately.

Asthma Management Component 2: Environmental Control Measures

You can identify what makes a patient’s asthma worse by taking a thorough history of past asthma episodes. If needed, have patients keep written records of all their episodes. The information you want from patients includes:

• The number of asthma episodes and how long they lasted.
• When symptoms first appeared.
• What patients suspected made their asthma worse.
• Whether emergency department visits or hospitalizations were necessary.
• What patients felt reduced the number of episodes.

Improvement in symptoms is often directly related to the degree patients follow environmental control recommendations. How well patients follow the recommendations is greatly affected by the strength of the partnership established with the patient and the completeness and quality of the patient education provided. Develop with patients plans and methods they will use to stay away from asthma triggers. Use the handout “How To Stay Away From Things That Make Your Asthma Worse”.

Allergens

The diagnosis of allergy is made after taking a thorough history and then using skin tests or in vitro methods to assess sensitivity to the allergen(s). The outdoor molds and pollens that commonly bring on allergic symptoms are usually seasonal. Exposure is year round for the most common indoor allergens: house-dust mites, cockroach feces, and animal dander. There are three main treatments for allergies. These are listed in the order in which they should be tried: (1) reducing the exposure to the offending allergens, (2) medications, and (3) immunotherapy.

Irritants

Actions/Implications for Nurses: Environmental Control

• Help patients eliminate—or reduce as much as possible—exposure to the things that make their asthma worse. Use the handout “How To Stay Away From Things That Make Your Asthma Worse” in appendix D. Highlight the control measures most appropriate for each patient. Urge patients and their families to attempt one or two control measures at a time, starting with the least expensive and/or the most effective.
• Ask about the presence of smokers in every household and advise them to quit. Recommend to the smokers directly that they stop smoking for the health of the patient and for themselves. Ask them to set a quit date, and refer them to quit-smoking materials and programs. Follow up with all smokers periodically to assess and reinforce their progress in thinking about or actually quitting. If the smokers are not ready to quit, ask them not to smoke in the house or car and ask them to keep thinking about quitting. It is best for them to quit.

Asthma Management Component 3: Pharmacologic Therapy

Two Major Groups of Asthma Medications: Anti-inflammatory and Bronchodilator

• Anti-inflammatory medications prevent and reduce airway inflammation. Inhaled corticosteroids, cromolyn sodium, and nedocromil sodium are taken daily to prevent symptoms and keep asthma under control. Short courses of oral corticosteroids are used to help reverse the increased inflammation of a severe acute episode, speed recovery, and prevent recurrence. Sometimes, oral corticosteroids are used longer term to control severe chronic asthma.
• Bronchodilator medications relax bronchial smooth muscles. Short-acting inhaled beta 2 -agonists are taken as needed to relieve symptoms. Longer acting bronchodilators can help prevent symptoms, especially nighttime symptoms. Longer acting bronchodilators include extended-release theophylline or oral beta 2 -agonists and long-acting inhaled beta 2 -agonists.

Clearly distinguish and review at each visit the medications patients are to take to relieve symptoms and those they are to take to prevent symptoms. Ask patients to bring their medicines to their visits and label them with terms they readily understand. Try the terms below to help make the distinction with your patients:

• Inhaled anti-inflammatory medications have been called “controllers,” “preventive,” “preventers (of symptoms),” and the medicine for the “quiet” part of asthma.
• Short-acting beta 2 -agonists have been called “symptom relievers,” “quick-relief medicine,” “rescue medicine,” and the medicine for the “noisy” part of asthma.

Step-Care for Chronic Asthma and Acute Asthma Episodes

Written Medication Plans for Patients— An Important Aid

• Green zone—stay away from things that make their asthma worse. Take daily medications to control chronic symptoms.
• Yellow zone—take medications to relieve asthma episodes at home.
• Red zone—call doctor or seek emergency care.

Recommendations for Exercise-Induced Asthma

minutes of vigorous exercise and results in a 15 percent or more drop in PEFR or FEV 1 . EIA usually peaks 3 to 12 minutes after stopping the exercise and resolves within 30 to 60 minutes. An exercise challenge helps diagnose the existence of EIA. Emphasize to patients that they should be able to exercise. Ask them to contact their doctor or you if their plan to control EIA is not working effectively.

Actions/Implications for Nurses: Pharmacologic Therapy Asthma Management Plan

• Emphasize long-term ongoing therapy and swift treatment of the early warning signs of an asthma episode (PEFR falls 20 percent below their predicted or personal best or symptoms occur).
• Emphasize that patients with moderate and severe asthma need daily inhaled anti-inflammatory medication to prevent asthma episodes.
• Work with the patient and physician to develop a written Asthma Management Plan tailored to the patient’s needs.
• At each visit, assess and review each patient’s use and understanding of his or her Asthma Management Plan. Review how patients are taking their medicines.
• At each visit, ask patients about all medications they are using, including over-the-counter medications. Ask patients to be sure they are NOT taking beta blockers (frequently used for high blood pressure, for migraines, and in eye drops for glaucoma). For patients sensitive to aspirin, advise them NOT to take aspirin-containing drugs and nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs can cause severe and even fatal acute asthma episodes. Teach patients to read labels carefully and to wear medical alert bracelets. Remind them that safe alternatives to aspirin and NSAIDs include acetaminophen, sodium salicylate, or salsalate.
• Coordinate and integrate for patients the different recommendations that may arise when several nurses and physicians are involved (e.g., recommendations from primary care, pulmonology, allergy, or emergency department staff).

Correct Metered-Dose Inhaler Technique

• Teach the correct techniques for using metered-dose inhalers, spacers, and nebulizers. (Use handouts in appendix D.)
• At each visit, have the patient demonstrate the use of medications via the inhaler, spacer, or nebulizer. Emphasize the importance of correct technique and reteach as needed.

Asthma Management Component 4: Patient Education

Additional content should include an explanation of asthma, the goals and principles of asthma management discussed earlier, and the dangers of the underuse as well as overuse of medications.

Planning Patient Education: Keys to Success

• Plan to do the action at a specific time and place.
• Find it easy to do.
• Benefit from doing it at an acceptable cost and find it helps them avoid serious consequences or prevents them from losing something they value.
• Believe they can do it.
• Remember to do it.

1. What will make it more likely for the patient to take the action?
2. What will make it difficult for the patient to take the action? How can the difficulties be reduced?
3. What will the patient agree to do?