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Asthma Management: A Multi-Faceted Approach

Course Authors

Cathy G. Benninger, R.N., M.S., C.N.P., and Jennifer W. McCallister, M.D.

Ms. Benninger is a staff member and Dr. McCallister is Associate Professor of Internal Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, OH.

Within the past 12 months, Ms. Benninger and Dr. McCallister report no commercial conflicts of interest.

Albert Einstein College of Medicine, CCME staff, and interMDnet staff have nothing to disclose.

Estimated course time: 1 hour(s).

Albert Einstein College of Medicine – Montefiore Medical Center designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

In support of improving patient care, this activity has been planned and implemented by Albert Einstein College of Medicine-Montefiore Medical Center and InterMDnet. Albert Einstein College of Medicine – Montefiore Medical Center is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

 
Learning Objectives

Upon completion of this Cyberounds®, you should be able to:

  • List four key components of long-term asthma care as defined by the National Heart, Lung, and Blood Institute National Asthma Education and Prevention Program Expert Panel Report-3

  • Describe the essential elements of an asthma action plan

  • Implement strategies for improving adherence to asthma therapy in the outpatient setting

  • Identify co-morbid conditions which may contribute to poor asthma control.

 

This presentation may include discussion of commercial products and services.

Based on national survey data, 24.6 million people report a diagnosis of asthma in the United States, representing approximately 7.7% of adults and 9.6% of children.(1) Certain populations including women, blacks and the poor are disproportionately affected. The direct and indirect costs related to adult asthma care in the United States were estimated to be $18 billion in 2008, contributing significantly to the expanding healthcare financial burden [2]. The excessive costs are in part associated with poor asthma control, which leads to increased asthma-related morbidity and mortality, and increased healthcare utilization with more frequent use of emergency departments and hospitalizations for care.(2)(3)

Under-utilization of Guidelines

Evidence-based guidelines such as the National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and Prevention Program Expert Panel Report-3 (NAEPP EPR-3)(3) and the Global Initiative for Asthma (GINA) report [Global Strategy for Asthma Management and Prevention (GINA 2012)](4) provide best practice advice and help guide optimal disease management for practicing clinicians managing asthma patients. Research has shown that a systematic approach to asthma care using guideline-based changes in treatment provides adequate control in the majority of patients,(5) and results in improved health-related quality of life, regardless of asthma severity.(6)

Unfortunately, the guidelines are often under-utilized. Wisnivesky et al.(7) surveyed 202 inner-city primary care providers and found that 30% were unaware of the NAEPP EPR-3 guidelines, and in those who were familiar with the guidelines, only 46% reported routinely using them for asthma management. Providers were most confident following the guideline recommendations for prescribing inhaled corticosteroids (ICS) and administering influenza vaccines (62% and 73% respectively). Conversely, guideline recommendations were followed less often for peak expiratory flow rate monitoring (34%), asthma action plans (9%), and referral for allergy testing when appropriate (10%).

Unfortunately, the guidelines are often under-utilized.

Barriers to adherence included lack of familiarity and confidence in ability to perform specific components, a belief that interventions would not be effective or well received by patients, and time limitations. In a similar survey of 2500 patients with asthma and 309 physicians (including 104 allergists, 54 pulmonologists, 101 family practitioners and 50 internists), Murphy and colleagues demonstrated a higher rate of awareness of the NAEPP EPR-3 guidelines (96%) with 87% of respondents reporting routine use in clinical practice.(8) However, adherence to specific components of the guidelines varied greatly with sub-specialty, with allergists and pulmonologists reporting guideline based management strategies more often than other specialties.

By increasing familiarity with current guidelines and addressing barriers to their implementation and routine use, providers have the opportunity to improve their practice and positively influence the overall care of their patients with asthma.

Overview of NAEPP-EPR3 Guidelines

After the diagnosis of asthma is established, the NAEPP EPR-3 guidelines recommend a stepwise approach for the treatment of asthma based on the level of asthma severity (for initiation of therapy) or degree of control (for adjustments in therapy). Therapy is increased (stepped up) when control is inadequate, and decreased (stepped down) whenever possible to achieve the minimum level of medication necessary to maintain control, minimize side effects and cost.

Although a detailed discussion of the selection of therapy is beyond the scope of this Cyberounds®, the Asthma Care Quick Reference--Diagnosing and Managing Asthma(9) provides an overview of the NAEPP EPR-3 guidelines for stepwise adjustments in therapy, including estimated comparative daily dosages of inhaled corticosteroids for long-term asthma management.

The guidelines provide recommendations for long-term management of asthma with an emphasis on four key components of care (Table 1): assessment and monitoring, education, control of environmental factors and co-morbid conditions, and medication selection and use. By incorporating these in a multi-faceted approach to the care of the patient with asthma, an individualized treatment plan that actively involves the patient in management can be developed.

Table 1. Clinical Strategies for the Improvement of Asthma Control.

Medications
  1. Use a step-up and step-down approach to therapy as directed in current guidelines(3) for medication adjustment
  2. Manage medication adherence issues
Assessment and Monitoring
  1. Provide a means for patients to monitor asthma control at home
  2. Assess asthma control at each visit using a validated tool and adjust medications accordingly
  3. Schedule regular follow-up visits
Education
  1. Provide asthma education to assist with disease self management
  2. Develop an asthma action plan
  3. Review inhaler technique
Control of Triggers and Co-Morbidities
  1. Identify personal allergen or irritants and avoidance techniques for limiting or managing exposure
  2. Identify and manage co-morbid conditions which affect asthma control

Source: based on the four key components of asthma management as outlined in the current National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and Prevention Program Expert Panel Report-3 (NAEPP EPR-3)(3).

Assessment and Monitoring

Frequent monitoring of asthma control is essential to achieving and maintaining long-term control. Patients should be taught to monitor for inadequate control with either symptom or peak expiratory flow rate monitoring. The "Rule of Twos®" (10) (Table 2) can be taught to patients as a method of asthma control self-assessment.

Frequent monitoring of asthma control is essential to achieving and maintaining long-term control.

Table 2. Rules of Two® -- One Method for Patients and Providers to Assess Asthma Control.

Do you...
  1. Have asthma symptoms or take your quick-relief inhaler more than Two times a week?
  2. Awaken at night with asthma symptoms more than Two times a month?
  3. Refill your quick-relief inhaler more than Two times a year?
  4. Measure your peak flow at less than than Two times 10 (20%) with asthma symptoms?
If you answered "yes" to any of these questions, current guidelines suggest you talk with your physician.

Source: Adapted from: Rules of Two® (www.baylorhealth.com).(10)

Daily peak flow monitoring is recommended in patients with moderate to severe disease, those with prior history of severe exacerbations and in patients who poorly perceive airflow obstruction.(3) Patients with concomitant vocal cord dysfunction (VCD) may also benefit from the use of a peak flow meter to assist in differentiating upper airway induced dyspnea from asthma, since expiratory flows are rarely affected by vocal cord spasm.(11)

Assessment of Control

Physicians should routinely assess asthma control during clinical visits, although eliciting an accurate estimate of asthma control may be difficult in patients whose self-perceived symptoms do not always correlate with more objectives measures. Telephone-based surveys of large populations have demonstrated that patients are poor at assessing their own level of asthma control, with many overestimating their degree of control when self-reported symptoms are correlated with guideline-based determinations.

As an example, the Asthma Insight and Management (AIM) survey screened 2500 households with one or more members who had asthma.(8) Among those asthmatics surveyed, 71% reported they were controlled or well controlled but only 29% were categorized as such when survey responses were compared with NAEPP parameters of control. The reasons for patients' poor awareness of inadequate control have been difficult to characterize, and do not seem to be specific to any unique patient characteristics or management strategies.(12)

Physicians may also overestimate asthma control. In a study of 354 primary care physicians who individually evaluated the control of 50 consecutive asthma patients encountered in their practices (10,428 patients total), 42% were classified as uncontrolled by the providers, compared to 59% when researchers applied current consensus guidelines.(13) Similarly, Boulet and colleagues reported that asthma care providers misclassified 40% of patients with uncontrolled asthma as adequately controlled.(14)

These findings underscore the importance of incorporating the use of validated tools such as the Asthma Control Questionnaire (ACQ),(15) the Asthma Control Assessment Questionnaire (ATAQ)(16) or the Asthma Control Test (ACT) (17) to assess control during visits rather than relying solely on patient-reported symptoms and open ended questions. If a validated tool is not used, assessments should include review of a symptom diary or targeted questions regarding asthma impact on activity, sleep, work or school and frequency of use of short-acting beta-agonists.

It has been noted that asthma symptoms do not correlate well with the degree of airflow obstruction in some patients,(18) so evaluation of lung function should be used in combination with other measures of asthma control. In the office, spirometry is the preferred objective measure of airflow obstruction [3], especially in those who are poor perceivers of symptoms and may not easily recognize inadequate control or worsening asthma [12]. Current guidelines recommend spirometry assessment at least every one to two years, with more frequent evaluation in patients with poorly controlled disease.

Measurement of fractional exhaled nitric oxide (FeNO) may serve as an additional diagnostic tool for the identification of eosinophilic airway inflammation and inadequately controlled asthma in some patients.(19) FeNO may be useful in determining the need for inhaled corticosteroids (ICS) and monitoring response or compliance with therapies. However, limitations in its wide applicability exist, including the lack of reimbursement from some insurers.

Education

Asthma self-management has been shown to improve medication adherence,(20) asthma control(21) and quality of life, while reducing hospitalizations, emergency department visits, unscheduled provider visits and lost work days due to asthma.(22) Though adherence to asthma self-management is often poor, it may be improved by actively engaging patients in their care, establishing a provider-patient partnership and individualizing the management plan. (23)(24)(25) After a provider has characterized a patient's asthma, identified triggers and co-morbid conditions and implemented a treatment plan, asthma education individualized to the patient (Table 3) and a written asthma action plan can be developed.

Asthma self-management has been shown to improve medication adherence.

Table 3. Key Points of Asthma Education.(3)(20)

  1. Action and importance of medications
  2. Proper use of the inhalers, spacers and nebulizers
  3. Differentiating controller verses reliever therapy
  4. Use of short-acting beta-agonist (SABA) as rescue and preventive therapy
  5. Common asthma triggers and avoidance measures
  6. Signs and symptoms of inadequate asthma control
  7. Verbal and graphic interpretation of spirometry and peak expiratory flow rates
  8. Appropriate self-treatment of asthma symptoms
  9. Indications for seeking medical care if not successfully managed at home
  10. Results of allergen skin testing and strategies for avoidance
  11. Strategies and importance of managing other co-morbid conditions
  12. Importance of regular follow-up

Educational materials and communication approaches must be patient-centric and should consider current level of understanding, level of literacy as well as any potential associated cognitive, visual or hearing impairments.(26) It is estimated that 50% of the U.S. adult population has limited health literacy, requiring written materials to be prepared at or below a 5th grade reading level and accompanied by pictures to explain the text. Comprehension can be improved by presenting information through a variety of modalities and keeping the message clear and simple.

Proper education can be time-consuming and a challenge to integrate into a busy clinical practice. To lessen the burden on the provider, we recommend a team-based approach in which nurses and other staff are trained to perform the various components of asthma monitoring and education.(27)[The American Lung Association] offers the Asthma Educator Institute, a two-day educational course on the provision of asthma education and care to individuals and families following NAEPP EPR-3 guidelines. The course also prepares the participant to sit for the National Asthma Educator Certification Exam offered by The National Asthma Educator Certification Board [(NAECB)]. For smaller practices, it may be more practical to refer patients to an asthma specialist or to a certified asthma educator (area listings can be found on the NAECB website) for initial education (Table 4).

Table 4. Asthma Management "Tool Box" for Asthma Care Providers.

  1. Identify practice gaps in asthma care and develop quality improvements through self-assessment
    • Physicians' Practice Assessment Questionnaire (PPAQ)(98)
  2. Review the current guidelines
  3. Train staff to assist in asthma management
  4. Select an asthma control assessment tool to be administered to all asthmatics regardless of appointment type
    • Asthma Control Questionnaire (ACQ)(15)
    • Asthma Control Assessment Questionnaire (ATAQ)(16)
    • Asthma Control Test (ACT) (17)
  5. Identify documentation tools to improve monitoring and documentation of asthma control, education and interventions
  6. Assess and modify barriers to medication adherence
  7. Develop an asthma action plan and update it annually
  8. Identify and manage triggers and co-morbid conditions.
  9. Refer persistently uncontrolled patients or those who may benefit from specialized medications or novel treatments to an asthma specialist.

Asthma Action Plans

Asthma action plans have been associated with reduced morbidity and decreased use of health care resources(3) but are often under-utilized in practice. The National Health Interview Survey in 2009(1) found only 34% of 27,686 respondents had an asthma action plan. Similarly, in the Asthma Insight and Management (AIM) Survey, only 51% (157 of 309) physicians surveyed reported developing an action plan for the majority of their asthma patients with results varying widely by the specialty of the respondent [68% (71/104) of allergists, 46% (46/101) of family practitioners, 41% (22/54) of pulmonologists, and 36% (18/50) of internists].(8) In this same survey, patients (n=797) reported that the frequency of review of the plans varied greatly -- from 39% reporting discussion at every follow-up visit to 5% reporting that it was never reviewed after initial development.

Asthma action plans are designed to be individualized and developed jointly with the patient, and may be based on symptoms or peak flow measurements.(22)(28) A well-written action plan contains the following key components: avoidance of patient specific triggers, identification of signs and symptoms or peak flow measurements that suggest worsening asthma, precise action points for medication use, and indications for calling a provider or seeking emergency care.(28)(29) Precise medication action points should include recommendations for increasing or adding medication for the treatment of worsening symptoms, instructions regarding the specific dose and duration of therapy, and the anticipated action of the chosen medication (Table 4).

Control of Triggers and Co-morbid Conditions

Common Asthma Triggers

Identification of asthma triggers is a cornerstone of asthma management and the basis of individualized self-management plans as outlined above. However, evidence suggests that there is opportunity for improvement in this area of guideline-based care as well. Rank et al. followed asthma subjects for two years and found trigger assessment was performed during the majority of 686 asthma-related visits.(30) However, only 30% of the patients received specific advice for avoiding or eliminating triggers and only 10% of those who received advice were reassessed for their compliance with the recommendations.

Identification of asthma triggers is a cornerstone of asthma management.

Patients often require assistance in the identification and avoidance of their personal triggers. Targeted questioning or an assessment tool may be used to facilitate this process.(31)(32) While asthma triggers will be unique for each patient, knowledge of the most common contributors to worsening control will be beneficial for all providers. Upper respiratory infections caused by viruses are a common cause of asthma exacerbations in adults.(33)(34)(35) Nicholson followed 138 adults with asthma and found 89% of colds were associated with asthma symptoms and reductions in peak flow rates for up to 7 days after the onset of symptoms.(34) Similarly, Corne reported rhinovirus infections were associated with more lower respiratory tract infections in those with asthma, and the symptoms were more severe and longer lasting when compared to those without asthma.(33) Although viral infections occur throughout the year, hospitalizations related to rhinovirus-induced asthma exacerbations are more common in the spring (April and May) and the fall (September to December).(35) Prevention of infection through immunizations, hand washing, and avoiding those who are ill should be reviewed with patients.

Patients with asthma are known to be at increased risk for complications from influenza, so all persons over six months of age without contraindications should be immunized.(36) Live attenuated influenza vaccines (LAIV) have been linked to asthma exacerbations in some patients, therefore inactivated influenza vaccines (IIV) are recommended instead.(37) The risk of invasive pneumococcal disease in people with asthma is less clearly defined,(38)(39) but the Centers for Disease Control and Prevention (CDC) recommends vaccination with the pneumococcal polysaccharide vaccine (PPSV23) in all adults age 65 or older and in adults age 19 and over who have asthma or who smoke.(36)

Despite these recommendations, overall vaccination rates for adult asthmatics remain low. Based on data from the National Health Interview Survey, it was estimated that only 36.2% of people with asthma were vaccinated for influenza during the 2006-2007 flu season,(40) and only 12.3% received pneumococcal vaccines during 2009.(41) Even during the H1N1 pandemic of 2009, vaccination rates averaged only 25.5% among 25-64 year olds with asthma.(42)


It is estimated that 24-35% of asthmatics smoke,(43)(44) and second-hand tobacco smoke exposure is pervasive among non-smokers.(45) Direct and significant indirect exposure to tobacco smoke is associated with more frequent and more severe asthma exacerbations,(43)(46) lower lung function, greater rescue inhaler use (46) and absenteeism from work.(47) Harmsen and colleagues (48) evaluated 793 asthma patients between the ages of 14 and 44 and noted more breathing symptoms and more significant airflow obstruction in smokers compared to non-smokers. Limitation of tobacco smoke exposure in public areas has been associated with declines in asthma-related emergency department (ED) admissions and hospitalizations.(49)(50) Rayens et al. reported a 22% decline in ED visits for adults and children with asthma following the institution of a public area smoking ban in Kentucky.(50) In order to minimize the mortality and morbidity associated with tobacco smoke, diligent efforts for smoking cessation, elimination of smoking in the home and public smoking bans are required.(45)

Other asthma triggers include exercise,(3) sulfite sensitivity, stress,(51) weather (especially high humidity,(52) cold or dry air,(53) air pollution (particularly long-term exposure to traffic-related pollution),(54) occupational exposures, as well as medications (beta-blockers(55) and aspirin products.(56)(57)(58) The use of beta-adrenergic blockers has been avoided or limited in asthmatics due to the potential risk of bronchospasm, but a 2002 Cochrane Review concluded that cardioselective beta-blockers can be prescribed for mild to moderate asthmatics with minimal respiratory effect and may be considered in asthmatic patients with concomitant cardiovascular conditions which warrant the use of such agents for management.(55)

Co-morbid Conditions

The clinician can assist patients in moving toward improved well-being and asthma control though identification and aggressive management of co-morbid conditions known to exacerbate asthma. In a recent cluster analysis of 2205 adults presenting with asthma exacerbations in primary care, investigators identified seven distinct adult phenotypes, with sinusitis and gastroesophageal reflux disease (GERD) associated with more severe disease.(59) In all clusters, an increased body mass index (BMI), lack of asthma control and concurrent respiratory tract infections were associated with increased risk of an exacerbation.

Allergic Rhinitis

The relationship between asthma control and allergic rhinitis has been well demonstrated, with poor control of rhinitis contributing significantly to asthma exacerbations and ED visits.(59),(60),(61),(62),(63),(64) Corren et al. reviewed a managed-care database representing 215,000 enrollees.(62) They identified 361 participants with asthma and allergic rhinitis evaluated in the ED for asthma exacerbations and compared them to 1444 controls with both conditions and without ED visits. Those patients treated with a nasal steroid or a second-generation antihistamine were less likely to present to the ED or be hospitalized for an asthma exacerbation than those without rhinitis treatment, and those on both therapies had the lowest ED utilization rate.

These findings support the importance of identifying and properly managing allergic rhinitis in asthmatics. In those patients with difficult-to-control asthma and allergic rhinitis, referral to an allergist is recommend. Skin testing to identify patient specific allergens can assist in guiding therapy or avoidance measures.(61) Once the allergen(s) have been confirmed, targeted avoidance measures can be instituted but general avoidance measures in those with non-confirmed allergies are not recommended.(65)

Obesity

Although the relationship is not completely understood, obesity is associated with an increased incidence of asthma in both men and women.(66) Hjellvik et al.(67) reported a 3.5 times higher incidence of asthma among middle aged never-smokers with BMI ??JPY35 kg/m2 compared to normal weight individuals. In the Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) study of 3489 adults with severe asthma, a five-pound weight gain over one year was associated with poorer asthma control and greater need for oral corticosteroids.(68) Additionally, obesity has been associated with reduced responsiveness to inhaled corticosteroids,(69),(70) which may contribute to more asthma related symptoms.

Several small studies support weight-loss as a strategy for improving asthma control in obese patients (71),(72),(72) but a recent Cochrane Review evaluated four published studies and cautioned that current data fail to demonstrate weight-loss as a specific intervention for asthma control.(73) While additional well designed studies are needed to support weight-loss as a specific measure to improve asthma control, providers should consider the potential added benefits of weight reduction on other co-morbid conditions.

Overall, asthmatics tend to have poorer sleep quality than non-asthmatics,(74) but those with co-morbid obstructive sleep apnea (OSA) or those who are at high risk of OSA report more daytime and nighttime asthma symptoms and experience greater difficulty controlling their asthma.(75),(76),(77) Teodorescu et al. found a 2.87 higher odds ratio for poorly controlled asthma among patients at high risk for OSA.(76) More research is needed to fully understand the relationship between sleep and asthma control, but current data support screening and treating OSA in overweight poorly controlled asthmatics.

Gastroesophageal Reflux Disease

The relationship between asthma control and GERD is not as clearly defined. Asthma patients with GERD report more asthma symptoms and lower quality of life, yet there is no physiological difference in lung function, methacholine reactivity, nocturnal awakenings or short-acting bronchodilator use when compared to asthmatic patients without GERD.(78) In a parallel-group, double-blind trial of 412 inadequately controlled asthmatics, the presence of asymptomatic GERD was common but treatment with proton pump inhibitors did not improve asthma control.(79) However, in a randomized, double-blind, placebo-controlled study of 828 asthmatics with GERD, treatment with esomeprazole 40 mg twice a day improved FEV1 and quality of life scores.(80) Additionally 59% of asthmatic patients with severe GERD treated with Nissen fundoplication (a procedure in which the lower esophageal sphincter is reinforced by wrapping and securing the fundus of the stomach around the lower esophagus to prevent reflux) reported a reduction in asthma symptoms; however, 30% reported no change in symptoms despite intervention.(81) GERD is common in asthmatics but support is lacking for empirically treating those with asthma without the presence of GERD symptoms

Medications

Medication Nonadherence

Medication adherence improves asthma control and may reduce the frequency and severity of asthma exacerbations.(82) However, overall adherence to prescribed asthma medications is estimated to range between 30-70%.(83),(84) A nine-state Medicaid claims database review evaluating the quality of care for common chronic diseases revealed that only 49% of participating asthmatics filled initial prescriptions for an asthma controller therapy and only 18% obtained more than two refills.(85) Of additional concern, in those participants who filled prescriptions for short-acting beta-agonists, 23% refilled the prescription more than four times in one year indicating poor asthma control.

Assessing patient adherence to medication use is the first step towards improving it, but factors affecting adherence are multiple and complex, requiring a sensitive approach to inquiry. To facilitate assessment of potential barriers, the validated ASK®-20 (86) or ASK®-12 (87) questionnaires can be administered (Table 4). Assessment of pharmacy refill data may provide additional insight into medication adherence, although such information offers only an estimate of best possible adherence [88]. Once barriers have been identified, efforts can be made to address the issues and move the patient toward improved adherence and asthma control.

Common barriers to medication adherence may include difficulties with access to care, cost of medications, concerns about therapies or misunderstandings about prescribed regimens.(88) In addition, patients may alter regimens based on opinions of nonmedical professionals such as friends and family, perceived safety of the medications or medication-related side effects,(89) cost (90) or simple forgetfulness.(84)

Proper education and a better understanding of the mechanism of action of the medication and reason for its use may be helpful. Those with difficulty remembering doses may respond to cues such as setting cell phone reminder alarms or placing medications by routinely used items in the home such as tooth brushes, coffee pots, or chargers for electronic devices.(91) Medication-related side effects are usually easily remedied by changing formulations, delivery devices or adding a valved holding chamber also known as a spacer to metered dose inhalers to slow the delivery of the medication in order to lessen deposit in the upper airway.

Affordability of medications is a significant challenge to prescribers and patients alike. Nominal increases in monthly co-pays of more than five dollars have been associated with reductions in asthma medication use, precipitating more unscheduled office and emergency room visits for uncontrolled asthma.(90) The uninsured are four times less likely to fill prescriptions for asthma than those who are insured.(1) For the uninsured and those with gaps in insurance coverage or high co-pays, there are discount programs offered by various organizations or pharmaceutical manufacturers which can be explored.

Many applications are available on-line and will require varying degrees of input from the provider (Table 4). Unintentional non-adherence may occur through poor inhaler technique,(92),(93),(94) inadequate knowledge regarding the action and use of the medication(95) or complicated and poorly understood medication regimens.(84) Current inhalers require complex coordinated motor skills for accurate delivery of the medication dependent upon physical manipulation of the device, coordinated deep breath with actuation, if using metered dose inhalers (MDI),(96) or sustained adequate inspiratory flow for powder dose inhalers (PDI).(97)

Misuse of inhalers is common and has been associated with older age and lower education.

Misuse of inhalers is common and has been associated with older age, lack of instruction by a health care provider (96) and lower education.(93) Critical errors in the use of MDI occur in 12-71% of users,(93),(96) and commonly involve not breathing out before actuating the device (93) or poor coordination in actuating the inhaler at the start of inhalation.(96) Among users of three different PDI inhalers, 35-44% were observed to have critical errors with the most common being stopping inhalation of the medication prematurely.(93) Patient education and inhaler instruction improves accuracy but competency has not been found to be maintained over time, requiring regular review and reinstruction.(94) Some patients may continue to make critical mistakes requiring a change in their inhaler delivery devices.(92)

Summary

Asthma is a highly variable condition, with changes expected in most individuals over time. The process of monitoring and assessment of control with appropriate adjustments in therapy, review of medication adherence and technique, and management of triggers and co-morbidities should be continuous in all patients. Asthma self-management should be viewed as an ongoing, interactive process requiring reassessment, education, and reinforcement at each follow-up visit. The ultimate goals of successful asthma management are to reduce impairment by limiting symptoms and impact on quality of life, and to minimize risk by preventing exacerbations, loss of lung function and adverse effects from asthma therapy.

Despite the availability of evidence-based guidelines to assist clinicians in effectively managing asthma, significant practice gaps remain. Opportunities exist to improve clinical practice by increasing comfort with existing guidelines and implementing goal-driven asthma management plans that are individualized to each patient. The Physicians' Practice Assessment Questionnaire (PPAQ) based on the GINA and Canadian adult asthma consensus guidelines can be used for self-assessment and identification of gaps in practice for quality improvement planning for interested providers.(98)

Strategies described within this Cyberounds® provide suggestions for providers to develop collaborative management plans which include an emphasis on the four components of the NAEPP-EPR3 guidelines including assessment and monitoring, education, control of environmental factors and co-morbid conditions, and medication use/adherence.

Footnotes

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3Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007 Nov;120(5 Suppl):S94-138.
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9Asthma Care Quick Reference Diagnosising and Managing Asthma--Guidelines from the National Asthma Education and Prevention Program Expert Panel Report 3. Bethesda, MD: U.S. Department of Health and Human Services National Institues of Health, National Heart, Lung, and Blood Institute September 2012 Contract No.: 12-5075.
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20Janson SL, McGrath KW, Covington JK, et al. Individualized asthma self-management improves medication adherence and markers of asthma control. J Allergy Clin Immunol. 2009 Apr;123(4):840-6.
21Bravata DM, Sundaram V, Lewis R, et al. Closing the quality gap: a critical analysis of quality improvement strategies (vol.5: asthma care). AHRQ Technical Reviews. Rockville (MD): Agency for Healthcare Research and Quality; 2007.
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