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Asthma Patient Management
It all starts with an accurate diagnosis. As there are no diagnostic markers for basic asthma diagnosis, asthma may be confirmed through detailed patient history, lung function assessments, serological testing and clinical observation. Long term management of your patient’s asthma will depend largely on their personal manifestation of signs, symptoms, and IgE mediated diseases and other comorbidities. Allergies are a trigger of asthma symptoms in a majority of asthma patients.1
The presence of such comorbidities is an important contributing factor, and can aid in proper asthma care, while also resulting in:2
- 2.1 fewer unscheduled office visits per year
- 21.3 fewer symptomatic days per year
- 4.4 fewer missed school days per year
The primary goal of long term asthma management remains two-pronged:3
1. Reduce impairment
- Prevent chronic and troublesome symptoms (i.e., coughing or breathlessness in the daytime, in the night, or after exertion)
- Require infrequent use (≤2 days a week) of inhaled short-acting beta2-agonist (SABA) for quick relief of symptoms (not including prevention of exercise-induced bronchospasm (EIB))
- Maintain (near) normal pulmonary function
- Maintain normal activity levels (including exercise and other physical activity and attendance at work or school)
- Meet patients’ and families’ expectations of and satisfaction with asthma care
2. Reducing risk that leads to impairment:
- Prevent recurrent exacerbations of asthma and minimize the need for emergency department (ED) visits or hospitalizations
- Prevent progressive loss of lung function; for children, prevent reduced lung growth
- Provide optimal pharmacotherapy with minimal or no adverse effects
The mainstays of asthma management include:
- Pharmaceutical management
Management of environmental triggers- exposure reduction and avoidance of:4
- Pollens
- Molds
- Animal dander
- Dust mites
- Cockroaches
- Fumes
- Airborne chemicals or dusts
- Extreme weather
- Activities that may exacerbate asthma symptoms
- Patient education
Following diagnosis, well established clinical guidelines for management of asthma will better facilitate patient management:
Patient Education - A Powerful Tool
Communicating with and teaching patients how to manage their asthma can have a profound impact on their daily quality of life. Following a confirmed diagnosis of asthma, it is important to provide your patient with a personal asthma action plan: including their unique, confirmed, triggers. Your patients may have a difficult time eliminating all their potential allergic triggers from everyday life. Provide them with a comprehensive avoidance strategy.
Once patients have been thoroughly versed on how to lessen their symptoms, it is vital the following key points are reinforced to optimize patient outcomes:5
- The signs and symptoms that indicate asthma may be worsening
- Correct medication administration (e.g., inhaler technique, use of devices, understanding difference between long-term control and rescue medications)
Benefits of avoiding the following environmental factors that worsen asthma, including:
Animal dander
Pollen
Molds
Dust mites
Cockroaches
Exposure to smoking
Extreme weather
Exercise
Findings have indicated that a majority of asthma-related deaths are avoidable (up to 46%) when recommendations about support and self-management were appropriately administered.3 It has been reported that up to 77% of those who died had never been taught about the danger signs, been informed about how their medicine was to be taken, or instructed on when to call for help. Due to the fact that past asthma attacks are a clear risk indicator for additional attacks, it is imperative that patients be properly followed up with in the wake of an asthma attack, and are informed to seek medical assistance in the event of subsequent attacks.5 Providing patients with self-management plans may severely lessen the mortality associated with severe asthma.
Referral to an asthma specialist may be recommended if a patient experiences difficulty achieving or maintaining control of asthma on their current plan. The importance of referrals for patients has been recently highlighted in a British evaluation of asthma deaths, whereby 20% of deaths investigated were related to avoidable factors associated with referrals (including delays or failure of referral for specialist opinion) and over 50% of patients were not under specialist supervision prior to their deaths.5,7
Tests
Diagnostic tests give reliable results that support primary care physicians as well as specialists in providing optimal patient management.
Baxi SN, Phipatanakul W. The role of allergen exposure and avoidance in asthma. Adolesc Med State Art Rev. 2010;21(1):57-71.
Morgan WJ, Crain EF, Gruchella R, et al. Results of a Home-Based Environmental Intervention Among Urban Children with Asthma. N Engl J Med. 2001;351:1068-1080.
US Department of Health & Human Services. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/files/docs/guidelines/08_sec4_lt_ovw.pdf. Accessed December 2017.
National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK7232/
Royal College of Physicians. Why Asthma Still Kills: The National Review of Asthma Deaths (NRAD) Confidential Enquiry Report. London, RCP, 2014.www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf. Accessed December 2017.
American Academy of Allergy, Asthma & Immunology. Asthma triggers and management. https://www.aaaai.org/conditions-and-treatments/library/at-a-glance/asthma-triggers-and-management. Accessed December 2017.
Price D, Bjermer L, Bergin DA, et al. Asthma referrals: a key component of asthma management that needs to be addressed. J Asthma Allergy. 2017;10:209-223.
US Department of Health & Human Services. National Asthma Education and Prevention Program Expert Panel Report 3. Guidelines for the Diagnosis and Management of Asthma. https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf Accessed December 2017.
Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis executive summary. Otolaryngol Head Neck Surg. 2015;152(2):197-206.
Guerra S, Sherrill DL, Martinez FD, et al. Rhinitis as an independent risk factor for adult-onset asthma. J Allergy Clin Immunol. 2002;109:419-425.
Bergeron C, Hamid Q. Relationship between Asthma and Rhinitis: Epidemiologic, Pathophysiologic, and Therapeutic Aspects. Allergy Asthma Cl Im. 2005;1(2):81-87.
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