Jim, a 23-year-old construction worker, comes to your ED with acute shortness of breath, complaining of chest tightness that has progressively worsened over the past week while he was installing Sheetrock at a construction site. When he arrives he's acutely dyspneic, with an oxygen saturation level on room air of 88%, a respiratory rate of 40 breaths/minute, and a heart rate of 140 beats/minute. He's afebrile, with a BP of 170/100 mm Hg. Jim has difficulty speaking due to shortness of breath. A head, eye, ear, nose, and throat exam shows no evidence of acute infection. Circumoral cyanosis (a bluish tint to the skin around the lips) and nasal flaring are present. Examination of his chest shows decreased air entry bilaterally, with inspiratory and expiratory wheezes. Suprasternal and intercostal retractions are noted. Jim is examined and stabilized by the ED healthcare provider and admitted to the hospital for management of an acute asthma exacerbation.
A review of Jim's past medical history reveals intermittent asthma since age 5, with no previous hospitalizations or acute care visits. However, his asthma symptoms have worsened since he moved in with his brother, who smokes two packs of cigarettes per day and works as a pet groomer at home. Over the past 4 weeks, he has experienced daily wheezing responsive to albuterol, which he uses once every night shortly after he returns home. Today his symptoms became worse at the construction site; he's used albuterol every 2 hours for a total of three doses without significant improvement in his symptoms.
Each year, asthma is responsible for 1.8 million ED visits, 500,000 hospital admissions, 400 deaths, and 100 million days of restricted activity. In order for you to be able to help your patients with asthma, you need to become familiar with the latest recommendations for asthma care and management as presented in the updated National Institutes of Health's National Asthma Education and Prevention Program (NAEPP) guidelines. In this article, I'll outline the key changes to the components of asthma care, but first let's briefly review what asthma is and how it develops.
Meet the inflamed airways
Asthma is a chronic inflammatory disorder of the airways that's a result of a complex interaction between mast cells, eosinophils, basophils, Th-2 lymphocytes, neutrophils, and chemical mediators such as histamine, prostaglandin, leukotrienes, and cytokines (see Mechanisms of bronchospasm). It's characterized by episodic reversible airway obstruction, increased bronchial reactivity, and airway inflammation. In genetically susceptible individuals, these interactions can lead to breathlessness; wheezing; recurrent episodes of coughing, particularly at night or in the early morning; and chest tightness. These episodes are usually associated with variable airflow obstruction, which is often reversible spontaneously or with treatment. The bronchospasms that occur during an asthma attack result when the bronchial smooth muscle contraction constricts the airways in response to exposure to an allergen or irritant (see Pathogenesis of bronchial asthma). Patients with asthma often have airways that are hyperresponsive. This means that the patient has an exaggerated bronchoconstrictor response, causing airflow limitations.
A diagnosis of asthma is considered if a patient meets three criteria: 1. symptoms of asthma in response to a trigger (airway hyperreactivity); 2. repeated episodes of symptoms (recurrence); and 3. response to treatment (reversibility). However, spirometry is needed to confirm the diagnosis.
Asthma severity is classified as follows:
- —symptoms twice a week or less and nighttime symptoms twice a month or less
- —symptoms don't cause interference with normal activity
- —using a short-acting beta2-agonist (SABA) inhaler 2 days or less a week for control of symptoms
- mild persistent
- —symptoms more than twice a week but less than once a day and nighttime symptoms three to four times per month
- —minor limitation with normal activity because of symptoms
- —using a SABA inhaler more than 2 days a week, but not daily for control of symptoms
- moderate persistent
- —having daily symptoms and nighttime symptoms more than once a week, but not every night
- —some limitation of normal activity because of symptoms
- —using a SABA inhaler daily for control of symptoms
- severe persistent
- —having continual daytime symptoms and frequent nighttime symptoms, often seven times per week
- —extreme limitation of normal activity because of symptoms
- —no control of symptoms.
More than one cause
The development of asthma is thought to be multifactoral, involving environment and genetics. One hypothesis, called the hygiene hypothesis, is based on observations that asthma is more common in urban rather than rural communities. The hygiene hypothesis states that if environmental exposures occur at a critical time in the development of the immune system, it can lead to a change in the balance between Th-1 and Th-2 type cytokine responses. For example, if a child is exposed to respiratory infections early in life through exposure to day care or older siblings and lives in a rural community, he's likely to have a Th-1 response and a lower incidence of asthma. The absence of these factors is associated with a persistent Th-2 response and a higher rate of asthma.
Recent studies have found that there's a genetic component to asthma. Genetic differences may alter susceptibility to asthma, as well as responsiveness to medications. Different phenotypes, varying intensity of inflammation, cellular mediator patterns, and therapeutic responses to asthma exist. Research in the area of genetics may lead to new treatment approaches targeted at specific patient phenotypes and genotypes.
Signs and symptoms, please
Signs and symptoms of asthma may include sudden shortness of breath, chest tightness, wheezing, cough, and sputum production. Not every patient has all of these symptoms; some may experience only a cough. During a patient's acute asthma attack, you may observe an elevated respiratory rate due to an increased work of breathing. This patient may have a decreased activity tolerance and may not be able to complete a full sentence when speaking to you. When auscultating the patient's lungs, you may hear wheezing, crackles, or rhonchi. The air movement or air entry will be diminished or absent and may have a prolonged expiratory phase.
Remember that the absence of wheezing isn't always a good sign. It may mean that the obstruction is so severe that it's limiting the passage of air within the airways. Other signs of respiratory distress may include nasal flaring and suprasternal or intercostal retractions. The patient will have a pale or cyanotic color to his skin, lips, or mucous membranes and bluish nasal turbinates. Chronic asthma sufferers may have allergic shiners (bluish rings under their eyes), transverse nasal creases (a line across the bridge of their nose) from chronic sinusitis, and a barrel chest or clubbing of the fingers from chronic hypoxia.
Ask the right questions
When conducting an initial history and physical exam on a patient with asthma it's important to ask not only about signs and symptoms, but also about their pattern. Be sure to ask when the symptoms occur. Do they occur during the fall, winter, spring, or summer? What are the onset, duration, and frequency of the symptoms? Make sure to ask about the number of days and nights per week or month that he experiences signs and symptoms. Ask him if he experiences symptoms at night or early in the morning.
What are the precipitating or aggravating factors? Does he experience increased episodes of shortness of breath when he has a viral respiratory infection? Does he experience increased symptoms when exposed to indoor allergens (such as mold or mildew, dust mites, and animal dander) or outdoor allergens? Does pollen, pollution, exposure to occupational chemicals or allergens, or an irritant such as tobacco smoke or smoke from a wood burning stove bother him? Has he noticed that emotions (such as fear, anger, or crying), stress, or changes in the weather trigger symptoms? Does his asthma get worse when he takes certain medications such as aspirin or nonsteroidal anti-inflammatory drugs? Do certain foods or food additives such as sulfites aggravate his symptoms?
Ask the patient about when he first developed asthma, the progression of the disease, and his present treatment and care during exacerbations. Ask him how often he uses a short-acting inhaler and whether he has been prescribed oral corticosteroids or inhaled corticosteroids. If so, how often does he use them? A family history of asthma, allergies, sinusitis, eczema, or nasal polyps is significant in the development of asthma, according to the latest research. A social history should include characteristics about his work setting (or day care or school setting for a child or adolescent) that may interfere with adherence to treatment. Ask about his social support network and level of education and employment. If your patient is a woman, does menstruation, pregnancy, or thyroid disease influence her symptoms?
If the patient is in acute distress, shorten the history and wait until he feels better to ask more detailed questions such as a profile of typical exacerbation. Other questions that are important to record, but not during an acute episode, include: What impact does asthma have on the patient and his family? Does he go to the ED for unscheduled care or hospitalization? How many days of work or school does he miss? Does asthma limit his activity, especially playing sports or strenuous work? Does he wake up at night? What effect has asthma had on his growth, development, and behavior or school performance? What's the impact on his family's routines, activities, or dynamics? Does the family have financial concerns about coping with or treating his asthma?
During a physical exam of the patient, perform a general appraisal by observing his color, posture, and respiratory rate and note increased work of breathing and signs of decreased activity tolerance. Auscultate his lungs for adventitious breath sounds and decreased air movement or use of accessory muscles. Also note whether he's able to finish a complete sentence.
Medications coming right up
Prescribed therapy for patients with asthma includes long-term control medications and short-term, quick relief medications for an acute attack.
Long-term control medications include:
- inhaled corticosteroids—these agents, such as beclomethasone, budesonide, budesonide with formoterol, fluticasone, fluticasone with salmeterol, mometasone, and triamcinolone, block late phase reaction to allergens, reduce airway hyperresponsiveness, and inhibit inflammatory cell migration and activation; the most effective medications for the long-term treatment of asthma
- cromolyn sodium and nedocromil—stabilize mast cells and interfere with chloride channel function
- immunomodulators—omalizumab is a monoclonal antibody that prevents the binding of immunoglobulin E to the high-affinity receptors on basophils and mast cells; note the black box warning to be prepared to treat anaphylaxis
- leukotriene modifiers—leukotriene receptor antagonists, such as montelukast and zafirlukast, are an alternative but not preferred treatment for mild persistent asthma, and the 5-lipoxygenase inhibitor zileuton is an alternative but not preferred adjunct therapy in adults; liver function must be monitored with zileuton
- long-acting beta2-agonists (LABAs)—salmeterol and formoterol are bronchodilators, with action lasting up to 12 hours, that may be used in combination with inhaled corticosteroids (they shouldn't be used as monotherapy); note the new black box warning about asthma-related deaths on all preparations containing a LABA
- methylxanthines—sustained-release theophylline is a mild-to-moderate bronchodilator that's used as an alternative, but not preferred, therapy; it's essential to monitor serum theophylline levels because of the drug's narrow therapeutic range.
Quick relief medications include:
- anticholinergics—these agents, such as ipratropium, ipratropium with albuterol, and tiotropium, inhibit muscarinic cholinergic receptors and reduce intrinsic vagal tone of the airways
- inhaled SABAs—bronchodilators that relax smooth muscle include albuterol tablets, metered-dose inhaler, and solution for nebulization; levalbuterol metered-dose inhaler; and pirbuterol autohaler (metered-dose inhaler); in December 2008 the majority of chlorofluorocarbon inhalers were removed from the marketplace because of the threat to the ozone layer
- systemic corticosteroids—oral steroids, such as methylprednisolone and prednisone, may be used concomitantly with a SABA for treatment of moderate-to-severe asthma exacerbations to quicken recovery time.
Asthma guidelines update
The NAEPP Expert Panel Report 3 (EPR-3) was built on the comprehensive guidelines issued in 1991, 1997, and an update in 2002. Its purpose is to provide updated recommendations for selecting care and treatment based on the individual needs of patients with asthma. These new guidelines include an expanded section on childhood asthma with an additional age group (ages 5 to 11), new guidelines on medications, recommendations on patient education in settings beyond the healthcare provider's office, and advice for controlling environmental factors that can cause asthma symptoms. Information for developing these guidelines was based on data from the scientific literature and evidence-based practice in the field. The focus of the guidelines is to help patients with asthma gain better control of their condition so that they can "be active all day and sleep well at night."
Key changes to the four components of care are as follows:
- assessment and monitoring of asthma severity. Severity is described as the intrinsic intensity of the disease process. It can be measured in a patient who isn't receiving long-term control therapy, after asthma control is achieved, or by the amount of medication required to maintain control. Control is obtained when asthma symptoms are minimized by therapeutic interventions and the therapeutic goals are achieved. Some patients are unable to determine their level of airway obstruction and, despite their best intentions, may not give an accurate portrayal of their level of asthma control. Specific questions about sleep, level of activity, and use of an inhaler rather than just asking about how the patient's asthma is doing can give more information about the real level of his asthma control. Asthma responsiveness is considered to be the ease with which asthma control is achieved by the prescribed therapy. New features in the EPR-3 include the use of multiple measurements to assess the patient's level of current impairment and future risk.
- According to the NAEPP guidelines, the severity and control of a patient's asthma can determine his level of impairment and future risk. Impairment is defined as the frequency and intensity of symptoms, low lung function, and current or recent limitations of daily activities. Future risk is identified as the patient's risk of exacerbations, progressive loss of lung function, or adverse reactions from medications. The new guidelines state that patients can still be at high risk for frequent exacerbations even if they experience minimal day-to-day effects of asthma. A detailed history is the first step to assessing and monitoring asthma severity and control. It can also help determine the presence of impairment and possible future risks.
- education for partnership in care. Teamwork can improve quality of care. For example, the pharmacist might be the first to recognize that a patient is experiencing poor asthma control because he's requesting multiple refills of albuterol inhalers in a short period. Cultural and ethnic factors and health literacy of the patient and his family are important to consider when tailoring treatment goals. Open lines of communication and agreement on the treatment plan can improve patient adherence to treatment.
- According to the Health Belief Model, before the patient is adherent to the treatment plan, he and his family need to recognize that there's a problem, acknowledge that it can be serious, and believe that something can be done about it. The patient also needs to know what to do and believe that it's worth doing. He must be able to correctly complete the action and be reinforced for his accomplishments. Self-monitoring skills are also needed to ensure that the patient will know how to manage his asthma. By using a written asthma action plan, instructions are outlined to allow the patient to learn how to recognize and handle worsening asthma.
- control of environmental factors and other conditions that can affect asthma. Factors that precipitate asthma or cause symptoms to persist include indoor or outdoor allergens, weather changes, tobacco smoke, and smog. Indoor allergens can be controlled by encasing pillows and mattresses in allergen-proof covers, dusting and vacuuming weekly, washing bedding weekly with water hotter than 130° F (54.4° C), reducing clutter that can collect dust, avoiding upholstered furniture, and reducing indoor humidity to less than 50%. Control measures for pollen include drying clothes in the dryer, showering after spending time outside, and staying inside with air conditioning on days with high pollen counts.
- The EPR-3 recommends that several approaches be used to control environmental factors. If there's a clear relationship between exposures to an allergen to which the patient is sensitive, subcutaneous immunotherapy may be used for patients with mild or moderate persistent asthma. However, the healthcare provider must be prepared to treat anaphylaxis if it occurs. Asthma patients may have several comorbid conditions that may add to breathing problems, such as obesity, gastroesophageal reflux disease, sleep apnea, and sinusitis. And psychiatric diagnosis such as depression may decrease a patient's medication compliance. Therefore, the new guidelines also recommend treating chronic problems to help improve asthma control.
- medications. The NAEPP guidelines still use a step-wise approach to treatment. Medications are stepped up or down when needed to achieve control. Charts were revised and expanded to include three age groups: ages 0 to 4, ages 5 to 11, and ages 12 and older. This was due to emerging evidence that children may respond to medication differently than adults. The old guidelines grouped 5- to 11-year-olds with adults. EPR-3 found that inhaled corticosteroids are still the most potent and effective long-term control medications across all age groups.
Under your influence
Let's check in with our patient. According to the new guidelines, Jim's baseline classification is moderate persistent and poorly controlled. He has daily symptoms and requires rescue therapy once a day. At the present time, he's having an acute exacerbation, so his control classification is changed to very poorly controlled. The treatment strategies for managing acute asthma exacerbations include the administration of oxygen, albuterol, and systemic corticosteroids. After the acute episode is over, he'll need to return to his healthcare provider for follow-up care and long-term medication. Pulmonary function testing and evaluation and treatment of asthma triggers and comorbidities, as well as the development of an asthma action plan, will be important factors in helping him achieve future control.
Before beginning patient teaching, you should assess the patient's and his family's perception of the disease. How much does he really know about asthma? Does he know what happens to the airways during an asthma attack? Ask him about his health beliefs regarding the chronic nature of asthma and the effectiveness of treatment. What's his belief about the long- and short-term effects of medication? Does he know how to use an inhaler, spacer, and nebulizer? Does he know how to perform daily monitoring to detect early airflow changes that may require treatment? Inquire about the level of support within the patient's family and his capacity to recognize the severity of an exacerbation.
Demonstrate the proper use of an inhaler and describe how to recognize when the canister is empty. Teach the patient how to use a peak flow meter so that he can perform self-monitoring of his asthma symptoms and understand what to do in case of worsening symptoms. Encourage him to avoid smoking and perform regular aerobic exercises to improve cardiopulmonary and musculoskeletal conditioning. Also encourage him to maintain adequate fluid intake to help thin bronchial mucus and balanced nutrition. It's highly recommended that asthma patients receive influenza and pneumococcal vaccinations, if not contraindicated. Teach the patient about the importance of follow-up visits with his healthcare provider. Referral to an allergy specialist, respiratory specialist, or pulmonologist may be needed.
Partnering for effective care
Asthma education should occur at every point of care (see The PACE curriculum). It should begin in the ED, during the patient's hospitalization, at the follow-up appointment with his healthcare provider, and even with his pharmacist when he's refilling his prescriptions. The patient should be familiar with his asthma action plan. Patients with persistent asthma, like our patient Jim, should have two plans: one for rescue and one for control. If the patient is refilling his rescue inhalers frequently or getting several at a time, his asthma may be poorly controlled and he needs to be reevaluated by his healthcare provider. Family members should also be able to recognize airway or activity limitations, be supportive, and encourage the patient to be compliant with his treatment. Nurses in both inpatient and office settings can be instrumental in facilitating an asthma management partnership to improve adherence, compliance, avoidance of triggers and, ultimately, control.
Key changes to the NAEPP asthma guidelines
Four components of effective asthma care
Component 1: Assessment and monitoring
- Asthma severity
- Daytime symptoms
- Nighttime symptoms
- Lung function (peak flow measurements, pulmonary function tests)
- Asthma control
- Current degree of impairment
- Risk of future impairment Component 2: Education
- Should occur at every point of care
- Importance of partnering for effective care
- Assess and teach self-monitoring skills
- Develop an asthma action plan for every patient
Component 3: Control of environmental factors
- Identify allergic sensitivities/triggers
- Incorporate measures to reduce indoor and outdoor allergens/irritants
- Manage comorbidities
Component 4: Medication therapy
- Step-wise approach to treatment based on achieving good asthma control
- Long-term controller medication (corticosteroids, LABAs, mast cell stabilizers, immunomodulators, leukotriene modifiers, methylxanthines)
- Short-term rescue medication (anticholinergics, SABAs, systemic corticosteroids)
did you know?
There are new areas of specialization in asthma care. Nurses can join the Association of Asthma Educators or take a certification exam to become certified as an asthma educator, or AE-C. More information about asthma specialization can be found at the National Asthma Educator Certification Board website at http://www.naecb.org.
The PACE curriculum
Nurses can help improve outcomes and quality of life for patients with asthma by partnering with other healthcare professionals. The National Heart, Lung, and Blood Institute's physician asthma care education, or PACE, curriculum is available for health educators at http://www.nhlbi.nih.gov/health/prof/lung/asthma/pace/curriculum.htm. This program discusses the clinical aspects of asthma, communication strategies, patient education information, clinical case studies, and information on documentation. It includes a slide presentation and discussion for healthcare professionals to learn more about asthma.
On the Web
These online resources may be helpful to your patients and their families: