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March/April 2010

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Asthma update
Four components of care
Asthma is on the rise in the United States, with approximately 22 million people affected by this chronic disorder. To provide optimal care for your patients with asthma, you must be familiar with the latest management guidelines. We spell it out.
By Margaret J. McCormick, MS, RN Clinical Assistant Professor, Nursing Towson University Towson, Md.
The author has disclosed that she has no signicant relationships with or nancial interest in any commercial companies that pertain to this educational activity.

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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 hes 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. Hes 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 Jims 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,

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Pathogenesis of bronchial asthma


Increased mucus production Antigen IgE Mast cell

Mucusproducing goblet cell

Cytokines

Bronchial smooth muscle

which he uses once every night shortly after he returns home. Today his symptoms became worse at the construction site; hes 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 Healths National Asthma Education and Prevention Program (NAEPP) guidelines. In this article, Ill outline the key changes to the components of asthma care, but first lets briefly review what asthma is and how it develops.

A: Immediate
or early-phase response Bronchospasm

Meet the inflamed airways


Asthma is a chronic inflammatory disorder of the airways thats 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). Its 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.
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Mucus

Increased vascular permeability and edema

Basophil

Neutrophil Eosinophil

Epithelial cell injury

Afferent and efferent vagal fibers

B: Late-phase
response Bronchospasm and heightened airway responsiveness

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A diagnosis of asthma is considered if and genetics. One hypothesis, called the a patient meets three criteria: 1. symptoms hygiene hypothesis, is based on observaof asthma in response to a trigger (airway tions that asthma is more common in hyperreactivity); 2. repeated episodes of urban rather than rural communities. symptoms (recurrence); and 3. response to The hygiene hypothesis states that if envitreatment (reversibility). However, spiromeronmental exposures occur at a critical try is needed to confirm the diagnosis. time in the development of the immune Asthma severity is classified as follows: system, it can lead to a change in the bal intermittent ance between Th-1 and Th-2 type cytokine symptoms twice a week or less and responses. For example, if a child is exnighttime symptoms twice a month or less posed to respiratory infections early in life symptoms dont cause interference with through exposure to day care or older sibnormal activity lings and lives in a rural community, hes using a short-acting beta2-agonist (SABA) likely to have a Th-1 response and a lower inhaler 2 days or less a week for control of incidence of asthma. The absence of these symptoms mild persistent symptoms more than twice a Mechanisms of bronchospasm week but less than once a day and nighttime symptoms three Allergen to four times per month minor limitation with normal activity because of symptoms Early Phase using a SABA inhaler more Mast cells than 2 days a week, but not daily for control of symptoms Release histamine, leukotrienes, moderate persistent interleukins, and prostaglandins having daily symptoms and nighttime symptoms more than once a week, but not every night Infiltration of inflammatory cells some limitation of normal Airflow activity because of symptoms Release cytokines, interleukins, limitation using a SABA inhaler daily and other inflammatory mediators for control of symptoms severe persistent having continual daytime Late Phase symptoms and frequent nightAirway inflammation time symptoms, often seven times per week extreme limitation of normal activity because of symptoms Epithelial injury Edema no control of symptoms.

Bronchospasm

Increased airway responsiveness

More than one cause


The development of asthma is thought to be multifactoral, involving environment
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Impaired mucociliary function

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What would we do without you?

factors is associated with a persistent Th-2 response and a higher rate of asthma. Recent studies have found that theres 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.

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 its 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
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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 patients 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 patients 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 isnt always a good sign. It may mean that the obstruction is so severe that its 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.
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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? Whats the impact on his familys 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 hes 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 corticosteroidsthese agents, such as beclomethasone, budesonide, budesonide with formoterol, fluticasone, fluticasone with salmeterol, mometasone, and triamcinolone,
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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 nedocromilstabilize mast cells and interfere with chloride channel function immunomodulatorsomalizumab is a monoclonal antibody that prevents the binding of immunoglobulin E to the highaffinity receptors on basophils and mast cells; note the black box warning to be Key changes to prepared to treat the NAEPP anaphylaxis asthma guidelines leukotriene modiFour components of effective fiersleukotriene asthma care receptor antagonists, Component 1: Assessment and such as montelukast monitoring and zafirlukast, are Asthma severity an alternative but Daytime symptoms not preferred treat Nighttime symptoms ment for mild per Lung function (peak flow measurements, sistent asthma, and pulmonary function tests) the 5-lipoxygenase Asthma control inhibitor zileuton is Current degree of impairment an alternative but Risk of future impairment not preferred adComponent 2: Education junct therapy in Should occur at every point of care adults; liver func Importance of partnering for effective care tion must be moni Assess and teach self-monitoring skills tored with zileuton Develop an asthma action plan for every patient long-acting beta2Component 3: Control of environmental agonists (LABAs) factors Identify allergic sensitivities/triggers salmeterol and for Incorporate measures to reduce indoor and moterol are outdoor allergens/irritants bronchodilators, Manage comorbidities with action lasting Component 4: Medication therapy up to 12 hours, that Step-wise approach to treatment based on may be used in achieving good asthma control combination with Long-term controller medication (corticosinhaled corticosteroids, LABAs, mast cell stabilizers, teroids (they immunomodulators, leukotriene modifiers, shouldnt be used as methylxanthines) monotherapy); note Short-term rescue medication (anticholinerthe new black box gics, SABAs, systemic corticosteroids) warning about

cheat sheet

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did you know?


There are new areas of specialization in asthma care. Nurses can join the Association of Asthma Educators or take a certication exam to become certied as an asthma educator, or AE-C. More information about asthma specialization can be found at the National Asthma Educator Certication Board website at http://www.naecb. org.

asthma-related deaths on all preparations containing a LABA methylxanthinessustained-release theophylline is a mild-to-moderate bronchodilator thats used as an alternative, but not preferred, therapy; its essential to monitor serum theophylline levels because of the drugs narrow therapeutic range. Quick relief medications include: anticholinergicsthese agents, such as ipratropium, ipratropium with albuterol, and tiotropium, inhibit muscarinic cholinergic receptors and reduce intrinsic vagal tone of the airways inhaled SABAsbronchodilators 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 corticosteroidsoral 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 providers 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 evi48 Nursing made Incredibly Easy! March/April 2010

dence-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 isnt 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 patients 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 patients level of current impairment and future risk. According to the NAEPP guidelines, the severity and control of a patients 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 patients 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
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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 hes 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 theres 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 its 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 allergenproof 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 environmenwww.NursingMadeIncrediblyEasy.com

tal factors. If theres 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 patients 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.

Stress the importance of an asthma action plan.

Under your influence


Lets check in with our patient. According to the new guidelines, Jims baseline classification is moderate persistent and poorly controlled. He has daily symptoms and requires rescue therapy once a day. At the present time, hes 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, hell 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
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development of an asthma action plan, will be important factors in helping him achieve future control. Before beginning patient teaching, you should assess the patients and his familys 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. Whats 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 patients 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 aerThe PACE curriculum obic exercises to Nurses can help improve outcomes and quality improve cardiopulof life for patients with asthma by partnering monary and muscuwith other healthcare professionals. The loskeletal conditionNational Heart, Lung, and Blood Institutes ing. Also encourage physician asthma care education, or PACE, him to maintain curriculum is available for health educators adequate fluid at http://www.nhlbi.nih.gov/health/prof/lung/ intake to help thin asthma/pace/curriculum.htm. This program bronchial mucus discusses the clinical aspects of asthma, communication strategies, patient education inforand balanced nutrimation, clinical case studies, and information tion. Its highly recon documentation. It includes a slide presentaommended that tion and discussion for healthcare professionals asthma patients to learn more about asthma. receive influenza and pneumococcal

Make sure your patient knows how to use one of these.

vaccinations, if not contraindicated. Teach the patient about the importance of followup 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 patients hospitalization, at the follow-up appointment with his healthcare provider, and even with his pharmacist when hes 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.

Learn more about it


Kelly W, Oppenheimer J, Argyros G. Allergic and environmental asthma. http://www.emedicine.medscape. com/article/137501-overview. McCormick M. Boost your asthma IQ. Nursing made Incredibly Easy! 2009;7(1):42-52. National Asthma Education and Prevention Program Expert Panel Report 3. Education for a Partnership in Asthma Care. Bethesda, Md: National Heart, Lung, and Blood Institute; 2007:93-164. National Asthma Education and Prevention Program Expert Panel Report 3. Measures of Asthma Assessment and Monitoring. Bethesda, Md: National Heart, Lung, and Blood Institute; 2007:36-92. National Asthma Education and Prevention Program Expert Panel Report 3. Medications. Bethesda, Md: National Heart, Lung, and Blood Institute; 2007:213-276. National Heart, Lung, and Blood Institute. Guidelines for the diagnosis and management of asthma (EPR-3). http:// www.nhlbi.nih.gov/guidelines/asthma/index.htm.

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National Heart, Lung, and Blood Institute. The PACE curriculum. http://www.nhlbi.nih.gov/health/prof/ lung/asthma/pace/curriculum.htm. Otto N, OHollaren MT. Recently updated National Institutes of Health asthma treatment guidelines: important clinical applications, part 1. http://www.medscape.com/ viewarticle/580163. Otto N. Recently updated National Institutes of Health asthma treatment

guidelines: important clinical applications, part 2. http:// www.medscape.com/viewarticle/581937. Porth CM. Essentials of Pathophysiology: Concepts of Altered Health States. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:497-498. Wu F, Takaro TK. Childhood asthma and environmental interventions. Environ Health Perspect. 2007;115(6): 971-975.

On the Web
These online resources may be helpful to your patients and their families: Asthma and Allergy Foundation of America: http://www.aafa.org CDC: http://www.cdc.gov/ASTHMA MedlinePlus: http://www.nlm.nih.gov/medlineplus/asthma.html National Heart, Lung, and Blood Institute: http://www.nhlbi.nih.gov/health/dci/Diseases/Asthma/ Asthma_WhatIs.html U.S. Environmental Protection Agency: http://www.epa.gov/asthma.

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