At the conclusion of this exercise, the learner will be prepared to:
- Discuss the lifestyle changes and environmental adjustments that can be instituted to reduce the symptoms and severity of asthma in all asthma patients.
- Discuss the immunotherapy options for the treatment of asthma in those with known allergies.
- Explore the procedural options for the management of severe or uncontrolled asthma.
- Outline the importance of coordination of care in the successful management of asthma patients.
Asthma is a chronic inflammatory airway disorder characterized by airway hyperresponsiveness and recurrent episodes of acute symptoms such as wheezing, coughing, chest tightness, and/or shortness of breath (SOB) that affects between 235 and 300 million people worldwide (Lynn & Kushto-Reese, 2015; World Health Organization [WHO], 2017). According to the Centers for Disease Control and Prevention (CDC), asthma affects more than 24 million Americans and is responsible for over 430,000 hospitalizations, 1.6 million emergency department (ED) visits, and over 10 million office visits to medical providers annually. Asthma costs more than $62 billion annually to treat and causes over 13 million missed school days, and 14 million missed workdays in the United States alone. Amongst patients diagnosed with asthma, roughly half of adults and 40% of pediatric patients are not well controlled (Hsu et al., 2018). When discussing asthma, the term control refers to the presence of symptoms, any limitations in daily activities, and general quality of life (Bostantzoglou et al., 2015).
The management of asthma has three components: non-pharmacological treatment, reliever medications, and control medications. We will be discussing non-pharmacological treatments available that apply to all asthma patients regardless of severity, age, or phenotype, as well as some procedural options for severe/uncontrolled asthma. The Global INitiative for Asthma (GINA, 2018), a collaborative report between the WHO and the National Heart, Lung, and Blood Institute (NHLBI), was last updated and published in 2018. These guidelines emphasize a reasonable and comprehensive list of treatments that asthma patients should be educated on. They recommend quitting smoking (if the patient smokes) or avoiding any exposure to secondhand smoke (if they live with a smoker). The GINA guidelines recommend seeing all adolescent patients separate from their caregivers at least briefly to ask about smoking. They recommend regular physical activity, regardless of whether or not the patient has exercise-induced symptoms (GINA, 2018). Those diagnosed with exercise-induced bronchospasms (EIB) should be counseled on appropriate conditioning and warm-up, or the use of a mask or scarf if cold-induced (NHLBI, 2012). The practice parameter on EIB published in 2016 suggests that a warm-up period prior to high-intensity exercise decreases the severity of EIB (Weiler et al., 2016). EIB patients should be encouraged to exercise regularly, like all asthma patients, despite symptoms (NHLBI, 2012).
The GINA guidelines suggest asthma patients avoid exposure to any known triggers when possible, especially if these are occupational, indoor allergens, or air pollution. Occupational asthma refers to patients that are triggered by a chemical or environmental exposure that occurs as part of their regular workday. It generally increases in severity over time. The primary goal of treatment is to limit exposure. Although many asthma patients may not feel comfortable making extreme decisions such as changing their profession, switching schools, or moving to a rural area that has less smog and air pollution, they can at least engage in a program to reduce exposure to indoor allergens in their own homes and schools. Obesity has been shown to make asthma control more difficult to achieve. Patients who are obese should be strongly encouraged to attempt a comprehensive weight loss plan. Anxiety and depression may lead to worse asthma control, poor adherence, and decreased quality of life (QOL) if not appropriately treated (GINA, 2018).
The National Asthma Education and Prevention Program (NAEPP) last published guidelines, called the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (EPR-3), in 2007. This included a useful algorithm regarding the assessment of asthma severity at initial diagnosis (see Table 1 below) based on the frequency of symptoms, nighttime awakenings, SABA use, and exacerbations in combination with everyday impairment and spirometry results broken down by age group. Notice that symptoms and lung function testing results vary depending on whether the patient is under the age of 5, 5-11, or over the age of 12, which is typically classified as an “adult” in most asthma guidelines (NHLBI, 2012).
These levels of severity, once assessed, then correspond with EPR-3’s stepwise treatment algorithm, which is covered in great detail in The Assessment and Pharmacological Treatment of Mild-to-Moderate Asthma, a separate activity available on NursingCE.com. Suffice it to say, for the purposes of this discussion on nonpharmacological management, step 1 is management for intermittent asthma, while steps 2-6 refer to persistent asthma ranging from mild to severe in ascending order (NHLBI, 2012).
An evidence summary conducted in preparation for the next update to the EPR-3 found that there is a paucity of high-quality studies looking at the effectiveness of managing indoor allergen exposure and its effect on asthma morbidity and control. Consistently, studies that incorporate the use of high-efficiency particulate air filter (HEPA) vacuums appear to decrease the rate of exacerbations and increase the patient's report of QOL. Mattress covers designed to reduce allergens improve non-validated measures of respiratory symptoms when used in combination with other interventions but have no clinical effect when tested on their own. Consistent pest control service reduces the number of asthma exacerbations (Leas et al., 2018). For pediatric patients who spend a large portion of their waking hours in a school environment, JAMA published a study in 2017 regarding the impact of indoor allergens in schools and the students' asthma morbidity. They followed 284 patients between the ages of 4 and 13 in 37 different urban schools in the northeastern US. They collected samples from the students' school and home environments to see how allergen exposure differed in the two environments. They found a higher percentage of school samples contained mouse allergen than home samples, and at a higher concentration. The students who were exposed to a higher than average amount of mouse allergen were statistically more likely to report an “asthma symptom day” with a significant decrease in lung function based on forced expiratory volume (FEV1). In this study, the other allergens found in most samples, including rat, cockroach, cat, dog, and dust mite allergens, do not seem to have the same correlation with asthma symptoms or lung function (Sheehan et al., 2017).
Certain medications can cause worsening asthma symptoms, such as the non-selective ß-blockers and nonsteroidal anti-inflammatory drugs (NSAIDs), as well as ACE inhibitors, non-potassium-sparing diuretics, and cholinergic drugs. These medications should be avoided in asthma patients or stopped if a decline in function or increase in symptoms is seen after starting a trial of these medications (Lynn & Kushto-Reese, 2015). NSAIDs should always be avoided in patients with aspirin-exacerbated asthma, although COX-2 inhibitors and acetaminophen (Tylenol) are usually well-tolerated. All asthma patients should be educated on the importance of a balanced, healthy diet to maintain a healthy weight and breathing exercises to enhance or maintain lung function (GINA, 2018). The American Lung Association (2019) has helpful patient education videos on their website regarding pursed-lip breathing (which involves breathing in through the nose, and then out very slowly through pursed lips, making sure that the exhale lasts at least twice as long as the time spent inhaling), and diaphragmatic breathing (also known as belly breathing, where again the patient breathes in through the nose but places their hands or another object on their belly to reinforce filling the lungs by pulling down and out with the diaphragm into the abdomen, and then slowly exhaling, again taking two to three times the amount of time to exhale as the time spent on inhaling) (American Lung Association, 2019). Decreasing stress has been shown to beneficially enhance asthma control and lung function, and asthma patients should be educated on whichever stress-relief activity or program that fits best with their lifestyle and personality. Finally, GINA and the AAFA both recommend that all asthma patients pay very close attention to their vaccination record and ensure that all recommended vaccinations are up to date, especially influenza and pneumococcal vaccinations (Asthma and Allergy Foundation of America [AAFA], 2015; GINA, 2018).
Immunotherapy for the treatment of allergic asthma has become more commonplace and better studied in recent years. GINA guidelines (2018) list this particular therapy amongst the recommended non-pharmacological treatments that should be considered with asthma patients. Specifically, they recommend sublingual allergen immunotherapy (SLIT) in patients that have allergic rhinitis related to a proven allergy to house dust mites along with an FEV1 of at least 70% of predicted and persistent exacerbations despite treatment with ICS (GINA, 2018). In 2016, a promising study was published in JAMA regarding the use of SLIT. It enrolled 834 adults in Europe with asthma and a proven house dust mite allergy based on positive serum IgE test and/or skin prick test. Of note, severe asthma patients (with hospitalization in the last three months or an FEV1 less than 70% of predicted) were excluded from this study. The study design started with all enrolled patients on oral budesonide (Pulmicort) inhaler as well as a PRN SABA from 7-12 months. Two doses of immunotherapy were tested against an equally sized group of patients given a placebo. After three months of the SLIT therapy, the patients' budesonide (Pulmicort) dose was cut in half, and if no reported exacerbations, was stopped altogether at the six-month mark. They found that both groups of patients given the sublingual allergen had a significantly lower risk of moderate or severe exacerbation versus placebo, although no significant effect on asthma control or QOL was seen. The most frequently reported adverse events include oral pruritus, mouth edema, and throat irritation (Virchow et al., 2016).
In preparation for the upcoming revision of EPR-3, an evidence summary was completed by the Effective Health Care Program. This evidence summary looked at two versions of immunotherapy: SLIT as well as subcutaneous immunotherapy (SCIT). Almost all studies were conducted on patients with house dust mite allergies. They found moderate strength of evidence that SCIT decreased the need for asthma patients to take their long-term control medication such as ICS. SCIT may (low strength of evidence) also increase QOL, decrease the need for reliever or rescue medication use, decrease systemic steroid use, and increase FEV1 amongst asthma patients. They found insufficient evidence regarding SCIT's effect on symptom control, health care utility, or use in pediatric asthma patients. They found local reactions were common, and even systemic reactions were common but mild. There were no reported events of anaphylaxis or death in 462 pediatric patients, but they found insufficient evidence regarding anaphylaxis and death risk associated with SCIT in adults (61 cases of anaphylaxis reported out of 1,037 patients, one death reported). Regarding SLIT, the Effective Health Care Program concluded that there exists high strength of evidence of improvement in asthma symptoms, moderate strength of evidence that it improves FEV1 and decreases the use of long-term ICS, and low strength of evidence that it may decrease the use of reliever medications and improve QOL. They found insufficient evidence regarding SLIT's use in pediatric patients or its effect on systemic steroid use or health care utilization. Regarding the safety of SLIT, they found local reactions to SLIT were common, systemic reactions were frequent, but with only a few (three) reports of anaphylaxis and no reports of death. The conclusion of the reporting committee was that while further studies are needed, such as studies regarding treatment in severe asthma, pediatric patients, and multi-allergen regimens, the current evidence points towards immunotherapy being a safe and effective option for adult allergic asthma patients (Lin et al., 2018). It remains to be seen what the newest final recommendation will be when EPR-4 is published, including this additional research, as the 2007 version recommended considering SCIT for asthma patients with persistent allergic asthma with sensitivities to dust mites, animal dander, and/or pollen (NHLBI, 2012).
Procedural Treatment Options
Bronchial thermoplasty (BT) is another adjunctive therapy mentioned in the GINA guidelines (2018) for adult patients with severe asthma not well controlled with step 4 treatments available. They caution that evidence is limited, and long-term effects are not well known at this time. The procedure involves three bronchoscopy procedures performed monthly to deliver a local radiofrequency pulse. GINA guidelines (2018) caution against a large placebo effect, as well as a transient increase in the number of asthma exacerbations during the three-month treatment period, followed by a subsequent reduction in exacerbations following treatment. They cited no effect on lung function testing or asthma symptoms compared with sham procedures. They suggest a longer follow-up of treated patients and additional studies (GINA, 2018). In 2014, the European Respiratory Society and the American Thoracic Society (ERS/ATS) guidelines on severe asthma suggested BT only be performed within the context of IRB-approved studies (Chung et al., 2014). EPR-3 did not recommend BT as a treatment adjunct but instead requested a systematic review of the evidence to provide a future evidence-based recommendation, presumably in EPR-4. The systematic review found the basic concept of BT to deliver controlled radiofrequency thermal energy to the proximal airway to reduce exacerbations by decreasing excess smooth muscle tissue. They reviewed 15 studies, including 432 patients and three primary randomized clinical trials. Two of the trials compared BT with medical care, and one with a sham procedure. They found a significant reduction in the use of reliever medication but questioned the clinical relevance of this finding. They found that BT combined with standard medical care significantly improved asthma control and QOL scores compared to medical care alone but found low strength of evidence for this. There was insufficient evidence regarding a reduction in severe exacerbations, although there was low strength of evidence of a reduction in mild exacerbations when BT plus medical care was compared to medical care alone. When compared with a sham procedure, BT resulted only in a significant reduction in ED visits (moderate strength of evidence) and exacerbations (low strength of evidence) following the initial treatment period, but did not have a significant effect on asthma control scores, hospitalizations, reliever medication use, or PFT results. QOL results were inconclusive. There were frequent adverse effects reported, including bronchial irritation, chest discomfort, cough, discolored sputum, dyspnea, wheezing, and nighttime awakenings. No deaths were reported, but serious adverse events occurred more frequently in the BT group in all studies. Their final conclusion was that BT should be considered in a very select group of patients and is modestly beneficial. Alair BT is FDA-approved in the US for use in adult patients with severe persistent asthma (D’Anci et al., 2017).
Integration of Care
Asthma is best treated in an integrated, multidisciplinary manner. A study in 2017 looked at the results of such a model in Cincinnati youth between the ages of 2-17. Hospitalizations, ED visits, and the number of readmissions were reduced by over 40%; the number of primary care visits with well-controlled asthma increased by ~50% during the course of three years of implementing the plan. It incorporated inpatient factors during phase 1, such as discharging patients with a 30-day supply of all medications in hand, an asthma action plan (AAP) with training, inhaler training, electronic decision support embedded in the history and physical in the electronic health record, and home health referrals for up to five visits from a registered nurse after discharge. Phase 2 targeted outpatient care and included care coordination services, enhanced pre-visit screening, home health referrals when needed, and a web-based patient registry to track ED visits and hospitalizations. Phase 3 targeted community features, which included a partnership between a primary care practice, the health department, and local public schools to train school nurses on asthma control test (ACT) administration and written action plans for the children at school as well as read-only access to the electronic health records for the school nurse (Kercsmar et al., 2017). A similar concept, the school-based asthma management program (SAMPRO), is designed by the American Association of Allergy, Asthma, and Immunology (AAAAI). It involves four components:
- Circle of support- this support and communication network includes the child, the provider, the family, the school registered nurse, and the community.
- Asthma Management Plan (AMP)- this includes an AAP (medical authorization for self-carry and administration of asthma medications as needed, parental release of information) in combination with a generic asthma emergency treatment plan (AEP) which is an emergency plan for all students in the school, including stock albuterol and a way to administer the medication.
- A comprehensive education plan for all the school personnel.
- Assessment of the school environment with remediation of any triggers present.
They point out that the presence and utilization of an AAP, both at home and at school, has been shown to reduce mortality and ED visits (Lemanske et al., 2016).
Asthma Action Plan
A crucial component of comprehensive care, an AAP serves as a patient’s road map for the management of symptoms at home on a daily basis. In 2014, Dinakar et al. discussed the use of the AAP in the management of acute loss of control, termed the "yellow zone". AAPs utilize a traffic light analogy, and thus the yellow zone is a loss of control that is mild or moderate in nature and not severe enough to require an ED visit. An AAP helps the patient monitor their symptoms and their lung function to first identify where they are in the plan (green, yellow, or red zone) and the appropriate actions to take based on that self-assessment. They recommend that all asthma patients, regardless of age, be given a written or electronic AAP that is reviewed, and if needed, edited or updated at each follow-up visit. They define the green zone as less than two days per week of symptoms (cough, wheeze) or reliever medication use. They define the yellow zone as an increase in symptoms, increased use of reliever medication, a peak expiratory flow (PEF) reading that is decreased 15% from previous reading or less than 80% of PB, or the presence or increase in nocturnal symptoms. Medications can be adjusted by the patient (if necessary) based on their self-assessment and their AAP instructions (Dinakar et al., 2014). GINA guidelines state that all adolescent and adult patients should be educated on and given an AAP (GINA, 2018, p.77). As mentioned above, the AAP is also a crucial component of a school’s asthma management program and planning, as it outlines the best practices for each asthma patient student enrolled (Lemanske et al., 2016). See Figure 1 for a sample plan from the NHLBI, recommended by the EPR-3 guidelines.
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