LONG-TERM ASTHMA MANAGEMENT

Asthma is a chronic illness, and good asthma therapy is built on a long-term plan. The ultimate goal for a patient with asthma is the prevention of functional and psychological morbidity to provide as healthy a lifestyle as possible for the individual’s age. Because the goal of asthma treatment and control is for each patient to live a near-normal life, asthma control should minimize the symptoms that interfere with work, school, sleep, exercise, and leisure activities. Asthma exacerbations should be prevented or reduced, and ED visits should be rare.

Control of symptoms and risk reduction are the main features of long-term asthma management. Asthma control, adherence, and inhaler technique are assessed at every visit, and not just when the patient presents because of their asthma.

Control of Symptoms

Symptom control relies on medication that is adjusted in a continuous cycle of assessment, fine-tuning, and review of response. Medications are prescribed at the minimum necessary to maintain control of symptoms.

ASTHMA MEDICATION MANAGEMENT

Medication management for a patient diagnosed with asthma is based on the patient’s severity of symptoms and follows step-therapy guidelines (see “Pharmacology Step Therapy” above). Patients should be seen 1–3 months after starting treatment and every 3–12 months thereafter. After an exacerbation, a review visit within 1 week should be scheduled.

Pregnant women, however, should be reviewed every 4 weeks. Once control of asthma is achieved and maintained for at least 3 months, a gradual reduction of the maintenance therapy should be tried in order to identify the minimum therapy required to maintain control (GINA, 2021).

ASSESSING ASTHMA CONTROL

Asthma control has two domains that require assessment: symptom control and future risk of adverse outcomes. Lung function is an important part of the assessment of future risk and should be measured at the start of treatment, after 3–6 months of treatment (to identify the patient’s personal best), and periodically thereafter for ongoing risk assessment (GINA, 2021).

Achieving and maintaining asthma control are the goals of therapy. Accurate assessment is difficult due to the complex nature of asthma control and to the limitations of assessment methods. Lung function testing is insufficient because patients may have normal spirometry readings between exacerbations. Asthma control level is often overestimated by both clinicians and patients. Patients often under-report asthma symptoms, failing to recognize how asthma affects their daily activities.

There are several standardized tools developed to quantify the level of asthma control, including the following:

  • Asthma Control Test (ACT) is a 5-item questionnaire for patients ages 12 and older. It is a patient-centered/completed questionnaire that assesses only symptom control (night and day) and asks about symptom control over the prior 4 weeks, including:
    • Activity limitation
    • Shortness of breath
    • Use of rescue medications
    • Night time awakening
    • Patient’s perception of asthma control
  • Childhood Asthma Control Test (cACT) is used with children ages 4 to 11 years. Both child and caregiver perspectives are assessed for the previous 4 weeks. It is composed of seven questions, four child-reported and three caregiver-reported.
  • Asthma Control Questionnaire (ACQ), a 5-, 6- or 7-item questionnaire, including spirometry for ages 11 and older, involves asking patients to recall their symptom control over the previous week. It is the only tool that includes lung function testing.
  • Asthma Therapy Assessment Questionnaire (ATAQ) is a brief, self-administered tool for use in adults 18 and older that assesses the level of asthma control during the prior 4 weeks. It includes questions about symptoms, missed work or school, effect on activities of daily living and use of rescue inhalers. A parent-completed ATAQ version is available for children and adolescents ages 5–17 years.
  • Global Initiative for Asthma (GINA), provides a 4-item questionnaire for ages 5 and older about daytime and nighttime symptoms, reliever inhaler use, and activity limitation (University of Newcastle, 2020; Oppenheimer, 2019).
  • Asthma Daytime Symptoms Diary (ADSD) and Asthma Nighttime Symptom Diary (ANSD) are 6-item daily measures of asthma symptom severity that assess breathing symptoms, chest symptoms, and cough. Together, they are intended for twice-daily completion, once upon awakening referring to symptoms during the night and once in the evening referring to symptoms experienced during the day (FDA, 2020).

Once asthma has been diagnosed, lung function is useful as an indicator of future risk and should be done at time of diagnosis, 3–6 months after starting treatment, and periodically after that. Most patients should have lung function measured at least every 1–2 years, more often in children and those at higher risk of flare-ups or lung function declines (GINA, 2021).

ASSESSING QUALITY OF LIFE

Health-related quality of life is considered an important variable to be managed in patients with asthma. Besides physical symptoms, patients may experience fatigue, psychomotor sluggishness, irritability, and mood and cognitive disturbances. The combination of physical symptoms and emotional and functional problems may diminish a patient’s quality of life.

The Asthma Quality of Life Questionnaire (AQLQ) is one of several assessment tools used to measure functional problems (physical, social, occupational) that are most bothersome to adults ages 17–70 with asthma. There are also several questionnaires appropriate for pediatric patients with asthma. (See also “Resources” at the end of this course.)

ADDRESSING CHALLENGES

There are many challenges to successfully maintaining asthma control. Adherence to asthma medication regimens tends to be very poor, with reported rates of nonadherence ranging from 30%–70%. Medication-related factors include difficulties with inhaler devices, complex regimens, side effects, dislike of medication, distant pharmacies, and especially the price of inhalers (Apter, 2021).

HIGH COST OF ASTHMA MEDICATIONS

Asthma is an expensive condition to manage in the United States compared to other developed countries. In some states as many as 20% of people with asthma do not have insurance and are forced to pay out-of-pocket for their inhalers. Individuals lacking insurance tend to live in lower-income areas that also tend to have higher rates of asthma.

An analysis of cash prices for asthma inhalers shows that prices climbed about 35% from 2013 to 2018, from an average price of around $280 in 2013 to more than $380. The average cash price for one inhaler of Advair, for example, increased from $316 in 2013 to $496 in 2018 (56%) (Marsh, 2020).

Other challenges to asthma control that are not related to medications include:

  • Misunderstanding or lack of instruction
  • Fears about side effects
  • Dissatisfaction with healthcare professionals
  • Unexpressed/undiscussed fears or concerns
  • Inappropriate expectations
  • Poor supervision/training or follow-up
  • Anger about one’s condition or its treatment
  • Underestimation of severity
  • Cultural issues
  • Stigmatization
  • Forgetfulness or complacency
  • Attitudes toward ill health
  • Religious issues
  • Social barriers such as work schedules
  • Stress, depression, and comorbidities

In addition to the above challenges, adolescents face developmental challenges that can affect adherence. At this age, individuals are searching for greater autonomy and have a need to be accepted by peers. Challenges may include:

  • Denial of asthma diagnosis or severity
  • Burdensome medication routine that conflicts with the need for greater autonomy
  • Embarrassment around the use of inhalers in front of peers
  • Greater risk of depression and anxiety among this age group

Developing an Asthma Action Plan

A successful asthma management plan requires the continued attention of a disease manager, and the patient or patient’s caregiver should take that role. With their primary care provider, patients design a plan that is realistic, and the patients and caregivers must then ensure that the plan is carried out. To these ends, it is important that providers and patients design an action plan together.

The more patients understand the reasons for their healthcare providers’ recommendations, the more likely it is that those recommendations will be carried out. Providers must shape their recommendations to be realistic for and understandable to each patient; they should also listen to be certain that they are working on their patients’ goals (Apter, 2021b; Kaplan & Price, 2020).

ASTHMA PATIENT EDUCATION

The plan of action includes patient education. It is known that clinician care is necessary, but such care is not sufficient for a patient to achieve control of asthma. The patient also must be taught effective self-management strategies that result in:

  • Improved quality of life
  • Improvement in symptoms
  • Fewer activity limitations
  • Improved medication adherence
  • Fewer urgent care visits
  • Fewer hospitalizations
  • Reduced asthma-related expenditures

Patient education begins at the initial visit and is reinforced with every visit thereafter. Both patients and caregivers are involved in the educational process, which includes instruction and demonstration of understanding of:

  • Pathophysiology of asthma and causes for airflow obstruction that leads to the symptoms of asthma
  • Recognition of various symptoms of a potential asthma attack
  • Medications used for treatment of asthma, including clear instructions and demonstration of the correct use of each type of inhaler and spacer or chamber device being considered for treatment
  • Explanation for and demonstration of the use of a peak flow meter to help detect changes in airflow before symptoms are present and to obtain objective confirmation of changes in airflow when symptoms do develop
  • Premedicating to prevent onset of symptoms and treatment of symptoms
    (Apter, 2021b)
CASE
Patient Education

JONAH, AGE 11   (continued from earlier in this course under “Comorbid Factors”)

Jonah, the 11-year-old identical twin who was brought to the pediatrician’s office by his mother, returned to the office to meet with the nurse after being diagnosed with asthma and given a prescription for a quick-relief inhaler. The following patient education was accomplished at this visit:

  • The nurse gave Jonah the inhaler, described how to use it, and told him he is to use it when he experiences an asthma attack while at home or at school. The nurse then explained how the inhaler works, demonstrated the technique, and had Jonah return the demonstration using a dummy inhaler. She also gave him a pamphlet that pictorially describes the use of the inhaler and instructions on the prescribed dosage and frequency of inhaler use.
  • The nurse gave Jonah tips to help him assess the severity of an attack, noting that when he starts to wheeze, cough, and have difficulty breathing or talking during normal activities, those symptoms signal a need for the use of the inhaler.
  • The nurse reviewed the use of the peak flow meter with Jonah and his mother. Jonah practiced using it to arrive at his “personal best.” This and detailed instructions on how to assess Jonah’s values were discussed.
  • The nurse helped prepare a written set of instructions for Jonah and a separate, more detailed set of instructions for his mother. The mother’s instructions focused more specifically on when to repeat bronchodilator treatment, call his primary care provider, or take Jonah to the emergency department based on his response to the quick-relief bronchodilator as determined by peak flow values and the severity and/or persistence of symptoms.
  • The nurse gave Jonah and his mother a list of patient education websites and videos addressing asthma in children, including a link to an online video series on asthma education for children. (See “Resources” at the end of this course.)
  • Because Jonah’s identical twin brother also has asthma, the nurse discussed with his mother some issues and challenges that might arise between the two brothers. This might include competing between themselves to see who waits the longest before using a rescue inhaler or other ways they may find in which to compare and contrast their illness.
  • The nurse made a separate copy of the mother’s instructions for the school nurse, which Jonah’s mother indicated she would deliver herself.

ELEMENTS OF THE ASTHMA ACTION PLAN

The most effective way to ensure that patients understand how to manage their asthma is by developing an individualized action plan between the patient and their healthcare provider. An action plan is a written worksheet that indicates specific instructions for early treatment of asthma symptoms, what steps should be taken to prevent asthma from worsening, and guidance on when to call a healthcare provider or when to seek emergency treatment (CDC, 2020a).

The following is an example of an action plan that includes recommendations and directions for both adults and children.

SAMPLE ASTHMA ACTION PLAN
 

Person’s name: _________________________

Primary care provider: _________________________

Provider’s phone number: _________________________

Hospital or emergency department phone number: _________________________

Date: _________________________

Personal best peak flow: _________________________

GREEN ZONE: DOING WELL
  • No cough, wheeze, chest tightness, or shortness of breath during the day or night
  • Can do usual activities
  • Peak flow more than: _______ (80% of best peak flow)
Medicine How much to take When to take it
Long-term control medicines (include an anti-inflammatory):
     
     
     
     
Before exercise:
  Number of puffs: _____ 5 minutes before exercise
YELLOW ZONE: ASTHMA IS GETTING WORSE
  • Cough, wheeze, chest tightness, shortness of breath (if not better in 24–48 hours, call primary care provider)
  • Waking at night due to asthma
  • Can do some, but not all, usual activities
  • Peak flow: _______ to _______ (50% to 79% of best peak flow)
Medicine How much to take When to take it
1. Keep taking green zone medications
2. Add quick relief medicines (short-acting beta-2 agonist).
     
     
3. If symptoms (and peak flow) do not return to Green Zone after 1 hour of treatment, increase or add the following:
     
     
4. Call the doctor before/within _____ hours after taking an oral steroid
RED ZONE: MEDICAL ALERT!
  • Very short of breath, fast breathing, or
  • Trouble walking and talking due to shortness of breath, or
  • Lips or fingernails are blue, or
  • Quick-relief medicines have not helped, or
  • Cannot do usual activities, or
  • Symptoms are same or get worse after 24 hours in Yellow Zone
  • Peak flow less than: _______ (50% of best peak flow)
Medicine Amount How Often
1. Take these medications:
     
     
2. Call your primary care provider now. Go to your hospital or call an ambulance if you are still in the Red Zone after 15 minutes and you have not reached your provider.

(See also “Resources” at the end of this course for a link to the NHLBI “Asthma Action Plan” worksheet.)

(Adapted from NHLBI, 2020c.)

CASE
Asthma Action Plan

Sixteen-year-old Nadia, recently diagnosed with asthma, is meeting with the office nurse, who is assessing Nadia’s current status so she can report her findings to Nadia’s physician. The nurse judges Nadia’s asthma severity to be moderate and notes her baseline FEV1 and PEF values. She also notes that Nadia’s asthma appears to be triggered by exercise, dust mites, and fragrances, and that Nadia’s knowledge of the disease appears to be minimal.

The nurse then counsels Nadia on the basics of asthma management, focusing on issues such as carrying an inhaler (particularly during exercise), avoiding asthma triggers, using a peak flow meter, and anticipating and handling an attack. These matters are incorporated into the written asthma action plan, which includes a diary for Nadia to record the following information:

  • The daily state or level of Nadia’s asthma (including assessment of her symptoms, lung function, and ability to perform routine activities)
  • Nadia’s response to asthma attacks
  • Phone numbers and website addresses for Nadia’s physician, the local hospital, and organizations providing asthma-related educational information and counseling

The medication portion of the written plan outlines step therapy for asthma management, starting with short-acting beta agonist inhalers and progressing to corticosteroids (at increasing doses) and other medications as appropriate. These instructions emphasize the need to administer the minimal amount of medication to control Nadia’s symptoms as well as the importance of assessing her asthma severity level at each step of the protocol.

Once Nadia has reviewed and accepted the written plan, she schedules a follow-up appointment in two weeks, at which time her degree of asthma control will be assessed and her medications will be adjusted as necessary.

Recognizing Asthma Triggers and Exposure Reduction

Patients will usually know many of the things that trigger or worsen their asthma symptoms. As the patient and clinician work to identify all the environmental factors that are asthma aggravators, it is helpful to give the patient a list showing the wide range of common triggers and how to avoid them. (See also “Asthma Triggers and Aggravating Factors” earlier in this course.)

EXPOSURE REDUCTION STRATEGIES FOR COMMON ASTHMA TRIGGERS

Dust mites are tiny insects, too small to see, that can be found in every home in dust, mattresses, pillows, carpets, cloth furniture, sheets and blankets, clothes, stuffed toys, and other cloth-covered items. If sensitive:

  • Use mattress and pillow covers that prevent dust mites from going through them, along with high-efficiency particulate air (HEPA) filtration vacuum cleaners.
  • Launder bedding weekly in hot water.
  • Do not use down-filled pillows, quilts, or comforters.
  • Consider reducing indoor humidity to below 50% using a dehumidifier or central air conditioning system.

Cockroaches and rodents leave droppings that may trigger asthma. If sensitive:

  • Consider professional pest management.
  • Keep food and garbage in closed containers to decrease chances for attracting roaches and rodents.
  • Use poison baits, powders, gels, pastes (e.g., boric acid), or traps to catch and kill pests.
  • If using a spray to kill roaches, stay out of the room until the odor goes away.

Animal dander (the flakes of skin or dried saliva from animals with fur or hair) are an allergen to some people. If sensitive:

  • Consider keeping pets outdoors.
  • Confine pets to common areas of the home only and keep out of bedrooms.

Indoor mold:

  • Explore professional mold removal or cleaning to support complete removal.
  • Wear gloves to avoid touching mold with bare hands if removing it by oneself.
  • Ventilate the area if using a cleaner with bleach or strong smell.
  • Dry damp or wet items within 24–48 hours.
  • Do not let damp clothes sit in a basket or hamper.
  • Fix water leaks throughout the home.
  • Remove carpet from basements, bathrooms, and bedrooms.
  • Replace absorbent materials, such as ceiling tiles and carpet, if mold is present.
  • Use an inexpensive hygrometer to check humidity levels and keep humidity no higher than 50%.
  • Empty, defrost, and clean refrigerators regularly.
  • Empty and clean air conditioning drip pans regularly.
  • Run the bathroom exhaust fan or open a window when showering.

Pollen and outdoor mold. When pollen or mold spore counts are high:

  • Keep windows closed.
  • If possible, stay indoors with windows closed from late morning to afternoon, which is when pollen and some mold spore counts are highest.
  • When traveling by car, keep windows closed and air conditioning on in the recirculation mode.
  • Leave lawn mowing, weed pulling, and other gardening chores to others.
  • After going outside, change clothes as soon as possible and put dirty clothes in a covered hamper or container to avoid spreading allergens in the home.
  • Wear a pollen mask if doing outside chores.
  • Talk with a healthcare provider to see if it is necessary to increase anti-inflammatory medicine before the allergy season starts.

Tobacco smoke:

  • Quit smoking (or ask a healthcare provider for assistance).
  • Ask and encourage family members to quit smoking.
  • Do not allow smoking in the home or the car.

Smoke, strong odors, and sprays:

  • If possible, avoid using a wood-burning stove, kerosene heater, or fireplace.
  • Vent gas stoves to outside the house.
  • Avoid air fresheners.
  • Avoid strong odors and sprays, such as perfume, talcum powder, hair spray, and paints.

Vacuum cleaning:

  • Enlist someone else to vacuum once or twice a week, if possible. Stay out of rooms while they are being vacuumed and for a short while afterward.
  • If one must vacuum, use a HEPA filtration vacuum cleaner.

Foods and medications:

  • To avoid sulfites in foods and beverages, do not drink beer or wine or eat dried fruit, processed potatoes, or shrimp if they cause asthma symptoms.
  • Inform a healthcare provider about all medicines being taken. Include aspirin, vitamins, and other supplements as well as nonselective beta blockers (including those in eyedrops).

Weather:

  • Monitor the weather forecast to be prepared for changes that may trigger asthma symptoms.
  • Carry a small scarf to go over the nose and mouth in windy or cold weather.

Physical activity and exercise:

  • Use rescue medicines before sports or exercise to prevent symptoms, if included in asthma plan.

Viruses, colds, influenza, bronchitis:

  • Wash hands often.
  • Avoid touching eyes, nose, or mouth.
  • Avoid contact with people who have colds.
  • Get a flu shot every year, preferably in the fall, per provider recommendations.
  • Get a pneumonia vaccine if over the age of 65.
  • Get the COVID-19 vaccine if eligible.

Recreational drugs increase the risk of life-threatening exacerbation and can cause missed doses of prescribed asthma medications.

  • Avoid use of recreational drugs, including cannabis, cocaine, crack cocaine, hallucinogens and dissociative drugs, heroin, inhalants, and poppers.

Strong emotions (laughing, crying, feeling stressed or anxious, anger, fear, yelling):

  • Avoid stress-inducing situations whenever possible.
  • Use relaxation exercises and techniques.
  • Take advantage of work breaks and lunch hour.

(NHLBI, 2021; Mayo Clinic, 2020d; CDC, 2020b; CDC, 2021c; Asthma UK, 2019)