Taking Control of the Airways

In order for the 17 million Americans who suffer from asthma to take control of the disease, managing their asthma is critical. Undertreatment can mean frequent symptoms and attacks, missed work and school, activity limitations and an overall decline in health. For some it can be fatal.

The number of people with asthma is growing rapidly as a result of increased exposure to environmental allergens and irritants, increased exposure to parents' tobacco smoke, socioeconomic factors and better diagnoses, according to the Asthma Sourcebook, a new publication from Omnigraphics Inc. that draws on the expertise from government agencies, nonprofit organizations and periodicals.

There is no cure for asthma. Reasons vary for onset, severity and frequency of attacks from one person to another. It affects people of all ages. Some struggle to breathe on a daily basis, while others only have an attack from time to time. It can range from a nuisance to a life-threatening condition. It can even change within one person, fluctuating as the person ages.

With such an unpredictable disease, it is important for asthmatics to take control of their condition when they can.

When properly managed, asthma-related deaths and hospitalizations are preventable. Patients can live full and active lives by following an appropriate asthma treatment plan, a document specifically tailored to meet the needs of an individual. Using asthma management plans is a patient-focused concept that is growing with increased efforts by many organizations to prevent deaths due to asthma. Currently, 15 people in the United States die each day as a result of asthma, according to the Allergy and Asthma Network / Mothers of Asthmatics Inc. (AANMA).

"Asthma is a serious, potentially life-threatening condition which can migrate among mild, moderate and severe forms of the disease," said Nancy Sander, founder and president of AANMA.

"While asthma can go into periods of remission, it can reappear at any time. This is why each person with a diagnosis of asthma should have a written management plan," Sander said.

The National Institutes of Health's National Asthma Education and Prevention program also recommends written plans for handling asthma attacks, which make it clear when intervention is needed.

Asthma patients, along with family members who care for asthmatic children and their health care providers all need to ask questions to begin formulating effective treatment plans.These questions help determine what triggers the asthma episodes; how reactions to those triggers can be controlled with early recognition of symptoms; and what medications and products are best suited for the individual's treatment goals.

What triggers the asthma attacks?

Asthma is a chronic lung disease characterized by inflammation of the air passages, resulting in narrowing of the airways that transport air from the nose and mouth to the lungs. According to the Journal of the American Medical Association (JAMA), physicians do not know exactly what causes asthma nor are they able to explain why one person gets asthma and another does not. However, physicians do know the triggers that lead to symptoms and how to prevent them from occurring.

The best way to prevent attacks is first to identify what triggers them. Working with a physician, asthmatics can construct a written asthma management plan that identifies personal triggers to avoid, as well as signs that symptoms may be getting worse.

There are two types of asthma triggers: allergic and non-allergic. Allergic triggers include indoor and outdoor molds, animal dander, dust mite particles, food additives and certain medications. Non-allergic triggers include irritants in the air such as tobacco smoke, room deodorizers, paint, household cleaning items, cooking odors, perfumes and outdoor air pollution. In addition, respiratory infections, exercise, sudden changes in temperature and gastroesophageal reflux also are non-allergic triggers.

Triggers lead to asthma episodes where inflammation, constriction and sensitivity get worse at the same time. This causes blockage of air flow, thick mucus plugging the smaller airways, difficulty in breathing, whistling or wheezing, a tight chest and coughing.

In order to prevent asthma attacks, peak flow meters can help patients more accurately determine their triggers by measuring how well breathing is occurring. Peak flow meters tell an asthmatic when an episode is coming.

"Every person with a diagnosis of asthma should know how to use a peak flow meter to measure airway function at home and maintain a daily symptom diary, both of which take less that one minute twice a day to do," Sander said.

Having a documented list of asthma triggers serves to remind patients of ways to avoid exposure, particularly to simultaneous multiple triggers. In cases where triggers cannot be avoided, the list includes the symptoms to look for that warn of an oncoming asthma episode. This warning alerts patients that it is time to prevent a full attack from occurring by following the prescribed method of treatment from their physician.

Each symptom should have a corresponding medication, product to use or other action to be taken. Patients should monitor the effectiveness of the medicine or products that they are using by how well it is controlling or preventing an asthma attack. This information should be documented for later discussion with physicians. Developing and making changes to asthma management plans with physicians encourages communication, helps identify any lapses in effective treatment, and ensures that the patient is receiving the best quality of care.

"Patients frequently do not know what is important for the physician to know about lifestyle, problem solving skills, or even symptoms," Sander said.

If patients possess the right knowledge of their disease, they will be accustomed to recognizing symptoms. Catching symptoms early is important because this is when they are the easiest to control.

How can asthma be controlled?

After learning what brings on asthma symptoms and how to avoid those factors, specific treatments using both medications and products are outlined for each individual plan.Two treatment plans are usually established: one for daily treatment and one for emergencies.The daily treatment plan varies according to the severity of asthma per individual.

In the past, physicians used to focus primarily on bronchoconstriction -- the tightening of the smooth muscles surrounding the lung's airways -- and the role it played restricting airflow. Now physicians address both bronchoconstriction and the damage caused by inflammation. Using bronchodilators combined with inhaled corticosteroids (for inflammation) now offers greater control of asthma.

"It is projected that asthma related deaths in the United States would decrease by half if inhaled corticosteroids were more widely prescribed to those patients who use two or more puffs of their bronchilators each week," Sander said.

The FDA has recently approved the first and only asthma medication that simultaneously treats both of the underlying components of the disease: the dual- action Advair Diskus.

"With the approval of Advair Diskus, we have a medicine that can have a major impact on asthma management," said Dr. Stuart Stoloff, clinical associate professor of family and community medicine at the University of Nevada, Las Vegas.

"It can help people control their asthma by getting to the root of the problem --treating asthma's two components at once.... It's like giving asthma the one-two punch," Stoloff said.

Products commonly used in asthma management plans include inhalers, holding chambers and nebulizers. Insurance providers can inform patients on the maximum number of inhalers covered, allowing patients to stock up and have access to inhalers at work, at home, in the car or at the gym. Having access to inhalers at all times is an effective control measure for asthmatics.

The beneficial use of inhalers can be enhanced with holding chambers. The holding chamber contains the medication released from the inhaler so patients can breathe it in more easily than if they were just using an inhaler alone.

Nebulizers break liquid medication into a fine mist that can be inhaled deeply into the airways.

As part of an overall asthma management plan, an emergency treatment plan -- often referred to as an action plan -- is developed. A prepared action plan established with a physician indicates when to change, increase or add medicines, and what to do if improvement does not occur. Often, an action plan prevents a full-blown episode from occurring by outlining the steps patients need to take in case of emergency. The plan reminds patients to pay attention to warning signs and what to do when they begin to see a warning sign or symptom, because it is all documented.

"Every person with asthma, adult or child, should have a written plan of action with detailed instructions for recognizing and responding to asthma emergency situations," Sander said.

In order to measure the effectiveness of a specific asthma management plan and the products patients are using, the plans are reviewed periodically to see if the treatment goals are being met.

What are the goals of treatment?

Patients should expect to meet certain goals from their established asthma management plans. Goals generally include sleeping through the night without asthma symptoms; not taking off from work or school due to asthma; fully participating in physical activities; breathing with a near normal peak flow rate; not needing emergency room visits or hospitalization; and suffering little or no side effects from asthma medicine.

Goals can be assessed based on the established treatment plan. Patients can inform health care providers of what is or is not working within their management plan. If certain goals are not being met, the long term treatment plan could need to be changed.

With this self management approach to controlling asthma, the success rate of treatment should improve in the future.

What does the future hold?

With asthma management plans, patients can be directly involved in their quality of care. Decisions for treatment will be made based on the information that patients provide, and increased patient involvement typically leads to increased compliance.

JAMA reports that asthma treatment cost an estimated $6.2 billion in 1990. Now, just 10 years later, costs have reached $11 billion, according to the AANMA.

In a study by Health Benchmarks Inc. for a large California HMO, specially designed asthma management programs improved quality of life for patients and reduced costs. Hospitalization for asthma dropped 4 percent and absenteeism from work or school declined by nearly 12 percent among the 1,043 asthma program participants.

"This approach had a significant effect on the asthmatics we worked with because it empowered them to take better control of their lives," said Antonio Legorreta, MD, president and CEO of Health Benchmarks, Los Angeles.

HME providers offer a wide selection of products that can assist patients in the implementation of their asthma management plans.

"This asthma program encourages a partnership among the patient, the patient's family and the physician. If implemented nationally, this method of asthma management could help millions of Americans who suffer from asthma enjoy better lives," said Raeburn Evans, MD, vice president of medical affairs for Integrated Therapeutics Group and co-author of the study.

According to a study released by the Pew Environmental Health Commission at the John Hopkins School of Public Health, asthma is expected to strike 29 million Americans by 2020. With the exact cause of asthma still unknown and the number of asthmatics growing each year, the need for patients to have effective methods of managing their asthma will continue to grow.

Managing asthma with a formulated plan requires more of the patients, but ultimately it will lead to increased control of the disease, allowing patients to lead more active and productive lives.

Internet Resources

  • American Academy of Allergy, Asthma and Immunology
  • American Academy of Family Physicians
  • Allergy and Asthma Network / Mothers of Asthmatics Inc.
  • American Academy of Pediatrics
  • American Association for Respiratory Care
  • American College of Sports Medicine
  • American College of Allergy, Asthma & Immunology
  • An asthma education Web site co-sponsored by five national medical and respiratory associations
  • Asthma in America survey information
  • American College of Chest Physicians
  • American Lung Association
  • National Heart, Lung and Blood Institute
  • National Association of School Nurses, Inc.
  • Web Sites provided by Asthma Outlook, sponsored by Glaxo Wellcome Inc., a research-based pharmaceutical company.

    This article appeared in Home Health Products, November/December 2000, Vol. 8, #10, pg 24, 26-27.

    This article originally appeared in the November 2000 issue of HME Business.

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