Chapter 26: Asthma

Patient Care Process for the Management of Persistent Asthma

Collect

• Patient characteristics (e.g., age, race/ethnicity, sex, pregnant)

• Patient history (past medical, known triggers, psychosocial history, gastroesophageal reflux disease)

• Family history (asthma, allergy, atopic dermatitis)

• Home/work environment (environmental, occupational, tobacco smoke, carpet/bedding, pets) (see Table 26-1)

• Current medications and prior response to controller therapies (e.g. ICS+/-LABA; montelukast; LAMA; biologic therapies)

• Subjective and objective data (see Table 26-2)

  • Symptoms (description and frequency)

  • Nocturnal awakenings

  • Albuterol use frequency for symptom control

  • Activity limitation

  • Exacerbation frequency

  • Peak expiratory flow readings

Assess

• Co-morbid conditions (atopy, rhinosinusitis, obesity, obstructive sleep apnea, gastroesophageal reflux, smoking)

• Symptom frequency, including exercise tolerance (see Tables 26-2 and 26-10)

• Exacerbation history (oral corticosteroid use, emergency department visit, hospitalization)

• Current medications that may contribute to or worsen asthma (NSAID, aspirin)

• Appropriateness and effectiveness of current medications in controlling symptoms and preventing exacerbations

• Inhaler technique (see Figure 26-5) and adherence; potential barriers

• Socioeconomic barriers to obtain medications

• Adherence to nonpharmacologic recommendations (allergen avoidance, environmental control)

Plan^*

• Tailored environmental modifications (e.g., pet removal, carpet removal, pillow and mattress covers, exercise pre-treatment, occupational exposures) (see Table 26-1)

• Medication therapy regimen: dose, route, frequency, duration, and MDI spacer; specify the continuation and discontinuation of existing therapies (see Tables 26-4, 26-7, 26-10, 26-11, 26-12; Figure 26-5)

• Monitoring parameters including daily symptoms, nocturnal awakenings, albuterol use, exercise tolerance, peak expiratory flow (in selected patients), and timeframe (see Table 26-11)

• Patient/family education (e.g., purpose of treatment, environmental modifications, drug therapies, inhaler technique)

• Self-monitoring of symptoms, albuterol use, peak expiratory flow (in selected patients)—where and how to record results

• Referrals to other providers when appropriate (e.g., specialist physician)

Implement^*

• Provide patient/family education regarding all elements of treatment plan

• Use motivational interviewing and coaching strategies to maximize adherence

• Schedule follow-up based on symptoms and medication changes

Follow-up: Monitor and Evaluate

• Determine symptom control and exacerbation outcomes

• Presence of adverse effects

• Patient adherence to treatment plan using multiple sources of information

KEY CONCEPTS

• Asthma is a disease of increasing prevalence that is a result of genetic predisposition and environmental interactions; it is one of the most common chronic diseases of childhood.

• Asthma is primarily a chronic inflammatory disease of the airways of the lung for which there is no known cure or primary prevention; the immunohistopathologic features include cell infiltration by neutrophils, eosinophils, T-helper type 2 lymphocytes, mast cells, and epithelial cells.

• Asthma is characterized by either the intermittent or persistent presence of highly variable degrees of airflow obstruction from airway wall inflammation and bronchial smooth muscle constriction; in some patients, persistent changes in airway structure occur.

• The inflammatory process ...