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The Pharmacist's Role in Asthma Prevention
US Pharm. 2005; 7:61-65 (July 2005)
by Jake Mossman, BSPh, RPh, President and Pharmacist-in-Charge
Taos Pharmacy and Total Health and Wellness Center, Taos, NM
Copyright © 2005, Jobson Medical Information LLC. Posted with permission.
By individualizing treatment plans, pharmacists help patients self-manage their asthma and avoid costly hospitalizations.
Asthma, a reactive airway illness and a chronic respiratory disease, affects nearly 20 million Americans.1 Over the past two decades, the cost of treating asthma has increased in the United States, while the rates of mortality and hospitalization due to asthma have decreased. These trends may indicate a higher level of disease management.1 Self-management intervention techniques have proven beneficial. In a study measuring the effectiveness of an Asthma Self-Management Program (ASMP) that included instruction on the respiratory system, trigger avoidance, monitoring techniques, and the use of a peak flow meter, metered dose inhaler, and asthma journal, the ASMP improved patient function and reduced nighttime wakings, work and school absences, hospitalizations, and emergency department visits.2 Pharmacists can have an important role in continuing this trend through patient education, improved monitoring of symptoms, and individualized treatment action plans.
Signs and Symptoms
Asthma is characterized by episodes or attacks in response to triggers, such as cigarette smoke, dust, and other environmental irritants. The primary clinical features of asthma are inflammation and increased sensitivity of the airways to a variety of stimuli and obstruction of airflow. Inflammation of the airway lining is the most common symptom and causes the lining to swell, narrow, and become increasingly sensitive. This sensitivity causes the smooth muscles surrounding the airways to constrict and obstruct airflow. Some patients also produce excessive mucus along the airways, which further restricts airflow and may cause a whistling sound during breathing, known as wheeze. Other symptoms of airflow obstruction include coughing, tightness of the chest, and difficulty breathing.3
Rates of asthma decrease with age. Eighty-three of 1,000 children up to age 17 years had asthma, compared to 68 of 1,000 adults ages 18 years and older.4 In one study, the prevalence of asthma was 30% higher in adult female patients than in male patients.4 However, this pattern is reversed in children. The rate of asthma in male children up to age 17 years is 30% higher than in their female counterparts.
Asthma Medications
Asthma can be managed in most people. It may be fatal if not properly treated. Asthma is classified as mild intermittent, mild persistent, moderate persistent, or severe persistent. Goals of treatment include lessening symptoms and number of attacks, reducing the need for short-acting bronchodilators, and increasing the ability to complete normal activities without experiencing symptoms.4 Quick-relief and long-term control medications are the main types of asthma treatment. Quick-relief medications stop symptoms from worsening and prevent serious asthma attacks. The most common quick-relief medications are short-acting inhaled bronchodilators. Albuterol is used most often and is administered orally in solid or liquid forms, or through a metered-dose inhaler by a nebulizer.
Long-term medications are used daily over long periods of time to prevent asthma symptoms. The most common long-term medications are inhaled corticosteroids such as fluticasone propionate (Flovent), beclomethasone dipropionate, and triamcinolone acetonide (Azmacort). Other long-term treatments include long-acting bronchodilators, cromolyn, nedocromil, theophylline, and leukotriene modifiers such as montelukast (Singulair). Most patients need quick-relief medications to relieve worsening symptoms and long-term medications to reduce inflammation. FIGURE 1 lists treatments of asthma at varying intensities. Treatment of asthma also includes nonpharmacologic strategies such as patient education, patient monitoring, and a treatment action plan.
Self-Management Interventions
Patients and parents of children with asthma should be able to identify the signs of a worsening condition (TABLE 1). The National Asthma Education and Prevention Program (NAEPP) recommends the use of written action plans as part of a self-management program, especially in patients with moderate or severe persistent asthma or with a history of severe exacerbations.6 A patient's daily action plan program may list triggers, daily medications, doses, and data from peak flow meter readings. Action plans should also include an annual flu vaccination. Although adults with asthma are at high risk of developing complications following infection with the influenza virus, only about one third of asthmatic adults are vaccinated for influenza each year.7
An emergency action plan may include warning signs, peak flow meter readings, medications and doses, a doctor's telephone number, and a hospital's emergency department telephone number. Patients with asthma should learn to recognize emergency warning signs that indicate a medical intervention is needed immediately. Emergency warning signs include changes in breathing patterns (e.g., faster, shallower, more difficult than usual), coughing or wheezing that won't stop, and a bluish coloration of the lips or fingertips.
Action plans should identify the triggers that can start or worsen an attack (TABLE 2). Keeping an asthma diary that records the conditions of an attack is a good way to identify triggers (see sample "Your Asthma Diary" below). Patients should remember the circumstances that worsened their asthma. Were they around someone that was smoking or in a particularly dusty room? Were they petting a friend's dog? Once triggers are identified, an effort should be made to avoid them. Avoiding triggers sometimes involves difficult decisions such as getting rid of a household pet or missing a family picnic if the air quality is very poor.
The benefit of patient action plans was demonstrated in a study that compared the use of self-management interventions in adults.8 One group included the use of written action plans in their self-management strategy, while the other group did not. The group using written action plans had the greatest benefits, including improved lung function and a reduction in hospitalizations and emergency department visits.
Peak Flow Meters
Daily peak flow meter measurements can help monitor disease status. The NAEPP recommends peak flow monitoring for patients with moderate or severe persistent asthma. An inability to recognize or report signs and symptoms of worsening asthma, or bias in patient reporting may warrant peak flow meter monitoring. Peak flow meter monitoring can also improve patient-clinician communication and may increase patient awareness of disease status and control.6
A peak flow meter is a simple, inexpensive, portable device that measures air flow in the lungs. To use a peak flow meter, the sliding marker should be at the bottom of the numbered scale, and patients should stand up straight and take the deepest breath possible. With the lips closed tightly around the mouthpiece, the user should blow out as hard and quickly as possible in one breath and keep blowing until the lungs are emptied. The force of the air will move the marker along the scale. The process should be repeated three times, and if the proper technique is used, the three readings should be close. The highest reading, and not the average, should be recorded. Measurements can be taken in the morning and in the evening at approximately the same times each day. When used daily, a peak flow meter can warn of diminishing airflow before symptoms arise. Although the patient's breathing may feel fine, a peak flow meter can identify slightly decreased lung function.9
Metered Dose Inhalers
Patient education should include proper inhalation technique with a metered dose inhaler and spacer device, when indicated. To use a metered dose inhaler, patients should stand, shake the inhaler three or four times, remove the mouthpiece cover, and breathe out slowly to the end of a normal breath.
Open-mouth and closed-mouth inhalation techniques are recommended with a metered dose inhaler, and patients should use the method recommended by their health care practitioner. The open-mouth technique involves holding the inhaler between the thumb and one or two fingers and placing it 1 to 2 inches in front of a widely opened mouth. The closed-mouth technique involves placing the mouthpiece between the teeth and over the tongue, with the lips wrapped tightly around it. With both methods, the patient slowly breathes in through the mouth while pressing the top of the canister to get one puff of medicine, continues breathing in for three to five seconds, and holds the breath as long as he or she can for up to 10 seconds. This gives the medicine time to settle into the airways and lungs. The patient then takes the mouthpiece away from the mouth and breathes out slowly.
It is important that the patient simultaneously press the canister and slowly breathe in for the medicine to reach the lungs. If a fine mist comes from the mouth or nose during the closed-mouth method, the inhaler is not being used correctly. If a physician has instructed the patient to inhale more than one puff of medicine at each dose, the patient should wait 30 to 60 seconds, shake the inhaler, and take the next puff. When done, patients should wipe the mouthpiece and replace the cap.10 Inhaled corticosteroids require rinsing the mouth with water after using the inhaler.
The FDA has banned the use of chlorofluorocarbons in inhaler devices after 2008. Newer nonaerosol inhaler devices such as Serevent Diskus and Advair Diskus are available. Pharmacists should review the use of these devices with patients when dispensing the initial prescription and periodically review proper techniques for all inhaled medications.
Spacer Devices
Spacer devices are inexpensive, portable tools that can assist the delivery of inhaled medications. Spacer devices can be especially helpful to children, the elderly, and patients with arthritis of the hands who have difficulty coordinating the activation of a metered dose inhaler. To use a spacer device, patients should attach the spacer to the inhaler according to the manufacturer's directions, gently shake the inhaler and spacer three or four times, and breathe out slowly to the end of a normal breath while holding the mouthpiece away from the mouth. The mouthpiece is then placed between the teeth and over the tongue with the lips closed around it, and the canister should be pressed to release one puff of medicine into the spacer. Within one or two seconds, a patient should begin to breathe in slowly through the mouth for three to five seconds, and hold the breath as long as he or she can for up to 10 seconds. Without removing the mouthpiece, the patient should then slowly breathe in and out two or three more times to empty the spacer. If a doctor has instructed more than one puff of medicine to be taken at each dose, the inhaler and spacer should be gently shaken and the next puff should be administered. More than one puff of medicine should not be put into the spacer at a time. When finished, patients should remove the spacer from the inhaler, wipe the mouthpiece, and replace the cap. The inhaler and mouthpiece should be cleaned once a week by removing the canister from the inhaler, washing the mouthpiece and cap with warm, soapy water, and allowing the parts to dry completely before reassembling the inhaler.
Conclusion
Controlling asthma requires an appropriate diagnosis, effective use of medications, and awareness of environmental exposures and behaviors that negatively impact the patient. Self-management interventions can be effective in controlling asthma.11 Pharmacists can help patients manage asthma through education, monitoring symptoms, and developing individualized treatment action plans.
REFERENCES
1. Trends in Asthma Morbidity and Mortality. American Lung Association. Available at: www.lungusa.org/atf/cf/{7A8D42C2-FCCA-4604-8ADE-7F5D5E762256}/asthma1.pdf. Accessed June 2005.
2. Lucas DO, Zimmer LO, Paul JE, et al. Two-year results of the asthma self-management program: long-term impact on health care services, cost, functional status, and productivity. J Asthma. 2001;38:321-330.
3. What is Asthma? National Jewish Medical and Research Center. Available at: http://asthma.nationaljewish.org/about/what. Accessed June 2005.
4. Asthma Prevalence, Health Care Use and Mortality 2002. National Center for Health Statistics. Available at: www.cdc.gov/nchs/products/pubs/pubd/hestats/asthma/asthma.htm. Accessed June 2005.
5. How is Asthma Treated? National Heart, Lung, and Blood Institute. Diseases and Conditions Index. Available at: www.nhlbi.nih.gov/health/dci/Diseases/Asthma/Asthma_Treatments.html. Accessed June 2005.
6. The NAEPP Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma Update on Selected Topics 2002. National Institutes of Health, National Heart, Lung and Blood Institute. NIH Publication No. 02-5075.
7. Ford ES, Mannino DM, Williams SG. Asthma and influenza vaccination findings from the 1999-2001 National Health Interview Surveys. Chest. 2003;124:783-789.
8. Gibson PG, Powell H, et al. Self-management education and regular practitioner review for adults with asthma (Cochrane Review). The Cochrane Library, Issue 2, 2005. Chichester, England: John Wiley & Sons, Ltd.
9. Tips to Remember, Public Education Committee of the American Academy of Allergy, Asthma and Immunology, 2003 (brochure).
10. Bronchodilators, Adrenergic (Inhalation). Medline Plus, U.S. National Library of Medicine and the U.S. National Institutes of Health. Available at: www.nlm.nih.gov/medlineplus/druginfo/uspdi/202095.html#SXX14. Accessed June 2005.
11. Centers for Disease Control, National Center for Environmental Health. Potentially Effective Interventions for Asthma. Available at: www.cdc.gov/asthma/interventions. Accessed June 2005.
12. United States Environmental Agency, Indoor Environments Division. Office of Air and Radiation, EPA 402-F-04-021. November, 2004 (brochure).
US Pharm., Vol. No: 30:07 Posted: 7/15/2005
DOWNLOAD a pdf here of the actual Journal article, reprinted with permission from US Pharmacist.
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