Asthma III: Management, Asthma Severity and Environmental Controls Flashcards
why is asthma management important?
improved quality of life may be primary goal
prevent
• Short-term complications e.g., sleep disruption, missed school or work
• Long-term complications e.g., severe exacerbations
• Trying to assess future risk of adverse outcomes.
• Morbidity e.g., hospitalizations
• Mortality / death
Asthma Goals of Therapy
also identify pt’s own goals
- Achieve good symptom control
- Follow the control-based asthma management cycle: Assess, Adjust, Review response
- To minimize future risk of exacerbations, fixed airflow limitation, and side-effects of treatment.
- Develop patient/HCP relationship including shared goals for asthma management.
- Use communication skills that meet the health literacy of patient
Asthma Control Criteria >/= age 6 (CTS/GINA)
Daytime symptoms Nighttime symptoms Physical activity Exacerbations Absenteeism from work or school?
Daytime symptoms <4 days / week Nighttime symptoms <1 night / week Physical activity Normal Exacerbations Mild, infrequent Absenteeism from work or school None
Asthma Control Criteria >/= age 6 (CTS/GINA)
Need for a fast-acting β-agonist
FEV1 or PEF
PEF diurnal variation
Sputum eosinophils
Need for a fast-acting: β-agonist < 4 doses / week (including exercise)
FEV1 or PEF: >90% personal best
PEF diurnal variation: <10-15%
Sputum eosinophils: <2-3%
Assessing Asthma Control in Primary Care
which 2 tests can be used?
extra:
• “Loss of control” is when a person’s asthma is outside of any one of the
control criteria.
• Asthma control should be described in terms of both symptom control and future risk domains.
• Guidelines suggest assessing at every clinical encounter
• 30 Second Asthma Test:
• Yes to any question warrants further assessment and
adjustments to treatment plan.
• For Children 30 Second Asthma Quiz (6-11):
- Asthma Control Test (ACT, various languages, tailored to age group, 1-5 minutes)
- Scores range from 5-25 (higher is better)
- 20-25 well-controlled
- 16-19 not well controlled
- 5-15 very poorly controlled
Assessing Asthma Control in Primary Care
– Children 6 -11
what other qs should you ask them?
- Ask if asthma is having an impact on play, sports, social life and school absenteeism.
- Parents may report irritability, tiredness and change of mood as the main problems.
- Parents have a longer recall period so it is important to involve the parent or caregiver in assessment.
Assessing Asthma Control in Primary Care
– Children 5 and younger
what other qs should you ask them?
• daytime symptoms: wheezing, coughing, diff breathing
- limitations of activities
- nocturnal symptoms, awakening
- need for reliever/rescue treatment
categories under table
Additional Questions to Assess Control
qs to ask to assess future risk of exacerbations
- Is there a history of > 1 exacerbation in the past year?
- Poor adherence?
- Incorrect inhaler technique?
- Is patient willing to demonstrate?
- Low lung function (recent PEF pattern, spirometry results)?
- Recording of spirometry values at diagnosis, 3-6 months after starting treatment, periodically thereafter.
- Smoking?
- comorbidities - chronic sinusitis
- med AE
- pt understanding of condition, goals
Asthma Patient Self-Monitoring
what 5 questions should pts ask themselves to see if asthma is not well controlled
My asthma is not well controlled if I answer ‘Yes’ to any 1 of these questions (at any point in time):
- Do I cough, wheeze, or have a tight chest because of my asthma?
- Does coughing, wheezing, or chest tightness wake me at night?
- Do I stop exercising because of my asthma?
- Do I miss work or school because of my asthma?
- Do I use my reliever medicine 3 or more times a week?
2 strategies for self monitoring for asthma
PEF
• An objective measure of lung function.
• Routine testing not necessary for most patients.
May be useful for patients who have poor awareness of their symptoms
May be useful for patients following an Asthma Action Plan for exacerbation
Asthma Diaries & Calendars
• Teaches patients how to monitor their symptoms, medication use, and possibly PEF.
• Components include an area to document symptoms, scoring of symptoms, identifying medications currently used, PEF (if applicable), and documenting exposureto triggers.
asthma severity
what does it refer to?
mild vs severe asthma meaning?
- Severity refers to overall disease severity, not severity of asthma exacerbations. Retrospective analysis from the level of treatment required to control symptoms and exacerbations.
- Patients with mild asthma may have severe exacerbations, and those with severe asthma may have well-controlled asthma (no exacerbations)
- Confused with uncontrolled asthma which is a more common reason for persistent symptoms and may be easily improved.
Mild asthma = requires lower-intensity treatment to maintain control
Severe asthma = requires higher-intensity treatment to maintain control
Asthma Management Strategies
4 strategies for CTS Asthma Management Continuum
Cycle to assess (3 steps)
- Patient education
- Environmental controls
- Pharmacotherapy
- Written action plan (seminar)
cycle
1. Assessment of symptoms, risk factors and comorbidities.
2. Treatment (pharmacological) and (non pharmacological)
1. Trained on essential skills such as asthma information, inhaler skills, adherence,
action plan, self-monitoring and medical review)
3. Review response
- Patient Education
Should include the patient and/or caregiver
- Explanation of what asthma is
- Definition of asthma control
- Asthma triggers
- Asthma medications / management strategies
- device technique, action plan
- Patient Education – Asthma Action Plan
what are action plans?
highly effective therapeutic tools, particularly
when combined with asthma education, self-monitoring and regular review, shared with HCPs
Canada: (red = emergency, yellow = loss
of asthma control, green = asthma controlled)
- Patient Education – Asthma Action Plan
what should be outlined? (3)
- Recommended daily preventive management strategies to maintain control,
- When and how to adjust reliever and controller therapy for loss of control, and
- Provide clear instructions regarding when to seek urgent medical attention
- Environmental Controls
general principles (3)
- Re-evaluate over time
- Consider financial and emotional impact of suggestions
- Multi-faceted changes are more effective than single interventions in achieving measurable changes in asthma control
- Environmental Controls
Tobacco exposure
what happens with firsthand, secondhand, thirdhand exposure?
Firsthand (active) exposure to fumes and particles
May increase symptoms, cause a decline in lung function, and reduce the efficacy of inhaled corticosteroids
Secondhand exposure to fumes
Is a significant trigger for all ages
Children whose parents smoke may have a higher incidence of infection that causes increased number of exacerbations
Thirdhand exposure to toxic chemicals that remain on surfaces
Can get into household dust
Babies may take in 20x more thirdhand smoke than adults
- Environmental Controls
House Dust Mites (HDM)
microscopic spider found in all homes
what does it do?
• Atopic sensitization is commonly associated with asthma
• Is a perennial allergy source for allergic rhinitis and asthma
• Favorable environments include high humidity and high temperatures
• Results in more feeding/mating, and increased egg production
• Feed on human skin cells
Commonly found in mattresses, bedding, carpets,etc
- Environmental Controls
HDM Control Strategies
- encase mattresses and pillows
- wash all bedding in hot water and hot dryer every 1-2 weeks
- tumble dry pillows
- steam cleaning carpets
- ventilation
- dehumidifier
- discourage sprayed pdts
- Environmental Controls
other helpful strategies
READ
- If asthma symptoms at night, sit up and take reliever inhaler (usually blue) as prescribed.
- Always make sure reliever inhaler is beside bed before sleep, so don’t have to search for it in the middle of the night
- Wait to see results before going back to bed.
• Check bedroom for damp patches on walls and mould growing around
windows.
• Some people are triggered by cold air at night, or by sleeping in a cold room.
If this is a trigger, keep windows closed and keep the heating on low in the bedroom.
• Keep windows closed during high pollen count
