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Improving management of the asthma patient

Alison Conway
RN BSc(Hons)
Respiratory Nurse Specialist
Department of Respiratory Medicine
Glenfield Hospital
Leicestershire
Regional Trainer
National Respiratory Training Centre
E:alison.conway@uhl-tr.nhs.uk

Asthma is a chronic inflammatory disease of the airways characterised by bronchial hyperreactivity and airflow obstruction. The airway obstruction is partially or completely reversible either spontaneously or in response to treatment.(2) In genetically susceptible individuals, allergens, respiratory infections, environmental and occupational exposures, and a gamut of as yet unknown host or environmental stimuli, result in the development of asthma. Once airway inflammation and bronchial hyperreactivity are established, asthma may be triggered by additional factors, such as cold air, laughter, exercise, cigarette smoke and emotional stress.
When a sensitised individual inhales a specific allergen, the antigen attaches to immunoglobulin E (IgE) molecules on the surface of mast cells. This causes rapid (within 30 minutes) degranulation of the mast cell releasing multiple inflammatory mediators, including histamine, prostaglandins, leukotrienes and other mediators. These mediators cause smooth muscle contraction, capillary congestion and increased vessel wall permeability, mucosal oedema, hypersecretion of mucus and epithelial shedding. This inflammatory cascade may be biphasic, in that the initial degranulation of mast cells occurs rapidly but also resolves rapidly within 30-60 minutes. This is known as the early asthmatic response (EAR). However, approximately 50% of asthmatics will go on to develop further airflow obstruction 3-8 hours later, known as the late asthmatic response (LAR).(1) This phase is often prolonged and more severe. Key inflammatory cells implicated in the LAR include eosinophils, lymphocytes and macrophages. The physiological response to the inflammatory cascade results in the clinical picture of airflow obstruction (characterised by a fall in peak flow or FEV(1) [forced expiratory volume in 1 second]), breathlessness, wheeze, cough and eventually impaired gaseous exchange.
The mainstay of asthma management includes control of inflammation, through the use of inhaled corticosteroids, and bronchodilation from short- and/or long-acting b-agonists. For patients with a highly atopic history and/or aspirin sensitivity, leukotriene modifiers (montelukast/zafirlukast) may be used as adjunct ­therapy and these now appear in step 3 of the new British Thoracic Society guideline.(3)
Recent national surveys have shown that asthma continues to cause significant disruption to millions of people's lives and the symptoms they report are largely due to inadequate asthma control.(4)
The Impact of asthma survey found that4:

  • 27% of respondents felt that asthma totally ­controlled their life.
  • 42% experienced asthma symptoms every day.
  • 44% were woken at least once a night by cough, wheeze or breathlessness.
  • 1 in 4 people felt that asthma had a "major impact" on their lives.

One possible reason for this persistent morbidity is the failure to adhere to treatment regimens.
Of the 52,664 patients questioned within the Impact of asthma survey, only 55% reported that they followed exactly the instructions for taking their medication and a recent World Health Organization report supports this.(5)
The reasons given for failure to adhere to advice are shown in Figures 1 and 2.

[[NIP12_fig1_18]]

[[NIP12_fig2_18]]

Estimated costs for asthma medication in the UK are in excess of £500m per year.(6) However, patients are not taking the drugs prescribed and poor compliance with therapy has been shown to be a major factor in the morbidity and mortality among patients with asthma.(7)
One of the most important roles of the healthcare professional in the care of patients with asthma is evaluating and improving adherence to treatment. If a patient presents with persistent symptoms, poor adherence should always be investigated before increasing or adding in additional medication.
Nonadherence may be deliberate (the patient knowingly omits treatment) or mistaken (the patient is unable to use the device). The latter is generally easier to address given the vast array of devices currently available on the market. Deliberate noncompliance is a much more complex situation and requires skillful questioning and negotiation on the part of the healthcare professional (see Table 1). Key factors for improving noncompliance include education, empathy, negotiation and setting patient-specific goals.

[[NIP12_table1_19]]

In order to address these and other issues surrounding adherence the health professional must assume a number of roles including counsellor, educator, problem solver and negotiator. If successful in implementing these roles:

"Health professionals are able to influence the outcomes of patients … not only by competent medical care, but also by shaping how patients feel about their disease, their sense of commitment to the treatment process, and their ability to control or contain its impact on their lives."(8)

The ability of the health professional to influence the patient derives from a number of sources, including the credibility of the prescriber in the patient's eyes, the delivery of education which is relevant to the individual, the degree of rapport and "liking" the patient has for the prescriber, and their ability to motivate. To provide an effective consultation the prescriber and patient must be seen to be at least on equal terms, preferably with the health professional as the "junior partner".(9)
Health professionals must break down the previously upheld barriers between practitioner and patient, allowing a partnership approach in asthma care. In this context:

"The patient is seen to enter the picture not just as a ­recipient of drugs and ­goodwill, but as a ­partner in management, someone who will and can learn to adjust, anticipate, control their disease with ­reference back to the carers when needed, but more and more self-managing."(9)

The three basic principles of successful asthma education can be summarised as " three Ps and one R"(9):

  • Personalised.
  • Practical.
  • Preventive
  • Repeated.

As a problem solver the nurse/doctor must first look at making the treatment regimen as simple and straightforward as possible. The health professional may be forced to accept that the ideal treatment regimen for the patient may not be the ideal regimen in the patient's eyes. Ideally treatment should be tailored so that the patient has to take doses as infrequently as possible during the day, minimising disruption to lifestyle. Trying to associate the medication with an everyday task undertaken by the patient can help to jog their memory. The most frequently used example is leaving an inhaler next to the patient's toothbrush. However, not everyone cleans his or her teeth twice a day, or even once a day. It is therefore necessary to avoid make assumptions based on one's own ideas of what is normal routine, but to find out more about the patient's lifestyle. It may be more appropriate to leave the inhaler by the dog's lead!
Prescription costs may be a significant factor in non-adherence with asthma therapy. Nonredemption of prescriptions for asthma medication is more likely in those patients with mild-to-moderate asthma and in those in lower socioeconomic groups.(10)
One recent survey has shown that as many as one in eight people have on occasion been unable to afford the medication prescribed.(4) Unfortunately the item most frequently not redeemed is inhaled steroids.(11) This may be because the patient does not perceive any immediate benefit to this therapy:

"Many patients are able to participate in an ­analysis of the risks/benefits of treatment, when applied to themselves, providing health ­professionals offer sufficient information in an open, honest and understandable format."(4)

If the patient is not adhering to the prescribed regimen then the prescriber must discuss with the patient the reasons for this and try to renegotiate new, agreed goals. This process may be cyclical.
From the literature it appears that key elements for improving adherence include:

  • Education (on disease processes, self-management and medication).
  • Breaking down of traditional barriers between healthcare professionals and patients.
  • A partnership approach
  • The adoption of a number of roles by the healthcare professional to facilitate all of the above.

Therefore within the context of a therapeutic alliance, treatments and the patient's commitment to them are the result of education, persuasion and negotiation with the ultimate goal of settling on the most efficacious treatment to which the patient will commit. If the patient does not follow the negotiated regimen, then the treatment and/or therapeutic goals are renegotiated following discussion about the reasons for nonadherence.
Conway suggests that noncompliance should be considered "normal behaviour" and that the healthcare professional must alter his or her own behaviour in the light of this.(12)
Persistent inflammation within the airways will lead to irreversible epithelial damage, collagen deposition and subsequent airway remodelling, ultimately resulting in fixed airflow obstruction. Prevention of this is the main aim of asthma management.

Key points

  • The majority of asthma is managed in primary care
  • Asthma causes significant ­morbidity and disruption to patient lifestyle
  • Nonadherence with medication is a major factor in this persistent morbidity
  • Device selection should be based on the patient's ability to use the device, their personal ­preference and drug availability with the device
  • Education, self-management and jointly negotiated goals for ­treatment are the cornerstone of caring for the patient with asthma

References

  1. National Asthma Campaign Asthma Audit. Out in the open. A true picture of asthma in the United Kingdom today. Asthma J 2001;6 Suppl.
  2. Dweik R, Stoller JK. Obstructive lung disease: COPD, asthma and related diseases. In: Scanlan CL, Wilkins RL, Stoller JK, editors. Egan's fundamentals of respiratory care. 7th ed. St Louis: Mosby; 1999. p. 441-62.
  3. The British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Thorax 2003;58 Suppl 1:S1-94.
  4. National Asthma Campaign. Impact of asthma survey. London: Allen & Hanburys; 1996.
  5. World Health Organization. Adherence to long-term therapies. Evid­ence for action. Switzerland: WHO; 2003.
  6. Hoskins G, McCowan C, Neville RG, Thomas GE, Smith B, Silverman S. Risk factors and costs associated with an asthma attack. Thorax 2000;55:19-24.
  7. Bender B, Milgrom H, Rand C. Nonadherence in asthmatic patients: is there a solution to the problem? Ann Asthma Immunol 1997;79:177-86.
  8. Kaplan SH, Greenfield S, Ware JE. Impact of the doctor patient relationship on the outcomes of chronic disease. In: Stewart M, Roter D, editors. Communicating with medical patients. London: Sage; 1989. p. 313-28.
  9. Pearson R. Asthma management in primary care. Oxford: Radcliffe Medical Press; 1990.
  10. Watts RW, McLennan G, Bassham I, el-Saadi O. Do patients with asthma fill their prescriptions? A primary compliance study. Aust Fam Physician 1997;26 Suppl 1:S4-6.
  11. Wilcock M. Primary non-­compliance with prescriptions for ­respiratory inhaler devices. Asthma J 1998;March.
  12. Conway SP, Pond MN, Hamnett T, Watson A. Compliance with treatment in adult patients with cystic fibrosis. Thorax 1996;51:29-33.

Resources
British Thoracic Society
W:www.brit-thoracic.org.uk

National Asthma Campaign
W:www.asthma.org.uk

American Academy of Allergy, Asthma and Immunology
W:www.aaaai.org

Global Initiative for Asthma
W:www.ginasthma.com