| Home |
 |
Chapter 13 |
|
For successful long-term asthma management, it is essential to identify and reduce exposures to relevant allergens and irritants that have been shown to increase asthma symptoms and /or precipitate asthma exacerbations. These factors fall into categories: inhalant allergens, occupational exposures and nonallergic factors.
Inhalant allergens:
Irritants
IS THE ASTHMA MANAGEMENT PLAN MEETING EXPECTED GOALS?
| Ask the patient: | Action to consider: |
|
Has your asthma awakened you at night? Are you participating in your usual physical activities? Have you needed more quick-relief medications than usual? Have you needed any urgent medical care Has your peak flow been below your personal best? | Adjust medications and management plan as needed (step up or step down). But first, assess compliance. |
IS THE PATIENT USING INHALERS, SPACERS OR PEAK FLOW METERS CORRECTLY?
| Ask the patient: | Action to consider: |
| Please show me how you take your medicine? | Demonstrate correct technique. Have patient demonstrate back to you. |
IS THE PATIENT TAKING THE MEDICATIONS S AND AVOIDING TRIGGERS ACCORDING TO THE ASTHMA MANAGEMENT PLAN?
| Ask the patient, for example: | Action to consider: |
| So that we may plan therapy, please tell me how often you actually take the medicine. | Adjust plan to be more practical. |
| What problems have you had following the management plan or taking your medicine? | Problem solve with the patient to overcome barriers to following the plan. |
| During the last month, have you every stopped taking your medicine because you were feeling better? | Review how the drugs work with the patient and clarify any misunderstandings. |
DOES THE PATIENT HAVE ANY CONCERNS?
| Ask the patient: | Action to consider: |
| What concerns might you have about your asthma, medicines or management plan? | Provide additional education to relieve concerns and discussion to overcome barriers. |
Age related patient factors include anatomical physiologic, pathophysiologic and compliance.
Elderly patients with asthma are basically treated using the adult asthma guidelines, with special attention to side effects. Elderly patients may be at increased risk of side effects such as cataracts, glaucoma or osteoporosis from corticosteroids. They may also have more dexterity problems with hand-held inhalers or nebulizers that may influence treatment decisions.
Since pediatric patients are unable to perform pulmonary function testing, they are diagnosed primarily on medical history and a trial of drug therapy. Classification of asthma is the same for pediatrics as adults, but side effects of corticosteroids may make a trial of cromolyn worthwhile before corticosteroids.
The annual cost of treating asthma in children is estimated at $1.9 billion. Children with asthma require approximately 200,000 hospitalization yearly and 2.7 million physician visits. Many pediatric patients are cared for by general practitioners rather than asthma specialists. An initiative to promote Best Practice in Pediatric Asthma has resulted in pediatric asthma treatment guidelines. They are available at www.aaaai.org.
Update: COPD
New guidelines on COPD from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) have recently been released. www.goldcopd.com
COPD Exacerbations
Exacerbations are common as the underlying stage of COPD becomes more severe. The most common causes of an acute exacerbation are bronchitis, pneumonia, and air pollution. In some cases these exacerbations can precipitate acute respiratory failure and may be fatal. Treatment is based on the severity of the exacerbation and whether or not the patient needs to be hospitalized. Factors influencing the decision to hospitalize include: initial response to increased bronchodilator therapy, presence of worsening hypoxemia or respiratory acidosis, presence comorbid disease states, severity of symptoms, stage of COPD prior to the exacerbation, and degree of home support. The first step in managing an acute exacerbation is to increase the patient's bronchodilator therapy. This may mean increasing doses or frequency of inhaled agents, combining a β-2 agonist with an anticholinergic, switching to nebulizer therapy, or adding IV aminophylline. Antibiotics may also be added if the patient is showing signs of an increase in sputum purulence and either an increase in their dyspnea or an increase in sputum volume. Oral or intravenous corticosteroids are usually considered at the same. Corticosteroids are most likely to benefit patients whose baseline FEV1 is ≤ 50%. In these cases, corticosteroids have been shown to shorten the patient's recovery time. Oxygen therapy is a key component of therapy for hospitalized patients, and in some cases, ventilatory support will be needed.
|