Dr. Pellegrino is a clinical assistant professor at the University of Illinois at Chicago College of Pharmacy.
Asthma is a chronic inflammatory disease of the lungs, leading to airway constriction and ultimately, remodeling of the bronchial mucosa.1 It is estimated that >17 million Americans are currently diagnosed with the disease. In 2004, it was estimated that the indirect costs associated with missed school days was $1.5 billion, and missed work days related to asthma mortality was $1.7 billion.2 The need for better control of the clinical manifestations of this disease is dire. Pharmacists in all settings are in a unique position to help in this process.
Control recently has been clarified to encompass the minimization of asthma manifestations through therapeutic intervention along with the attainment of treatment goals.3 Pharmacologic therapeutic interventions are aimed at reducing airway inflammation and decreasing bronchospasm.4 Six main medication classes are involved in the control of asthma: beta adrenergic receptor agonists, chromones, glucocorticoids, immunoglobulin E inhibitors, leukotriene inhibitors, and methylxanthines. The National Asthma Education and Prevention Program (NAEPP) identifies patient education and patient self-management as a cornerstone in asthma control.
Many triggers contribute to asthma exacerbations. Patient education should focus on identifying them and developing trigger-avoidance plans. Environmental triggers include tobacco smoke, dust mites, pollen, mold (indoor and outdoor), and animal dander Avoidance is the best method for minimizing exacerbations; however, it is not always practical. Educating patients to clean their sheets in hot water (>130°F) once a week and to use protective pillow and mattress covers are options for dust mite avoidance. Patients also may be encouraged to wear protective face masks while vacuuming or when outside on days with high mold or pollen counts.
Smoking cessation is a critical step in asthma control for those patients who smoke. For children with asthma, it is important to stress that keeping the house smoke free will help in their child's disease management.
Some triggers can be found in food products or medication classes used to treat comorbid conditions. Aspirin and nonsteroidal anti-inflammatory drugs have been shown to cause exacerbations in up to 20% of adults and 5% of children.2 Nonselective beta-blockers do not potentiate an exacerbation but prevent the reversal with short-acting β2-agonists.
Certain food products containing sulfites trigger exacerbations, such as beer, dried fruit, open salad bars, and wine.5 Providing education on these potential triggers is an important part of disease state management. It also is important to note that these are potential triggers, and not all of them will affect every patient.
Although avoiding triggers is 1 step in the management of asthma, medication adherence plays another important role. Some patients, although equipped with the correct medication, lack the skills to correctly use their medication as a result of physical inability or a lack of proper education.
Valved holding chambers (spacers) are delivery aids that fit between the inhaler and the patient's mouth, allowing for better aerosolized drug transport to the lungs and potentially decreasing systemic side effects. For proper use, the patient should fit the inhaler into 1 end of the spacer, actuate the inhaler, take a slow deep breath, and hold for 5 to 10 seconds. If a dose of a particular medication calls for >1 actuation, this process should be repeated; only 1 actuation should be administered at a time.
The use of spacers is recommended for young children (>4 years old), adolescents, and adults to aid in the delivery of aerosolized medication to the lungs. Spacers are an important tool in drug administration, as it has been shown that more than half of patients do not use proper technique in the inhaler administration and deliver an inadequate amount of drugs to the lungs.4 In children <4 years old, spacers with face masks are recommended. The face masks should fit snugly on the face and fully cover the nose and mouth. Parents and health care professionals should never use face masks unless they are placed securely against the patient's face, as it has been shown that a space as little as 2 cm reduces the delivery of aerosol medication by as much as 80%.2
Patients also should be counseled about proper spacer maintenance. Static can accumulate along the sides and cause a decrease in the delivery of aerosolized medications to the lungs. It is recommended that spacers be washed in a dilute solution of water and dish soap (1:10) once a week, and allowed to drip dry.
One of the last steps in patient self-management is recognition and monitoring of symptoms. Two key components in this area are the peak flow meter (PFM) and asthma action plan. Routine monitoring with the use of PFMs alone does not improve patient outcomes, but it can be a useful tool for patients who are not able to recognize airway obstruction.3 Currently, the NAEPP recommends the use of PFMs for patients with severe asthma who are not able to recognize airway obstruction; this could be a patient with multiple emergency department (ED) visits for asthma exacerbations in a given year.
In addition to the use of PFMs, the NAEPP has developed an asthma action plan system using a traffic light approach to the self-management of manifestations.3 The following percentages are based on the patient's individual best value: the green zone is 80% to 100%, the yellow zone is 50% to 79%, and the red zone is <50%. The red zone usually requires a call to the patient's primary care provider or 911 if unable to walk or talk due to shortness of breath. The yellow zone is a caution zone that requires an oral corticosteroid with steps to take if a green zone value is not achieved within 1 hour.
Although the use of PFMs and asthma action plans are important steps in monitoring and controlling symptoms, they are completely useless if the patient does not understand how they work or how to use them correctly. As pharmacists, it is important to recognize the patient just discharged from the ED and to ensure understanding of these tools. Refilling of short-acting β-agonists too soon signals that the patient may not have his or her asthma symptoms under control, and warrants a call to the primary care provider for further evaluation.
Too often, patients have the proper tools for disease state management, but do not know how to use them appropriately. Pharmacists can empower asthma patients to get more involved in their health care, help them to better understand their disease state, and ultimately achieve better management.