Too often, asthma patients have the proper tools to manage their disease but do not know how to use them properly; the pharmacist is uniquely positioned to help.
Dr. Pellegrino is a clinical assistant professor at the University of Illinois at Chicago College of Pharmacy.
Asthma is a chronic inflammatorydisease of the lungs, leadingto airway constriction and ultimately,remodeling of the bronchialmucosa.1 It is estimated that >17million Americans are currently diagnosedwith the disease. In 2004, itwas estimated that the indirect costsassociated with missed school dayswas $1.5 billion, and missed workdays related to asthma mortality was$1.7 billion.2 The need for better controlof the clinical manifestations ofthis disease is dire. Pharmacists inall settings are in a unique positionto help in this process.
Control recently has been clarified toencompass the minimization of asthmamanifestations through therapeuticintervention along with the attainmentof treatment goals.3 Pharmacologictherapeutic interventions are aimedat reducing airway inflammation anddecreasing bronchospasm.4 Six mainmedication classes are involved in thecontrol of asthma: beta adrenergicreceptor agonists, chromones, glucocorticoids,immunoglobulin E inhibitors,leukotriene inhibitors, and methylxanthines.The National AsthmaEducation and Prevention Program(NAEPP) identifies patient educationand patient self-management as a cornerstonein asthma control.
Many triggers contribute to asthma exacerbations.Patient education shouldfocus on identifying them and developingtrigger-avoidance plans. Environmentaltriggers include tobaccosmoke, dust mites, pollen, mold (indoorand outdoor), and animal dander Avoidance is the best method for minimizingexacerbations; however, it is notalways practical. Educating patients toclean their sheets in hot water (>130°F)once a week and to use protective pillowand mattress covers are optionsfor dust mite avoidance. Patients alsomay be encouraged to wear protectiveface masks while vacuuming or whenoutside on days with high mold or pollencounts.
Smoking cessation is a critical stepin asthma control for those patientswho smoke. For children with asthma,it is important to stress that keepingthe house smoke free will help in theirchild's disease management.
Some triggers can be found in foodproducts or medication classes used totreat comorbid conditions. Aspirin andnonsteroidal anti-inflammatory drugshave been shown to cause exacerbationsin up to 20% of adults and 5% ofchildren.2 Nonselective beta-blockersdo not potentiate an exacerbation butprevent the reversal with short-actingβ2-agonists.
Certain food products containing sulfitestrigger exacerbations, such as beer,dried fruit, open salad bars, and wine.5Providing education on these potentialtriggers is an important part of diseasestate management. It also is importantto note that these are potential triggers,and not all of them will affect everypatient.
Although avoiding triggers is 1 step inthe management of asthma, medicationadherence plays another important role.Some patients, although equipped withthe correct medication, lack the skillsto correctly use their medication as aresult of physical inability or a lack ofproper education.
Valved holding chambers (spacers)are delivery aids that fit between theinhaler and the patient's mouth, allowingfor better aerosolized drug transportto the lungs and potentially decreasingsystemic side effects. For proper use,the patient should fit the inhaler into 1end of the spacer, actuate the inhaler,take a slow deep breath, and hold for5 to 10 seconds. If a dose of a particularmedication calls for >1 actuation,this process should be repeated; only1 actuation should be administered ata time.
The use of spacers is recommendedfor young children (>4 years old),adolescents, and adults to aid in thedelivery of aerosolized medication tothe lungs. Spacers are an importanttool in drug administration, as it hasbeen shown that more than half ofpatients do not use proper technique inthe inhaler administration and deliveran inadequate amount of drugs to thelungs.4 In children <4 years old, spacerswith face masks are recommended.The face masks should fit snugly onthe face and fully cover the nose andmouth. Parents and health care professionalsshould never use face masksunless they are placed securely againstthe patient's face, as it has been shownthat a space as little as 2 cm reducesthe delivery of aerosol medication by asmuch as 80%.2
Patients also should be counseledabout proper spacer maintenance. Staticcan accumulate along the sides andcause a decrease in the delivery of aerosolizedmedications to the lungs. It isrecommended that spacers be washedin a dilute solution of water and dishsoap (1:10) once a week, and allowedto drip dry.
One of the last steps in patient self-managementis recognition and monitoringof symptoms. Two key componentsin this area are the peak flow meter(PFM) and asthma action plan. Routinemonitoring with the use of PFMs alonedoes not improve patient outcomes,but it can be a useful tool for patientswho are not able to recognize airwayobstruction.3 Currently, the NAEPP recommendsthe use of PFMs for patientswith severe asthma who are not able torecognize airway obstruction; this couldbe a patient with multiple emergencydepartment (ED) visits for asthma exacerbationsin a given year.
In addition to the use of PFMs, theNAEPP has developed an asthma actionplan system using a traffic light approachto the self-management of manifestations.3 The following percentages arebased on the patient's individual bestvalue: the green zone is 80% to 100%,the yellow zone is 50% to 79%, and thered zone is <50%. The red zone usuallyrequires a call to the patient's primarycare provider or 911 if unable to walk ortalk due to shortness of breath. The yellowzone is a caution zone that requiresan oral corticosteroid with steps to takeif a green zone value is not achievedwithin 1 hour.
Although the use of PFMs and asthmaaction plans are important steps in monitoringand controlling symptoms, theyare completely useless if the patientdoes not understand how they workor how to use them correctly. As pharmacists,it is important to recognize thepatient just discharged from the ED andto ensure understanding of these tools.Refilling of short-acting β-agonists toosoon signals that the patient may nothave his or her asthma symptoms undercontrol, and warrants a call to the primarycare provider for further evaluation.
Too often, patients have the propertools for disease state management, butdo not know how to use them appropriately.Pharmacists can empower asthmapatients to get more involved in theirhealth care, help them to better understandtheir disease state, and ultimatelyachieve better management.