Ask your patients these seven asthma questions

Many patients don’t know enough about management of asthma, warns Rita Cydulka, MD, residency director for the department of emergency medicine at Case Western Reserve University in Cleveland.

"The goal is to make asthmatics responsible for their care at home, recognize when they are able to adequately treat themselves at home, and seek emergency care before it’s too late," she recommends. "We need to make the general population realize that although asthma is very common and we frequently think of it as a mild disease, about 4,000 people die from it each year."

Take the time to ask asthmatics the following questions:

1. Do you understand what asthma is?

Explain to patients that asthma is a chronic inflammatory disorder of the airways, recommends Karen Huss, RN, DNSc, CANP, FAAN, associate professor at the Johns Hopkins University School of Nursing in Baltimore, and member of the National Asthma Education Program Nurses’ Committee, part of the Bethesda, MD-based National Heart, Lung, and Blood Institute. "This has implications for the diagnosis, management, and prevention of the disease," she says.

Asthma includes the following immunohistopathologic features, she says:

    • denudation of airway epithelium;
    • collagen deposition beneath basement membrane;
    • edema;
    • mast cell activation;
    • inflammatory cell infiltration;
    • airway inflammation contributes to airway hyper-responsiveness to a wide variety of stimuli;
    • airway inflammation contributes to airflow limitation including acute bronchoconstriction, airway edema, mucus plug formation, and airway wall remodeling. These lead to bronchial obstruction; and atopy, the genetic predisposition for the development of mediated response to common aeroallergens, is the strongest identifiable predisposing risk factor for developing asthma.

Before discharge, patients must know how to take their medications through written and verbal information, (usually) be provided with a peak flow meter, trained on inhaler technique, and referred for medical follow-up, says Huss. "Also, they should know when to return to the ED if symptoms return or peak flows drop," she advises.

2. Do you know what triggers your asthma?

Studies demonstrated that patients presenting to EDs for asthma have a high rate of sensitization to indoor allergens, says Huss. "About 80% of young children and 50% of more of adults will have an allergic component to their disease."

Asthmatics may be allergic to indoor allergens such as house dust mites, cat hair, dog dander, and cockroaches, says Huss. "Once I determine what the patient is allergic to by allergy skin testing, I emphasize allergen specific environmental control measures to reduce chronic inflammation in the airways."

3. Do you know when to come to the ED?

Revised asthma guidelines from the National Heart, Lung, and Blood Institute include a home management protocol that gives a sample strategy for using the inhaler with two or three puffs every 20 minutes for an hour.

"But it’s guided by pulmonary function testing, and if it’s not improving, then patients need to go to the ED," says Richard Nowak, MD, FACEP, vice chairman of the department of emergency medicine at Henry Ford Health System in Detroit.

Patients may be managed by primary care practitioners who aren’t following the guidelines, notes Nowak. "You may need to look at what the chronic care physician is doing. They might not meet the [institute’s] recommendations. If a patient comes in who isn’t being managed as well as they should be, we should write them a prescription for analcoteroid steroids if they need them."

The goal is to reduce visits to the ED, says Nowak. "In addition to treating acute exacerbation, it would be nice if we can add therapies so the patient can better control the disease."

4. Do you understand the difference between your medications?

"Review with patients which are the long-term medications that prevent symptoms and reduce inflammation, and which are the quick-relief meds like bronchodilators to take if you feel obstructed to help relax the muscles around their airways," says Cydulka.

A common problem occurs when a patient uses long-term control medications when they have an exacerbation, she says. "So they’ll furiously take puffs on steroid inhaler and expect quick relief when that’s not the way those medications work," Cydulka explains.

5. Will you seek follow-up care?

"The ED nurse should emphasize the importance of follow-up with primary care provider or an asthma doctor so they can develop action plans," says Cydulka.

6. Do you know how to use your inhaler?

"I find that many patients in the ED just don’t know how to use their inhalers," says Cydulka. "Have the patients show you how they use it, then review with them step by step. There are picture guides in the guidelines which you can use."

7. Do you monitor symptoms at home?

"Talk to them about monitoring their symptoms and peak flows at home, so they can recognize early on that their asthma is worsening," suggests Cydulka. "It’s rare that we see patients early on in the asthma attack. We usually see them as time goes on."

[For more information, contact:

Rita Cydulka, MD, Metrohealth Medical Center, 2500 Metrohealth Drive, Department of Emergency Medicine, Room S1-203, Cleveland, OH 44122. Telephone: (216) 778-5747. E-mail: rcydulka@metro health.org.

Karen Huss, RN, DNSc, CANP, FAAN, Johns Hopkins University School of Nursing, 52 N. Wolfe St., Room 416, Baltimore, MD 21205. E-mail: khuss @son.jhmi.edu.

Richard Nowak, MD, FACEP, Emergency Department, Henry Ford Health System, 2799 W. Grand Blvd., Detroit, MI 48202. Telephone: (313) 916-1909. E-mail: rnowak@home.com.]