Concise Review for Primary-Care Physicians

Practical Considerations for Managing Asthma in Adults

ASHOK M. P ATEl., M.D., DIANNE M. AXEN, R.N., S ARA L. B ARTU NG, R.N., ANDJ UAN C. G UARDERAS, M .D.

Asthma is a common, chronic inflammatory di sorderor the ai rw ays as socia ted with pronounced health andeconomic conseq uences. Consiste nt and effect ive edu ­cation th at promot es a n active partnership with pa ­tients remain s the cornerst one for managing asthma.Id entificalion a nd control or as thma triggers, regularmunitoring or lun g funct ion, and adeq ua te pharma­cologic therap y are three other critical components.

Asthma has been identi fied as one or the five most pressingglobal lung problems.' In the United Sta tes, 14 10 15 millionpeople have asthma, and more than 5,000 deaths due toasthma arc reported annually .' Allhough the onset of asthmamay occur at any age, more than 80% of cases deve lop inpeople younger than 45 years or age. Approximate ly 70% orpeople with asthma have mild disease, whereas 20% and10% have moderate and severe d isease. respectively. Thesocial and economic burdens or asthma in the United Statesare pronounced; more than $6 billion were spent on asthma­related care in 1990.'" Asthma contrib utes 10 the loss ormore than 10 million school days and 3 mill ion workdaysannually, as well as more than $700 million in potentialwages of caregiver' s income. Allhough asthma has a vari­able and unpredictable course , most cases and expenses canbe controlled with appropriate management. Recent guide­lines from the Glo bal Init iative for Asthma and the NationalAsthma Education and Preve ntion Program are now avail­able.'" To be able to cont rol asthma, patients must beencouraged to learn abo ut their asthma and become partnerswith their health- care team, Specifically, pat ients must beable to apply the ir know ledge and ski lls to mon itor andadjust their therapy acco rding to their condition. and theymust know when to seek help .

GOAL OF ASTHMA MANAGEMENTThe goa l of asthma management is to normalize symptomsand functioning while minimizing adverse drug effec ts and

From the Division of Pulmonary and Critical Care Med icine and InternalMedicine (A. M.P., D.M.A., S .L.B.), Mayo Clinic Rocbcsrcr. Rochester,Minnesota; and Division of Allergy and Internal Medi cine (J.e .G.), MayoClinic Jacksonville, Jack sonvil le. Florida.

Address reprint req uests 10 Dr. A. M. Patel . Division of Pulmon ary andCritica l Care Medicine , Mayo Clinic Roc hester . 20D First Street SW. Roch­ester , MN 55 90S.

In thi s article, we describe se vera l practical consider­ations for developing a collaborative, multidisciplin­ary approach 10 asthma care that emphasizes patienteducation and st rengthens the partnership betweenpatien ts and health-care professionals.

(Mayo Clin Proc 1997;72:749-756)

CFC = cbloroffueroca rbon; PElt'= peak expira tory now

preventi ng exacerbations. Thi s goal can be achieve d by (1)confirming the diagnosis or asthma; (2) assessing the sever­ity or asthm a; (3) prov iding compre hensive, consistenl pa­ticnt self-management education; (4) monitoring airwaysobstruc tion objectively; (5) controlling asthma triggers ap­propri atel y; and (6) partnering for effec tive step-carepharmacotherapy.

Diagnostic Eraluation.-Asthma. a chronic inflamm a­tory disorder or the airways. is assoc iated with increasedairways responsiveness and usually widespread but variableairway s obstruc tion that is ofte n reve rsible. either spcntane­ously or with treatment.Y The airways obstruction resultsfrom smooth muscle bronchoco nstrictio n, mucous hyperse­cre tion or plugg ing , airway edema. and thickening of thebasement membrane.' Establishing the diagnosis of asthmaand any contributing factors is extremely important.6.8·'o

To establish a d iagnosis of asthma, the cl inician shoulddetermine tha t episodic symploms and at least partially reoversible airflow obstruction are present and that alternativediagnoses have bee n reasonably excl uded. Other help fulclues from the clinical eva luatio n incl ude a grea ter than 20%reduct ion in forced expiratory volume in I second aftermethacholine inhalation challenge, nocturnal worse ning ofrespiratory symp toms, presence of other atopic conditionssuch as allergic rhinit is or eczema, fam ily history of asthma.and substantial symptomatic and objective improvement af­ter use of short-acting inhaled ~2-adrenergic agonists. De­spite these considerations. the cl inical eva luation of asthmacan still be challenging, partic ularly in patients with coexist­ing problems such as coronary artery disease. serious psychi­atric conditions. or central airway lesions.'?

Assessment of Severity and Monitoring.--0nce the di­agnosis or asthma has been confirmed, an attempt should bemade to classify the seve rity of the disease as either mildinterm ittent asthma or persistent asthma. Persistent asthma

Mayo Clin Proc 1997 ;72:749-756 749 © / 997 Mayo Foundation/or Medical Education and Research

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750 MANAGING ADULT ASTHMA

Table I.- Assessment of the Seventy of Persistent Asthmas

MaJo Clin l'roc, August 1997, Vol 72

Asthma

Factor Mild Moderate Severe

Symptom frequency 1-2 times/wk 3-5 times/wk DailyNocturnal symptoms <2 1imes/wk 2-5 timcs/ wk Almost nightlyActivity limitation Brief « '/2h) M ild to moderate SubstantialSchool or work Rarely affected Perform ance affected Poor performa nceCorticosteroid bursts/yr Oor I 2 or 3 >3PEFR/FEV, ~80% of best 60-80% of best <60% of bestPFMdaily variability 20-30% >30% >30%Drug used to relieve

symptoms <daily 2-3 times/day >3 times/dayRecommended follow-up 6- 12 mo 4-6 mo 2-4 mo

*FEV I = forced expiratory volume in I second; PEFR = peak expiratory flow rate; PPM =peak flowmeter.

can be class ified as mild , moderate, or severe (Table I).Note that any patient can have mild, moderate, or severeacute exacerbations of the ir chronic state. Additional detailon the pauern of symptoms or exace rbations , precipitating oraggravating factors. and relevant psychosoc ial issues affec t­ing the patient or family must be elicited. A careful aSSeSS­ment of any risk factors for Severe or fatal asthma (Table 2),barriers to sel f-management education (Table 3), and thepatient 's acce ss to the health -care system is also war­ranted.": " Because of the time constraints of a busy officepractice . physicians must develop creative ways to obtainthis information and prioritize which components of asthmacare are to bedelivered (Tables 3 and 4)."

Ongoi ng monitoring and periodic assessment are neededto establish whether the goal of asthma therapy has beenachieved or is being maintained. Regular monitoring forchanges in severity of disease . control o f any aggravating orcontributing factors. and medication compliance is vital foroptimal asthma care. The frequency and com plexity of thefollow-up assessment and education should be tailored onthe basis of individual needs and severity of asthma (TableI)."

Patient Self-Management Education.- Education is acritical component in the management of asthma in adults.Asthma self-management generally refers to the strategiesused by patients to monitor symptoms and communicateessential information 10 their health-care providers. Theterm "self-management" is somewhat of a misnomer be­cause partnering or comanagement is involved. Se lf-man­agement programs rely on a patient's will ingness to monitor,analyze. and report symptoms, These programs also relyheavily on the practitioner's ability to teach the necessaryinformation, skills. and attitudes. I II A consistent and effec­tive partnership among the health-care team, patients. andtheir families is essential for successful long-leon asthmamanagement.6.13.16.19.20

Asthma self-management plans should be based on stan­dard content with usc of sound theoretic principles, and theyshould be tailored to fulfill the specific needs of individualpersons and spec ial popu lations.16.11I.20.23 The physicianshould e lici t the patient's perception on necessary changesand incorporate the patient's ideas when formulating thetreatment strategy. The initial need is often knowledge,followed by time to gain expericoee with the illness in orderto increase se lf-awareness and se lf-confidence in the ability10 partner with the health -care provider in managing theasthma.?" The physician should allow sufficient lime forpatients to adapt to new knowledge. Celebrating successesin se lf-management and readdressing problematic issuesduring follow-up visits are important.

Table 2.- Risk Facto rs for Death Due to Asthma.

Prior history of sudden. severe exacerbationsPrior intubation or admission to intensive-care unit for asthma3 or more emergency-care visits for asthma during the past year2 or more hospitalizations for asthma during the past yearSerious psychiatric disease orpsychosocial problemsIllicit drug useLow socioeconomic status and urban residenceInfants <1 yr old

Nonadherence with asthma medication or self-managementprinciples

Difficulty in perceiving airflow obstruction or its severityOveruse of inhaled l3-adrenergic agonists (>2 canisters/molCurrent usc of or recent withdrawal from systemic corticosteroids

PEFR("E V.) improvement in emergency department of :S; I0%PEFR (FEV,) ';25% predicted of personal bestPaCO, ~42 mm Hg and/or PaO, <60 mm Hg (SaO, <91%)Daily PEFR fluctuations >20· 30%

"' FEV. = forced expiratory volume in I second; PaC02

= part ialanerial pressure of carbon dioxide; Pa0 2 = partial arterial pressureof oxygen; PEFR = peak expiratory now rare; 5a0

2= arterial

oxygen saturation.

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Malo e lin Proc, August 1997, Vol 72 MANAGING ADULT ASTHMA 751

Table 3.- Management Considerations for Adults With Asthma

Self-managementtopic

Activity or lifestyle

Self-monitoring

Trigger control

Health-care partnership

Medications

Action plan

Barrier

Smoking-active or sidestreamObesityDccond ition ingIncomplete immunizationPsychosocial problems

Inadequate symptom recognitionLack of objective monitoringImproperor lack of asthma diary

Limited insight or identificationInadequate control measures

No primary physician

Limited resources or supportInconsistent follow-upLack of uniform approach

Lackof understandingAdverse side effectsUnsatisfactory inhaler technique

Nonadherence

No written plan on adjustment ofmedication

Poor understanding of planInconsistent feedback

Intervention

Smoking cessationDiet consultationExercise and rehabilitationVaccinationPsychiatry. social services. relaxation

therapy

Education. stress reductionPeak flow meterDiary sheets. education. remote

monitoring

Education and allergy testingEducation and allergy consultation.

family support

Designate primary physician.emphasize partnership

Soc ial services. community awarenessSchedule next follow-upProvide guidelines. communication.

timely feedback. support

Education (control versus relict)Optimization of medicationReview of inhaler technique. usc of

extender (spacer) deviceCloser follow-up

\Vriuen action plan

Education and regular reviewRegular review of plan

ASTHIlfA IIfIl'monic.-The ed ucational approach forself-management of asthma used at our institution is summa­rized in Table 3. The mnemonic ASTHMA is used tocategorize the self-management tasks into a concise methodfor patients and practitioners. Key educational messages forpatients include basic facts about lifestyle and asthma. self­monitoring skills . env ironmental and other trigger controlmeasures. and understanding the role of medications as partof a rational action plan. The three components of the plan(Table 3) are as follows: (I ) essential self-managementtopics . (2) barriers to self-management.P-" and (3) poss ibleinterventions involving a multidisciplin ary tcam approach.IS

We recommend that health-care providers use the mnemonicat each patient encounter as a simple ye t comprehensivemethod to address critical self-management issues relevantto asthma care. Each category o f the mnemonic is describedin detail in the follow ing sec tions.

Act ivity, Altitudes, a nd Lifes tyle.e-Excrcise-inducedbronchospasm occ urs in more than 60% of people withasthma, espec ially when cont rol is subopumal."> For pa­tients who have limitations to their activities. the physi -

cian should outline an exercise program or enroll them ina pulmon ary rehahilitation program . As with other chron­ic conditions. the patient 's attitude toward the disease ,psychosocial suppo rts, and financi al concerns should be reoviewed because these issues may influence co mplianceand usc of resources. The importance of cessation o f smok­ing should be reiterated to patient s who smoke and tothose in the same household or social area. Preventivemeasures such as an annual influenza vacc ination shouldalso be co nsidered.

Table 4 .-Rule of the Physician in Asthma Care

Confirmdiagnosis and severityIdentify and provide education on control of contributing

or aggravating factorsRecognize and minimize any adversedrug effects or

interactionsSpecify additional testing or consultationsPrescribe medications and complete actio n plan (when

appropriate)Arrange timely follow-up

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752 MANAGING ADULT ASTHMA

Number (Above) and Name

Ma}'oClin Proc, August 1997. Vol 72

~~:J ()(P~ <t)OCP~~~~ 40 0 CP~

AdultAsthma Action Plan C8J m=JNote: This is a tw o-part form . Ptease print firmly and clearty.

Provider: Date: _

Personal best peak flow: _

Type of peak flow meter:

Green ZOne (St.ble)

No symptoms

Able to do daily activities without muchdifficulty

PEA K FLOW REAOING: -r-r-r-__(80% - 100% of personal best)

CJ Trigger control _

o Take quick-relief medications:

_ _ _ _ _ _ _ _ _ _ as needed

o Take long-term controlme dications:

CJ Before exercise. take:_ _ ____ ( _ minutes prior)

o Annual flu vaccination

I Yellow Zone (Caution)Coughing

Sleep disturbed by asthma symptoms

Short of breath/wheezing

Difficulty doing daily activ ilies

PEAK FLOW READING:(65% - 60% of personal 00:;--"::-)--

U Resta Increase: _

U Contilue othergreenzonemedication(s)U Add:. _

PEAK FLOW READ ING: :;--:;--_ _(50% - 65% of personal bes t)

o Callyour physician: _

U Continue above med ications

f,J Add oral corticosteroid:

Red Zone (AI .rt) ..

Symptoms are worse . even while resting

Very shortof breath

Trouble wal king or talking

Unab le to do daity activities

PEAK FLOW READING: ....,.,:;--,-_(Less than 50 % of personal best)CJ Call you r ph ysician: _

Q Add or increase oral corticosteroid:

Q Cont inue other green and/or yellowlone medicati on(s)

o Epi.Pen instructionsSpecial notes: _

• you strugg le to breath e• medication doesn' t help

• Have someone ta ke you to an emergency room immediately if:• you have blu e lips or nails • you feel very ti red• you r chest feels tight • you teel faint or pass out

If there is no one to drive you , ca ll 91 t .Part 1 - M edical RecordCopy Part 2 - Patient Copy MC23~OllR597

Fig. J. Sample of asthmaaction plan foradults. (Forsample of completed form, sec Mayo Clinical Upda te 1997;1 3INo. 2):4.)

Self.!\1onitoring.-Sclf·m on itoring data are the ce ntralcommunication links between the patientand the health-careteam. All patients with moderate to severe persistentasthmaor those with frequent orseve re exacerbations should moni­tor peak expiratory flow (PEF) rates at least once daily. Thepatient 's personal best PEF (if determined ) is the most ap­propri ate refe rence value and is preferred 10 the predictedbest PEF. Regular review of the peak flow meter techniqueand the patient 's as thma diary is irnponaru, especially forpatients with moderate or seve re asthma or those who havedifficult y perceiving the severity of their asthma. Patientsconsider completion of d iaries less of a burden if they re­ceive timely feedback from their health -care prov ider aboutthe value of self-monitoring. Determining the patient's per­sonal best peak flow and calculating the red (less than 50%of personal best), yellow (50 to 80% of best), and green(more than 80% of best) zones (Fig. I) arc necessary. Oth erfactors to monitor include the frequency, dose. and type of

medication; symptoms; and school or work attendance orperformance. The physician should remind patient s to bringthese records to their follow-up visits for review and feed­back .

Tr igger Co nlrol.- The sea rch 10 identi fy and controlindividual asthma triggers is crucial. Assessing the patient'sperception and attitude toward managing potential triggersof the asthma is important. Patients need to know whetherthe benefit of avo idance out weighs the cost, whether avoid­ance is feasible, and the perce ived barriers. Exercise. viralinfection, animals, dust mites. mold. smoke and pollution.pollen. weather and other environmental factors, emotions,and menses arc some of the factors that may trigger anasthma exacerbation. Consultation with an allergist may behelpful for pat ients with a history suggestive of spec ificallergens that do not respond to standard avoidance mea­sures. The physician should inquire about any conditionsthat may aggravate or mimic asthma. such as cardiac dys-

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Mayo Clin Proc, August 1997, Vol 72

function, thyroid illness, vocal cord dysfunction , sleep ap­nea. reflux, and rhinosinusitis.

Healt h-Care Partnership.--Optimal asthma care neces­sitates a multidisciplinary and consistent approach by thepatient's health-care team. with an emphasis on responsiblepartnership . Representation on this team should be through­oUI the health-care continuum, from home life to prima rycare to subspecialty ca re, including inpat ient facilities. Theideal health-care environment should be responsive to a pa­tient's fears and needs but effec tive in fostering a true part­nership in the management of asthma. For this type of care,several initiatives arc necessary. First. health-care profes­sionals must be trained in a unifonn approach to the treat­ment of asthma. Second , members from health-care disci­plines must learnto work together-building on each other'sskills rather than working parallel or contrary to each other.Third. health -care professionals must discover ways to beeasily acce ssible to all patients with asthma; the networkmust extend to the community where patients with asthmaconduct their lives-school . sports, day care. and work orsocial environments.

Medications.-Distinguishing between the role of long­tcrm control medications and quick-relief medications (secsubseq uent section on pharmacotherapy) is important(fables 5 and 6). Aggressive control of underlying airwayinflammation is essential for asthma management. Regularreview of inhaler technique is also advised for patients whouse inhaled medications because more than 50% of patientsuse these devices incorrectly. Reinforcing adherence to amedication regimen has a vital role in self-management pro­grams.

Action Plan.- The action plan is the central point ofmanagement or partnering (Fig. I ). All components of self­management so lidify with usc of a written action plan. in­eluding educational efforts, individualized dru g therapy, andteam communication with a unified approach. The planmust be clear. concise, and written in terms that the patientunderstand s. It should be written from the patient 's perspec­tive, incorporating his goals and resources . To be effective,an action plan should be rev iewed at each health -care en-

MANAGING ADULT ASTHMA 753

counter and by mem bers of all disciplines who interact withthe patient. The actio n plan is the basis for ongo ing plan­ning, and hence patients should be instructed to bring it toevery follow-up appointment for their asthma. Likewi se,health -care providers should be prepared 10 request and re­view the written action plan regularly.

Partnership for Effective Step-Care Pharmaco­t/lerapy,--Optimal drug therapy for asthma involves appro­priate drug prescription by the physician as well as adequateadherence to and understanding of dose adjustments by thepatient-that is, partnership in care. The current med ica­tions used for asthma are generally con sidered for eitherlong-term control or quick relief (fable 5). Long-term con­trol strateg ies are directed at minimiz ing or eliminating air­ways inflammation , whereas quick-relief medications pro­vide relatively rapid bronchodilatation . Perhaps the mostimportant practical consideration with respect to pharmaco­therapy is that adult patients with persistent asthma, no mat­ter the severity, should receive regular anti-inflammatorytherap y- for exam ple, inha led corticosteroids. The mecha­nisms of action. pharmacokinetics, and algorithms describ­ing the use o f various asthma medications have been rece ntlyreviewed ." :" Types and amounts of medi cal ions usedshould be adjusted in a stepwise fashion, either upward ordown ward based on the clinical response. in order to mini­mize adverse effects. Because of increasing concern aboutthe detrimental effect of chlorofluorocarbon (Cf'Cj-contain­ing products on the environment, newer agents that are CFC·free or that usc a dry powder formulation are available.Recent plans by the Food and Drug Administration to phaseout asthma inhalers that contain CFC prope llants will alsoaffec t future use of asthma drugs. Examples of CFC-freeprodu cts include Proventil HFA and Pulmicort Turbuhal er.

Inhaled corticosteroids are currently the most effectiveant i-inflamm atory agents for long-term control." Manyproducts are ava ilable with vary ing modes of drug deliveryand dosages per actuation. and thus comparisons and gener­alizat ions are difficult . The usual daily dosages of inhaledcorticosteroids recommended by the National Asthma Edu­cation and Prevention Program for moderate persistent

Table 5.-Antiasthma Medications

Long-term control

Conicostcroids-inhaled or oralLong-acting l3·adrenergic agonistsThe oph yllineAnricholinergicsCromolyn sodium,

nedocrom il sodiumLeukotricne antagonistsOther- lidocaine

Quick rel ief

Short-acting ~2·adrcncrgic agonistsSystemic corticosteroidsEpinephrineTcrbutalinc

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7.1-1 MANAGING ADULT ASTIlMA Mayo elin Proc, August 1997. Vol 72

Table 6.- Usual Daily Dosages of Inhalt"d Corticosteroids for Moderate Persistent Adult Asthma*t

DosageDrug TOIal Total

Generic name Trade name Ilg/puff puffs/day ug/day

Bcclomcthasone dipropionatc MOl Bcclovent 42 12-20 504-840Beclomcthasone MOl V anceril 42 12-20 504-840

VanceriJDS 84 6-10 504-840Flunisolide MOl Aerobid 250 4·8 1.000-2.000Fluticasone propionate MDI Flovent 110 2-6 220-660Flut icasone DPf 100 3·6 300-600Triamcinolone acetonide MOl Azmacon 100 8-16 800- 1.600Budesonide DPt Pulmicort Turbuhaler 200 2-3 400-600

*DPI = drypowder inhaler; MOl =metered-dose inhaler.tOnce- or twice-daily dosing of these medications. with an emphasis on appropriate inhaler technique. is

recommended.Appropriate dosing necessitates regularmonitoring of clinical status andpatient's response to therapy.Stepwise titration of the dose of medication to the minimal amount necessary to maintain control will

minimize adversedrugeffects.From Mayo Clinical Update 1997;13(No. 2);3.

asthma in adults are listed in Table 6. Physicians must knowthe Ilg per puff for a specific inha led med ication and thenum ber of puffs per day whe n rev iew ing a patient's med ica­tion regimen. The avai labili ty of nebulized con icos te ro idsor a dry powder inha ler in the futu re (in the United Stales)may a lso be an option for pat ients unable to master the use ofa me tered-dose inhaler. Oral candidias is and dysph oni a maybe decreased by using a space r device and rinsing theoropharynx after completion of inhalation.

System ically administered co rticostero ids are used forsevere persistent asthma, ei ther daily or on alternate days.They arc also useful for short-term "burst" therapy (usua llyfor 3 10 10 da ys) as pan o f the strategy for man aging seve reexac erbations. Pincus andassociates'P' emphasized the roleof chronobiology in as thma and suggested that the moste fficacious time frame to take anti-inflammatory medica­tions may be between 3 and 5 "M.

Long-acting ~,-adrenergic agonis ts also see m 10 be effec­tive, particularly for worsening of nocturnal symptoms.P-"They arc generally well tolerated. and twice-dail y dosin gfacilitates compliance. These agents should not be used forreliefofacute symptoms ormore than twice a day. Increasedusc of shon-aeting inhaled ~-adrenergic agonists wi thoutsymptomatic improvement is an indication of worseningairways inflamma tion,

Othe r long-term contro l agents that may be used incl udethe chromo nes, cromolyn sod ium and nedocrom il sodium;Iheophylline; and most recently. oral leu kotri cnc antago­nists.' Nedocromil is prob abl y effec tive in less than 30% ofpatients with asthma but may have some stero id-sparingeffect s." Regul ar monitoring of the serum theophyllin elevel is import ant when a Iheophylline product is bei ng used

because of wide inte rpa tient variabi lity in theophylli ne clear­ance and the potentia l for drug interact ions." Adj ustme ntsin the do sage of theophyll ine may be necessary to achievesteady-state serum concentrations of 5 10 15 lIg1mL. Thefollowi ng drugs or conditions increase serum theophyllin elevels: cime tidine, erythromyc in. qu inolones, allop urino l.oral contraceptives, propranolol, liver disease, and conges ­tive hean fai lure. Th e following fac tors or drugs decreaseserum theophylline levels: ac idosis . smoking. phenobarbi­tal . nfampin, and phenytoin.

Th e oral leukotriene antagonists provide additional thera­pcutie options for pati ent s. Zafirlukast (Accolate). an LTD4receptor antagoni st. aod zileuton (Zyflo), a 5-lipoxygenaseinhibitor. have been approved by the Food and Dru g Admin­istrati on for pre scription usc in the United Stales. The use ofantileukotrienes in long-term asthma eare necessitates fur­ther study and clinical experience.v -" Nebulized lidocainealso see ms promising as an alternative agent for long-termcontrol. at least in patients with corticos te ro id-depende ntasthma."

FACTORS TO CONSID ER Wil ENASTHMA CONT RO L IS DIFFICULTThe vas t majorit y of patie nts with as thma will benefi t froma consistent , comprehensive. and mul tid isciplinary ap­proach that emphasizes se lf-manageme nt ed ucation and theco ncept of partnership in care. So me o f the importantfac tors 10 cons ide r when asthma control is difficult toachieve or maintain are listed inTable 7. Lack of response toan adequate asthma program should alert the clin ician toconsider other diagnostic possibilities, Disease states thatcan mimic asthma symptoms incl ude chronic obs tructive

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Mayo Clin Prec, August liJ97. Vol 72

Table 7.- Factors to Consider WhenAsthma Control Is Ilinicult

Determine whether patient ac tually has asthma

Assess effectiveness of se lf-manag ement prog ramProblems with recognition of symptoms or severi ty?Problems with adherence to treatmen t?Change in medication necessary?Possible alternat ive medicine or therapy?

Consider other agg ravating factorsPersistent expos ure to triggers?Adve rse drug effects or drug inte ractions?Aggravating medi cal conditions'?

pulmonary disease, congestive bean failure, cystic fibro­sis. bronchiectasis, central airway lesions, and pulmonaryembolism.

An incomplete response to asthma treatment suggestsprob lem s with se lf-management, suboptimal medication, orinadequately treated agg ravating fac tors. Nonadherence is amajor problem with many patients and is often related toincomplete understandin g of self-management concepts,limited financial resources, or psychosocial and cultural is­sues. Suboptimal use of effective step-care pharmaco­therapy may also be due to lack of recognit ion of theseve rity of an asthma exacerbation, inadequate deliverytechni que with inhaled med ications, comp lexity of a med­ication program, or absence of an action plan for exacerba­tion s that is understood by patients, Ad verse drug effects ordrug interactions may also aggravate control of asthma."Aspirin or nonsteroidal anti-inflammatory agents, nonselec­tive Jl·blockers, and topically administered eye drops con­taining ketorolac tromethamine or timolol maleate areamo ng the mor e th an 200 drugs that may aggravatebronchospasm. Alternative approaches to med ica l therapyfor asthma are often explored by patients and may influencemanagement."

Control of persistent or undetected exposures to asthmatriggers is a potentially challenging issue. Exposures occ ur­ring from the pat ient ' s workp lace , soc ial encounters, andhobbies should be co nsidered. Several coe xisting, con­founding medical problems sho uld also be addressed whenasthma care is difficult , including gastroesophageal reflux,chronic rhinosinusiti s, sleep apnea , allergic bron chopulmo­nary aspergillos is, and vocal co rd dysfunct ion. Furthermore,a thorough review of the patient's access to health care andresources for maintaining control is crucial.

ACKNOWLEDGMENTDr. A. M. Patel thanks his forme r co lleag ues at the AlbertaAsthma Center (Ed monton, Canada ) for their permission 10

mod ify and develop further the ASTH MA mnemonic.

MANAGING ADULT ASTHMA 755

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15. Corbridge 'I'C, Hall JB. Th e asses sment and management ofadults with status asthmaticus. Am J Respir Crit Care Med1995;151:1296-1316

16. Kehl er CL, Davies SL, Bailey WC. Self-management andother behav iora l aspects of asthma . Curr Opin Pulm Med1996;2:16-22

17. Li JTC. Sheeler RD. Ge tting the most out of a 15-minuteasthma visit. J Respir Dis 1997;18:135-141

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20. Green LW. Fran kish CJ. T heories and princip les of heal theducation applied to asthma. Chest 1994;106(Suppl):219S.230S

21. Clark NM, Evans D. Zimmerman 81, Levi son MJ, MelliosRB. Patient and family management of asthma : theory­based techniques fo r the clinician. 1 Asthma 1994;31:427­435

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.

756 MANAGING ADULT ASTHMA

22. McLe roy KR, Clark NM. Simons-Morton BO. Forster J,Connell eM.Altman D, et al. Creating capacity: establish­ing a health education research agenda for special popula­tions. Health Educ Q 1995;22:390-405

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25. Nastasi KJ, Heinly TL. Blaiss MS. Exerc ise-induced asthmaand the athlete. J Asthma 1995;32:249·257

26. Mcf-adden ER Jr . Gilbert IA. Exercise-induced asthma. NEngl J Med 1994;330:1362-1367

27. Barnes Pl . Current therapies for asthma: promises andlimitations. Chest 1997;1I I(Suppl):I7S-26S

28 . Barnes Pl. Inhaled glucocorticoids for asthma. N Engl JMcd1995;332:868-875

29. Nelson liS. ~-Adrenergic bronchodilatcrs. N Engl J Med1995;333:499-506

30. Holgate ST. Bradding P, Sampson AP . Leukotricne an­tagonists and sy nthe sis inhibitors: new directions in

Questions About Management of Adult Asthma(See article, pages 749 to 756)

I. Which =of the following is least likel y to mim icasthma?

a. Severe emphysem ab. Pulmonary embolismc. Co nges tive heart failured. Pulmonary fibrosise. Vocal cord dysfun ction

2. Which =of the following medications isleas' likely to provide qu ick relief of asthmat icsympto ms?

a. Albuterolb. Salmeterolc. Methylxanthinesd. Oxygene. lpratropium bromide

3. Wh ich = of the following was introduced in theUnited States in response 10 the concern of thepossible detrimental effects of chlorofluorocarbo n­containing products?

a. Fluticasone propi onate (Flove nt)b. Zafir lukast (Accolate)c. Albuterol HFA (Proventil HFA)d. Zileuton (Zyflo)e. Ipratropium bromid e (Arrovent)

Mayo Clio Prec, August 1997. Vol 72

asthma therapy. J Allergy Clin Immunol 1996;98;1­13

3 1. Smith Ll . Lcuko trienes in asthma: the poten tia l therapeuticrole of antileukotriene. Arch Intern Med 1996;156:2181 ·2189

32. Weinberger M, Hcndeles L. Theophylline in asthma. N EnglJ Med 1996;334:1380-1388

33 . Pincus DJ, Beam WR, Martin RI . Chronobiulogy andchronotherapy of asthma. Clin Chest Med 1995;16:699-713

34. Pincus DJ, Szcflcr 5J. Ackerson LM. Martin RJ. Chrono­thera py of asthma with inhaled steroids: the effect of dosagetiming on drug efficacy . J Allergy Clin Immunol 1995;95:1172-1178

35. lnsel PA. Adrenergic receptors---evolving concepts andclinical implications. N Engl J Med 1996;334:580-585

36. Keenan JM. Nedocromil: a new agent for the treatment ofasthma. Am Fam Physician 1994;50:1059-1064

37. Hunt LW. Swedlund HA, Gleich GJ. Effect of nebulizedlidocaine on severe glucocorticoid-dependent as thma, MayoClin Proc 1996;71;361-368

38. Ziment I. Alternat ive therapies for asthma. CUlT Opin PulmMed 1997;3:61-71

4. Which = of the following is tus. facilitated by awritten action plan?

a. Partnership with health- care prov iders is improvedb. Patients are assi sted in adjusting medication s based

on sy mptom or peak flow read ingsc. Regular review and feedback are documentedd. Techniques for using inhalers or peak flow meters

are improvede . Individualized patient care plan for asthma

exacerbations is co mmunicated to co lleag ues

5. Wh ich = of the follow ing is IlflJ. emphasized in theupdated (1997) National Asthm a Education andPrevent ion Program guidelines?

a. Four potential categories for chronic asthma,includ ing mild interm ittent disease

b. Di stinction between long-term "controller"medication s and quicker "reliever" drugs

c. Partnership in care with patient and family educationas an essential compo nent

d. Use of systemic corticostero ids for all patients withpersis tent asthma

e. Objective monit oring of airflow lim itation inmoderate or severe asthm a

Correct answers ; 1. d, 2. b, 3. c, 4 . d, 5. d

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.