Asthma: Pathopharmacological Foundations for Advanced Nursing Practice

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Investigated Disease Process

Asthma is one of the most common diseases with heterogeneous distribution not only in the USA but also worldwide. In the USA, asthma is acknowledged to be one of the most costly illnesses (“Asthma facts and figures,” 2019). The disease leads to swelling in the airways, which can cause a narrowing in the latter. Individuals suffering from asthma frequently experience trouble breathing, coughing, and wheezing.

There is currently no cure for asthma, but proper prevention measures allow minimizing the risk of attacks (“Asthma facts and figures,” 2019). The prevalence rate of asthma in the USA is rather high. Twenty-five million Americans – 7.7% of adults and 8.4% of children – have asthma (“Asthma facts and figures,” 2019). The most typical etiological factors include inheritance, immunization, T_H2 immunity, and the environment (Yang, Lozupone, & Schwartz, 2017).

Still, researchers have not found a unifying mechanism responsible for the mentioned events. The lifetime prevalence ranges from 1% to 18% in different countries (Nunes, Pereira, & Morais-Almeida, 2017). Since there are countries with a considerably low prevalence of asthma, it is viable to conclude that the disease may develop differently due to specific environmental factors.

Because of the high prevalence of asthma in the USA, mortality and morbidity rates in the country are also excessive. High morbidity and mortality are frequently related to the population’s aging (Pennington, Yaqoob, Al-kindi Sadeer & Zein, 2019). Apart from age disparities, prevalence differs by gender and ethnicity characteristics. For instance, females have higher mortality rates and more severe asthma than males (Pennington et al., 2019).

African Americans have a more inadequate disease control and die of asthma more often than any other ethnic group (“Asthma facts and figures,” 2019). As Pennington et al. (2019) note, 61,815 Americans died of asthma between 1999 and 2015. The overall incidence of mortality fell from 2.1 in 1999 to 1.2 in 2015 per 100,000 people (Pennington et al., 2019). However, women continue to die of asthma twice as often as men. In 2017, 3,654 Americans died of asthma (“Asthma facts and figures,” 2019). According to the Centers for Disease Control and Prevention (CDC), one in thirteen Americans has asthma. High morbidity and mortality rates persisting in the USA signify the urgent need for clinicians and policymakers to come up with viable prevention measures.

Pathophysiology

Asthma is one of the most common diseases in the USA, with high prevalence and death rates. Asthma is more common in boys than girls but more typical in adult women than men (“Asthma facts and figures,” 2019). As of 2017, over 11.4 million Americans, including 3 million children, had at least one asthma attack or episode. The highest level of prevalence is among African Americans (“Asthma facts and figures,” 2019).

Due to this illness, 9.8 million doctor’s office visits are recorded in the USA annually. Every day, ten American citizens die of asthma, but many cases could have been avoided with relevant care and treatment (“Asthma facts and figures,” 2019). Risk factors include environment, ethnicity, race, gender, family history, and occupation (“Asthma,” n.d.). Exposure to cigarette smoke during pregnancy raises the risk of the child developing asthma (“Asthma,” n.d.). The most typical comorbidities are reflux disease, rhinitis, sleep apnea, cardiac diseases, gastroesophageal reflux disease, and psychiatric diseases (Nunes et al., 2017). About 10% of asthmatics have chronic sinusitis, and nearly 60% have allergic rhinitis (Nunes et al., 2017). The disease can cause changes in different organs and systems.

Asthma leads to changes in the respiratory system at the cellular level. Due to the constriction of smooth muscles, inflammation appears, which causes swelling in the airways. Apart from smooth muscle contraction, airway edema from “leaky bronchial vessels” and vascular congestion can also serve as triggers (Barnes, 2017, p. 1542). Furthermore, cellular structural changes may result in an irreversible narrowing of the airways.

Such changes include fibrosis and escalated airway smooth muscle bulk (Barnes, 2017). Airway inflammation can cause not only narrow but also hyperresponsiveness, which is the major physiological abnormality of the disease emerging as a reaction to various environmental factors (Barnes, 2017). There are several types of cells engaged in the inflammatory process: mast cells, eosinophils, activated T lymphocytes, macrophages, endothelial cells, and epithelial cells (Wendling, 2015). Mast cells initiate acute bronchoconstrictor reaction to allergens and are frequent contributors to severe asthma development (Wendling, 2015).

Airway hyperresponsiveness is commonly associated with the elevated count of eosinophils. Epithelial and endothelial serve as the “source of inflammatory mediators” (Wendling, 2015, p. 5). Due to the inflammatory process and smooth muscle constriction, asthmatics have a decreased ability to exchange oxygen and carbon dioxide.

When considering organs affected by asthma, lungs suffer most of all. When one has asthma, the lining of the lungs’ airways is constantly in a hypersensitive state. Airways become red and swollen, which makes them react to such triggers of asthma as smoke, dust, or pets (“How asthma affects,” 2020). When any of such provoking aspects affect an individual, the insides of the airways become inflamed even more. As a result, there is less space for air to move in and out of the lungs (“How asthma affects,” 2020).

The muscles wrapped around the airways constrict, and it becomes much more difficult to breathe. Recently, scholars started paying more attention to the role of the central nervous system in asthma (Irani, 2019). Specifically, researchers note that individuals with asthma are more likely to have neuropsychological impairments than non-asthmatics (Irani, 2019). Children with asthma frequently have behavioral disorders and learning disabilities. In adults, the incidence of cognitive impairments tends to increase due to chronic illnesses like diabetes, hypertension, and chronic obstructive pulmonary disorder (COPD) (Irani, 2019). Hence, while the lungs are most severely affected by asthma, other organs may be influenced.

Asthmatics may use some compensatory mechanisms to alleviate their symptoms. Tachypnea and tripod breathing are two of the most common mechanisms related to asthma in this respect. Tachypnea is a voluntary or involuntary reaction of the organism to pulmonary obstruction (Jean, Yang, Crawford, Takahashi, & Sheikh, 2018). Additionally, tachypnea may serve as compensation for central nervous system dysfunction or an abnormal breathing pattern (McGann & Long, 2017).

Tachypnea can also emerge from primary cardiac abnormalities and pulmonary vascular abnormalities, including congestive heart failure and obstructed return to the heart (McGann & Long, 2017). Another typical manifestation of compensatory activity for asthmatics is the so-called “tripod” breathing pattern. The “tripod” position allows an individual to relieve dyspnea (shortness of breath) (Almond & Chung, 2018). In this position, a person leans forward with outstretched arms while supporting one’s weight on elbows or palms. By using this approach, it is possible to prolong the expiratory phase of the respiratory cycle (Almond & Chung, 2018).

Frequently, audible wheeze on forced expiration may be noticed in the “tripod” position. With the help of compensatory mechanisms, asthmatics can relieve the symptoms of an asthma attack.

According to the National Asthma Education and Prevention Program, asthma is classified into intermittent and persistent. The latter can be mild, moderate, and severe (“Classification of asthma,” 2018). The type of asthma is defined based on the severity of one’s symptoms, as well as lung function tests. It is necessary to mention that classification may alter over time, so diagnostic procedures should be performed on a regular basis.

Irrespective of the category, one can have severe asthma attacks occasionally (“Classification of asthma,” 2018). Also, symptoms can change with age, so the type of asthma one has been diagnosed within early childhood can modify with older childhood or adult age. Asthma is intermittent when such symptoms as wheezing, difficulty breathing, or coughing occur fewer than two times a week and fewer than two nights a month.

Also, intermittent asthma does not prevent a person from performing any usual activities (“Classification of asthma,” 2018). Meanwhile, persistent cases occur more than twice a week in mild, daily in moderate, and more than once daily in severe asthma (“Classification of asthma,” 2018). The ultimate treatment goal is to control the disease’s symptoms.

The overview of asthma’s pathophysiology allows making several conclusions. Firstly, the disease has an alarmingly high prevalence and death rates in the USA, which means that sufficient measures are not being taken to decrease these statistics. Asthma is common both in children and adults, and the severity of some symptoms leads to considerable discomfort. Secondly, it is necessary to note that there is no treatment for asthma. Therefore, the best management approaches largely involve preventative practices. Specifically, asthmatics should avoid triggers leading to asthma attacks and use prophylactic medicine as prescribed.

Thirdly, it is crucial to understand the mechanisms of asthma on every level of the respiratory system in order to understand the course of the illness better. It is necessary to teach asthmatics and their families how to cope with asthma attacks by utilizing compensatory mechanisms. Also, preventive measures should be given much attention: asthmatics have to know how to apply an inhaler or how to check its capacity. To deal with the mentioned issues, the National Standards of Practice will be discussed in the next section. These include the gold standard methods for asthma assessment, diagnosis, and management.

Standard of Practice

The U.S. Department of Health and Human Services, along with the National Institutes of Health, issued the standard of practice for asthma in 2007. The document is titled “Guidelines for the diagnosis and management of asthma” (2007). According to the guidelines, the standard gold method for assessing asthma includes three elements:

severity (the intensity of the illness’s process); most easily measured in those who have been receiving a short-term therapy;
control (the level to which the symptoms of asthma are eliminated by therapy and the degree to which the purposes of therapy are achieved);
responsiveness (the efficiency with which disease control is gained by therapy) (“Guidelines for the diagnosis,” 2007).

Recommended methods for diagnosing asthma include a detailed medical history, physical examination, and spirometry (“Guidelines for the diagnosis,” 2007). Additionally, it is recommended to take a differential diagnosis into consideration. To exclude the latter, such studies as pulmonary function examination, bronchoprovocation, chest x-ray, and biomarkers of inflammation should be utilized (“Guidelines for the diagnosis,” 2007).

Apart from assessment, successful asthma management includes several other elements. These involve education for a partnership in care, control of environmental characteristics and comorbid diseases affecting asthma, and medications (“Guidelines for the diagnosis,” 2007).

Pharmacological Treatments

Drugs Used to Treat Asthma

The most common medication categories recommended by the National Guidelines include long-term drugs and quick-relief medications. Long-term medications are used by patients on a daily basis since they allow gaining and maintaining control of persistent asthma (“Guidelines for the diagnosis,” 2007). This category of drugs includes corticosteroids, immunomodulators, leukotriene modifiers, cromolyn sodium and nedocromil, long-acting beta-2 agonists, and methylxanthines (“Guidelines for the diagnosis,” 2007).

The most effective of these are the ones that weaken the inflammation factor. Quick-relief medications are not used daily, their major function being the treatment of acute exacerbations and symptoms (“Guidelines for the diagnosis,” 2007). Quick-relief asthma drugs include short-acting beta-2 agonists, anticholinergics, and systemic corticosteroids (“Guidelines for the diagnosis,” 2007). There are also complimentary and alternative medication options, but patients should use them with caution and only upon careful consideration of their ingredients.

Beta2-Agonists

Beta2-agonists are bronchodilators, which can be of two types: short- (SABAs) and long-acting (LABAs). SABAs helps to relax smooth muscles, so they are used for acute symptoms relief and exercise-induced bronchoconstriction (“Guidelines for the diagnosis,” 2007). It is not recommended to use SABAs (pirbuterol, levalbuterol, and albuterol) regularly. LABAs are recommended for prolonged use but not as monotherapy (“Guidelines for the diagnosis,” 2007). LABAs (formoterol and salmeterol) have a twelve-hour bronchodilation duration and are used for prevention and control of moderate or severe persistent asthma (“Guidelines for the diagnosis,” 2007). The major adverse effects of beta2-agonists include tachycardia and skeletal muscle tremor (“Side effects: Bronchodilators,” n.d.).

Corticosteroids

This category of medications is represented by anti-inflammatory drugs reducing airway hyperresponsiveness, blocking late-phase reaction to allergens, and inhibiting inflammatory cell activation and migration (“Guidelines for the diagnosis,” 2007). Corticosteroids are the most common long-term medications used for persistent asthma treatment. Their adverse effects include mycosis, shortness of breath, leg edema, and sleep disturbance (Yasir, Jatana, & Sonthalia, 2020). Corticosteroids promote asthma control both in children and adults (“Guidelines for the diagnosis,” 2007).

Local Practices and Outcomes

The state of Illinois takes measures to adhere to the National Guidelines’ recommendations in regard to medications. However, according to local statistics, 17.8% of adults with asthma cannot afford to buy medications (“The impact of asthma on Illinois,” n.d.). This factor contributes to a high asthma prevalence in Illinois, which constituted 13.5% in 2011 (“The burden of asthma in Illinois,” 2013). The data indicate that local practices are not sufficient, and the state should take more serious measures to decrease the prevalence of the disease and increase people’s access to medications.

Clinical Guidelines

Assessment

Prior to diagnosing a person with asthma, it is necessary to perform his or her assessment. First of all, the physician needs to evaluate the patient for asthma symptoms, which include coughing, wheezing, shortness of breath, and chest tightness (“Asthma,” n.d.). The more indicators one has, the more likely it is that they have asthma (“Guidelines for the diagnosis,” 2007). Asthmatics’ vital signs include an increased respiratory rate, an increased heart rate, wheezing during inspiration and expiration, an indication of suprasternal retractions, and the use of accessory respiratory muscles (Almond & Chung, 2018).

Pulsus paradoxus (systolic paradox) is not considered as a valid measure of asthma severity (Almond & Chung, 2018). The assessment of episodic symptoms of airway hyperresponsiveness and airflow obstruction should be made. If the mentioned conditions are present, it is highly likely that the patient has asthma (“Guidelines for the diagnosis,” 2007). During the assessment, it is necessary to take into account the frequency and severity of symptoms, such as whether they are manifested at night, making the person wake up. Recurrence of symptoms, including difficulty breathing, wheeze, or chest tightness, should be included in the assessment.

Diagnosis

The methods recommended by the clinical guidelines for establishing the diagnosis of asthma include inquiring the patient about his or her medical history, performing a physical examination, and running the spirometry test. Questions that should be asked during the medical history interview cover symptoms and their pattern, aggravating factors, and the development of disease and its treatment (“Guidelines for the diagnosis,” 2007).

Other questions are concerned with the family and social history, the effect of asthma on the patient and his or her family, the history of exacerbations, and the evaluation of the patient’s and family’s perceptions of asthma. History components that might indicate that the patient might have asthma include early-life injury to airways, history of asthma in close relatives, substance abuse, the level of education, and employment (“Guidelines for the diagnosis,” 2007).

Physical exam has the potential to reveal findings that raise the likelihood of asthma. However, the lack of these findings cannot be treated as the justification for ruling out the disease (“Guidelines for the diagnosis,” 2007).

Due to the nature of asthma, some of the symptoms and signs may not be present between episodes. Physical examination concentrates on such systems and organs as the upper respiratory tract, chest, and skin (“Guidelines for the diagnosis,” 2007). Finally, spirometry is the most objective measure of diagnosing asthma since it allows evaluating reversibility and noticing obstruction (“Guidelines for the diagnosis,” 2007). Unlike the physical examination and medical history, spirometry offers a reliable assessment of lung status and rules out other diagnoses.

Patient Education

Teaching patients about their condition and the ways of preventing symptoms is the key measure in reaching successful patient outcomes. For children, it is crucial that their parents or caregivers master asthma management (“Guidelines for the diagnosis,” 2007). For adults, self-management skills can be taught, which allow controlling asthma effectively (“Guidelines for the diagnosis,” 2007). Such education promotes patient outcomes, including hospitalization rate, the number of urgent care visits, and activity limitation.

The primary educational messages in this regard are concerned with getting the patient or a caregiver acquainted with the basic facts about asthma, instructing them on the use of medications, and training vital patient skills. Basic asthma facts to be taught are the difference between the airways of an asthmatic and a non-asthmatic person and the physiology of an asthma attack (“Guidelines for the diagnosis,” 2007).

When teaching patients on medications, it is necessary to explain the difference between long-term control medications and quick-relief ones. The patient or caregiver should understand that quick-relief medicines can relax airway muscles, but they will not provide long-term control over the disease (“Guidelines for the diagnosis,” 2007). Meanwhile, long-term control drugs allow preventing symptoms of asthma and eliminating inflammation but do not offer quick relief.

Finally, education should incorporate training the following patient skills: taking medicines timely and correctly, identifying unsuitable environments and avoiding them, self-monitoring, and keeping an asthma action plan, and seeking medical care when needed. Self-monitoring skills enable patients to evaluate their level of asthma control and monitor symptoms (“Guidelines for the diagnosis,” 2007).

Furthermore, self-monitoring helps to identify early signs of asthma, such as irritants, tobacco smoke, and allergens. The use of an action plan trains patients on taking measures each day to control their disease and adjusting medicines in case of worsening (“Guidelines for the diagnosis,” 2007). Additionally, patients may be offered some learning materials, library sources, or internet resources, such as the National Heart, Lung, and Blood Institute’s website (“Asthma,” n.d.). With the help of teaching, physicians can prevent exacerbations and difficulties caused by asthma.

Standard of Practice Disease Management

The state of Illinois follows the national standard practices for managing asthma. Specifically, the state follows the National Guidelines’ recommendations for achieving a high level of communication and collaboration between patients and providers (“Guidelines for the diagnosis,” 2007; “Illinois asthma state plan 2015-2020,” n.d.). Only one of the cities, Chicago, has been listed on the Top 100 Most Challenging Places to Live with Asthma list (“Asthma capitals,” 2019). Chicago occupies the 36^th place on this list with a worse than average death rate for asthma (“Asthma capitals,” 2019). When considering these statistics, one can presume that the state does not perform above the national guideline recommendations.

While nationally, 7.7% of adults have asthma, in Illinois, the number reaches 13% (“Asthma facts and figures,” 2019; “Illinois asthma state plan 2015-2020,” n.d.). Childhood asthma prevalence is 8.4% in the USA and 13.6% in Illinois (“Asthma facts and figures,” 2019; “Illinois asthma state plan 2015-2020,” n.d.). As of 2011, the state had a similar age-adjusted rate of hospitalization compared to the USA (“The burden of asthma in Illinois,” 2013).

Another common trend at both levels is that females are hospitalized more often than males (“The burden of asthma in Illinois,” 2013). Still, it is evident that overall, Illinois statistics are not better than those of the country in general. Hence, it is possible to conclude that the state of Illinois does not adhere to the national guidelines promptly. It is, therefore, crucial for the state authorities to take more serious measures on the way to meeting the national asthma plan.

Managed Disease Characteristics and Resources

There are certain features characterizing a patient who manages asthma well. Most importantly, such an individual has a positive relationship with the healthcare provider and strictly follows the suggested health plan (Miller, 2015). Next, the patient should visit a doctor regularly to perform reassessments of his or her symptoms since the severity of asthma can alter with age (“Guidelines for the diagnosis,” 2007).

A well-managed individual with asthma knows how to use the inhaler and can identify whether the environment is suitable or puts their health under threat. Another characteristic is adequate adherence to one’s medications (“Guidelines for the diagnosis,” 2007). Avoiding the most common asthma triggers is another effective approach to successful management. When one has access to optimal treatment options and makes use of them, he or she can increase life expectancy. Moreover, such individuals considerably improve the outcomes by preventing severe asthma attacks and controlling their disease (“Guidelines for the diagnosis,” 2007).

Patients can use a variety of resources to cope with asthma management. The disease is covered in the articles published on the websites of governmental organizations and healthcare institutions (“Asthma,” n.d.; “Data, statistics, and surveillance,” 2020; “Managing asthma every day,” n.d.). Additionally, one can ask for valid data on asthma at a hospital or read scholarly literature dedicated to the disease. Finally, smartphone applications may be utilized to help an individual follow the plan of treatment and ensure that all medications are taken on time.

International and National Disparities

At a global level, as well as in the USA, asthma remains one of the greatest burdens. Although deaths due to asthma are not numerous, their severity lies in the fact that many of them could have been prevented (Strachan et al., n.d.). According to a survey conducted by the International Study of Asthma and Allergies in Childhood, the highest prevalence of wheeze among children (more than 20%) was recorded in English-speaking countries of North America, Europe, Australasia, and in parts of Latin America (Marks, Pearce, Strachan, Asher, & Ellwood, n.d.). Meanwhile, the lowest prevalence (less than 5%) was observed in Eastern and Northern Europe, Asia-Pacific, Indian subcontinent, and Eastern Mediterranean (Marks et al., n.d.).

In the USA, the approximate asthma rate among children is 8.3% (“Asthma statistics: the United States,” n.d.). A survey by the World Health Organization indicates a 4.3% prevalence of asthma among adults globally (Becker & Abrams, 2017). In the USA, this number reaches 7.7% (“Asthma facts and figures,” 2019). Therefore, it is possible to conclude that the overall rate of asthma prevalence in the USA is considerably higher than in the world.

Death rates caused by asthma in the USA and globally also differ. Approximately 1000 people die of asthma daily in the world (Strachan et al., n.d.). Out of these, ten people die every day in the USA alone (“Asthma facts and figures,” 2019). High-income countries with the lowest death toll include Italy, the Netherlands, Canada, Czech Republic, and Portugal (Strachan et al., n.d.). Low- and middle-income states with a low death rate are Bulgaria and Ecuador (Strachan et al., n.d.).

Among high-income countries with a high asthma-related death rate are Latvia, Germany, Israel, Uruguay, Puerto Rico, and the USA. The highest death rate has been recorded in the Republic of Korea (Strachan et al., n.d.). Among low- and middle-income countries, the highest death rate belongs to Fiji, which is followed by South Africa, the Philippines, and Mauritius (Strachan et al., n.d.). Statistics indicate that the USA is one of the countries with a high level of life with an alarmingly high mortality rate due to asthma.

The divergences between morbidity and mortality rates signify different approaches to disease management. First of all, each country’s approach to asthma prevention and management depends on the thorough preparation of the national asthma guidelines. Four states have the most recently updated guidelines: the USA, Canada, Great Britain, and Australia (Becker & Abrams, 2017). However, it is crucial to update these recommendations in order to reach out to the target audience. The last edition of such guidelines in the USA was published in 2007, which is considered outdated if compared to other countries’ editions (Becker & Abrams, 2017).

Access to appropriate care is another important aspect in the process of managing asthma. In the USA, for instance, ethnic disparities lead to poor access to high-quality health care, underprescription, and underutilization of medication in Latinos and African Americans (“Guidelines for the diagnosis,” 2007). Cultural beliefs can also serve as barriers to asthma management. Hence, the countries with low asthma-related morbidity and mortality rates must be paying more attention to population disparities and guidelines updates than the USA does.

Managed Disease Factors

There are specific factors that can contribute to a patient being able to manage asthma. For US citizens, the most important of such determinants include socioeconomic status, access to care, and the environment. Individuals with high socioeconomic status can afford medical insurance and, as a result, can be sure that their disease is being managed at an appropriate level. The most favorable options exist for those under Medicaid or Medicare programs, as well as for employed citizens (“Health insurance marketplace guide,” 2018). A sufficient level of access to care is another crucial determinant of asthma management. This factor influences one’s patient-provider communication and effectiveness of treatment (“Guidelines for the diagnosis,” 2007).

Finally, a suitable environment is a determinant impacting one’s ability to manage asthma well. If one lives in an ecologically clean area and is not exposed to cigarette smoke at work or at home, the likelihood of managing the disease is much higher (García-Marcos et al., n.d.). The mentioned factors are not exclusive, but their value in asthma management cannot be overestimated. When the patient does not have to worry about negative influences, he or she has more opportunities to prevent asthma attacks and lead a life free of disease-related complications.

Unmanaged Disease Factors

While some factors can improve asthma control, their lack can lead to poor disease management. Unmanaged disease factors include a low socioeconomic status, poor access to care, and an unfavorable environment. The first aspect largely concerns the population groups that are most vulnerable in relation to asthma, Latinos, and Blacks (“Guidelines for the diagnosis,” 2007). Many of these citizens cannot afford to enroll in an insurance program (“Health insurance marketplace guide,” 2018).

As a result, their disease management level is not sufficient. Poor access to care is another unmanaged factor since it deprives people of the opportunity to communicate with a healthcare provider and control the disease (“Guidelines for the diagnosis,” 2007). Finally, the role of the environment in insufficient asthma management should be considered. Frequently, people are exposed to occupational risks or cannot avoid air pollutants at home (García-Marcos et al., n.d.). Environmental factors are more detrimental than genetic ones (García-Marcos et al., n.d.). Hence, when a person’s socioeconomic status, access to care, and environment are not favorable, one cannot manage asthma at an appropriate level.

Unmanaged Disease Characteristics

There are several typical characteristics of patients who poorly control their asthma. Firstly, such individuals do not communicate with their providers regularly and do not follow their treatment plans. Such behavior may be caused by socioeconomic disparities in access to care or the unwillingness of a patient to receive such care even when it is available (“Guidelines for the diagnosis,” 2007). Another characteristic of a patient with poor asthma management is presented with poor coping strategies (Braido, 2013). A patient who cannot stick to a regular medication time is not likely to gain high management outcomes.

Further, if one does not pay due attention to selecting proper environments, he or she will not succeed in coping with asthma attacks (García-Marcos et al., n.d.). For instance, a patient may not avoid places with elevated levels of common asthma triggers (García-Marcos et al., n.d.). Another characteristic is one’s unwillingness to follow a diet, which is known to have some positive effect on the course of the disease (García-Marcos et al., n.d.). Generally speaking, the unmanaged disease characteristics include the patient’s low to none degree of following the guidelines and doctors’ prescriptions.

Patients, Families, and Community

Burden to Patient

Asthmatic patients typically suffer from a variety of burdens associated with their health condition. Physical signs include shortness of breath, wheezing, and coughing spells. It is common for an asthmatic to carry around an inhaler and medications helping to cope with attacks. However, there are other issues apart from physical ones that can present difficulties for patients. First of all, asthmatics are limited in physical activities since many of the former can cause shortness of breath. Secondly, people with asthma have to be cautious when building social relationships. Specifically, they have to avoid individuals who smoke or engage in any other activities that can cause an asthma attack.

Also, asthmatics are limited in the choice of venues where they can spend their pastime or even where they can work. Young patients miss school, and adults miss work, which results in discomfort and uneasiness due to extra tasks they have to cover upon returning to educational or occupational duties. Finally, children and some adults require support from family members, which may result in feeling depressed due to the impossibility of coping with one’s disease alone.

Burden to Family

Families of individuals with asthma also experience certain disadvantages and limitations due to the disease of their loved ones. If a child has asthma, his or her parents have to be alert all of the time. Their social life is quite different from those parents whose children are not so closely dependent on them. For instance, parents of asthmatic children cannot go out by themselves since they cannot be sure that their child does not have an attack while they are away.

Furthermore, such parents may need to make considerable changes in regard to their place of living and employment. If a child’s symptoms exacerbate in a certain environment, the family may need to move. Such alterations will evidently affect not only parents but also other children in the family.

Adult individuals diagnosed with asthma usually can cope with their disease personally. However, their significant others, children, and other family members may need to participate in patient-provider communication and help asthmatics control their treatment process. Patients with severe asthma may choose not to drive to avoid accidents. In that case, other family members have to take on some of the responsibilities of the family member with asthma. Overall, the family burden is contingent on the age of the asthmatic and the severity of the disease. Family members may merely support their close ones or dedicate their whole lives to these people.

Burden to Community

When discussing the burden of asthma, one cannot but mention community outcomes. The most common community issues that arise due to asthma prevalence include medical costs, as well as missed school and workday costs (“Asthma statistics: the United States,” n.d.). According to the Illinois Department of Public Health, as of 2010, it cost the community $383.3 million to cover asthma hospitalizations (“Illinois asthma state plan 2015-2020,” n.d.).

Furthermore, the asthma-related burden to society includes loss of productivity costs and hospitalization expenses (“Illinois asthma state plan 2015-2020,” n.d.). The creation and implementation of educational programs for asthma partners also become the duty of the community (“Illinois asthma state plan 2015-2020,” n.d.). Thus, the state of Illinois should take measures to meet the goals set for asthma management in order to relieve the burden to the community.

Costs

Patient Costs

Costs of asthma, as well as of any other common disease, can be divided into direct and indirect. Direct costs include emergency services visits, hospitalizations, medicines, outpatient visits, and complementary treatments or analyses (Nunes et al., 2017). Other direct costs may involve transportation to medical visits, help with home care, and professional or domestic preventive measures (Nunes et al., 2017). Indirect costs include temporary or permanent disability and early mortality. Finally, there are also intangible costs, which incorporate non-modifiable losses, such as an increase in pain, a decrease in quality of life, physical activity limitations, and work-related changes (Nunes et al., 2017).

Research by Nurmagambetov, Kuwahara, and Garbe (2018) reports patient costs for asthma as of 2015. According to researchers, the annual cost constituted $3,266 per patient (Nurmagambetov et al., 2018). Out of this sum, $1,830 was spent on prescription medication, $640 – on office visits, and about $530 – on hospitalizations (Nurmagambetov et al., 2018). Other expenditures included in these statistics included hospital-based outpatient visits and emergency room visits.

Researchers note that for some groups of patients, costs were different from those spent by the average population. For instance, $3.581 was spent on patients living below the poverty line and $2,145 – on uninsured individuals (Nurmagambetov et al., 2018). It is necessary to note that these costs are interconnected with community costs. However, since patients pay for insurance, it is viable to say that their personal costs of asthma are high.

Family Costs

This type of expenditure is closely associated with personal patient costs. Families whose members have asthma have to spend money on transporting to a hospital, buying medications, and participating in educational activities. If one is a parent of an asthmatic child, the days of missed work due to taking care of the child are added to the costs. Additionally, families experience the financial burden related to asthma when they have to move home or when one or several family members have to change jobs.

Community Costs

An increasing number of people with asthma means that expenditures on the disease at the community level should also increase. As of 2002, the total cost of asthma in the USA constituted $53 billion (“Cost of asthma on society,” n.d.). Within five years, the number grew to $56 billion (“Cost of asthma on society,” n.d.). About $50 billion was spent on direct costs and about $6 billion – on indirect ones. Adult patients miss nearly 14 million workdays annually, which contributes to $2 billion of indirect costs (“Cost of asthma on society,” n.d.).

Community costs for Illinois are also rather high due to a large number of asthmatics and the expenditures associated with the disease. As of the 2010s, the state of Illinois spent $383.3 million on asthma hospitalizations (“Illinois asthma state plan 2015-2020,” n.d.). There were 19,968 cases of hospitalizations with the primary diagnosis of asthma. As many as 72,810 emergency department visits with the same factor were recorded in Illinois in the 2010s (“Illinois asthma state plan 2015-2020,” n.d.). Hence, both at the state and national level, community costs of asthma are rather high.

Best Practices

My current healthcare organization is the University of Illinois Hospital. A specialized asthma program has been implemented at the organization, along with the establishment of the asthma education clinic (“Asthma education clinic,” n.d.; “Asthma program,” n.d.). Apart from that, there is the Breath Chicago Center at the University of Illinois, where research on asthma is conducted (“Asthma research,” n.d.). The asthma education clinic offers discussions on asthma action plans, disease’s objective measures, proper utilization of inhalers, and allergen avoidance (“Asthma education clinic,” n.d.).

All of these measures are undoubtedly crucial since self-management is necessary for every asthma patient to master. However, one important aspect is lacking in this system, and I would like to suggest adding it in order to promote the best disease management within the organization. According to the National Guidelines, education for a partnership in care is one of the core components of asthma care (“Guidelines for the diagnosis,” 2007). Therefore, I suggest introducing education for asthmatics and their caregivers (for children) as the best practice currently unavailable at our organization.

Plan Implementation

To implement the suggested best practice, I will make use of the following three interventions:

the promotion of patients’ self-care through mHealth applications;
the establishment of teaching courses given by nurses who work with asthmatic children and communicate with their caregivers;
the arrangement of meetings for patients and their providers where the former can ask the latter questions and share experiences with one another.

Promotion of patients’ self-care through mHealth applications

One of the most effective innovative approaches to disease management is represented by mobile health applications. Patients can not only record and monitor their disease-related data but also share it with their providers. Research by Farzandipour, Sharif, Arani, Anvari, and Nabovati (2017) indicates a high functionality of mHealth apps for asthma self-management. Scholars note that applications for smartphones allow improving asthma control, promoting better lung function, increasing the quality of life, and reducing the number of disease-related hospitalizations.

mHealth programs offer a variety of features and opportunities, such as recording data, getting information and instructions, communicating with family members or healthcare providers, and reminding patients about medication times. Mobile health apps are known to have a positive effect on asthma self-management (Farzandipour et al., 2017). The introduction of this approach is likely to decrease the incidence of severe asthma attacks in the organizations’ patients.

Nurse-delivered education for young patients and their parents or caregivers

Teaching adult patients about asthma is already a part of the organization’s management plan. However, it is not less crucial to educate young patients about the disease. In fact, instructing children on how to live with asthma, monitor their signs and symptoms, and report them promptly to a parent or caregiver is of utmost importance. Study findings by Frey, Contento, and Halterman (2019) report a beneficial effect of nurse-delivered outpatient education on asthma for young children and their caregivers.

The most prominent positive outcome of such an approach is elevated child accountability (Frey et al., 2019). Apart from that, children who have undergone such an intervention demonstrate better self-efficacy and increased symptoms at each consequent examination. At the same time, positive effects can be achieved for caregivers, as well. Specifically, the quality of parents’ or caregivers’ lives can be promoted significantly with the help of nurse-delivered educational sessions.

Shared decision-making and exchanging information

The third intervention involves close collaboration and communication between healthcare providers and patients with the aim of improving asthma-management outcomes. According to Kew, Malik, Aniruddhan, and Normansell (2017), shared decision-making presupposes the involvement of at least two parties: the patient and the medical practitioner. In the course of communication, both patients and providers can share information and concerns.

Also, patients can express their apprehensions and values, as well as emphasize their preferences in the treatment process (Kew et al., 2017). Moreover, arranging meetings for a group of asthma patients, their caregivers, and healthcare providers can lead to a constructive dialogue on the disease that is a burden for each of the stakeholder groups. This intervention, as well as two others, corresponds with the National Guidelines’ recommendation on education for a partnership in care (“Guidelines for the diagnosis,” 2007). The implementation of the suggested best practice will affect the asthmatics’ quality of life.

Plan Evaluation

In order to verify the success of the suggested interventions, it is necessary to come up with effective evaluation strategies. Based on the character of the planned interventions, the following assessment methods:

measuring the rate of hospitalizations of asthmatic patients in the organization;
evaluating the social burden of the disease on young patients, their parents, and their families;
assessing the economic burden of asthma-related costs on the organization.

They measure hospitalization rates

The evaluation of an intervention involving mHealth application use may be performed by comparing the hospitalization rates before and after the program. Baseline data should be collected before the introduction of the intervention. Then, at the end of the intervention (in five weeks), a post-audit will be done with the aim of finding out whether the number of hospitalizations has decreased, remained the same, or increased.

The measurement indicating the program’s effectiveness is the decreased number of hospitalizations by at least 10-15%. If the difference between the pre-and post-assessment is not considerable, the intervention will be considered unsuccessful and unproductive. In such a case, it will be necessary to ask participants to fill out a survey inquiring about their perceptions of the intervention. If the hospitalization rate proves to be significantly decreased, it will be a sign that the suggested change had a positive effect and that it could be utilized within the organization on a regular basis.

They are evaluating the social burden of asthma on young patients and their families

The second intervention is aimed at teaching children about the disease, and it involves three parties: children, their parents or caregivers, and nurse educators. Hence, the assessment of this intervention’s success will involve each of the stakeholder groups. Both parents and nurse educators will fill out surveys with questions concerning the burden of the disease before and after the program.. The desired effect is an alleviated social burden on the families who have an asthmatic child within the intervention period (two months).

This measurement will include the physical and psychological burden on parents and caregivers, such as the time spent traveling to the hospital. Additionally, the survey will help to evaluate how children’s self-management behaviors have changed. If findings indicate that families whose children have asthma started to be more confident and feel more at ease, the intervention will be considered as successful. The ideal expected measure is a 20% increase in children’s self-management abilities and a 20% increase in parents’ confidence that they can cope with their child’s asthma without having to rush to the hospital every other day.

They are assessing the economic burden of asthma-related costs

The third intervention, as well as the two previously discussed ones, focuses on increasing asthmatics’ level of life. However, this one pursues one more significant goal: that alleviating the economic burden of asthma on the organization. To evaluate whether the level of collaboration between patients and providers has increased, two methods will be used. Firstly, a survey for patients will be introduced, in which they will share their impressions of the suggested change.

Secondly, the organization’s expenditures on asthma patients will be compared before and after the intervention. It is expected that with shared decision-making, individuals will feel the need to be hospitalized less frequently. As a result, the hospital will not spend extra money on transporting patients, admitting them, keeping them inwards, and using equipment and medications excessively. If the economic burden on the hospital decreases at least by 10% within the intervention period (three months), it will be considered a successful one.

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