Gaining basic understanding of your family’s medical history or the story of your family’s health is one of the most important activities available to people of all ages. Acquire this knowledge and improve the family’s ability to fight the onset of preventable diseases and lifestyle-induced ailments. In my case, some of my family members are suffering from the effects of high blood pressure, colon cancer, asthma, and diabetes. However, for the purpose of this study, my focus is to look into my mother’s struggle with asthma. A deeper understanding of asthma makes it possible to apply effective treatment and prevention strategies.
My mother is named Lakisha. She is a 38-year old African American woman. She weighs approximately 160 pounds. My mother adheres to the belief that she has asthma as a result of repeated exposure to second hand smoke. In her opinion, she has no known allergies.
Definition of the Disease
Ancient historians left behind recorded references of respiratory diseases, and they described the medical condition as “noisy breathing” (Allergy & Asthma Medical Group & Research Center, 2017). Hippocrates was the one who labeled the disease as asthma, a Greek word that was used to denote the idea of “wind or to blow”, perhaps an attempt to describe the wheezing sound produced by those suffering from the effects of the said condition (Allergy & Asthma Medical Group & Research Center, 2017).
Modern medicine defined asthma as a disease characterized by “recurring spasms of difficulty with breathing (Rizzo, 2011). Physicians pointed out that those with asthma produces wheezing sound when inhaling or exhaling (Rizzo, 2011). There are also instances when symptoms are manifested through coughing or shortness of breath (Rizzo, 2011).
Risk Factors and Physiological Factors
Experts in the field of anatomy and physiology shed some light into this ancient medical problem. They revealed that this medical condition is brought about by the “narrowing of the bronchial passageway” (Murphy, 2011). At the same time, air passages are being constricted by the buildup of mucous secretions, a process that occurs in the bronchial tubes (Murphy, 2011). Nevertheless, it is a challenge to pinpoint risk factors, because medical experts are unable to figure out the exact root cause of the said ailment. In other words, people are not predisposed to acquire this disease on the basis of weight issues, age, and diet. However, health specialists in the field of respiratory diseases made assertions that allergies are the culprits in asthma attacks (Rizzo, 2011). Although it is impossible to identify the ultimate causative factor, health experts are saying that the “inhalation of pollen, dust mites, animal dander, emotional stress, rigorous exercise or exposure to extremely cold air” may trigger the manifestation of an asthma attack (Murphy, 2011).
Treatment and Prevention
Before going any further into the discussion about treatment strategies, it is imperative to point out that symptoms may reverse spontaneously even without the application of proven medical procedures. For example, in 20 to 50 percent of cases of patients known to suffer from asthma attacks, doctors were able to document the absence of symptoms when patients reached the age of adolescence (Rizzo, 2011). However, in most cases, therapy is needed in order for the patient to become symptom-free (Rizzo, 2011). It is possible to accomplish this goal by evaluating the causative agent. It is also a common practice to use an aerosol bronchodilator or the short-term application of corticosteroids (Rizzo, 2011). It is also important to clarify that these drug-based intervention strategies are not going to treat asthma in the same way that medicines may purge the presence of pathogens that caused measles or cholera.
As discussed earlier asthma is a different type of disease, unlike those that are caused by bacteria or an unhealthy diet. In fact, asthma is a non-contagious disease. Thus, there is no clear prevention strategy that asthma-suffering patients may adopt in order to prevent the onset of the said medical condition. Nevertheless, it is prudent to take note of possible causative agents.
In the case of my mother, she repeatedly made it clear that her asthma problem has nothing to do with certain allergies. However, in the aftermath of seasonal changes, she struggles from shortness of breath and she requires medical attention. During specific times in a given year asthma attacks occur more frequently. She needed appropriate medical intervention in order to prevent complications rising out from more serious medical issues due to the inability to breath oxygen into her lungs.
It is prudent to develop prevention strategies based on the simple description of my mother’s health history. The development of the said prevention strategy must take into consideration the physiological factors linked to asthma attacks. Furthermore, an effective prevention effort is more effective after integrating insights regarding the causative agents associated to asthma attacks. After taking everything into consideration, one can make the argument that my mother will have to learn to live with seasonal bouts of asthma problems. Thus, it is important to monitor her health especially during certain times of the year when weather patterns may affect the temperature of the air, a phenomenon that specialist considered as one of the causative factors of asthma attacks.
Conclusion
It is interesting to note that health experts in the field of respiratory diseases are unable to pinpoint the exact root cause of asthma. This assertion about the inability to determine specific anatomical processes that may help explain the onset of symptoms manifested by the patients makes sense when perceived from the point of view of my mother’s health history. She suffers from shortness of breath each time she is afflicted with the manifestation of the said ailment. However, she made it clear that her asthma problems were in no way linked to allergies. Although it is safe to assume that changes in seasons or weather patterns are causative factors, there is no way to figure out the exact physiological process that may explain the said outcome. As a result, my family had to accept the fact that my mother is going to deal with this medical problem until a medical breakthrough cures asthma for good. At this point the best thing that her family members can hope for is the application of effective therapeutic-based interventions in order to remedy her discomfort each time she suffers from shortness of breath. Looking back to the process of collecting information linked to my mother’s medical issue made me realize the value of understanding a person’s family health history. It is of great value to understand the science behind a specific ailment or medical problem. Insights into common ailments like asthma and high blood pressure helps in the development of effective treatment or prevention strategies.
References
Allergy & Asthma Medical Group & Research Center. (2017). History of asthma. Web.
Murphy, W. (2011). Asthma. Minneapolis, MN: Twenty-First Century Books.
Rizzo, D. (2011). Introduction to physiology and anatomy. Mason, OH: Cengage.
Asthma considered the disease of airway hypersensitivity and narrowing, causing shortness of breath, chest tightness, wheezing sound while breathing, and coughing that frequently get worse at night or early in the morning and often wakes a patient up. Asthma is mostly detected during childhood, yet it affects people of all ages. The identified disease has no cure, and it can occur anytime even when one is feeling well (Arcangelo & Peterson, 2013). A patient with chronic asthma most of the times might not have any signs and symptoms, although the inflammation may exist.
When an acute asthma attack occurs, the airway muscles tighten and swell making the airway narrow, thus decreasing the airflow into the lungs. When the cells in the airway thin, mucus is produced making more thick mucus that further narrows a patient’s airway and causes mucus plugs. Patients struggle to take a breath experiencing dyspnea, chest tightness, and lung functions’ decrease (“What is asthma?,” 2014). This paper will focus on a quick relief and a long-term control asthma treatment and management. This essay will also explain the stepwise management approach that can help healthcare personnel in maintaining and gaining control of asthma.
Long-Term Control and Quick Relief Treatment
While asthma cannot be cured, it can be controlled. Every patient experiences asthma differently. Therefore, healthcare providers need to create an asthma treatment plan specific to a certain patient. There are two categories of asthma medications such as long-term controllers and quick-relievers (GINA, 2016).
Long-Term Control
Long-term control medications are essential and should be taken every day to sustain control persistently. These medications are the most effective ones when it comes to preventing asthma attacks and controlling chronic symptoms. Inhaled corticosteroids help to prevent and reduce airway swelling, while inhaled Long-Acting Beta Agonists (LABAs) open the airway by making the smooth muscles relax. Oral corticosteroids are prescribed for the treatment of asthma attacks when a patient does not respond to other asthma medicines (“What is asthma?,” 2014). Sometimes medication is combined containing both corticosteroids and beta agonists. Omalizumab (anti-IgE) is to be given every two or four weeks to anticipate a patient’s reaction to allergic triggers. Leukotriene modifiers help to reduce swelling inside the airways and improve it as well as relax the smooth muscles. Cromolyn sodium non-steroid medicine inhalation prevents airways from swelling when a patient encounters an asthma trigger. Theophylline medicine helps to relax the smooth muscles, hence opening the airway.
These medications have side effects, and it is the responsibility of a healthcare provider to educate a patient on potential complications. Among the key side effects, one may note voice changes (hoarseness), cough, and oral thrush (candidiasis) (Arcangelo & Peterson, 2013). Taken systematically in high doses, the described long-term control medications may cause adrenal suppression or skin thinning.
Quick-Relief Treatment
These medications are used to relieve asthma symptoms when they occur quickly. They act fast to relax constricted muscles around a patient’s airways by opening them so that air can flow through them. Patients are supposed to take their quick-relief medications once they develop asthma symptoms. In case they use them more than two days in a week, the patients should consult with their health professional as they may need to make changes in their treatment process. These medications include Short-Acting Beta Agonists (SABAs), which are inhaled to rapidly relieve asthma symptoms. They relax the smooth muscles around the airways and reduce swelling that blocks the airflow. These medicines are the initial choice for quick relief of symptoms. Anticholinergics are inhaled medication that acts slower than SABA as they open the airways by relaxing the smooth muscles in the airways and reduce mucus production. The combination contains both an anticholinergic and a short-acting beta agonist (GINA, 2016). Even though these medications eliminate symptoms, it is essential to clarify for a patient that the side effects of the medicines such as anxiety, restlessness, tremors, headaches, and fast and irregular heartbeats may occur (Arcangelo & Peterson, 2013).
Stepwise Approach to Asthma Treatment and Management
The goal of asthma patients is to prevent symptoms, reduce morbidity from acute occurrences, and lead a healthy lifestyle without exacerbations and outbreaks. The stepwise approach to asthma treatment and management is a six-step approach, according to which the number and the dose of medications and frequency of management are increased as necessary when symptoms persist and then decreased when goals are achieved and maintained (Arcangelo & Peterson, 2013).
All asthma patients regardless of the severity require SABA bronchodilator for quick relief of symptoms. The treatment depends on the severity of symptoms, while fast acting is used for more than two days in a week for symptoms control, stepping up is necessary. Patients are reassessed one to three months after starting their treatment and every three to twelve months after it. Treatments can be stepped down to a lesser regimen if the symptoms are well controlled during three months. Stepping down of treatment is done systematically accompanied by close monitoring of signs and symptoms. At this point, medication adherence and environmental exposures should be assessed before stepping up to a more intense medication regimen (Arcangelo & Peterson, 2013).
Stepwise Management Assists Health Care Providers and Patients
The stepwise approach can be utilized by health care providers and patients to optimize asthma treatment. This tool can help to determine the effectiveness of medications and reduce overusing of unnecessary drugs. By reassessing patients three to 12 months, it is possible to determine if a patient is adhering to the stipulated regimen, if he or she is getting exposed to triggers that prevent decreasing the symptoms, or if the symptoms are not being controlled by the current medications (Arcangelo & Peterson, 2013). Due to a step-by-step monitoring, it helps to promote understanding of asthma and benefits both healthcare providers and patients in recognizing the conditions of asthma and knowing how to manage and treat the symptoms. In other words, the stepwise management improves the quality of treatment by preventing overdose and complications in patients as well as clarifying for health care providers how to treat a certain patient.
Conclusion
To conclude, asthma is a chronic condition that often remains uncontrolled for reasons that may be associated with the disease progression, symptoms management by clinicians, a patient’s perceptions of the disease and self-management behaviors, or a combination of these factors. All in all, the goal of asthma treatment is symptoms control and management so that a patient can live comfortably. The use of pharmacotherapy and the stepwise approach can significantly help to achieve these goals (Rance, 2011). If quick-relief treatment should be used to rapidly react to asthma symptoms and eliminate them, long-term control is important to ensure a sustainable control. Apart from treating symptoms, triggers should be identified early to decrease the burden of the disease, and even though there is no cure, asthma symptoms can be controlled.
Asthma is one of the ailments that cause persistent morbidity and deaths across the globe. Studies show that its dominance has augmented in the past two decades. This chronic disease affects the lungs and causes reversible airway barriers due to swellings along the lung airways as well as contraction of the muscles surrounding the lungs.
The airway obstruction is present in most asthma patients, but a number of triggers exacerbate this condition depending on the patient’s environment. Some of these triggers include smoke, pollen grains, dust, industrial chemicals, fur, and cold air. Asthma can be managed successfully; however, most of its morbidity is due to bad management and particularly when taking preventive medication.
Pathophysiology of Asthma
The pathology observed in the lungs of asthmatic patients who succumb to the disease indicates that a high degree of lung inflation. A closer view of this over-inflation shows a striking alveoli distention. The smooth muscles located in the bronchi undergo substantial hyperplasia whilst the submucosal layers become dangerously thick.
Furthermore, mucosa is present in the lungs with a bogged mucosal epithelium due to the inadequate quantity of ciliated epithelium cells. The submucosa undergoes an upsurge in mucus gland hypertrophy. The upsurge in quantity of muscle, mucous glands, and tissue edema causes the airway wall to congeal while the caliber minimizes (Harver & Kotses, 2010).
The alteration of the latter structures is known as remodeling, which generally explains the intricate morphological modifications in the bronchial wall. The changes in the bronchial wall make the columnar cells detach themselves from basal attachments (Clark, 2010). The inconsistent quantity of mucous in the lumen of a patient’s airway triggers the airway obstruction that can even utterly block the airway. The complete occlusion of the airway can lead to growth of a distal at the atelectasis in the lung parenchyma.
Inflammation
Most patients who succumb to asthma have acutely inflamed airways. Inflammation is caused by a convoluted multifactorial process that entails the collaboration of various cells coming from disparate tissues and organs such as bone marrow, the lymphoid, and nervous system among other organ systems.
The cells, which include respiratory cells, CD4 helper T- lymphocytes, and leukocytes, produce cytokine that causes inflammation. Two possible pathways facilitate asthma inflammation. In the first pathway, large amount of immunoglobulin E (IgE) facilitates allergic inflammation. The second pathway is structural change in the bronchial wall (remodeling), which is by caused enzymes, proinflammatory cytokines, and the destroyed bronchial epithelium (Clark, 2010).
The indicators of inflammation include calor and rubor, tumour, and dolor. In the case of asthma, inflammation occurs when triggered by IgE-dependent agents. This allergic reaction is facilitated by eosinophils that accumulate when worms or parasites attack the body. Apart from providing a severe protection against harm, inflammation helps in healing and restituting tissues following an attack by toxins. Nevertheless, in the case of asthma, inflammatory reaction is triggered in an erroneous way, which leads to harm rather than gain.
Medical practitioners do not have a conclusive research on the link between inflammation and indicators of asthma. Probably, the level of inflammation is influenced by the airway responsiveness (AHR). The level of AHR is connected to the signs of asthma and the urgency of one to seek medical attention. Swelling of the airways has the potential to raise AHR and thus enable triggers that compress the airways even when such triggers did not initially have the potential (Harver & Kotses, 2010).
Inflammation can also be an express indication for asthma in various ways such as cough and chest constriction. Apart from inflammatory mechanisms, some anti-inflammatory mechanisms can exacerbate inflammatory responses. Endogenous cortisol can act as a good controller of allergic inflammatory reactions.
Diagnosis
Detecting asthma in children can be difficult particularly in children below the age of 5 years. There is no definite form, severity, or regularity of indication. The ambiguity in the description implies that the evidence-based recommendations are not likely to be certain.
However, common symptoms in children include wheezing, cough, obscurity breathing, and chest constriction (Redwood & Neil, 2013). During the initial clinical assessment, the latter signs are checked, and if most observations are linked with getting consistent wheezing or other respiratory symptoms, then it can be deduced that the patient has asthma.
Nursing Management of Asthma
As aforementioned, poor management of Asthma leads to high morbidity cases; however, following doctors’ prescriptions can help in managing the condition. The prescriptions differ from one patient to another. Two forms of treatment can be offered including quick relief and prolonged management. Quick-relief medication plan helps in relieving the patient from the signs of asthmatic attacks. Patients who aspire to have a longer quick-relief plan should consult their doctors to check if the medication needs to be changed.
In the case of long-term management plan, a patient protects him/herself from frequent attack, but it cannot relieve one from asthmatic attacks. The medications often have side effects and patients should seek the relevant information from their doctors (Clark, 2010). Patients should develop asthma management plan to ensure that the treatment is in line with the symptoms. Patients should share their management plan with individuals that they trust in a bid to monitor them.
Special Treatment for Particular Asthma Patients
Pregnant asthmatic patients should be given specific treatments, as at the time of pregnancy, the condition becomes very severe, hence the need for a closer supervision and modifications in medications. The unborn child is at risk if the mother does not adhere to the doctor’s prescription. Obese patients should receive similar treatment as those who are not, as a reduced weight in obese patients enhances lung function and reduces asthma severity.
The pharmacology treatment of occupational asthma is similar to management of other kinds of asthma, but it does not act as a replacement for sufficient exposure. Asthma patients who undergo thoracic or respiratory surgeries are likely to have trouble during and after the surgery. Doctors should conduct a lung function test prior to the surgery and in case it is below the 80% of the patient’s best, then he or she should take glucocorticosteroids drugs (Redwood & Neil, 2013).
Patients with other respiratory infections apart from asthma should also have special attention. Patients suffering from aspirin-induced asthma also deserve special consideration. Most asthmatic adults are allergic to aspirin and several nonsteroidal anti-inflammatory medicines. Doctors should carryout checkups first before prescribing the medication. Checkups can be done using cardiopulmonary which are able to do resuscitation (Redwood & Neil, 2013).
Conclusion
Asthma is an intricate disease. Evidently, it is not a single disease, but a combination of interaction between different phenotypes that encompass disparate cells and mediators. Currently, the treatment of asthma emphasizes on managing inflammation.
Perhaps, as further studies are done on the subject, medical practitioners will develop more a definite treatment. However, the existing management methods can reduce morbidity as long as patients are loyal to take their treatment as advised. Moreover, application of non-pharmacological management interventions can reduce the dominance of asthma.
References
Clark, M. (2010). Asthma: A Clinician’s Guide. Sudbury, MA: Jones & Bartlett Learning.
Harver, A., & Kotses, H. (2010). Asthma, Health and Society: A Public Health Perspective. New York, NY: Springer.
Redwood, T., & Neill, S. (2013). Diagnosis and treatment of asthma in children. Practice Nursing, 24(5), 222-229.
Community health issues affect entire populations and require increased attention from medical specialists. The effect of such large problems on people can lead to many adverse outcomes and change the health of generations. For example, one of the top healthcare issues in the Bronx, NY, is asthma. The rate of people, especially children, with asthma in this area is among the highest ones in the city (DiNapoli, 2014).
Multiple factors cause this healthcare issue, and systematic change is needed to improve the current situation. Some of the problems in other communities differ from the discussed one. However, asthma is a disorder that has an impact on all regions of the country. Possible interventions for treating asthma in children include learning opportunities for families and patients affected by asthma, the recognition of a connection between the onset of the condition and environmental and socioeconomic factors, and timely preventive and ongoing treatment.
Main body
The issue of asthma in New York and the Bronx, in particular, is connected to multiple factors. According to Abraham et al. (2015), the quality of air in the city and the changing temperature and environment directly correspond to the rising rates of people with asthma exacerbations. The high concentration of pollutants in some regions of the city can also be linked to asthma diagnoses – chemicals used in manufacturing, fumes, and smoke are considered to be among the risk factors for asthma (DiNapoli, 2014).
Rohr et al. (2014) investigated the health of children in South Bronx and East Harlem, NY, and found that the city had increased concentrations of nitrogen dioxide and carbon, as well as various metal sulfates. These pollutants come from industrial production, causing the atmosphere to affect children’s respiratory system. The effect of the altered air contents is substantial – the Bronx is among the regions with the highest and most consistent death rate of people with asthma (DiNapoli, 2014). Therefore, all healthcare professionals, including community nurses, should pay attention to the changes in people’s respiratory health.
The problem of asthma is not a unique issue for the Bronx or even New York. It is a global issue that affects countries with developed transport manufacturing industries (DiNapoli, 2014). Reznik, Bauman, Okelo, and Halterman (2015) state that asthma affects around 10% of all children in the United States. Thus, other communities may also have similar problems with their populations along with other conditions such as hypertension.
It can be argued that underserved groups that live in areas located near manufacturing and farming facilities are exposed to similar environmental problems. They may have the same respiratory problem as people in the Bronx. Nurses can address the problem of pediatric asthma by raising awareness, providing patient education, and advocating for the community. For example, community nurses should initiate learning-based asthma campaigns such as one introduced by the Health Department of New York (NYC Health, 2016). For families whose children are affected by asthma, it is vital to understand that this condition is chronic, and the child’s health can deteriorate because of unfavorable living conditions.
Conclusion
Many people’s socioeconomic position does not allow them to make significant changes in their living arrangements. However, education can help parents, caregivers, and teachers to become aware of effective asthma managing techniques (Reznik et al., 2015). Advocating for patients with asthma and those who are at risk of developing the condition may have an impact on the region’s environmental policies.
References
Abraham, R., Toh, J., Desai, T., Shum, M., Patel, P., Rosenstreich, D. L., & Jariwala, S. (2015). Association between asthma-related emergency department visits, meteorological measurements, and air quality concentrations in the Bronx (2001-2008). Journal of Allergy and Clinical Immunology, 135(2), AB87.
NYC Health. (2016). Health Department launches asthma campaign “Your Child’s Asthma Is Always There, Even When They Seem Perfectly Fine.” Web.
Reznik, M., Bauman, L. J., Okelo, S. O., & Halterman, J. S. (2015). Asthma identification and medication administration forms in New York City schools. Annals of Allergy, Asthma & Immunology, 114(1), 67-68.
Rohr, A. C., Habre, R., Godbold, J., Moshier, E., Schachter, N., Kattan, M.,… Koutrakis, P. (2014). Asthma exacerbation is associated with particulate matter source factors in children in New York City. Air Quality, Atmosphere & Health, 7(2), 239-250.
Medically complicated cases come to routine dental surgery for various procedures. While many of these patients are dealt with successfully, some of these patients may suffer from extreme anxiety. Reducing this anxiety is essential for proper execution of the various procedures. Conscious sedation is one of the most commonly employed methods to relieve anxiety and is now widely gaining acceptance as a safe method for reducing anxiety.
The introduction of various forms of sedation dentistry has made it possible to treat many of the patients who may not be cooperative otherwise. Among the various techniques, the most commonly used these days is the conscious sedation method, most commonly used in pediatric dentistry as well as in anxious adults. Conscious sedation has many forms of administration, and usually it is through clinical knowledge and experience that the dentist may choose a particular one regarding a particular patient.
Ideally a patient who is fit to receive any form of anesthesia is either Class I or a Class II patient. Class I patients comprise normal healthy patients, who are not suffering from any kind of medical condition or disorder. Class II patients, are those who suffer from mild systemic conditions such as well-controlled diabetes or epilepsy, or mild asthma and controlled hypertension. With proper history and medical information, it is possible to conduct various forms of anesthesia with good success in such patients.
The requisite is to have good controlled conditions of the diseases.[1] Even type III patients can be given various forms of anesthetic depending on the individual history, but here more experience is of benefit. Understanding the role of various drug interactions and the effect of various drugs on the medical conditions of the patients is of valuable assistance.
However, as mentioned, there are many cases of patients who may not be in optimal condition for receiving anesthesia. Many medical conditions may require careful medical evaluation before the patient can be considered fit for conscious sedation. A proper medical history and knowledge of any previous medically significant events are essential before carrying out any form of anesthesia.
Consider a case of a patient who is hypertensive as well as asthmatic and is in need of an extraction of the mandibular second molar. Such a patient is also suffering from extreme anxiety, and normal anxiety remission protocols have been considered inadequate for his case. The option comes to the adoption of conscious sedation method. Such a case is not an unusual presentation, and every dentist may be presented with it. The question arises is that how do we determine the correct method of sedation for the patient, and what do we need to consider.
Understanding the patient’s medical history and the severity of his or her condition is the first step that will lead to good diagnosing, clinical decision and successful management. Therefore, the first and foremost is to understand what is the relevance of asthma and hypertension in dental context, and how these conditions can affect the treatment planning.
Asthma is a chronic inflammatory condition of the lungs, which presents as reversible airway obstruction, airway inflammation and increased bronchial hyperresponsiveness.[2] Asthma can be of intrinsic or extrinsic nature, and causes airway obstruction by smooth muscle contraction, inflammation and edema and mucous production. [3]
The asthmatic attacks may be mild, moderate or severe. This is perhaps the main determinant of the condition of the patient, and how dental management will take place. There are many possible causes of an asthmatic attack in a patient. These possible causes increase the risk assessment of the patient, and it is important to clarify them during history taking from the patient. Many of the cases may not even have an asthmatic attack, but sometimes, even the mild cases of asthma may get one during the dental procedure.[4]
Prophylactic measures of preventing asthma attacks include beta 2 antagonists. H1 blocking antihistamines are also considered good methods for the prevention of asthma attack. Promethazine and diphenhydramine are antiasthmatic, antiemetic and sedative all in one, and therefore a very suitable choice for such patients. [5] thiopental and morphine are contraindicated in asthma as they may cause bronchospasm.[6]
The management of the patient, therefore, is dictated by his or her asthma condition. If the patient is anxious, the cause of anxiety is alleviated through counseling and reassurance. Patients are advised to bring their asthma medications during every dental procedure, as a precaution. In many cases, a bronchodilator can be administered before starting treatment. Treatment must not be continued during an asthmatic attack, and proper management procedures must be undertaken to relieve asthma.
Supine position is among the triggers of an asthma attack, therefore, sitting the patient upright may help in relieving it. Mostly in such cases, salbutamol is given, supplemented by oxygen should the condition not improve. Hydrocortisone, as well as prednisolone, can also be used.[7] Since many of the patients may be using chronic steroid therapy, their defense mechanism may not be optimal, and therefore, it is ideal that an antibiotic cover is given to such patients.[8]
Hypertension is the second feature of the supposed patient. While controlled hypertension is not a contraindication for conscious sedation, nevertheless, hypertension can occur during it. Among the various conscious sedation methods, the use of nitrous oxide-oxygen is considered the best in the treatment of hypertensive patients. Nitrous oxide has been shown to improve the homeostatic mechanisms of the body. Although slight changes in the blood pressure and heart rate do take place, the technique is relatively safe. Nitrous oxide effects are essentially dose-related. Nitrous oxide is also seen to increase oxygen tension are therefore is considered as a good technique for hypertensive patients.[9]
Patients with severe hypertension or poorly controlled hypertension are not ideal candidates for conscious sedation.[10] An important point in this regard is that hypertensive drugs enhance the effects of sedatives. Therefore, a proper protocol would require a small dose followed by studying responses, and increasing the doses according to the need. Oxygen mask application is necessary to prevent MI, stroke, renal failure, congestive heart failure or lung edema.
During the sedation, it is necessary to record arterial blood pressure continuously. Even ASA IV patients are not contraindicated for sedation dentistry, provided the treatment is carried out under hospital settings with experienced staff and equipment at disposal. Most of the patients may suffer from orthostatic hypotension after the conscious sedation wears off, therefore, patients must be allowed sufficient time before they are allowed to leave the dental chair. Due to the enhanced effects of sedatives, the inhalational and the intravenous routes can be considered as the best options for such cases.[11]
The IV route of conscious sedation is among the commonly used routines in the adult patients. IV sedation can be used in combination with inhalation or oral sedation as well. This method was first introduced when pentobarbital, meperidine and scopolamine were administered intravenously, and were shown to have sedative and analgesic effects for three or more hours.[12] Proper titration of the dose is necessary for the individual patient, according to his or her particular history. The most common drug used in IV is midazolam, whose dose must be determined by studying the individual patient, and maintaining the IV line until the culmination of the treatment.[13] Other most commonly used agents include benzodiazepines, ultra short-acting barbiturates, antisialogogues either alone or in varying combinations.[14]
Propofol is another drug that has been used as IV sedation in children. It has been demonstrated that a mean dose of 2.5mg/kg given to children was successful in conscious sedation in children for operative dentistry procedures.[15]
Midazolam has shown good efficacy in achieving amnesia and anxiety reduction in patients. Midazolam administered with fentanyl following is the second common procedure that gives better results than midazolam alone, albeit transient respiratory depression. If both these drugs are administered along with methohexital, a deep sedation is achieved. However, oxygen saturation and respiratory rates do decrease transiently, therefore, must not be used in asthmatic patients, or if necessary, must be done with great caution.[16]
Intravenous sedation however, requires a thorough clinical checkup for the health of the patient. The blood pressure is among the most important findings to be kept in mind when opting a patient for this method of induction.
Among the various intravenous drugs, secobarbital has been found to depress the respiratory center and therefore may not be a very good option in an asthmatic patient. Promethazine is known to cause a significant respiratory depression along with orthostatic hypotension. Ativan has been found to have no significant effect on the respiratory or the cardiovascular system, and is therefore considered a very good option.[17]
The Treatment Plan For a Hypertensive and Asthmatic Patient With Anxiety
Considering the evidence, a patient with hypertension and asthma and who suffers from anxiety is most likely to benefit from the midazolam intravenous conscious sedation. Benzodiazepines may also be a good option in such cases. But before carrying it out, a thorough medical and dental history with complete knowledge of medications being used should be taken from the patient. After a thorough evaluation the best mode of conscious sedation method should be used.
The patient should be given a beta 2 antagonist as prophylaxis. The procedure should be ideally carried out at a time when the risk of asthma attacks and peak hypertension levels is not expected. Usually this time is in the afternoon or late mornings. IV dosing of midazolam or any other appropriate drug will be calculated by the specialist based on the patient’s age, gender, health status, presence of any conditions such as asthma etc.
However, since at rapid dosage, midazolam also carries a risk for apnea, the dosage must be given slowly, and with proper titration, with constant monitoring. Midazolam initially is given in 1-2 mg dosing, followed by titrating and maintenance dosage of 0.5-2 mg q 5. Mostly the onset of the drug is within two to three minutes with peak time at 3-5 minutes. If diazepam is given, there must be a slow infusion rate of 5-10 mg, followed by titration of 2 mg q 5 minutes. The patient must be given an oxygen mask to maintain perfusion. Mostly, to help ease the process, inhalation sedation is given followed by IV infusion of the drug.
However, sedatives and opioids must be avoided in such patients due to risk of respiratory depression.[18] The drug must be properly titrated and continuously infused, with constant monitoring of the patient’s vital signs. There should also be a constant monitoring of the arterial blood pressure due to the hypertensive nature of the patient. Some time should be given to the patient after the procedure to adjust, and there should be a proper manner of delivery of the patient to home. With these considerations in mind, the chances of an uneventful procedure are maximized.
References
G D Allen. Dental Anesthesia and Analgesia (Local and General) Third Edition. CBS Publishers and Distributors.
Conscious Sedation. A Referral Guide for Dental Practitioners. Dental Sedation Teachers Group. Web.
Paul Coulthard, Keith Horner, Philip Sloan and Elizabeth Theaker. Master Dentistry. Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine, vol 1. Churchil Livingston.
Raymond A Dionne, John A Yageila, Paul A Moore, Arthus Gonty, John Zuniga, Ross Beirne, 2001. Comparing Efficacy and Safety of Four Intravenous Sedation Regimes in Dental Outpatients. Journal of American Dental Associaiton. Vol. 132, No. 6 740-751.
Hosey M T, Makin A, Jones R M, Gilchrist F, Carruthers M, 2004. Propofol Intravenous Conscious Sedation for Anxious Children in a Specialist Paediatric Dentistry Unit. International Journal of Paediatric Dentistry, Vol 14,no. 1, pp 2-8.
Dominic Lu, Winston I Lu, 2006. Practical Oral Sedation in Dentistry. Part I: Pre-Sedation Consideration and Preparation. Compendium of Continuing Education in Dentistry. Web.
Lopez-Jimenez J, Gimenez-Prats MJ. Sedation in The Geriatric Patient. MED ORAL 2004;9:45-55.
Managing Maladaptive Behaviors: The Use of Dental Sedation for Persons with Disabilities. Southern Association of Institutional Dentists. Web.
Managing Medically Complex Patients. Web.
Procedural Sedation Provider Module for Adult Patients, 2001. Web.
Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment. Churchil Livingston Derek M Steinbacher and Micheal Glick, 2001. The Dental Patient with Asthma. An Update on Oral Health Considerations. JADA Vol 132, PP 1229-1239.
Conscious Sedation. A Referral Guide for Dental Practitioners. Dental Sedation Teachers Group. Web.
Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment. Churchil Livingston.
Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment., Churchil Livingston.
Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment. Churchil Livingston.
Derek M Steinbacher and Micheal Glick, 2001. The Dental Patient with Asthma. An Update on Oral Health Considerations. JADA Vol 132, PP 1229-1239.
G D Allen. Dental Anesthesia and Analgesia (Local and General) Third Edition. CBS Publishers and Distributors.
Crispian Scully, Oral and Maxillofacial Medicine, 2nd Edition. The Basis of Diagnosis and Treatment. Churchil Livingston.
Managing Medically Complex Patients. Web.
G D Allen. Dental Anesthesia and Analgesia (Local and General) Third Edition. CBS Publishers and Distributors.
Paul Coulthard, Keith Horner, Philip Sloan and Elizabeth Theaker. Master Dentistry. Oral and Maxillofacial Surgery, Radiology, Pathology and Oral Medicine, vol 1. Churchil Livingston.
LÓPEZ-JIMÉNEZ J, GIMÉNEZ-PRATS MJ. SEDATION IN THE GERIATRIC PATIENT. MED ORAL 2004;9:45-55.
Raymond A Dionne, John A Yageila, Paul A Moore, Arthus Gonty, John Zuniga, Ross Beirne, 2001. Comparing Efficacy and Safety of Four Intravenous Sedation Regimes in Dental Outpatients. Journal of American Dental Associaiton. Vol. 132, No. 6 740-751.
Raymond A Dionne, John A Yageila, Paul A Moore, Arthus Gonty, John Zuniga, Ross Beirne, 2001. Comparing Efficacy and Safety of Four Intravenous Sedation Regimes in Dental Outpatients. Journal of American Dental Associaiton. Vol. 132, No. 6 740-751.
Hosey M T, Makin A, Jones R M, Gilchrist F, Carruthers M, 2004. Propofol Intravenous Conscious Sedation for Anxious Children in a Specialist Paediatric Dentistry Unit. International Journal of Paediatric Dentistry, Vol 14,no. 1, pp 2-8.
Raymond A Dionne, John A Yageila, Paul A Moore, Arthus Gonty, John Zuniga, Ross Beirne, 2001. Comparing Efficacy and Safety of Four Intravenous Sedation Regimes in Dental Outpatients. Journal of American Dental Associaiton. Vol. 132, No. 6 740-751.
Managing Maladaptive Behaviors: The Use of Dental Sedation for Persons with Disabilities. Southern Association of Institutional Dentists. Web.
Procedural Sedation Provider Module for Adult Patients, 2001. Web.
Huether and McCance (2016) define asthma as an “inflammatory disorder of the bronchial mucosa that causes bronchial hyperresponsiveness, constriction of the airways, and variable airflow obstruction that is reversible” (p. 698).
The major distinction of chronic asthma (CA) from acute asthma exacerbation (AAE) is that an acute condition implies a rapid onset of adverse symptoms and a relatively short-term duration, while the term “chronic” refers to an enduring aggravated condition progressing in a slow manner. The two conditions have both similar and distinct features which will be discussed in the following paragraphs along with their pathophysiological mechanisms, diagnosis, and available treatment procedures.
CA: Pathophysiology
In a simplified form, the pathogenesis of bronchial asthma can be represented as a combination of two basic mechanisms: chronic inflammation of the respiratory tract and bronchial hyperresponsiveness. The inflammatory process in the bronchi leads to the obstruction of the airways causing a decrease in the airflow. These functional changes cause such symptoms of bronchial asthma as dyspnea, cough, chest tightness, and wheezing.
The narrowing of the bronchial lumen in CA is the result of the action of numerous factors. The main one is the contraction of the smooth muscles of the bronchi, caused by the action of agonists, such as histamine, released from the inflammatory cells (Janssen, 2012).
The consequences of the smooth muscles’ tightening can be aggravated by the thickening of the bronchial wall due to acute edema, cellular infiltration, and remodeling of the airways − chronic hyperplasia of smooth muscles, vessels, and secretory cells, and the deposition of the matrix in the bronchus wall (Janssen, 2012). Obstruction is exacerbated by a tight, viscous discharge produced by goblet cells (Janssen, 2012).
Hyperreactivity of the bronchi is a state when they narrow either too easily or too much in response to various provoking factors. As noted by Bjørke-Monsen et al. (2017), this process is “mediated via airway smooth muscle tone and is modulated by the autonomic nervous system, nitric oxide, and airway inflammation” (p. 83). Moreover, in patients with CA, excess sputum in the airways is accumulated over time, and it strengthens the response of the bronchi to external stimuli leading to spasms and, in this way, also affecting the volume and the composition of sputum. The substances released in the inflammatory cascade including epidermal growth factors, IL-4, IL-9, and IL-13, etc. play the primary role in this process (Ha & Rogers, 2015).
AAE: Pathophysiology
AAE differs from the chronic condition mainly by its association with a rapid onset of severe bronchial obstruction. AAE-related bronchospasm results in the increase of the residual capacity of the lungs, a decreased volume of reserve breath and exhalation, acute shortness of breath, and impaired venous return of blood to the heart, etc. (Niimi, Lewis, & Fanning, 2015) These alterations promote the development of pulmonary hypertension. Reduction of venous return of blood contributes to fluid retention in the body due to the increase in the level of antidiuretic hormone and aldosterone (Gershwin & Halpern, 2012).
Moreover, the condition leads to hypoxia − the deprivation of the organism from oxygen. The dysfunction of external respiration and cardiovascular system disrupts the acid-base balance and gas composition of the blood (Gershwin & Halpern, 2012). As a result, some organs can undergo a process of irreversible transformations.
Contributing Factors: Gender and Ethnicity
Gender and ethnicity indirectly affect asthma incidence. Researchers observe that the prevalence of CA in a particular demographic group is rather determined by gender- or ethnicity-specific socioeconomic and environmental factors. For instance, Greenblatt, Mansour, Zhao, Ross, and Himes (2017) observe that the rate of asthma development in Native Americans and Alaskan Natives is higher than in Whites because these minority populations are associated with low economic status and exposure to adverse environmental influences.
The researchers note as well that “individuals of both genders living below the poverty line” are “at increased risk of having asthma” (Greenblatt et al., 2017, p. 2). Such multicultural behavioral indicators as engagement in physical activity, overeating and unhealthy dieting leading to overweight and obesity, smoking, etc. also proved to increase the risk for asthma occurrence in the study by Zahran and Bailey (2013).
To identify which behavioral factors contribute to asthma development in an individual of any gender or ethnic background, the health practitioner should carry out a holistic assessment of all systems relevant to the patient’s health including the psycho-social, ecological, and cultural ones. Additionally, to differentiate asthma from other similar respiratory disorders, Brigham and West (2015) suggest using spirometry − a tool that allows the detection of any functional abnormalities in the lungs. At the same time, AAE can be diagnosed through the assessment of blood gas composition because the level of carbon dioxide in plasma in this condition is significantly elevated.
When speaking of treatment methods, lifestyle interventions addressing reduce ethnicity- and gender-specific behavioral peculiarities may help reduce asthma symptoms. Based on the results of the patient assessment, the practitioner can recommend him/her to make some changes in nutrition, physical activity, environment, and so on. Along with this, pharmacologic remedies can be prescribed for distinct asthmatic events and situations.
For example, beta-agonists can be used to relieve CA symptoms, while glucocorticosteroids will help against inflammation (Institute for Clinical Systems Improvement, 2012). When speaking of AAE treatment, researchers recommend to implement the following steps: treat hypoxemia, provide the patient with ß2-agonists and corticosteroids, evaluate the response to treatment, and make alterations if needed (Ortiz-Alvarez, Mikrogianakis, & Canadian Paediatric Society, Acute Care Committee, 2012).
β-2-agonists can be regarded as the first-line drugs in the treatment of bronchospasm attacks because they help relieve adverse symptoms in a short time. However, they can induce arrhythmia, arterial hypertension, agitation, and so on. Thus, these drugs should be used with greater care in patients with cardiovascular conditions.
References
Bjørke-Monsen, A., Vollsæter, M., Ueland, P. M., Markestad, T., Øymar, K., & Halvorsen, T. (2017). Increased bronchial hyperresponsiveness and higher asymmetric dimethylarginine levels after fetal growth restriction. American Journal of Respiratory Cell and Molecular Biology, 56(1), 83-89. Web.
Brigham, E. P., & West, N. E. (2015). Diagnosis of asthma: Diagnostic testing. International Forum of Allergy & Rhinology, 5(S1). Web.
Gershwin, M. E., & Halpern, G. M. (2012). Bronchial asthma: Principles of diagnosis and treatment. New York, NY: Springer.
Greenblatt, R., Mansour, O., Zhao, E., Ross, M., & Himes, B. E. (2017). Gender-specific determinants of asthma among U.S. adults. Asthma Research and Practice, 3, 2. Web.
Ha, E. V., & Rogers, D. F. (2015). Novel therapies to inhibit mucus synthesis and secretion in airway hypersecretory diseases. Pharmacology, 97(1-2), 84-100. Web.
Huether, S. E., & McCance, K. L. (2016). Understanding pathophysiology. St. Louis, MO: Mosby/Elsevier.
Janssen, L. J. (2012). Airway smooth muscle as a target in asthma and the beneficial effects of bronchial thermoplasty. Journal of Allergy, 2012, 593784. Web.
Niimi, K. S., Lewis, L. S., & Fanning, J. J. (2015). Impairment of venous drainage on extracorporeal membrane oxygenation secondary to air trapping in acute asphyxial asthma. The Journal of Extra-Corporeal Technology, 47(2), 109–112.
Ortiz-Alvarez, O., Mikrogianakis, A., & Canadian Paediatric Society, Acute Care Committee. (2012). Managing the paediatric patient with an acute asthma exacerbation. Paediatrics & Child Health, 17(5), 251–256.
Zahran, H. S., & Bailey, C. (2013). factors associated with asthma prevalence among racial and ethnic groups—United States, 2009–2010 behavioral risk factor surveillance system. Journal of Asthma, 50(6), 583-589. Web.
Obstructive pulmonary disease (COPD) is a widespread health problem both in the United States and in other areas of the world. There are a lot of known cases of the COPD-asthma overlap in different populations, particularly in older adults. According to Soler-Cataluna et al. (2012), “The patients in whom the characteristics of the two diseases overlap could potentially have different responses to treatment and the evolutional course” (p. 331).
Nevertheless, the COPD-asthma overlap remains poorly understood, as there have been limited attempts to explore its epidemiology (Iwamoto et al., 2014). Potentially, research on the epidemiology of the COPD-asthma overlap could provide some useful insights into the issue.
For example, a study by Fu, Gibson, Simpson, and McDonald (2014) showed that the prognosis for patients for COPD-asthma overlap is generally much better than for those with COPD alone, while Cazzola et al. (2012) showed that the presence of asthma alongside COPD is associated with a higher incidence of cardiovascular morbidity. In their article “The Coexistence of Asthma and Chronic Obstructive Pulmonary Disease (COPD): Prevalence and Risk Factors in Young, Middle-aged and Elderly People from the General Population”, De Marco et al. (2013) aimed to fill the existing gap in knowledge by studying the development of COPD-asthma overlap in different populations.
Research Problem and Purpose
The overlap between COPD and asthma is a major health issue due to its high prevalence, as well as the associated morbidity, mortality, and socioeconomic costs (De Marco et al., 2013). Yet, the issue has not received sufficient attention in clinical research, as very few epidemiological studies on the overlap are available. De Marco et al. (2013) place the study problem within the context of existing knowledge by summarizing the previous research findings. The purpose of the research was to expand the current knowledge of the overlap syndrome in order to determine its prevalence and risk factors. Potentially, this study could be used in nursing practice to better understand the condition, although it would be more useful in further research on treatment and prevention.
Review of the Literature
The report does not include a separate section on the literature review, which is probably because limited research on the COPD-asthma overlap is available. However, the authors managed to cover the most important concepts that were addressed in existing research. For example, researchers state that COPD and asthma are considered to be connected conditions even where the overlap is not present: over 40 percent of COPD patients report a history of asthma, which is considered to be among the risk factors for developing COPD (De Marco et al., 2013).
The authors also describe the reasons as to why the overlap of the two conditions remains poorly studied: “studies on asthma are usually performed in populations of children or young adults, where the prevalence of COPD is negligible, while studies on COPD are usually performed in elderly populations where the prevalence of asthma is low” (De Marco et al., 2013, p. 2). The majority of the articles addressed in the literature review are fairly recent, although there are sources from 1998-2005. This is probably due to the low availability of studies on the overlap of COPD and asthma. Overall, the literature review forms a useful basis for the research study proposed by the author, despite the limited knowledge of the issue.
Theoretical Framework and Initial Presentation
The authors do not provide any theoretical framework for the study, which is one of its major limitations. The theoretical concepts applicable to the research are not defined. However, this is somewhat justified by the fact that the study draws primarily from the existing research of the condition, which is limited. Nevertheless, the study would benefit from a distinctive theoretical framework.
For instance, the authors could introduce their theories regarding the prevalence of COPD-asthma overlap in different populations and the factors that influence the development of the overlap. Age, sex, smoking, levels of education, and high levels of heavy traffic were the independent variables for the study. The existing diagnoses of asthma, COPD, or COPD-asthma overlap are the dependent variables. Operational definitions of the variables were not provided. Clear research questions are not included in the report, although the goals for both stages of research are defined.
Methodology and Data Analysis
The study used quantitative design methodology, which is appropriate to the large sample size and the goals of the study. The authors did use inductive reasoning to determine the effect of different risk factors on the conditions studied. The sample consisted of 5163 adults aged 21-44, 2167 older adults aged 45-64, and 1030 elderly people aged 65-84. The study was set in medium to large cities of Italy, including Verona, Palva, Torino, and Sassari.
The authors chose a non-probability sampling method as only the results from people with diagnosed COPD, asthma, or overlap of the two were included. Although probability sampling is perceived to be more reliable, the non-probability sampling method is suitable for the study, as the researchers aimed to gather data from all the available subjects. The authors achieve concurrent validity through the use of statistical tools for determining the correlation between the variables.
The authors state that the approval of the Institutional Board Ethics Committee was obtained in each city where the study was performed and that the participants were fully aware of all aspects of research and provided informed consent, which satisfies ethical requirements for this type of research.
In order to analyze the data, the authors performed the Pearson Chi-squared test, which is a popular and relatively efficient statistical data analysis tool. The results were presented in text form, as well as in tables. This is an important advantage of the study as it ensures that the findings are presented in a comprehensive form. The authors found that 1 out of 8 subjects below 65 years of age and 1 out of 5 subjects aged 65 or over reported a physician diagnosis of asthma-COPD overlap (De Marco et al., 2013).
Moreover, researchers state that “Subjects with the overlap syndrome had a statistically significantly higher frequency of respiratory symptoms, functional limitation and hospitalization with respect to subjects with the diagnosis of asthma or COPD alone” (De Marco et al., 2013, p. 4).
Conclusion
Overall, this study addresses the existent gap in knowledge of COPD-asthma overlap syndrome by studying the prevalence and risk factors associated with its development, which is the main strength of the study.
The report is neatly organized and provides a concise yet useful summary of the current knowledge on the condition, which is also a significant advantage. Finally, the research sample is large enough to apply the findings of the study to other populations, although further research in other countries is required. However, the primary limitation of the study is that it does not provide a sufficient discussion of the theoretical framework. By developing a clear hypothesis and research questions, the authors would ensure a better structure of the study.
The authors’ conclusions are consistent with the presented results. Although the research showed no significant predictors of COPD-asthma overlap, the study contributes to the understanding of its prevalence and outlines the incidence of symptoms associated with the overlap. All in all, the study can be used in nursing practice to enhance the differential diagnosis of COPD and asthma, as well as in further nursing research on the conditions.
References
Cazzola, M., Calzetta, L., Bettoncelli, G., Cricelli, C., Romeo, F., Matera, M. G., & Rogliani, P. (2012). Cardiovascular disease in asthma and COPD: A population-based retrospective cross-sectional study. Respiratory Medicine, 106(2), 249-256.
De Marco, R., Pesce, G., Marcon, A., Accordini, S., Antonicelli, L., Bugiani, M.,… Pirina, P. (2013). The coexistence of asthma and chronic obstructive pulmonary disease (COPD): Prevalence and risk factors in young, middle-aged and elderly people from the general population. PLoS One, 8(5), 1-7.
Fu, J. J., Gibson, P. G., Simpson, J. L., & McDonald, V. M. (2014). Longitudinal changes in clinical outcomes in older patients with asthma, COPD and asthma-COPD overlap syndrome. Respiration, 87(1), 63-74.
Iwamoto, H., Gao, J., Koskela, J., Kinnula, V., Kobayashi, H., Laitinen, T., & Mazur, W. (2014). Differences in plasma and sputum biomarkers between COPD and COPD–asthma overlap. European Respiratory Journal, 43(2), 421-429.
Soler-Cataluna, J. J., Cosío, B., Izquierdo, J. L., López-Campos, J. L., Marín, J. M., Agüero, R.,… González, M. C. (2012). Consensus document on the overlap phenotype COPD–asthma in COPD. Archivos de Bronconeumología (English Edition), 48(9), 331-337.
The clinical guideline and associated recommendations
Asthma is a chronic inflammatory disorder of the airways with airway hyper-responsiveness. The aim of this term paper is to assess the latest report on asthma guidelines (EPR-3) (Busse et al., 2007). The guideline illustrates diagnostic procedures for assessment of severity and control of asthma based on presence of airway hypersensitiveness, reversibility of airflow, detailed medical history, respiratory tract, skin and chest examinations, spirometry to assess obstruction, and exclusion of other chronic pulmonary obstructive diseases.
Forced expiratory volume to forced vital capacity ratios (FEV/FVC), by spirometry, was recommended as the main criterion to assess severity. Periodic monitoring (signs and symptoms, FEV/FVC, and peak flow measurements, asthma exacerbations’ history, etc.), and referral to a specialist in extreme severity were also recommended. Education through the written asthma action plan of handling metered-dose inhalers, smoking avoidance, household environmental consciousness (indoor and outdoor allergens, mites, cockroaches, etc.), and clinical guidance was emphasized.
Avoidance of non-specific beta2 blockers and aspirin, sulfite-containing and other food, occupational pollutants, single and multiple allergen immunotherapy, and tests for sensitivity to non-steroidal anti-inflammatory drugs, sinusitis, and nasal polyps were also recommended. Chronic comorbid conditions like obesity, rhinitis/sinusitis, chronic stress/depression, gastroesophageal reflux disease, obstructive sleep apnea were related to asthma severity.
Recommendations for medications for long-term control were: inhaling corticosteroids, cromolyn sodium, nedocromolin, immunomodulators, leukotriene modulators, bronchodialators, methylxanthines, and short term quick relief were: anticholinergics, strong bronchodialators, systemic corticosteroids etc. It was recommended that use of immunomodulators inhalations may have potential risk. In adults, health problems associated with prolong treatment were listed, and possible remedy measures were formulated. Adjunctive drugs (omalijumab) were recommended in severe untreatable cases only. Other specialized drugs recommended to be within recommended doses were leukrotriene receptor antagonists (fluticasone), lipoxygenase inhibitors (Zileuton) and beta2 agonists.
Indicate the group who developed the guidelines on the particular topic
The recommendations were delivered by National Asthma Education and Prevention Program (NAEPP) coordination committee. An expert panel was set up by the National Heart, Lung, and Blood Institute (NHLBI) to update the asthma guidelines. It is an update from previous published report by same agency (EPR-2 Update; Murphy et al., 2002).
The committee comprised experts from University of Wisconsin Medical School Madison, University of California–San Francisco, Massachusetts General Hospital, Columbia University, Advocate Health Center, Chicago, University of New Mexico Health Sciences Center, Albuquerque, University of Wisconsin Hospital and Clinics, University of Arizona Medical Center, U.S. Food and Drug Administration, National Jewish Medical and Research Center, University of Virginia School of Medicine, University of Washington, University of Nevada School of Medicine, Brigham & Women’s Hospital, and Olmstead Medical Center.
Indicate whether the guidelines are evidence based or not
Based on numerous asthma related research articles, evidence tables were prepared. These evidences were generated from tabulating the abundance of cases of a particular type and these were then categorized as:
randomized trials with consistent findings,
limited yet positive evidence after statistical analysis,
nonrandomized uncontrolled trials and further less consistent data,
to selected observations deemed to be important by the panel members.
The strength of recommendations was also graded on a ranking system, based above category of observations and interpretations. Normally, the evidence category A was highly emphasized, and D was not recommended or with caution.
Assess the validity of the guideline
The guidelines were based on factual observations from peer-reviewed journal, and wherever doubts existed, were clarified. Urbano (2008), based on recommendation of nine asthma experts, came up with all-positive validation report. Seven key educational messages were extracted,
accurate diagnosis,
comprehensive management,
monitoring control,
step-wise initial and follow-up therapy,
special situation management, and
managing exacerbations.
Loschen (2008) attempted to practically apply the guideline for patient care. In limited samples tested, the patients were not controlled as per guidelines, and a change in therapy was required. Considering this anomaly in evidence- and trial-based recommendations, Bousquet et al. (2006) emphasized for a true global guideline, considering varied socio-economic conditions and racial/ethnic groups.
This is because asthma is diagnosed late in low-income communities, who can not afford inhaled corticosteroids and visits to specialists (Ait-Khaled et al. 2006). Though genetic lineage of asthma prevalence is not proven in ethnic communities, it can be another factor (Ghosh et al., 2003). Smith et al. (2005) found that non-Hispanic black children were more affected by asthma than American Whites. There are also country-specific asthma guidelines (Rai et al., 2007), and for validation, such evidence-based regional guidelines need to be considered and their specific recommendations to be incorporated.
Use the agree instrument
The agree instrument (Cluzeau & Burger, 2001) is used with ranking in parenthesis and comments:
The overall objectives of the guideline are specifically described [4]: Due to recent innovation in asthma-related medication, an update was necessitated. Five objectives were identified:
Establishing accurate diagnosis system to evaluate asthma severity,
Initial step-wise approach of therapy depending on severity,
Educating patients, family and the physicians to control asthma,
Establishing pharmacologic therapy for asthma and exacerbations, which includes written asthma action plan, and
Managing special situations. The asthma action plans, special education, and diagnostic and therapeutic innovations were novel components, not considered earlier.
The critical questions covered by the guideline are specifically described [4]: The questions as to how effective is spirometry in accurate diagnosis, does reversibility on spirometry demonstrate reversibility of signs and symptoms, how to avoid misdiagnosis of other pulmonary conditions, how to maintain written asthma plan, what should be the course of pharmacologic therapy, the doses of inhaled corticosteroids (ICS), long acting beta2 agonists (LABA), leukotriene modifiers (LM) and the new immuno-modulators (omalizumab), and the risks associated with such therapy, what is the step-wise approach for initial and ongoing therapy like short-acting bronchodialators, LABA LM and omalizumab etc, and in case of severe life threatening exacerbations, how to switch to other therapy like of short acting beta2 agonists (SABA), oxygenation etc., have been elaborately described, discussed and explained.
The patients to whom the guideline is meant to apply are specifically described [3]: Age is an important consideration, and besides adults, children of < 5, 5-12, and > 12 age groups were segregated. Accordingly, treatment strategies were formulated. In the step-wise approach, only low dose of ICS and no adjunctive therapy was recommended for 1 – 4 year. For older children, medium dose ICS was combined with low dose low dose LABA, and for > 12, addition of omalizumab was considered. Pharmacologic treatments were also age specific, and in children recommendation was for only minimum therapy, and if required step-down therapy. Asthma intermittent groups were to be treated by SABA, while persistent groups were to be treated initially with ICS followed by step-wise medication. For managing special situations like exercise-induced bronchospasm, surgery, pregnancy, and racial and ethnic groups, the treatment strategies included intranasal corticosteroids and SABA.
The guideline development group includes individuals from all the relevant groups [4]: NAEPP coordination committee comprised of experts like healthcare research professionals, experts from allergy and asthma network and academies, pharmacists, clinical environmentalists, epidemiologists, food and drug controllers, family physicians, pediatricians, and doctors from chest, respiratory and lung associations. The EPR-3 was constituted by experts who served as officials or were consultants for leading companies like GlaxoSmithKline, Merck, Novartis, Pfizer, Centocor, Dynavax, Genentech/Novartis, Isis, Schering, Atlanta, Wyeth etc. There was a 12 member panel of reviewers from reputed medical centers who reviewed the draft before publication.
The patients’ views and preferences were sought [2]: The recommendations were based on medical papers, in which patients’ comments might have been incorporated. EPR-3 refers to the data of Gaining Optimal Asthma Control (GOAL) randomized double-blind study, which involved 3,421 patients with intermittent asthma, who were treated with fluticasone propionate and salmeterol/fluticasone with lower incidences of exacerbations and better life-style. The FEV1/FVC data were gathered from patients at National Health and Nutrition Examination Survey, National Center for Health Statistics and Centers for Disease Control and Prevention, for diagnosis recommendations.
The target users of the guidelines clearly identified [2]: The guideline was not targeted to any specialist clinician, but was directed to patients and family/community members and environmentalists. Apparently, the primary targets are the pharmaceutical companies manufacturing the asthma drugs. Indirectly, the professionals in research and development sector were benefited with vast information on generic drugs, which are still under trials for asthma and can be directly applied for patient care.
The guidelines have been piloted among target users [3]: As indicated, pilot study was done by GOAL. Another randomized placebo-controlled trial of salmeterol vs. placebo was included for adults to assess its safety. The outcomes of the study revealed concern of using LABA as sole drug in prolong therapy. Later, FDA warned about the side effects of such treatments and LABA was prescribed in conjunction with long-term ICS treatment.
Systematic methods were used to search for evidence [4]: The panel members searched for peer reviewed medical journals in MEDLINE database. To organize the review process the panel was divided in 10 committees with lead teams, who were responsible for topics like, assessment and monitoring, patient and provider education, control of causative factors, pharmacologic therapy (ICS, LM, and bronchodialators), special alternative medication, and managing exacerbations. About 15,444 titles were searched, of which 4,747 were short-listed, 2,800 abstracts were retrieved based on relevance and quality, from which 2,122 full text articles were reviewed and from this 1,654 were finally used for referencing.
The criteria for selecting the evidence are clearly described [4]: A total of 20 evidence tables were prepared from 316 articles. Evidence category 1 was based on randomized controlled trials-rich body data, which means consistent pattern of findings for a particular population. Evidence category 2 included only the limited evidence of patients, and was subjected to post hoc and statistical treatments, and Meta analysis. The interpreted data were less significant, though highly consistent. In evidence category 3, observations from nonrandomized uncontrolled trials were kept, and evidence category 4 included selected observations deemed to be important by the panel members. The strength of recommendations was also graded on a ranking system, based above category of observations and interpretations. For e.g. long-term corticosteroid and cromolyn treatments, and beta2 agonists as short-term treatment was recommended as Evidence A. Immuno-modulators were, however, recommended as Evidence B for age >12 year, which means data are not strong enough to unequivocally recommend. Dose dependence and drug delivery system had even less consistency and was recommended as Evidence C.
The methods used for formulating the recommendations are clearly described [4]: After preparing the evidence tables, the respective members adopted an iterative process of interpreting the evidences and drafted initial report after incorporating reviewers’ comments. All such drafts were compiled and after a panel discussion with full consensus the final guideline was drafted.
The health benefits, side effects, and risks have been considered while formulating the recommendations [4]: As many new drug formulations and therapy choices were prescribed, there were discussions held on their merits/demerits. Health benefit of spirometry was highly emphasized. Equal weight was given to increase doses of ICS and LABA and on adding immunodialating therapy with omalizumab, for persistent and severe asthma. The risk components were also highlighted in asthma action plan, such as likelihood of exacerbations, progressive decline in lung function (reduced lung growth in children), risks of side effects of medication etc. Use of omalizumab was recommended with reservations, because of its anaphylactic action. LABA associated asthma related life-threatening risks were cautioned. It was cautioned that children < 5 can be misdiagnosed for asthma and treatments that too only with ICS have to be very carefully evaluated before applying.
There is an explicit link between the recommendations and the supporting evidence? [3]: Every recommendation was supported by references from which the evidence tables were made, regardless of whether the evidences support or oppose the nature of particular therapy. As the evidences were ranked, they were linked to the recommendations at every stage.
The guidelines have been externally reviewed by experts prior to publication [3]: The guidelines were also externally reviewed by a panel of consultant reviewers comprising 14 experts in the field of asthma and pulmonary diseases. Besides, the NHLBI staff (5 members) and American Institute for Research Staff (4 members) were also instrumental in preparation of guidelines. Many other professional societies, voluntary health and consumer/patients advocacy organizations and industry were also consulted during public review of the guideline.
A procedure for updating the guidelines provided [3]: As this is already an updated guideline of EPR-update (Murphy et al., 2002), not much systematic procedure has been laid to suggest mechanisms to further update it. There were lacuna in the previous guidelines mostly because the information were either not available or were misleading, and these were rectified. However, updating guidelines is sought for children > 5 year and for special cases like exercise, surgery, pregnancy, other pulmonary diseases etc.
The recommendations are specific and unambiguous [4]: As the evidence tables were ranked, there was clear difference between certainty and uncertainty of the management. Precise description of management was given at every level, from diagnosis, initial therapy, and follow-up pharmacological and environmental control. Every procedure was elaborately described without any ambiguity. Further, the recommendations were spelled in charts, pictures, tables and figures, enabling easy understanding of the procedures. For example, step-wise improvement of therapy was explained in point-wise manner in algorithm with respect to every drug included in the therapy, their health effects, dose, duration of application and risk factors.
The different options for management of the condition are clearly presented [4]: Different options for medication were considered. For e.g. in step-wise therapy the following medication was recommended: step 1 includes SABA, step 2 gives preferred low dose ICS or alternatively low dose LM drugs, step 3 gives low dose ICS + LABA or medium dose ICS or low dose ICS + LM drugs, step 4 gives medium ICS + LABA or medium ICS + LM, and steps 5-6 give high dose ICS + LABA or omalizumab.
Key recommendations are clearly identifiable [4]: Recommendations were presented in boxes and figures at the end of the section. The figures include charts, questionnaire, pictures and algorithms Step-wise treatment was very well depicted in a seven bar algorithm. Asthma management section had 4 boxes and 34 figures, Long term asthma management section had 1 box and 15 figures, and Managing exacerbations of asthma section had 10 figures.
The guideline supported with tools of application [3]: Introductory sections preceded each detailed sections. Key points gave an overview summary of each section followed by the key differences from the previous guidelines. At the end of each section many references were provided to support the contents given in the section. This means that the previous guidelines were taken as baseline tools, and all improvements were thoroughly depicted in the current document.
The potential organizing barriers applying the recommendations have been discussed [4]: Although many panel members independently searched references, short-listed the relevant texts and made their own sets of evidence tables, their interests never clashed and in the panel discussions they could arrive to a common set of guidelines. No organizational, bureaucratic or even procedural problems were associated with this report, as mentioned.
The potential cost implications of applying the recommendations have been considered [2]: This aspect is completely missing. The cost of diagnosis, treatment and management of asthma and environmental clean-up costs should have been assessed. Most of the immunomodulators, leukotriene modulators, bronchodialators etc. must be expensive and regular use may lead to side effects, which has to be treated by experts, involving cost. In special cases like life-threatening exacerbations, surgery, pregnancy etc. the cost becomes a critical issue; did not fine any space in the report.
The guideline presents key review criteria for monitoring and/or audit purpose [3]: Asthma diagnosis to evaluate severity of the symptoms decides the follow-up treatment strategy. In this guideline, the review to evaluate the severity during diagnosis is well documented. For e.g. frequency of severe or recurrent episodes of coughing, wheezing, chest tightness, night awakening, pre- and post bronchodialator, FEV/FVC, etc. are criteria to review the patient’s conditions for determining the step-up therapy. The complete medical history has been considered as another instrument to evaluate the nature of allergy, which should be tested before suggesting course of treatment.
The guideline is editorially independent from the funding body [4]: NHBLI partially supported the members while most funding was done for the independent sources not related to this work, or they volunteered. The EPR members received independent funding for travel etc., as they disclosed, from pharmaceutical companies, they are associated with. Thus editorially it was independent fro funding bodies.
Conflicts of interest of guideline development members have been recorded [4]: On record, there is no conflict among the panel members as they worked independently gathering information and prepared their evidence tables. Subsequently, they prepared initial document with consensus and sought help of external agencies for reviewing.
Further comments
It appears that there was a bias towards drug manufacturers and pharmaceutical companies, who probably would be most benefited as the complete set of new medication was introduced. Another important feature is rehabilitation of the patients by educating them to cope with asthma health- and environment related problems.
Overall recommendations: [Strongly recommended]
The given guideline is the most updated and most comprehensive document for asthma diagnosis, management and cure. Novel drugs were prescribed with their doses and courses, which certainly would benefit society at large. The rehabilitation strategy and pharmaceutical therapy will have long term implication in patient care.
References
Aït-Khaled, N., Enarson, D.A., Bencharif, N., Boulahdib, F., Camara, L.M., Dagli, E., et al. (2006). Implementation of asthma guidelines in health centres of several developing countries. International Journal of Tuberculosis and Lung Diseases, 10(1), 104-109.
Bousquet, J. Godard, P. & Grouse, L.(2006).Global integrated guidelines are needed for Respiratory diseases. Primary Care Respiratory Journal, 15, 10-12.
Busse, W.W., Boushey, H.A., Foggs, M.B., Janson, S.L., Kelly, W.H., Lemanske, R.F., Martinez, F.D., et al.(2007). EPR-2007-Expert panel report: guidelines for the diagnosis and management of asthma. Update on selected topics. Bethesda, NIH Publication No. 07-4051.
Cluzeau, F. & Burger, J. (2001). Appraisal of guidelines for research & evaluation AGREE) – Appraisal instrument. Web.
Ghosh, B., Sharma, S. & Nagarkatti, R. (2003). Genetics of asthma: current research paving the way for development of personalized drugs. Indian Journal of Medical Research, 117, 185-197.
Loschen, J. (2008). New asthma guidelines: how will they affect patient care? Web.
Murphy, S., Bleecker, E.R., Boushey, H.A., Buist, A.S., Busse, W.W., Clark, N.M., et al. (2002). EPR-2 Update-Expert panel report: guidelines for the diagnosis and management of asthma. Update on selected topics. Bethesda, NIH Publication No. 02-5074.
Rai, S.P., Patil, A.P., Vardhan, V., Marwah, V., Pethe, M. & Pandey, I.M. (2007). Best treatment guidelines for bronchial asthma. Medical Journal of Armed Forces India, 63, 264-268.
Smith, L.A., Hatcher-Ross, J.L., Wertheimer, R &.Kahn, R.S. (2005). Rethinking race/ethnicity, income, and childhood Asthma: racial/ethnic disparities concentrated among the very poor. Public Health Reports, 120, 109-120.
Urbano, F.L.(2008). Review of the NAEPP 2007 Expert Panel Report (EPR-3) on asthma diagnosis and treatment guidelines. Journal of Managed Care Pharmacy, 14(1), 41-49.
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, TH2 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 36th 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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Asthma is a disorder of the human respiratory system in which there is swelling of principal air corridors of the lungs and bronchial tubes. It is not similar to other chronic obstructive lung diseases, as it cannot be reversed. However, it has one positive quality that it can be arrested and controlled. Actually it happens that the muscles of the bronchial walls are squeezed and the additional mucus is generated evoking the airways to be contracted. Diverse consequences are thus in the offing. They may range from small wheezing to very enormous pain in breathing. There are cases that the process becomes so much complicated and labor demanding that there is risk of safety of life. The importance of the disease can be known after the true comprehension of patterns it is able to generate in its victims. As asthma is capable of doing the resistance to the air output, that is why it is called an obstructive lung disease. It is medically called chronic obstructive pulmonary disease, or COPD. COPD is conglomerate of diseases, which have in their fold other diseases including the asthma.
Some people develop resistance against the disease and thus overcome it with their age and are not attacked by it any more. Other people become capable of shunning the things that are instrumental in bringing forth the asthma attack. It is but a disease which persists over a period of time and hence it is the opinion of many that a lot of care and caution is needed to manage this monster. More than half of the kids who are visisted by the disease whn they are between 2 and 10 years of age develop the resistance power and can thus successfully control the disease. Howver, asthma has the potential to fight back when the very kids reach their 30s and 40s. it is a challenging enemy ans gives a lot of tough time by bouncing back.
The better way is conventional one which pertains to suppressing the evil in the bud. There are reliable ways of the treatment of the diease which is safer and easier too. Consequently all efforts should be undertaken not to permit kids to continue to suffer from symptoms. When the breathing corridors are out of order, an attack itself is avtivated. It is a process which moves slowly but steadily. However, it may also abruptly happen. Wheezing is the most frequent symptom to be noticed. It may happen both during inhalation and exhalation. However, it must be interestingly noticed that there is not an essential relationship between wheezing and asthma. Both may exist independently without exclusion to the other. Breathing is not comfortable process for asthamic patient. Coughing is also seen. If the syptoms occur at night, one has to pass sleepless nights. The sevrity of asthama also undergoes different ranges. There are asthama with attacks frequently occuring, less frequently happening and the least frequently in esistence.
Residents who are living beside one of the biggest landfills in America are deeply worried about the respiratory health conditions in their society. Various surveys have been done to gauge the enormity and frequency of the incidence. A telephone survey based on a 30 day data collection tenure warranted response from the inhabitants of the two communities living on the Staten island. All this was done to identify the nature of respiratory illness among these residents. People living in these areas responded with enthusiasm and it was found that people of the north-shore residents were afflicted with asthma in higher numbers. “Responses were received from 541 residents of the landfill community and 289 residents the north-shore community, over 7 miles from the landfill. In addition, 449 persons living elsewhere on Staten Island responded voluntarily” (Questa journal article, Exploratory Analysis of Respiratory Illness among Persons Living near a Landfill).
Asthma is also prevalent in the portions of the New York city that contain the most of the poverty afflicted and minority inhabitants. If we correlate the socio-economic conditions with the disease there is direct relationship between the poverty and less possessed people with the disease. The poorest boroughs are afflicted with the highest incidence of the disease. The hospitalization rates in the environment there is not otherwise much circulation of wealth are higher than those in which there is comfortable flow of wealth. There is borough of Bronx, which is considered to be the poorest, and the case with it has been stated here that asthma is the fate of the residents. A study has found that it has higher asthma rates of about one and half times higher than the average in the New York City.
Socio-economic conditions have overbearing effect on the decrease or the increase of the disease. According to application of the same principal. The lowest rates have been found on the Staten Island, which has the average income higher than that of the New York City average. “The lowest hospitalization rates were found on Staten Island, which has a median income 1.3 times higher than the New York City average and Staten Island’s asthma hospitalization rate was half of the New York City average.” (NYU student and three investigators, Study links asthma, demographics). The same study reveals that the highest incidence has been found in Northern Manhattan, South Bronx, Brooklyn and Jamaica, Queens. Tulton pertains to areas with highest asthma hospitalization rates and can rightly be characterized as hot zones. Three factors have been found lying at the base of these areas.
It refers to regions with high asthma hospitalization rates as “hot zones” and found that each has three common factors. “The characteristics of these hot zones are that they are low income, have a high concentration of minorities and have a large percentage of children under 18,” the study said. Kids are also found to be most vulnerable to asthma. Within these hot zones, there is lesser availability of preventive health care and other affiliated provisions to effectively deal with the disease. This helps the disease to stay and prosper in these particular areas. In all of the areas where it is prevalent, there is felt a great need of having a management plan being supervised by physicians. “The key to reducing incidents of asthma is having [a physician-administered] asthma management plan,” the specialists said. The housing conditions are most important to gauge the level of the asthma prevailing in the region. The dilapidated housing conditions also give rise to the disease to great extent. Higher hospitalization rates are thus directly proportional to the poor housing conditions as is exemplified by the colonies that have such housing conditions.
These conditions are featured as poor system of cross of air. There is always abundant of dust there. There is highly quantity of dampness, which is the major cause of the development of mold that becomes the reason of triggering an attack of asthma. Roaches contain protein within their saliva and feces, which evoke asthma attacks in some people; however, scientists have no consensus on this theory and the reasoning put forward by it. They are deeply divided about the nature of the disease. The hot zones are also identified as unbalanced number of air polluting provisions. Environment policy is also greatly affiliated with the disease. In the areas with greater bus depots servicing diesel busses, there is greater expectancy of the disease.
For instance, the environmental policy being pursued in the New York City and other metropolitan areas in America are not transparent and fairly regulated. The studies undertaken have always brought much awareness about the demography and the disease along with the links with other important factors like housing conditions and socio-economic ones. We can move out of slumber and all studies are an urge towards reawakening. “I’m hoping to make people aware so they push for some sort of action plan where the [government] will initiate some sort of asthma awareness plan specifically targeted toward low income or minority groups, which are suffering the most,” this study further said. “The only way we can stop this from happening in our community is to organize and get political.” It also provides the rate of hospitalization in boroughs per 10000 residents. The borough, which comes at, the top is East Harlem.
There is need of complete revamping of the living conditions that prop up the diseases. We should also highly focus on the socio-economic ambience to get rid of the diseases. The housing conditions should be improved to have a better sense of living. Spacious corridors and airy ways are a must when planning architecture of the house. Living standards must be raised to have healthy effect on the population living in the worst poverty afflicted areas. Proper and modern method of treatment must be undertaken to ward off the serious consequences of the disease rather than merely acting as spectator and allowing it to play the havoc with the patient. Appropriate treatment can permit a person to overcome the disease and absence of care can worsen the situation and thus permitting forever the association of disease with the patient in hand.
References
NYU Student & Three Investigators (1999), Study Links Asthma, Demographics: washington square news. Web.
Questa journal article (2000), Exploratory Analysis of Respiratory Illness among Persons Living near a Landfill. by Sherri A. Berger, Paul A. Jones, Mary C. White; Journal of Environmental Health, Vol. 62.