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Asthma.DiagnosisandTreatment.NP2017.pdf

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Keywords: adult asthma, airway infl ammation, airway obstruction, allergens, asthma, asthma exacerbations,

bronchial provocation, peak expiratory fl ow, respiratory conditions, spirometry

By Catherine O. Durham, DNP, FNP; Terri Fowler, DNP, FNP; Whitney Smith, MSN, AGNP; and James Sterrett, PharmD

Abstract: Adult asthma is a prevalent chronic medical condition that is associated with high

morbidity, mortality, and cost. Early identifi cation, evidence-based diagnosis, and step-wise

management can lead to improvements in patient outcomes, decrease exacerbations, and

eliminate respiratory function decline as the patient ages.

Adult asthma: Diagnosis and treatment

dult asthma is a prevalent chronic condition character- ized by recurrent episodes of airfl ow obstruction as- sociated with bronchial hyperresponsiveness and

chronic airway infl ammation.1,2 This obstruction is generally reversible, which differentiates asthma from other respiratory conditions.2 Although the obstruction is reversible, failure to address symptom control and prevent exacerbations can lead to a decline in respiratory function, increasing asthma morbidity and mortality.1 This article provides an overview of the epide- miology, pathophysiology, diagnosis, and management of adults with asthma for the primary care provider (PCP) utilizing current evidence-based guidelines.

■ Epidemiology

In the United States, approximately 18 million individuals over age 18 (7.7%) are living with asthma.3,4 The prevalence of asthma peaks in early adolescence and decreases with age, declining to approximately 6.6% in individuals over age 65. However, the prevalence of asthma increases in females over age 18 (9.7%) compared with females under age 18 (6.9%).3 The inverse is true for males, as 9.9% under age 18 are diag- nosed with asthma compared with 5.4% of males over age 18.3 A higher prevalence of asthma is seen in Black adults (9.1%) compared with White adults (7.9%) in the United States.3

The burden of asthma is signifi cant in terms of morbidity, mortality, and cost. In adults over age 18 living with asthma, 46.6% have experienced at least one asthma attack, and 13% have been hospitalized.3 Hospitalization rates are dispropor- tionate, with hospital admission of Black adults at almost 30% compared with almost 9% of White adults with asthma.3

Although the overall rate of asthma mortality has de- creased each year since 2001 at a rate of over 3% per year, asthma mortality increases with age and remains approxi- mately 10%.3 Medical cost related to increasing asthma mor- bidity and mortality in the United States is an estimated $56 billion.5 From 2002 to 2007, asthma was estimated to cost over $3,000 per individual per year.6 In 2012, over 10 million pro- vider offi ce visits were due to asthma, and 1.6 million ED visits were secondary to asthma in 2013.7,8

In addition to medical cost, loss of productivity is signifi - cant with asthma. Asthma exacerbated by work-related expo- sures and conditions affects approximately 25% of adults with asthma.4 One-third of adults with asthma miss work or school.5

Additional cost is attributed to decreased work productivity, increased number of sick days, and higher unemployment.5,9

Given the prevalence of asthma and its burden on morbid- ity, mortality, cost, productivity, and potential adverse reac- tions, it is important for the PCP to use current evidence to develop adult treatment plans. Two comprehensive reports are

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available to help PCPs improve assessment, diagnosis, and management of patients with asthma: the 2007 National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Report and the 2017 Global Initiative for Asthma (GINA) Global Strategy for Asthma Management and Prevention.1,10

■ Pathophysiology

Airway limitation related to infl ammation, bronchoconstric- tion, airway hyperresponsiveness, mucus production, and edema are the underlying etiologies of common asthma signs and symptoms.1,10 Activation of infl ammatory cells and me- diators as well as an altered immune response contribute to the underlying infl ammation, which is the primary underly- ing physiologic change associated with asthma.1,10

There are often no or mild symptoms associated with the underlying infl ammation. This leads to increases in airway hyperresponsiveness to irritants such as allergens, respira- tory infections, and exercise. Asthma is characterized by re- versible airfl ow limitation, but in the presence of chronic airway remodeling, there may be only partially reversible airfl ow limitation.1,10

■ Clinical evaluation

Chief complaint and history. Asthma is often a lifelong chron- ic condition; understanding the historical pattern of typical onset and recurrence of symptoms is crucial.1,10 The chief complaint and history of present illness typically reveals a

recurrent pattern of cough, wheezing, chest tightness, and dyspnea. Symptoms are typically worse at night or upon waking and with exposures to triggers and allergens (see Asthma allergens and triggers).1,10

Adults with asthma may also present with multiple re- spiratory symptoms that may be associated with an upper respiratory infection. Asthma symptoms often occur concur- rently with respiratory infections, and the symptoms can be very similar. Assessing the pattern of symptoms to include onset, duration, frequency, and seasonal and diurnal varia- tions is critical in distinguishing the diagnosis of asthma from other conditions. Assessing medical history, current medications, allergies, family history, and social history also provides key fi ndings that support the diagnosis of asthma.1,10

Medical and social history. Diagnoses associated with asthma or the potential to precipitate asthma include gastro- esophageal refl ux disease (GERD), obstructive sleep apnea (OSA), allergic rhinitis, sinusitis, atopic dermatitis, and nasal polyps.1,10 If the onset of symptoms occurs later in life, espe- cially in the presence of tobacco use and other nonasthma symptoms, the likelihood of asthma decreases, and alternative diagnoses are to be considered.

Assessing for allergies may reveal potential asthma trig- gers or medication intolerance related to the worsening of asthma. A family history of atopic dermatitis, allergies, and asthma may increase the risk of developing asthma. A fam- ily history of a fi rst-degree relative with asthma with or without atopic dermatitis increases the risk of developing asthma (odds ratio ranging from two to four); however, atopic dermatitis alone may not be as strong a risk factor, especially if only one relative or a nonfi rst-degree relative is affected.11 A thorough social history can help identify potential triggers such as tobacco, exercise, work, environ- mental exposures, and stress.1,10

Medications. Assessing current medications may reveal potential triggers, such as aspirin, nonsteroidal anti-infl am- matory drugs (NSAIDs), angiotensin-converting enzyme (ACE) inhibitors, and beta-blockers. Aspirin may induce respiratory symptoms up to 3 hours after ingestion and affects approximately 20% of adults with asthma.12 In less than 10% of individuals with an aspirin sensitivity, a cross sensitivity with both acetaminophen and NSAIDs may occur.12

The pathophysiology of aspirin-induced asthma is not well defi ned but is likely related to an increase in leukotrienes and infl ammatory factors. Similar to aspirin, ACE inhibitors are associated with an increase in proinfl ammatory mediators in the lung tissue, which can lead to infl ammation, cough, wheez- ing, and dyspnea.13 However, studies have not found a correla- tion with worsening pulmonary function and clinical symp- toms with ACE inhibitor therapy in patients with asthma.13

Asthma allergens and triggers1

Allergens

• Mold

• Grass

• Pollen

• Dust and dust mites

• Animal fur/dandruff

• Cockroaches

Triggers

• Exercise

• Infection

• Changes in weather

• Menstrual cycle

• Stress or strong emotions

• Work conditions/exposures

• Smoke

• Chemicals

• Comorbid conditions (such as GERD, rhinitis, sinusitis)

• Medications (such as aspirin, NSAIDs, ACE inhibitors,

beta-blockers)

Adult asthma: Diagnosis and treatment

Because of possible adverse respiratory effects in patients with asthma taking an ACE inhibitor, an angiotensin II recep- tor blocker (ARB) may be substituted because ARBs are not associated with an increase in infl ammatory mediators in the lungs. Beta-blockers have been associated with an increase in bronchoconstriction and a decline in pulmonary function; however, their effect on signs and symptoms may not be as signifi cant.14,15 The greatest decline in lung function is associ- ated with nonselective beta-blockers and is dose-dependent.15 In the presence of asthma, cardioselective beta-blockers are an option for patients with strong clinical indications at the lowest effective dose.15

Physical fi ndings. Physical exam fi ndings associated with asthma can vary signifi cantly depending on the severity of asthma, if an exacerbation is present, and the presence of other associated diagnoses. The most frequent fi nding is ex- piratory wheezing.10 The absence of wheezing does not rule out asthma or an exacerbation. Patients presenting with asthma, not in an acute exacerbation, often have a complete- ly normal physical exam. With an exacerbation, the pulmo- nary exam may reveal chest hyperexpansion, accessory mus- cle use, retractions, and a prolonged expiratory phase.1

In severe exacerbations, additional physical exam fi ndings may include hypoxia, tachypnea, tachycardia, tripod position (seated position with bilateral arms extended to knees to sup- port the chest), pulsus paradoxus, and the absence of wheezing in imminent respiratory failure. Crackles and inspiratory wheezing are not consistent with asthma and should warrant alternative diagnoses.1 Extrapulmonary fi ndings may include rhinitis, nasal polyps, cobblestone appearance of the posterior oropharynx, and atopic dermatitis.1

■ Diagnosing asthma

The diagnosis of asthma is based on history, physical exam, and diagnostic testing. Diagnostic testing indicated for di- agnosis or monitoring of asthma may include spirometry, peak expiratory fl ow (PEF), bronchial provocation, and chest X-ray.1,10 Peak fl ow meters that measure PEF are easy to use and widely found in primary care offi ces.16 Many primary care offi ces offer spirometry (which also allows for bron- chial provocation). Blain and Craig found that almost half of the family practice providers and 60% of the internal medicine practices they studied had the necessary equipment to utilize spirometry.17 Of the offi ces without spirometry, the majority referred patients to a hospital for spirometry, with only 6% referring to a specialist for spirometry.17

Spirometry measures obstruction and severity of asthma and confi rms chronic airfl ow limitation by assessing forced expiratory volume in 1 second (FEV

1 ), forced vital capacity

(FVC), and FEV 1 /FVC, which represents the proportion of

the vital capacity (maximum amount of air expelled from the lungs) an individual expires in the fi rst second of forced expiration.10 Spirometry should be obtained to determine respiratory obstruction and reversibility in patients age 5 years and older.1 Diagnosis and reversibility are determined by obtaining pulmonary function measures prior to and after (10 to 15 minutes) inhalation of a short-acting beta2- agonist (SABA).10 (See Interpretation of spirometry fi ndings.)

The NHLBI recommends that spirometry be repeated after treatment has started and symptoms have stabilized to allow for documentation of the patient’s normal level of lung function; again during times of persistent diminished asthma control or if asthma symptoms progress; then on a routine basis every 1 to 2 years to assess progression of airway disease.1

PEF, most often measured by a peak fl ow meter, is not generally considered diagnostic; it is best suited to monitor asthma. If spirometry is not available, a change in PEF of 20% (or excessive variability between attempts greater than 10%) in adults in twice-daily PEFs over 2 weeks is considered ad- equate for the diagnosis of asthma.10 The GINA guidelines recommend short-term PEF measurements after diagnosis to identify changes in respiratory function, assess the need for adjustment in management (PEF variation greater than 10%), establish a response to treatment, determine triggers, and/or establish a baseline for an asthma action plan.10 Long-term monitoring of PEF is recommended for patients who have

Interpretation of spirometry fi ndings1,10

Assessment Findings

Normal spirometry

values

May indicate asthma between

symptoms or controlled

Diagnosis of asthma Reduction (at least once) in

FEV 1 and confi rmed that FEV

1 /

FVC is reduced; variation from

baseline of FEV 1 >12% and >200

mL between visits; increase in

FEV 1 >12% and >200 mL from

baseline following bronchodilator

or increase in FEV 1 >15% and

>400 mL from baseline following

bronchodilator (high probability

of asthma)

Signifi cant

reversibility

Increase in predicted FEV 1 of

>12% and >200 mL from base-

line after inhalation of a SABA

(200–400 mcg albuterol)

Decreased likelihood

of asthma diagnosis;

consider alternative

diagnoses

Symptomatic patient, but a

normal or elevated FEV 1 or FEV

1 /

FVC; post-SABA FEV 1 /FVC <0.7

indicates mild limitation

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moderate or severe persistent asthma, frequent exacerbations, are unable to accurately perceive limitation in airfl ow, or those who prefer this monitoring method.1

Bronchial provocation test (also known as bronchial chal- lenge test) is used to determine airway hyperresponsiveness. Bronchial provocation can be useful when asthma is a dif- ferential diagnosis, but spirometry is near normal or normal.10 This test is considered moderately sensitive with low specifi city for the diagnosis of asthma. Therefore, a positive test can signify asthma, but it can also be indicative of other diagnoses (al- lergic rhinitis, chronic obstructive pulmonary disease [COPD], or cystic fi brosis); conversely, a negative test sup- ports ruling out asthma as a diagnosis.1,10

Chest X-ray. Chest X-rays are not recommended to rou- tinely assess or diagnose asthma. Typically, a chest X-ray is normal or possibly displays hyperinfl ation. A chest X-ray is only recommended when other conditions are suspected beyond asthma, such as cardiopulmonary diagnoses in older adults.10

Special considerations. Sputum eosinophil counts, frac- tional exhaled nitric oxide (FeNO), and allergy testing are not recommended routine assessment tools in the diagnosis and treatment of asthma for the general population.1 Sputum-

guided treatment is recommended for patients with moder- ate or severe asthma not responding to a high-dose inhaled corticosteroid (ICS) or ICS and a long-acting beta2-agonist (LABA) and are referred to specialty medical offi ces that have access to and are experienced with this type of testing.1,10

Allergy testing may reveal sensitivity to certain triggers, but this does not determine if those triggers cause asthma symptoms.10 Elevated FeNO in nonsmokers without specifi c respiratory symptoms may indicate eosinophilic asthma and a potential for positive short-term results of ICS use, but this fi nding may also designate nonasthma-related diagnoses such as allergic rhinitis and is therefore not considered valuable in diagnosing asthma.10

There are specifi c considerations when approaching cer- tain populations or scenarios that may vary the testing order or recommendations (see Special considerations).

■ Nonpharmacologic management

Medication health literacy. Ensure good communication with the patient and family, and ensure they have a good under- standing of the patient’s medication regimen, when to take the prescribed medication, which medications are daily/ controllers versus those that are fast/rescuers, when to adjust medications, and when to seek medical attention. Examples of helpful health literacy strategies include the provider ac- tively listening to help the patient feel comfortable asking for clarifi cation; observing for visual cues that may indicate con- fusion or discomfort; starting with the most important in- formation and avoiding the use of complex numerical de- scriptors; use of illustrations or tables to explain instructions; ensuring that the written action plan is at the patient’s liter- acy level; having the patient and another person with the patient repeat instructions back to the provider; and avoiding the use of medical terminology.1

Avoidance and prevention. Avoidance of known environ- mental triggers can help manage asthma and decrease exacer- bations.1,10 Examples include smoking cessation (patient and family); avoiding pets, chemicals, and environmental and oc- cupational exposures that are triggers; and removing or limit- ing carpets and upholstered furniture in the home. Use of al- lergen-impermeable mattresses and pillow covers and weekly washing of linens and pets can also be helpful.1 If asthma is related to allergens, allergen immunotherapy may be considered but has limited documented effi cacy in the management of asthma.1,10

Treatment and control of certain comorbid conditions can improve asthma management and quality of life. These conditions include anxiety and depression, OSA, GERD, obesity, and rhinitis/sinusitis.10 Screening patients for these conditions when appropriate may improve asthma control.

Special considerations10

Population of interest

Testing/important to note

Athletes • Pulmonary function test (PFT),

usually with bronchial provocation

testing

• Rule out: dysfunctional breathing,

cardiac conditions, overtraining

Pregnant

women

• Confi rm in history, may need

special medication consideration

• Bronchial provocation testing not

recommended

Smokers/

ex-smoker

• May be diffi cult to distinguish

from COPD; important to be aware

of potential for asthma-COPD

overlap syndrome

• COPD is distinguished with

postbronchodilator FEV 1 /FVC ratio

<0.7 and reversibility

>12% and >200 mL

Using controller

medications

without a formal

diagnosis

• Confi rmation with testing is

recommended; may need specialty

referral and consultation

Low resource

setting

• If limited to no access to PFT, may

utilize PEF meters

Adult asthma: Diagnosis and treatment

Written asthma action plan. The PCP should encourage the patient to use a written asthma action plan, which details daily management (including medication and personalized environmental avoidance strategies), steps to recognizing an exacerbation or increase in symptoms, what to do in the case of worsening symptoms (the provider should be certain that patients have enough of their medications to increase usage if necessary), and when to seek medical attention. These action plans are dynamic and should be reviewed at all follow-up visits. The written action plan can be used to guide treatment by indicating the need to step up or step down the treatment regimen.10

■ Pharmacologic management

Optimizing respiratory function and asthma control may be dependent on pharmacologic therapy if prevention measures fail. Current evidence-based guidelines endorse a stepwise approach while considering patient-level treatment decisions, such as cost, adherence, and ability to master inhaler tech- nique.1,10 There are fi ve specifi c steps in control-based man- agement based on presenting symptoms, with severity increas- ing with each step.10

Asthma medications fall into two main categories: re- lievers for short-term symptom relief (also referred to as rescue) and controllers for long-term management. Con- trollers are often differentiated into usual and late-stage controllers (add-on therapies). (See Medication class and category.)

Relievers. SABAs are the mainstay of treatment for acute asthma symptoms.10 Albuterol is the most common medica- tion prescribed in this class and is available as a dry powder inhaler (DPI), metered-dose inhaler (MDI), and nebulizer (NEB) solution. Although levalbuterol is the R enantiomer of albuterol (racemic mixture with equal parts of R and S enantiomers) and the primary contributor to albuterol’s phar- macologic bronchodilating activity, it does not offer any clear benefi t in regards to an improved airway response nor ad- verse-reaction profi le at therapeutic doses when compared with albuterol.18

An MDI plus a spacer is better at dose delivery compared with an MDI alone and equivalent to nebulizer treatments.1,10,19

For bronchospasm, the usual dose for albuterol MDI is 2 puffs every 4 to 6 hours as needed.20 The intensity and duration of SABAs are dose-dependent. Higher doses may be needed for full relief of symptoms.20

Ipratropium, a short-acting muscarinic antagonist (SAMA), can be used in addition to albuterol. There is evi- dence for using ipratropium for rescue in the ED with mod- est benefi t in improving lung function and a decreased need for hospital admission.21 It can also be used as an alternative to a SABA for patients with intolerable adverse drug reac- tions to a SABA (tachycardia, dysrhythmia, or tremors).

In patients with an incomplete or poor (persistent or marked wheezing and dyspnea) response to inhaled SABA following an exacerbation, a timely short course or burst of systemic corticosteroids may improve the response to an acute exacerbation and can often prevent an ED visit or hospitalization. Even shortening the time to administration by less than 1 hour has shown benefi ts in admission rates in the ED.22 Time to peak serum levels for oral corticosteroids is 1 to 3 hours, so it is prudent to begin therapy as soon as possible.20

There is no evidence to suggest an added benefi t of I.V. versus oral corticosteroids. The I.V. route is reserved for pa- tients in the emergency setting with limited ability to take oral medications, such as those who are obtunded, endotrache- ally intubated, or too dyspneic to swallow medications. The burst should be continued until symptoms resolve and PEF is at least 80% of personal best. Adverse reactions include increases in blood glucose levels, appetite, and BP. These drugs may also alter mental status, including worsening psychosis and insomnia.20

Medication class and category10,20

Consult the manufacturer’s prescribing label for

complete prescribing information for each drug.

Relievers (short-term control)

• SABAs (albuterol [preferred drug] and levalbuterol

can be added to SABA)

• SAMA (ipratropium for moderate-severe exacerbations)

• Systemic corticosteroid burst (prednisone or predniso-

lone added to SABA for severe acute exacerbation)

Controllers (long-term control)

• ICS (beclomethasone, budesonide, ciclesonide, fl uni-

solide, fl uticasone, mometasone)

• ICS/LABAs (budesonide/formoterol, fl uticasone/

salmeterol, fl uticasone/vilanterol, mometasone/fo-

moterol [LABA should not be used alone without ICS

for asthma])

• LTRAs (montelukast, zafi rlukast, zileuton)

Add-on therapies (long-term control)

• LAMA (tiotropium)

• Anti-IgE antibody (omalizumab)

• IL-5 inhibitors (mepolizumab, reslizumab)

• Systemic corticosteroids

• Methylxanthine (sustained- release theophylline)

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Controllers. ICSs are the drugs of choice for controlling asthma-related infl ammation.10 Benefi ts include a decrease in symptoms, improved lung function and quality of life, and decreased risks of asthma exacerbations, hospitalizations, and death. There are a variety of corticosteroids categorized as low-, medium-, and high-intensity based on dosing.1

Three different LABA are currently available for use in the treatment of asthma. Formoterol and vilanterol have a relatively quick onset of action at approximately 5 minutes, and salmeterol starts working in about 20 minutes.20

Salmeterol and formoterol work for 12 hours, and vilanterol has a 24-hour duration.20 Common adverse reac- tions of LABAs are similar to SABAs; however, LABAs have a black box warning due to an increased risk of severe asth- ma exacerbations and death in postmarketing surveillance studies.23 As a result, the FDA is requiring follow-up prospec- tive studies; initial results indicate no difference in safety or asthma-related events (hospitalization, intubation, and death) when a LABA is added to an ICS compared with an ICS alone. The use of a LABA without an ICS is not recom- mended.23 Benefi ts of the combination of a LABA with an ICS include comparable benefi ts in lung function and asth- ma symptoms at lower doses of the ICS.10

Three leukotriene receptor antagonists (LTRAs) are indi- cated for control of asthma: montelukast, zafi rlukast, and zileuton. Their onset of action is 30 minutes, peak at 1 to 2 hours, and it may take weeks before maximum benefi ts are seen. Benefi ts include a steroid-sparing effect and a reduction in exercise-induced bronchospasms. They are less effective than an ICS and a LABA in combination with an ICS but may be appropriate for patients who are unable or unwilling to use an ICS or have concurrent allergic rhinitis.10

Montelukast may have an advantage for the PCP over other LTRAs due to the number of dosage forms available in- dicated over a wide age range and fewer adverse reactions, drug-drug, and drug-food interactions. Therefore, zafi rlukast and zileuton may be best reserved for asthma specialists.20

There are drug/drug and drug/food interactions to consider before prescribing LTRAs. Phenobarbital may decrease montelukast levels. Zafi rlukast’s bioavailability is dramatically (40%) decreased if taken with food and may increase international normalized ratio (INR) if given with warfarin. Zileuton can also increase INR with warfarin and may also increase theophylline levels. LTRAs are generally well tolerated but may have signifi cant adverse reactions, including increase in liver function tests, headache, dyspep- sia, myalgia, weakness, respiratory infections, restlessness, abnormal dreams, and hypersensitivity reactions.20

Add-on therapies for severe asthma. Several inhaled long- acting muscarinic receptor antagonists (LAMAs) are available

for COPD, and tiotropium bromide inhalation spray for oral inhalation is approved by the FDA for long-term management of asthma in patients age 6 years and older.20,24 Adding tiotro- pium to a medium-dose ICS for asthma can provide a similar benefi t to lung function as adding a LABA; however, it does not reduce hospitalizations nor improve quality of life. The 2017 GINA guidelines recommend tiotropium late in the stepwise approach to therapy (step four or five) in severe asthma that is uncontrolled despite two or more controllers.10,20

In patients who are uncontrolled on a high-dose ICS plus a LABA, adding tiotropium daily should be considered. In patients who cannot tolerate a LABA, tiotropium can be added to the high-dose ICS and an LTRA.24

Serious but rare adverse reactions of tiotropium include bronchospasms and angioedema. The most common adverse reactions include sore throat, bronchitis, sinus infection, bit- ter taste, and headache. Tiotropium use can lead to typical anticholinergic adverse reactions, such as dry mouth, blurred vision, increased intraocular pressure, urinary retention, constipation, and dizziness.20,24

Other add-on therapies for uncontrolled severe asthma include three different monoclonal antibodies: omalizumab (an anti-immunoglobulin E [IgE] antibody), mepolizumab (an interleukin-5 [IL-5] antagonist monoclonal antibody [IgG1 kappa]), and reslizumab (an IL-5 antagonist monoclo- nal antibody [IgG4 kappa]). These agents are usually reserved for specialists due to both required injections and potential serious adverse reactions and are not covered in this article.

Long-term systemic corticosteroids dosed either every day or every other day can be used in severe asthma; however, the lowest possible dose is preferred due to their extensive sys- temic-related adverse-reaction profi le.10 Adverse reactions include increased BP, hyperglycemia, weight gain, gastroin- testinal bleeding and ulcers, cushingoid signs, cataracts, and muscle aches. Long-term use decreases immune response, growth, bone density, and hypothalamic pituitary adrenal axis suppression.20

Medication delivery selection. Once a particular control- ler class is identifi ed as appropriate, there are several factors to consider when selecting a particular medication. It is key to appreciate the advantages and disadvantages of each delivery method: NEB, MDIs, MDI plus holding chamber, and DPIs. NEBs deliver high doses and patient coordination is not required, but they lack portability and require a long administration time. MDIs are portable and compact, do not require drug/device preparation, are administrated over a short period of time, and lack the risk of contamination.

Disadvantages of MDIs include the required coordina- tion of breathing and actuation, and high pharyngeal de- position of medication. Many devices do not have dose

Adult asthma: Diagnosis and treatment

counters, so it can be difficult to determine how many doses are remaining after use begins. Despite added cost and reduced portability, adding a holding chamber or “spacer” decreases the coordination required and reduces pharyngeal deposition of the medication. DPIs are easier for most patients to use because they do not require the coordination of inhalation and actuation of the propellant/ medication. DPIs are small, portable, and have dose coun- ters. On the downside, they require adequate inspiratory flow rates (30 to 120 L/min depending on the device) to properly draw the medication into the lungs.25

Guidelines suggest providing device education and prop- er technique with written instruction to every patient.1,10 Providing feedback or correction of technique as appropriate is necessary. Providing patients with supplemental video in- structions may be a good method of educational reinforce- ment. Proper technique should be verifi ed at each follow-up visit. Repeating instructions is much more likely to insure proper device use.26

■ Summary

A stepwise approach to making the diagnosis of asthma and consideration of special populations ensures accurate and timely intervention. An evidence-based and systematic ap- proach to medication management and patient engagement is a safe and effective means to reduce asthma symptoms, exacerbations, and decline in respiratory function.

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18. Borkowski J, Crader M. Nebulized albuterol versus levalbuterol in pediatric and adult patients: a review. Formulary Watch. 2009. http://formularyjournal. modernmedicine.com/formulary-journal/news/clinical/clinical-pharmacolo- gy/nebulized-albuterol-versus-levalbuterol-pediat?page=full.

19. British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Thorax. 2014;69(suppl 1):1-192.

20. Lexicomp Online. 2016. https://online.lexi.com.

21. Kirkland SW, Vandenberghe C, Voaklander B, Nikel T, Campbell S, Rowe BH. Combined inhaled beta-agonist and anticholinergic agents for emergency management in adults with asthma. Cochrane Database Syst Rev. 2017;1:CD001284.

22. Brown K, Iqbal S, Sun SL, Fritzeen J, Chamberlain J, Mullan PC. Improving timeliness for acute asthma care for paediatric ED patients using a nurse driven intervention: an interrupted time series analysis. BMJ Qual Improv Rep. 2016;5(1).

23. U.S. Food and Drug Administration. FDA drug safety communication: drug labels now contain updated recommendations on the appropriate use of long- acting inhaled asthma medications called long-acting beta-agonists (LABAs). 2011. www.fda.gov/drugs/drugsafety/postmarketdrugsafety informationforpatientsandproviders/ucm213836.htm.

24. Spiriva Respimat [prescribing information]. Ridgefi eld, CT: Boehringer Ingel- heim Pharmaceuticals; 2017.

25. Capstick TG, Clifton IJ. Inhaler technique and training in people with chronic obstructive pulmonary disease and asthma. Expert Rev Respir Med. 2012;6(1):91-103.

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Terri Fowler is an assistant professor at the Medical University of South Carolina, Charleston, S.C.

Whitney Smith is an adult NP team leader at St. Francis Hospital, Greenville, S.C.

Catherine O. Durham is the director of the MSN/DNP program and associate professor at the Medical University of South Carolina, Charleston, S.C.

James J. Sterrett is an assistant professor at the Medical University of South Caro- lina College of Pharmacy, Charleston, S.C.

The authors and planners have disclosed no potential confl icts of interest, fi nan- cial or otherwise.

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/ENU (Use these settings to create PDF's if you are not downloading low Res ads from AdSpring.) >> >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice