OR Challenge Accepted Practical Tips, Tricks & Patient Education - Karla Stoermer Grossman, MSA, BSN, RN, AE-C Rural Health Grand Rounds June 23 ...
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Challenge Accepted
OR…
Practical Tips, Tricks & Patient Education
Karla Stoermer Grossman, MSA, BSN, RN, AE-C
Rural Health Grand Rounds
June 23, 2021
Objectives • Review the NAEPP 2020 Targeted Updates and explore why good asthma control may be difficult to achieve for some asthmatics. • Describe strategies to improve asthma control including review of appropriate device technique. • Explore effective teaching strategies for patients with challenging medications schedules and/or lives.
National Asthma Statistics
• Asthma is common:
• 7.0% percent of children under age 18 currently have asthma
• Black children are 2 times more likely to have asthma than white children
• Asthma is disruptive:
• Nearly 1 in 2 children with asthma report missing at least 1 day of school each year due to asthma
• 3 in 5 people with asthma limit their physical activity
• Nearly 1 in 3 adults with asthma report missing at least one day of work each year because of asthma.
• Asthma is deadly:
• 1 in 5 children with asthma went to an ED for asthma-related care in 2009. There were a total of 1.9 million
ED visits (adult + ped)
• In 2009 there were 479,000 asthma-related hospitalizations
• 9 people die from asthma every day (2012)
• Black Americans are 2-3 times more likely to die from asthma than any other racial or ethnic group
• Asthma is expensive:
• Asthma costs our nation $81.9 billion per year in healthcare costs, missed school and work days and
premature mortality
• 1 in 4 black adults and 1 in 5 Hispanic adults can’t afford their asthma medicines
https://www.cdc.gov/nchs/fastats/asthma.htm
Asthma Disparities
Racial Disparities In Health Care Utilization • Black children more likely to have adverse events. • Black children were less likely than white children to have preventive utilization
Social Determinants of Health and
Asthma
Sullivan, K and Thakur, N. “Structural and Social Determinants of Health in Asthma in Developed Economies: a Scoping Review of Literature Published Between
2014 and 2019; Curr Allergy Asthma Rep 2020; 20(2) 5
www.cdc.gov
Guidelines For The Diagnosis and
Management of Asthma (EPR-3)
Expert Panel Report 3
2020 Focused Updates
(EPR3)
National Heart, Lung and Blood Institute
(NHLBI)
National Asthma Education and
Prevention Program
(NAEPP)
GINA 2021 Guidelines https://ginasthma.org/gina-reports/
Summary GINA 2021
NAEPP Step Mild Intermittent Moderate Persistent Severe Persistent
GINA 2020 SUMMARY
GINA Step Step 1 Step 2 Step 3 Step 4 Step 5
Continue controller and
5 and younger Daily low dose ICS Double ‘low dose’ ICS
refer to Specialist
Low dose ICS-LABA or
Medium Dose ICS-LABA
medium dose ICS or
Preferred Controller or low dose ICS-
Low dose ICS taken very low dose ICS- High dose ICS-LABA,
6-11 yo Daily low dose ICS formoterol
whenever SABA taken formoterol phenotypic
maintenance and
maintenance and assessment to decide
reliever
reliever add-on or tiotropium
Daily low dose ICS or or biologics
PRN low dose ICS-
12 & older PRN low dose ICS- Low dose ICS-LABA Medium Dose ICS-LABA
formoterol
formoterol
Daily LTRA or
Low dose ICS + LTRA Add LTRA, or increase
intermittent short
5 and younger Consider Specialist ICS frequency, or add
courses ICS at onset of
referral intermittent ICS
URI
Other Controller Options Daily LTRA, or low dose Add tiotropium or add-
6-11 yo Daily low dose ICS Low dose ICS with LTRA
ICS taken with SABA prn on LTRA Add-on low dose OCS,
but consider side-
High dose ICS, add-on effects
Low Dose ICS taken with Daily LTRA, or low dose Medium dose ICS, or
12 & older tiotropiom or add-on
SABA prn ICS taken with SABA prn low dose ICS with LTRA
LTRA
5 and younger PRN SABA
Reliever 6-11 yo PRN SABA or ICS-formoterol
12 & older PRN low-dose ICS-formoterolFOCUS on Decreasing SABA-only treatment
• Regular use of SABA, even for 1–2 weeks, is associated with adverse effects
• b-receptor downregulation, decreased bronchoprotection, rebound
hyperresponsiveness, decreased bronchodilator response (Hancox, Respir Med
2000); increased allergic response, and increased eosinophilic airway inflammation
(Aldridge, AJRCCM 2000)
• Higher use of SABA is associated with adverse clinical outcomes
• Dispensing of ≥3 canisters per year (i.e. daily use) is associated with higher risk of
severe exacerbations (Stanford, AAAI 2012; Nwaru, ERJ 2021)
• Dispensing of ≥12 canisters per year is associated with much higher risk of death
(Suissa, AJRCCM 1994; Nwaru, ERJ 2021)
• Inhaled corticosteroids reduce the risk of asthma deaths, hospitalization
and exacerbations requiring oral corticosteroids (OCS) (Suissa, NEJM 2000
& 2002; Pauwels, Lancet 2003)
• BUT adherence is poor, particularly in patients with mild or infrequent symptoms
https://ginasthma.org/wp-content/uploads/2021/05/Whats-new-in-GINA-2021_final_V2.pdfGINA 2021
CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN CHILDREN
0-4 YEARS OF AGE
Classification of Asthma Severity
Components of
Intermittent Persistent
Severity
Mild Moderate Severe
Symptoms 2 days/week not daily Daily Continuous
Nighttime 0 1-2x/month 3-4x/month
Awakenings >1x/week
SABA use for sx
Impairment 2 days/week not daily Daily Several times daily
control
Interference with none Minor limitation Some limitation Extremely limited
normal activity
0-1/year >2 exacerbations in 6 months requiring oral
Exacerbations steroids, or >4 wheezing episodes/ year lasting >1
(consider
day AND risk factors for persistent asthma
Risk
frequency and
severity) Frequency and severity of may fluctuate over time
Exacerbations of any severity may occur in patients in any category
Step 1 Step 2 Step 3
Consider short course of oral steroids
Recommended Step for
Initiating Treatment In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordinglySTEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN
0 - 4 YEARS OF AGE
Step up if
need (check
adherence
environmental
control )
Step down if
possible
(asthma well
controlled for
3 months)CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
CHILDREN 5 - 11 YEARS OF AGE
Classification of Asthma Severity
Components of
Intermittent Persistent
Severity
Mild Moderate Severe
Symptoms 2 days/week not daily Daily Continuous
Nighttime >1x/week
80% • FEV1=60% -80% •FEV1 80% •FEV1/FVC=75%- •FEV1/FVC <
• FEV1 > 80% 80% 75%
• FEV1/FVC> 85%
Exacerbations 0-2/year > 2 /year
Risk (consider Frequency and severity may vary over time for patients in any category
frequency and
Relative annual risk of exacerbations may be related to FEV
severity)
Step 1 Step 2 Step 3 Step 3 or 4
Recommended Step for
Consider short course of oral steroids In 2-6 weeks, evaluate control and adjust treatment
Initiating TreatmentSTEPWISE APPROACH FOR MANAGING ASTHMA IN CHILDREN
5-11 YEARS OF AGE
Step down if
possible
(asthma well
controlled for
3 months)CLASSIFYING ASTHMA SEVERITY AND INITIATING TREATMENT IN
YOUTHS > 12 YEARS AND ADULTS EPR-3, p74, 344
Classification of Asthma Severity
Components of
Intermittent Persistent
Severity
Mild Moderate Severe
Symptoms 2 days/week not daily Daily Continuous
Impairment
Nighttime >1x/week
80% • FEV1 >60% but< •FEV1 80% •FEV1/FVC reduced reduced> 5%
• FEV1/FVC normal 5%
Exacerbations 0-2/year > 2 /year
Risk (consider Frequency and severity may vary over time for patients in any category
frequency and
Relative annual risk of exacerbations may be related to FEV1
severity)
Step 1 Step 2 Step 3 Step 4 or 5
Consider short course of oral steroids
Recommended Step for
Initiating Treatment In 2 -6 weeks, evaluate asthma control that is achieved and adjust therapy accordinglySTEPWISE APPROACH FOR MANAGING ASTHMA IN YOUTHS
> 12 YEARS AND ADULTS
Step down if
possible
(asthma well
controlled for
3 months)A New Class of Medications:
BiologicsYou’ve figured out Severity…
Now what?
Patient perspectiveIt can be really, really, really, really, really, complicated….
It’s complicated…. • Complicated medication schedules • Complicated device techniques • Complicated histories • Complicated family lives/adherence • Complicated insurance issues • It’s JUST Complicated…
Complicated Schedules
• What to take daily
• Symptoms to treat
• What to treat with
• How to use
• How often to use
• How long to treat
• When to call the MD
• When to seek ED carehttp://www.health.state.mn.us/divs/healthimprovement/content/documents-asthma/medications/MedsPoster14x24.pdf
Complicated Device Techniques
What does research say? • It is estimated that between 70% and 80% of patients do not use their inhaler correctly (GINA, 2014). • “…correct use of inhalation devices by children and adolescents is associated with improved lung function, reduced school absenteeism, decreased number of days with restricted activities, and fewer visits to emergency departments” (Inhaler Error Steering Committee, 2013).
Even our providers don’t know…
• Only 15% to 69% of health care
professionals (across all disciplines)
are able to demonstrate correct
inhaler use
(Inhaler Error Steering Committee, 2013).Poor outcomes • Confusion leads to incorrect use; bad technique results in poorly controlled asthma and higher costs, either as a result of increased morbidity or increased use of relief medication (Inhaler Error Steering Committee, 2013). • The perceived complexity of inhaled medications may lead to discontinuation of the medication, which will further erode asthma control (Chorão et al., 2014).
Device Techniques • Metered Dose Inhalers (MDI) • “Puffer”- chamber/chamber with mask • Redihaler (no chamber) • Dry Powdered Inhalers (DPI) • RespiClick • Turbuhaler/Twisthaler • Diskus/Wixela • Ellipta • Respimat • Chamber/chamber with mask
Complicated Insurance Issues
Honesty is the best policy
Adherence vs “truth”
Check adherence Importance of truth-telling
• Adherence to controller regimens • Increasing medications
have consistently been found to be
only 30% to 40% in clinical practice
• Increased risk of exacerbation
settings and only as high as 70% in • Over-use of oral steroids
well monitored clinical trial
settings (Sumino & Cabana, 2013).
• Call the pharmacy- fill v pick-up
• Sumino. K., & Cabana, M.D. Medication Adherence in Asthma Patients.
Current Opinions Pulmonary Medicine. January 2013. Volume 19, Number 1.Additional challenges: • Racial disparities • Black and Hispanic/Puerto Rican > White • Environmental Justice issues • Housing • Air pollution • Highways • Psychosocial issues • Mental health challenges • Insurance
Social Determinants of Health and Asthma
• Housing conditions, particularly indoor air
pollution and microbial/pest allergen exposures, CONCLUSION:
are key determinant of asthma morbidity,
particularly for poor urban populations. This large body of evidence support a
• Parent-reported food insecurity in the year before fundamental connection between the structural
kindergarten or in second grade was associated and social aspects of health and asthma
with incident asthma by the third grade. morbidity across one’s lifetime. It is essential
• Vitamin D insufficiency, higher in black
that these factors are considered when
populations, has been associated with asthma developing asthma prevention and treatment
prevalence and morbidity; however, a causal programs. Substantial improvements for asthma
mechanism remains controversial. outcomes will not be made without addressing
underlying societal processes that have created
• Adverse Childhood Events (ACES)- linked to poor large and persistent disparities in asthma
health, including asthma prevalence in children outcomes.
and adults.
Sullivan, K., Thakur, N. Structural and Social Determinants of Health in Asthma in Developed
Economies: a Scoping Review of Literature Published Between 2014 and 2019. Curr Allergy
Asthma Rep 20, 5 (2020). https://doi.org/10.1007/s11882-020-0899-6
https://link.springer.com/article/10.1007/s11882-020-0899-6What about Control?
Asthma Control Test • Validated tool • Well controlled: 20 and higher • Not well controlled: 17-19 • Very poorly controlled: 16 and below • Need to use with a bit of skepticism?
Symptom perception–
under, over, just right
• Cough– is it really asthma?
• “Just used to it”
• Paradoxical vocal fold motion disorder
• “Shortness of breath”
• Parent attribution- face is red
• What else?
• Anxiety
• DepressionWhat can we do? Bridging the gaps….
EDUCATE ourselves and our patients!
• Newest updates to the NAEPP Guidelines
• https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-
2020-updates
• Know medications and devices
• MDI- 2 puffs twice daily with chamber/chamber with mask
• RespiClick- one dose twice daily
• Diskus- one dose twice daily
• Ellipta- one dose once daily
• Respimat- two puffs once daily
• Assess understanding and device technique at each contactWhat patients MUST know
15 minute Asthma Education
• Symptoms to treat
• What to treat with
• How to use
• How often to use
• How long to treat
• When to call the MD
• When to seek ED careKarla’s Rules of 3
CALL if:
You have used albuterol:
• 3 times in one day
• 3 times in one week
• Albuterol only lasts 3 hours5 Steps of Windpipe -
Proper Trachea
Inhalation
Lungs
1- Blow all of your air out
2- Place the mouthpiece in your mouth/mask
on face
3- Push down on the canister
4- Slowly take a deep breath/10 tidal breaths
5- Hold your breath for 10 seconds
Bronchial tubes –
Air passages of the lungsAction Steps • Create an environment of trust • Get family buy-in • Create the easiest plan • Address psychosocial issues that might make things more challenging • Address family/friends/internet advice/pharmacies • Have families bring all of their medications • Call pharmacies to check on adherence • Explain things multiple ways every time • Have the patient/family demonstrate their technique • Simplify as needed • Standardized education across the health system
Additional Resources
• Clinical Care Guidelines
• Provider tools
• Patient education materials
• Languages
• https://www.uofmhealth.org/provider/clinical-care-guidelines
• MDHHS Asthma Initiative of Michigan
• https://getasthmahelp.org/
• NAEPP Targeted Updates
• https://www.nhlbi.nih.gov/health-topics/asthma-management-guidelines-2020-
updatesKarla Stoermer Grossman kstoerme@med.umich.edu
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