RTs are often key players in helping establish an asthma diagnosis, delivering patient education, and providing treatment. Understanding how to help patients perform self-monitoring and self-management in the home is the key to provide quality, effective support.

By Bill Pruitt, MBA, RRT, CPFT, FAARC 


Asthma is a chronic lung condition that affects about 1-in-13 people in the US. It may be apparent in childhood or may not appear until becoming an adult. There is no cure for asthma and asthma is a serious disease that can cause death.1 But with careful monitoring, effective and properly administered treatment, good self-care and professional management, and solid patient support and patient education, many people with this diagnosis are able to achieve control of symptoms and live a normal, fulfilling life.1 This article will discuss a quick overview of asthma and address the issues of caring for asthma at home.

Asthma Overview

According to the most recent version of the Global Initiative for Asthma (GINA 2024) asthma is a heterogeneous lung disease and is usually associated with symptoms that vary over time and include wheezing, shortness of breath, coughing, and/or chest tightness. It is characterized by chronic airway inflammation, airway hyper-responsiveness, and variable limitation of expiratory airflow.2 The symptoms and airflow limitation are often triggered by factors like exercise, exposure to allergens or irritants, weather changes, or viral pulmonary infections. Symptoms and airflow limitation may go away on their own or with pharmacologic treatment and symptoms may range from frequent occurrence (ie, daily) to rare (ie, weeks or months passing between flare-ups). The level of severity is based on symptoms and can range from mild intermittent (with the reminder- any level of severity carries the possibility of having a severe and even fatal exacerbation) to moderate persistent to severe persistent.2

There are many clinical phenotypes of asthma, including:

  • Allergic asthma (associated with issues like eczema, allergic rhinitis, food or drug allergies)
  • Nonallergic asthma (not associated with any allergies)
  • Cough variant asthma (the only symptom is cough)
  • Adult-onset asthma (presenting for the first time in an adult)
  • Asthma with persistent airflow limitation (bronchospasm reversibility with medication is blunted or absent)
  • Asthma with obesity
  • Occupational asthma (associated with exposure to irritants from a work environment) 

Diagnosing asthma may be difficult due to the variable nature of the disease and due to many other diagnosis that can mimic asthma symptoms. Confirming the diagnosis relies on confirming variable expiratory airflow limitation by having one or more of the following: a positive bronchodilator response using spirometry, excessive variability in peak expiratory flow (PEF) over two weeks, increased lung function after four weeks of treatment as seen in improved forced expiratory volume in the first second (FEV1) or in the PEF, a positive bronchial challenge test, and/or excessive variability in lung function between medical care visits.2

According to the GINA 2024 guidelines, treatment follows making the diagnosis, and the preferred path (called Tract 1) has five steps.

  • Steps 1-2 uses an inhaler providing a combination of low dose inhaled corticosteroid (ICS) with a long-acting beta-2 agonist (formoterol) as needed.
  • Step 3 moves to a maintenance regimen of ICS-formoterol (and continues the low-dose ICS-formoterol as needed continues throughout all five steps).
  • Step 4 moves up to using a medium dose of the ICS-formoterol combination regularly as a maintenance approach (with the as-needed low dose ICS-formoterol).
  • Step 5 moves up to adding a long-acting muscarinic antagonist (LAMA) with the maintenance combination of medium-dose ICS/formoterol approach (with the as-needed low dose ICS-formoterol), along with as assessment for phenotype, and consideration for using a high dose ICS plus formoterol, plus consideration of adding an anti-IgE medication, an anti-IL5/5R medication, an anti-IL4Rα medication, and/or an anti-TSLP medication (with the as-needed low dose ICS-formoterol).*2

A flare-up of asthma symptoms may call for a short-course of treatment using an oral corticosteroid, and the personalized plan should contain information on how/when to take this medication if needed. (Tract 2 provides alternative medications in some of the steps).

Planning for Care at Home 

Every patient should have a personalized written Asthma Action Plan (AAP, plan of care). The AAP gives the patient guidance on how to approach asthma self-care at home, when and how to move to a higher level of medication support, and when/how to contact professional help (ie, call their asthma-care professional provider or emergency services if needed).2 Personalized plans should be appropriate for and consider the patient’s age, their current treatment , their reliever medication, their level of asthma control, and their health literacy. The intention of the AAP is that the patient will recognize and respond to increasing issues related to an asthma flare-up (based on changes in symptoms and/or PEF monitoring). The AAP provides guidance to the patient for how to make short-term changes to their treatment options in consideration of their symptoms and/or changes in their PEF monitoring. The AAP also informs the patient how and when to contact their primary/asthma care provider and/or emergency assistance. 

Patients with asthma should avoid infections; this involves staying up-to-date with immunizations for issues such as pneumococcal pneumonia, pertussis, influenza, respiratory syncytial virus (RSV), and COVID-19.2 The Centers for Disease Control and Prevention (CDC) also recommends several actions for those caring for asthma at home to help prevent getting an infection.3 These include:

  • Frequent, proper handwashing;
  • Avoid touching the eyes, nose, and mouth with unwashed hands;
  • Avoid close contact (ie, kissing, sharing cups or utensils, etc) with someone who is sick;
  • Clean and disinfect surfaces like toys, doorknobs, mobile phones, etc;
  • Wear a NIOSH Approved N95 respirator or other mask in crowded indoor environments;
  • Ensure good ventilation and filtration of air in the home to prevent accumulation of virus particles.

Other recommended steps to take for those with asthma include avoiding/controlling allergens and irritants (ie, mold, dust mites, cigarette smoke, cockroaches), weight reduction for obese patients, regular exercise (with a warm-up period and pre-exercise administration of a short-acting bronchodilator or low dose ICS/formoterol combination, and management of exacerbations following the personalized AAP and asthma professionals’ directions.2 

Nebulizers and Inhalers

Inhaled medications are foundational in caring for asthma at home. Many people use nebulizers to administer these medications, as these devices are easy to use, effective in delivering inhaled medications, and use affordable medications. However, these devices require electricity to power the compressor (or ultrasonic device) and some medications are not available to use with a nebulizer. (GINA 24 advises not to use nebulizers in localities where risk of COVID-19 is moderate or high to avoid possible spread of infection).2 Other inhaled medication delivery devices include powered metered dose inhalers, dry powder inhalers, and mist inhalers. 

Proper technique is especially important for each of these devices and each device has specific directions for proper use. Patient education on proper technique is available from the manufacturer or pharmaceutical company in package inserts (and also on the company’s website). People with asthma should be taught proper technique at the start of using a device and proper technique should be reviewed with each office or clinic visit, and at the pharmacy when filling prescriptions for inhaled asthma medications. 

Cleaning and caring for these devices is also important and guidance on this is also available in the resources mentioned above. Which device is best for a patient is a shared-decision between the health care professional and the patient, as some patients will not be able to properly use a device, may not be able to afford the particular medication/device, or may not have access to a device in their locality. 

Albuterol Update

In late 2022 and extending through 2023 the nation experienced a serious shortage of albuterol sulfate. The main cause of the shortage was the bankruptcy and subsequent shutdown of Akorn Pharmaceuticals, one of the major suppliers of generic liquid albuterol. This left only one other domestic pharmaceutical company (Nephron Pharmaceuticals). The shortage has lifted with the market now seeing three other sources of albuterol (Mylan, Ritedose, and SunPharma).4-5

Patient Education

Successfully managing asthma at home (asthma self-management) is largely based on effective, thorough, and understandable patient education. Several sources for patient education are available, including publications from the National Asthma Education and Prevention Program (NAEPP) 2024 update, the GINA 2024 update, and the National Asthma Council Australia: Australian Asthma Handbook 2022 update.6 Patient asthma education has three primary areas that need to be taught in the overall approach; the function and appropriate use of asthma medications, pathophysiology of asthma, and how to prevent and treat symptoms. 

Effective self-management has three key components; how to monitor symptoms (with or without a peak flow meter), using a personalized written asthma action plan (AAP) that provides information on how to recognize and respond to worsening asthma symptoms, and a regular review of the components of asthma control, the treatments being used to achieve control, and the skills needed to be effective in self-management and self-care at home. These topics need to be provided by a knowledgeable asthma professional.6 This could involve a pulmonologist, allergy, asthma, and immunology physician, or an Asthma Educator Specialist (also known as a Certified Asthma Educator or AE-C). 

The AE-C credential is offered through the National Board for Respiratory Care (NBRC) and is obtained by passing a comprehensive exam that measures current knowledge of asthma pathophysiology and management. The 175-question multiple-choice exam (150 scored items and 25 pretest items) includes developmental theories, cultural dimensions, the impact of chronic illness, and principles of teaching-learning .7

Conclusion

Asthma is a serious disease that can be a constant health issue or appear in periodic flare-ups. It affects all ages, has no cure, and can be fatal, but in many people, it can be managed and treatment can greatly reduce symptoms and impact on quality of life. Effective patient education is very important in helping a person with asthma know about the disease, their medications and devices, monitoring symptoms, and can be a motivating factor for the individual to be adherent to the plan of care. Respiratory therapists are often key players in helping establish a diagnosis, providing care, giving patient education, and providing treatment. Understanding how to help patients with asthma perform self-monitoring and self-management in their home is important for therapists to know in order to provide quality, effective support.

RT

Bill Pruitt, MBA, RRT, CPFT, FAARC, is a writer, lecturer, and consultant. Bill has over 40 years of experience in respiratory care in a wide variety of settings and has over 20 years teaching at the University of South Alabama in Cardiorespiratory Care. Now retired from teaching, Bill continues to provide guest lectures, participates in podcasts, and writes professionally. For more info, contact [email protected].


References

  1. What Is Asthma? National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health/asthma.
  2. Global Initiative for Asthma 2024 update. https://ginasthma.org/2024-report.
  3. Centers for Disease Control and Prevention (CDC)  Respiratory Infections and Asthma. Jan 2024. https://www.cdc.gov/asthma/respiratory-infections/index.html.
  4. Albuterol Inhalation Solution Shortage. Drugs.com. Feb 2024. www.drugs.com/drug-shortages/albuterol-inhalation-solution-820.
  5. Asthma Drug Albuterol Shortage Is About To Worsen: Here’s Why—And How Hospitals Are Filling The Gaps. Forbes. Mar 2023. www.forbes.com/sites/ariannajohnson/2023/03/06/asthma-drug-albuterol-shortage-is-about-to-worsen-heres-why-and-how-hospitals-are-filling-the-gaps.
  6. Patel P. Asthma education and self-management. UpToDate. Updated Aug 2024. https://www.uptodate.com/contents/asthma-education-and-self-management.
  7. Asthma Educator Specialist (AE-C). National Board for Respiratory Care. https://www.nbrc.org/examinations/certified-asthma-educator-ae-c/.

*IgE: Immunoglobulin E; 

IL5/5R: Interleukin-5 receptor; 

IL4Rα: Interleukin 4 alpha receptor; 

TSLP: Thymic stromal lymphopoietin.

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