REVIEW

Practical guidance on the recognition of uncontrolled asthma and its management Haley M. Hoy, PhD, ACNP (Interim Associate Dean) & Louise C. O’Keefe, PhD, CRNP (Assistant Professor) College of Nursing, University of Alabama in Huntsville, Huntsville, Alabama

Keywords Uncontrolled asthma; symptomatic asthma; exacerbation; practical guidance; tiotropium. Correspondence Haley M. Hoy, PhD, ACNP, College of Nursing, University of Alabama in Huntsville, 301 Sparkman Drive, Huntsville, AL 35899. Tel: 1-256-824-6669; Fax: 1-256-824-6026; E-mail: [email protected] Received: 3 December 2014; accepted: 12 May 2015 doi: 10.1002/2327-6924.12284 Disclosure Each author meets the criteria for authorship as recommended by the International Committee of Medical Journal Editors. The authors take full responsibility for the scope, direction, and content of the article and have approved the submitted article. The authors received no compensation related to the development of the article.

Abstract Purpose: To highlight the significance of asthma in primary care and offer a practitioner-friendly interpretation of the asthma guidelines for the busy provider, while introducing new treatment options currently in clinical trials, such as the once-daily long-acting anticholinergic bronchodilator tiotropium Respimat. Data sources: Articles with relevant adult data published between 2004 and 2015 were identified via PubMed. Additional references were obtained by reviewing bibliographies from selected articles. Conclusions: In the United States, uncontrolled or symptomatic asthma is common, with rates of 46%–78% in primary care. Uncontrolled asthma has a substantial impact on patients’ quality of life and represents a significant healthcare burden. Nurse practitioners can improve patients’ asthma control through education, monitoring, assessment, and treatment. Although asthma management guidelines are readily available, the authors recognize that nurse practitioners see patients with multiple comorbidities, all of which have treatment guidelines of their own. Implications for practice: Nurse practitioners have a compelling opportunity as frontline caregivers and patient educators to recognize and assess uncontrolled asthma, along with determining the steps necessary to help patients gain and maintain symptom control.

Funding This review was commissioned by Boehringer Ingelheim, who also supported the publication costs for this article. The authors have not received any honorarium in relation to this article.

Introduction Despite the availability of evidence-based management guidelines and the many treatment options, there is still a high rate of uncontrolled or symptomatic asthma. Asthma has an estimated global prevalence of 4.3% (To et al., 2012). It is the most common chronic disease in children and also affects a significant number of adults (To et al., 2012). The World Health Organization estimates that 300 million people suffer from asthma (World Health Organization, 2007). A U.S. survey in 2009 inferred that asthma prevalence was 8.2% and affected 25 million people. The survey also showed higher asthma prevalence in populations such as children, women, and people of 466

non-Hispanic African-American or Puerto Rican race or ethnicity (Akinbami, Moorman, & Liu, 2011). The steady increase in the prevalence of asthma over several decades may be attributed to the lack of implementation of evidence-based management guidelines and knowledge of treatment options (van Schayck, 2013). For example, a recent survey showed that almost 50% of patients were not using a controller medication, and only 14% of the patients using a maintenance medication had asthma that was well controlled (Colice et al., 2012). This review highlights the significance of asthma in primary care and offers a practitioner-friendly interpretation of the asthma guidelines for the busy provider. New Journal of the American Association of Nurse Practitioners 27 (2015) 466–475  C 2015 American Association of Nurse Practitioners

H. M. Hoy & L. C. O’Keefe

treatment options, including those currently being investigated in clinical trials, are also discussed.

Methods The PubMed database was searched in April 2015 for English-language articles published between 2004 and 2015 using the following search terms: “anti-asthmatic agents,” “asthma,” “asthma allergens,” “asthma comorbidities,” “asthma control,” “asthma education,” “asthma exacerbations,” “asthma guidelines,” “asthma management,” “asthma pathophysiology,” “asthma prevention strategies,” “asthma therapy,” “asthma treatment,” and “impact of asthma exacerbations.” Search results were reviewed, and publications related to uncontrolled asthma and its management were selected for inclusion as appropriate. Additional references were identified by reviewing the bibliographies of relevant articles. Only studies in humans were included, but studies were not limited by the number of individuals or by the study design.

Practical guidance on the recognition of uncontrolled asthma

$6452 (Sullivan, Rasouliyan, Russo, Kamath, & Chipps, 2007). Furthermore, acute exacerbations of asthma result in 2 million emergency-room visits and 500,000 hospitalizations every year (Dougherty & Fahy, 2009). Nurse practitioners can reduce the burden of asthma on the healthcare system by implementing suggested asthma guidelines and utilizing new treatment options.

Comorbidities Nurse practitioners must use a holistic approach, carefully treating the asthmatic patient and not just their symptoms. This holistic approach includes the assessment of comorbid conditions that can have a significant impact on asthma symptoms and control. Being aware of the common comorbid conditions and knowledgeable about their effect on asthma symptoms and control will allow nurse practitioners to effectively manage asthmatic patients (Table 1). These conditions must be treated appropriately in order to avoid adverse outcomes.

Burden of uncontrolled asthma

Asthma control and treatment goals

In the United States, uncontrolled or symptomatic asthma has a substantial impact on quality of life, productivity, work performance, and school attendance (Chen et al., 2007; Colice et al., 2012; Dean, Calimlim, Kindermann, Khandker, & Tinkelman, 2009; Dean et al., 2010). The reduced quality of life in patients with asthma is more marked in those with uncontrolled disease because of frequent hospitalizations and emergency treatment (Gonzalez-Barcala, de la Fuente-Cid, Tafalla, Nuevo, ˜ & Caamano-Isorna, 2012). In 2008, symptomatic asthma was responsible for 14 million missed work days and 10.5 million missed school days (Akinbami et al., 2011). The rate of absenteeism among adults with uncontrolled asthma is 43%, which is significantly higher than the 24% of absenteeism found in adults with controlled asthma (Dean et al., 2009). Children with uncontrolled asthma are more likely to miss school (5.5 vs. 2.2 days) and school-related activities (40.6% vs. 6.2%), and often arrive at school late or leave early (26.7% vs. 7.1%), compared with children with controlled asthma (Dean et al., 2010). Regularly assessing and monitoring asthmatic patients may improve their quality of life and minimize absenteeism. Moreover, uncontrolled or symptomatic asthma places a significant burden on the U.S. healthcare system. In 2007, symptomatic asthma was responsible for 1.75 million emergency-room visits and 456,000 hospitalizations (Akinbami et al., 2011). Average healthcare costs for patients with uncontrolled asthma are more than double the costs for patients with controlled asthma: $14,212 versus

Several asthma guidelines are available, such as Global Initiative for Asthma (GINA; Global Initiative for Asthma, 2015), the National Heart, Lung, and Blood Institute (NHLBI)/National Asthma Education and Prevention Program (NAEPP; National Heart, Lung, and Blood Institute & National Asthma Education and Prevention Program, 2007), and the American Thoracic Society/European Respiratory Society (Reddel et al., 2009). All of these guidelines broadly agree on both the definition of asthma control and the treatment goals. According to these guidelines, asthma control is defined as the degree or extent to which the manifestations of asthma (e.g., symptoms, functional impairments, and risk for untoward events) are reduced or removed by treatment. Treatment goals aim to achieve and maintain control of asthma, thus reducing chronic disability, preventing exacerbations, and enabling patients to lead productive and fulfilling lives. The GINA guidelines (Global Initiative for Asthma, 2015) define three levels of asthma control (well controlled, partly controlled, and uncontrolled) and describe the clinical characteristics of each level (Table 2). Patients with partly controlled asthma are those who experience one or two of the following in a 4-week period: daytime symptoms more than twice a week, any limitation of activities, any nocturnal symptoms and/or awakening, the need for reliever and/or rescue treatment more than twice a week. Patients with uncontrolled asthma are those who experience three or more of the features of partly controlled asthma. Any exacerbation should prompt 467

Practical guidance on the recognition of uncontrolled asthma

H. M. Hoy & L. C. O’Keefe

Table 1 Common comorbid diseases in patients with asthma Disease

Effect on asthma

Diabetes (Song, Klevak, Manson, Buring, & Liu, 2010)

In the Women’s Health Study, asthma was independently associated with an increased risk for type 2 diabetes in women, indicating that chronic airway inflammation may contribute to diabetes pathogenesis and indicating the importance of reducing the risk for diabetes for patients with asthma (Song et al., 2010). Cardiovascular disease (Iribarren et al., 2012; Lee, Adult asthma has been associated with an increased risk for cardiovascular disease, particularly Truong, & Wong, 2012) coronary heart disease in those on oral corticosteroids alone or in combination (Iribarren et al., 2012; Lee et al., 2012). Rhinitis (Scadding & Walker, 2012) Occurs in >80% of asthma patients (Scadding & Walker, 2012); those with significant rhinitis are four to five times more likely to have poorly controlled asthma than those without (Scadding & Walker, 2012). Sinusitis (Bhattacharyya & Kepnes, 2009; Marseglia et al., In children, sinusitis is thought to be a key factor in uncontrolled asthma (Marseglia et al., 2012). 2012) Patients with asthma and sinusitis versus asthma alone have more healthcare visits and emergency-room visits (p < .001), higher healthcare expenditures (p ࣘ .002), and more work absences (p < .001, Bhattacharyya & Kepnes, 2009). GERD (Gaude, 2009; Pinto Pereira & Seemungal, 2010) GERD may interfere with asthma control and trigger nocturnal asthma. Patients with difficult-to-treat asthma should be assessed for the possible presence of GERD and offered proton pump inhibitor therapy (Gaude, 2009; Pinto Pereira & Seemungal, 2010). Obesity (Boulet, 2013; Scott et al., 2013; Wilson et al., Obesity is common in people with asthma (Boulet, 2013; Scott et al., 2013; Wilson et al., 2010) 2010) and impairs the efficacy of asthma medications, making control difficult to achieve (Boulet, 2013). Diet and weight-loss advice improves asthma control and symptoms, and should be included in a management plan (Boulet, 2013; Scott et al., 2013). OSA (Julien et al., 2009) OSA-hypopnea is significantly more prevalent among patients with severe asthma compared with moderate asthma, and more prevalent for both asthma groups than controls without asthma (Julien et al., 2009). Pathophysiologic interactions between OSA-hypopnea and asthma severity and control suggest that all patients with severe asthma should be assessed for OSA (Julien et al., 2009). Anxiety (Fernandes et al., 2010) Anxiety is associated with worse subjective asthma outcomes, increased use of medication and healthcare resources, and decreased airway inflammation (Fernandes et al., 2010). Depression (Walters, Schofield, Howard, Ashworth, & Patients with asthma and depression have a higher mortality rate than patients with asthma Tylee, 2011; Wilson et al., 2010) alone (Walters et al., 2011) and require integrated comprehensive care (Walters et al., 2011; Wilson et al., 2010). GERD, gastroesophageal reflux disease; OSA, obstructive sleep apnea.

a review of the patient’s maintenance regimen to ensure it is therapeutic. The NHLBI/NAEPP guidelines also define three levels of asthma control (well controlled, not well controlled, and very poorly controlled) and describe the clinical characteristics by age group. However, the NHLBI/NAEPP guidelines recommend measuring control as the degree to which the manifestations of asthma (symptoms, functional impairments, and risk for untoward events) are minimized and the goals of therapy are met when assessing and monitoring asthma. The GINA guidelines recommend that a global approach to asthma should include patient care based not only on population-level recommendations but also on patient characteristics or phenotype, patients’ preferences, and practical issues (Global Initiative for Asthma, 2015). The goal of asthma treatment is to achieve and maintain clinical control of asthma symptoms (Global Initiative for Asthma, 2015; National Heart, Lung, and Blood Institute & National Asthma Education and Prevention Program,

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2007; Reddel et al., 2009). As asthma exacerbations are associated with significant morbidity, mortality, and utilization of healthcare resources, it is important to prevent and minimize the risk of exacerbations (Global Initiative for Asthma, 2015). Other factors include maintaining normal activity levels, such as exercise, maintaining lung function as close to normal as possible, avoiding the adverse effects of medication, and preventing asthma mortality. Periodic assessment and monitoring of asthma control is essential for asthma management (National Heart, Lung, and Blood Institute & National Asthma Education and Prevention Program, 2007). Although spirometry can be easily performed in the primary care setting (Licskai, Sands, Paolatto, Nicoletti, & Ferrone, 2012), it is generally underutilized (Buffels, Degryse, & Liistro, 2009; Lusuardi et al., 2006). Measuring lung function with spirometry provides useful information on the level of asthma control and should be used to monitor a patient’s progress in the

Practical guidance on the recognition of uncontrolled asthma

H. M. Hoy & L. C. O’Keefe

Table 2 GINA definition of asthma control (Global Initiative for Asthma, 2015) Levels of asthma control A. Assessment of current clinical control (preferably over 4 weeks)

Characteristic Daytime symptoms

Limitation of activities Nocturnal symptoms and/or awakening Need for reliever and/or rescue medication Lung function (peak expiratory flow or FEV1 )c

Well controlled (all of the following) None

None None None Normal

Partly controlled (any measure present) More than twice a week

Uncontrolled Three or more features of partly controlled asthmaa,b

Any Any More than twice a week

Practical guidance on the recognition of uncontrolled asthma and its management.

To highlight the significance of asthma in primary care and offer a practitioner-friendly interpretation of the asthma guidelines for the busy provide...
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