Breathing Lessons
Changes in asthma management in the last 40 years — and
a growing incidence of the disease — make it vital for nurses
to refresh their knowledge of the ailment.

By Linda Childers
November 15, 2004

A 55-year-old woman who had been admitted to the hospital the previous night was still short of breath when Chris Garvey, MSN, FNP, MPA, entered her room at Seton Medical Center in Daly City, Calif.

Because it was the woman’s first bout of asthma, Garvey explained how certain genetic and environmental factors can trigger asthma, and how patients can become allergic to animal dander, pollen, and other particles in the air.

After explaining how to use the appropriate medications, Garvey suggested they meet with the woman’s primary care physician to devise a long-term asthma management plan.

Garvey is one of many nurses who work with adult asthma patients. As one of the most common chronic diseases in the United States, asthma affects more than 20 million Americans. Although many advances have been made in asthma care, the disease remains a growing public health concern.

According to the national Centers for Disease Control and Prevention, asthma accounts for more than 10 million outpatient clinic visits, and nearly 2 million emergency department visits each year in the United States.

Garvey, who has worked in asthma care for the past 27 years, and is a volunteer with the American Lung Association, also can empathize with the fears and concerns of her patients. Four years ago, she was diagnosed with asthma and chronic bronchitis.

“Patients know I’m speaking from experience,” Garvey said. “I’m a former smoker, so when I tell them smoking exacerbates their asthma symptoms, they take me seriously.”

Two major types of oral and inhaled treatments are used to control asthma symptoms: long-acting medications that prevent and control asthma, and short-acting medications used for relief of asthma symptoms.

Long-acting medications include long-acting bronchodilators and anti-inflammatory drugs such as inhaled corticosteroids that stop or prevent inflammation in the airways. A newer class of asthma medications, called anti-leukotrienes, block leukotriene receptors in the body. This prevents leukotrienes from contributing to inflammation in the airways.

Short-acting inhaled bronchodilators, or inhaled steroids, open the air passages and are generally used as “rescue medications” to stop an asthma attack.

Six years ago, the emergency department at Seton Medical Center was inundated with asthma patients. Realizing that patients weren’t receiving optimal care from their brief ED visits, the hospital instituted a standardized intervention to assist patients in managing their conditions.

“Now, when patients come to the ED, they receive training from a nurse who teaches them to identify triggers, how to use medications, and stresses the importance of following up with their doctor and having an asthma management plan,” Garvey said.

“We teach them asthma can’t be cured but it can be controlled, and through this program we’ve seen our return rate in the ED drop from 56% to 1%.”

Uphill battle

Susan Janson, RN, DNSc, ANP, FAAN, a professor of nursing and medicine at the University of California, San Francisco, and a longtime American Lung Association volunteer, has seen a lot of progress in asthma care, yet she’s also watched the condition become more prevalent.

“The inhaled therapies we use today are more effective than the oral therapies we used years ago,” Janson said. “And I’ve seen significant improvements from teaching patients individualized self-management practices.”

Despite the many advances made in asthma care, more patients are being diagnosed with the condition.

The CDC reports that between 1980 and 1994, the prevalence of asthma increased 75%.

“We’re definitely seeing more adults diagnosed with asthma, including an increase in the number of menopausal women,” Janson said. “We’re not clear if this is due to environmental factors, but women have more severe disease and a higher mortality rate.”

Researchers also note that asthma prevalence varies considerably by race and ethnicity, with Hispanics and African Americans having a much higher incidence rate than other ethnic groups.

In May, the Commonwealth Fund International Working Group on Quality Indicators released a study, How Does the Quality of Care Compare in Five Countries? that found the United States had a higher asthma mortality rate than Australia, Canada, New Zealand, and England among those aged 5 to 39. The study stated the U.S. mortality rate for asthma is higher now than it was 10 years ago, while it has been decreasing in the other countries.

“You wouldn’t think patients would be dying from a treatable disease such as asthma,” Janson said. “Yet there are many disparities in our health care system. Not everyone has access to quality care.”

Janson uses one of San Francisco’s impoverished neighborhoods as an example. “Many patients take three buses to reach our medical center,” Janson said.

Insurance coverage also can be a problem. For example, MediCal doesn’t cover the cost of spacers, a device that is attached to the metered dose inhaler used by asthma patients.

Because asthma is a complex condition with a wide array of symptoms, Janson notes it is often difficult for health care practitioners without extensive experience in the field to accurately diagnose and treat the disease.

“Often, patients will also have allergic rhinitis or gastric esophygeal reflux, and if these conditions aren’t treated, they can exacerbate asthma,” Janson said. “Older patients are often misdiagnosed with chronic obstructive pulmonary disease when, in fact, they have asthma.”

Janson recommends that all nurses who work in primary and acute care take a CEU class on asthma management.

“Because so many people are being diagnosed with asthma, it benefits all nurses to learn about devices such as peak flow meters, and how to recognize the signs of an asthma attack, which can mimic the signs of a heart attack,” Janson said.

The hygiene hypothesis

Some nurses, including Gayle Traver, RN, MSN, a pulmonary clinical nurse specialist at the Arizona Respiratory Center and University Medical Center in Tucson, Ariz., cite the hygiene hypothesis as a possible explanation of why asthma is on the rise.

The hypothesis revolves around a theory originally developed by David Stratham, MD; the theory was further studied by health researcher Erika von Mutius, MD. She compared the rates of allergies and asthma in East and West Germany in the late 1990s. Her hypothesis was that children growing up in the poor, dirty, and generally less healthful cities of East Germany would suffer from more allergy and asthma symptoms than youngsters in West Germany, where it is typically cleaner and the environment is more modern.

When the two regions were unified in 1999, von Mutius compared the disease rates and found exactly the opposite. Children in the polluted areas of East Germany had lower allergic reactions and fewer cases of asthma than children in the West.

Those who support the hygiene hypothesis propose that children who are around other children and animals early in life are exposed to microbes, which help their immune systems to mature and develop, and their immune systems develop more tolerance for the irritants that cause asthma.

“While those who support this hypothesis don’t recommend letting our children become critically ill, it does raise the possibility that preventing early diseases through vaccinations and antibiotics may not allow our immune systems to mature properly,” Traver said.

“We are a society that definitely prides itself on being ultraclean and using antibacterial soaps, and maybe this isn’t always best.”

Looking back over the last 40 years of asthma management, Traver notes that dramatic improvements have been made in patient care.

“Years ago, we only saw asthma patients who were having acute severe exacerbations and there was little chronic management or emphasis on prevention,” she said. “When we did treat these exacerbations, the medications we used had many more side effects than those available today.”

Traver sees a growing need for nurses who are more knowledgeable in asthma care to better educate patients.“Working with asthma patients is a constant education process,” she said. “If we can help patients effectively manage their symptoms and recognize triggers, we can prevent them from progressing to the point of chronic airway obstruction.”

Lisa Nicoud, RN, director of critical care services at North Vista Hospital in Las Vegas, says that despite advances made in asthma care, many patients continue to be plagued by the stigma of being labeled asthmatic.

“Many patients don’t see having asthma as a lifelong condition that constantly needs to be monitored,” she said. “As nurses, I think we have a responsibility to impress the seriousness of the condition upon patients.”

Nicoud would also like to see programs that track noncompliant patients. “We have patients who come into the hospital for an asthma attack and then we don’t see them until their next flare-up,” she said. “I’d like to see us address the emotional aspects of asthma and offer more support groups and educational resources for patients.”

Additional information and fact sheets on asthma are available on the American Lung Association website at www.lungusa.org. For more information on asthma education classes for nurses or volunteer opportunities within the American Lung Association, call (800) LUNG-USA.