Hello, I am Dr. David Callahan, with CDC's National Asthma Control Program and a Captain in the US Public Health Service. I am speaking to you as part of the CDC Expert Commentary Series on Medscape.
Today I would like to discuss how clinicians can provide evidence-based
care for their patients with asthma in a routine 15-minute office
visit. Today's discussion is based on the National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.
The goal for long-term management is to control asthma by reducing
impairment and risk.
Reducing impairment involves limiting the impact on
the patient's day-to-day life by preventing symptoms, limiting the need
for quick-relief medications, and maintaining normal activity levels.
Reducing risk means minimizing the need for emergency department visits
and hospitalizations and avoiding adverse effects from medications.
Here
are 4 key steps to follow:
1.
Schedule regular 15-minute visits.
Routine follow-up care -- scheduling
office visits at periodic intervals-- is an essential part of caring for
patients with asthma.
It allows the clinician to monitor and adjust
therapy and reinforce the key components of asthma management over time.
An asthma management flow sheet, updated at each visit, can provide a
way to make sure that essential components of asthma care are covered
across multiple appointments. These routine follow-up visits can reduce
the challenge of providing quality asthma care in a typical 15-minute
office visit.
2.
Assess control, beginning with a standardized questionnaire.
Assessing control is part of every
routine asthma visit and is the basis for stepwise management of asthma
medications. Assessing impairment -- a component of control -- can be
done using a questionnaire that the patient completes while awaiting the
visit. Standardized questionnaires like the Asthma Control Test™, the Asthma Control Questionnaire, and the Asthma Therapy Assessment Questionnaire
and others are informative and easy to use. Risk can also be inferred
by asking the patient about unplanned, urgent care visits for asthma
exacerbations, in conjunction with an analysis of spirometry results
that may have been done at a recent separate visit. Occasional
spirometry can also help assess progressive loss of lung function over
time, another component of the risk domain.
3. Review the patient's written asthma action plan at each visit and discuss asthma triggers.
Reviewing the patient's written plan
can serve several functions in the routine visit. It offers an
opportunity to provide focused self-management education, including use
of a peak flow meter or an asthma symptom diary.
Similarly, you can
review daily asthma management, including use of long-term controller
medications, as you discuss the "green zone" used when the patient is
doing well. Discussing the yellow and red zones can help the patient
recognize symptoms that call for prompt attention, as well as
appropriate use of short-acting beta-agonist quick-relief medications.
The asthma action plan should include information on specific asthma
triggers that the patient should avoid. Encouraging a multipronged
approach to reduce exposure to asthma triggers can be done over multiple
visits and reinforced with written patient education materials.
Two
triggers demand special attention: tobacco smoke and air pollution.
If
the patient is a smoker, a return visit should be scheduled to
specifically address smoking cessation. For all other patients,
avoidance of environmental "secondhand" smoke can be recommended at each
visit.
Air pollution is a common asthma trigger, and the air quality index
(AQI) can provide the day-to-day information your patients need to know
in order to determine when to modify their activities. In particular,
ground-level ozone, a primary component of smog, can trigger asthma
symptoms directly and can also sensitize the patient to other triggers.
Particulate-matter air pollution is also an important asthma trigger.
When air pollution levels are high -- when the AQI is "code orange" or
worse -- patients with asthma should avoid outdoor activities. Informing
patients where to find the AQI -- such as the newspaper, weather
forecasts, or the Environmental Protection Agency Website -- takes only a moment and can be included on the asthma action plan.
4. Review medications.
Of course, long-term management depends
on optimal use of asthma medications. Inhaled corticosteroids are the
most effective medications for long-term management of persistent
asthma, and assessing their use in the context of stepwise management of
asthma can be done as you review medications and administration
techniques. Ensuring that the patient has an adequate supply of
controller and rescue medications, and scheduling the next follow-up
visit, can wrap up your 15-minute office visit.
Finally, the goal of good asthma care is for your patient to be able
to enjoy life with as few symptoms as possible, and partnering with your
patient through scheduled follow-up care can achieve that goal.
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