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Breathing Easier Asthma is a prime example of a chronic disease requiring that patients take major responsibility for managing their own care. A chronic inflammation of the airways in the lungs, asthma leaves the afflicted feeling breathless or worse.
It is unclear why asthma is on the rise, although researchers are investigating possible causes. These include everything from air pollution to allergies to dust, cockroaches, and pets, to airway irritants such as respiratory viruses and exposure to cigarette smoke, to a decline in minor infectious diseases that might keep the immune system in tune. The number of emergency room visits for asthma has increased to about 1.8 million cases annually, even though improved treatments are available to treat the disease. Asthma is the ninth-leading cause of adult hospital admissions and the third-leading cause for children, and it is the leading cause of school absences. Clearly some people who need treatment are not getting the best available. Some may not yet be diagnosed, but often the problem is that a patient does not abide by the treatment program and does not monitor symptoms diligently. "Asthma requires daily management," says Susan Janson, professor of nursing at UCSF. "Successful treatment requires the informed and direct participation of the patient. The patient must have the knowledge to carry out the treatment plan at home, at work or school. This is why patient education is an essential component of asthma management." For mild and moderate persistent asthma, treatment normally consists of inhaled anti-inflammatory drugs, taken daily. In addition, patients carry a "beta-agonist," inhaled as needed to relax the muscles that constrict the airways in an asthmatic's lungs. Monitoring of symptoms may lead to adjustments in medication. Janson, a key shaper of new national guidelines for asthma education, summarizes the guideline's goals: "Each patient must understand the roles of medications and possess the skills to use inhaled medication correctly. The patient must be able to monitor the status of the disease, to reduce environmental exposure to allergens and irritants, and to recognize when an asthma episode is worsening and requires that the patient take medication and seek medical care without delay." The best treatment program in the world is of no use if the patient will not stick with it. But nurses and doctors know that the difficulty of maintaining healthy behavior, understood so well by all who have tried to lose weight or conquer substance abuse, also can pose a problem in diseases where one might expect compliance to be less difficult. A gradual falling-off in compliance is a well-known phenomenon for any disease treatment program, one that can be nearly predictably charted over time. In asthma, symptoms -- wheeziness, shortness of breath, a feeling of chest constriction -- often subside while the patient's airways remain quite irritable. It is these symptomless patients who may be the most tempted to quit inhaling their daily doses of anti-inflammatory medicine to forego minor inconveniences or side effects, such as a dry throat. A recent national survey revealed that although more than 90 percent of doctors said that anti-inflammatory drugs were essential or very important for asthma management, only 18 percent of asthma patients reported using anti-inflammatory medication within four weeks of being interviewed for the study. Similarly, a vast majority of doctors prescribe "peak-flow meters" that allow patients with chronic asthma to monitor their condition by blowing into a hand-held tube, but only about one-fourth actually own one, and only one in nine reported using it at least once a week. Yet ridding the lungs of inflammation requires abiding by the treatment program for months or years. Research Reveals What Works Nursing is not only an art; it is also a science in which new ideas about how to manage disease can be put to the test. Janson leads a major National Institutes of Health study designed to evaluate an individualized asthma education program. The goal is to see if education can bolster compliance with treatment, reduce symptoms and decrease airway inflammation. The first part of the study included 65 adults with moderate, persistent asthma. Participants had earlier been prescribed an inhaled corticosteroid, which is a long-term anti-inflammatory treatment, as well as albuterol, a fast-acting beta-agonist that quickly relaxes the airway muscles that normally constrict during an asthmatic episode. As part of the education process, Janson and colleagues showed patients how to use inhalers and monitor symptoms and they described what happens inside the lungs of an asthmatic. They explained how asthma may be triggered initially by allergens in the environment, by exercise, or by respiratory infection, and how the airways, once triggered, can remain reactive for weeks, months or years. They also emphasized the importance of drugs in combating these suffocating biological responses. The ongoing study already has shown that individualized asthma education improves compliance with treatment over seven weeks. Measurements of asthma symptoms and biological markers of asthma, including certain inflammatory immune cells, also decreased more in the group that received education in comparison with the control group. The control group received instruction on how to monitor symptoms and airflow with a peak-flow meter and by keeping a journal. Interestingly, they also complied better with the treatment program than would be expected in patients receiving no instruction about how to monitor the disease. These results demonstrate that simply showing patients how to monitor themselves can have an impact on disease control that is greatly enhanced when combined with specific asthma education, according to Janson. "Asthma education can have a powerful effect on patient adherence to prescribed therapy and result in reduction of airway inflammation and improved asthma control," Janson concludes. The studies conducted so far reveal differences in cultural attitudes toward asthma that need to be understood in order to improve asthma education for specific cultural and ethnic populations, Janson says. This is a critical need, as asthma death rates among African-Americans and Latinos are disproportionately high. Living with Incurable Lung Disease Also on the rise, affecting an additional 15 million people, are two irreversible lung diseases: chronic bronchitis -- in which mucus-producing cells run amok and gum up the lungs -- and emphysema, in which airways become fibrous and inelastic. Both most often cause symptoms after age 50. Collectively, emphysema, chronic bronchitis and asthma are the fourth-leading cause of death after heart disease, cancer and stroke.
In contrast to asthma, which may subside for long stretches or even for good, emphysema and chronic bronchitis worsen over time. The death toll in the US for both combined is about 85,000 lives each year. "Shortness of breath is the most frequent and severe complaint of emphysema and chronic bronchitis patients," explains professor of nursing Virginia Carrieri-Kohlman. "It disrupts activities of daily living and decreases quality of life." Debility and death from emphysema and chronic bronchitis can be forestalled by exercise. But even though exercise can greatly improve a patient's quality of life, as with asthma treatment, compliance with an exercise treatment program often leaves much to be desired. Carrieri-Kohlman believes the problem is fear. She, along with pulmonary specialist Michael Stulbarg, earlier led a study in which researchers showed that allowing patients to exercise in a nurse-monitored environment helped them to reduce their anxiety and to feel less out of breath. Carrieri-Kohlman now is testing three levels of nurse intervention. The most basic includes education on self-care strategies and instructions to walk at home. The second adds exposure to shortness of breath during four nurse-monitored, self-paced treadmill exercise sessions. The third group will complete 24 sessions of high intensity treadmill training. The researchers will assess patients' perceived shortness of breath, quality of life, anxiety, exercise capacity and health status. The idea is to build their confidence so that they can exercise harder without feeling like they are out of breath. "If they believe they can do it, they will do it more often," Carrieri-Kohlman predicts. Links: Source:
Jeffrey Norris |
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The
incidence of asthma has doubled to 15 million people in the past 15
years, including 6 million children. Asthma deaths have risen beyond
5,000 annually.
The
increase in emphysema and chronic bronchitis is largely due to the still-rising
population of aging smokers. In part it reflects a delayed impact on
a now-aging cohort of female smokers, who took up smoking in large numbers
decades after men did.