Pathophysiology
Asthma is a chronic condition that affects airways and results in difficulty breathing. In the United States of America, bronchial asthma is one of the most common chronic diseases in children with the prevalence rate ranging from 6% to 9% (Asthma and Allergy Foundation, 2019). In the adult population, the share of those who are affected by this disease amounts to 7,5% (Asthma and Allergy Foundation, 2019).
In patients with asthma, the condition causes the inflammation of air passages that is followed by the significant narrowing of airways. As a result, oxygen cannot be carried directly to the lungs, and a person with this condition experiences coughing, wheezing, shortness of breath, and tightness in the chest area. Early symptoms before the final onset of the condition include a frequent cough at night, shortness of breath during mild physical activities, and fatigue.
The mechanisms that explain the pathophysiology of asthma are quite complex and intricate. It has been common medical knowledge since a long time ago that the subepithelial connective tissue of the airway in asthma patients differs from that in patients without asthma. The tissue displays many more blood vessels that are identified in the same locations in healthy individuals (Sullivan, Hunt, MacSharry & Murph, 2016). Even though the important role of bronchial vessels in the pathophysiology of asthma is now firmly established, there are still significant knowledge gaps about the mechanism itself. The reason for this is the difficulty of measuring airway blood flow.
Despite the scientific challenges of researching asthma, some facts have been successfully clarified. The bronchial circulation is likely to be regulating airway caliber because an increased vascular volume is associated with airway narrowing. A possible explanation is that increased airway blood flow is needed for the removal of inflammatory mediators from the airway. The question arises as to exactly how the body of an asthma patient builds more blood vessels.
Sullivan, Hunt, MacSharry, and Murphy (2016) show that the human body may respond to the stress associated with high respiratory pressures with gene transduction and enhanced production of nitric oxide by type III (endothelial) NO synthase. One of the key components of the inflammatory response is microvascular leakage that is responsible for increased airway secretions and impeded mucociliary clearance. Some other processes that occur due to microvascular leakage are the creation of new mediators from plasma precursors and mucosal edema (liquid retention) that narrow the airways in asthma patients.
Another characteristic that has received a great deal of attention in asthma research is the primary abnormality of smooth muscle cell activity. From this standpoint, asthmatic inflammation of the airways has been explained by a persistent neural abnormality engaging the cholinergic and noncholinergic nonadrenergic bronchospastic tone. It should be noted, however, that what triggers the onset of asthma is not a single abnormality or an event.
Recent research has shown that asthma has self-exacerbating mechanisms. The chronic decline and impairment of lung function that is characteristic of asthma lead to permanent changes in the structure of the airways (Sullivan, Hunt, MacSharry & Murph, 2016). Namely, the submucosa of the bronchi (the extracellular matrix (ECM), vessels, glands, and smooth muscle) undergoes modifications in asthma patients (Sullivan, Hunt, MacSharry & Murph, 2016). These pathophysiological mechanisms manifest themselves at the early stages of the disease, which suggests that early monitoring may as well be possible.
Standard of Practice
Currently, it is recommended to take a stepwise approach to asthma therapy. The course of action depends on the severity of the disease, and its objective is to reduce the symptoms of airway obstruction and inflammation. Another important objective is to avert exacerbation and maintain healthy lung function. At present, the most effective drugs available for asthma patients are β2‐adrenoceptor agonists and glucocorticoids.
Second and third-line therapy includes drugs such as theophylline, leukotriene receptor antagonists, and anticholinergics. In general, asthma medication can be divided into two categories:
- long-term controllers (corticosteroids) that are taken on a daily basis;
- relievers (β2‐adrenoceptor agonists) that relieve bronchoconstriction.
The latter should only be used on a need basis as a rescue medication and not as a long-term solution.
In the case of mild persistent asthma, patients are given inhaled steroids, 200–500 μ µg, hormones, or, alternatively, sustained-release theophylline on a daily basis. To relieve an acute asthma flare, patients should be treated with inhaled β2‐adrenoceptor agonists; however, this treatment should not exceed three or four times a day. Treatment of moderate persistent asthma requires increased doses of inhaled corticosteroids at 800–2,000 μ µg and long-acting β2‐adrenoceptor agonists. If a patient struggles with symptoms at nighttime, he or she should be given sustained-release theophylline or long-acting oral β2‐adrenoceptor agonists.
As for acute symptoms, short-acting bronchodilators may be helpful, but their use should not exceed three-four times a day. For some people, doubling the dose of inhaled steroids might not make as much sense as adding a long-acting β2‐adrenoceptor agonist or low-dose theophylline. Lastly, severe persistent asthma requires inhaled corticosteroids at ≥800–2,000 μ µg and long-acting β2‐adrenoceptor agonists. If a patient manages to sustain control over asthma for more than three months, a gradual stepwise reduction in doses is recommended.
To researchers’ current knowledge, there is no feasible replacement for the aforementioned drugs or anything that would have superior effects. The National Health Institutes (2012) promote drug combinations of inhaled steroids, preferably with long-acting β2‐adrenoceptor agonists. They were chosen for their enhanced efficacy and the potential for a steroid-sparing effect. Treatment choices vary by country because of different levels of access to healthcare and convenience for the patient. Selecting the right medication should also take into account the occurrence of side effects. Lastly, the cost of therapy and relevant reimbursement policies also impact the choice of treatment.
Assessment, Diagnosis, and Patient Education
Guidelines for assessment, diagnosis, and patient education for medical professionals handling asthma patients can be found in the asthma care reference guide issues by the National Institutes of Health (NIH) (2012). The institutions write that the initial visit should include diagnosis, asthma severity assessment, medication prescription, action plan development, and scheduling follow-up appointments. Establishing an asthma diagnosis requires identifying symptoms of recurrent airway obstruction, based on a patient’s anamnesis and exam.
Some of the information that needs to be taken into account includes a history of cough, wheezing, difficulty breathing, and a feeling of tightness in the chest area, especially if they are recurrent. Patients are likely to be diagnosed with asthma if the aforementioned symptoms occur or worsen in the nighttime or when a patient is physically active. For patients older than five years, the NIH recommends using spirometry to determine the airway obstruction. However, it should be noted that for the sake of validity, other reasons for lung obstructions should also be considered.
The National Institutes of Health (NIH) (2012) describe asthma as a chronic but controllable disease. In its asthma care reference guide, the NIH states that asthma control serves two main purposes. Firstly, a good asthma management strategy must seek to reduce impairment: it must help to mitigate the frequency and intensity of symptoms. Besides, asthma control should help patients mitigate or eliminate functional limitations that they are currently experiencing.
The second objective of asthma control under the supervision of a medical professional is to reduce risk. It is important to avert severe asthma flares as well as the progressive decline of lung function due to organic transformations described in the previous section. Lastly, asthma control means mitigating medication side effects in which a significant role is assigned to asthma patients themselves.
Asthma control should be a mutual effort made by both medical professionals and asthma patients. A healthcare provider does monitor the progression of the disease and prescribes medication, but he or she can only do so much. The overwhelming majority of the time, asthma patients are left to their own devices, which is why they need to be educated and conscientious enough to take charge of their health. The National Health Institutes suggest that at each visit, medical professionals encourage and reinforce self-monitoring and treatment compliance. Regarding the former, patients need to be taught to assess the severity of their symptoms and be aware of the signs of worsening asthma.
As for the latter, it is essential that patients know how to use an inhaler and other devices and understand the difference between long-term and short-term medications. Long-term control medications are preventive: for instance, corticosteroids reduce inflammation of the airways. Because they have an accumulated effect that might not be noticeable at once, some patients prefer short-term medications such as short-acting beta2-agonists or SABAs that relax the muscles of the airways. Unfortunately, if these medications are abused, patients may develop resistance and find themselves in a situation where their usual way of relieving asthma no longer works. It is the duty of a health professional to warn patients about these adverse consequences and teach them responsible medication use.
Another important element of patient education is developing an action plan that should be maintainable over vast periods of time. There is no one-size-fits-all plan: any asthma control strategy needs to be customized and finely tuned to a patient’s wants and needs. Firstly, it is critical to identify environmental factors that trigger asthma flares: it can be certain foods, smells, or living spaces. After understanding personal triggers, a patient can move forward with the strategy and change their daily routines accordingly. Another valuable idea is to investigate what other medications a patient is taking and monitor their interactions with each other.
It is possible that some of the medications are not appropriate for asthma patients and can worsen their conditions. Taking all these facts into consideration, a health professional should devise a plan that is grounded in small actions that a patient can take to maintain their health and prevent adverse outcomes. At all times, a health provider should be patient and encouraging to boost a patient’s confidence in his or her ability to control the disease.
Lastly, the National Institutes of Health (2012) highlight the importance of family involvement and support. As a chronic and potentially life-threatening condition, asthma can be overwhelming to handle alone. For this reason, it is advised that health professionals communicate with a patient’s family and educate family members as well. It should be noted that not only family members but also other health professionals play a significant role in the recovery process. The NIH writes that physicians, pharmacists, nurses, respiratory therapists, and asthma educators should all unite their efforts to provide education to patients.
Comparison with Standard Practice within the Community
In the community under investigation, health professionals manage to only partly follow the asthma control guidelines outlined by the National Institutes of Health (2012). Health professionals are successfully diagnosing asthma at early stages and develop treatment plans that include both long-term and short-term medications. In the case of a severe asthma attack, patients are promptly hospitalized, which ensures a fast rate of recovery and discharge. Health professionals make sure that patients make follow-up appointments, in which they assess their state and determine whether they have been adhering to the established treatment plan.
For all the progress that the community has made with regard to treating and controlling asthma, there are still problems that require more attention. The problems can be roughly put into two categories: provider-related and patient-related. Health professionals are often pressed for time and lack resources, which impedes them from providing patients with a high-quality education. There is an apparent discrepancy between doctors’ intentions and their behavior. Boulet (2015) reports the same lack of congruency in UK medical professionals. The researcher conducted a survey that has shown that while 98.4% of physicians understood the importance of asthma education, only 12.8% offered their patients actual action plans.
Boulet (2015) also mentions the lack of medical educators to which doctors could refer patients – this problem is observed in the analyzed community as well. Another persistent issue is therapeutic communication, in which many doctors lack training and experience. Possessing the right knowledge is the norm, but spreading it in an understandable and compassionate manner is challenging for health professionals. If a patient feels unheard and misunderstood, he or she is less likely to adhere to medication. In the community analyzed, health professionals need to find ways to put medical instructions in simpler words to eliminate ambiguities and misunderstandings.
Patients tend not to put in enough effort handling the disease, even when their well-being is at stake. Even if educational programs are free or available at a minimal cost, patients are reluctant to participate. This passivity and withdrawal can happen for many reasons: some individuals do not have time, while others lack motivation or think that this kind of intervention is unnecessary. Boulet (2015) explains that decision-making is challenging for many patients: they do not have sufficient knowledge and experience to make well-informed decisions.
The second barrier is the patients’ inability to make long-term plans reported by the doctors in the analyzed community. Many affected individuals rely on short-term medications that provide brief relief. At that, they ignore long-term solutions and do not improve their health in the long run. In summation, asthma healthcare in the community is rather reactive and proactive. Formal treatment is compliant with the guidelines; however, personal and systemic barriers prevent asthma care from being more robust.
Characteristics of and Resources for a Patient
A patient who manages the selected disease well is likely to display two characteristics: resources and positive psychological qualities such as resilience, optimism, and accountability. Since asthma is a chronic disease, it is important for patients to have the financial stability to afford medication and regular appointments. Besides, good asthma management is nigh on impossible without having easy, unimpeded access to healthcare services. Nunes, Pereira, and Morais-Almeida (2017) make an optimistic prognosis: they claim that if a patient adheres to medication and manages asthma well, their life expectancy may be the same as that of a healthy person. Therefore, in the United States, an asthma patient who follows recommendations may as well live up to 79 years.
The best possible outcome would be a life with rare and mild asthma flares without a significant decline in lung function. In this case, a patient will be able to function no worse than healthy people and act on their aspirations without asthma symptoms getting in their way. Daytime and nighttime symptoms are minimal or non-existent: on average, less than two times a week. A patient who manages the selected disease well does not rely on short-term medication for a brief relief because they have been able to take more proactive measures. He or she does not suffer from any adverse side effects from the chosen medication, nor do they experience exacerbations.
Disparities in Treating the Disease
Internationally, asthma management and control differ at operational and conceptual levels. For instance, Canadian asthma guidelines conceptualize the severity of the condition in a slightly different way than US guidelines. Canadian healthcare standards include additional endpoints that take into account the most recent hospital admissions and near-fatal flares (Bakel et al., 2017). At the same time, Canadian guidelines lack differentiation, where US guidelines make a point to highlight specific details such as paying attention to daytime episodes on par with nighttime episodes (Bakel et al., 2017).
UK GINA-05 provided a more detailed description of severe asthma, including limited physical activity that was not considered by US guidelines (Bakel et al., 2017). As compared to Canada, in the US, the number of SABA uses for classifying asthma as severe is not specified either.
Another difference between approaches to asthma management in developed countries lies in the definition of controlled asthma. The US guidelines suggest that a patient should have minimal or no daytime symptoms to classify their condition as controlled (Bakel et al., 2017). UK GINA-06 and Canadian guidelines reach consensus on this point but show more precision (Bakel et al., 2017). In them, well-managed asthma is characterized by less than two times a week and less than four times a week, respectively. As seen from this description, the US standards of asthma treatment do not differ much from those recognized in other developed countries: Canada, Australia, and the UK.
Factors Influencing Access to Care
Asthma management requires not only knowledge and motivation but also sufficient financial resources and access to care. American Thoracic Society (2018) reports that the total annual asthma cost in the US amounts to $90 billion. When calculated on a per-person basis, the cost reaches $3,266: $1,830 for prescriptions, $640 for office visits, $530 for hospitalizations, $176 for hospital outpatient visits, and $105 for emergency room care. The Census Bureau states that the number of uninsured Americans is steadily growing: if in 2016, 27.3 million did not have insurance, by 2018, the figure had grown to 28.6 million. These costs are likely to be the most straining for those Americans who are uninsured or whose insurance plan does not cover all the necessary expenses.
Another important factor to acknowledge is patients’ eligibility for Medicaid, a cornerstone of the so-called Obamacare healthcare program. The Affordable Care Act (ACA) sought to curtail inefficient healthcare expenses and low quality of medical services by turning to proactive measures (U.S. Centers for Medicare & Medicaid Services, 2020). Before the ACA, insurance providers would rarely if ever covered preventive care. In the long run, the failure to tackle a disease at early stages would have an accumulative detrimental effect on patients. They were more likely to have a health emergency later in life, which would require much more expensive interventions.
Medicaid helps asthma patients address their condition early after the onset, averting exacerbation. Lastly, access to proper asthma care is determined by the presence of specialists in a patient’s area of residence. The University of North Carolina (2020) reports that since 2010, 126 rural hospitals have been closed across the United States. This fact means that thousands of people lost easy access to medical services and had to resort to remote providers. Given that asthma is a chronic disease that requires regular monitoring, not having a hospital in close proximity is not only inconvenient but may even be life-threatening.
Nunes, Pereira, and Morais-Almeida (2017) describe the so-called indirect costs of asthma. The researchers explain that poorly managed asthma, especially if a patient experiences exacerbations, is associated with the loss of work productivity, which, in turn, means less financial stability. The adverse effects of asthma may take the form of a temporary disability when a patient cannot fulfill their usual work duties because of asthma symptoms (Nunes, Pereira & Morais-Almeida, 2017).
In the case of a severe lung function decline, an affected individual may as well be confronted with permanent disability and early retirement. The loss of work productivity also applies to working adults who care for underage asthma patients. Because managing the disease takes time and resources, caregivers may discover that they are unable to adhere to the normal work schedule and have to take days off to help their children. In summation, asthma is associated with both direct and indirect costs: health expenses associated with treatment, medication, and appointments and adverse impact on affected individuals’ work life.
Interventions
One strategy that could bring about an organizational change with regard to asthma treatment is creating and launching a so-called medical home for the asthma program. The program would target children from low-income families and seek to tackle the lack of continuity in primary care. “Medical home” can take up office space at a healthcare organization and be run by local medical professionals. The key function of the “medical asthma home” would be to provide detailed information to patients. More often than not, healthcare specialists do not have enough time to consult each patient comprehensively, even though clear and straightforward information is one of the elements of adherence promotion. “Medical home” will be a place that patients could be referred to to receive needed support.
Another objective of the planned intervention could be the creation, edition, and distribution of asthma control materials. Many patients these days seek information on the Internet, but without proper training and education, they might not have the expertise to distinguish between reliable and unreliable sources. “Medical home” could do this for them: the experts would review sources, compile them, and recommend to patients. Patient satisfaction will be the key evaluation metric for this intervention. How satisfied patients are with the experience of attending the center could be measured through regular surveys.
Another possible intervention is promoting continuing education among physicians that often lack knowledge and resources to empower asthma patients. Continuing education could take the form of a short-term study program that would not only enlighten medical professionals on the aspects of asthma management that are often ignored but also improve their communication skills. The self-regulation theory borrowed from the field of psychology could direct the development of the study program. The self-regulation theory suggests that individuals are capable of holding themselves accountable for their actions and controlling their impulses. Self-regulation, in this context, means being conscientious and aware of one’s actions.
The two main components of the seminar should include guidelines for optimal clinical practice in alignment with the standards established by the National Institutes of Health (NIH) and patient empowerment, teaching, and communication. The seminar starts with a series of brief lectures by invited asthma experts. The lectures are accompanied by videos that, among other things, demonstrate effective therapeutic communication and patient teaching techniques. Surely, outlining the key theoretical aspects suffices not: for this reason, medical professionals will be offered to solve practical cases that present common situations in asthma control and management.
Lastly, invited speakers and couches could review available sources and materials about asthma management and point out those that are appropriate for recommending patients. The success of the intervention could be measured shortly after the seminar and in the long run. Right after the event, the healthcare organization could set up a knowledge test to evaluate how well the participants have understood the material. The long-term effects might be more challenging to pinpoint: they might manifest themselves in the rehospitalization rate, treatment adherence, and patient satisfaction.
The third intervention is in line with the recent advent of technology in medicine. Merchant et al. (2018) write that even though the standards of asthma care are well-established, in practice, it is quite difficult to motivate patients to follow them. One of the greatest issues in asthma control is in patients’ overreliance on “rescue medication.” As it has been mentioned before, short-term asthma medication should only be used in the case of emergency, and patients should not resort to it more than three to four times a week. Merchant et al. (2018) propose a solution that seems to be effective in tackling the said problem and that could be used in our healthcare organization.
The intervention included electronic medication monitors (EMMs) that logged inhaler medication use. As an extra aid, Merchant et al. (2018) employed a digital platform with exhaustive information for both doctors and patients. The best evaluation metric for this intervention would be the “rescue” medication use rate. The desired outcome would be a decrease in the use of short-term asthma medication.
References
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Asthma and Allergy Foundation. (2019). Asthma facts and figures. Web.
Bakel, L. A., Hamid, J., Ewusie, J., Liu, K., Mussa, J., Straus, S.,… & Cohen, E. (2017). International variation in asthma and bronchiolitis guidelines. Pediatrics, 140(5), e20170092.
Becker, A. B., & Abrams, E. M. (2017). Asthma guidelines: The Global Initiative for Asthma in relation to national guidelines. Current Opinion in Allergy and Clinical Immunology, 17(2), 99-103.
Boulet, L. P. (2015). Asthma education: An essential component in asthma management. Web.
Merchant, R., Szefler, S. J., Bender, B. G., Tuffli, M., Barrett, M. A., Gondalia, R.,… & Stempel, D. A. (2018). Impact of a digital health intervention on asthma resource utilization. World Allergy Organization Journal, 11(1), 28.
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Nunes, C., Pereira, A. M., & Morais-Almeida, M. (2017). Asthma costs and social impact. Asthma research and practice, 3(1), 1.
Sullivan, A., Hunt, E., MacSharry, J., & Murphy, D. M. (2016). The microbiome and the pathophysiology of asthma. Respiratory research, 17(1), 163.
Tolbert, J., Orgera, K., Singer, N., & Damico, A. (2019). Key facts about the uninsured population. Web.
The University of North Carolina. (2020). 168 rural hospital closures: January 2005 – present (126 since 2010). Web.
U.S. Centers for Medicare & Medicaid Services. (2020). Preventive health services. Web.