Affiliations: Cleveland, OH
Dr. Poponick is Senior Instructor at Case Western Reserve University.
Correspondence to: Janet Poponick, MD, MetroHealth Medical Center, Department of Emergency Medicine, 2500 MetroHealth Dr, Cleveland, OH 44109; email@example.com
Asthma is a very common chronic disease with a
self-reported prevalence of 13.7 million persons (1993–94
survey).1 In 1995, there were an estimated 1.8 million
emergency department visits for treatment of acute
asthma.1 Office visits for asthma have more than
doubled in the past 20 years.1Estimated costs of asthma
management exceed $5 billion per year, with half of all costs used for
acute exacerbations that are managed in the hospital
setting.2–3 With this type of expenditure for asthma, why
are so many of our patients not doing well?
To improve the overall management of asthma, the National Asthma
Education Program expert panel published guidelines in
1991,4and an international consensus was published in
1992.5 The statements stress the importance of asthma
education, self-monitoring of asthma symptoms, and outlines a stepwise
approach to asthma care including the use of inhaled corticosteroids
for moderate and severe asthma. They also recommend providing the
patient with a written “plan of action” that can be initiated at
the onset of an acute attack. In discussions with colleagues and
teaching of residents, we all refer to the consensus statement. But why
has this not become actual practice?
There are many reasons that can be listed: psychosocial issues
including the inability to afford medications, the lack of a primary
care physician, and continued exposure to known irritants, especially
cigarette smoking. In this issue of CHEST (see page 1638),
McD Taylor et al surveyed their asthma population in a Pittsburgh
emergency department and compared the patient’s knowledge and their
outpatient treatment with the consensus guidelines. Patients in this
study and those using hospital emergency departments generally have a
poor understanding of their disease and poor management techniques.
Acccording to McD Taylor et al, approximately 60% of patients were
undertreated with medications, and > 80% had no plan of action for
acute exacerbations. Their patient population had a poor understanding
of their disease and were unclear on the use of their medications. With
regards to the recommendation of inhaled steroids for moderate to
severe disease, only 50% of their patient population used some
form of steroid therapy (but again, some did not understand its proper
Another recent study by Legorreta et al6 demonstrated
dismal results also. Of interest, this study was conducted by written
survey of an asthma population enrolled in a large health maintenance
organization (HMO) in California. Of those patients with severe
asthma, 72% had a steroid inhaler, but only 54% of those patients
used it daily. As for monitoring peak flow, only 26% of respondents
had a peak flowmeter, but only 16% of those patients used it daily to
monitor their disease. Remember, this was a population of patients with
insurance who should have been able to obtain medication, peak
flowmeters, and access to care.
Many patients seeking care in emergency departments may not have a
primary care provider. According to McD Taylor et al, only 38% of the
patients could name a primary physician as the person from whom they
obtained asthma education. Therefore, a significant number of
patients received information from other sources. Many did not see a
physician on a regular basis, which is important for patient education
and adjustment of medications. Perhaps if the patient had a primary
care physician with regularly scheduled follow-up visits, they would be
managed and educated more appropriately and not use the emergency
department for care.
The article by Kolbe et al7 should remind us that other
factors influence the ability of our patients to manage their disease.
Asthma knowledge was compared to actual behavior during an acute
attack. It was found that a reasonable knowledge base alone does not
translate into appropriate action. Factors that may influence the“
gap” include non-European descent, feeling stigmatized by the
disease, high anxiety, concerns over the cost of medical care, living
on Social Security benefits alone, low education, and the recent loss
of a partner. When seeing asthma patients, it is important to realize
that there are other social and psychological issues influencing that
particular individual. Asthma education should begin with dealing with
some of these issues that affect the everyday life of our patients.
Education is a big principle of current asthma management. The patient
should understand their disease process, understand their medication
and how to use it, and be able to react to changes in their disease by
symptoms and/or actual measured peak flow. In the above-mentioned
studies, it is clearly demonstrated that these points are not being
made to our patients. Peak flowmeters were not widely available or used
by this patient population. Peak flow is a valuable tool to aide the
patient and physician in the management of asthma. It provides an
objective measurement of airflow obstruction. However, it is only
valuable when used, and those who use the peak flowmeters are usually
well-monitored, well-motivated patients.8Peak flow-based
action plans have been shown to improve asthma control and reduce the
number of emergency department visits.9 However, this has
been a short-term effect. The patients may benefit from continued
support and reminders from their primary care provider or asthma
specialist concerning peak flow measurement and the use of inhalers.
Education and good follow-up with a provider seems to influence the use
of an inhaled steroid, at least over a short-term period.9
The guidelines suggest that all asthmatic patients measure their peak
flow and symptoms daily. Some patients can only follow their symptoms,
and those patients should be educated to do so. While it would be
beneficial to the patient to have a peak flowmeter and to use it daily,
the reality is that only well-motivated patients will do so. Certainly
knowing the patient’s best peak flow is a valuable tool to guide
emergency management. Perhaps measuring the peak flow in the office
when the patient is feeling well is the best we can do for some
The article by McD Taylor et al, along with the study by
Legorreta et al6 should be a wake-up call for all who see
asthma patients, whether it is in the primary care setting, the asthma
specialty setting, or in the emergency department. All of us need to
work harder at educating our patients and helping them deal with all
aspects of their disease. Yes, the medications can be expensive, but
this seems to be an excuse. The study by Legorreta et al6
was conducted with people enrolled at an HMO; all patients should have
had their medicines provided through their health plans. There are
programs available to patients who cannot afford medication such as
state insurance plans, or even through some of the pharmaceutical
We may not be able to motivate our patients to do everything suggested
in the guidelines, but we can strive for a few of the basics. All of
us, including those practicing in the emergency department setting, can
make an effort to do better. At each patient encounter, we can
readdress the basic issues and educate our patients about their
disease. The most important aspect of education is inhaler technique
and a review of the medications. Inhaler technique is generally
suboptimal, and many may benefit from the addition of a spacer. Explain
the need for daily use of an inhaled steroid, and explain the use of a“
quick reliever” medicine. Give them a specific plan of action when
they leave the emergency department or urgent-care clinic. This plan
can be symptom or peak-flow based and should be adequate until they see
their primary care provider in a few days. Stress the importance of
follow-up in 2 to 3 days. Finally, stress the importance of avoiding
known irritants, especially cigarettes. If we as physicians do basic
education at every visit, we will eventually do better!
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