Counseling for Asthma

Anxiety and depression may have a negative impact on self-management of asthma.

Within the United States, 25 million people suffer from asthma, including 7 million children. Asthma’s hallmark symptoms are coughing, wheezing, chest tightness, and shortness of breath. Most asthma patients have allergies and more than 80% with allergic asthma have concomitant rhinitis ymptoms.¹ Additionally, up to 50% of patients have concurrent sinus disease, which exacerbates symptomatology.²

Children and Adolescents

Most asthmatic children develop symptoms before the age of 5 years. Two-thirds of asthma sufferers are diagnosed before age 18 years. Among children, the male-to-female ratio is 2:1 until puberty, when the ratio becomes 1:1. Interestingly, boys are more likely than girls to experience symptom decreases with puberty.²

Among youth aged 7 to 17 years, concurrent mental health issues (eg, depression, anxiety, behavioral disorders) are common. Both anxiety and depression are linked to poorer asthma control. Family conflict also impacts asthma severity, resulting in increased hospitalizations. Researchers believe a bidirectional causal relationship exists. Living with asthma may induce anxiety and depression, and anxiety and depression may induce increased asthma severity.³

Treatment

Treatment’s goal is to reduce or eliminate symptoms with the least amount of medication. While the National Asthma Education Prevention Program (NAEPP) issued treatment guidelines updates in 2009 and 2010, they are not consistently applied. Many patients fail to get symptoms under control, partly due to the lack of an asthma action plan, inadequate education, and the lack of follow-up visits.^4,5

Current guidelines recommend long-term treatment with inhaled corticosteroids; they are extremely effective in reducing chronic inflammation of the air-ways for 12 hours or longer.⁶ Inhaled corticosteroids are more effective in children and adults than any other single long-term controller medication. Monotherapy is initially recommended before alternatives (leukotriene modifiers and long- acting beta agonists) are prescribed. The FDA issued a warning in 2010 noting that leukotriene modifiers and long-acting beta agonists should never be used alone due to increased risk of severe symptom exacerbation resulting in hospitalization.⁷

Asthma severity guides treatment. Severity is categorized by symptom frequency: intermittent (symptoms are present 2 or fewer times per week); persistent to mild (symptoms are greater than twice a week but not daily); persistent to moderate (daily symptoms); and persistent to severe (symptoms are present throughout the day).⁷ NAEPP recommends a stepwise approach for asthma management for those 12 years and older.

Table: National Asthma Education Prevention Program’s Stepwise Therapy

Step 1

Inhaled short-acting beta agonist as needed

Step 2.

Preferred: Low dose inhaled corticosteroid

Alternative: Cromolyn, leukotriene receptor agonist, nedocromil, theophylline

Step 3

Preferred: Low dose inhaled corticosteroid plus a long-acting inhaled beta agonist or medium dose inhaled corticosteroid

Alternative: Low dose inhaled corticosteroid plus leukotriene receptor agonist, theophylline or zileuton

Step 4

Preferred: Medium dose inhaled corticosteroid plus a long-acting inhaled beta agonist

Alternative: Medium dose inhaled corticosteroid plus leukotriene receptor agonist, theophylline or zileuton

Step 5

High-dose inhaled corticosteroid plus a long-acting inhaled beta agonist with consideration of omalizumab for patients with allergies

Step 6

High dose inhaled corticosteroid plus a long-acting inhaled beta agonist plus an oral corticosteroid with consideration of omalizumab for patients with allergies

Step 1 targets intermittent asthma, whereas steps 2 through 6 target persistent asthma. Regardless of the step, all patients should use an inhaled short-acting beta agonist. Patients should be evaluated 2 to 4 weeks after initiating therapy. Additionally, consultation with an asthma specialist is recommended for patients reaching step 3 or higher. All steps should be accompanied by patient education and management of comorbidities.^5,8

Asthma Action Plan

Patients, or the parents of a child, need to take an active role in self-management. The asthma action plan is critical for asthma self-management. It provides guidance on the correct way to take medication and instructions on using a peak air flow meter, identifies known triggers, and provides instructions when symptoms worsen.

The asthma action plan also provides guidance for measuring and interpreting peak air flow. If the peak air flow is 80% and above, asthma is considered to be well controlled. Peak air flow between 50% and 70% indicates asthma is not under control. If peak air flow is below 50%, this signals a medical emergency and patients need to call their doctor or an ambulance.² Patients whose asthma is well controlled for 3 months or longer are candidates for a stepdown medication adjustment.^5,8

Counseling Guidelines

The Table provides guidelines for asthma counseling. All patients should be counseled on the importance of self-management in controlling asthma.

Final Thought

Asthma is highly controllable, but only if patients take an active role in self-management and adhere to an asthma action plan.

Dr. Zanni is a psychologist and health-systems consultant based in Alexandria, Virginia.

References:

• Jenerowicz D, Silny W, DaÅ„czak-Pazdrowska A, et al. Environmental factors and allergic diseases. Ann Agric Environ Med. 2012;19:475-481.
• Morris M. Asthma: practice essentials. http://emedicine.medscape.com/article/296301-overview. Accessed March 15, 2013.
• Goodwin RD, Bandiera FC, Steinberg D, et al. Asthma and mental health among youth: etiology, current knowledge and future directions. Expert Rev Respir Med. 2012;(6):397-406.
• Zanni G. Asthma symptoms are highly controllable. Pharmacy Times. 2006;72(4);24-26.
• Pollart SM, Elward KS. Overview of changes to asthma guidelines: diagnosis and screening. Am Fam Physician. 2009;7:761-767.
• Schiffman G. Asthma medications. www.emedicinehealth.com/asthma/page9_em.htm. Accessed March 15, 2012.
• Spangler DL. The role of inhaled corticosteroids in asthma treatment: a health economic perspective. Am J Manag Care. 2012;18(2 suppl):S35-S39.
• Elward KS, Pollart SM. Medical therapy for asthma: updates from the NAEPP Guidelines. Am Fam Physician. 2010;82:1242-1251.
• National Heart, Lung, and Blood Institute. What is asthma? www.nhlbi.nih.gov/health/health-topics/topics/asthma/. Accessed March 13, 2013.
• Centers for Disease Control and Prevention. Asthma. www.cdc.gov/asthma/faqs.htm. Accessed March 13, 2013.