Asthma: Focus on correct, objective Dx and guideline-driven Tx
This story appears courtesy of Clinician Reviews.
By Lisa Hack
REPORTING FROM THE ANNUAL CARDIOLOGY, ALLERGY, AND RESPIRATORY DISEASE SUMMIT
SAN DIEGO--“It’s very important that we know how to correctly diagnose this disease,” began nurse practitioner, Mary Lou Hayden, RN, MS, FNP-BC, AE-C, referring to the disease of asthma. She explained that correct diagnosis is important partly because the disease is so common, affecting 7.6% of adults and 8.4% of children in the United States, and partly because it is responsible for significant health care utilization, including 6.5% of office visits and 1.6 million emergency department visits.
Advanced Education in Primary Care, Presented by and for NPs and PAs.|
July 25 - 27, 2019
Correctly and objectively diagnosing asthma is also important, Hayden continued in a presentation at the annual Cardiology, Allergy, and Respiratory Disease Summit, because, “We cannot simply rely upon patients’ reports of symptoms. Patients very frequently underreport their symptoms and don’t assume it’s asthma.” She says that while peak flow meters can be helpful, they are not diagnostic. “It’s important that we have objective measures . . . and the most important measure is spirometry.”
“You can buy a small office spirometer for as little as $1000,” Hayden continued at the conference, held by Global Academy for Medical Education, “and as a reimbursable procedure, it pays for itself in a short period of time.” “It actually becomes a revenue center for the practice,” she added.
She explained that she’s seen patients with supposed uncontrolled asthma referred to her practice who don’t, in fact, have asthma at all. “If the [referring] office had had a spirometer, they would have perhaps not needed to refer.”
So important is spirometry to the diagnosis and management of asthma that Hayden offers an annual pre-conference workshop on the test, so that “NPs and PAs can leave the conference having all the tools they need to optimize treatment.”
Hayden explained that because the US National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (https://www.nhlbi.nih.gov/files/docs/guidelines/asthgdln.pdf), commonly known as NAEPP or EPR-3, haven’t been updated since 2007, that it’s important to look to the Global Initiative for Asthma: Global Strategy for Asthma Management and Prevention (GINA) (https://ginasthma.org/2018-gina-report-global-strategy-for-asthma-management-and-prevention/), 2018, which is updated annually, for treatment guidance.
For example, personalized or precision medicine is now heavily influencing the field of asthma. Phenotypes, endotypes, and genotypes are helping to guide treatment of severe asthma with monoclonal antibodies and other therapeutic agents, remarked Hayden.
Other aspects important to the selection of appropriate therapies include the severity of disease, the level of asthma control, patient preference, and practical issues such as is the patient able to use a particular device, is the patient likely to adhere to the dosing schedule, and, of course, cost. “Cost overlies everything,” said Hayden, “because if a patient can’t afford to buy [a drug], or their insurance doesn’t cover it, or their deductible is so high that it is unlikely that they are going to use it, then we need to think of an alternative that is on their formulary that they are more likely to use.”
At every visit . . .
“We need to measure for control at every visit,” Hayden emphasized, explaining that we assess control in terms of impairment and risk. Impairment includes aspects such as the number of times the patient has had symptoms or used their reliever medication in the past 2 weeks. It can also include results of lung function tests.
Risk includes questions about occurrence of exacerbations, use of systemic corticosteroids, any unscheduled or acute visits for asthma, significant deterioration in lung function, and adverse effects from the medications that have already been prescribed.
Another event that should occur at every visit is review of inhaler technique, said Hayden. She explained that there’s a wide variety of inhalers available that utilize different techniques. “With inhaled medicine, if you are not using the inhaler correctly, you are not going to get good drug deposition in the airways where its meant to be.”
Hayden summarized, “Even people with mild disease can have severe exacerbations following a viral cold or an unfortunate air pollutant exposure, so primary care [practices] need to feel comfortable managing mild to moderate asthma and need to know when to refer those who are not responding appropriately to recommended treatment plans.”
Global Academy for Medical Education and Clinician Reviews are owned by the same parent company.