Asthma is a chronic, heterogeneous disease with symptoms and features that include wheeze, cough, dyspnea and chest tightness, variable airway obstruction, and bronchial hyper-responsiveness. The ultimate goals of asthma treatment are to achieve and maintain control of asthma symptoms, reduce future risk of hospitalization or emergency department (ED) visits, and enable the patient to lead a life without restrictions due to the disease.1
In this article, we review four areas of controversy in asthma management including use of written asthma treatment plans, the role of long-acting beta-agonists (LABAs), spirometry measurement in disease management, and engagement of school nurses. For each area, we provide suggestions and guidance for the primary care clinician about how to incorporate these elements into patient care effectively and efficiently.
Asthma Treatment Plans
Asthma treatment plans (ATPs) (also referred to as “asthma action plans”) are a set of individualized written instructions, decided jointly by the clinician and patient or caretaker, about how to manage the disease. A written ATP for every child with asthma, provided to both the family and the child's school nurse, is recommended by the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report-31 (EPR-3), but is used by only 16% of primary care providers and 31% of asthma specialists.2
What Is the Evidence to Support Use of an ATP?
Written ATPs guide decision-making and support asthma self-management.3 They reduce patient confusion about their medications and remind patients about the proper way and time to use them. They also improve provider-patient communication and enhance patient knowledge, skills, capacity, and confidence. Some studies have demonstrated improved asthma control when ATPs are used.4,5 We recommend the use of written treatment plans for all children with persistent asthma.
What Are the Components of a Good ATP?
A good ATP has three main components that correspond to the lights on a traffic signal: daily asthma treatment plan including exercise (green zone), a plan for management of a mild-moderate asthma exacerbation (yellow zone), and a plan for when to call the doctor and how to respond to an asthma emergency (red zone).
Daily Treatment Plan
The daily treatment plan consists of instructions for how the child is to manage his or her asthma every day. For children with persistent asthma, this should consist of a controller medication (eg, an inhaled corticosteroid [ICS] or ICS/LABA, or for mild persistent asthma, a leukotriene receptor antagonist [LTRA]) consistent with asthma severity and instructions about when to use rescue medication (eg, short-acting beta-agonist [SABA]). The instructions should be specific (eg, do not suggest a range of puffs such as “2 to 4 puffs”) and in a format that is easily understood by the parent and child (eg, do not write “bid”). Specific instructions about when to use SABAs before exercise are important.
Sick Treatment Plan
The sick treatment plan describes what to do during an asthma exacerbation. Specific instructions about when to begin the sick plan, how long to use the sick plan, and when to move to the next step because the sick plan is not working are important components. In general, a sick treatment plan consists of regular use of rescue medication (eg, “[SABA name], two puffs 4 times per day and 2 times at night as needed”). The plan should instruct children to continue to use their daily controller medication. Doubling or quintupling the dose of the ICS has not been shown to be effective in reducing the need for oral corticosteroids, ED visits, or hospitalizations in children.6
Emergency Treatment Plan
The emergency treatment plan provides instructions on when to call the doctor and when to call emergency medical technicians. Some practices give parents a prescription for oral corticosteroids (OCS) to have in case of a severe exacerbation. There are no data to support this practice, but it can expedite starting OCS during the night or on weekends. Instructions for when to use OCS are needed and could include calling the office immediately after starting OCS therapy.
How Can a Written ATP Be Incorporated into Your Practice?
It is important to create a workflow that assures that every child with asthma in your practice has an ATP at home, anywhere they spend significant time, and at school. Create a standard form for your practice that conveys this information to your patients in a way that they can understand. Keep the form and the language simple; if you wish to add asthma educational materials to the form, use the back of the page. An example of a completed form is included in Figure 1 with environmental control information on the back of the page. This ATP has been tested in families with low literacy levels with approximately 80% comprehension.7 If your patients do not speak English, you will need to translate the instructions into the appropriate language. Everyone in the practice should use the same form to convey consistent information to patients and their families.
Example of (A) an asthma treatment plan with a school authorization and (B) an illustration of asthma triggers.
Challenges to using ATPs include language barriers, ambiguity in the instructions, or limited understanding of the condition itself. ATPs can be difficult for some parents and children to understand. It is important to keep the plan simple and be conscious of how people with lower literacy levels take in information (eg, left to right). Sharing an ATP between different stakeholders and keeping it up to date pose logistical challenges but storing ATPs in a consistent place in the electronic health record can help this issue.
The Role of Long-Acting Beta-Agonists in Managing Childhood Asthma
The NAEPP EPR-3 recommends the addition of a LABA for children age 5 years or older with asthma that is poorly controlled on low-dose ICS.1 LABAs effectively relax airway smooth muscle by stimulating the beta2-receptors resulting in 12 hours of bronchodilation.8 LABAs are currently only available in combination with ICS as LABAs themselves have no anti-inflammatory properties and, when used alone, can result in an increase in severe asthma exacerbation and even death. This finding resulted in the placement of a US Food and Drug Administration black box warning in 2006 on all medications containing a LABA.9 However, the black box warning was removed from the ICS/LABA combination medications in 2017 after several well-designed studies demonstrating the safety of ICS/LABA combination inhalers.10,11 There remains some reluctance among providers to use the ICS/LABA medications,12 despite the evidence that these medications are safe and effective.10,11,13,14 The 2012 National Asthma Survey of Physicians demonstrated equivalent use (around 50%) of ICS/LABA combination medications between primary care providers and specialists.2
Long-Acting Beta-Agonists Are Effective in Children
Studies have demonstrated that stepping therapy up from a low or medium dose of ICS to an ICS/LABA combination medication is more effective than increasing the ICS dose and spares some of the side effects associated with higher doses of ICS.13,14 In addition, there is some in vivo and in vitro evidence that LABAs can activate glucocorticoid receptors, resulting in enhanced transcription of anti-inflammatory mediators.15 Additionally, adding corticosteroids to a LABA helps to protect against the down-regulation of beta2 receptors that can be seen with LABAs and SABAs16 and synergistically suppresses smooth muscle proliferation more than either medication alone.17 All of these findings provide the scientific plausibility to support the clinical trials, which have demonstrated an increase in lung function and a decrease in asthma symptoms and exacerbations when an ICS/LABA medication is used.
When to Use Long-Acting Beta-Agonists
For children age 5 to 11 years, NAEPP EPR-3 recommends a low-dose ICS plus LABA or LTRA as the preferred therapy for moderate persistent asthma. For children older than age 12 years, the current guidelines recommend low-dose ICS plus LABA or medium-dose ICS for moderate persistent asthma. There is limited evidence to guide clinicians as to which of these treatment regimens will work better for which patients. The BADGER (Best Add-On Therapy Giving Effective Responses) trial at tempted to determine clinical predictors of response to therapy. Markers of more significant airway obstruction (such as forced expiratory volume at 1 second [FEV1] responsiveness to bronchodilator) were slightly favorable for a response to LABA therapy, whereas higher urinary leukotriene E4 levels was marginally favorable to LTRA therapy.18 This remains an important area of research as we attempt to incorporate personalized medicine into asthma management. We recommend considering an ICS/LABA combination for any child older than age 5 years who continues to suffer from poorly controlled asthma on a low or medium dose of ICS alone. Start with the ICS/LABA combination medication that keeps the ICS dose equivalent to the previous dose. Alternatively, for those newly diagnosed with moderate or severe persistent asthma, we would recommend starting with an ICS/LABA combination and then stepping down to an ICS alone once control is established.
When assessing response to therapy and determining the need to step up therapy, it is critical that elements of nonadherence be assessed first. Improper inhaler technique is the most common cause of nonintentional nonadherence and should be assessed at every asthma visit. If inhaler technique is not good, then changing the medication in the inhaler will not improve control. However, if inhaler technique is determined to be a problem, then an oral medication, such as an LTRA might be the preferred next step. Once adherence has been assessed and good inhaler technique confirmed, then the evidence would suggest the next step up from a low-dose ICS should be an ICS/LABA combination medication.
Spirometry Measurement in the Primary Care Office Setting
Uses of Spirometry in the Office Setting
Spirometry testing is recommended by the NAEPP EPR-3 to assess asthma severity and asthma control. Accurate assessment of asthma severity is critical to choosing the appropriate therapy. Underestimating asthma severity results in suboptimal asthma treatment and increased morbidity.19 Spirometry can also be used in the primary care clinician's office to assess a child's response to asthma therapy and to diagnose exercise-induced asthma. However, children with intermittent and mild, persistent asthma have normal spirometry. In addition, a significant spirometric response to an inhaled bronchodilator (defined as a >12% increase in the FEV1 or a >10% increase in the forced vital capacity) can be observed in children with allergic rhinitis without asthma.
Spirometry can guide the primary care clinician in optimizing therapy for children with asthma. In one large study of Medicaid-insured children on optimal therapy determined clinically, outcomes from spirometry would have resulted in increasing therapy in almost one-third of the children.20 In a study of family medicine practices, abnormal spirometry test results would have changed therapy in 48% of the participants.21 Abnormal spirometry test results have also been associated with increased risk of an asthma attack in the subsequent year.22
Peak Flow Testing
Peak flow testing is no longer recommended in the office setting, as it has not been found to be useful in monitoring asthma in children. Two randomized controlled trials failed to show a benefit of peak flow-guided treatment in comparison to management based on symptoms alone, and the addition of peak flow measurements did not enhance self-management even during acute exacerbations.23,24
Barriers to Spirometry Testing
If spirometry can benefit treatment of asthma, why is it used infrequently in primary care settings where more than 60% of all asthma care is provided? Equipment should not be a barrier as many hand-held spirometers, which are easy to use, affordable, and meet all ATS-spirometry testing requirements, are readily available. The major barriers to office spirometry testing are poor coaching, poor patient effort, and/or inappropriate interpretation. High-quality spirometry test results require patient cooperation and maximal effort. Staff training in how to coach children to obtain high-quality, reproducible results is critical, and many pediatric offices may not have time or resources to produce reliable interpretable studies. For the smaller practices, access to pulmonary function laboratories in neighboring hospitals that are experienced in testing children can meet the needs of testing in their patient population. For larger practices, spirometry testing is cost effective and regularly scheduled provider-specific asthma clinics where spirometry testing is performed in conjunction with inhaler technique assessment and asthma education are an efficient approach. Efforts to sustain high-quality testing and interpretation using long-distance learning and peer mentors have had mixed results, but in all studies, utilization has remained low.25,26
School Nurses and Their Role
School nurses are in a unique position to close gaps in care for school-aged children with asthma but are underutilized by the medical community. Since students spend 7 to 10 hours per day and 180 days per year at school, school nurses could serve an important role in the health of students with chronic health conditions including asthma.27 The school nurse is ideally situated to reinforce asthma management, to recognize asthma symptoms and lack of asthma control, and to assist with care coordination. Asthma is the leading cause of school absenteeism; children with asthma miss 3 times more school days than their peers, which directly affects their educational success.28 Rates of school absenteeism are higher for children who are African American, low income, or attend schools in urban locations.29 In such communities, resources are often cut and a nurse may visit a given school for only a few hours once or twice a week.
Barriers to School Nurse and Primary Care Clinician Collaboration
School nurses report multiple barriers to successful asthma management in the school setting,30 including inadequate time, lack of parental and institutional support, knowledge deficits, and lack of respect for school nurses by students, parents, school staff, and administrators as well as physicians. One of the biggest barriers reported by school nurses is communication with the primary care clinician. Pediatricians, on the other hand, want to know when a child's asthma is out of control, when a child is not using his or her medication or is using medication incorrectly.31
Despite these barriers, families are generally satisfied with the asthma care provided to their children in school.31 Students who are taught asthma management skills by school nurses experience improved outcomes, including decreases in school absenteeism and improved inhaler technique,32 reductions in medical services use, increased asthma education, and improved pulmonary function.33
Improving Asthma Care and Creating Partnerships
The most important assessment that school nurses can perform is proper inhaler technique. Students who need to pretreat with a bronchodilator prior to exercise may be required to go to the school nurse's office. Thus, the school nurse has multiple opportunities to assess inhaler technique during the school year. Improper inhaler technique is a major problem for many children with asthma. A simple 5-step inhaler technique checklist can be used by the school nurse to assess and coach students in proper inhaler technique.34
Additionally, school nurses can report poor asthma control to the family and, with permission, to the child's pediatrician. Both school nurses and pediatrician offices are busy, and it is often difficult to communicate directly with each other. One solution is a preprinted asthma checklist that can be faxed or sent electronically to the pediatrician's office. This checklist could include important reasons why nurses want to communicate with pediatricians and the information that pediatricians want to know from the school nurse. As schools and pediatric offices move toward electronic communication systems, opportunities to communicate electronically may exist soon.
What Pediatricians Can Do to Engage School Nurses As Partners in Asthma Care
There are four specific activities that pediatricians can undertake to engage school nurses and improve asthma control for their school-aged children: (1) share a copy of the child's ATP; (2) use a mutually agreed upon bi-directional communication tool; (3) encourage school nurses to use a standardized inhaler technique checklist; and (4) communicate directly with school nurses about children with asthma that is difficult to control.
- National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120(suppl):S94–S138. doi:. doi:10.1016/j.jaci.2007.09.029 [CrossRef]
- Cloutier MM, Salo PM, Akinbami LJ, et al. Clinician agreement, self-efficacy, and adherence with the guidelines for the diagnosis and management of asthma. J Allergy Clin Immunol Pract. 2018;6:886–894. doi:. doi:10.1016/j.jaip.2018.01.018 [CrossRef]
- Waldecker A, Malpass A, King A, Ridd MJ. Written action plans for children with long-term conditions: a systematic review and synthesis of qualitative data. Health Expect. 2018;21:585–596. doi:. doi:10.1111/hex.12643 [CrossRef]
- Agrawal SK, Singh M, Mathew JL, Malhi P. Efficacy of an individualized written home-management plan in the control of moderate persistent asthma: a randomized, controlled trial. Acta Paediatr. 2005;94:1742–1746. doi:. doi:10.1080/08035250510039973 [CrossRef]
- Akhter LS, Monkman JL, Vang G, Pfeiffer J. Improving asthma control through asthma action plans: a quality improvement project at a Midwest community clinic. J Community Health Nurs. 2017;34:136–146. doi:. doi:10.1080/07370016.2017.1340764 [CrossRef]
- Jackson DJ, Bacharier LB, Mauger DT, et al. Quintupling inhaled glucocorticoids to prevent childhood asthma exacerbations. N Engl J Med. 2018;378:891–901. doi:. doi:10.1056/NEJMoa1710988 [CrossRef]
- Marder D, Cloutier MM. Asthma education: are inner city families getting the message?J Resp Dis. 1999;20(9):630–635.
- Kips JC, Pauwels RA. Long-acting inhaled beta(2)-agonist therapy in asthma. Am J Respir Crit Care Med. 2001;164:923–932. doi:. doi:10.1164/ajrccm.164.6.2010107 [CrossRef]
- US Food and Drug Administration. Safety report updates. https://www.fda.gov/ScienceResearch/SpecialTopics/PediatricTherapeuticsResearch/ucm123229.htm. Accessed March 4, 2019.
- Stempel DA, Szefler SJ, Pedersen S, et al. Safety of adding salmeterol to fluticasone propionate in children with asthma. N Engl J Med. 2016;375:840–849. doi:. doi:10.1056/NEJMoa1606356 [CrossRef]
- Busse WW, Bateman ED, Caplan AL, et al. Combined analysis of asthma safety trials of long-acting beta2-agonists. N Engl J Med. 2018;378:2497–2505. doi:. doi:10.1056/NEJMoa1716868 [CrossRef]
- Arellano FM, Arana A, Wentworth CE, Vidaurre CF, Chipps BE. Prescription patterns for asthma medications in children and adolescents with health care insurance in the United States. Pediatr Allergy Immunol. 2011;22:469–476. doi:. doi:10.1111/j.1399-3038.2010.01121.x [CrossRef]
- Lemanske RF Jr., Mauger DT, Sorkness CA, et al. Step-up therapy for children with uncontrolled asthma receiving inhaled corticosteroids. N Engl J Med. 2010;362:975–985. doi:. doi:10.1056/NEJMoa1001278 [CrossRef]
- Chauhan BF, Chartrand C, Ni Chroinin M, Milan SJ, Ducharme FM. Addition of long-acting beta2-agonists to inhaled corticosteroids for chronic asthma in children. Cochrane Database Syst Rev. 2015;(11):CD007949. doi:10.1002/14651858.CD007949.pub2 [CrossRef].
- Usmani OS, Ito K, Maneechotesuwan K, et al. Glucocorticoid receptor nuclear translocation in airway cells after inhaled combination therapy. Am J Respir Crit Care Med. 2005;172:704–712. doi:. doi:10.1164/rccm.200408-1041OC [CrossRef]
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- Rabinovitch N, Mauger DT, Reisdorph N, et al. Predictors of asthma control and lung function responsiveness to step 3 therapy in children with uncontrolled asthma. J Allergy Clin Immunol. 2014;133:350–356. doi:. doi:10.1016/j.jaci.2013.07.039 [CrossRef]
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