An average of 1 in 12 adults and 1 in 11 children in the United States are affected by asthma.1
That means that in the typical primary care setting, a provider who sees 30 to 40 patients per day could see two or three patients with asthma daily. Managing asthma in a busy primary care setting can be challenging. This article outlines guidelines to follow when treating a patient with asthma.
The primary goals of asthma management center on four actions: determining asthma triggers and instructing the patient to avoid them; educating patients about asthma to encourage adherence and establish a strong patient-provider relationship; prescribing appropriate medications; and routinely monitoring peak flow readings or spirometry results.2
Consider the 5-year-old boy who presents with increased asthma symptoms. He recently visited an urgent care clinic and was diagnosed with strep pharyngitis. The provider prescribed penicillin and his throat symptoms improved. However, in the past 10 days, he has needed to use his albuterol inhaler every 4 to 6 hours. His mother has noticed him coughing throughout the night.
The boy's past medical history is significant for elevated IgE levels with exposure to dog hair, dust mites, grass and weeds. He is taking montelukast (Singulair) 5 mg daily and cetirizine (Zyrtec) 10 mg daily. He uses an albuterol inhaler when ill. Typically, montelukast controls his asthma symptoms. He pretreats with albuterol 20 to 30 minutes before exercise.
Using the four management goals described, the primary care provider should take the following steps:
Triggers: The boy's primary asthma trigger appears to be infection, since he is otherwise controlled with montelukast and cetirizine. It would be important to recommend the influenza vaccine and/or the pneumococcal vaccine to help prevent infection.3,4 This is an important recommendation for all patients with asthma.
Education: Educate the parents that this child's asthma worsens with infections. Therefore, at the first sign of an infection, more preventive measures are necessary to decrease the risk of asthma exacerbation. For instance, the provider could recommend a nebulized treatment with albuterol three times daily or the albuterol inhaler with a spacer and a mask to be used three times daily at the first sign of infection.
Prescribe: Prescribe an inhaled corticosteroid twice daily at the first sign of infection and continue this medication for 10 to 30 days to decrease inflammation in the lungs while he is ill and recovering from illness. Reinforce that he should use albuterol more frequently during this time to dilate his airways.
Monitor: Instruct the parents to perform peak flow readings and/or develop an asthma action plan (http://tinyurl.com/AAAAIAsthmaActionPlan) in order to feel more comfortable about determining when it is necessary to seek further medical attention.
In 2007, the National Asthma Education Prevention Program (NAEPP) published updated guidelines for asthma.5 This expert panel introduced two concepts to the treatment of patients with asthma. The first concept focuses on increased control of asthma symptoms and the second focuses on decreasing risk.
In the same way that patients with diabetes or high blood pressure are seen regularly, patients with asthma should be seen at least every 1 to 6 months to assess asthma control and risk for reoccurring hospitalizations, emergency department visits or urgent care visits.
Increased control of asthma requires the provider to ask questions about how often the patient is using an albuterol inhaler. The guidelines state that the patient should not use an albuterol inhaler or short-acting beta agonist (SABA) more than two times in a day, more than twice a week, or more than twice a month during the night. If a patient is using albuterol more often, his or her asthma is not well controlled.
Other factors to explore are: Is the patient having increased symptoms of chest tightness, cough, wheezing, shortness of breath or nighttime awakenings? Is the patient able to exercise and play sports? Has the patient been missing school or work due to asthma symptoms?
When a patient's asthma is not well controlled, treatment with a step-up approach to daily controller medication is necessary. The patient should be seen again in a month to determine whether adequate control has been established with the higher dose. If the patient's asthma is well controlled, he or she may be able to be stepped down to a lower dose.
Patients should be on the lowest dose of asthma medication that is effective. With regard to risk in patients with asthma, it is important to minimize exacerbations, hospitalizations and emergency department and urgent care visits. Oral corticosteroids should not be prescribed more than once in a year.
Spirometry is essential to maintaining and preventing long-term loss of lung function. However, in a primary care setting, it may not be realistic. The office staff must know how to instruct patients to get the best results, and primary care providers need to feel comfortable interpreting results. Due to the volume of patients seen and the other conditions that primary care providers need to be knowledgeable about, it may be difficult to perform and interpret spirometry regularly for all asthma patients. When a concern about lung function exists, the patient should be referred to a specialist.
The next case example illustrates key recommendations from the NAEPP guidelines. A 23-year-old woman presents to her primary care provider with a third sinus infection in 6 months and another asthma exacerbation. She takes fexofenadine (Allegra) once daily, montelukast once at bedtime, fluticasone and salmeterol 250/50 mcg one puff twice daily.
At this visit, the primary care provider prescribes a third course of antibiotics and a third course of prednisone. The patient reports that she has been using her albuterol inhaler 2 puffs every 4 hours for the past 3 days and that she routinely needs albuterol four or five times weekly.
This patient has severe persistent asthma5 and is at a high risk for hospitalization. She fits the criteria for allergy or pulmonology referral. She recently had an IgE level drawn and it was 256 IU/mL (normal is less than 100 IU/mL), so she was referred to an allergist/immunologist.
The NAEPP guidelines provide recommendations about when to refer a patient to a specialist for consultation or for managing a patient in combination with a specialist.2,5 The following conditions warrant referral or coordinated management:
• The patient has experienced a life-threatening asthma exacerbation.
• The patient has required hospitalization or more than two bursts of oral corticosteroids in a year.
• The patient older than 5 requires step 4 care or higher, or a child younger than 5 requires step 3 care or higher.
• Asthma is not controlled after 3 to 6 months of active therapy and monitoring.
• The patient appears unresponsive to therapy.
• The diagnosis of asthma is uncertain.
• Other conditions are present that complicate management.
• Additional diagnostic tests are needed.
• The patient may be a candidate for allergen immunotherapy.
• The patient older than 5 requires step 3 care or higher or a child younger than 5 requires step 2 care or higher.
• Occupational triggers may exist.
• Psychosocial or psychiatric problems are interfering with asthma management and referral may be required.2,5
Meeting the Challenge
Managing asthma effectively in a primary care setting may be challenging. When a primary care provider finds that a patient's asthma is becoming harder to manage or a patient has had a severe episode of asthma, referral to a specialist is in the best interest of the patient and adheres to the NAEPP guidelines. Providers in primary care should feel confident in managing less severe forms of asthma.
1. Centers for Disease Control and Prevention. Asthma's Impact on the Nation Fact Sheet. http://www.cdc.gov/asthma/impacts_nation/AsthmaFactSheet.pdf
2. Fanta CH. An overview of asthma management. Up to Date. http://www.uptodate.com/contents/an-overview-of-asthma-management
3. Centers for Disease Control and Prevention. Flu and people with asthma. http.//www.cdc.gov/flu/asthma/index.htm
4. Centers for Disease Control and Prevention. Pneumococcal vaccination. http://www.cdc.gov/vaccines/vpd-vac/pneumo/
5. National Heart, Blood and Lung Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. www.nh/bi.nih.gov/guidelines/asthma/asthgdhpdf
Susan Symington is a physician assistant at Arizona Asthma and Allergy Institute in Glendale, Ariz. She has completed a disclosure statement and reports no relationships related to this article.