Asthma has been on the rise, but so has the ability to control it with better medications, technology and patient education. Today, for properly guided patients with asthma, visits to the emergency room should be fewer than ever before. However, that is not the case-primarily because of a fervent lack of adherence.
Although asthma may be considered part of the "COPD umbrella" of respiratory diseases, patients often forget that it bears the distinction of being nearly always reversible and highly preventable. Additionally, it is a disorder that spares some people for significant periods of time, occasionally without any aggressive management or therapeutic adherence at all, leading patients to believe it will "disappear" if they wish hard enough. But therein lays asthma's real danger: Wishful thinking leads to neglect, which can be disastrous.
Some people have varying levels of asthma symptoms daily while others are completely normal until they are exposed to their specific physical and psychological triggers. Therefore, the absence of preventive measures in between episodes has become a marked concern in the big picture. The patient with chronic asthma who is unaware and/or uncooperative is just another asthma episode waiting to happen, usually under the worst of circumstances. To paraphrase the often-quoted Murphy's Law, asthma is likely to exacerbate at the most improbable moment where the least amount of help is available.
Steve Dolan, RRT, offers an interesting point of view on the causation and prevention of asthma episodes because, in addition to being a skilled, highly experienced respiratory therapist, he has asthma. According to Dolan, adherence is all about consistent control of triggers through avoidance, short- and long-term prescription medications and preventive self-care. He says, in many cases, the real problem is patients' lack of self-discipline when they're feeling good; this is when they're likely not to use their medications as prescribed while exposing themselves to known triggers. They get slap-happy, allowing the triggers like dust mites, seasonal cold, cockroach parts, pet dander, mold, air fresheners and allergic responses to cause inflammation and bronchoconstriction, necessitating emergency action far in excess of what would be needed under a regimen of proper adherence.
Some patients may take their medication but don't follow instructions, creating another kind of adherence problem. "Using an inhaler without a spacer substantially reduces effectiveness because a good portion of the medication is completely wasted," Dolan says. He feels that true adherence is not only getting the patient to act on their list of do's and don'ts, but to perform the do's with maximum efficiency. It is imperative to ensure that a dose is a true dose and not just the act of squeezing off a compromised shot of medicine, he says. "I tell my patients to always use a spacer and then show them exactly how it is done. The difference is huge."
Dolan's comments offer a good example of the role clinicians must play in educating and gaining the trust of asthma patients. In short, we can promote adherence by:
• Understanding the positive power of good patient-clinician relationships;
• Promoting an in-depth understanding of asthma, its treatment and prevention;
• Determining a patient's true attitude and perception of the disease and treatment; and
• Teaching patients to take a daily active part in asthma management.
These four principles are the keys for clinicians to treat and manage asthma, but our knowledge of them is not enough to solve the problem of patient adherence. It has been estimated that adherence could be grossly improved in more than two-thirds of chronic asthma cases, so we must be vigilant in continuously reminding patients of preventive measures and prophylactic care. The likelihood of increased long-term clinical success may be a matter of clinicians participating in prevention in the most aggressive manner that skill and time allows.
Daniel Fardella, RRT, PhD, has been a writer and filmmaker in addition to practicing as a respiratory therapist.