ASTHMA CLINICIANS WORK TOO HARD 2009 4.5 · • Asthma learning tools ASTHMA BOOKLETS. When I...
Transcript of ASTHMA CLINICIANS WORK TOO HARD 2009 4.5 · • Asthma learning tools ASTHMA BOOKLETS. When I...
Copyright©2009ThomasF.PlautM.D.Maybecopiedforpersonaluse.Contactjtplaut@pedipress.comforpermissiontopublish.
ASTHMACLINICIANSWORKTOOHARDThomasF.Plaut,MD
Mostasthmacliniciansworktoohard.Theycouldmakethisjobeasierbyenlistingpatientsastheircolleagues.Afterpracticingpediatricsfor20years,Ispent25yearsdevelopingmaterialsandmethodsforimprovingasthmacare.TheExpertPanelReport3(EPR‐3)1statesthatpatienteducationshouldoccuratallpointsofcareincludingclinicsettings,EmergencyDepartments,hospitals,pharmacies,schoolsandpatienthomes.Thousandsofprofessionalshaveusedmymethodsmaterialsinthesevenuestocareforasthmamoreefficientlyandeffectively.Mymajortechniquesincludetheuseof:
• Asthmabooklets• Peakflowmonitoring• Asthmadiaries• Asthmaactionplans• Asthmalearningtools
ASTHMABOOKLETS.WhenIpublishedOneMinuteAsthma:WhatYouNeedtoKnowin1991,Dr.AlbertSheffer,chairofthe1991NHLBIExpertPanelonAsthma,calledit“…accurate,clearandconcise…anidealguideforpatientsandparentsstartingtolearnaboutasthma.”Theeighthedition,publishedin2008,isthenation’smostcomprehensiveandcurrentasthmabooklet.
Clinicianscanreducetheirworkload,increasepatientsatisfactionandincreasetheirrevenuebyusingOneMinuteAsthma.In2001Iencouragedapediatricgrouptousethebookletintheexamroomandtoassignreadingbetweenvisits.Thishelpedtheirpatientslearnmoreeffectivelyandreducedthelengthofa15‐minutevisitbythreeminutes.Theycalculatedthatthiswouldenablethemtoincreasetheirpracticeincomeby$14,000eachyear.2AfterpatientslearnbasicinformationfromOneMinuteAsthmaaprofessionalcanprovideadditionalinformationthatisspecifictothemortheirchild.Forexample,whenyoudecidetoprescribeaninhaledsteroidduringanofficevisitthepatientdoesn’trealizethataninhaledsteroidisthemosteffectivemedicineusedtotreatasthma.Theymayhaveheardthatsteroidscaninterferewithachild’sgrowthinheightorcauseosteoporosis.Theydon’tknowthattakinganinhaledsteroiddailycausesonlyatinyfractionoftheproblemscausedbyoralsteroids.Theydonotknowthat,iftheydeclinetouseinhaledsteroids,theirchanceofneedingtreatmentwithanoralsteroidwillincreasegreatly.Apediatriciancanaskaparenttoreadonepageaboutinhaledsteroidsintheexamroomwhileheleavestoseeanotherpatient.Whenhereturnshewillhaveamucheasiertimediscussingthiscomplexsubject.Thesameistrueforothermedicinesanddevices.Thereisalotofdetailtobecoveredwhenexplainingtheuseofapeakflowmeter,aholdingchamber,adrypowderinhaleroracompressordrivennebulizer.EachofthesetopicsiscoveredinoneortwopagesofOneMinuteAsthma.
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Readinginthewaitingroomcanalsostreamlinevisits.IstudiedtheuseofOneMinuteAsthmainthewaitingroomofeightpractices.3Areceptionistgavethebooklettoeachnewasthmapatient.Alabelonthefrontcoverdirectedthemtoreadfourpagesdescribingasthmacontrol,asthmamedicinesandchangesintheairwayduringanepisode.Patientswhoreadthesepagesinthewaitingroomaskedbetterquestionsandhadamorefocusedvisitthancontrols.Thistacticincreasedofficeefficiencyyetcostnomoneyorstafftime.PEAKFLOWMONITORING.Thepeakflowscore4isanobjectivemeasureofairflow.Itisthefastestspeedatwhichthepatientcanblowairout.Peakflowcanbemeasuredwithasmallhandheldmeter.Itfrequentlydetectsadropinairflowbeforeadoctorcanhearawheezewithastethoscope,addingimportantobjectiveinformationtothehistoryandphysicalexam.Ihaveusedapeakflowmeterformorethan25yearstomonitorandtreatasthmaintheofficeandathome.Instructionsare:
• Movethepointertozero.• Standup,holdthemeterstraight.• Openyourmouthwideandslowlybreatheinasmuchairasyoucan.• PlacethemouthpieceFLATonyourtongue.• Closeyourlipssnuglyaroundit.• Blowoutashardasyoucan.• Movethemarkertozero.• Waitatleast15seconds.• Recordthebestofthreetries.
Youcanusepeakflowscorestoguidetreatmentwithnebulizedalbuterolinyouroffice.Thescorewillincreaseasthechildimproves.Thechangeisobvious.Astethoscopewillnotgivethesameclear‐cutinformationbecausewheezingmaydecreaseastheairwaysopenORastheyclose.Youshouldcheckpeakflowfiveminutesaftereachalbuteroltreatmenttoassessprogressand30minutesafterthefinaltreatmenttomakesurethattheimprovementissustained.Apeakflowscorewillbefalselyhighifpatientsblockairflowwiththeirlips,theirtongueortheirglottis.Whentheblockisremoved,airwillshootoutunderhighpressure.5The“spit”orthe“peashooter”techniquecanraisepeakflowby300pointsoverthescoreobtainedusingpropertechnique.Sixsubjectsblewpeakflowwitheachof10differentpeakflowmeterbrandsusingthespitandpeashootermaneuvers.Whentheyusedimpropertechniqueallincreasedtheirpeakflowscoresby100to300liters/min.inatleasteightoftenbrands(Plaut,TF.personalobservation).Whenapatient,whowaspreviouslyabletoblowanormalscore,blowsaverylowscoreorisunabletomovethemarker,shemayhaveaveryseriousproblem.Neverblamealowscoreonpoortechniqueoreffort.Youshouldbeabletocorrecthertechniqueonthenextblow.Ifthescoredoesn’tincrease,thepatient’sconditionmaybeworsethanyouthink.Youmaybedealingwithfatiguedrespiratorymuscles,alifethreateningemergency.
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Allofmypatientsagefiveandoverchecktheirpeakflowathome.Thepersonalbestscoreisthereferencepointformakingtreatmentdecisions.Itisthehighestscoreapatientcanblowwhen:
• theyarehavingnosignorsymptomofasthma,• havetakenamoderatedoseofaninhaledsteroidandotherneededmedicinesfortwo
months,and• theirscoreshavestayedattheirhighestlevelforaweek.
Patientscanusuallyestablishtheirpersonalbestwithinamonthoffulltreatmentwithaninhaledsteroid.BeforethattimeIusetheirhighestscoreorapredictedscorefromatableofaverages,whicheverishigher.Iadjustthepersonalbestscorewheneverthepatientblowsahigherscoreontwodifferentdays.Achild’spersonalbestincreaseswithgrowthinheight.TheinstructionsforestablishingthepersonalbestinEPR‐3andmanyotherpublicationsareflawed.EPR‐3identifiesthepersonalbestasthe“highestpeakflownumberyoucanachieveoveratwoweekperiodwhenyourasthmaisundergoodcontrol.Goodcontroliswhenyoufeelgoodanddonothaveanyasthmasymptoms.”6However,somepeoplecan’tnoticesymptomswhentheirairflowissignificantlyreduced.Fifteenpercentof82patientsinonestudywerenotabletosenseareductioninairflowunlessitwasgreaterthan50percentoftheirpredictedvalue.7Astudyoftreatedhospitalizedpatientsfoundthattheywerenotabletofeelsymptomswhentheirpulmonaryfunctionwas50percentofpredicted.8Anasthmaactionplanbasedonafalselylowpersonalbestmayleadtotardyorinadequatetreatment.ASTHMADIARIES.Anasthmapeakflowdiary(seeFig.4)givestheclinicianandthepatientorparentagoodunderstandingofrecenthistory.Youcanscanatwo‐weekrecordinabouttwominutes.Mypatientsoftenbringindiariesspanningseveralmonths.TheinformationrecordedinthePedipressAsthmaPeakFlowDiaryismoreaccurateanddetailedthanapatientcanrecallorthancanberecordedinanyotherdiary.Iftheypayattentiontothesedetails,clinicianscanprovidebettercare.Parentsandpatientsusethediarytolearnaboutasthmaandtoguidetheirtreatmentathome.AcombinationoffivedesignfeaturesisuniquetothecurrentPedipressAsthmaPeakFlowDiary.9
• Thegraphicformatdisplaystrendsbasedonthepersonalbest.Thisiseasiertoanalyzethanaseriesofnumbers.
• Twoyellowzonesidentifymildandmoderateepisodes• Thereisamplespacetorecordsigns• Relationshipsamongtriggers,medicines,peakflowandsignsareeasytosee.• Coloredzoneshighlightthechangefromonetreatmentzonetoanother.
Thefourzonesnotedonthediaryare:
• Greenzone,80‐100percentofthepersonalbest.Thisindicatesthatcurrenttreatmentisadequate.
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• Highyellowzone,65‐80percentofthepersonalbest.Thisindicatesamildepisode• Lowyellowzone,50‐65percentofthepersonalbest.Thisindicatesamoderateepisode.• Redzone–lessthan50%ofthepersonalbest.Thisindicatestheneedforemergency
treatment.
Figure 1. The Asthma Peak Flow Diary
ThesampleAsthmaPeakFlowDiarydisplayedaboveandinOneMinuteAsthma10showsapatientwhohasapersonalbestpeakflowof650.Thetopofhishighyellowzoneis520.Thetopofhislowyellowzoneis420andthetopofhisredzoneis325.Peakflowscoresbeforebronchodilatorarerecordedwitha0.ThescoresafteralbuterolaremarkedwithanX.Whenyouconnectthe0sortheXsyoucanseeatrend.Thenameanddoseofeachmedicineareenteredintheleftcolumn.Acheckmarkindicatesthatadosehasbeengiven.Thescoresoftheasthmasignsshouldbeconsistentwiththepeakflowscore.Ifnot,youneedtodeterminethereason.Mypatientsrecordtheirpeakflow,signs,medicines,triggersandnotableevents(suchasanupperrespiratoryinfection,exposuretotobaccosmokeoratriptothezoo)eachmorninguntiltheyhavebeeninthegreenzonefortwomonths.Theycontinuerecordingdailyifthediary
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helpsthemmanagetheirasthmaorbecauseitremindsthemtotaketheirmedicinesoridentifytriggers,otherwisetheystop.Theyrestartrecordingwhentheyhaveanysignorsymptomofasthma,atthefirstsignofacold,whentheyenterathreateningarea,goonvacationandfortheweekbeforetheyseeme.Theyusuallyrecorddataintheirdiariesabout30dayseachyear.FifteenyearsagoIwasinvitedtospeakabouttheuseofpeakflowandasthmadiariestotheallergystaffatamajorteachinghospital.MostphysiciansintheroomknewmoreaboutasthmathanIdid.Oneallergistaskedmehowmanyofmypatientskeepadiary.“Allofthem,”Ianswered.“Howdoyoumakethemkeepadiary?”heasked.ItoldhimthatIcouldn’tmakemypatientsdoanything.Theyuseadiarybecausetheyfindithelpsthemincreasetheirunderstandingofasthma.Coupledwithanasthmaactionplan,thediaryenablesthemtotreatmostepisodesathome.Manydoctorssaythattheirpatientswon’tkeepadiary.Isitpossiblethatthesedoctors:
• failtopointoutthebenefitsofusingadiary,• failtolookatthediarysheetthatthepatientbringsin,• failtousethedatainthediarytoincreasethepatient’sunderstandingor• failtorelatethedatainthediarytoanactionplan?
Adiaryisanextremelyhelpfultoolasphysicianspartnerwithpatientsintheircare.The1997NHLBIGuidelinesfortheDiagnosisandManagementofAsthmadisplayedasinglediary.11Thatdiarywasfirstpublishedinmybook,ChildrenwithAsthma:AManualforParents.12ThecurrentEPR‐313notesthat“Patientsdetailedrecallofsymptomsdecreasesovertime,thereforetheclinicianmaychoosetoassessovera2‐week,3‐week,or4‐weekrecallperiod.”EPR‐3mentionsadiaryonsixseparatepagesbutdoesn’tdisplayoneormentionthatpatientswhokeepadiaryhavefarbetterrecallthanthosewhodon’t.PedipressdiarieshavebeentranslatedintoSpanish,depictedinseveralarticles14,15,16,17,18,19andbooks20,21,22andpurchasedforusebythousandsofprofessionals.ASTHMASIGNSDIARY.Patientslessthanfiveyearsofagecan’tblowaconsistentpeakflow.IdevelopedtheAsthmaSignsDiary(seeFig2)tohelpparentsofyoungchildrenlearnaboutasthmaandmanageepisodesathome.Signsaremoreaccurateandreliablemarkersthansymptoms.Theyareobjectiveandcanbescoredbyanobserverusingaprecisescale.InconstructingtheAsthmaSignsDiary,Ichosesignsthatarecommon,appearearly,changewiththeworseningorimprovementofanepisodeandareeasytoscore.Theyarecough,wheeze,suckinginthechestskinandincreaseinbreathingrate.PleaseseethescoringsystemontherightsideoftheAsthmaSignsDiary.23Atotalsignsscorebetween1and4fallsintheHighYellowZone(mildepisode);atotalbetween5and8isintheLowYellowZone(moderateepisode)and9oroverisintheRedZone(severeepisode).EPR‐3notes“Itisoftendifficultforphysiciansandparentstoassesstheseverityofanasthmaepisodeinaninfantorayoungchild.”24Thisstatementistrueifthesephysiciansandparents
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don’tknowhowtoscorethefoursignsofasthma.Oncetheylearn,theycaneasilyassesstheseverityofanepisode.Toprovethis,trytoscoreayoungchildwhois:coughingtwiceaminute,wheezingthroughoutexhale,suckinginthechestskinslightlyandhasaslightincreaseinbreathingrate.Itisnotdifficulttocalculatethatthetotalscoreisseven,whichplaceshiminthelowyellowzone.
Figure2.TheAsthmaSignsDiary
.Parentsneedtoknowhowtoassesstheirinfantoryoungchildinordertostarttreatmentearly.Theyneedguidancefromtheirdoctorastheylearn.Thisknowledgeisparticularlyimportantbecauseinfantsandyoungchildren:
• don’tcomplain,• can’tdescribetheirsymptomsand• getintotroublemorequicklybecausetheyhavesmallairways.• arenotoldenoughtouseapeakflowmeter.
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ASTHMAACTIONPLANS.Agoodasthmaactionplan25(Seefigures3and4)willtellpatientsandparentswhattodoineveryasthmasituation.Whento:
• reduceactivity,• changemedicinedose,• addamedicine,• callthedoctorand• gototheER.
Theplanshouldbeclearenoughsothatpatientsandparentswillrarelyneedtocallforadvicebetweenvisits.Itcanbebasedonpeakflowscoresorthefoursignsofasthma.26Eachplancallsforearlyactionateachlevelofanepisode’sseverity.Youcandownloadandcustomizetheseplansfromwww.pedipress.comforuseinyouroffice.
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Figure3.ThePeakFlowAsthmaActionPlan
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Figure4.TheSignsAsthmaActionPlan
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Abasicasthmaactionplanforpersistentasthma27mayincludethefollowing:
• Greenzone(maintenance):Takeaninhaledsteroidorothercontrollerdaily.Takealbuterolbeforestrenuousexerciseorwhenincontactwithatrigger.
• Highyellowzone:Avoidtriggers,givealbuterolonetofivetimesadayasneeded,startaninhaledsteroidorquadruplethecurrentdose.
• Lowyellowzone:Continuehighyellowzonemedicines.Givefourpuffsofalbuteroltoseeifpeakfloworsignswillenterthehighyellowzoneandstaythereforfourhours.Ifnotthepatientisstuckandneedstostartprednisone.
• Redzone:Ifpatientisstuckinredzoneafterfourpuffsofalbuterol,giveadoseofprednisoneandgotoER.
Ifsignsorsymptomsoccurwhenpeakflowisingreenzone,eitherthepersonalbesthasbeensettooloworthesmallairwaysareinflamed.Thelatterdoesnotreducepeakflow.Ineithercasetheparentshouldfollowthehighyellowzoneplan.Thepersonalbestshouldtheneitherbeconfirmedorrecalculated.ASTHMALEARNINGTOOL(ALT)Idesignedthistooltohelpalliedhealthprofessionalslearnbasicfactsaboutasthma.TheALTisfree,effectiveandtakes30to90minutes.Morethan200nurses,studentnurses,schoolnurses,pharmacistsandrespiratorytherapistshavedownloadedtheALTfromwww.pedipress.comorreceivedahardcopyfromacolleagueoraninstructor.Theyanswered40questionsandthenlookeduptheanswersinOneMinuteAsthma.Themediantimeforansweringthequestionswas30minutesandforlookinguptheanswerswas20minutes.Ninety‐eightpercentsaiditwasworththetimetheyspent.Almostallnamedatleastonethingtheylearnedthatwouldhelpthemteachotherstocareforasthma.PracticesthataskstafftousethewordsandconceptsintheALTandOneMinuteAsthmaimprovecommunicationamongstaffandwiththeirpatients.Useofseveraltermswiththesamemeaningoftencausesconfusion.Forexample,thereareatleasteighttermsforalbuterol:quickrelief,reliever,rescue,fastactingbeta‐agonist,quickactingbetaagonist,shortactingbetaagonist,ProventilandVentolin.Patientswhohearmorethanonetermforalbuterolmaythinkthattheyaredifferentmedicines.Theymaythinkthatoneclinicianischangingthemedicinethatanotherprescribed.SUMMARYHealthprofessionalscanusefivesimpletoolstoimprovetheefficiencyandeffectivenessoftheirasthmacare.
• Askpatientsandparentstoreadapageortwofromanaccurateandcurrentasthmabookintheexamroom,thewaitingroomandbetweenvisits.
• Teachpatientsandparentshowtouseapeakflowmetertolearnaboutandmonitorasthma.
• Teachpatientsandparentshowtouseacomprehensiveasthmadiary.
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• Usefour‐zoneasthmaplansbasedonpeakfloworasthmasignsscorestoguidetreatmentintheofficeandathome.
• EmploythefreeAsthmaLearningTooltoincreasestaffknowledgeandimprovecommunicationintheirpractice.
Professionalswhousethesetoolsareabletoprovidemoreeffectivecare,increasepatientsatisfactionandboostpracticerevenue.Endnotes 1 EPR‐3:ExpertPanelReport3:GuidelinesfortheDiagnosisandManagementofAsthma.2007,NIHPublicationNumber08‐
5846.Availableat:http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.AccessedJuly27,2009. 2Plaut,TF,Hartman,L.Asthmadistancelearningprogramforstaffincreasespracticeeffectivenessandrevenue.Annalsof
AsthmaAllergyandImmunology.2003.Vol.92,Jan.2004,No.1,pages109‐110
3Plaut,TF.AsthmaEducationintheWaitingRoom.AnnalsofAsthmaAllergyandImmunology.Vol.90,No.1,Jan.2003,page
141
4Ibid.28‐31.
5StrayhornV,Leeper,K,TolleyE,SelfT.ElevationofPeakExpiratoryFlowbya“Spitting”Maneuver.CHEST.1998:1134‐46.
6NationalInstituteofHealthPublication.EPR‐3:ExpertPanelReport3:GuidelinesfortheDiagnosisandManagementof
Asthma.2007:122.Availableat:http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.AccessedJuly2,2009.
7PerceptionofAsthma.Rubinfield,AR.Pain,MC,Lancet.1976Apr24;1(7965):882‐4.
8Acutebronchialasthma.Relationsbetweenclinicalandphysiologicmanifestations.McFaddenERJr,KiserR,DeGrootWJ.N
EnglJMed.1973Feb1;288(5):221‐5.
9Plaut,TF.OneMinuteAsthma:WhatYouNeedtoKnow.Amherst,MA.Pedipress;2008:32.
10Ibid.34.
11EPR‐2:ExpertPanelReport2:GuidelinesfortheDiagnosisandManagementofAsthma.1997.NIHPublicationNo.97‐4051.
p37.
12Plaut,TF.ChildrenwithAsthma:AManualforParents.Amherst,MA.Pedipress,1985.
13EPR‐3:ExpertPanelReport3:GuidelinesfortheDiagnosisandManagementofAsthma.2007,NIHPublicationNumber08‐
5846.Availableat:http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.AccessedJuly27,2009.
14PlautTF.Thepeakflowdiary:Apowerfultoolforasthmamanagement,ContemporaryPediatrics,1993;10:61.
15Plaut,TF.ThePeakFlowDiary,AmericanJournalofAsthma&AllergyforPediatricians,1994;7:37‐39.
16Plaut,TF.AsthmaPeakFlowDiaryImprovesCare”(letter)AnnalsofAllergy,Asthma,&Immunology,1996;76:476‐8.
17Plaut,TF.ThePeakFlowDiary,AmericanJournalofAsthma&AllergyforPediatricians,1994;7:37‐39.
18Plaut,TF.ManagingAsthmaCare,AmericanJournalofManagedCare,1997;3:485‐490.
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19Plaut,TF.ASystemsApproachtoAsthmaCare,withHowellT,WalshS,PastorM,JonesT,ManagedCareQuarterly,1996;
4:6‐18.
20BiermanWC,PearlmanDS,ShapiroGG,BusseWW.Allergy,Asthma,andImmunologyfromInfancytoAdulthood.
Philadelphia,PA.WBSaunders;1996:277.
21Berkowitz,CarolD.Pediatrics:APrimaryCareApproach.Philadelphia,PA.WBSaunders;2000:270
22 Govias,G,MitchellI.AsthmaEducation:PrinciplesandPractices.Edmonton,Alberta.TheAsthmaEducationClinic;
2005:245.
23Plaut,TF.OneMinuteAsthma:WhatYouNeedtoKnow.Amherst,MA.Pedipress,Inc;2008:42.
24NationalInstituteofHealthPublication.EPR‐3:ExpertPanelReport3:GuidelinesfortheDiagnosisandManagementof
Asthma.2007:392.Availableat:http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.AccessedJuly2,2009.
25Plaut,TF.OneMinuteAsthma:WhatYouNeedtoKnow.Amherst,MA.Pedipress,Inc;2008:30.
26ibid.42
27ibid.40