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Using Your Inhaler

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The Official Publication of AAN - MA

Focus on Allergies & Asthma

By Thomas J. Kallstrom

Are you in compliance? As a patient, that’s your biggest job. Stick to the health care regimen offered to you by your respiratory therapist and other health care providers.

Asthma patients may have a lot to remember – take your medicines, do it right, remember your triggers, use your devises correctly. But for those who comply with a plan of care set out by their health care providers, good control of your asthma is the result.

Respiratory therapists work hard to increase compliance among their patients and this article in their professional magazine, AARC Times, talked about their role with helping you help yourself manage your asthma care plan.

Improving compliance or adherence in the self-management of asthma, which is in line with the wisdom imparted by the National Heart, Lung, and Blood Institute’s (NHLBI) Expert Panel Report II (EPR-II), is a daunting task. It is an issue that we all struggle with as we work to establish best practice. The success or failure of an asthma management program is centered in large part on the patient.

As we prepare for the Expert Panel Report III to be released sometime in the near future (hopefully by the end of 2006 or early next year), it is important that we pull together plans to allow patients and clinicians to be in a better position to embrace the revision. In anticipation of this, the NHLBI has created an implementation committee composed of representatives from all branches of medical care that tend to asthma patients. Its charge is to put in place a plan that will allow the end user to implement the updated document.

Respiratory care is represented on this NHLBI committee. It is through this interaction that our concerns and initiatives can be discussed and integrated into the final product. When EPR-II was released in 1997, despite our best intentions, many clinicians were not quick to read or adopt the guidelines and, in some cases, were resistant. This committee hopes to circumvent this for the next go around.

Improving compliance
Even beyond that, the issue of compliance is an important one that cannot be overestimated. As respiratory therapists, we encounter compliance failures on a daily basis. In some cases, a patient who presents to the emergency department or is admitted to the hospital may be considered a compliance failure. The interaction in the hospital affords an opportunity for the respiratory therapist to discover the underlying barriers that the patient may be faced with and to evaluate, educate, and reeducate as well. I have often asked my patients to demonstrate their technique for using a metered-dose inhaler (MDI), only to see a procedure that is far from valid. We all can relate to the experience of the patient who, when asked to demonstrate technique, proudly produces a cloud of aerosol after actuating the MDI several times in succession. This experience allows us the opportunity to intercede and make a difference.

As we seek to promote better ways to improve compliance, it is important that we first get our patients’ buy in and earn their trust. Conventional wisdom from the EPR-II tells us that the best way to do this is to get the patient to provide some type of a verbal or written agreement stating that they agree with their particular plan of action. Clinicians should then follow up and reinforce the plan in subsequent interactions with the patient. Also, it is very important that the patient’s medication be easily integrated into the patient’s current daily routine. If medications are taken at different times, or if multiple devices are used, the patient will need to possess a high level of proficiency, which may cause adherence difficulties.

Knowing the patient
It makes sense that long-term controllers be administered, if possible, with the same device and at the same time each day. It is through this scheduled repetition that the patient can make the drug regimen a daily routine. In the past, many of our patients were told to engrain this routine into daily activities — and so patients were instructed to use the inhaler before they brushed their teeth. That usually meant that the patient would store his respiratory medications, which sometimes included a dry-powder inhaler (DPI), in the bathroom cabinet. This is no longer a wise idea because the bathroom has the potential for producing a humid environment that could cause the dry powder to be less effective. So while it is a good idea to have long-term medication administration included in a daily activity, it should be stipulated that it take place outside the bathroom or other humid environments.

Ultimately, every patient will be different, so it is important to get as much background information about the patient’s activities of daily living before making a recommendation. Other options include enlisting family involvement in the asthma care plan. A caring parent or spouse can make a huge difference by making sure that there is a higher level of adherence. Families have the power to assure that their family members receive optimal care.

Involving the patient in the process
Goal setting is another key that brings the patient into the process. Attainable goals should be agreed upon before any plan of action is formulated. If a patient does not see improvement in his condition, it may be an uphill struggle in getting the patient to continue his plan of action. If there is a history of chronically missed school days, work, or perhaps an activity that the patient wishes to participate in but cannot due to poor control, this may afford an opportunity to set reasonable and attainable goals. It may be as simple as deciding that the patient should miss half the amount of school that he did the previous year, or participate in a sporting activity that previously was unattainable due to poor control of asthma. Once these goals are met, it may be easier to move on to a higher level.

Asthma control is not out of reach, but it does take effort by both the patient and clinician. As respiratory therapists, we are in a position of authority that allows us to evaluate, critique, and educate our patients. Ultimately, it is the self-management of asthma that will determine how successful our patients will be. As patient advocates, respiratory therapists can make a huge difference.

Thomas J. Kallstrom is associate executive director and chief operating officer of the AARC. He is also a member of the NAEPP Coordinating Committee and is a certified asthma educator.

Additional Reading
National Asthma Education & Prevention Program. (1997). Expert panel report II. Guidelines for the diagnosis and management of asthma. Bethesda, MD: U.S. Department of Health and Human Services.

 

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