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Asthma Management: Literature Review

Introduction

            Asthma is a common chronic inflammatory disease that impact potential burden to the patients, care providers, families and by extension the community. This infection affects an estimated 300 million patients in the world posing a great health concern globally as it affects all age groups from children to adults. Worldwide death as a result of asthmatic infection is estimated to be about 250,000 annually (Beasley, 2011). Based on its prevalence in the world scale, asthma is connected to great loss with regard to cost of management and potential work output missing from the patients and care providers. In a wider view, asthma is heavily, putting the world economy at a burden. Asthma is characterized by such symptoms as; wheezing, cough, shortness of breath, chest tightness and variable expiratory airflow limitations among other symptoms. These symptoms are normally triggered by the presence of environmental stimuli like cold and allergen or irritant exposure. Asthma management is concerned with the long term goals of risk reduction symptoms control with the aim of potentially reducing the burden to both the patients and the medication side effects (Beasley, 2011). For effective management of asthma, better management and control guidelines, including population level asthma check, effective patient treatment, a partnership that increases, the relation bond between the patient and health care providers, patient increased knowledge about coping and management as a result of good communication skills from the health care providers purposely to increase health literacy (Asher et al., 2014). In this paper, summaries of peer reviewed publication about asthma management are addressed. Emphasis is given to prevalence, diagnosis, asthma management in adults and children, inhaler devices and techniques, high risk factors leading to contraction of asthma and barriers to effective management and control of asthma. With regard to potential further research, this paper also addresses the recommended interventions to improve the status of health in relation to disease prevention and harm reduction and health literacy to increase the disease awareness.

            Prevalence and burden of Asthma worldwide

            Asthma prevalence worldwide is reported to have reached the highest mark of about 334 million in 2011 following a study undertaken between the year 2008 to2010 (Beasley, 2011). As compared to the prevalence of 235 million in 2003 reported by another study between the year 2000 to 2002, it is obvious that the number of people keeps on increasing with time posing a great health risk to the world by saying, the year 2030. Well, it is difficult to pinpoint evidence claiming that between the year 2003 to 2013, the number of asthma, infection worldwide increased from 235 million to 334 million (Woolcock and Peat, 2013). However, from this report a call for more research to enable reduction or stop further increase in the number of asthma infection. In another study on the global burden of asthma, 14% of the world’s children and 8.6% of adults are reported to have asthma symptoms while 4.5% of adults have been diagnosed with asthma infection (Asher et al., 2014). From the results, it is evidence that the global asthma burden is greater in children than adults. Asthma is becoming more and more popular making the impact of its infection related disability and premature death to increase tremendously especially in children.

            Asthma Diagnosis

            According to Asher et al., (2014), the percentage prevalence of asthma infection is reportedly higher when data is based on the occurrence of asthmatic symptoms and relatively lower when actual diagnosis is made to confirm the presence of infection. This means that the only surest test that can confirm asthma infection rely on the diagnostic test. Similarly, Pauwels et al., (2012), also reported that for an effective confirmation of asthma, identification should be inclined on characteristic pattern of the symptoms since the occurrence of the symptom may as well be as a result of other acute and chronic conditions other than asthma. The patterns that can confirm asthma with utmost confidentiality includes more than one symptom comprising of wheezing, cough, chest tightness and shortness of breath. These symptoms become worse or excessively felt during cold nights and very early morning and vary in intensity over time. Viral infection, physical activity that involves heavy energy consumption, exposure to allergen, irritation such as strong scented smell and smoke can trigger the symptoms. However, the occurrence of isolated cough with no other respiratory symptom, production of sputum, paresthesia, dizziness, shortness of breath, chest pain and exercise related dyspnea with wheezing inspiration do not confidently tell the likelihood of asthma infection (Pauwels et al., 2012).

            After close and careful examination of the pattern of the symptoms in relation to individual and family history as well as the physical examination, testing of lung function to assess possible airflow limitation. Even during testing, more historical assessment still needs to be carried out since a well-controlled asthma and a poorly controlled asthma have a big difference in the variability of lung function. Further research in diagnosis is still a requirement, especially when it comes special population such as occupational asthmatic individuals, patients with only one respiratory symptom, especially cough, asthmatic pregnant women to give more useful information for both the mother and the child. In as much as the pattern of physical signs are key in asthma diagnosis, latent manifestation of these signs is common for some infected individuals, consequently, the absence of physical symptoms does not completely exclude the confirmation of asthma infection (Bousquet, 2000).  According to Bousquet (2000), the surest test for asthma confirmation is spirometry.

            Managing asthma in adults

            Management of asthma refers to the degree to which the manifestations of asthma symptoms are controlled to maintain the state of normal activity.  Management’s goal of asthma control is a necessity towards risk and burden reduction through effective and efficient systems of symptom control. These goals are achieved by an organized partnership between the care providers or family members and the hospital health professional team. Both in children and adults, management of asthma follow a cycle that continuously assesses, adjusts treatment and review the resulting treatment response (Stanojevic et al., 2012). This is achieved through a combined effort of education to improve the asthma awareness, skillful training for effective response to the call of action, close monitoring of one’s behavior in line to the manifestation of significant intensity and having an asthma action plan. In adults, management is relatively easier following the ease in education and reduced level of active engagement in physical activities as well as ease in management of environmental trigger. The initial treatment for adult asthma management involve either continuous inhalation of short acting agonist or using an inhaler for effective bronchodilation, the addition of the substance in aerosolized solution, especially in adults with severe obstruction of airflow or systemic injection of corticosteroids for rapid response. Depending an availability and level of need, oxygen supply can also be considered as a supplement. After this treatment, repeated clinical assessment is carried out to suggest further actions based on the response. For a good and timely response, the patient can be discharged, but treatment through inhalation process continues. When the response is delayed or examination is incomplete within the required timeline, the patient is then admitted back to the hospital. On the other hand, poor response within the expected time line should facilitate the patient being admitted to the intensive care unit.  In the assessment of response, good, delayed or incomplete and poor response is based on physical examination, Peak Expiratory Flow (PEF) level, distress level and oxygen saturation. A good response is characterized by normal physical examination with PEF above 70%, above 90% oxygen concentration and no distress by the end of the first hour after last treatment. When the physical examination report mild to moderate symptoms with a PEF ranging between 50% – 70% characterized with little or no improvement in oxygen concentration within the first two hours after last treatment then the state is described as incomplete response. Lastly, poor response is a state characterized by severe manifestations of signs, confusion, PEF less than 30% as well as less than 90% oxygen concentration.

            Managing asthma in children

            The goal of asthma management in children is to achieve better asthma control of symptoms and effective maintenance of normal life activities. This is to make the infected children to have a sense of belonging and to equally feel optimistic about future life like their uninfected counterparts. Managing asthma in children require close attention and monitoring than the adults because children, especially the young ones will not understand the situation and the predisposing factors like exercise (Asher et al., 1995). In addition, children are always very active and enjoy engaging themselves in active exercise like the others. Complete elimination of the physical activities in their lives has been highly discouraged since by engaging in such activities the children end up developing socially and actively and this is a key requirement in development stage. These daily exercises on the other hand will worsen their situation by an increased expression of symptom intensity. Therefore, unlike adults, children require an ever present care provider whose work is reduced to that of monitoring, evaluating and applying the corrective actions immediately need arises. The challenges commonly faced by the practitioners in managing asthma in children normally arise from diagnosis difficulties, efficacy and drug safety and delivery gaining good normal and physical development necessary for their growth. Asthma is similar in both children and adults, however, the distinctive features include; intensity of the symptoms, interfere with normal activity and response to treatment among other features. In children, asthma is said to be well managed when symptoms intensity is less or equal to two per week, not well controlled for signs per week greater than two and very poorly controlled when the signs appear throughout. Even in children, despite their active engagement in physical activities, a well-controlled asthma will not in any way hinder their activities. However, poor asthma control is associated with extreme limitation in the activity of the infected child.

            Educational awareness for self-management of asthma

            According to Guevara (2003), effect of educational interventions is meant to increase the health literacy of the patients with regard to self-management of the vise. In their research, a controlled clinical trial of educational program was evaluated for possible effect on self-management of asthma in children and adolescents. Assessment was done based on the methodological quality and effect on ability to try seek for a solution when the need arises. The patients were trained on safety measures for self-asthma management, then unknowingly subjected to sign trigger somewhere and monitored on how fast they will respond to try getting the required help. The control group was also subjected to the same trigger purposely to determine the difference in trigger related behavior. Out of 45 trials made, 32 trials were eligible and clearly showed that lung function improved in the treatment group as compared to control group. The resulting effect of this is increased self-efficacy and reduced school absenteeism as well as a reduced number of emergency visits to hospitals. Therefore, education programs on self-management can effectively be used to reduce over reliance on care providers making them engage in other economic activities. Through risk reduction, health literacy can also result in reduced number of deaths as a result of emergency related asthma needs when the program is effectively reached by the majority of patients. Another study by Bousquet (2000), also reported the effect of education access on the number of visits to the hospital. According to Bousquet (2000), re-attendance to the hospital depends greatly on whether or not the patients accessed education on inhaler technique, PEEF record keeping, information and support to maximize adherence to PEEF symptom based action plan prior to initial hospital discharge and information about avoiding triggers. These education measures were related to a reduction in morbidity and relapse rates and thus the patients who adjusted their therapy within the recommendations had a relatively lower rate of readmission to hospitaze due to asthma related causes.  Similarly, Tapp et al., (2007), found out that the use of education and behavioral measures in the management of chronic asthma are beneficial to reduced emergency presentation. However, according to Tapp et al., (2007), the estimated education related reduction in risk of re-presentation at the emergency department in the hospital was not confident due to very low statistical significance between the treatment groups (following education intervention measures) and control group who were not subjected to the measures. The asthma education group and control group had no significant differences in terms of peak flow, study withdrawal, quality of life, days lost and withdrawals. Therefore, in as much as educational interventions supports effective management and control of asthma, the impact of education in this context especially on large scale application is unclear. Consequently, there is a call of more research to prioritize on the assessment of health related life qualities, asthma morbidity in relation to social and economic status with regard to access of education.

            High risk factors associated with severe asthma outcomes

            For children, adolescent and adults patients exposure to high risk factor may worsen their asthmatic status. The effects of exposure include; increased risk of flare-ups, asthma related life threats, accelerated decline in lung function and treatment related adverse events (Gelber et al., 1993). Flare-up is associated with poor lung function, peripheral blood eosinophilia suggesting air way inflammation and difficulties or airflow limitation. Exposure to cigarette smoke either through smoking or environmental exposure increases occurrence of flare-up resulting in poor asthma control (Gelber et al., 1993).  If the situation is not checked in time, it can lead to mental illness and major psychological problems. Life threats related to asthma causes may be as a result of continuous exposure to sensitive and potentially unavoidable allergen, inadequate treatment, and lack of the asthma action plan, socioeconomic disadvantages, solitude, mental illness, poor access to health care (patients in remote regions) and use of alcohol. For example, an asthmatic woman married to a smoking husband is predisposed to unavoidable life threatening trigger every night. The smoking environment turns the woman into a passive smoker and in turn triggers the manifestation of signs. Similarly, an asthmatic individual living alone risks losing his life as a result of high chances of the lack of supportive emergency care from the providers or relatives. Treatment related risks such as long term control dose and frequent usage of drugs often result into anxiety disorders. In a case of well controlled asthma, a patient may be reluctant to reduce the dose and as a result expose himself to adverse effect. In the same line, frequent users of asthma drugs ends up developing euphoria (Call et al., 1992).

            Action Item Checklist

SUBJECT: Literature Review and project preparation
Item No Who Due Date Item Description and action
1 Student. November 5 2016 Supervisors’ meeting Present to the supervisor a summary of background and rationale of proposed research

Hold a discussion with the supervisor concerning the research and problem statement

2 Student. November 20 2016  Supervisors’ meeting Complete drafting the introduction part of the proposed research
SUBJECT: Biosafety Training and Methodology
3 Student January 4-30, 2017  Attend a Biosafety training for effective and efficient handling of asthmatic patients
4 Student and supervisors Feb 14-April 30 2017     Provide key elements to study design

Describe the advantages and disadvantages leading to choice of participants for the cohort study, case-control study and cross-sectional study

Describe the inclusion and exclusion selection criteria for participant’s selection

Describe follow up activity

Clearly define the measurable outcomes and variable input factors to the study participants

Seek research ethical approval from a recognized research and ethical body

5 Student May 3 2017 Defend the project proposal at the faculty level
SUBJECT: Data collection
6 Student, clinical staffs and supervisor June 1- Aug 30 2017 Participants orientation and role explanation

Consented agreement signing

A research study data collection based on the parameters and variables

Describe the approaches that can be used to overcome any occurrence of a potential bias like prior participant knowledge permitting them to behave out of their way

Explain how the study is conducted clearly showing how the participants are handled

For all the study variables explain data source and methods of assessing the data

SUBJECT: Data analysis and Results presentation
7 Student, and supervisor Sep 1- Oct 30 2017 Describe all statistical methods applied to both treatment and control group data and explain how statistical significance is arrived at

Explain the meaning of statistical significance achieved with regard to the study objectives

By describing the study participants and the data results give inference of the study to the general population for generalizability

Relate the limitation with potential bias

 

References

Beasley R, (2011). Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC. The Lancet, 351(9111), 1225-1232.

Asher, M. I., Keil, U., Anderson, H. R., Beasley, R., Crane, J., Martinez, F., … & Stewart, A. W. (1995). International Study of Asthma and Allergies in Childhood (ISAAC): rationale and methods. European respiratory journal, 8(3), 483-491.

Bousquet, J. (2000). Global initiative for asthma (GINA) and its objectives. Clinical and Experimental Allergy, 30(6; SUPP/1), 2-5.

Asher, I., & Pearce, N. (2014). Global burden of asthma among children. The International Journal of Tuberculosis and Lung Disease, 18(11), 1269-1278.

Stanojevic, S., Moores, G., Gershon, A. S., Bateman, E. D., Cruz, A. A., & Boulet, L. P. (2012). Global asthma prevalence in adults: findings from the cross-sectional world health survey. BMC public health, 12(1), 1.

Pauwels, R. A., Buist, A. S., Calverley, P. M., Jenkins, C. R., & Hurd, S. S. (2012). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine.

Guevara, J. P., Wolf, F. M., Grum, C. M., & Clark, N. M. (2003). Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. Bmj, 326(7402), 1308-1309.

Woolcock, A. J., & Peat, J. K. (2013, January). Evidence for the increase in asthma worldwide. In Ciba Foundation Symposium 206-The Rising Trends in Asthma (pp. 122-139). John Wiley & Sons, Ltd..

Tapp, S., Lasserson, T. J., & Rowe, B. H. (2007). Education interventions for adults who attend the emergency room for acute asthma. The Cochrane Library.

Gelber, L. E., Seltzer, L. H., Bouzoukis, J. K., Pollart, S. M., Chapman, M. D., & Platts-Mills, T. A. (1993). Sensitization and exposure to indoor allergens as risk factors for asthma among patients presenting to hospital. American Review of Respiratory Disease, 147(3), 573-578.

Call, R. S., Smith, T. F., Morris, E., Chapman, M. D., & Platts-Mills, T. A. (1992). Risk factors for asthma in inner city children. The Journal of pediatrics, 121(6), 862-866.

 

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