1. Quick Fixes for Poor Asthma Control Barbara Carroll Langham RN,BSN Pediatric Asthma Care Manager Kaiser Permanente

2. Simple mistakes can sabotage asthma management. Little details matter.

3. Seems like a good asthma plan so why is it not working? Seems like a good asthma plan so why is it not working? Investigate reasons for poor asthma control prior to increasing dose of a medication or adding another drug. Investigate reasons for poor asthma control prior to increasing dose of a medication or adding another drug.

4. Three Groups of Patients with Poor Asthma Control Patient/parent believes they are following instructions for asthma management correctly but they are not. Patient/parent believes they are following instructions for asthma management correctly but they are not. Patient/parent choosing nonadherance with asthma medications and/or are not following other medical advice. Refill history can help identify this group. Patient/parent choosing nonadherance with asthma medications and/or are not following other medical advice. Refill history can help identify this group. Asthma in poor control despite good adherence Asthma in poor control despite good adherence

5. Working Toward Better Asthma Control Accurate history and assessment Accurate history and assessment Targeted education to rectify errors in management Targeted education to rectify errors in management Develop written asthma plan with input from patient/parent Develop written asthma plan with input from patient/parent Regular follow up Regular follow up Revise plan as needed Revise plan as needed

6. Obtaining Accurate Information Obtain refill history prior to appointment if possible Obtain refill history prior to appointment if possible Try to mimic home conditions Try to mimic home conditions Instruct pt to bring in all meds, equipment Instruct pt to bring in all meds, equipment Provide atmosphere where pt is comfortable telling the truth Provide atmosphere where pt is comfortable telling the truth

7. Obtaining Accurate Information Accurate current list of medications Accurate current list of medications Ask questions correctly: “How often do you forget to take you meds?” Ask questions correctly: “How often do you forget to take you meds?” Have patient/parent demonstrate how to use medications/spacer Have patient/parent demonstrate how to use medications/spacer Exposure to irritants? Exposure to irritants? Address patient/parent concerns Address patient/parent concerns

8. Common Problems with Asthma Management Confusion about medicines: controller and symptom reliever Confusion about medicines: controller and symptom reliever Unsure when to start/stop, increase/decrease medications Unsure when to start/stop, increase/decrease medications Using clogged inhaler or one with little/no medication Using clogged inhaler or one with little/no medication Inadequate inhaler or spacer technique or not using spacer Inadequate inhaler or spacer technique or not using spacer

9. More Problems With Asthma Management Used to poor asthma control, don’t know symptoms can be prevented Used to poor asthma control, don’t know symptoms can be prevented Failure to identify early asthma symptoms and treat promptly Failure to identify early asthma symptoms and treat promptly Exposure to irritants Exposure to irritants Allergy symptoms are not being treated Allergy symptoms are not being treated

10. Solution: Identification of problems Identification of problems Targeted education Targeted education Solutions to problems Solutions to problems Ensure spacer, proper technique Ensure spacer, proper technique Written Asthma Action Plan Written Asthma Action Plan

11. Patient/Parent Should Know: Onset of action and role of each medicine; symptom reliever/controller Onset of action and role of each medicine; symptom reliever/controller Dose and frequency of drugs Dose and frequency of drugs When to start/stop and step up/step down meds When to start/stop and step up/step down meds When should inhaler be replaced? When should inhaler be replaced? How to clean inhaler How to clean inhaler

12. Problems with HFA and DPI Meds Different meds have different priming needs Different meds have different priming needs MDI can clog easily (ProAir) MDI can clog easily (ProAir) Need proper cleaning Need proper cleaning Need to be aware of and look at counter Need to be aware of and look at counter Need to count puffs: Qvar, ProAir, Proventil Need to count puffs: Qvar, ProAir, Proventil

14. Spacer Use Not just for children Not just for children Does patient have one? Does patient have one? Appropriate spacer? Appropriate spacer? Effective technique? Effective technique? Demonstration worth a thousand words Demonstration worth a thousand words

15. Asthma Action Plan Road map for asthma management: Keep it simple and personalize Road map for asthma management: Keep it simple and personalize Explains: when and how to use meds: step up/down; start /taper off meds Explains: when and how to use meds: step up/down; start /taper off meds Emphasizes early identification and treatment of symptoms Emphasizes early identification and treatment of symptoms When to call for advice/help When to call for advice/help May be filled out in a few minutes May be filled out in a few minutes Good teaching tool, good review Good teaching tool, good review

18. Websites for Asthma Action Plans http://www.calasthma.org/resources/show _resource/1082/ http://www.calasthma.org/resources/show _resource/1082/ http://www.calasthma.org/resources/show _resource/1082/ http://www.calasthma.org/resources/show _resource/1082/ www.kp.org/asthma : Select Northern California www.kp.org/asthma : Select Northern California www.kp.org/asthma

19. Environmental Triggers: Irritants Smoking Smoking Second hand smoke Second hand smoke Fireplace/woodstove use Fireplace/woodstove use Incense Incense Air fresheners /plug ins Air fresheners /plug ins Strong smelling cleaning products: ammonia is an asmagen Strong smelling cleaning products: ammonia is an asmagen

20. Keeping Asthma in Good Control Monitor albuterol and anti-inflammatory medications refills Monitor albuterol and anti-inflammatory medications refills Regular Follow Up Regular Follow Up Check technique at office visit Check technique at office visit Revise asthma plan as needed Revise asthma plan as needed

21. Monitoring Albuterol Use Mind the albuterol and your are half way there Mind the albuterol and your are half way there Most patients can get by with 2 to 4 canisters per year Most patients can get by with 2 to 4 canisters per year Check previous refill history Check previous refill history Check refills of controller drugs Check refills of controller drugs Increased albuterol use= increased chance of hospitalization/ER visit Increased albuterol use= increased chance of hospitalization/ER visit

22. Patient Reasons for Noncompliance with Medication Doubt asthma diagnosis Doubt asthma diagnosis Cost of medications Cost of medications Safety concerns; steroid phobic Safety concerns; steroid phobic Medication doesn’t work Medication doesn’t work Believes medication only needed for serious symptoms Believes medication only needed for serious symptoms

23. The little details are important for good asthma management.