Download pdf - ASTHMA CLINICIANS WORK TOO HARD 2009 4.5 · • Asthma learning tools ASTHMA BOOKLETS. When I published One Minute Asthma: What You Need to Know in 1991, Dr. Albert Sheffer, chair

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.

AsthmaCliniciansWorkTooHard4.4Page2of13

Copyright©2009ThomasF.PlautM.D.Maybecopiedforpersonaluse.Contactjtplaut@pedipress.comforpermissiontopublishorquote.

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.



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.



• 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



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



don’tknowhowtoscorethefoursignsofasthma.Oncetheylearn,theycaneasilyassesstheseverityofanepisode.Toprovethis,trytoscoreayoungchildwhois:coughingtwiceaminute,wheezingthroughoutexhale,suckinginthechestskinslightlyandhasaslightincreaseinbreathingrate.Itisnotdifficulttocalculatethatthetotalscoreisseven,whichplaceshiminthelowyellowzone.

Figure2.TheAsthmaSignsDiary

.Parentsneedtoknowhowtoassesstheirinfantoryoungchildinordertostarttreatmentearly.Theyneedguidancefromtheirdoctorastheylearn.Thisknowledgeisparticularlyimportantbecauseinfantsandyoungchildren:

• don’tcomplain,• can’tdescribetheirsymptomsand• getintotroublemorequicklybecausetheyhavesmallairways.• arenotoldenoughtouseapeakflowmeter.



ASTHMAACTIONPLANS.Agoodasthmaactionplan25(Seefigures3and4)willtellpatientsandparentswhattodoineveryasthmasituation.Whento:

• reduceactivity,• changemedicinedose,• addamedicine,• callthedoctorand• gototheER.

Theplanshouldbeclearenoughsothatpatientsandparentswillrarelyneedtocallforadvicebetweenvisits.Itcanbebasedonpeakflowscoresorthefoursignsofasthma.26Eachplancallsforearlyactionateachlevelofanepisode’sseverity.Youcandownloadandcustomizetheseplansfromwww.pedipress.comforuseinyouroffice.



Figure3.ThePeakFlowAsthmaActionPlan



Figure4.TheSignsAsthmaActionPlan





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.



• 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.



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