Here are 5 questions or issues that Dr. Ty Reidhead, Internal Medicine
Chief Clinical Consultant, suggests you ponder as you read the following
précis of the Adult Asthma Introductory comments below. Please let us
here your thoughts

**Questions for discussion:      **

1.  How can we improve community and institutional surveillance of
    asthma to measure the impact of the disease on our patient
    population? 

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1.  How hard or easy is it for you to get spirometry on a patient for
    diagnosis and follow-up of a patient with asthma?  Are providers in
    your clinic and hospital checking spirometry in patients with
    asthma?

2.  How difficult is it for you to get a pulmonary and/or allergy
    consultation when needed?

3.  Do you use the Asthma Register System at your facility and have you
    used the asthma action plans that are available through this
    program?  If not, do you have a method of providing written action
    plans for your patients that is usable? 

4.  Is there any role for remote/telemetric monitoring of peak flows,
    home spirometry, and use of MDI's where providers can keep tabs on a
    patient's status?

**Rydberg, Matt \[Matt.Rydberg@IHS.GOV\]**

**Wed 8/25/2004 7:00 AM**

Spirometry is essential in diagnosing asthma.  It would be more helpful
to us to be able to get spirometry during flares, and before multiple
nebs for treatment.  Peak flows, however, are more easily obtainable. 
We have good support from nursing to get peak flows at the time of
triage in patients who present with a history of asthma or a chief
complaint of wheezing.  We can then document an objective response to
treatment. 

 

I have not had much success in eliciting specific allergens. I am
suspicious that many patients are allergic to juniper tree pollen. 
However, I am not satisfied that specific allergen therapy is more
effective than standard care for asthma.  Has anyone seen a better
response?

 

As we move towards an electronic health record, computer access in our
clinics will improve.  This should allow us to more easily use written
templates for asthma patients.  Written action plans for patients can be
very useful - especially in our population of patients without easy
access to phones.

 

Patient understanding and compliance with inhaled steroids seems
difficult.  Since there is not an immediate improvement, I have a hard
time getting my patients to faithfully use ther inhaled steroids.  Any
tricks that anyone has had in achieving success?

 

Bratsch, John \[John.Bratsch@IHS.GOV\]

Wed 8/25/2004 7:35 AM

Agree with **Spirometry** being essential for Dx, and the Peak Flows
currently being easier to obtain.  However, hopeful that we\'ll
eventually be able to obtain full spirometry with acute flares (entails
training more personnel on administering Spirometry and maybe a unit for
**ER** and/or **Urgent care**).  Would be easier if we had an individual
or set of individuals (like RT\'s) available around the clock to
administer the spirometry.  Ty/Matt, do you know where we stand with
regards to the RT situation?

 

**Allergens**:

For those patients that get to the Allergy clinic (current waiting list
is \~2 months) AND actually make the appointment (high no-show rate)
we\'re able to usually find at least a couple possible allergen
triggers.  For our patients there are quite a few with Juniper allergy. 
Very few patients are opting for Immunotherapy desensitization.

 

**Inhaled Corticosteroids**:

Agree with the lack of compliance and understanding for use of ICS.  For
the most part ICS are only used by the patient when they feel \"sick\". 
Of course most patients use the Beta agonists religiously as there is an
immediate relief of symptoms and they can tell that they \"work\".  The
rare few patients I\'ve had success with in sticking with ICS use are
the ones that are willing to do a Trial on ICS for \~3 months, then off
and they keep a symptom diary.  This is a very select group, and highly
motivated.  However, the few that have done this keep on the ICS.

 

**Lamer, Chris (EBCI) \[chris.lamer@IHS.HHS.GOV\]**

**Wed 8/25/2004 9:07 AM**

Hello,

First of all, I would like to apologize for seeming so long winded in my
response. This e-mail is actually part of a couple of e-mails that I was
unable to get through to the listserv over the past week or two.
Secondly, Cherokee Indian Hospital is promoting asthma awareness,
implementing the RPMS package called the Asthma Register System, and
starting some new pharmacy based patient education programs - so I have
a lot of questions to ask and learning to do! Thank you very much and
have a great week!

Chris

Here are some of my comments on Ty\'s questions\...

**1. How can we improve community and institutional surveillance of
asthma to measure the impact of the disease on our patient
population? **

Asthma has chronically been under-diagnosed among Native American
populations in the primary literature. It was believed that Native
Americans suffered very little from asthma based upon data from the
1970s and early 80s - possibly asthma is a new epidemic among Native
American populations, or it has not been well documented or
inappropriately documented in the past. I think that we need to increase
provider awareness of asthma and extinguish the fear of \"labeling\"
persons with asthma. Asthma diagnosis can be active or moved to an
inactive status in RPMS over time under the problem list/purpose of
visit area of the PCC/PCC+/EHR. Appropriate diagnostic codes should be
used - and lackluster codes such as RAD should not be encouraged. *What
ICD-9-CM codes are providers using most commonly for documentation of
asthma?* Community screening or education could help raise personal
awareness of asthma and asthma screening could be incorporated into
school activities.

**2. How hard or easy is it for you to get spirometry on a patient for
diagnosis and follow-up of a patient with asthma?  Are providers in your
clinic and hospital checking spirometry in patients with asthma?**

Cherokee Indian hospital recently received a spirometer and we are still
working on the logistics of using it. Initially, it was thought that
clinic nurses could perform the spirometry; however we quickly realized
that this is an unreasonable request considering the amount of work and
responsibility already placed upon our clinic nursing staff. We are in
the process of evaluating the potential of getting a respiratory
therapist to manage the spiromety. *What has worked best at other sites?
How many places have RTs? If you have an RT, how large is your facility
and what is their role?*

**3. How difficult is it for you to get a pulmonary and/or allergy
consultation when needed?**

**4. Do you use the Asthma Register System at your facility and have you
used the asthma action plans that are available through this program? 
If not, do you have a method of providing written action plans for your
patients that is usable?** 

We are in the process of updating the ARS (Asthma Registry System)
registry. We have not provided written action plans for the past for our
patients, but that is changing as we work with the system. Currently the
package is not functional for entering asthma related data but if this
functionality is added, it will be very nice for ensuring that asthma
related data gets entered into the system and for printing patient
specific education forms. Currently the system if great for running
reports, displaying important information on the health summary and
raising awareness of asthma as a chronic disease that requires
continuous monitoring and management. It is important for us to test out
the system and determine what aspects of the application we would like
to change or could improve.

**5. Is there any role for remote/telemetric monitoring of peak flows,
home spirometry, and use of MDI's where providers can keep tabs on a
patient's status?**

Home peak flow monitoring has been advocated by the NHLBI as a
monitoring tool to assess asthma status. I am aware of some patients
(not many) who have been willing to bring in their PF monitoring sheets
in for review, but again - very few. Remote monitoring or even PF meters
with memory would be interesting tools that could help increase usage
and benefit of this type of monitoring and patient education. *Are there
any such devices in existence?*

**In response to the questions & comments raised by Neil Murphy**:

What is the role of the pharmacist in the asthma care team? Any good
'work around'(s) or systems that have worked OK at your facility? (any
pharmacists on this e-mail, please chime in here, too)

Asthma is a chronic disease that is managed by medications and intensive
education and assessment. Pharmacists should serve a number of roles:

\(a\) Serving as members of P&T committee to help determine optimal
asthma medications

i*) With respect to potency and delivery device, are all steroid
inhalers the same? Are there additional benefits of one steroid device
over another?*

*ii) Are there significant differences between the available short
acting/relief inhalers available on the market?*

*iii) Has anyone moved from Atrovent to tiotropin (Spiriva) for COPD
patients?*

\(b\) patient counseling and assessment of inhaler usage. The pharmacy
is unique in that patients can show up any time they want with a
question, concern, or refill request. This places the pharmacist in a
unique position that may provide patients with the opportunity to obtain
valuable education when they want/need it or enables patients to express
concerns that they may have forgotten or not thought about during the
provider visit. This should be capitalized upon by all staff to
encourage patients to actively participate in their health care and
obtain help and guidance through a number of sources including the
pharmacy.

*i) how helpful are the National IHS Patient Education codes for
developing an asthma education session?*

*ii) how do you document asthma education? With the codes? Is it easiest
with PCC, PCC+, EHR, or another method?*

c\) Participation in asthma management teams to formalize methods to
improve asthma recognition, treatment, and management. Sites interested
in improving asthma management should have some type of
interdisciplinary committee established, whether it be an asthma focused
group, an education committee, or medical staff meeting that can address
how asthma education will occur. The IHS standards of care require that
pharmacists provide patient counseling and education, so it is a good
idea to include pharmacy staff members in these committee to ensure that
education and training is consistent and uniform throughout all
departments and disciplines. Ideally sites should use the National IHS
Patient Education Codes to guide patient education and documentation and
further guidance can be provided by the development of lesson plans.

d\) The pharmacist also has a responsibility to educate patients,
augment education provided by other disciplines, and to assess patient
knowledge/ability to use their medications, and to assess responses to
therapy or identify factors that may indicate that asthma symptoms are
not under control such as requesting early refills of albuterol
inhalers.

*i) does anyone have a standing order protocol for asthma medication
management? If so, what disciplines are encouraged to actively assess
pharmacologic response to therapy and make adjustments to dosage as
needed?*

*ii) what pharmacist work in an asthma clinic? What are your roles and
what do you do to improve asthma patient care? *

How much do you think it is worth it to ask about allergens in our AI/AN
patients?

Assessing asthma triggers is an important part of asthma management and
assessment. I don\'t know how much this is done throughout IHS. With the
new asthma register system case management application for RPMS, there
is now a place to record this information. I would imagine that
allergens vary from site to site... for example, wood burning stoves in
the Cherokee areas is a well recognized allergen... so much so that
certain tribal agencies will help families find alternative heating
sources if a family member has severe or uncontrolled asthma worsened by
the smoke and ash.

*What triggers are unique to other sites?*

**Reidhead, Charles \[Charles.Reidhead@IHS.GOV\]**

**Tue 8/31/2004 10:24 PM**

Chris raises a lot of good points and more questions.

I am only going to address his question on who can do spirometry in a
busy clinic and leave any other comments to others.

In our hospital we do not have respiratory therapists, but we are
fortunate to have an outstanding physical therapy that has been willing
to take on the task. In the PT department, four therapists have learned
to perform spirometry and because of the shared responsibility they are
almost always able to perform the test at the time that it is needed (as
long as it is during daytime hours, which is obviously not true). It is
also important to note that with training, spirometry can be performed
in approximately the same time that a peak flow meter can be performed
if you are only interested in the expiratory loop.

**Johnson, Erik \[Erik.Johnson@MAIL.IHS.GOV\]**

**Mon 8/30/2004 9:53 AM**

We almost NEVER get peak flows done unless I do them myself, even though
there is a space for it on the PCC, no matter WHAT the patient\'s
complaint or history is\...

**Reidhead, Charles \[Charles.Reidhead@IHS.GOV\]**

**Tue 8/31/2004 5:05 AM**

Why do you think it is hard to get peak flows? Is it because of too many
other things to address, availability of peak flow meters, unfamiliarity
of nurses with the peak flow meter or other reasons?

This also raises an important point also - peak flow results are very
dependant upon technique.

Good day,

I\'d like to share some of our thoughts on asthma. Originally our
facility used flunisolide inhalers and singulair to treat asthma. The
pharmacy presented to P&T and med exec. committees to change our inhaler
to fluticasone . This allowed the providers to increase  the dose of the
inhalers without increasing the number of inhalations a day. Also
flunisolide left a poor after taste which

reduced compliance. We also presented and implemented an asthma policy
which states that montelukast will only be used after the patient has
failed to reach control with a fluticasone 110mcg inhaler for adult
patients. The idea was to make sure the patient was using their
corticosteroid inhaler and not just montelukast to control the
inflammation of asthma.

Unfortunately we were unable to get the pediatric physicians to accept
this policy. The policy has been in place for 7 months ,and after the
agonizing process of getting patients off montelukast and on a
corticosteroid inhaler, we are seeing some positive results. We have
decided to wait until next spring to do a DUR and accurately access what
we have accomplished.

As far as getting patients to use their corticosteroid inhaler and not
just their albuterol inhalers I use a couple of explanations that seem
to make sense to the patient. First I explain that asthma is an
inflammation process inside their lungs. Then I explain that albuterol
opens their bronchioles up by relaxing the smooth muscles, but does
nothing to affect inflammation. And while they may

feel better, the inflammation  continues and that over time a process
called remoduling can take place. I then explain ,in the only terms I
feel comfortable using, that remoduling is similar to scarring the lung
tissue which over time can result in the tissue no longer being able to
get oxygen into the blood. I then say that if your lung function is
this, and separate my hand by say 18 inches and if remoduling occurs,
then reduce the space between my hands to say 12 inches.

Explaining that their lung capacity can be reduced significantly, and
that no matter how much medicine you take that you\'ll never regain this
lost capacity. The patients seems to accept this explanation.

Our Pharmacy does fill out asthma action plans along with peak flow
meter counseling on all asthmatics. I must admit we have had little feed
back on their effectiveness.

We are not using any coding of our counseling and interventions. Quite
honestly I did not know they existed. I think the idea of an asthma team
makes sense. We do have MD who is quite active in asthma education with
his patients. Perhaps a team approach would increase awareness with
other providers, pharmacists, and nurses.

**Reidhead, Charles \[Charles.Reidhead@IHS.GOV\]**

**Mon 9/20/2004 8:45 AM**

Thank you Jon for your excellent thoughts.

 

I have not had the experience of the taste of flunisolide, but
compliance with fluticasone and fewer inhalations is a real improvement.

Asthma/medication policies/guidelines can be difficult to implement, but
I definitely think that the use of fluticasone before montelukast is the
right way to go. Following up the process with a DUR is the right way to
see what impact you have accomplished. The only problem with the DUR is
that these usually don't include outcome measures such as: changed usage
of rescue medications or urgent care and ED visits, unless you include
this. Then, you also may not have the numbers to prove to yourself and
the providers that they have made a real improvement.

I like your explanation for remodeling and loss of lung capacity with
asthma.

I agree that I also like the asthma team idea. The pharmacist is a key
member of this team, as is true for all of our system oriented
approaches to management of chronic medical conditions. My only fear is
that with so many other chronic problems to manage at each service unit,
asthma will not be given enough energy. For the majority of patients,
asthma should be a disease that can be fully controlled minimizing the
impact on the patient's life expectancy as well as their lifestyle.

Do any other sites have formal or informal asthma teams?

**Lamer, Chris (EBCI) \[chris.lamer@IHS.HHS.GOV\]**

**Mon 9/20/2004 12:31 PM**

I can verify the bad taste of flunisolide - there are two flavors,
regular and menthol; both taste like the butt of a cigarette! We had a
patient who complained of vomiting after she used it because it tasted
so bad. We have had some patients who enjoyed the taste and would
request regular or menthol flavor and, at least with Amerisource, it was
much less expensive than other inhalers (about \$2 an inhaler)!

Another question that comes up - which liquid prednisone tastes better?

We have ordered both pediapred (prednisolone) and liquid prednisone -
and they both taste bad to me. What are people using for children who
have an asthma exacerbation that requires oral prednisone? We have
recommended crushing tablets and mixing them with applesauce or ice
cream.

**Rydberg, Matt \[Matt.Rydberg@IHS.GOV\]**

**Mon 9/20/2004 12:38 PM**

We are using the crushed tablets at Whiteriver. The taste of all of the
syrups were too bad to force on children.

I have also tried to explain asthma to my patients as an inflammatory
disease - not just transient dyspnea. I think that the model that Jon
described is an excellent one to get across that point.

Perhaps all providers should taste the meds that we prescribe to our
patients. We would likely be more understanding of our patients
\"noncompliance\" with meds!

**McLaughlin-Middlekauff, Jane \[jlmclaughlin@ANMC.ORG\]**

**Tue 9/21/2004 10:26 AM**

We are using Orapred (prednisolone) oral solution 15mg/5mL and have not
received any complaints to my knowledge about the grape taste.

Editor:

For the full background and primer on this topic:

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/AsthmDisc.doc>

Cherokee Asthma Cards:

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/AsthCheroCard.doc>

Asthma Action Plans and Register:

<http://www.ihs.gov/MedicalPrograms/MCH/M/documents/AsthRegist.doc>