Understanding Asthma From a Pharmacological Perspective

Pathopharmacological Foundation

Asthma

Analyze the Pathophysiology of Asthma

The complex chronic inflammatory disease known as asthma, involves several inflammatory cells, more than a hundred distinct mediators of inflammation, and various inflammatory outcomes, such as plasma exudation, broncho-constriction, activation of the sensory nerves, and hyper-secretion of mucus. Mast cells contribute immensely to mediation of acute symptoms of asthma; on the other hand, T-helper 2 cells, eosinophils, and macrophages are factors that cause airway hyper responsiveness, by inducing chronic inflammation. It has been realized by an increasing number of researchers that structural airway cells, including smooth muscle and epithelial cells in airway, are a major inflammatory mediator source. Asthma involves several inflammatory mediators, such as growth factors, peptide and lipid mediators, chemokines, and cytokines. Chemokines have a crucial role to play in selective inflammatory cell recruitment from circulation, while cytokines coordinate chronic inflammation, which may cause structural airway modifications, including angiogenesis, sub-epithelial fibrosis, mucus hyperplasia, and airway smooth muscle hyperplasia/hypertrophy (Zaoutis, n.d).

Patients having persistent or aggravating respiratory trouble during asthma episodes require hospitalization, just like patients who need essential continuous asthma treatment, but it can't consistently be carried out, following discharge. Chronic or increasing asthma symptoms, in spite of bronchodilator treatment, are termed as status 'asthmaticus'. Hospitalization aims are described in varying perspectives: status asthmaticus control the stabilization and improvement of asthma-linked respiratory symptoms by suitable respiratory support de-escalation/escalation; monitoring and medication; investigating and managing asthma comorbidities or triggers; and planning patient discharge. Patients' asthma history should be examined, and post-discharge home-care plans for acute asthma exacerbation episodes and maintenance should be recommended with alterations made when required. The state has made it mandatory for family as well as patient to receive asthma education. Patients should meet with subspecialty or primary medical team and discuss proper follow-up after discharge (Zaoutis, n.d).

The Standard of Practice of Asthma

Clinical practice guidelines have been set by the National Asthma Control Initiative and provide a solid foundation for standards of practice. There are four general components involved in the standards of practice, measuring and monitoring, education of patients, control of environmental factors, and pharmacologic therapy, which will be discussed in a later section. The first component of care is the assessment and monitoring of asthma in individuals. According to the report, "the functions of assessment and monitoring are closely linked to the concepts of severity, control, and responsiveness to treatment" (National Heart, Lung, and Blood Institute, 2007). The severity of an individual's expressed asthmatic symptoms is a baseline for future treatments and control measures. Often, severity needs to be measured before treatment can be decided upon and requires the patient to stop control therapy for a period in order to assess the level of asthma that then needs to be addressed, as the true severity is often masked through control therapies. Tests for severity include "spirometry, especially forced expiratory volume in 1 second (FEV1) expressed as a percent of the predicted value or as a proportion of the forced vital capacity (FVC) or FEV1/FVC" (National Heart, Lung, and Blood Institute, 2007). It is critical for healthcare professionals to understand the real severity in order to know the potential risk factors and then mitigate them appropriately with long-term control care. This leads to the notion of control factors in the standard practices for dealing with asthma. The report suggests that control relates to "the degree to which manifestations of asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met" (National Heart, Lung, and Blood Institute, 2007). Physicians and healthcare professionals consistently monitor control factors in order to gauge the success and efficiency of particular treatments implemented within an individual's healthcare regiment. Finally, in the monitoring standard of care is the element of assessing responsiveness, which relates to how well a particular patient responds to treatments. Like control, this must be actively monitored on a consistent basis in order to detect any potential failures before they become major risk factors.

The next standard of practice that comes after diagnosis and maintenance is the education of patients. Within standard care practices, it is critical for healthcare professionals to evaluate how well a patient can manage asthma on their own, in order to then create the most tailored approach to asthma management. Essentially, "successful management of asthma requires that the patient or patient's caregiver have a fundamental understanding of and skills for following the therapeutic recommendations, including pharmacotherapy and measures to control factors that contribute to asthma severity" (National Heart, Lung, and Blood Institute, 2007). Physicians and healthcare professionals must assess how capable each individual patient is in regards to how they understand their asthma and how to manage it appropriately before setting a healthcare regiment. If a patient is unable to understand the scope and severity of their asthma, which is often the case for patients who are very young children or older seniors, it is critical that the healthcare team work with patient caregivers to educate them so that the can manage the asthma symptoms and controls in lieu of the patient. The Education for a Partnership in Asthma Care provides a great detailed assessment on how to evaluate a patient's capability and then educate them or their caregivers accordingly.

Finally, there is the component of controlling environmental factors. Physicians and healthcare professions are required to try to mitigate potential environmental factors that may augment a patient's asthmatic severity. This often requires allergy testing and lifestyle training on how to avoid certain activities or environmental stimuli that would trigger an asthma attack. Exposure to particular allergens, like pet dander and pollen, and other irritants, like tobacco smoke and industrial pollution, all contribute to the severity of a patient's asthma. Physicians must help patients evaluate their lifestyles in order to mitigate exposure to such environmental factors as a way to better control asthma symptoms and severity.

Pharmacological Treatments

There are a number of pharmacological treatments that are suggested by the accepted standards of care. According to the research, "the current concept of asthma therapy is based on a stepwise approach, depending on disease severity, and the aim is to reduce the symptoms that result from airway obstruction and inflammation to prevent exacerbations and to maintain normal lung functioning" (Rabe & Schmidt, 2001). There are a number of pharmacological treatments currently favored by physicians for the treatment and maintenance of asthma. Beta2-andrenoceptor agonists and glucocorticoids are commonly used in modern practice and are often thought to be one of the more effective drugs for treating inflamed airways in the lungs. Such regiments also include a second line of theophylline, leukotrien receptor atagonists, and anticholinergics to augment the beta2 treatments (Rabe & Schmidt, 2001). New treatments also gaining favor include inhaled steroids, "primarily with long-acting beta2-adrenoceptor agonists" (Rabe & Schmidt, 2001). Asthma is a serious condition, but one that can be controlled by following standard practices presented by some of the leading asthma researchers and advocates in the field. By utilizing such control methods, individuals with asthma "can stay active, sleep through the night, and avoid having their lives disrupted by asthma attacks" (National Heart, Lung, and Blood Institute, 2007).

Discuss the Evidence-Based Pharmacological Treatments in Your State and How they Affect Management of the Selected Disease in Your Community

Magnesium Sulfate was recommended for use after 1 hour of treating both mild and life-threatening asthma, and administered in a period of more than 20 minutes. The drug is administered infrequently (Vincent, 2014). It has been proven that Magnesium sulfate inhibits the contraction of smooth muscle, decreasing the release of histamine in mast cells, and preventing the release of acetylcholine. Studies conducted in both children and adults show varying levels of improvement in patients that have severe limitation in airflow and unresponsive to conventional treatment using beta agonist, corticosteroid, and anti-cholinergic medications (Rowe & Camargo, 2008).

Clinical Guidelines for Assessment, Diagnosis and Patient Education of Asthma

Galveston relies on The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3(EPR-3): Guidelines for the Diagnosis and Management of Asthma that promote comprehensive approach to management and control of asthma that include:

Avoidance of triggers from the environment;

Self-management education;

Proper use of daily medications to avoid attacks;

Partnering with the asthmatic individual, healthcare provider and family; and Using asthma action plan (AAP) that helps in daily management of asthma and when the condition symptoms worsen.

The two essential goals in asthma management are decreasing its risk and impairment (Texas Asthma Plan, 2012).

The gold standard associated with the asthma practice guidelines is 1997 Expert Panel Report (EPR) by national Heart, Lung and Blood Institute: these guidelines deal with asthma evaluation and treatment in a way that is comprehensive. Professionals interested in such issues in the guideline must familiarize themselves with EPR. The EPR highlights four levels associated with asthma severity distinguished by a number of factors, such as lung function, daytime symptom frequency, and nocturnal symptom frequency: mid-intermittent, moderate-persistent, severe-persistent and mild-persistent. Recommended treatment is algorithmically correlated to the degree of asthma severity, giving way to a stepped-care model in asthma treatment (Brown, 2003).

Asthma is diagnosed through the presence of chronic airway obstruction symptoms, on the basis of history (of cough, persistent breathing difficulties, persistent chest tightness and persistent wheezing) and examination. Symptoms transpire or aggravate during nighttime, while exercising, by irritant and allergen exposure, viral infection, stress, crying/laughing hard, weather changes, etc. Asthma assessment, with regard to its control, established action plan, appropriate treatment method, patient concerns, and compliance to plan and treatment is performed at every visit. In the assessment, spirometry measures lung function no less than once every two years; the test should be conducted more often for poorly-controlled asthma, to ascertain whether any adjustments should be made in therapy, or the same method needs to be maintained. If necessary, more advanced treatment techniques should be followed (Morris, 2015).

Patient asthma education is able to improve outcomes past symptom control. Various factors must be considered when planning to deliver asthma education to a patient, such as age, language differences and other communication barriers, cultural influences on health beliefs, access to care, health literacy, setting, psychosocial issues, and method of education (Jones, 2008).

Compare the Standard Practice for Managing Asthma within Your Community With State or National Practices.

The management of asthma in Galveston involves education. Asthma education encompasses pediatric asthma education, inpatient education program, outpatient asthma education, clinical guidelines, and school-based asthma clinics (The Growth Chart, 2000).

At the state level, on the other hand, the first plan to deal with issues affecting Texans with asthma came up in 2000 from the Asthma Coalition of Texas (ACT) and Texas Department of Health (TDH). Since then, the plan underwent several revisions that reflect current surveillance, developments in asthma knowledge and best practices. The 2011-2014 Texas Asthma Plan (TAP), which is data driven develops a continuous public health approach aimed at reducing the burden of asthma in Texas. The plan acts like a strategic blueprint, highlighting priority goals, objectives, and advocated activities, together with the promotion of action for increased and coordinated activities in asthma activities amongst partners and stakeholders (Texas Asthma Plan, 2012).

Discuss Characteristics of and Resources for a Patient Who Manages Asthma Well, Including Access to Care, Treatment Options, Life Expectancy, and Outcomes.

Access to Care

Effective asthma management necessitates the development of a partnership between the asthmatic individual and his or her healthcare team. With the help of health care teams, patients are able to learn how to:

Avoid risk factors

Take proper medication

Comprehend the differences between "reliever" and "controller" medications

Seek medical assistance when appropriate (Clark, 2002)

Treatment Options

The aim of asthma treatment involves achieving and maintaining clinical control that can be attained in many patients through constant cycle that entails:

Evaluating asthma control

Treating to Attain control

Observing to maintain control (Clark, 2002)

People who manage asthma properly comprehend the differences between "reliever" and "controller" medications, and are able to seek medical assistance when appropriate. Such people know that relievers help them treat symptoms of asthma, while controller medications assist in treating underlying inflammation in the airways (Clark, 2002).

Life Expectancy

Many people understand that a lot of asthma attacks can be deadly when left unmanaged. Although many people think that anyone who suffers from asthma should expect a shorter life expectancy; this assertion has not been proven to be true. The aim of asthma treatment involves achieving and maintaining clinical control that can be attained in many patients through constant cycle in trying to alleviate the deadly effects when left unmanaged (Clark, 2002).

Outcomes

Pharmacotherapy improvements lead to possible improvements in economic and clinical outcomes. Evidence shows that various adverse clinical results can be circumvented through delivery of proper medical care. Controller treatment helps improve symptoms, reduce acute resource use, enhance quality of life, and reduce medication costs (Luskin, 2005).

Analyze Disparities between Management of Asthma on a National and International Level

As asthma guidelines approached their 25th year in literature, they have positively affected the value and outcomes associated with care of asthma across the world. The U.S.' NAEPP (National Asthma Education and Prevention Program) guidelines and the GINA (Global Initiative for Asthma Guidelines) guidelines are often cited and endorsed by American clinicians. Both guidelines are evidence-based and use similar approaches because they originated from National Institutes of Health (Myers, 2008).

Since the GINA (Global Initiative for Asthma Guidelines) guidelines focus on international asthma, various financial statuses in different countries led GINA to generate comprehensive guidelines that focus on preferred treatment levels for chronic and acute asthma, but never focused on certain medications. Nevertheless, the guidelines highlighted acceptable therapies as well-referenced review of extra therapies (Myers, 2008).

On the contrary, the 1997 NAEPP guidelines can be abridged as follows:

1. Fresh appreciation of the core role airway plays in inflammation in pathogenesis of asthma

2. Effort focused on emphasizing therapy for anti-inflammatory maintenance

3. Attention center-tasked with establishing important risk factors associated with asthma development and identifying appropriate programs for its prevention and control

The NAEPP guidelines provide an outstanding vehicle for interpreting findings in research into clinical recommendations (Myers, 2008).

Discuss Three or Four Factors (E.G., Financial Resources, Access To Care, Insured/Uninsured, Medicare/Medicaid) that Contribute to a Patient Being Able to Manage Asthma

Financial Resources

Since costs can prohibit access to appropriate care, the caregiver works with the patient to obtain financial assistance necessary for optimum adherence to a physician's care plan (Stanhope & Lancaster, 2014).

Access to Care

The primary care physician is essential in recognizing poorly managed asthma and improving asthma management for patients (Stanhope & Lancaster, 2014).

Medicare/Medicaid

Medicaid, which is a state-funded health insurance program targeting low-income individuals is useful in covering many vulnerable people. It helps many patients get a healthy life. Medicaid makes it possible for such people to see a doctor when needed, get prescriptions, and continue screenings and various preventive care, so that the patient can act swiftly in case their condition worsens or recurs (Stanhope & Lancaster, 2014).

Detail the Treatments at Each Step for Adults and Children Aged 5 and Over

At an individual treatment level, patients must be provided with reliever medication for speedy symptom relief, when required. One must, however, keep track of the amount of reliever medication used by individual patients; frequent or increased usage hints at poorly-controlled asthma.

At steps 2-5, patients need at least one regular controller medicine (like inhaled glucocorticosteroids) for preventing the surfacing of symptoms and asthma attacks (Global Initiative for Asthma (GINA) Program 1997).

Explain How a Lack of the Factors Discussed in Part A4 Leads to an Unmanaged Disease Process

Without Medicaid, many asthmatic people would not afford the care they require. Thus, for them, Medicaid is critical. Lack of financial resources serves to complicate treatment and self-management of both chronic and mild asthma. Access to health care is an important part of asthma management. High asthma prevalence implies several extra problems like the limitations associated with access to medical care and accessibility of the basic medication in nations that have limited economic resources (Sanchez-Borges, Capriles-Hulett, & Caballero-Fonseca, 2011).

Describe Characteristics of a Patient with Asthma that is Unmanaged

Uncontrolled asthma has the ability to cause permanent scarring in the airways, a condition known as airway remodeling. After the airways are remodeled, it becomes very hard to treat using traditional asthma medications. Such patients usually experience shortness of breath, chest tightness, wheezing, and fatigue every day, which often leaves them disabled (Myers, 2013).

Poor asthma control is associated with a higher likelihood of hospitalization and impulsive physician visits. Not surprisingly, it is also associated with higher asthma costs. A patient's characteristics can affect the cost of hospitalization (Bahadori et al., 2009).

Analyze How Asthma Affects Patients, Families, and Populations in Your Community

Consistent with asthma's severity, manifestation includes: impairment of pulmonary functioning and symptoms of wheezing, chest tightness and dyspnea; asthma impairs the well-being of the patient and can interfere with his/her daily activities. Also, asthma affects family members who provide care for the patient as they assume the role of care givers, losing a considerable amount of work hours. Close to 8% of the United States population suffers from asthma, and in most of the patients, it is poorly-controlled, in spite of the developments in knowledge regarding asthma pathophysiology, and accessibility of efficient therapy (Gelfand, 2008).

Discuss the Financial Costs Associated With Asthma for Patients, Families, and Populations from Diagnosis to Treatment

In U.S., annual costs associated with asthma is approximately $14billion, including both indirect and direct costs. Poorly controlled asthma increases the possibility of caregivers losing considerable time in productive work (Gelfand, 2008). Asthma imposes direct costs via the consumption of resources through hospitalizations, visiting physicians, and medications. Indirect costs are incurred through loss of productivity. It is clear economic burden associated with asthma is high, which is underpinned by it being recognized as a priority in public health. Medications are essential in guaranteeing good asthma management and hindering and relieving attacks, although the cost of medication for asthma hinders many individuals from achieving the treatment they deserve (Sadatsafavi & FitzGerald, n.d).