Asthma Pathophysiology, Treatment Standards, and Community Management

Pathophysiology of Asthma

Asthma is a complex chronic inflammatory disease involving several inflammatory cells, more than a hundred distinct mediators of inflammation, and various inflammatory outcomes, such as plasma exudation, bronchoconstriction, activation of sensory nerves, and hypersecretion of mucus. Mast cells contribute immensely to the mediation of acute asthma symptoms; by contrast, T-helper 2 cells, eosinophils, and macrophages cause airway hyperresponsiveness by inducing chronic inflammation. An increasing number of researchers have recognized that structural airway cells — including smooth muscle and epithelial cells — are a major source of inflammatory mediators. Asthma involves several inflammatory mediators, such as growth factors, peptide and lipid mediators, chemokines, and cytokines. Chemokines play a crucial role in the selective recruitment of inflammatory cells 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 and hypertrophy (Zaoutis, n.d.).

Patients experiencing persistent or worsening respiratory trouble during asthma episodes require hospitalization, as do patients who need continuous asthma treatment that cannot consistently be carried out following discharge. Chronic or increasing asthma symptoms, despite bronchodilator treatment, are termed status asthmaticus. The goals of hospitalization are described from several perspectives: controlling status asthmaticus, stabilizing and improving asthma-related respiratory symptoms through appropriate respiratory support escalation or de-escalation, monitoring and medication management, investigating and managing asthma comorbidities or triggers, and planning patient discharge. A patient's asthma history should be reviewed, and post-discharge home-care plans — covering both acute exacerbation episodes and maintenance — should be recommended with adjustments made as required. Both the patient and family must receive asthma education. Patients should meet with their subspecialty or primary medical team to discuss proper follow-up after discharge (Zaoutis, n.d.).

Evidence-Based Pharmacological Treatments and Clinical Guidelines

Magnesium sulfate is recommended for use after one hour of treating both mild and life-threatening asthma, administered over a period of more than 20 minutes. The drug is administered infrequently (Vincent, 2014). It has been demonstrated that magnesium sulfate inhibits smooth muscle contraction, decreases the release of histamine in mast cells, and prevents the release of acetylcholine. Studies conducted in both children and adults show varying levels of improvement in patients who have severe airflow limitation and are unresponsive to conventional treatment using beta agonists, corticosteroids, and anticholinergic medications (Rowe & Camargo, 2008).

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, which promotes a comprehensive approach to asthma management and control that includes avoidance of environmental triggers, self-management education, proper use of daily medications to prevent attacks, partnering among the asthmatic individual, healthcare provider, and family, and using an asthma action plan (AAP) to assist in daily management and when symptoms worsen. The two essential goals in asthma management are reducing risk and reducing impairment (Texas Asthma Plan, 2012).

The gold standard in asthma practice guidelines is the 1997 Expert Panel Report (EPR) by the National Heart, Lung and Blood Institute. These guidelines address asthma evaluation and treatment in a comprehensive manner. The EPR highlights four levels of asthma severity, distinguished by factors such as lung function, daytime symptom frequency, and nocturnal symptom frequency: mild intermittent, mild persistent, moderate persistent, and severe persistent. Recommended treatment is algorithmically correlated to the degree of asthma severity, giving rise 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 — including cough, persistent breathing difficulties, persistent chest tightness, and persistent wheezing — and physical examination. Symptoms occur or worsen at nighttime, during exercise, with exposure to irritants and allergens, during viral infections, with stress, when crying or laughing hard, or with weather changes. Asthma assessment with regard to its control, established action plan, appropriate treatment method, patient concerns, and adherence 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 frequently for poorly controlled asthma to determine whether adjustments in therapy are warranted. More advanced treatment techniques should be pursued as necessary (Morris, 2015).

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

Comparing Community, State, and National Asthma Management

Asthma management in Galveston centers on education. Asthma education in the community encompasses pediatric asthma education, inpatient and outpatient education programs, adherence to clinical guidelines, and school-based asthma clinics (The Growth Chart, 2000).

At the state level, the first plan to address issues affecting Texans with asthma emerged in 2000 from the Asthma Coalition of Texas (ACT) and the Texas Department of Health (TDH). Since then, the plan has undergone several revisions reflecting current surveillance data, 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 serves as a strategic blueprint, highlighting priority goals, objectives, and recommended activities, while promoting coordinated asthma action among partners and stakeholders (Texas Asthma Plan, 2012).

At the national and international levels, asthma guidelines have positively affected the quality and outcomes of asthma care across the world as they approach their 25th year in the literature. The NAEPP guidelines and the Global Initiative for Asthma (GINA) guidelines are frequently cited and endorsed by American clinicians. Both are evidence-based and use similar approaches, as they originated from the National Institutes of Health (Myers, 2008).

Because the GINA guidelines address international asthma care, the varying financial statuses of different countries led GINA to produce comprehensive guidelines focusing on preferred treatment levels for chronic and acute asthma without specifying certain medications. Nevertheless, the guidelines highlight acceptable therapies as a well-referenced review of additional treatment options (Myers, 2008).

The 1997 NAEPP guidelines, by contrast, can be summarized as follows: (1) fresh appreciation of the central role of airway inflammation in the pathogenesis of asthma; (2) emphasis on anti-inflammatory maintenance therapy; and (3) attention to identifying important risk factors associated with asthma development and appropriate programs for its prevention and control. The NAEPP guidelines provide an outstanding vehicle for translating research findings into clinical recommendations (Myers, 2008).