During a session at the 2018 AAAAI Annual Meeting speakers discussed tips for the healthcare team to control asthma and prevent exacerbations. Gregory M. Metz, MD, FAAAAI, of the Oklahoma Allergy & Asthma Clinic, began by discussing concepts of asthma development, including genetic and epigenetic factors. Epigenetics is a growing area of research, with many studies targeting maternal factors that lead to an increased risk of asthma. When maternal stress is high, for example, there is dysregulation in the pathways involved in lung development. Epigenetic changes have also been identified in children of mothers who smoked during pregnancy.
Infections are one of the biggest factors of asthma development, he said. Respiratory syncytial virus (RSV) is the most common cause of bronchiolitis in children under 1 year. It is also possible that prenatal RSV infections occur, as animal models have shown the infection crossing the placenta and affecting the fetus in utero. Rhinovirus is the most common cause of upper respiratory tract infections, and species A and C are more severe in young children and are most likely to cause lower respiratory infections.
Viral infections enhance airway epithelial production of IL-33, which promotes airway inflammation. Viral wheezing may damage the airway, making it more susceptible to obstruction and remodeling. Respiratory infections and treatment may lead to airway dysbiosis.
He then discussed airway dysbiosis, in which the microbial composition in the lungs and gut can affect the development and progression of asthma. The microbiome is influenced by the mode of delivery, diet, micro-aspiration, antibiotics, environment, and microbial exposures. Bacteria in normal lungs is similar to the oral microbiome, while colonization in the upper airway in children with certain respiratory bacteria is associated with dysbiosis.
Dr. Metz highlighted a 2016 study published by Stein et al in the New England Journal of Medicine that looked at farm exposure asthma risk in Amish and Hutterite farmers. Both groups have similar genetic backgrounds and daily lives; however, the Amish practice traditional farming, using horses for transportation and single-family dairy farms, while the Hutterite practice industrial farming, which is highly industrialized with communal farms. They found that the prevalence of asthma in Amish and Hutterite children was very different: 5.2% versus 21.3%. The prevalence of allergic sensitization was 7.2% and 33.3%, respectively.
He also discussed air pollution, which can lead to allergies and asthma. Children who grow up close to a highway, for example (a higher pollution area), have higher asthma rates, which could be due in part to the inflammatory pathway.
Karen L. Gregory, DNP, APRN-BC, RRT, AE-C, of the Oklahoma Allergy & Asthma Clinic, discussed the role of targeted interventions to prevent asthma. “When do we intervene?” she asked. “Timing is everything,” as early intervention is crucial to reduce the health burden of asthma.
Asthma management should focus on achieving asthma control by decreasing symptoms and optimizing lung function, reducing future risk of asthma, and improving activities of daily living. The challenge of this is that asthma is a heterogeneous and complex disease, which does not allow for single-intervention strategies. Targeted interventions help prevent exacerbations and forecast the development of uncontrolled asthma. “It is very important that we construct individualized assessments and treatment regimens, and we need to use multiple interventions to help patients achieve asthmatic control,” she said. Interventions must address risk factors for chronic persistent asthma, early pathogenic changes in asthma, potential pharmacologic and non-pharmacologic interventions, and potential immune modulatory therapies and prevention.
Since asthma development peaks in preschool age, the most optimal time to conduct targeted interventions is in utero and early postnatal life, as the infant microbiome plays a central role in healthy immune development. Increasing evidence supports the hypothesis that the maternal microbiome during pregnancy has a profound impact on fetal immune development and the infant’s predisposition to allergic disease and asthma. In childhood, early allergic sensitization is an important risk factor for later asthma development, so it is necessary to identify what may put a child at risk for early sensitization. Ms. Gregory advised developing and tailoring effective adherence interventions that actively engage. In adolescence, clinical manifestations of asthma are variable. Physicians should undertake a patient-focused approach about the normal developmental stages and hormonal influences. In adults, the focus should be on patient-centered education: Address adherence barriers and build on patient experiences. However, in older patients, physicians should consider cognition, polypharmacy, and immobility.
She noted that personalized management should include identifying biomarkers of allergen sensitization and environmental resources. “We need more precise biomarkers that can aid in early diagnosis,” said Ms. Gregory. An ideal asthma biomarker links the disease endotype with the phenotype that predicts disease behaviors, including exacerbation, severity, response to treatment, and stable or predictable variation pattern.
She concluded by asking, “What would be your dream interventions if there were no limitations?”
Nina A. Zimmermann, MSN, RN, ANP-BC, AE-C, of Maryville University in St. Louis, Missouri, discussed strategies to improve asthma care. “What do patients need to know?” she asked, noting that education needs to start at diagnosis. Physicians should assess the patient’s education style and the best learning route (auditory, verbal, tactile), then ask questions such as:
- How do you stay well?
- What are the triggers?
- What are the medications?
- What is the action plan?
- How often do you follow-up with your provider?
“Set mutual goals with your patients and tailor education to meet their needs,” she advised. Ms. Zimmermann described the teach-back method and its importance. The physician—or another member of the healthcare team who has been trained in this area—should demonstrate a concept, such as inhaler technique, then have the patient demonstrate it back.
Racial and ethnic minorities and those with low literacy have increased prevalence of disease, mortality risk, exposure to risk factors, and poverty, and are less knowledge about their disease. Because of this, physicians need to address barriers and patient home condition. She gave important communication skills:
- Listen actively
- Do not use medical jargon
- Include family members
- Anticipate resistance
- Give rationale
- Change behavior not feelings
- Confront issues
- Compliment skills or knowledge
Barriers to education that physicians may encounter are social (financial), psychological (denial), behavioral (readiness to learn), learning/literacy, cultural, and spiritual. “Establish relationships and trust with patients,” she said, admitting that this is “definitely a skill.” Physicians should build a resource list for patients with things like specialists, ways to get reduced-price medications, and tips for interventions such as mattress covers. “Ask patients: ‘Is anything preventing access to medical care, not just asthma care?’” she recommended.
“Make it an active partnership,” Ms. Zimmermann said, one that respect patients’ health beliefs and choices, and develop a self-management plan with not for the patient, empower the patient to be proactive, and advocate for their right to care.
She said detailing a lot of information to patients at once is overwhelming to both the patient and provider. So, break the information into different sections, adding on new information at each visit. At the end of a visit, reinforce simple education, such as, “These are two things I want you to remember…”
Presentation 2321: AH: Empowering the Health Care Team: Prevention of Asthma Development and Exacerbation