Asthma is a common affliction of the human respiratory tract in which the airways get constricted and inflamed with excessive amounts of mucus. Asthma occurs often in response to exposure to an environmental stimulant called allergen, cold air, physical exercise or psychological stress.The disease asthma is probably not a single disease, but rather a complex of multiple, separate syndromes that co-exist (Wenzel ,2006). The factors that cause asthma are sometimes referred to as ‘triggers’. The asthmatic symptoms can range from mild to life threatening and can be controlled by drugs and changes in the environment. “The National Heart, Lung and Blood Institute”, USA, classifies four categories of asthma namely, mild intermittent, mild persistent, moderate persistent and severe persistent. "Severe persistent asthma" symptoms are continual with frequent exacerbations and nighttime symptoms resulting in limited physical activity and the lung function as measured by PEV or FEV1 tests is less than 60% .Since there is no known complete cure for asthma, prevention of attacks and relief from the symptoms is the solution. Educating asthma patients regarding respiratory peak flow and symptom management seems to be one of the best ways to control episodes of asthmatic exacerbation. Forced expiratory volume (FEV1) is defined as the maximal amount of vital capacity expressed in one second. Peak expiratory flow rate (PEFR) is defined as the largest amount of expiratory flow achieved with a maximally forced effort.
Nurse Practioner’s Role
Dorothea Orem (1971) defined nursing with emphasis on client’s self-care needs. Self-care, according to Orem, is a learned, goal-oriented activity directed towards the self in the interest of maintaining life, health, development and well-being. Thus, the primary role of a nurse practioner is to increase the client’s ability to independently meet their needs i.e., the self care of the client. Patient education on asthmatic symptom management by careful monitoring of the symptoms and peak expiratory flow measurements is an effective way in asthma management towards this self care of the client.
Studies on FEV1 % correlations with asthma symptoms have shown that asthma patients with poor symptom control have a correlation with FEV1 % (Aburuz et.al, 2005) elucidating that there is a definite relationship between lung function and asthmatic symptoms. A study to evaluate the effectiveness of routine self-monitoring of peak flow for asthma outpatients by a pragmatic randomized trial in hospital outpatient clinics and general practices has shown that there is an increase in general practice consultations after one year in those patients who have been given a peak flow meter for self-monitoring taking us to the conclusion that peak flow meters and giving self management guidelines to asthma patients benefit the patients (GRASSIC, 1994). Research studies to compare the use of patient-performed peak expiratory flow (PEFR) and symptom monitoring as asthma (Bheekie et.al, 2001) self-management tools have shown that PEFR self-monitoring is a more useful asthma tool than symptom self-monitoring. Patients performing symptom monitoring were assessed using a visual analogue scale to assess symptoms, whereas those in the PEFR monitoring group self assessed symptoms using a pocketsize peak flow meter to measure lung function for two months. The studies were carried out with 110 patients over 6 years of age recruited from five private-sector community pharmacies using a questionnaire to classify patients as mild, moderate or severe. Another study to determine whether routine assessment of peak expiratory flow (PEF) in association with a self management plan based on inhaled corticosteroid use is effective in the management of chronic asthma (Beasley et.al, 1989) with 36 consecutive adult patients has shown that routine measurement of PEF in association with a self management plan is effective in reducing symptoms of asthma and improving lung function.
The effect of a peak flow-based action plan in the
prevention of exacerbations of asthma has been recently elucidated (Cowie
et.al, 1997). This study designed to determine the effect of a symptom-based
and a peak flow-based action plan in preventing acute exacerbations in subjects
with poorly controlled asthma has been based on a randomized controlled trial
with one hundred fifty subjects assessed by questionnaire at 3 and 6 months
after enrollment with questions relating to their asthma control and their need
for urgent treatment or hospital admission for asthma. The studies have shown a
striking reduction in emergency department visits for asthma in the peak
flow-based action plan group (p=0.006)
taking us to the conclusion that a peak flow-based action plan is effective, at
least in the short term, in protecting patients with asthma. A study to determine whether there is a
correlation between changes in asthma symptoms during treatment and changes in
lung function, as measured by peak expiratory flow (Dorinsky et.al, 2001) has
shown that there is a strong correlation between lung function as expressed as
peak respiratory flow and symptom management. The effect of patient education
in asthma has been studied by a randomized controlled trial (Galipos et.al,
2002) and has recorded a 6 percent improvement in lung function (FEV1) in the
study population in twelve months.
Respiratory peak flow and symptom management is an evidence-based approach to asthma management. Patients who practice self-monitoring in conjunction with use of a written action plan and regular medical review have been shown to undergo significantly fewer hospitalizations, emergency department visits, and lost time from work (Gibson, 2000). A randomized trial comparing peak expiratory flow and symptom self-management plans for patients with asthma attending a primary care clinic has been elucidated by Turner et.al (1998). The study recommends the use of peak flow meters (PFM) as an important part of self-management plans after a trial with 92 adult asthma patients in a primary care setting to compare the effectiveness of action plans using either peak flow monitoring or symptoms to guide self-management. The study has found significant improvements within groups for FEV1.
A prospective controlled trial of home monitoring of peak expiratory flow rate (PEFR) conducted to determine the usefulness of an objective measure of lung function in association with an education program and a medication self-management plan in reducing morbidity in adult patients with asthma (Ignacio-Garcia et.al, 1995) in a six month study period has shown that patients in the experimental group exhibit statistically significant improvements in morbidity parameters including days lost from work, acute asthma attacks, days on antibiotic therapy, physician consultations, and emergency room admissions for asthma, increases in FVC, FEV1, and FEV1/FVC, mean PEFR and mean morning PEFR, decrease in percentage of the mean PEFR amplitude, and a reduction in the use of inhaled beta-agonists, oral theophylline, and oral prednisone.
Improving self-care in adults with asthma using peak expiratory flow rate self monitoring can be treated as a therapy incorporated into an individualized patient treatment plan (Stach, 2000).Management of asthma based on PEFR measurements can result in early recognition and prompt treatment of asthma exacerbations and PEFR monitoring in the setting of a comprehensive self-management program can lead to fewer symptoms of asthma, fewer emergency examinations, fewer hospitalizations, lower requirements of inhaled β-antagonists and oral corticosteroid therapy, and better pulmonary function (James, 1995). A nurse practioner plays an important role in educating asthma patients regarding respiratory peak flow self monitoring and symptom management.
- Adams, R., Boath, K., Homan, S., Campbell, D., and Ruffin, E. (2001).A ramdomized trial of peak-flow and symptom-based action plans in adults with moderate-to-severe asthma. Respirology 6: 297-304.
- Bheekie, A., J. A. Syce, et al. (2001). Peak expiratory flow rate and symptom self-monitoring of asthma initiated from community pharmacies. J Clin Pharm Ther 26(4): 287-96.
- Buist, A. S., W. M. Vollmer, et al. (2006). A randomized clinical trial of peak flow versus symptom monitoring in older adults with asthma. Am J Respir Crit Care Med 174(10): 1077-87.
- Chmelik F, Doughty A (1994). Objective measurements of compliance in asthma treatment, Ann Allergy. 73(6):527-32.
- Cote, J., A. Cartier, et al. (1998). Compliance with peak expiratory flow monitoring in home management of asthma. Chest 113(4): 968-72.
- Cowie, R. L., S. G. Revitt, et al. (1997).The effect of a peak flow-based action plan in the prevention of exacerbations of asthma. Chest 112(6): 1534-8.
- Dorinsky, P. M., L. D. Edwards, et al. (2001). Use of changes in symptoms to predict changes in lung function in assessing the response to asthma therapy. Clin Ther 23(5): 701-14.
- Gallefoss, F. and P. S. Bakke (2002). The effect of patient education in asthma, a randomized controlled trial. Tidsskr nor Laegeforen 122(28): 2702-6.
- Garg, V. K., R. Bidani, et al. (2005). Asthma patients` knowledge, perception, and adherence to the asthma guidelines. J Asthma 42(8): 633-8.
- Gibson, P. G. (2000).Monitoring the patient with asthma: an evidence-based approach. J Allergy Clin Immunol 106(1 Pt 1): 17-26.
- Gibson, P. G., F. S. Ram, et al. (2003).Asthma education. Respir Med 97(9): 1036-44.
- Horne, R., D. Price, et al. (2007). Can asthma control be improved by understanding the patient’s perspective? BMC Pulm Med 7(1): 8.
- GRASSIC (1994). Effectiveness of routine self monitoring of peak flow in patients with asthma. Grampian Asthma Study of Integrated Care (GRASSIC). Bmj 308(6928): 564-7.
- Aburuz, S., J. McElnay et al. (2005). Relationship between lung function and asthma symptoms in patients with difficult to control asthma. J Asthma 42(10): 859-64.
- Ignacio-Garcia, J. M. and P. Gonzalez-Santos (1995). `Asthma self-management education program by home monitoring of peak expiratory flow. Am J Respir Crit Care Med 151(2 Pt 1): 353-9.
- (1995).Home Peak Expiratory Flow Rate Monitoring in Patients With Asthma, Mayo Clin Proc 70:649-656.
- Janson S. (1995). Value of home peak flow monitoring for asthma control. West J Med 163(4): 370-1.
- Jones, K. P., M. A. Mullee, et al. (1995). Peak flow based asthma self-management: a randomised controlled study in general practice. British Thoracic Society Research Committee. Thorax 50(8): 851-7.
- Kolbe, J., M. Vamos, et al. (1996). Assessment of practical knowledge of self-management of acute asthma. Chest 109(1): 86-90.
- Kotses, H., C. Stout, et al. (1996). Evaluation of individualized asthma self-management programs. J Asthma 33(2): 113-8.
- Lahdensuo, A. (1999). Guided self management of asthma--how to do it. Bmj 319(7212): 759-60.
- Lahdensuo, A., T. Haahtela (1996). Randomised comparison of guided self management and traditional treatment of asthma over one year. Bmj 312(7033): 748-52.
- Legorreta, A. P., K. M. Leung, et al. (2000). Outcomes of a population-based asthma management program: quality of life, absenteeism, and utilization. Ann Allergy Asthma Immunol 85(1): 28-34.
- Liam, C. K., C. T. Goh, et al. (2001). Relationship between symptoms and objective measures of airway obstruction in asthmatic patients. Asian Pac J Allergy Immunol 19(2): 79-83.
- Lopez Vina, A., P. Casan, et al. (1996). Recommendations for education of patients with asthma. Arch Bronconeumol 32 Suppl 1: 10-4.
- Lucas, D. O., L. O. Zimmer, et al. (2001). Two-year results from the asthma self-management program: long-term impact on health care services, costs, functional status, and productivity. J Asthma 38(4): 321-30.
- McGrath, A. M., D. M. Gardner, et al. (2001). Is home peak expiratory flow monitoring effective for controlling asthma symptoms? J Clin Pharm Ther 26(5): 311-7.
- Meltzer, MH Smolensky, GE D'Alonzo, RB Harrist and PH Scott (1989). An assessment of peak expiratory flow as a surrogate measurement of FEV1 in stable asthmatic children. Chest 96, 329-333.
- R Beasley, M Cushley and ST Holgate (1989). A self management plan in the treatment of adult asthma. Thorax. 44, 200-204.
- Stach, S. L. (2000). Improving self-care in adults with asthma using peak expiratory flow rate home monitoring. J Am Acad Nurse Pract 12(2): 59-70; quiz 71-3.
- Stahl, E. (2000). Correlation between objective measures of airway calibre and clinical symptoms in asthma: a systematic review of clinical studies. Respir Med 94(8): 735-41.
- Teeter, J. G. and E. R. Bleecker (1998). Relationship between airway obstruction and respiratory symptoms in adult asthmatics. Chest 113(2): 272-7.
- Tierney, W. M., J. F. Roesner, et al. (2004). Assessing symptoms and peak expiratory flow rate as predictors of asthma exacerbations. J Gen Intern Med 19(3): 237-42.
- Turner, M. O., D. Taylor, et al. (1998). A randomized trial comparing peak expiratory flow and symptom self-management plans for patients with asthma attending a primary care clinic.` Am J Respir Crit Care Med 157(2): 540-6.
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