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Using a matrix as an educational approach to asthma
ORIGINAL ARTICLE
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Using a Matrix as an Educational Approach to Asthma B e n ay Jo h n s o n , R N , M S N , C P N P, S a n d ra Wi e s e m a n n , R N - C S , M S N / M P H , & Ja n e A n d e r s e n , R N , M S
A
ABSTRACT Health care providers agree that asthma care must be individualized to fit the need of the child and family. A written plan in the form of a matrix enables the health care provider to give families a step-bystep individualized plan of care for asthma. This article discusses the use of a long-term treatment plan in matrix form as an educational tool for health care providers and for families. The written long-term plan can be used to guide treatment for any level of asthma severity. Following a review of asthma pathogenesis and diagnosis, categories of medications are presented, along with their role in a long-term treatment plan. The National Heart, Lung, and Blood Institute guidelines are used as a basis for the recommendations in the long-term treatment plan. J Pediatr Health Care. (2003). 17, 3-10.
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paradox exists regarding asthma. Although we now have a better understanding of the pathophysiology of asthma than ever before, along with access to better medications for asthma treatment, we are seeing an increased incidence of asthma, an increase in hospitalizations because of asthma, and higher rates of asthma morbidity and mortality. The treatment of asthma has been approached by way of medical and developmental models. Many resources, such as an educational booklet by Plaut (1991), an algorithm by Rachelefsky (1995), and a developmental model by Ladebauche (1997), provide suggestions for ways to simplify asthma treatment. However, the outcomes continue to be less than favorable, and asthma mortality continues to grow, especially among minorities and inner-city populations. Asthma is the most common chronic illness of childhood, with a prevalence rate of 6.9% (4.8 million children) in the United States (Centers for Disease Control and Prevention [CDC], 1996). The prevalence is even higher in minority populations. From 1980 to 1994, asthma has increased by 160% in children younger than 5 years (Yunginger et al., 1992). From 1979 to 1995, asthma deaths more than doubled in children 0 to 14 years of age (CDC, 1998). Benay Johnson is the Research Nurse Clinician for the Division of Pediatric Pulmonary and Pediatric Infectious Disease at Children’s Hospital of New York at Columbia University. She provides asthma education to families in the outpatient and inpatient settings. Sandra Wiesemann is a Certified Clinical Nurse Specialist in Community Health Nursing. She is the Nurse Educator/Project Coordinator for the School Health Asthma Study, which is a cooperative effort with the Columbia University College of Physicians and Surgeons, the New York City Department of Health Bureau of School Health, the Medical and Health Research Association of New York City, Inc, and the National Heart, Lung, and Blood Institute. Prior to this, Ms Wiesemann worked in the New York City public schools as a Public Health Nurse for the NYC Department of Health. Jane Andersen, RN, MS, is the Pediatric Pulmonary Clinical Nurse Specialist for the Division of Pediatric Pulmonary at Children’s Hospital of New York at Columbia University. For the purpose of this manuscript, Figures 1-4 are examples of matrices. They were originally in a periodical for family physicians, thus the reference to doctor/MD. However, advance practice nurses can readily use them in their practice. Reprint requests: Benay Johnson, RN, MSN, CPNP, Children’s Hospital of New York, 3959 Broadway BH 7 South, New York, NY 10032. Copyright © 2003 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2003/$30.00 + 0 doi:10.1067/mph.2003.27
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TABLE Classification of asthma Classification
Mild intermittent Symptoms ≤2×/wk; asymptomatic and normal PEF predicted between exacerbations; exacerbations brief Mild persistent Symptoms >2×/wk, <1 time/day; exacerbation may affect activity Moderate persistent Daily symptoms; daily use of inhaled short-acting β2-agonist; exacerbations affect activity; exacerbations ≥2×/wk that may last for days Severe persistent Continual symptoms; limited physical activity; frequent exacerbations
Frequency of nighttime symptoms
Lung function
≤2×/mo
FEV1 or PEF ≥80% predicted; PEF variability <20%
>2×/mo
FEV1 or PEF ≥80% predicted; PEF variability 20%-30%
>1×/wk
FEV1 or PEF >60%-80% predicted; PEF variability 30%
Frequent
FEV1 or PEF ≤60% predicted; PEF variability >30%
Adapted from NHLBI, 1997.
BOX Controllers and relievers Controllers Corticosteroids Inhaled Beclomethasone dipropionate Budesonide Flunisolide Fluticasone propionate Triamcinolone acetonide Systemic Methylprednisolone Prednisolone Prednisone Antiinflammatory agents Cromolyn sodium Nedocromil Leukotriene modifiers Zafirlukast Montelukast Long-acting β2-agonist Salmeterol Methylxanthines Theophylline (sustained release) Formoterol Relievers Short-acting β2–agonist Albuterol Terbutaline Corticosteroids (systemic) Methylprednisolone Prednisolone Prednisone Anticholinergics Ipratropium bromide Adapted from NHLBI Expert Panel Report 2, 1997
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Geller (1996) suggests that the increase in mortality from asthma is related to the failure of patients, parents, and health care providers to recognize the severity of asthma; delayed or inadequate treatment; and excessive reliance on β2-agonists. Other possible causes include insufficient dosing or improper administration of medication.
T
he goals of the
treatment plan are to control asthma by reducing inflammation and bronchoconstriction.
A long-term treatment plan in matrix form (Mellins, Evans, Clark, Zimmerman, & Wiesemann, 2000) was formulated to provide step-by- step guidelines in asthma care as baseline symptoms move between mild and severe or even when new symptoms exist—for example, the earliest sign of a respiratory infection, a known trigger for exacerbations. The health care provider will discover throughout this article that the matrix provides predictability. It saves time and is practical for practitioner and
family use. The matrix incorporates recommendations based on guidelines produced by the expert panel of the National Asthma Education and Prevention Program Coordinating Committee and published by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institute of Health (NHLBI, 1997). The goals of the treatment plan are to control asthma by reducing inflammation and bronchoconstriction. The goal or purpose of the matrix form is to facilitate the implementation of the therapeutic plan by promoting self-regulation (Clark & Zimmerman, 1990).
PATHOPHYSIOLOGY Asthma is a chronic lung disease characterized by airway inflammation, airway obstruction that is at least partially reversible, increase in airway mucous production, and airway hyperresponsiveness. Although the cause of asthma remains unknown, in all but the mildest forms of the condition airway inflammation is initiated by a variety of triggers. Postmortem examination by Dunhill (1960) revealed airway wall remodeling. This remodeling showed smooth muscle hypertrophy, an increased number of epithelial goblet cells, and deposition of interstitial collagens beneath the epithelium. The inflammatory changes in the airways are the result of a cascade of cytokines and chemokines from mast cells, eosinophils, epithelial cells, macrophages, and activated T cells (Bisgaard,
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Name
Date
Spacer
CLINICAL CONDITION
Baseline plan & when asthma is under control
At the FIRST sign of a cold or mild attack†
For rapidly worsening asthma (severe attack)
Peak flow (% personal best)
80% or above
50% to 80%
below 50%
2 puffs as needed
2 puffs every 4 hr‡¶
2-4 puffs every 20 minutes for 3 doses then 2-4 puffs every 4 hr
0
0
Begin with 1-2 mg/kg/day§ NOTIFY MD
MEDICATION Reliever: Inhaled short-acting β2-agonist* Albuterol
Corticosteroid tablet or syrup
For cough or wheeze with exercise
2 puffs 5-10 minutes before exercise
Footnotes for clinicians only * Use more than 2×/wk may indicate need to initiate long-term controller (antiinflammatory) therapy. See long-term treatment plan for mild persistent asthma. † If viral infections provoke severe attacks (exacerbations), consider short course of corticosteroid tablets or syrup at the first sign of a cold or viral illness; see dose next column. ‡ The need for β2-agonist for more than 24-48 hours indicates at least a moderate attack; consider short course of corticosteroid tablets or syrup. § Maximum corticosteroid dose 60 mg/day; 3- to 11-day course. If there is not a good response, seek emergency care immediately. If there is a good response, continue in this column and notify health care provider. ¶ If β2-agonist needs to be given for 24 hours or longer more often than every 6 weeks, initiate long-term controller (antiinflammatory) therapy. See sample longterm treatment plan for mild persistent asthma.
FIGURE 1 Sample long-term treatment plan for mild intermittent asthma. From Mellins, R. B., Evans, D., Clark, N., Zimmerman, B., & Wiesemann, S. (2000). Developing and communicating a long-term treatment plan for asthma. American Family Physician, 61, 2422-2425. Copyright 2000 by American Family Physician. Reprinted with permission. 2000, Djukanovic et al., 1990, and Larsen & Holt, 2000). Although the factors responsible for the cause of chronic airway inflammation remain unknown, the development of or worsening of symptoms start with exposure of the airway to a trigger. Triggers vary among individuals and can include such things as allergens, viral infections, and exercise. Other triggers include gastroesophageal reflux, environmental irritants, weather changes, and the expression of emotion (Rietveld & Prins, 1998). Successful asthma therapy reduces the frequency and severity of symptoms and slows down the deterioration of pulmonary function that occurs with age. The overall goal of asthma therapy is to maintain normal or near normal activity levels, prevent exacerbations, and minimize or eliminate emergency department visits and/or hospitalizations. Reaching this goal includes achieving optimal pharmacotherapy with the least amount of adverse effects from medication. Multiple criteria, in-
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cluding symptoms and pulmonary function tests, can be used to determine the type and amount of medication.
A
lthough the factors
responsible for the cause of chronic airway inflammation remain unknown, the development of or worsening of symptoms start with exposure of the airway to a trigger.
The NHLBI (1997) guidelines presented the idea that treatment should be based on disease severity and established the following levels of asthma severity: mild intermittent, mild persistent, moderate persistent, and severe persistent (Table). These classifications are based on frequency of daytime and nighttime symptoms and peak flow measurements of lung function.
DIAGNOSIS OF ASTHMA A detailed history, including psychosocial and environmental factors, along with a complete physical examination, are essential in the diagnosis of asthma. However, reliance solely on physical findings to diagnose asthma, which provides only a “snapshot” in time, may be misleading. Spirometry is used in combination with a detailed history and physical examination to exclude other causes of airway dysfunction and to aid in the diagnosis of asthma. For spirometry the child must be at an age where cooperation can be elicited, usually about 5 to 6 years of age.
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Johnson, Wiesemann, & Anderson
Name
Date
Spacer
CLINICAL CONDITION
Baseline plan & when asthma is under control
At the FIRST sign of a cold or mild attack†
For rapidly worsening asthma (severe attack)
When there is no cough or wheeze for 2 mo
Peak flow (% personal best)
80% or above
50% to 80%
Below 50%
Over 80% for 2 months
2 puffs as needed
2 puffs every 4 hr‡
2-4 puffs every 20 minutes for 3 doses then 2-4 puffs every 4 hr
2 puffs as needed
1-4 puffs 2×/day
1-4 puffs 2×/day
1-4 puffs 2×/day
0
0
0
0
2 puffs 2-3×/day¶
0
0
Begin with 1-2 mg/kg/day§ NOTIFY MD
0
MEDICATION Reliever: Inhaled short-acting β2-agonist* Albuterol
Controller: (1) Inhaled low-dose corticosteroid† Beclomethasome 42µg or (2) Nonsteroid** Nedocromil Corticosteroid tablet or syrup
For cough or wheeze with exercise
2 puffs 5-10 minutes before exercise††
Footnotes for clinicians only * Daily or increasing use indicates need for more long-term controller (antiinflammatory) therapy. † Equivalent drugs: fluticasone 44 (1-2 puffs, 2×/day), flunisolide 250 (1 puff, 2×/day), budesonide 200 (inhalation 1×/day) or triamcinolone 100 (2-4 puffs, 2×/day). ‡ The need for β2-agonist for more than 24-48 hours indicates at least a moderate attack; consider short course of corticosteroid tablets or syrup. § Maximum corticosteroid dose 60 mg/day; 3- to 11-day course. If there is not a good response, seek emergency care immediately. If there is a good response, remain in this column and notify MD. ¶ When free of symptoms for 4 to 6 months, may try discontinuing controller medicines. ** Nonsteroids include cromolyn and nedocromil; in young children, these may be tried before inhaled corticosteroids. Antileukotriene agents may also be considered as an alternative: zafirlukast (20 mg 2×/day) or zileuton (600 mg 4×/day) for patients ≥12 years; montelukast 5 mg 1×/day for patients 6-14 years, 10 mg 1×/day for patients ≥15 years. †† If it is difficult to take short-acting β2-agonists before exercise, consider long-acting β2-agonist (salmeterol) to protect against exercise induced bronchospasm for up to 8 hours.
FIGURE 2 Sample long-term treatment plan for mild persistent asthma. From Mellins, R. B., Evans, D., Clark, N., Zimmerman, B., & Wiesemann, S. (2000). Developing and communicating a long-term treatment plan for asthma. American Family Physician, 61, 2422-2425. Copyright 2000 by American Family Physician. Reprinted with permission.
Peak flow meters are tools for assessing severity and monitoring the course of the disease (NHBLI, 1997). We have found them to be most useful in teens and young adults to help with daily peak flow monitoring. Peak flow meters are especially helpful to follow the response to therapy and to provide an early warning sign of an impending attack when individuals have difficulty assessing early changes in airway obstruction; this is especially true of persons with chronic symptoms.
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USING MEDICATIONS IN THE TEACHING PLAN Several factors are important in the management of asthma, including (a) reducing environmental exposures (eg, eliminating molds and reducing dust mites), (b) using appropriate medications, including guidelines for increasing and decreasing medication, and (c) treating rapidly worsening asthma. The focus of the matrix is specifically how to teach families to use medication appropriately. Asthma was once thought to be an episodic airway disease with the
focus of therapy on the use of bronchodilators (Lazarus, 1998). Although there continues to be a role for bronchodilators, the focus now is more on reversing the chronic inflammatory disease and starting treatment early. There are two categories of medications: long-term control medications (controllers) and rescue or quick-relief medications (relievers) (Box). Controllers are medications that are used daily over a long period to achieve and maintain control of persistent asthma (NHLBI, 1997). Relievers are used to
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Name
CLINICAL CONDITION
Peak flow (% personal best)
Date
Spacer
Baseline plan & when asthma is under control
At the FIRST sign of a cold or mild attack†
For rapidly worsening asthma (severe attack)
When there is no cough or wheeze for 2 mo
Baseline—60% to 80%; under control: 80% or above
50% to 80%
Below 50%
Over 80% for 2 months
0
2 puffs every 4 hr‡
2-4 puffs every 20 minutes for 3 doses§ then 2-4 puffs every 4 hr
0
2-4 puffs 2×/day
2-4 puffs 2×/day
2-4 puffs 2×/day
1 puff¶ 2×/day
0
0
Begin with 1-2 mg/kg/day§ NOTIFY MD
0
MEDICATION Reliever: Inhaled short-acting β2-agonist* Albuterol
Controller: (1) Inhaled mediumdose corticosteroid† Beclomethasome 84µg and (2) Long-acting β2-agonist‡‡ Salmeterol and (3) Antileukotriene¶ Corticosteroid tablet or syrup
For cough or wheeze with exercise
2 puffs 5-10 minutes before exercise**
Footnotes for clinician only * Daily or increasing use indicates the need for more long-term controller (antiinflammatory) therapy. † Equivalent drugs: fluticasone 110 (1-2 puffs, 2×/day), flunisolide 250 (2 puffs, 2×/day), budesonide 200 (1 inhalation 2×/day) or triamcinolone 100 (4-6 puffs, 2×/day). If night time symptoms not controlled, add long-acting inhaled β2-agonist 2×/day. ‡ The need for β2-agonist for more than 24-48 hours indicates at least a moderate attack; consider short course of corticosteroid tablets or syrup. § Maximum corticosteroid dose 60 mg/day; 3- to 11-day course. If there is not a good response, seek emergency care immediately. If there is a good response, continue in this column and notify MD. ¶ When free of symptoms for 4 months, use low-dose inhaled corticosteroid. ** If it is difficult to take short-acting β2-agonists before exercise, consider long-acting β2-agonist (salmeterol) to protect against exercise induced bronchospasm for up to 8 hours. †† Antileukotriene agents may be used as additive therapy: zafirlukast (20 mg 2×/day) or zileuton (600 mg 4×/day) for patients ≥12 years; montelukast 5 mg 1×/day for patients 6-14 years, 10 mg 1×/day for patients ≥15 years. ‡‡ If needed, consider long-acting inhaled β2-agonist (salmeterol 2 puffs, 2×/day) especially for nighttime symptoms.
FIGURE 3 Sample long-term treatment plan for moderate persistent asthma. From Mellins, R. B., Evans, D., Clark, N., Zimmerman, B., & Wiesemann, S. (2000). Developing and communicating a long-term treatment plan for asthma. American Family Physician, 61, 2422-2425. Copyright 2000 by American Family Physician. Reprinted with permission.
provide prompt relief of bronchoconstriction and its accompanying acute symptoms such as cough, chest tightness, and wheezing (NHBLI, 1997). Bronchodilators are inhaled β2-receptor agonists, which maintain airway opening and are classified as asthma relievers. β2-Agonists can be short acting or long acting. Short-acting β2-agonists, such as albuterol, provide quick relief of symptoms or bronchoconstriction. Longacting β2-agonists, such as salmeterol
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and formoterol, have been found to be useful in persons who still have symptoms while receiving high doses of inhaled corticosteroids (Russell, Williams, Weller, & Price, 1995). One benefit of the long-acting β2-agonist is that it is given twice a day (every 12 hours). It is still emphasized that short-acting β2-agonists such as albuterol, not long-acting β2-agonists, should be used for acute episodes. Although β2-agonists continue to be
prescribed as liquids or tablets, albuterol liquid is not recommended (NHLBI, 1997). Liquid medication requires gastrointestinal and systemic absorption, which could potentially produce an increase in adverse effects, especially tremulousness, wakefulness, and an increase in heart rate. Inhaled bronchodilator therapy has the benefit of fewer adverse effects than systemic oral bronchodilators. With the use of spacers, inhaled medications can be admin-
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PH ORIGINAL ARTICLE C
Johnson, Wiesemann, & Anderson
Name
Date Baseline plan & when asthma is under control
For rapidly worsening asthma (severe attack)
When there is no cough or wheeze for 2 mo
Baseline—below 60%; under control: 80% or above
Below 50%
Above 80% for 2 months
2-4 puffs as needed
2-4 puffs every 20 minutes for 3 doses§ then 2-4 puffs every 4 hr
2-4 puffs as needed
4-5 puffs 2×/day
4-5 puffs 2×/day
2-4 puffs 2×/day
2 puffs 2×/day
2 puffs 2×/day
2 puffs 2×/day
0.25-2 mg/kg/day‡
2 mg/kg/day NOTIFY MD
0
CLINICAL CONDITION
Peak flow (% personal best)
MEDICATION Reliever: Inhaled short-acting β2-agonist* Albuterol
Controller: (1) Inhaled high-dose corticosteroid† Beclomethasome 84µg and (2) Long-acting β2-agonist Salmeterol and (3) Antileukotriene¶ Corticosteroid tablet or syrup
Spacer For cough or wheeze with exercise
2 puffs 5-10 minutes before exercise
Footnotes for clinician only *Daily or increasing use indicates need for more long-term controller (antiinflammatory) therapy. †Equivalent drugs: fluticasone 110 (2-3 puffs, 2×/day), flunisolide 250 (2-3 puffs, 2×/day), budesonide 200 (1-2 inhalations 2×/day) or triamcinolone 100 (>6 puffs, 2×/day). ‡Maximum corticosteroid dose 60 mg/day. With improvement gradually lower dose and if possible change to every other day schedule. §If there is not a good response, seek emergency care immediately. If there is a good response continue in this column and notify MD. When free of symptoms for 4-6 months, reduce inhaled corticosteroids to medium dose. ¶Antileukotriene agents may be used as additive therapy: zafirlukast (20 mg 2×/day) or zileuton (600 mg 4×/day) for patients ≥ 12 years; montelukast 5 mg 1×/day for patients 6-14 years; 10 mg 1×/day for patients ≥ 15 years.
FIGURE 4
Sample long-term treatment plan for severe persistent asthma.
istered to even the youngest of infants (Levinson, Reilly, & Worsley, 1985). Ipratropium bromide may be used in conjunction with a β2-agonist such as albuterol to provide an enhanced bronchodilator effect (NHLBI, 1997). Ipratropium has a slow onset and should not be used as single therapy. Corticosteroids such as beclomethasone, fluticasone, budesonide, and flunisolide are used to reduce inflammation in the airways. Studies have shown that although the symptoms may cease after the use of bronchodilators, airways can remain inflamed, resulting in hyperresponsiveness for up to 2 months (Fraenkel et al., 1995; Lemanske, Dick, Swenson, Vrtis & Busse,
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1989). Some health care providers may hesitate to prescribe corticosteroids, and we have found that some families have been noncompliant in administer-
T
he focus of the matrix
is specifically how to teach families to use medication appropriately.
ing them. There are several reasons for this noncompliance. It has been our experience that many families do not understand the necessity of continued therapy in the absence of symptoms. In addition, many families and health care providers have a fear of using steroids in children (Agertoft & Pedersen, 2000; Sherman & Hendeles, 2000). In our practice, many families express concern about the possibility of growth inhibition resulting from the use of corticosteroids. Health care providers should take the time to address both of these issues (the necessity of continued therapy and the possibility of growth inhibition) with the family when corticosteroids are prescribed. Temporary inhibition of
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PH ORIGINAL ARTICLE C linear growth should not deter health care providers in prescribing corticosteroids if they are indicated. Although still a controversial subject, long-term studies (Agertoft & Pedersen, 1998) have failed to demonstrate a long-term effect when compared with a control group that did not take steroids. The NHLBI guidelines (NHLBI, 1997) recommend the use of inhaled corticosteroids when symptoms are present more than two times a week. Although controversy still exists, the general consensus is that low-dose inhaled corticosteroids, up to 400 µg per day in children, can be considered safe and have no significant effect on bones and growth in the majority of patients with asthma (Agertoft & Pedersen, 2000; Wolthers & Pedersen, 1992). Bronchodilators and inhaled corticosteroids are now available in powder form for inhalation both as single agents (eg, formoterol, budesonide, salmeterol, and fluticasone) and in combination formulas such as Advair. The benefit of these formulations seems to be that no spacer device is needed and they can be used by any patient who can take a deep breath to inhale the powder. Other agents, such as cromolyn sodium and nedocromil, work mostly as prophylactic agents to prevent inflammation or swelling when airways are exposed to a trigger. Cromolyn sodium nebulizer solutions are used as a means of reducing bronchodilator therapy (Prenner, 1982). These agents are not as potent as corticosteroids and are not useful once an attack has started. Their role is only prophylactic. Nedocromil has the benefit of twicedaily administration, whereas cromolyn sodium must be administered three to four times a day. Leukotriene modifiers are the newest classification of asthma treatment. These modifiers inhibit cysteinyl leukotrienes, which are products of arachidonic acid metabolism and are released from various cells, including mast cells and eosinophils (Bisgaard, 2000; Lazarus, 1998). Leukotriene modifiers appear to help decrease the use of oral and inhaled corticosteroids; however, their precise position in the management of asthma (Drazen et al., 1999) and in reducing exercise-induced asthma (Finnerty, Wood-Baker, Thomson, & Holgate, 1992) remains to be defined.
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Johnson, Wiesemann, & Anderson
THE MATRIX The matrix provides the family with a baseline plan, as well as a plan for increasing or adding medications if asthma control is worsening and for reducing the amount of medication as it improves. In essence, it is a long-term treatment plan.
T
he matrix facilitates the
educational process and provides the family with a sense of independence in the implementation of the overall treatment plan.
Experienced health educators have found that for a plan of care to work, the family must be actively included in the formation of the plan. Many parents do not want their child to have to take medication, especially for a prolonged period; indeed, not all children require daily asthma medications. However, until a child’s asthma is stabilized, daily medication is a necessity. A common goal of asthma therapy for the health care provider and family is to reduce the asthma medication to the least amount required for good control. Achieving this weaning process may take several months or longer. Individual treatment plans are available for asthma of varying severity: mild intermittent, mild persistent, moderate persistent, and severe persistent (Mellins et al., 2000). The treatment plan to be used can be based on the child’s asthma history. By using a matrix as a guide, a plan of care can be developed as follows for a child with mild persistent asthma (Figure 1). Each column lists a level of severity within that plan, such as baseline, when the asthma is under control. If a child has asthma symptoms three to six times a week, the plan for mild persistent asthma would be used. Because the child is presenting with symptoms just prior to the time of an office visit, the health care provider
can direct attention to the column that says, “at the first sign”; then the child would receive 2 puffs every 4 hours of a β2-agonist and one to two puffs of an inhaled low-dose corticosteroid two times a day. No other columns need to be addressed at that first visit. Upon the patient’s return, the health care provider will assess the severity of the child’s asthma and the family’s ability to follow the treatment plan thus far. More columns can be added as symptoms change. The matrix is an educational and communicative tool. The matrix offers flexibility as the treatment plan for asthma and allows the user to move up and down the spectrum of asthma symptoms, always keeping the overall goal in sight. Development of the matrix with the family, and providing a copy for the family, helps in many ways. The matrix is portable and can be used as a plan for school and as a weaning tool. It will help the family to see that one goal is to reduce the amount of medications used once good control has been achieved. Figure 2 displays an example of a matrix for a child with mild persistent asthma. For the matrix to be successful, the family must be given the tools to carry out the plan. Each line and column of the matrix must be clearly filled out. One copy should go to the family, and one should remain in the patient’s chart.
MEDICATION The health care provider should remind the family to bring all asthma medication to each asthma follow-up visit and to keep dated medications only. Based on the supply of asthma medications on hand with the family, prescriptions should be given to ascertain that the family can obtain asthma medication as needed. The family should be taught not to wait until the medications are low to refill them. It is easier to refill medications during daytime hours rather than in the middle of the night, and it is easier and more likely that the family will administer the medication if it is in the home rather than sitting at the pharmacy.
CONCLUSION Asthma continues to be a major health threat to children. Appropriate treatment continues to be the answer to pre-
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PH ORIGINAL ARTICLE C venting hospitalizations and emergency department visits. It all starts with education. It is the responsibility of the health care provider to incorporate the family into the education process. We use the matrix as a means of outlining the long-term treatment plan. The matrix facilitates the educational process and provides the family with a sense of independence in the implementation of the overall treatment plan. We acknowledge Robert B. Mellins, MD, for his commitment to families and to teaching clinicians to encourage self-management as they apply state-of-the-art asthma care.
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Djukanovic, R., Roche, W. R., Wilson, J. W., Beasley, C. R. W., Twentyman, O. P., Howarth, P. H., et al. (1990). Mucosal inflammation in asthma. American Review of Respiratory Disease, 142, 434-457. Drazen, J. M., Israel, E., & O’Bryne, P. M. (1999). Treatment of asthma with drugs modifying the leukotriene pathway. New England Journal of Medicine, 340, 197-206. Dunhill, M. S. (1960). The pathology of asthma, with special reference to changes in the bronchial mucosa. Journal of Clinical Pathology, 13, 27-33. Finnerty, J. P., Wood-Baker, R., Thomson, H., & Holgate, S. T. (1992). Role of leukotrienes in exercise-induced asthma. Inhibitory effect of ICI 204219, a potent leukotriene D4 receptor antagonist. American Review of Respiratory Disease, 145, 746-749. Fraenkel, D. J., Bardin, P. G., Sanderson, G., Lampe, F., Johnston, S. L., & Holgate, S. T. (1995). Lower airway inflammation during rhinovirus colds in normal and in asthmatic subjects. American Journal of Respiratory Critical Care Medicine, 151, 879-886. Geller, G. (1996). Acute management of severe childhood asthma. AACN Clinical Issues, 7, 519-528. Ladebauche, P. (1997). Managing asthma: A growth and development approach. Pediatric Nursing, 23, 37-44. Larsen, G. L., & Holt, P. G. (2000). The concept of airway inflammation. American Journal of Respiratory & Critical Care Medicine, 162(2 Pt 2), S2S6. Lazarus, S. (1998). Inflammation, inflammatory mediators, and mediator antagonists in asthma. Clinical Pharmacology, 38, 577-582. Lemanske, R. F., Dick, E. C., Swenson, C. A., Vrtis, R. F., & Busse, W. W. (1989). Rhinovirus upper respiratory infection increases airway hyperreactivity and late asthmatic reactions. Journal of Clinical Investigation, 83, 1-10. Levinson, H., Reilly, P. A., & Worsley, G. H. (1985).
Spacing devices and metered-dose inhalers in childhood asthma. Journal of Pediatrics, 107, 662-668. Mellins, R. B., Evans, D., Clark, N., Zimmerman, B., & Wiesemann, S. (2000). Developing and communicating a long-term treatment plan for asthma. American Family Physician, 61, 24192426. National Heart, Lung, and Blood Institute (NHLBI). (1997). National asthma education and prevention program. Expert Panel Report 2. Guidelines for the diagnosis and management of asthma (No. 97-4056). Bethesda, MD: Author. Plaut, T. (1991). One minute asthma: What parents need to know. Amherst: Pedipress. Prenner, B. M. (1982). Safety, efficacy and bronchodilators-sparing effects of nebulized cromolyn sodium solution in the treatment of asthma in children. Annals of Allergy, 49, 186189. Rachelefsky, G. S. (1995). Asthma update: New approaches and partnerships. Journal of Pediatric Health Care, 9, 12-21. Rietveld, S., & Prins, P. J. (1998). The relationship between negative emotions and acute subjective and objective symptoms of childhood asthma. Psychological Medicine, 28, 407-415. Russell, G., Williams, D. A. J., Weller, P., & Price, J. F. (1995). Salmeterol xinafoate in children on high-dose inhaled steroids. Annals of Allergy Asthma, & Immunology, 75, 423-428. Sherman, J., & Hendeles, L. (2000). Practical pharmacotherapy for pediatric asthma. Pediatric Annals, 12, 768-773. Wolthers, O. D., & Pedersen, S. (1992). Controlled study of linear growth in asthmatic children during treatment with inhaled glucocorticosteroids. Pediatrics, 89, 839-842. Yunginger, J. W., Reed, C. E., O’Connell, E. J., Melton, L. J., O’Fallon, W. M., & Silverstein, M. D. (1992). Community-based study of the epidemiology of asthma. Incidence rates 19641983. American Review of Respiratory Disease, 146, 888-894.
CALL FOR MANUSCRIPTS The Journal of Pediatric Health Care welcomes manuscripts related to pediatric clinical practice (ambulatory care, primary care, home health care, school health, inpatient care), health care policy, or role issues relevant to the pediatric nurse practicing in an expanded role. Please submit manuscripts to the Editor at the following address: Bobbie Crew Nelms, PhD, RN, CPNP 3133 Barbara St San Pedro, CA 90731 For details about the Journal’s editorial policy and manuscript preparation, see the Information for Authors pages.
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PH C
Using a Matrix as an Educational Approach to Asthma B e n ay Jo h n s o n , R N , M S N , C P N P, S a n d ra Wi e s e m a n n , R N - C S , M S N / M P H , & Ja n e A n d e r s e n , R N , M S
A
ABSTRACT Health care providers agree that asthma care must be individualized to fit the need of the child and family. A written plan in the form of a matrix enables the health care provider to give families a step-bystep individualized plan of care for asthma. This article discusses the use of a long-term treatment plan in matrix form as an educational tool for health care providers and for families. The written long-term plan can be used to guide treatment for any level of asthma severity. Following a review of asthma pathogenesis and diagnosis, categories of medications are presented, along with their role in a long-term treatment plan. The National Heart, Lung, and Blood Institute guidelines are used as a basis for the recommendations in the long-term treatment plan. J Pediatr Health Care. (2003). 17, 3-10.
January/February 2003
paradox exists regarding asthma. Although we now have a better understanding of the pathophysiology of asthma than ever before, along with access to better medications for asthma treatment, we are seeing an increased incidence of asthma, an increase in hospitalizations because of asthma, and higher rates of asthma morbidity and mortality. The treatment of asthma has been approached by way of medical and developmental models. Many resources, such as an educational booklet by Plaut (1991), an algorithm by Rachelefsky (1995), and a developmental model by Ladebauche (1997), provide suggestions for ways to simplify asthma treatment. However, the outcomes continue to be less than favorable, and asthma mortality continues to grow, especially among minorities and inner-city populations. Asthma is the most common chronic illness of childhood, with a prevalence rate of 6.9% (4.8 million children) in the United States (Centers for Disease Control and Prevention [CDC], 1996). The prevalence is even higher in minority populations. From 1980 to 1994, asthma has increased by 160% in children younger than 5 years (Yunginger et al., 1992). From 1979 to 1995, asthma deaths more than doubled in children 0 to 14 years of age (CDC, 1998). Benay Johnson is the Research Nurse Clinician for the Division of Pediatric Pulmonary and Pediatric Infectious Disease at Children’s Hospital of New York at Columbia University. She provides asthma education to families in the outpatient and inpatient settings. Sandra Wiesemann is a Certified Clinical Nurse Specialist in Community Health Nursing. She is the Nurse Educator/Project Coordinator for the School Health Asthma Study, which is a cooperative effort with the Columbia University College of Physicians and Surgeons, the New York City Department of Health Bureau of School Health, the Medical and Health Research Association of New York City, Inc, and the National Heart, Lung, and Blood Institute. Prior to this, Ms Wiesemann worked in the New York City public schools as a Public Health Nurse for the NYC Department of Health. Jane Andersen, RN, MS, is the Pediatric Pulmonary Clinical Nurse Specialist for the Division of Pediatric Pulmonary at Children’s Hospital of New York at Columbia University. For the purpose of this manuscript, Figures 1-4 are examples of matrices. They were originally in a periodical for family physicians, thus the reference to doctor/MD. However, advance practice nurses can readily use them in their practice. Reprint requests: Benay Johnson, RN, MSN, CPNP, Children’s Hospital of New York, 3959 Broadway BH 7 South, New York, NY 10032. Copyright © 2003 by the National Association of Pediatric Nurse Practitioners. 0891-5245/2003/$30.00 + 0 doi:10.1067/mph.2003.27
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TABLE Classification of asthma Classification
Mild intermittent Symptoms ≤2×/wk; asymptomatic and normal PEF predicted between exacerbations; exacerbations brief Mild persistent Symptoms >2×/wk, <1 time/day; exacerbation may affect activity Moderate persistent Daily symptoms; daily use of inhaled short-acting β2-agonist; exacerbations affect activity; exacerbations ≥2×/wk that may last for days Severe persistent Continual symptoms; limited physical activity; frequent exacerbations
Frequency of nighttime symptoms
Lung function
≤2×/mo
FEV1 or PEF ≥80% predicted; PEF variability <20%
>2×/mo
FEV1 or PEF ≥80% predicted; PEF variability 20%-30%
>1×/wk
FEV1 or PEF >60%-80% predicted; PEF variability 30%
Frequent
FEV1 or PEF ≤60% predicted; PEF variability >30%
Adapted from NHLBI, 1997.
BOX Controllers and relievers Controllers Corticosteroids Inhaled Beclomethasone dipropionate Budesonide Flunisolide Fluticasone propionate Triamcinolone acetonide Systemic Methylprednisolone Prednisolone Prednisone Antiinflammatory agents Cromolyn sodium Nedocromil Leukotriene modifiers Zafirlukast Montelukast Long-acting β2-agonist Salmeterol Methylxanthines Theophylline (sustained release) Formoterol Relievers Short-acting β2–agonist Albuterol Terbutaline Corticosteroids (systemic) Methylprednisolone Prednisolone Prednisone Anticholinergics Ipratropium bromide Adapted from NHLBI Expert Panel Report 2, 1997
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Geller (1996) suggests that the increase in mortality from asthma is related to the failure of patients, parents, and health care providers to recognize the severity of asthma; delayed or inadequate treatment; and excessive reliance on β2-agonists. Other possible causes include insufficient dosing or improper administration of medication.
T
he goals of the
treatment plan are to control asthma by reducing inflammation and bronchoconstriction.
A long-term treatment plan in matrix form (Mellins, Evans, Clark, Zimmerman, & Wiesemann, 2000) was formulated to provide step-by- step guidelines in asthma care as baseline symptoms move between mild and severe or even when new symptoms exist—for example, the earliest sign of a respiratory infection, a known trigger for exacerbations. The health care provider will discover throughout this article that the matrix provides predictability. It saves time and is practical for practitioner and
family use. The matrix incorporates recommendations based on guidelines produced by the expert panel of the National Asthma Education and Prevention Program Coordinating Committee and published by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institute of Health (NHLBI, 1997). The goals of the treatment plan are to control asthma by reducing inflammation and bronchoconstriction. The goal or purpose of the matrix form is to facilitate the implementation of the therapeutic plan by promoting self-regulation (Clark & Zimmerman, 1990).
PATHOPHYSIOLOGY Asthma is a chronic lung disease characterized by airway inflammation, airway obstruction that is at least partially reversible, increase in airway mucous production, and airway hyperresponsiveness. Although the cause of asthma remains unknown, in all but the mildest forms of the condition airway inflammation is initiated by a variety of triggers. Postmortem examination by Dunhill (1960) revealed airway wall remodeling. This remodeling showed smooth muscle hypertrophy, an increased number of epithelial goblet cells, and deposition of interstitial collagens beneath the epithelium. The inflammatory changes in the airways are the result of a cascade of cytokines and chemokines from mast cells, eosinophils, epithelial cells, macrophages, and activated T cells (Bisgaard,
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Name
Date
Spacer
CLINICAL CONDITION
Baseline plan & when asthma is under control
At the FIRST sign of a cold or mild attack†
For rapidly worsening asthma (severe attack)
Peak flow (% personal best)
80% or above
50% to 80%
below 50%
2 puffs as needed
2 puffs every 4 hr‡¶
2-4 puffs every 20 minutes for 3 doses then 2-4 puffs every 4 hr
0
0
Begin with 1-2 mg/kg/day§ NOTIFY MD
MEDICATION Reliever: Inhaled short-acting β2-agonist* Albuterol
Corticosteroid tablet or syrup
For cough or wheeze with exercise
2 puffs 5-10 minutes before exercise
Footnotes for clinicians only * Use more than 2×/wk may indicate need to initiate long-term controller (antiinflammatory) therapy. See long-term treatment plan for mild persistent asthma. † If viral infections provoke severe attacks (exacerbations), consider short course of corticosteroid tablets or syrup at the first sign of a cold or viral illness; see dose next column. ‡ The need for β2-agonist for more than 24-48 hours indicates at least a moderate attack; consider short course of corticosteroid tablets or syrup. § Maximum corticosteroid dose 60 mg/day; 3- to 11-day course. If there is not a good response, seek emergency care immediately. If there is a good response, continue in this column and notify health care provider. ¶ If β2-agonist needs to be given for 24 hours or longer more often than every 6 weeks, initiate long-term controller (antiinflammatory) therapy. See sample longterm treatment plan for mild persistent asthma.
FIGURE 1 Sample long-term treatment plan for mild intermittent asthma. From Mellins, R. B., Evans, D., Clark, N., Zimmerman, B., & Wiesemann, S. (2000). Developing and communicating a long-term treatment plan for asthma. American Family Physician, 61, 2422-2425. Copyright 2000 by American Family Physician. Reprinted with permission. 2000, Djukanovic et al., 1990, and Larsen & Holt, 2000). Although the factors responsible for the cause of chronic airway inflammation remain unknown, the development of or worsening of symptoms start with exposure of the airway to a trigger. Triggers vary among individuals and can include such things as allergens, viral infections, and exercise. Other triggers include gastroesophageal reflux, environmental irritants, weather changes, and the expression of emotion (Rietveld & Prins, 1998). Successful asthma therapy reduces the frequency and severity of symptoms and slows down the deterioration of pulmonary function that occurs with age. The overall goal of asthma therapy is to maintain normal or near normal activity levels, prevent exacerbations, and minimize or eliminate emergency department visits and/or hospitalizations. Reaching this goal includes achieving optimal pharmacotherapy with the least amount of adverse effects from medication. Multiple criteria, in-
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cluding symptoms and pulmonary function tests, can be used to determine the type and amount of medication.
A
lthough the factors
responsible for the cause of chronic airway inflammation remain unknown, the development of or worsening of symptoms start with exposure of the airway to a trigger.
The NHLBI (1997) guidelines presented the idea that treatment should be based on disease severity and established the following levels of asthma severity: mild intermittent, mild persistent, moderate persistent, and severe persistent (Table). These classifications are based on frequency of daytime and nighttime symptoms and peak flow measurements of lung function.
DIAGNOSIS OF ASTHMA A detailed history, including psychosocial and environmental factors, along with a complete physical examination, are essential in the diagnosis of asthma. However, reliance solely on physical findings to diagnose asthma, which provides only a “snapshot” in time, may be misleading. Spirometry is used in combination with a detailed history and physical examination to exclude other causes of airway dysfunction and to aid in the diagnosis of asthma. For spirometry the child must be at an age where cooperation can be elicited, usually about 5 to 6 years of age.
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Johnson, Wiesemann, & Anderson
Name
Date
Spacer
CLINICAL CONDITION
Baseline plan & when asthma is under control
At the FIRST sign of a cold or mild attack†
For rapidly worsening asthma (severe attack)
When there is no cough or wheeze for 2 mo
Peak flow (% personal best)
80% or above
50% to 80%
Below 50%
Over 80% for 2 months
2 puffs as needed
2 puffs every 4 hr‡
2-4 puffs every 20 minutes for 3 doses then 2-4 puffs every 4 hr
2 puffs as needed
1-4 puffs 2×/day
1-4 puffs 2×/day
1-4 puffs 2×/day
0
0
0
0
2 puffs 2-3×/day¶
0
0
Begin with 1-2 mg/kg/day§ NOTIFY MD
0
MEDICATION Reliever: Inhaled short-acting β2-agonist* Albuterol
Controller: (1) Inhaled low-dose corticosteroid† Beclomethasome 42µg or (2) Nonsteroid** Nedocromil Corticosteroid tablet or syrup
For cough or wheeze with exercise
2 puffs 5-10 minutes before exercise††
Footnotes for clinicians only * Daily or increasing use indicates need for more long-term controller (antiinflammatory) therapy. † Equivalent drugs: fluticasone 44 (1-2 puffs, 2×/day), flunisolide 250 (1 puff, 2×/day), budesonide 200 (inhalation 1×/day) or triamcinolone 100 (2-4 puffs, 2×/day). ‡ The need for β2-agonist for more than 24-48 hours indicates at least a moderate attack; consider short course of corticosteroid tablets or syrup. § Maximum corticosteroid dose 60 mg/day; 3- to 11-day course. If there is not a good response, seek emergency care immediately. If there is a good response, remain in this column and notify MD. ¶ When free of symptoms for 4 to 6 months, may try discontinuing controller medicines. ** Nonsteroids include cromolyn and nedocromil; in young children, these may be tried before inhaled corticosteroids. Antileukotriene agents may also be considered as an alternative: zafirlukast (20 mg 2×/day) or zileuton (600 mg 4×/day) for patients ≥12 years; montelukast 5 mg 1×/day for patients 6-14 years, 10 mg 1×/day for patients ≥15 years. †† If it is difficult to take short-acting β2-agonists before exercise, consider long-acting β2-agonist (salmeterol) to protect against exercise induced bronchospasm for up to 8 hours.
FIGURE 2 Sample long-term treatment plan for mild persistent asthma. From Mellins, R. B., Evans, D., Clark, N., Zimmerman, B., & Wiesemann, S. (2000). Developing and communicating a long-term treatment plan for asthma. American Family Physician, 61, 2422-2425. Copyright 2000 by American Family Physician. Reprinted with permission.
Peak flow meters are tools for assessing severity and monitoring the course of the disease (NHBLI, 1997). We have found them to be most useful in teens and young adults to help with daily peak flow monitoring. Peak flow meters are especially helpful to follow the response to therapy and to provide an early warning sign of an impending attack when individuals have difficulty assessing early changes in airway obstruction; this is especially true of persons with chronic symptoms.
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USING MEDICATIONS IN THE TEACHING PLAN Several factors are important in the management of asthma, including (a) reducing environmental exposures (eg, eliminating molds and reducing dust mites), (b) using appropriate medications, including guidelines for increasing and decreasing medication, and (c) treating rapidly worsening asthma. The focus of the matrix is specifically how to teach families to use medication appropriately. Asthma was once thought to be an episodic airway disease with the
focus of therapy on the use of bronchodilators (Lazarus, 1998). Although there continues to be a role for bronchodilators, the focus now is more on reversing the chronic inflammatory disease and starting treatment early. There are two categories of medications: long-term control medications (controllers) and rescue or quick-relief medications (relievers) (Box). Controllers are medications that are used daily over a long period to achieve and maintain control of persistent asthma (NHLBI, 1997). Relievers are used to
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Name
CLINICAL CONDITION
Peak flow (% personal best)
Date
Spacer
Baseline plan & when asthma is under control
At the FIRST sign of a cold or mild attack†
For rapidly worsening asthma (severe attack)
When there is no cough or wheeze for 2 mo
Baseline—60% to 80%; under control: 80% or above
50% to 80%
Below 50%
Over 80% for 2 months
0
2 puffs every 4 hr‡
2-4 puffs every 20 minutes for 3 doses§ then 2-4 puffs every 4 hr
0
2-4 puffs 2×/day
2-4 puffs 2×/day
2-4 puffs 2×/day
1 puff¶ 2×/day
0
0
Begin with 1-2 mg/kg/day§ NOTIFY MD
0
MEDICATION Reliever: Inhaled short-acting β2-agonist* Albuterol
Controller: (1) Inhaled mediumdose corticosteroid† Beclomethasome 84µg and (2) Long-acting β2-agonist‡‡ Salmeterol and (3) Antileukotriene¶ Corticosteroid tablet or syrup
For cough or wheeze with exercise
2 puffs 5-10 minutes before exercise**
Footnotes for clinician only * Daily or increasing use indicates the need for more long-term controller (antiinflammatory) therapy. † Equivalent drugs: fluticasone 110 (1-2 puffs, 2×/day), flunisolide 250 (2 puffs, 2×/day), budesonide 200 (1 inhalation 2×/day) or triamcinolone 100 (4-6 puffs, 2×/day). If night time symptoms not controlled, add long-acting inhaled β2-agonist 2×/day. ‡ The need for β2-agonist for more than 24-48 hours indicates at least a moderate attack; consider short course of corticosteroid tablets or syrup. § Maximum corticosteroid dose 60 mg/day; 3- to 11-day course. If there is not a good response, seek emergency care immediately. If there is a good response, continue in this column and notify MD. ¶ When free of symptoms for 4 months, use low-dose inhaled corticosteroid. ** If it is difficult to take short-acting β2-agonists before exercise, consider long-acting β2-agonist (salmeterol) to protect against exercise induced bronchospasm for up to 8 hours. †† Antileukotriene agents may be used as additive therapy: zafirlukast (20 mg 2×/day) or zileuton (600 mg 4×/day) for patients ≥12 years; montelukast 5 mg 1×/day for patients 6-14 years, 10 mg 1×/day for patients ≥15 years. ‡‡ If needed, consider long-acting inhaled β2-agonist (salmeterol 2 puffs, 2×/day) especially for nighttime symptoms.
FIGURE 3 Sample long-term treatment plan for moderate persistent asthma. From Mellins, R. B., Evans, D., Clark, N., Zimmerman, B., & Wiesemann, S. (2000). Developing and communicating a long-term treatment plan for asthma. American Family Physician, 61, 2422-2425. Copyright 2000 by American Family Physician. Reprinted with permission.
provide prompt relief of bronchoconstriction and its accompanying acute symptoms such as cough, chest tightness, and wheezing (NHBLI, 1997). Bronchodilators are inhaled β2-receptor agonists, which maintain airway opening and are classified as asthma relievers. β2-Agonists can be short acting or long acting. Short-acting β2-agonists, such as albuterol, provide quick relief of symptoms or bronchoconstriction. Longacting β2-agonists, such as salmeterol
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and formoterol, have been found to be useful in persons who still have symptoms while receiving high doses of inhaled corticosteroids (Russell, Williams, Weller, & Price, 1995). One benefit of the long-acting β2-agonist is that it is given twice a day (every 12 hours). It is still emphasized that short-acting β2-agonists such as albuterol, not long-acting β2-agonists, should be used for acute episodes. Although β2-agonists continue to be
prescribed as liquids or tablets, albuterol liquid is not recommended (NHLBI, 1997). Liquid medication requires gastrointestinal and systemic absorption, which could potentially produce an increase in adverse effects, especially tremulousness, wakefulness, and an increase in heart rate. Inhaled bronchodilator therapy has the benefit of fewer adverse effects than systemic oral bronchodilators. With the use of spacers, inhaled medications can be admin-
January/February 2003
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PH ORIGINAL ARTICLE C
Johnson, Wiesemann, & Anderson
Name
Date Baseline plan & when asthma is under control
For rapidly worsening asthma (severe attack)
When there is no cough or wheeze for 2 mo
Baseline—below 60%; under control: 80% or above
Below 50%
Above 80% for 2 months
2-4 puffs as needed
2-4 puffs every 20 minutes for 3 doses§ then 2-4 puffs every 4 hr
2-4 puffs as needed
4-5 puffs 2×/day
4-5 puffs 2×/day
2-4 puffs 2×/day
2 puffs 2×/day
2 puffs 2×/day
2 puffs 2×/day
0.25-2 mg/kg/day‡
2 mg/kg/day NOTIFY MD
0
CLINICAL CONDITION
Peak flow (% personal best)
MEDICATION Reliever: Inhaled short-acting β2-agonist* Albuterol
Controller: (1) Inhaled high-dose corticosteroid† Beclomethasome 84µg and (2) Long-acting β2-agonist Salmeterol and (3) Antileukotriene¶ Corticosteroid tablet or syrup
Spacer For cough or wheeze with exercise
2 puffs 5-10 minutes before exercise
Footnotes for clinician only *Daily or increasing use indicates need for more long-term controller (antiinflammatory) therapy. †Equivalent drugs: fluticasone 110 (2-3 puffs, 2×/day), flunisolide 250 (2-3 puffs, 2×/day), budesonide 200 (1-2 inhalations 2×/day) or triamcinolone 100 (>6 puffs, 2×/day). ‡Maximum corticosteroid dose 60 mg/day. With improvement gradually lower dose and if possible change to every other day schedule. §If there is not a good response, seek emergency care immediately. If there is a good response continue in this column and notify MD. When free of symptoms for 4-6 months, reduce inhaled corticosteroids to medium dose. ¶Antileukotriene agents may be used as additive therapy: zafirlukast (20 mg 2×/day) or zileuton (600 mg 4×/day) for patients ≥ 12 years; montelukast 5 mg 1×/day for patients 6-14 years; 10 mg 1×/day for patients ≥ 15 years.
FIGURE 4
Sample long-term treatment plan for severe persistent asthma.
istered to even the youngest of infants (Levinson, Reilly, & Worsley, 1985). Ipratropium bromide may be used in conjunction with a β2-agonist such as albuterol to provide an enhanced bronchodilator effect (NHLBI, 1997). Ipratropium has a slow onset and should not be used as single therapy. Corticosteroids such as beclomethasone, fluticasone, budesonide, and flunisolide are used to reduce inflammation in the airways. Studies have shown that although the symptoms may cease after the use of bronchodilators, airways can remain inflamed, resulting in hyperresponsiveness for up to 2 months (Fraenkel et al., 1995; Lemanske, Dick, Swenson, Vrtis & Busse,
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1989). Some health care providers may hesitate to prescribe corticosteroids, and we have found that some families have been noncompliant in administer-
T
he focus of the matrix
is specifically how to teach families to use medication appropriately.
ing them. There are several reasons for this noncompliance. It has been our experience that many families do not understand the necessity of continued therapy in the absence of symptoms. In addition, many families and health care providers have a fear of using steroids in children (Agertoft & Pedersen, 2000; Sherman & Hendeles, 2000). In our practice, many families express concern about the possibility of growth inhibition resulting from the use of corticosteroids. Health care providers should take the time to address both of these issues (the necessity of continued therapy and the possibility of growth inhibition) with the family when corticosteroids are prescribed. Temporary inhibition of
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PH ORIGINAL ARTICLE C linear growth should not deter health care providers in prescribing corticosteroids if they are indicated. Although still a controversial subject, long-term studies (Agertoft & Pedersen, 1998) have failed to demonstrate a long-term effect when compared with a control group that did not take steroids. The NHLBI guidelines (NHLBI, 1997) recommend the use of inhaled corticosteroids when symptoms are present more than two times a week. Although controversy still exists, the general consensus is that low-dose inhaled corticosteroids, up to 400 µg per day in children, can be considered safe and have no significant effect on bones and growth in the majority of patients with asthma (Agertoft & Pedersen, 2000; Wolthers & Pedersen, 1992). Bronchodilators and inhaled corticosteroids are now available in powder form for inhalation both as single agents (eg, formoterol, budesonide, salmeterol, and fluticasone) and in combination formulas such as Advair. The benefit of these formulations seems to be that no spacer device is needed and they can be used by any patient who can take a deep breath to inhale the powder. Other agents, such as cromolyn sodium and nedocromil, work mostly as prophylactic agents to prevent inflammation or swelling when airways are exposed to a trigger. Cromolyn sodium nebulizer solutions are used as a means of reducing bronchodilator therapy (Prenner, 1982). These agents are not as potent as corticosteroids and are not useful once an attack has started. Their role is only prophylactic. Nedocromil has the benefit of twicedaily administration, whereas cromolyn sodium must be administered three to four times a day. Leukotriene modifiers are the newest classification of asthma treatment. These modifiers inhibit cysteinyl leukotrienes, which are products of arachidonic acid metabolism and are released from various cells, including mast cells and eosinophils (Bisgaard, 2000; Lazarus, 1998). Leukotriene modifiers appear to help decrease the use of oral and inhaled corticosteroids; however, their precise position in the management of asthma (Drazen et al., 1999) and in reducing exercise-induced asthma (Finnerty, Wood-Baker, Thomson, & Holgate, 1992) remains to be defined.
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Johnson, Wiesemann, & Anderson
THE MATRIX The matrix provides the family with a baseline plan, as well as a plan for increasing or adding medications if asthma control is worsening and for reducing the amount of medication as it improves. In essence, it is a long-term treatment plan.
T
he matrix facilitates the
educational process and provides the family with a sense of independence in the implementation of the overall treatment plan.
Experienced health educators have found that for a plan of care to work, the family must be actively included in the formation of the plan. Many parents do not want their child to have to take medication, especially for a prolonged period; indeed, not all children require daily asthma medications. However, until a child’s asthma is stabilized, daily medication is a necessity. A common goal of asthma therapy for the health care provider and family is to reduce the asthma medication to the least amount required for good control. Achieving this weaning process may take several months or longer. Individual treatment plans are available for asthma of varying severity: mild intermittent, mild persistent, moderate persistent, and severe persistent (Mellins et al., 2000). The treatment plan to be used can be based on the child’s asthma history. By using a matrix as a guide, a plan of care can be developed as follows for a child with mild persistent asthma (Figure 1). Each column lists a level of severity within that plan, such as baseline, when the asthma is under control. If a child has asthma symptoms three to six times a week, the plan for mild persistent asthma would be used. Because the child is presenting with symptoms just prior to the time of an office visit, the health care provider
can direct attention to the column that says, “at the first sign”; then the child would receive 2 puffs every 4 hours of a β2-agonist and one to two puffs of an inhaled low-dose corticosteroid two times a day. No other columns need to be addressed at that first visit. Upon the patient’s return, the health care provider will assess the severity of the child’s asthma and the family’s ability to follow the treatment plan thus far. More columns can be added as symptoms change. The matrix is an educational and communicative tool. The matrix offers flexibility as the treatment plan for asthma and allows the user to move up and down the spectrum of asthma symptoms, always keeping the overall goal in sight. Development of the matrix with the family, and providing a copy for the family, helps in many ways. The matrix is portable and can be used as a plan for school and as a weaning tool. It will help the family to see that one goal is to reduce the amount of medications used once good control has been achieved. Figure 2 displays an example of a matrix for a child with mild persistent asthma. For the matrix to be successful, the family must be given the tools to carry out the plan. Each line and column of the matrix must be clearly filled out. One copy should go to the family, and one should remain in the patient’s chart.
MEDICATION The health care provider should remind the family to bring all asthma medication to each asthma follow-up visit and to keep dated medications only. Based on the supply of asthma medications on hand with the family, prescriptions should be given to ascertain that the family can obtain asthma medication as needed. The family should be taught not to wait until the medications are low to refill them. It is easier to refill medications during daytime hours rather than in the middle of the night, and it is easier and more likely that the family will administer the medication if it is in the home rather than sitting at the pharmacy.
CONCLUSION Asthma continues to be a major health threat to children. Appropriate treatment continues to be the answer to pre-
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PH ORIGINAL ARTICLE C venting hospitalizations and emergency department visits. It all starts with education. It is the responsibility of the health care provider to incorporate the family into the education process. We use the matrix as a means of outlining the long-term treatment plan. The matrix facilitates the educational process and provides the family with a sense of independence in the implementation of the overall treatment plan. We acknowledge Robert B. Mellins, MD, for his commitment to families and to teaching clinicians to encourage self-management as they apply state-of-the-art asthma care.
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CALL FOR MANUSCRIPTS The Journal of Pediatric Health Care welcomes manuscripts related to pediatric clinical practice (ambulatory care, primary care, home health care, school health, inpatient care), health care policy, or role issues relevant to the pediatric nurse practicing in an expanded role. Please submit manuscripts to the Editor at the following address: Bobbie Crew Nelms, PhD, RN, CPNP 3133 Barbara St San Pedro, CA 90731 For details about the Journal’s editorial policy and manuscript preparation, see the Information for Authors pages.
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Volume 17 Number 1
JOURNAL OF PEDIATRIC HEALTH CARE