Two nurse practitioners specializing in asthma management discuss how to recognize when a patient’s asthma is uncontrolled, factors causing these exacerbations, and advice on management. NPs and PAs: claim your credit at pce.is/asthma
As many as 20% of patients with asthma may not be achieving adequate control of their symptoms, even after they have maximized inhaled corticosteroids and their long-acting beta 2 agonist. If left uncontrolled, patients are at increased risk for serious exacerbations that can lead to ED visits and extended hospitalizations. In this podcast, Corinne Young, FNP-C, president of the Association of Pulmonary Advanced Practice Providers, talks with her colleague Ann Hefel, FNP, an allergy and asthma specialist from Children’s Hospital Colorado about reasons for poor asthma control and how to conduct an effective patient workup to identify the potential causes. This episode is available for CE/CME credits for NPs and PAs.
YOUNG: Welcome to the Practicing Clinicians Exchange Podcast: Optimizing Outcomes in Moderate to Severe Asthma, Utilizing Add-on Therapy for Individualized Treatment. I'm your host, Corinne Young. I'm a nurse practitioner with Colorado Springs Pulmonary Consultants and I'm also the President of the Association of Pulmonary Advanced Practice Providers. This episode today, we're talking about how to recognize whether your patient's asthma is uncontrolled.
With me today is the one and only Ann Hefel. She is a nurse practitioner who works in asthma and allergy and she's worked at such giants as National Jewish, University of Colorado and is currently with Children's Hospital of Colorado.
This program is accredited for joint accreditation by Practicing Clinicians Exchange for 0.5 ANCC and AAPA credits with 0.5 credits applicable for pharmacology credits for NPs. This program is supported by an educational grant from Novartis. To receive credit for this program, go to PCE.is/asthma. Our learning objective for this program is at the conclusion of this podcast, you, the learner will be able to better recognize factors involved in controlled asthma. So, let's get started.
So, Anne, we know that up to 20% of our patients with asthma may not be achieving adequate control of their symptoms. even after we maximize inhaled corticosteroids and long acting beta2 dosages, uh, if left out of controlled, we know the problem with this is that our severe asthma patients start having exacerbations, hospitalizations, decreased lung function, uh, start having increased used overall of healthcare utilization. And so, we want to try to help these patients.
So, I wanted to talk a little bit with you about what an uncontrolled asthmatic looks like to you. Uh, what are some questions that you ask them? What are some things that you look for when you're talking about patients that maybe uncontrolled?
HEFEL: Yeah, thanks for having me. So, really one of the first things I want to talk to with the patient about is what are their symptoms? I often see things like a cough which can be productive or unproductive, trouble breathing, chest tightness or heaviness, wheezing, waking up at night or early in the morning. It's, you know, important I think to ask patients to tell you how they define wheezing or shortness of breath, because their definition might be different than yours. Uh-
YOUNG: Oh yeah.
HEFEL: Yeah, yeah. One example I can think of is, you know, we see a lot of nose issues in allergy and sometimes when a patient is describing shortness of breath, you get down to, , asking a few more questions to get more detail and you really find out that they're just congested. So, so, finding out what they mean, when they're describing those symptoms I think is really important.
YOUNG: And Anne, that congestion I think is also an important path to run down because it's one continuous airway, right? From the tip of their nose, to the bottom of their lungs and what may cause some irritation upstairs can influence downstairs and I know in my practice, I see that a lot. They could be independent but oftentimes kind of run together. So nasal symptoms along with their lower respiratory symptoms.
HEFEL: Yeah, absolutely, yeah. It's important to take care of all, all aspects of that.
YOUNG: So, how do you kind of tease away as far as symptoms that may be leaning towards, something other than asthma? You know, you're looking at maybe all differentials for this asthmatic to be uncontrolled, what, what other factors are you looking at?
HEFEL: I think, it's important to, to really determine if what they're truly experiencing is asthma. So, so not all shortness of breath is asthma, not all coughing is asthma. I'm thinking about could there be problems with their heart? Could they have an infection, maybe they have a long smoking history and they have a history of asthma but now, we're concerned about malignancy, or they traveled recently and we have to be worried about could they have a clot.
YOUNG: Mm-hmm. And then there are those other comorbid conditions that we know really aggravate their asthma like GERD, right?
HEFEL: Yeah, absolutely, yeah. So, so, allergies, gastroesophageal reflux disease, sleep apnea, obesity, cardiac issues, all of these are problems that can definitely exacerbate their asthma or make it worse. S
Some diagnoses that can make the asthma treatment more complicated would be, uh, allergic bronchopulmonary aspergillosis, or ABPA. This isn't very common, but you would want to think about it in a patient that has extremely elevated IGE levels, eosinophil levels, and a patient who has abnormal imaging. So, these patients will have bronchiectasis on their CT scan, and they'll also have positive allergy testing to aspergillosis.
So, this is a condition where the immune system has a severe response to the aspergillus, and it leads to changes in the airway. So, so these patients tend to need longer, more frequent courses of oral steroids and definitely need some specialized treatment. So, so you should be referring to a specialist if, if you're at all suspicious or finding that their numbers and their laboratory studies are, are very elevated. We also think about non-tuberculosis mycobacterium or other atypical infections and lean a lot on our, uh, pulmonary colleagues for that. But sometimes we see that with the sputum testing that we do, or we have to refer a patient for a bronchoscopy.
YOUNG: What other things do you look for in sputums when you run them on your asthma patients?
So, for the sputum testing, we're looking at both the cell counts. So, we're looking at eosinophils for the Type 2 asthmatic. We're also looking at neutrophils for the non-Type 2 asthmatic.
So with the sputum cultures, we also get acid-fast bacilli testing or AFB testing to look for non-tuberculosis mycobacterium, or NTM. Chronic rhinosinusitis or nasal polyps is a really common problem in patients with severe eosinophilic asthma. One way these patients might present is they may come to you and say that they can no longer smell their coffee in the morning, they have complete obstruction of their nasal passages or constant drainage. Maybe you look back at their primary care records, and you see that they have been all kind- been on lots of antibiotics for recurrent sinus infections. And these types of patients are also the ones that are most likely to suffer from that NSAID or aspirin sensitivity.
YOUNG: So, once you've identified that it may not be a comorbid influence or that there's no other differentials contributing to their symptoms being uncontrolled. The next thing you talk about is their medication. So, where do you start and, and how do you, you talk to them about their medications?
HEFEL: I generally start with questions about their rescue inhaler or their short acting beta agonist. So, how often are they using it and then if they are using it, does it help them? And if so, for how long? Once we get into that, if they're using it more than two to three times a week for symptoms, that's when I'm starting to get concerned. So, so, I separate out when they're just using it as a pretreatment for exercise versus how often they're using it for symptoms. That's really what I'm worried about or more concerned about.
Once we've gone into that, then, we like to talk about the control of therapy. So, I like to just start out with saying how many times a week do you miss your controller therapy? I think that's a better way to set it up with that expectation, we know that every patient is not compliant 100% of the time. So I want to frame it like that so, so they know we're not right here to judge them. We just want to get an honest answer to determine how much the compliance is affecting their lack of control.
With the controller therapy, there's a lot of reasons why a patient may not be taking it. So, it might be it's too expensive. Perhaps it gives them side effects. Like it makes their throat feel funny or it's really affected their voice or maybe they just can't remember it and if they live a really busy lifestyle. So, we try to troubleshoot ways to help them with those issues to see if we can bump up their adherence.
YOUNG: I like that. I'm going to steal that from you. How many times are you missing? I use that with smoking. I say, "Are you smoking two packs a day?" And they're like, "Oh God, no, just a pack a day." You know. (laughs) So, yeah, I, I agree. Kind of framing that a little bit as to the norm is that we understand patients missed doses. I'm going to steal that from you.
All right, so outside of medications, you, they're telling you they're taking everything. They're, they're as compliant as possible with their medications. What else do you look for that might be influencing them to exacerbate or not be well controlled?
HEFEL: Well, if it's a new problem, I want to ask them, has there been anything that changed since we last got together? So, did you get a new job? Maybe they've entered into a construction field and they're exposed to dirt and dust outside all the time. Maybe they recently started veterinarian school or they're a dog groomer and now they have frequent exposure to animal dander. Did they start smoking or vaping? Or did they start any new medications that might actually be interfering with their asthma treatment of making them feel worse.
YOUNG: Like what types of things would you look for as far as medications?
So, we might see medications that could be sedating, that may affect their respiratory drive like opioids, or some of the older non-selective beta blockers which could affect their bronchospasm and affect their long acting beta agonist from being effective. And then more acute situations might be a patient say that rarely needs to take any pain meds and they're taking ibuprofen and suddenly, you know, within 30 minutes, they are having trouble breathing, their nose is completely clogged and they're in the emergency room. There are those patients that are aspirin and NSAID sensitive and they may present you with a few exacerbations and once you ask more questions, you find out that those were actually directly tied to them using those types of meds.
YOUNG: Good pointer. All right, and then I'm sure we all see in the winter time with viruses and things like that, I know I see a ton of exacerbations on our clinic during that kind of cold, flu season, and I'm sure in your clinic, you see the same thing.
HEFEL: Yeah, absolutely.
YOUNG: Yeah.
HEFEL: I really think of, you know, teachers. I think of parents with young children that are in daycare. They're always bringing home all kinds of viruses and bacteria that they're spreading to their parents. So that's certainly an important indicator as well. If they're reporting a seasonal pattern and they say it's worse in the winter you might think more are we dealing with a patient who's suffering from frequent infections in the winter versus I have more trouble in the spring and the fall which might be more allergy-driven.
YOUNG: Okay. So, take me through, if I was a patient coming into you, you know, at Children's Hospital or University of Colorado and I have these symptoms, what, what's your exam going to look like for these patients? Other than the questioning with medications and those types of things that we just talked about, what's your go-to as far as examining and testing and tools that you use and resources?
HEFEL: Yeah, so we're definitely doing that that full like chest exam, you know, listening for things like wheezing, decreased air moment, prolonged expiratory phase, assessing for signs of cardiac disease like lower extremity edema, We look at the vital signs. So, you know, if a patient with asthma is hypoxic, that's a pretty bad sign that either, you know, something else is going on and they're in big trouble.
In kids, you might see things like a crease on the bridge of their nose which they can, uh, develop that just from wiping their nose frequently because their, you know, mucus is draining constantly, and then getting a really good look at their nasal passages to look for things like polyps, uh, or swelling or obstruction.
YOUNG: How frequently are you doing spirometry in your patients? Controlled, versus uncontrolled patients?
HEFEL: We like to get a spirometry on a patient at minimum once a year, and if we're changing treatments, we are doing that with every treatment change typically just to assess for a response or an improvement. I think it's also helpful to do it if you haven't really gotten the objective findings to confirm your diagnosis of asthma. So, maybe every time your patient comes in, their spirometry is normal, you might think, I don't need to get this anymore. , but, they may only have a decrease in their lung function when they're sick. And so, I think it's helpful to get some documentation so you can really provide that supporting evidence for your diagnosis.
YOUNG: Sure. So, I know, I'm in a private practice and time gets a little tight when you're seeing patients and doing things like the asthma control test, you know, maybe something that's kind of hit or miss at some times. And so, so how important is the asthma control test to you?
HEFEL: I think it's pretty important, uh, we, we use it with every asthmatic appointment. So, so, we have our medical assistant or registered nurse. If asthma is on the problem list, it's listed as one of the issues that are coming to see us for and they're automatically just get handed the clipboard with the questionnaire right when they sit down in the room.
So they're, they're pretty short. They're about five questions. You can do them in kids as young as four years of age. And they have a different one for people who are 12 and older. So, it's five questions, pretty quick.
And it's an easy way to assess their asthma. I think sometimes when you just throw that question out there, "Do you feel like you're doing well with your asthma?", the patients tell you, "Yes." But once you get into that ACT, you find out that really, that's not the case.
YOUNG: Okay, all right. So, let's talk a little bit more about phenotypes of asthma patients. This is where kind of a lot of the exciting research and, and papers and journal articles have been focusing over the last several years in asthma. So, when you talk about a phenotype of patient, tell me what you're looking for when you are phenotyping your patients.
HEFEL: Yeah, asthma is definitely not a one size fits all diagnosis. So, every person that comes in with asthma, it may look different. It's a heterogeneous disease. When we talk about phenotypes, we're really referring to those observable characteristics or their traits, individual to that type of asthma.
So some different phenotypes, some examples of these are allergic asthma, eosinophilic asthma. These are referred to typically as a Type 2 type of asthma versus the non-Type 2, which might be a neutrophilic form of asthma that might be adult onset, is more frequently associated with obesity. And then you can break it down into, are they severe, are they not severe, is it occupational, exercise-induced. There's a lot of different phenotypes, as I mentioned. And those phenotypes can actually help direct your treatment.
YOUNG: And when we talk about Type 2 inflammation in these patients, can you expand a little bit on that about what you're, exactly the, the markers you're looking at?
HEFEL: Yeah, So, Type 2 inflammation, what, what we're referring to with this is our TH2 cells. So, those cells, once they're activated, can lead to allergic and eosinophilic airway inflammation which then subsequently leads to the release of immunoglobulin E. And recruitment of those eosinophils to sites of inflammation in our body. Places that those eosinophils like to go are the lungs, the esophagus, and your sinuses.
YOUNG: All right. So, when you're looking for these phenotypes, what kind of testing are you doing on these patients to, to figure out if they, if they are this Type 2 inflammatory asthmatic?
HEFEL: We've got some tests that might be readily available to the primary care provider, and some of those could be spirometry. You can do a prebronchodilator. Give them some albuterol, and then wait 15 minutes and do a postbronchodilator to assess for a response.
You can get some blood work drawn. So, you can just get a basic CBC with the differential. That will tell you their eosinophil counts, and you can easily get an immunoglobulin E level as well.
So one important thing to note about that, one caveat is that if this patient of yours has just been on a course of oral steroids in the last one to two months, the numbers of their eosinophils and their IGE level will, will probably be decreased or depressed. So, it's not a bad idea if, if you can wait to give them some time after that exacerbation before you get that, that blood draw. Or you can always just refer them to the asthma specialist, and we're happy to work that out.
YOUNG: Yeah. Yeah, I had a patient, uh, discharged after intubated for an asthma exacerbation. She really strongly felt allergic triggers were causing it. Her CBC at discharge, her eosinophils were zero. And then, a few months later, a few weeks later it was elevated in the 400's. After she'd been off all the steroids from the hospital.
So, I've definitely seen that in practice.
HEFEL: Yeah. We sometimes have to do a little detective work and dig back. You know, most of our patients have had a CBC at some point, so sometimes we're looking for that information, digging back into their records.
YOUNG: Are you using FeNO in your practice? And if so, help me understand how you're utilizing that tool to manage these uncontrolled asthmatics?
HEFEL: So, I would say there's some situations where we would use the FeNO. So, that stands for exhaled nitric oxide. It's a pretty basic breathing test that you can do in the office with your patient. Where I find it to be helpful is say, I have a patient who has a completely normal CBC. The eosinophils are normal. They've had completely normal lung function, but I feel pretty strongly that they likely have asthma.
Then I might see if that FeNO provides that information that I need. So, an elevated FeNO is associated with that eosinophilic airway inflammation, and that type of airway inflammation usually does respond pretty well to oral and inhaled corticosteroids.
YOUNG: Ok so you’ve used these tools, you’ve decided your patient is uncontrolled as far as their asthma management goes. What’s your next step?
HEFEL: So, once we've determined it's definitely asthma, they're definitely uncontrolled, then we're starting to look at the treatments that they are on. Is their therapy suboptimal? So, we know that inhaled corticosteroids are a great treatment for asthma, but some patients need more than that.
So the next step up, step four therapy would be inhaled corticosteroid or ICS slash long-acting beta agonists, or LABA therapy. Once we've moved them onto a high dose of an ICS LABA, and they're still uncontrolled, that's where we do consider adding things like leukotriene receptor antagonists. Montelukast is an example of that, or a long-acting muscarinic agent like tiotropium, which, you know, this was previously labeled just for use in COPD, but more recently in the United States we've been able to start using in asthmatics all the way down to six years of age. So that might be a treatment that we'd start.
And once we're getting to that point, that's when we're starting to work them up for their phenotypes, as we had just talked about. But getting those laboratory studies, getting that allergy testing. just trying to figure out exactly what type of asthma we have, so that we can direct treatment if we have to go the next route, which would be the biologics.
YOUNG: And, you know, you get these eosinophils back, and they're horribly elevated. Like, they are significantly elevated, and your patient's only responding to prednisone. Are there other things you start thinking about?
HEFEL: That's where I start thinking about the biologic therapies. So, we've got five different biologic therapeutic options for our severe asthmatics. So, we start thinking about their phenotype. So, are they an allergic phenotype? Are they an eosinophilic phenotype? And then we can start to drill down to what types of medications might work best for them.
And, by doing that, we, we typically go over the patients, the dosing regimens. Whether they can get it at home, whether it's subcutaneous or IV. Or whether those biologics maybe have a secondary indication for a patient, for example, that also has atopic dermatitis. They might be a better candidate for dupilumab, which is indicated for both severe asthma and atopic dermatitis. As opposed to omalizumab, which is approved for allergic asthma and chronic idiopathic urticaria.
One other thing we didn't talk about yet was poor inhaler technique and how this can also be a factor. If you have the ability to do this, if your patient has their inhaler on them, it's nice to have them demonstrate to you how they use it.
YOUNG: Oh, yeah.
HEFEL: Yeah. Yeah, I don't know
YOUNG: I've learned a lot (laughing) watching patients use their inhalers.
HEFEL: I think, you know, especially sometimes with our elderly patients, they may be struggling with their inspiratory capacity to get a full dose. And with kids, the technique can be pretty poor. And also adding a spacer for those metered dose inhalers can be really helpful for some patients.
YOUNG: If you have addressed all their medications, you've addressed their triggers or risk factors, their comorbid conditions, what are the next things that you're looking for that may just be kind of outliers influencing or maybe mimicking this uncontrolled asthmatic type patient?
HEFEL: So, we consider heart failure. Those patients could present with lower extremity edema, fatigue, orthopnea. We also definitely see pulmonary hypertension, a little more so at the high altitude we're in in Colorado. I'm sure you see that a lot.
YOUNG: Oh, yeah.
HEFEL: Vocal cord dysfunction is another consideration, so sometimes those patients present with more trouble with inhaling versus exhaling. They describe throat tightness. They describe a rapid onset of symptoms when they have an irritant exposure like perfume or cleaning spray. And those patients might tell you that the albuterol just doesn't really work, or if it does, it lasts for 20 minutes to 30 minutes, and then wears off.
And then also just considering malignancy, sarcoidosis, COPD. Really, if, you know, in the asthma allergy world, if, if we are still struggling at that point once we've gotten them up to step five therapy, we're definitely doing a multidisciplinary approach. So, we're involving perhaps social work, if they're having trouble affording medications. We get our nurses and respiratory therapists involved for education. We involve the pulmonary team to see if there's anything that we're missing or any outliers that we have not covered.
So I think that, you know, in those severe asthmatics, it's definitely a team approach where we're all getting involved. And we're all trying to contribute and see what we can do to help those patients get a better quality of life.
YOUNG: Perfect. Ann, thank you so much for such a great discussion. I feel like I have learned a bunch from you, and I appreciate that. Please tune into our next podcast, which is Managing Uncontrolled Asthma, the Primary Care/Specialist Partnership. In this podcast, we'll be diving a little deeper into those treatment plans and treatment medications and how to utilize them.
You can find that podcast at PCE.is/asthma. Also, don't forget to claim your CEs at that same web address, PCE.is/asthma. Thank you for joining us.