Asthma Care Guide

Asthma is one of the most prevalent chronic conditions, affecting 2.3 million Canadians over the age of 4 years, with an estimated total cost of between $504 million and $648 million in 1991 (Krahn et al., 1996).

RNAO Resources Best Practice Guidelines · Adult Asthma Care Guidelines for Nurses: Promoting Control of Asthma · Promoting Asthma Control in Children   The Goal is Asthma Control Health Education Facts Sheet [PDF - 288 KB] Referencing this page?

According to the latest statistics, almost 1 million Ontarians aged 4 years and older have been diagnosed with asthma (Statistics Canada, 2000). A significant increase in the prevalence of asthma in Ontario has occurred in recent years – from 7.4% of those aged 4 and older in 1994/95 to 8.9% in 1998/99 (Statistics Canada, 2000).

Although most people with asthma can achieve good asthma control, many do not. Many underestimate the severity and control of their asthma and continue to restrict their everyday activities, and suffer needlessly. Proper asthma management can lead to better asthma control and may reduce the incidence of death from asthma by as much as 80% (Institute for Clinical Evaluative Sciences in Ontario, 1996). These increases in the prevalence of asthma and associated morbidity and cost are occurring despite advances in our understanding and treatment.

What Is Asthma?
Asthma is a chronic inflammatory disorder of the airways characterized by an increase in airway responsiveness and airway narrowing, which leads to difficulty in breathing. Asthma is usually classified as mild, moderate or severe. Although symptoms vary from person to person, common symptoms include shortness of breath, chest tightness, wheezing, and/or coughing.

Asthma episodes may begin suddenly or may have a slow onset with a gradual worsening of symptoms. These episodes can last for a few minutes to several days, and are attributed to a hyperresponsiveness of the airways and are typically reversible (The Lung Association, 2000). When individuals with asthma are exposed to triggers that they are sensitive to, the airway narrows. This narrowing develops in one or two ways:

• The airway becomes swollen and plugged with mucous (inflammation), thus making the airway opening considerably smaller. This is depicted in the middle picture. This inflammation can last from a few hours to a few days to a lifetime.
• The muscles surrounding the airway tighten and go into spasm (bronchospasm).

Regardless of the person’s asthma severity, any loss of asthma control can potentially be life-threatening. The goal of asthma care is to control or prevent the airway inflammation and to minimize the symptoms experienced and interruptions to daily life. Components of asthma management include education, environmental control measures, appropriate medications, action plans, establishing a partnership between the client and provider and regular follow-up care.

What causes asthma?
Although the exact cause of asthma is not known, several predisposing factors have been
implicated in its development. These include atopy – a greater tendency to have allergic reactions
to environmental allergens (Sporik et al., 1990); genetics – a family history of asthma and/or atopy (Larsen, 1992; Millar & Hill, 1998); and exposure to environmental tobacco smoke (Arshad, 1992; Cook &
Strachan, 1997; Soyseth, Kongerud & Boe, 1995; Stoddard & Miller, 1995).

There are several triggers that may irritate the hypersensitive airways in people with asthma and provoke an asthma episode. Common triggers include:

a) Irritants such as:

• Tobacco smoke (BTS/SIGN, 2003; Boulet et al., 2001, 1999; Chilmonczyk, Salmun & Megathlin, 1993;
  GINA, 2002; Murray & Morrison, 1986; Murray & Morrison, 1989; NIH, 1997; NZGG, 2002; United States
  Environmental Protection Agency, 1992);
• Exercise⁺ (American Academy of Allergies, Asthma, and Immunology et al., 1999; Boulet et al., 1999; GINA, 2002; NZGG, 2002);
• Exposure to work-related agents or indoor chemicals (American Academy of Allergy, Asthma,
  and Immunology et al., 1999; Boulet et al., 1999; Egan, 1985; GINA, 2002; NIH, 1997; NZGG, 2002; Packe, Archer & Ayres, 1983; Salvaggio et al., 1970; Usetti et al., 1983; Virchow et al., 1988);
• Outdoor pollutants (BTS/SIGN, 2003; Boulet et al., 1999; Burnett et al., 1995; Cody, Weisel, Birnbaun & Lioy, 1992; Delfino, 1994; GINA, 2002; Hoek & Brunekreef, 1995; NIH, 1997; NZGG, 2002; Pope, 1989; Pope, 1991; Rennick & Jarman, 1992; Roemer, Hock & Brunekreef, 1993; Schwartz, Slater, Larson, Pierson & Koenig, 1993).

⁺Despite its potential to be a trigger, with a proper warm up, people with exercise-induced asthma should be able to engage in physical activity (Boulet et al., 1999).

b) Allergens such as:

• Pollen (GINA, 2002; NZGG, 2002; Peat et al., 1993; Suphioglu et al., 1992);
• Moulds (GINA, 2002; Hide et al., 1994; NIH, 1997; Zacharasiewicz et al., 1999);
• Dust Mites (BTS/SIGN, 2003; Boulet et al., 2001; Chapman, Heymann, Wilkins, Brown & Platts-Mills, 1987; GINA, 2002; Kuehr et al., 1995; Marks et al., 1995; NIH, 1997; NZGG, 2002; Platts-Mills, Hayden, Chapman & Wilkins, 1987);
• Pet dander (BTS/SIGN, 2003; Boulet et al., 2001; Gelber et al., 1993; GINA, 2002; Kuehr et al., 1995;
  Millar & Hill, 1998; NIH, 1997; NZGG, 2002; Pollart, 1989; Sears et al., 1993; Sporik et al., 1995;
  Strachan & Carey, 1995; Warner et al., 1990);
• Foods or food additives (Freedman, 1977; GINA, 2002; Lee, 1992; NZGG, 2002; Taylor, Sears & van
  Herwaarden, 1994);
• Cockroach allergen (Boulet et al., 2001; GINA, 2002; NIH, 1997; Rosenstreich et al., 1997).

c) Other factors that can trigger or worsen asthma severity:

• Upper respiratory/viral infections (Boulet et al., 1999; GINA, 2002; Lemanske, 1989; NIH, 1997;
  NZGG, 2002; Pattemore, Johnston & Bardin, 1992);
• Rhinitis/Sinusitis (Boulet et al., 1999; Corren, Adinoff, Buchmeir & Irvin, 1992; GINA, 2002: Watson,
  Becker & Simons, 1993);
• Gastroesophageal reflux (GINA, 2002; Irwin et al., 1989; NIH, 1997; Nelson, 1984);
• Sensitivity to aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDS) (GINA,
  2002; NIH, 1997; NZGG, 2002; Settipane et al., 1995; Szczeklik & Stevenson, 1999; Sampson, 1999);
• Topical and systemic beta-blockers (GINA, 2002; NIH, 1997; Odeh, Olivern & Bassan, 1991;
  Schoene, Abuan, Ward & Beasley, 1984).

Some individuals with asthma may react to only one trigger, others may react to several. Further, an individual’s triggers may change over time. It is important for individuals with asthma to know their triggers and the appropriate steps to reduce exposure (Ministry of Health and Long-Term Care, 2000).

Gaining Control Over Asthma
Reducing the burden of asthma requires a greater understanding of why the prevalence of poorly controlled asthma is so high. Despite a high prevalence of uncontrolled asthma, Chapman et al. (2001) noted that most clients (91per cent) believe that their asthma is adequately controlled, while only 24 per cent of those studied achieved disease control by meeting the six symptom-based criteria listed by the Canadian Asthma Consensus Report (1999). One-half (48 per cent) of patients with poorly controlled asthma who used inhaled steroids did not understand the role of inhaled steroids and one-third (32 per cent) of patients with poorly controlled asthma who used short acting bronchodilators misunderstood the action of quick relief bronchodilators.

The study concluded that people with asthma have:

• Low expectations about their asthma control
• A poor understanding of the role of various medications
• And learned to live with and tolerate symptoms and limitations that are generally avoidable.

In addition, the survey highlighted that physicians were no better than their clients with asthma regarding the perception of asthma control.

Proper care of asthma including education, environmental control measures, appropriate medications, action plans and regular follow-up care leads to optimal asthma control, improved quality of life for individuals with asthma and reduces the burden of healthcare costs. Because nurses are in contact with clients with asthma in a multitude of settings, they are in a unique situation to promote asthma control, identify early indicators of poorly controlled asthma, positively influence self-care practices and facilitate the referral of individuals to community resources and specialized care.

The Asthma Best Practice Guideline
The purpose of the RNAO Nursing Best Practice Guideline, Adult Asthma Care Guidelines for Nurses: Promoting Control of Asthma, is to provide nurses (RNs and RPNs) working in diverse settings with an evidence-based summary of basic asthma care for adults.

The guideline aims to assist nurses and their clients to make informed decisions that lead to quality care and improved outcomes (improved quality of life and overall reduction in morbidity). It is not the intent of the best practice guideline to provide a comprehensive review of the literature or duplicate the recommendations of the Canadian Asthma Consensus Report. Rather, it’s designed to complement and expand upon existing guidelines.

The guideline assists nurses who are not specialists in asthma care to:

• Identify adults with asthma
• Determine whether or not their asthma is under acceptable control
• Provide asthma education (specifically, self-management action plans, use of inhaler/devices and medications)
• Facilitate appropriate referral(s), and access community resources.

It is acknowledged that successful asthma control involves a partnership with the individual with asthma and the interdisciplinary healthcare team.

Back to Clinical Practice
Back to Improving Care

Back to RNAO Knowledge Depot home

Page content adapted from Adult Asthma Care Guidelines for Nurses: Promoting Control of Asthma. Plese refer to guideline for sources cited in this document. Referencing this page?