Asthma Disease Management and the Respiratory Therapist

Thomas J Kallstrom RRT AE-C FAARC and Timothy R Myers RRT-NPS

Introduction

Disease Management

Prevention

Pharmacologic Management

Tracking and Follow-Up

Cost of Care

Protocol-Based Asthma Treatment

Emergency Department

Ambulatory Settings

Asthma Educators

Summary

The role of the respiratory therapist (RT) is expanding with the growing acceptance and use of the

disease-management paradigm for managing chronic diseases. RTs are key members of the asthma

disease-management team, in acute-care settings, patients’ homes, out-patient clinics, emergency

departments, and in the community. Utilizing RTs as disease managers allows patients to be treated

faster and more appropriately, discharged to home sooner, and decreases hospital admissions. RT

are leaders in the emerging field of asthma disease management. Key words: asthma, disease man-

Introduction

Approximately 22 million Americans have asthma

(6 million are children), and that number continues to

rise.

The challenge for the respiratory care community is

to identify undiagnosed patients, treat them appropriately,

and to teach them self-management skills to minimize

symptoms, avoid exacerbations, and maintain a normal

and undisturbed lifestyle. In meeting this challenge, respi-

ratory therapists (RTs) play an important part. Over the

past 2 decades the RT’s role in asthma disease-manage-

ment has grown, in acute-care settings, patients’ homes,

out-patient clinics, emergency departments, and in the com-

munity.

Chronic obstructive pulmonary diseases, includ-

ing asthma, are ideal for the disease-management para-

digm, and RTs can apply their abilities in treating and

teaching patients in various settings.

RTs’ scope of care in asthma management will probably

continue for the foreseeable future. According to the Amer-

ican Association for Respiratory Care (AARC)

and the

United States Bureau of Labor Statistics,

there will be a

substantial need for more RT manpower in the coming

years. The need for RTs is expected to grow faster than the

need for many other health care professions through 2014,

Thomas J Kallstrom RRT AE-C FAARC is affiliated with the American

Association for Respiratory Care, Irving, Texas. Timothy R Myers RRT-

NPS is affiliated with Pediatric Diagnostics and Respiratory Care, Rain-

bow Babies and Children’s Hospital, and Department of Pediatrics, Case

Western Reserve University School of Medicine, Cleveland, Ohio.

Mr Myers has served on the advisory board of Cardinal Health and been

a member of the speaker’s bureau for Sepracor. The authors report no

other conflicts of interest in the content of this paper.

Mr Kallstrom presented a version of this paper at the 41st RESPIRATORY

CARE Journal Conference, “Meeting the Challenges of Asthma,” held

September 28-30, 2007, in Scottsdale, Arizona.

Correspondence: Thomas J Kallstrom RRT AE-C FAARC, American

Association for Respiratory Care, 9423 MacArthur Boulevard, Irving TX

75063. E-mail: [email protected].

770 RESPIRATORY CARE • JUNE 2008 VOL 53 NO 6

because of the growing number of middle-age and elderly

patients, which will increase the incidence of cardiopul-

monary disease. RTs have an expanding role in early de-

tection of pulmonary disorders, case management, disease

prevention, and emergency care.

The National Heart, Lung, and Blood Institute’s Na-

tional Asthma Education and Prevention Program (NA-

EPP) asthma guidelines highlight the evidence that RT-

driven protocols are effective and improve asthma care.

The 2007 edition of the NAEPP guidelines frequently men-

tions the importance of RTs in asthma management.

There is increasing need for the disease-management

paradigm of managing chronic diseases, because chronic

respiratory diseases are on the rise. According to the Cen-

ters for Disease Control and Prevention, in 2000, over 90

million Americans had a chronic condition, and chronic

conditions accounted for 70% of all deaths.

Patients with

asthma are a substantial proportion of that number. By

2020 the number of Americans with at least one chronic

condition may grow to 157 million, of whom many will

have asthma.

Disease Management

Disease management is a comprehensive and coordi-

nated system of care that focuses on the chronic disease

state rather than on just the acute episode. Disease man-

agement includes prevention, treatment, and patient track-

ing and follow-up.

About 2 decades ago the focus of

asthma care shifted away from exacerbation treatment to-

ward daily management.

Prevention

Although pharmacologic intervention to treat established

asthma is highly effective in controlling symptoms and

improving quality of life, measures to prevent the devel-

opment of asthma, including avoiding or reducing expo-

sure to risk factors, should be implemented wherever pos-

sible.

Asthma prevention is a subject of increasing interest,

and much research is underway to investigate the patho-

physiology and pathogenesis of asthma. Because asthma

and allergies often go hand-in-hand, much research is aimed

at the prevention of allergic sensitization in the prenatal

and perinatal period,

8,9

and at the prevention of asthma

development in sensitized patients with atopy. One subject

of research is the hygiene hypothesis, that inadequate child-

hood exposure to various substances leads to hyperrespon-

siveness later in life, because the immune system did not

learn to deal with various substances during a crucial for-

mative period. For those who have developed asthma, the

focus of prevention is environmental control (ie, reducing

or eliminating exposure to asthma triggers).

Pharmacologic Management

Pharmacologic management is the component of asthma

management that gets the most daily focus. The goal is to

achieve and maintain control of symptoms and prevent

exacerbations; full control can be achieved in the majority

of patients with a pharmacologic strategy developed in

a partnership between the patient/family and health care

provider.

The current pharmacologic asthma-

management method relies on frequent monitoring and

assessment of asthma control and adjustment of the dos-

ages and/or addition (or subtraction) of medications. The

2007 NAEPP guidelines

use 6 levels (“steps”) of phar-

macologic management (Fig. 1). In the various “steps,” the

dosages are increased or decreased and drugs are added to

or subtracted from the treatment regimen, based on the

symptoms and severity.

Tracking and Follow-Up

All patients should be assessed to determine their cur-

rent level of asthma control and treatment, and their ability

to adhere to the treatment regimen. Disease-management

follow-up is multi-focused but customized to the individ-

ual patient. Asthma control should be regularly and fre-

quently monitored by the health care team and the patient

or caregiver. Asthma is a variable disease, and even if the

patient adheres to the treatment regimen, there will be

episodes of worsening symptoms, loss of control, and pos-

sibly exacerbation, all of which require adjusting the med-

ication dosage and/or adding medications to the regimen.

When control is regained, the dosage and/or types of med-

ications are decreased to the minimum amount that sus-

tains control.

The disease-management paradigm requires that cli-

nicians (1) understand and consistently pursue the ben-

efits of evidence-based medicine, (2) know and fully

utilize education concepts and strategies that promote

patient self-management, and (3) have the tools to mea-

sure patient outcomes and the effectiveness of the dis-

ease-management regimen. Asthma is exactly the kind

of chronic disease that is best handled with the disease-

management paradigm. There is a growing body of peer-

reviewed literature to guide and support evidence-based

disease management of asthma, and RTs’ didactic and

clinical experience positions them as key members of

the asthma disease-management team. After many in-

quires from RTs to the AARC, the AARC partnered

with the NAEPP to develop a document that describes

RTs’ role in asthma disease management.

The AARC

conducted an informal survey of RTs practicing in asthma

disease management, which revealed that many RTs

were doing what they called “disease management,” but

less than half were tracking outcomes, which is a vital

ASTHMA DISEASE MANAGEMENT AND THE RESPIRATORY THERAPIST

RESPIRATORY CARE • JUNE 2008 VOL 53 NO 6 771

component of disease management. Asthma interven-

tions, like most interventions, are typically general and

use a “one size fits all” approach, but maximizing ef-

fectiveness requires individualizing the regimen to the

patient’s specific situation and conditions. The 4 key

components of individualizing the disease-management

interventions are: (1) physician-patient interaction,

(2) case management, (3) patient-specific medications,

and (4) interventions tailored to patient-specific risks.

At the very least, an asthma disease-management pro-

gram should focus its outcome goals on asthma control

and should monitor items such as daytime and nocturnal

symptoms, activity limitations, frequency of exacerbations,

unscheduled ambulatory and emergency-department

asthma visits, hospitalizations, intensive care admissions,

intubation history, absenteeism from work and school, fre-

quency of

␤

-agonist use, objective measurement of lung

function, and quality-of-life indices.

Because key elements and outcome monitoring and track-

ing of disease-management interventions were missing in

the majority of the survey responses, a team of asthma

disease-management experts, including RTs, nurses, phy-

sicians, and scientists, was convened to research and write

an asthma disease-management guide for RTs, “Making a

Difference in the Management of Asthma: A Guide for

Respiratory Therapists,” which was published in May

2003.

It describes practical aspects of disease manage-

ment and gives examples of how RTs have been key fig-

ures in asthma disease management in the hospital, home,

community, emergency department, and out-patient clinic.

RTs are well-suited for asthma disease management:

• Asthma is one of the most common diseases that RTs

treat in the acute-care setting.

• Many RTs regularly conduct patient education about

asthma devices, medicines, and self-management.

• In many states, RTs’ licensure allows them to go beyond

task-oriented duties, and to implement asthma protocols,

interventions, and programs.

• RTs’ academic preparation includes the components and

concepts of asthma management, treatment, and patient

Fig. 1. Stepwise approach to asthma management in children 5–11 years old. (Based on a figure in Reference 1.)

ASTHMA DISEASE MANAGEMENT AND THE RESPIRATORY THERAPIST

772 RESPIRATORY CARE • JUNE 2008 VOL 53 NO 6

education.

• The majority of Certified Asthma Educators are RTs.

• RTs practice in various settings, including the hospital,

home, emergency department, out-patient clinic, and

community.

Cost of Care

The cost of asthma care is substantial. The direct costs

are easily tracked (eg, hospital admissions, visits to the

emergency department, physician office, or clinic, and phar-

maceutical costs). According to the National Heart, Lung,

and Blood Institute’s 2007 Morbidity and Mortality Chart

Book, the annual direct cost of asthma is approximately

$14.7 billion,

of which prescription drugs is the largest

component ($6.2 billion), followed by $4.7 billion for hos-

pital care, and $3.8 billion for physician services.

The indirect costs of asthma are difficult to ascertain,

but they include costs and losses caused by missed work or

school (Table 1), both by the asthma sufferer and family

members who devote time to taking care of the asthmatic

family member, and various costs related to asthma mor-

tality. The total indirect-plus-direct cost of asthma is con-

servatively estimated at approximately $19.7 billion.

Respiratory care accounts for a substantial portion of

acute asthma care costs. In 1999, respiratory care services

for asthma accounted for 11% of emergency-department

total costs. For patients who were admitted to the hospital

the respiratory therapy costs were 14% of the total in-

patient charges.

In a 1999 study by Stanford et al,

the

average stay was 3.8 days, and that stay was not unusual.

In 2007 the average stay was down to 2–2.7 days.

Du-

ration of stay is an important concern in all branches of

in-patient care, and RTs can significant improve stay and

other clinical, patient, and financial outcomes by imple-

menting asthma protocols. Asthma protocols decrease the

likelihood of hospital admission from the emergency de-

partment and shorten asthma-caused hospital stay. Respi-

ratory-care protocols have been successful in various ven-

ues.

Protocol-Based Asthma Treatment

A protocol-based treatment model assigns the RT some

decision-making responsibility in responding to changes

in the patient’s condition. An RT-driven asthma protocol

allows the RT to initiate, alter, or discontinue care as the

patient’s condition dictates, which, ultimately, is a more

cost-effective way of managing asthma. For the respira-

tory care manager such protocols offer the opportunity and

flexibility for better staffing decisions (eg, providing care

to patients who need it vs those who do not). In addition,

asthma protocols decrease the risk of clinical errors, im-

prove the effectiveness of treatments, and provide data by

which to assess current practices and study possible changes

in practice.

15-19

Protocols are essentially operational practice guidelines

for common procedures and tasks related to specific dis-

eases. Protocols are optimal for diseases/treatments for

which there is strong scientific evidence and well-estab-

lished care practices. The diseases best treated via protocol

are those that have a large number of patients, high cost of

care, large number of emergency-department patients,

higher risk of medications being improperly prescribed, an

opportunity to lower the cost of care through patient-ed-

ucation, and relatively easy and inexpensive ways to mea-

sure outcomes.

One of the pioneers in pediatric asthma protocols is the

respiratory therapy department at Rainbow Babies and Chil-

dren’s Hospital in Cleveland, Ohio. A benchmarking study

of 26 children’s hospitals found that Rainbow Babies and

Children’s Hospital had the longest stay (3.2 d per pa-

tient). They implemented an asthma protocol based on the

exacerbation components of the 1997 NAEPP asthma

guidelines,

and utilized RTs to assess and treat asthma as

indicated by the patient’s condition. A study of their inner-

city asthma in-patients found shorter stay after they im-

plemented the asthma protocol.

The same researchers

did a follow-up study in their dedicated asthma unit, which

was staffed primarily by RTs, who provided most of the

clinical care. In the asthma care unit the protocol signifi-

cantly decreased stay and lowered the overall cost of care

and readmission rate.

In addition to clinical and financial

outcomes, protocols may also reduce the number of bron-

chodilator treatments administered and minimize unnec-

essary interactions with RTs during an admission.

A re-

spiratory department in a nonacademic acute-care hospital

adopted the Rainbow Babies and Children’s Hospital

asthma protocol and had similar success.

Emergency Department

Protocol care succeeds in the emergency department as

well.

In the emergency department there is not as much

time to spend with the patient, but we can nevertheless

Table 1. Days Missed Due to Asthma

Days Missed

(millions)

2002 2003

School days (children 5–17 y old) 14.7 12.8

Work days (currently employed adults

ⱖ 18 y old)

11.8 10.1

*In the United States, among those who reported at least one asthma attack in the previous

year.

(Data from Reference 12.)

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RESPIRATORY CARE • JUNE 2008 VOL 53 NO 6 773

follow the NAEPP guidelines, make more appropriate use

of systemic corticosteroids, and teach the use of the peak

flow meter. McFadden et al found, in a sequential-design

study of one of the first asthma protocols, that using the

protocol in the emergency department decreased hospital

admissions, time spent in the emergency department, and

recidivism.

Their printed protocol included a decision-

making algorithm and a standardized documentation area

to record the assessment and treatment. They standardized

the assessment procedure, medications, administration

routes, and discharge criteria. The outcomes data from the

protocol period were compared with data from the 8 months

prior to implementation of the protocol. Data from a 12-

month period after strict protocol adherence had declined

(admixture period) were also analyzed. The strict protocol

period had significantly shorter stay (p ⬍ 0.001) and lower

hospital admission rate, in both divisions (p ⬍ 0.005 in the

medical intensive care unit, and p ⬍ 0.005 compared to

the 8 months prior to protocol implementation). The pro-

tocol also decreased 1-week recidivism (p ⬍ 0.05) and

reduced the charges per case (p ⬍ 0.01), compared to the

pre-protocol period. There were also significant differ-

ences between the protocol and admixture periods in stay

(p ⬍ 0.01), general-division admission rate (p ⬍ 0.05),

and charges per case (p ⬍ 0.01). McFadden et al con-

cluded that their protocol offered quick, efficient treatment

for asthma exacerbations, substantial cost savings, and de-

creased unnecessary and inappropriate physician prac-

tices.

Ambulatory Settings

RTs can greatly benefit asthma management in ambu-

latory care settings, including in patients’ homes. Beaver

Medical Group, a private pulmonology practice in Cali-

fornia, uses RTs in their clinical and patient-education

operations.

In the clinic the RTs participate in diagnostic

support, patient self-management education, assessment of

patients’ adherence to regimen, device allocation, and

smoking-cessation counseling. After RTs had been added

to the practice, a post-intervention measurement compared

Beaver Medical Group to other area practices from 2000

to 2002. Beaver Medical Group believes that using RTs

improves appropriate ordering of medicines and decreases

emergency-department utilization in their asthma patients.

Shelledy et al

studied a pediatric asthma disease-man-

agement program that involved 8 weekly home visits from

an RT. All the RTs underwent a standardized training

program to maximize proper and consistent application of

the program’s components (eg, procedures at each home

visit, patient assessment, program assessment, patient ed-

ucation, and record-keeping). The 8-week duration was

based on the key elements they needed to include in the

program and the objective of keeping the sessions to

1–2 hours. Though we must be cautious in interpreting

data from a nonrandomized, unblended study with a small

sample size (n ⫽ 18), during the 12-months study period

there were significant reductions in asthma exacerbation

visits per patient (1.78 ⫾ 3.0 vs 0.33 ⫹ 77, p ⫽ 0.001),

costs ($7,867 ⫾ $12,627 vs $806 ⫾ 1,783, p ⫽ 0.001),

intensive-care hospital days and non-intensive-care hospi-

tal days (p ⱕ 0.05), emergency department visits

(4.22 ⫾ 4.92 vs 0.61 ⫾ 1.04, p ⫽ 0.001), ambulatory

physician visits (p ⬍ 0.001), and school absenteeism

(19.0 ⫾ 11.98 d vs 6.69 ⫾ 7.47 d, p ⫽ 0.002). Shelledy

et al estimated an average total savings of $8,542 per

patient per year.

In another home-care pilot study, pediatric asthma dis-

ease management provided by RTs decreased hospitaliza-

tions, emergency department visits, unscheduled office vis-

its, and missed school days.

These benefits can be realized

by providing asthma education, including education about

avoiding and eliminating asthma triggers, proper use of

devices, and use of monitoring (peak flow meters and

asthma diaries).

Asthma Educators

Teaching and reinforcing optimal inhaler technique is

essential. The clinician should never assume that the pa-

tient uses optimal inhaler technique, even if the patient has

used an inhaler for years, because it is possible to forget

components of optimal technique.

The clinician should

check the patient’s inhaler technique at every opportunity.

Teaching and reinforcing optimal inhaler technique in the

out-patient clinic can improve the patient’s understand-

ing.

In a prospective trial in an out-patient clinic, Minai

et al studied a strategy in which physicians and RTs col-

laborated to improve metered-dose inhaler (MDI) tech-

nique and asthma outcomes in an inner-city clinic. The

children underwent a standardized assessment based on

the NAEPP asthma guidelines, and the clinicians used a

standardized form to collect data on demographics, MDI-

technique score (MDI steps done correctly, 0 – 8 scale),

pulmonary function, and asthma severity. RTs demon-

strated and reinforced correct MDI technique at each visit.

Forty-five patients underwent the assessment and educa-

tion interventions. The mean time between visit 1 and

visit 2 was 11.8 ⫾ 9.5 months. At visit 1 and visit 2,

respectively, the mean MDI-technique scores were 53%

and 81% (p ⬍ 0.001), the mean overall asthma severity

scores were 2.6 and 2.3, and the mean overall pulmonary

function scores were 2.4 and 2.1. The African-American

children had the largest MDI-technique improvement

(p ⬍ 0.001), but other outcomes (pulmonary function and

severity) did not improve significantly. The white children

had significantly improved MDI technique (p ⫽ 0.004)

and overall asthma severity score (p ⫽ 0.005). Minai et al

ASTHMA DISEASE MANAGEMENT AND THE RESPIRATORY THERAPIST

774 RESPIRATORY CARE • JUNE 2008 VOL 53 NO 6

concluded that the children showed sustained improve-

ment in MDI technique, and some of the patients improved

in pulmonary function and overall asthma severity.

Positive results are also seen in the in-patient setting

when RTs takes advantage of “teachable moments” to in-

struct patients on proper inhaler technique per the NAEPP

guidelines. Song et al studied the effects of RT instruction

on MDI technique in 58 hospitalized adults with obstruc-

tive lung disease.

In the control group, a physician counted

the number of correct/incorrect steps (based on the NA-

EPP’s recommended 8 steps) the patients made while per-

forming 2 actuations with an MDI. Another group under-

went an MDI-education intervention (which included

encouragement to use a spacer) conducted by RTs, then

those patients were also observed by a physician to deter-

mine their MDI-technique error rate. The control group’s

error rate was 6.72 (out of 15 possible) errors per patient,

whereas the intervention group made 2.43 errors per pa-

tient (p ⬍ 0.001). That significant difference remained

after controlling for greater spacer use in the post-instruc-

tion group (27.6% vs 91.7% spacer use before vs after

education). Song et al concluded that RT instruction of

hospitalized patients with obstructive lung disease signif-

icantly improved MDI technique and increased spacer use

while in the hospital. The take-home message is that RT

should use every patient interaction as an opportunity to

teach as well as treat patients with asthma exacerbations

Clinician and patient adherence to the asthma guidelines

is essential for optimal asthma therapy.

Poor patient ad-

herence to the guidelines is a major cause of poor out-

comes. Among children adherence is often below 50%.

For an asthma regimen to be effective, the medication

must be administered correctly. With poor adherence and/or

poor inhaler technique the patient will not obtain full ben-

efit from the medication, which could lead some patients

to be less adherent. Clinicians should not assume that pa-

tients will follow the step-by-step instructions once they

are on their own, particularly with inhalers. There is a

correlation between education and adherence.

35,36

Im-

proved adherence improves asthma control, but only if the

medical care system encourages and supports the alloca-

tion of sufficient resources to allow discussion of the bar-

riers to self-management and negotiation of solutions. At-

tempts to improve adherence outside of the caregiver-

patient relationship are less likely to succeed.

It is also important to consider the perceptions of health

care providers. Some providers (physicians, pharmacists,

nurses, and RTs) report that their most pressing concern

about aerosol medications is the time it takes to deliver

them,

especially in the acute-care setting. That concern

could negatively influence the adoption of inhalers and

holding chambers, as could an imagined superiority of

nebulizers over MDIs or powder inhalers. Some nurses

still favor nebulizers over MDIs and powder inhalers, de-

spite the compelling evidence that inhalers are as clinically

effective and more cost-effective than nebulizers, and that

bias could affect physician decisions and ordering. All

aspects of an aerosol device should be considered and

practice should be based on solid scientific evidence.

Though it is important to match the device to the patient

and the situation, all current aerosol devices are equally

efficacious if the treatment is administered correctly.

RTs are the logical and often preferred providers to

deliver aerosol device education. Their skills and experi-

ence make them well qualified to teach MDI use.

40,41

One

study found that only 1 in 3 patients used powder inhalers

correctly, but with training by a medical professional the

correct-use rate was higher.

A 2005 paper reported that

28 – 68% of patients do not use MDIs or powder inhalers

well enough even to obtain benefit,

so thorough and

repeated inhaler education is very important.

Summary

Self-management of asthma is crucial, and RTs can help

patients and families develop the knowledge and tech-

niques to achieve asthma control, avoid asthma triggers,

and correctly handle worsening asthma symptoms, with

minimal disruption of normal life. The RT is a key mem-

ber of the asthma disease-management team.

REFERENCES

1. Expert panel report 3: guidelines for the diagnosis and management

of asthma. Bethesda MD: National Institutes of Health, National

Asthma Education and Prevention Program; 2007. NIH Publication

No. 08-4051. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.

pdf. Accessed on April 7, 2008.

2. Making a difference in the management of asthma: A guide for

respiratory therapists. NIH Publication No. 02-1964, May 2003.

3. Dubbs B. Respiratory therapy by the numbers: Results from the

AARC’s 2005 human resources study. AARC Times 2006;30(4):36-

43.

4. Bureau of Labor Statistics, U.S. Department of Labor. Occupational

outlook handbook 2006-07 edition, Respiratory therapists. http://

www.bls.gov/oco/ocos084.htm. Accessed April 7, 2008.

5. Centers for Disease Control and Prevention. Chronic disease pre-

vention. http://www.cdc.gov/nccdphp/overview.htm. Accessed April

7, 2008.

6. Make B. Collaborative self-management strategies for patients with

respiratory disease. Respir Care 1994;39(5):566-579.

7. Arshad SH. Primary prevention of asthma and allergy. J Allergy Clin

Immunol 2005;116(1):3-14.

8. Gdalevich M, Mimouni D, Mimouni M. Breast-feeding and the risk

of bronchial asthma in childhood: a systematic review with meta-

analysis of prospective studies. J Pediatr 2001;139(2):261-6.

9. Jones CA, Holloway JA, Warner JO. Does atopic disease start in

foetal life? Allergy 2000;55(1):2-10.

10. Bateman ED, Boushey HA, Bousquet J, Busse WW, Clark TJ, Pau-

wels RA, et al. Can guideline-defined asthma control be achieved?

The Gaining Optimal Asthma Control study. Am J Respir Crit Care

Med 2004;170(8):836-844.

ASTHMA DISEASE MANAGEMENT AND THE RESPIRATORY THERAPIST

RESPIRATORY CARE • JUNE 2008 VOL 53 NO 6 775

11. Morbidity and mortality: 2007 chart book on cardiovascular, lung,

and blood diseases. NHLBI. http://www.nhlbi.nih.gov/resources/

docs/07-chtbk.pdf. Accessed April 7, 2008.

12. Asthma prevalence, health care use, and mortality: United States,

2003–05. National Health Interview Survey. National Center for

Health Statistics. http://www.cdc.gov/nchs/products/pubs/pubd/

hestats/ashtma03–05/asthma03–05.htm. Accessed April 3, 2008.

13. Stanford R, McLaughlin T, Okamoto LJ. The cost of asthma in the

emergency department and hospital. Am J Respir Crit Care Med

1999;160(1):211-215.

14. Ramnath VR, Clark S, Camargo CA Jr. Multicenter study of clinical

features of sudden-onset versus slower-onset asthma exacerbations

requiring hospitalization. Respir Care 2007;52(8):1013-1020.

15. Kwan-Gett TS, Lozano P, Mullin K, Marcus EK. One-year experi-

ence with an inpatient asthma clinical pathway. Arch Pediatr Ado-

lesc Med 1997;151(7):684-689.

16. Johnson KB, Blaisdell CJ, Walker A, Eggelston P. Effectiveness of

a clinical pathway for inpatient asthma management. Pediatrics 2000;

106(5):1006-1012.

17. Kelly CS, Andersen CL, Pestian JP, Wenger AD, Finch AB, Strope

GL, Luckstead EF. Improved outcomes for hospitalized asthmatic

children using a clinical pathway. Ann Allergy Asthma Immunol

2000;84(5):509-516.

18. Wazeka A. Valacer DJ, Cooper M, Caplan DW, DiMaio M. Impact

of a pediatric asthma clinical pathway on hospital cost and length of

stay. Pediatr Pulmonol 2001;32(3):211-216.

19. Bailey R, Weingarten S, Lewis M, Mohsenifar Z. Impact of clinical

pathways and practice guidelines on the management of acute exac-

erbations of bronchial asthma. Chest 1998;113(1):28-33.

20. Expert panel report 2: guidelines for the diagnosis and management

of asthma—Update on selected topics 2002. Bethesda, MD: National

Institutes of Health, National Asthma Education and Prevention Pro-

gram; 2003 June. NIH Publication No. 02-5074. Update on selected

topics. 2002. http://www.nhlbi.nih.gov/guidelines/archives/epr-

2_upd/asthmafullrpt_archive.pdf. Accessed April 1, 2008.

21. McDowell KM, Chatburn RL, Myers TR, O’Riordan MA, Kercsmar

CM. A cost saving algorithm for children hospitalized for status

asthmaticus. Arch Pediatr Adoles Med 1998;152(10):977-984.

22. Myers TR, Chatburn RL, Kercsmar CM. A pediatric asthma unit

staffed by respiratory therapists demonstrates positive clinical and

financial outcomes. Respir Care 1998;43(1):22-29.

23. Colice GL, Carnathan B, Sung J, Paramore LC. A respiratory ther-

apist-driven protocol for managing inpatients with asthma and COPD

incorporating a long-acting bronchodilator. J Asthma 2005;42(1):29-

34.

24. Kallstrom T. A pediatric asthma fast track (PAFT) can reduce the

number of patients admitted to an acute care unit (abstract). Respir

Care 2000;45(8):1021.

25. Steurer-Stey C, Grob U, Jung S, Vetter W, Steurer J. Education and

a standardized management protocol improve the assessment of

asthma in an emergency department. Swiss Med Wkly 2005;135(15-

16):222-227.

26. McFadden ER Jr, Elsanadi N, Dixon L, Takacs M, Deal EC, Boyd

KK, et al. Protocol therapy for acute asthma: therapeutic benefits and

cost savings. Am J Med 1995;99(6):651-661.

27. Shelledy DC, McCormick SR, LeGrand TS, Cardenas J, Peters JI.

The effect of a pediatric asthma management program provided by

respiratory therapists on patient outcomes and cost. Heart Lung 2005;

34(6):423-428.

28. LeGrand TS et al. Effect of a respiratory therapy designed asthma

management program on outcomes and cost of care compared to a

program designed by nurses or standard care (abstract). Chest 2005;

128(4):165S.

29. Lewarski J, Chao J, Stegmaier J, Kallstrom T, Lohser V, Woehrle L.

HME company based asthma program reduces the cost of care (ab-

stract). Respir Care 1998(11);43:864.

30. McFadden ER Jr. Improper patient techniques with metered dose

inhalers: clinical consequences and solutions to misuse. J Allergy

Clin Immunol 1995;96(2):278-282.

31. Minai BA, Martin JE, Cohn RC. Results of a physician and respi-

ratory therapist collaborative effort to improve long-term inhaler

technique in a pediatric asthma clinic. Respir Care 2004;49(6):600-

605.

32. Song WS, Mullon J, Regan NA, Roth BJ. Instruction of hospitalized

patients by respiratory therapists on metered dose inhaler us leads to

decrease in patient errors. Respir Care 2005;50(8):1040-1045.

33. Milgrom H, Wamboldt F, Bender B. Monitoring adherence to the

therapy of asthma. Curr Opin Allergy Clin Immunol 2002;2(3):201-

205.

34. Bender BG. Overcoming barriers to nonadherence in asthma treat-

ment. J Allergy Clin Immunol 2002;109(6 Suppl):S554-S559.

35. Blaiss MS. Part II: Inhaler technique and adherence to therapy. Cur

Med Res Opin 2007;23(Suppl 3):S13-S20.

36. Virchow JC, Crompton GK, Dal Negro R, Pedersen S, Magnan A,

Seidenberg J, Barnes PJ. Importance of inhaler devices in the man-

agement of airway disease. Respir Med 2008;102(1):10-19.

37. Bender B, Milgrom H, Rand C. Nonadherence in asthmatic patients:

Is there a solution to the problem? Ann Allergy Asthma Immunol

1997;79(3):177-185.

38. Hurley KF, Sargent J, Duffy J, Sketris I, Sinclair D. Ducharme.

Perceptual reasons for resistance to change in the emergency depart-

ment use of holding chambers for children with asthma. Ann Emerg

Med 2008;21(1):70-77.

39. Dolovich MB, Ahrens RC, Hess DR, Anderson P, Dhand P, Rau JL,

et al; American College of Chest Physicians; American College of

Asthma, Allergy, and Immunology. Device selection and outcomes

of aerosol therapy: Evidence-based guidelines. Chest 2005;127(1):

335-371.

40. Guidry GG, Brwon WD, Stogner SW, George RB. Incorrect use of

metered dose inhalers by medical personnel. Chest 1992;101(1):31-

33.

41. Hanania NA, Wittman R, Kesten S, Chapman KR. Medical person-

nel’s knowledge of and ability to use inhaling devices. Metered-dose

inhalers, spacing chambers, and breath-actuated dry powder inhalers.

Chest 1995;107(1):290.

42. Kuehn BM. Education key to treating airway disease: Focus on

inhaler users, rescue workers, athletes. JAMA 2007;298(22):2601-

2608.

43. Fink JB, Rubin BK. Problems with inhaler use: a call for improved

patient and clinician education. Respir Care 2005;50(10):1360-1374.

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Discussion

Kercsmar: Tom, why do you think

so few people have taken the asthma

educator examination? Should we pro-

mote it more? There has been discus-

sion of making asthma education re-

imbursable if it’s from a certified

educator. Who is going to pay to take

the test? Who is going to pay for the

service?

Kallstrom: The asthma educator ex-

amination costs $295 presently, which

is a minor deterrent. The more impor-

tant deterrent is the question, “OK,

I’ve passed the test: now what?” We

need to merge the education with re-

imbursement. There are CPT [Current

Procedural Terminology] codes for

asthma education reimbursement, but

the caveat is that you need to have

that program credentialed through a

professional organization. We’re

working on solving that within the

AARC.

Another thing about the asthma ed-

ucator examination is that RTs don’t

do as well as nurses, believe it or not.

That’s partly because many of the

questions focus on the clinical aspects

of care, and most RTs work in the

acute-care setting, so they don’t deal

with situations such as not having

enough money to buy medications or

psychosocial issues. We prepare RTs

for the examination with workshops

that we take around the country.

Kercsmar: Now that you have 2,000

people certified, is there any evidence

that the education provided by certi-

fied asthma educators improves out-

comes?

Kallstrom: Not that I know of. We

need to obtain that data to increase the

impetus for people to take the exam-

ination.

Giordano:* Tom, you mentioned

RTs’ obligations in patient educa-

tion. What about educating physi-

cians, nurses, and pharmacists? It’s

impossible for RTs, even if they were

as readily accessible as others, to in-

terface with all the asthmatic pa-

tients.

Kallstrom: In the hospitals, many

respiratory departments put on com-

petency days where they go over

these things. One thing I think would

be useful, and that we’re moving to-

ward, is something like the book we

produced about aerosol devices for

patients. We should put together a

book directed at physicians and

nurses. That would be useful. We

had over 120,000 hits on our Web

site

for the book on aerosol devices;

that’s almost more than there are RTs

in the country. So there’s a great

deal of interest, and we want to take

that to the next level.

1. From: Hess DR, Myers TR, Rau JL. A guide

to aerosol delivery devices. Irving TX:

American Association for Respiratory Care;

2007. Available from http://www.aarc.org/

education/aerosol_devices/aerosol_delivery_

guide.pdf.

* Sam P Giordano MBA RRT FAARC, Exec-

utive Director, American Association for Re-

spiratory Care, Irving, Texas.

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RESPIRATORY CARE • JUNE 2008 VOL 53 NO 6 777