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Management of Asthma in Children: Asthma Education

Although millions of prescriptions are filled each year for asthma medications, Lozano et al demonstrated that the insured population who are prescribed controller medications exhibit inadequate control. Thus, pharmacists should intervene proactively and offer education as appropriate. Pharmacists in all types of practices, including community, hospital, or ambulatory settings, have many opportunities to contribute to the management of asthma. Family-centered education with pharmacist participation using a multidisciplinary approach is important to help patients control their asthma and to reduce the need for hospitalizations. Key teaching areas include ensuring that the prescribed medications and devices, including peak flow meters (PFMs), are age-appropriate and used properly (TABLE 4). Pharmacists can help clarify and reinforce instructions outlined in the patient-specific action plan upon dispensing of the medication in the pharmacy, prior to the patient’s discharge from the clinic, ED, or hospital. Other educational opportunities include volunteering at asthma camps or other community outreach programs. In addition, pharmacists can provide pertinent information for other health care providers about their patients and can refer poorly controlled patients who overuse prescription or OTC bronchodilators for more appropriate medical care. Pharmacists can also share information from the NAEPP guidelines with pediatricians to assure proper diagnosis and management.

Table 4. Sample Asthma Education Checklist
What is asthma?
General symptoms
Mild symptoms
Recognizing a serious asthma attack
Things to do in case of an attack
Asthma attacks – causes and prevention
Your asthma treatment plan
How each medication works
Different devices for administering medications
Checking how much medicine is left
Monitoring asthma with a peak flow meter
Predicting an asthma attack
Before your appointment with your doctor
Asthma resources

It is advantageous to include a brief review of asthma as part of the counseling session. Because many children, especially younger ones, are visual learners, a lung model or diagram illustrating a cross-section of a normal, unobstructed bronchiole beside a narrow, obstructed one with evidence of bronchoconstriction, inflammation, and mucus plugging enhances the discussion of general symptoms of a mild or severe asthma exacerbation. Explanations of the effect of each medication can also be accomplished with this illustration. Pharmacists should emphasize the difference between quick-relief and long-term controller medications.

The pharmacist should use an icebreaker to gain the child’s attention and confidence. Nonverbal communication can negatively affect the success of an interaction with a child. Pharmacists should sit at the same height as the child and be aware of their facial expressions, tone of voice, and gestures. The discussion should be interactive. Asking the patient or caregiver to discuss specific signs and symptoms, triggers, and action plans will prevent losing his or her interest. Because it may be necessary to condense information, identifying weak areas early will be helpful. Biomedical terms should be avoided; terms such as puffers or pumps are easier to understand than metered dose inhaler. Open-ended questions better assess understanding. Examples include, “Why do you need to take this medicine?” and “How does this medicine work?” Repetition of information is key. Distracting infants and toddlers with toys will enable the caregiver to focus on the pharmacist.

Instruction on the proper techniques for inhaling medications should be conducted with placebo metered dose inhaler (MDI) or dry powdered inhaler (DPI) inhalers, if possible. Use of a spacer, or holding chamber, should also be demonstrated when indicated. Written instructions with diagrams should be provided.

Pharmacists should also look for signs of poorly controlled asthma. These include adverse effects from medications, presence of night symptoms more than twice a month, increased use of more than one canister of a short- or long-acting beta2-agonist in one month or more than one canister of a short-acting beta2-agonist in two months while using a controller agent, refilling long-term controller medications less than half as often as indicated, failure to achieve quick (within 10 to 20 minutes) and sustained response (longer than three to four hours) with quick-relief medications during an acute exacerbation, poor tolerance to physical activity (e.g., difficulty climbing four flights of stairs daily), missing school because of asthma symptoms, and frequent ED/pediatrician visits or hospitalizations for asthma.

The child with asthma should be directly involved in disease education. In fact, children as young as 2 years can be taught about asthma. However, it is important to realize that learning styles and attention spans vary by age group. Caregivers should be encouraged to remain involved in the care of adolescents, despite the adolescent’s independence. Resources include video games, Web sites, books, and support groups.

All relevant caregivers (parents, older siblings, day care providers, teachers and other school staff, and coaches) should also receive formal education. Ideally, education should begin at diagnosis and be reviewed with each subsequent visit to the clinic, ED, or hospital. Assessing baseline knowledge by asking patients what they already know engages them, increases their interest, and helps the pharmacist focus on key areas. It will also increase the likelihood that the patients and caregivers will gain new information.

Often, the hospital or community pharmacist is asked to help improve adherence to medication regimens. This is an opportunity to help the physician identify reasons for nonadherence. Common reasons may be lack of insurance; inability to use the device properly; poor taste of medication; lack of understanding of role, benefits, and risks of medication; inability to remember; lack of caregiver supervision; and fear of adverse effects. Pharmacists can provide verbal and written information to alleviate some of these issues. Insurance and other social concerns can be referred to social services.

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