Multidisciplinary Asthma Care: It Takes a Village

Effective care for patients with asthma involves so much more than medications-it takes the efforts of a “village.” At the 2015 ACCP meeting in Montreal, a panel comprised of Cynthia Rand MD (Johns Hopkins University), Li-Xing Man MD (University of Rochester), Heather Coles (University of Rochester) and Sumita Khatri MD (Cleveland Clinic Foundation) discussed the medical expression of that village- the multidisciplinary management of asthma.

Medication adherence: The link between availability of efficacious treatment and successful management is patient adherence. Pharmacy data have shown that adherence in asthma patients is only between 20% and 40%! Poor adherence is the norm and not the exception. Adherence does not correlate with severity of disease, and even in a “difficult to treat” asthma clinic, 74% of patients were found to be non-adherent. Risk factors identified for poor adherence include depression and lower income. Identifying non-adherent patients for intervention is the first step, but unfortunately “physician judgment” has been shown to be a very poor marker of identification. Effective communication and “partnering” with patients are key elements to addressing these issues. In an observational study it was found that less than 60% of physicians appropriately conveyed full directions when prescribing a new medication. Routinely collecting medication refill data, self-adherence data, and assessing patients’ understanding of their disease helps. Electronic reminders and feedback systems have bene shown to improve adherence and may be commercially available soon.

Endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS): CRS is extremely common and affects 1 in 8 adults, with approximately 20% of patients also having asthma. Eighty-five to 90% of asthma patients have nasal symptoms and an abnormal finding on sinus CT scan.  The management of CRS includes medical and surgical options. ESS can help open sinuses to allow better drainage and allow for improved medical therapy. Guidelines recommend consideration of ESS in CRS patients who have failed medical management after 12 weeks. ESS has been shown to improve quality of life and patient reported outcomes as well as asthma control, resulting in decreased asthma attacks and hospitalizations.  It can be very helpful to partner with an ENT physician early to help medically and surgically manage CRS.

Speech and language pathology in vocal cord dysfunction (VCD): The prevalence of VCD in people with asthma has been shown to vary anywhere between 19% and 74%. Physical examination findings are non-specific, with stridor and inspiratory wheezes often absent. The gold standard diagnostic test is fibrotic laryngoscopy, but only during an acute episode. Questionnaires like the Pittsburgh Vocal Cord Dysfunction Index have been used, but are not specific. Involvement of speech and language pathologists is important in diagnosis and management.  Education about disease pathology, biofeedback, and vocal cord hygiene are significant aspects of management. Relaxed throat breathing techniques have been used and shift focus from the upper airway to the diaphragm.

Gastroesophageal reflux disease (GERD): GERD is defined as a condition in which the reflux of stomach contents causes troublesome symptoms or complications. GERD has been reported in 20% to 80% of adult patients with asthma and is often asymptomatic. Diagnosis is based on symptom questionnaires, but is not sensitive or specific. A supraglottic index is calculated based on visualization of larynx with fibro-optic laryngoscopy and has shown good intraobserver reliability and can be a useful diagnostic tool. Esophageal impedance testing and impedance pH are invasive measures used when diagnosis is uncertain. Current guidelines recommend treatment with a proton pump inhibitor (PPI) twice daily for 6 to 8 weeks if GERD is suspected. Asymptomatic patients with GERD, even in poorly controlled asthma, have not been shown to benefit from PPI treatment.

Rand C, Man L-X, Coles H, Khatri S. Multidisciplinary management of asthma: it takes a village. Presentation at American College of Chest Physicians annual meeting (CHEST 2015); October 28, 2015; Montreal, Canada.