THE FUTURES OF RESPIRATORY

THERAPY
By Joe Flower
The futures of respiratory care are powered y cost pressures! "ew tech"olo#ies! a"d
co"su$er de$a"ds
To understand the possible futures of respiratory therapy, as with any future, we have to think
systemically. No simple list of trends or predictions can capture the complex tapestry of unfolding
reality. To begin to catch the favor of the future, we have to contemplate the cross-infuence of
each factor on the others.
%e$o#raphics
The most predictable trend in many countries is the aging of the population, and this shift will
afect respiratory care more heavily than it will other areas of health care. or instance,
emphysema and other forms of chronic obstructive pulmonary disease !"#$%& are strongly age-
related.
'n the (nited )tates, "anada, and *ustralia, this shift represents the aging of the +aby +oomers.
'n ,estern -urope and .apan, it is a more complex phenomenon, but has a similar outcome. 'n
"hina, it is the result of the long-time /#ne "hild0 policy.
1
'n all these countries, the result is
fewer workers to support more elderly frail people. This means two things, which both head in
the same direction2 1& ,ith fewer workers paying taxes for social support programs !such as
3edicare in the (nited )tates&, ever-increasing health care costs become unsustainable. 4& *t the
same time, fewer workers are available to do the necessary health care work. These two factors
come together to make it necessary that respiratory therapy be streamlined, networked, and
automated as much as possible and the role of the human operator, the therapist, reduced as
much as possible to decrease costs and to remove potential sources of error.
'n the (nited )tates, one other demographic shift is playing out2 The non-5ispanic -uropean-
*merican population is growing much more slowly than other groups, particularly 5ispanics. 'n
"alifornia, non-5ispanic whites are already a minority.
4
* number of other countries are
experiencing similar increases in diversity. This means that in respiratory therapy, much of which
takes place working directly with the patient and even in the home, diversity of background,
multilingual capabilities, and cultural sensitivity will increasingly be career assets.
&ost Pressures 'ead to a (alue Shift
)imply put, health care costs too much6outlandishly so in the (nited )tates, clearly so in all
countries. 7espiratory therapy is, on the one hand, a complex process that will be amenable to
much streamlining, automation, and cost reduction. *t the same time, it is often a preventive
strategy that reduces costs by keeping "#$% patients, for instance, from needing to access
much more expensive acute care. )o, while the 8eld will grow with an aging population, the
relative percentage of the 8eld representing direct intervention by human therapists will shrink,
and the relative value of each therapist will grow. *utomation will mean that the 8eld will show a
large rise in productivity, and that productivity will represent a great increase in the use of
respiratory therapy as a preventive and disease management strategy to cut acute care costs.
)ew Tech"olo#ies a"d )etwor*ed Auto$atio"
't is a simple truism that new technologies will revolutioni9e the 8eld. 't is important, though, to
recogni9e the directions the infuence of new technologies will take. They are three, and they are
related2 complexity, simplicity, and networked automation.
1. "omplexity2 New and increasingly complex and subtle instruments will allow therapists to
measure patients: respiratory health and capacity more directly than such simple measures as
;o4max and $ao4.
4. )implicity2 These instruments will become increasingly user-friendly, designed to decrease the
amount of time and efort the therapist needs to put into each case, to minimi9e the
opportunities for error, and even to relieve the necessity for the therapist at all, turning the
responsibility over to the patient or the patient:s family or other caregivers.
<. Networked automation2 'ncreasingly, instruments and therapies will be networked together,
with the output of one becoming the direct and automatic input of the next, removing the human
therapist from the transaction. +lood oxygenation monitors, for instance, will directly change the
settings of ventilators, "$*$s, and other respiratory devices.
&o"su$er Power
't is likely that the largest change vector of all is the awakening power of the consumer. This
force is emerging in diferent countries for somewhat diferent reasons and at diferent speeds. 'n
the (nited )tates, the key factor is the introduction of consumer-directed health plans !"%5$s&,
which make the consumer responsible for more of their health care expenses, but also give the
consumer more say in choosing their health care providers. * similar efect will be felt in
)ingapore and, of vastly greater importance, "hina, both of which are following the lead of the
(nited )tates toward "%5$s. 'n other countries, where insurance of any kind plays a lesser or
nonexistent role, consumer power is nonetheless increasing because of widespread
dissatisfaction with the efectiveness of health care spending, and the increasing transparency of
all health care systems in a digital age.
Three factors are necessary for a market to act like a consumer retail market2
1. "onsumer incentive2 't must make a diference, in some way !price, amenities, convenience&,
for the consumer to choose one product or service over another.
4. $rovider competition2 "onsumers must have not only the legal and regulatory ability to make a
choice, they must actually have diferent providers among which to choose, for any given
product or service.
<. ull information2 The consumer must have multiple sources of reliable, recent, and relevant
information on which to base the choice.
*ll three of these factors are growing, rapidly in the (nited )tates, but in most national systems
to an appreciable extent. *nd they need not become the ma=ority pattern for any system to
drastically reshape that system2 ,hen, in any system, providers actually compete for customers,
they will not be able to aford to lose any si9able fraction of the population that has the ability,
information, and incentive to make a good choice.
The potential efects of this change are still underappreciated across health care6and they will
fall diferently in respiratory care than elsewhere, for some fundamental, structural reasons.
The %i$e"sio"s of &o"su$er Power
The efect of consumer power on health care will have three separable dimensions2 cost, >uality,
and the patient experience.
Cost. Nowhere has health care sub=ected its processes to the kind of rigorous, iterative, and
minute cost-bene8t and >uality analyses that many retail, manufacturing, and service industries
now consider routine. "onsumer power, whether expressed through buyers: choices or through
political pressure, will combine with increased transparency to force everyone involved in health
care to make that level of analysis a regular part of doing business. * number of hospitals in the
(nited )tates, for instance, have adapted the Toyota $roduction )ystem to health care, rooting
out ine?ciencies, redundancies, and waste in the tiniest processes6the placement of a fax
machine, the cleaning of an infusion pump 8lter6and saved tens of millions of dollars in the
process.
Quality. 5ere, too, the new transparency is changing the face of health care. 'n the (nited )tates,
"anada, and some other countries, various state, provincial, business, regional, and federal
initiatives are forcing health care providers to publish their statistics for particular types of
outcomes, infection rates, adverse drug events, and so forth6and some initiatives are basing
payment on these outcomes, in /pay-for-performance0 !$$& schemes. This is about cost as well,
for lower >uality in health care often goes with higher costs6the kind of sloppy system that
produces higher costs typically also produces nosocomial infections and adverse drug events,
and those in turn generate even more costs.
or instance, in 3ilwaukee, 3inneapolis, and some other areas, business groups have created a
tiered payment system that tracks medical care by the case, not by the individual incident, and
uses co-payments to steer people through doctors and hospitals, with both better outcomes and
lower costs over time. 'f you carry insurance through one of the employers involved in this efort,
you can choose any doctor or hospital you want, but if you choose one that has not shown that
they can produce better outcomes at lower cost, you will have to pay more.
'n respiratory therapy, this will increase the push both toward networked automation, and to the
pervasive use of clinical protocols.
Patient experience. *s consumers gain a voice and a sense of choice, we are seeing an
increasing focus on the often-abysmal experience of being a patient2 the long waiting times, the
lack of real information, the feeling of powerlessness, the plain disrespect of the person evinced
by many health care institutions.
5ealth care leaders, especially in the (nited )tates, are becoming increasingly aware that they
face a future in which every mistake, every lawsuit, as well as complete price lists and outcomes
ratings, will be displayed for the world to see on the 'nternet. This year the federal government:s
"enters for 3edicare and 3edicaid )ervices !"3)& is rolling out the 4@->uestion "onsumer
*ssessment of 5ealthcare $roviders and )ystems !"*5$)& )urvey
<
for use by hospitals across the
country, and the results will be posted on the ,eb at www.hospitalcompare.hhs.gov. The survey
will start out as a voluntary program, but as of #ctober hospitals that do not participate will lose
4A of all federal reimbursements. *s ,illiam $owanda, vice president of Bri?n 5ospital in %erby,
"onn, points out, though, coercion may not be necessary2 /Think of a local community hospital
with a lay board. 'magine what will happen when their hospital shows up in the lowest >uartile.
7esources will be reallocated. The message to management will be2 Cix this and 8x it >uick.:
There is going to be a scramble to 8nd solutions.0
I$plicatio"s for Respiratory &are
3uch of the daily work of respiratory care is about education, remediation, monitoring, and hand-
holding. *ny system that involves an insurance model is skewed toward paying for the de8nable
medical event6the o?ce visit, the x-ray, the intubation6not for the longitudinal measure of
health, whether the case !3rs )mith:s pneumonia& or the person:s increased length and >uality
of life.
'n such a system, the preventive, educational, and monitoring aspect of respiratory care for
chronic disease is seen as a cost, twice over. Not only does it cost the system to provide the care,
but for the providers, it is an opportunity cost. 'nstitutions and physicians may not consciously
deny preventive care because it reduces their patient fow. *cross the spectrum of health care,
the trend is too obvious, though. $roviders will provide the oxygen bottle and the brief home-
health visit to hook it up, but they will not provide long-term, preventive care for which no one
will pay them, and which reduces the stream of patient visits and admissions for which they are
paid.
,hat do patients wantD "linicians who spend more time with them, listen to them, give them
more hands-on care. They would like to not have to go to the doctor so much. They would like
their condition to improveE they would like to feel healthier. *ll of this points to education,
remediation, monitoring, and hand-holding, which is often done most easily, cost-efectively, and
conveniently by a respiratory care provider.
,hat do those who pay for health care, whether employers or governments, wantD Fower cost
and higher >uality, happier employees and citi9ens, less waste, smarter use of the health care
dollar. *ll of this points to education, remediation, monitoring, and hand-holding.
This means that we are likely to see two diferent and somewhat conficting trends in the
relatively near future. +oth trends will show up sooner and in a greater degree in the (nited
)tates but will spread as well in other countries, especially among the rapidly growing urban
middle classes of "hina and 'ndia2
GThe tasks of respiratory care will become increasingly automated, networked, or even
outsourced. 'magine, in detail, each of the tasks involved in respiratory care. *sk yourself
whether that task re>uires the dexterity of a trained physical body present in the room with the
patient, andHor the in>uisitive =udgment of a trained mind. 'f it does not, it is likely that that piece
of respiratory therapy will be automated, so that a computer can do it. #r it will be made into a
home device the patient can use. #r it will be networked, so that a computer somewhere else
can do it. #r it may even be outsourced, so that someone in 'ndia or the $hilippines can do the
monitoring, the analysis, and even the phone consultation.
G*s consumer-oriented health care takes hold, as people increasingly make their own choices
about how to buy the health care that they need, encouraged and guided by governments,
employers: coalitions, and even the 8nancial services industry, we are likely to see a wholesale
shift toward recogni9ing respiratory care as the cost-saving preventive process that it is. )killed
respiratory counseling in the home helps keep people out of the emergency department and the
intensive care unit6through education, remediation, monitoring, and hand-holding. ,e are likely
to see this shift 8rst in private-sector pilots and partnerships in the (nited )tates, and then see it
taken up by government funding bodies.
These trends do confict, but together they paint a picture of a future for respiratory care in which
the parts that can be automated or outsourced will take up less time and funds, while the
preventive parts, which largely must be done in person with the patient, will likely grow in
importance.
Joe Flower is a health care futurist and founder and chief executive of Imagine What If Inc
(http://imaginewhatif.com. !lower has "een writing# spea$ing# and consulting a"out creating
health care changes for more than % decades.
Refere"ces
1. Flower J, Schwartz P, Ogilvy J. Chinas futures: scenarios for the worlds fastest growing econoy, ecology, and society. !o"o#en,
$J: Jossey%&ass' ())):*1%*+.
(. ,S Census &ureau. State and County -uic# Facts. .vaila"le at: htt/:001uic#facts.census.gov0gfd0. .ccessed 2ay (3, ())+.
4. ,S 5e/artent of !ealth and !uan Services. .gency for !ealthcare 6esearch and -uality. C.!PS Surveys and 7ools to
.dvance Patient%Centered Care. .vaila"le at: www.cahps.ahr>.govHdefault.asp. .ccessed 2ay (3, ())+.
7-;'-, # *'7,*I
"F-*7*N"- T-"5N#F#B'-)
4JJ@
By Jo"atha" Fi"der! +%
(arious de,ices ha,e pro,e" e-ecti,e i" airway cleara"ce. we
ta*e a loo* at so$e of the$
7ecognition of the critical role of secretion mobili9ation in cystic
8brosis !"& and other related diseases of impaired airway clearance has led to the interesting
challenge of having a large number of devices available to aid in secretion mobili9ation. $atients
with neuromuscular weakness have been able to bene8t from a new use of an old technology to
assist with coughing. This review will cover some of the devices available to aid in airway
clearance.
Ha"dheld Secretio" +oili/atio" %e,ices
Flutter
0
1A2ca" Sca"diphar$ I"c! Bir$i"#ha$! Ala3
'n diseases with impaired mucociliary clearance !cystic 8brosis, bronchiectasis, primary ciliary
dys-kinesia, ac>uired ciliary dyskinesia&, the mainstay of therapy for decades has been manual
chest physiotherapy !"$T&, also known as percussion and drainage.
1
The 8rst device to challenge
the supremacy of this therapy became popular following the publication of a report in the &ournal
of Pediatrics in 1KKL by Monstan et al
4
E it demonstrated e?cacy in secretion mobili9ation for a
handheld device called the /lutter,0 which was a modi8cation of a $-$ !positive expiratory
pressure& device in which a steel ball oscillated up and down in a cone, vibrating the column of
air between the mouth and the lower airways. Monstan et al
4
showed that the volume of sputum
produced was greater than that produced by manual "$T. The value of using a handheld device
rather than traditional "$T has been demonstrated.
<
* follow-up study showed that the lutter
device is at least as efective as other forms of secretion mobili9ation for patients with cystic
8brosis.
L
This device can be purchased for under NOJ.
Acapella

1S$iths +edical I"c! &arlsad! &alif3

* characteristic of the lutter device is that it must be held at a precise angle in order to
maximi9e the oscillation of the air column. This was overcome in the design of the /acapella0
handheld mucus clearance device. 't works on the same principle6an oscillating valve
interrupting expiratory fow6but uses a counterweighted plug and magnet to achieve the valve
closure. +y using a valve with a magnet, the acapella does not re>uire gravity to work and will
therefore work at any angle.
O
'n a head-to-head comparison of the performance characteristics of
acapella and the lutter, the acapella had a slight advantage in a more stable waveform and a
wider range of positive expiratory pressure.
@
The authors concluded that the magnetic design
had an advantage in ease of use for some patients despite what appeared to be otherwise
relatively small diferences in performance. This device originally came in a low-fow and a high-
fow model and now is available as the /acapella
P
"hoice0 model that can be broken down for
cleaningE it can be used in line with a nebuli9er. These devices can be purchased for under N@J.
TheraPEP
0
1S$iths +edical I"c! &arlsad! &alif3
-xhaling against a resistor will result in higher pressures within the airway. 'n theory, this will
result in greater patency of airways that tend to collapse !such as in bronchiectasis& and greater
ability to clear airways with coughing. *s a result, $-$ masks have been used for years in cystic
8brosis care. * long-term !1-year& study comparing the lutter to a $-$ mask demonstrated
better clinical outcomes in $-$ mask users compared to lutter usersE
Q
but a recent review of
evidence in $-$ therapy concluded that this therapy was unsupported by literature,
R
and one
study indicated that $-$ masks do not improve inhaled drug delivery.
K
"ost of the Thera$-$ is
less than N<J.
Quake
0
1Thayer +edical! Tucso"! Ari/3
The only device that oscillates a column of air in both inspiratory and expiratory phase is the
/Suake.0 This device does not rely on an oscillating valve like the lutter and the acapella.
'nstead, it uses a manually turned cylinder that 8ts within another cylinder. *irfow occurs only
when slots within the two cylinders line up. Therefore, the airfow is interrupted at regular
intervals as the user turns the crank. The rate at which the device is cranked will determine the
fre>uency of the fow interruption. )ince the resulting vibration is not determined by the patient:s
rate of fow, the Suake theoretically may be more helpful for patients with severe obstructive
lung disease who are unable to generate high peak expiratory fow rates. "omparative studies
have not been performed.
I"ter$itte"t Positi,e Pressure Breathi"# 1IPPB3 %e,ices
IPPB 1(ortra"! Sacra$e"to! &alif3 1a$o"# others3
'$$+ has been used for many years as an ad=unct in chest physiotherapy to augment lung
expansion.
1J
't is used to deliver short bursts of positive pressure and can be used to deliver
nebuli9ed medications. 't has fallen out of favor in " care and is to be used with caution in any
patient with severe obstructive disease as it may cause pneumothorax. 't does not result in
oscillation of the air column so it is likely less efective than the devices described earlier in the
article and high fre>uency chest wall compression !described on the next page&.
PercussiveNEB
0
1(ortra"3
'$$+ has been modi8ed recently to deliver high-fre>uency pulses of pressure !as opposed to a
single pulse as delivered by '$$+&. This device is referred to as a percussive ne"uli'er. * single
pilot study using this device, which demonstrated that it was at least as efective as manual "$T
!a trend toward more sputum production was not statistically signi8cant&, has been published.
11
't
re>uires a high fow rate so will not work of standard compressors and is likely more suited to in-
hospital use.
I"trapul$o"ary Percussi,e (e"tilatio"
IPV
0
1Percussio"aire! Sa"dpoi"t! Idaho3
'ntrapulmonary percussive ventilation delivers rapid, small volumes of air to help loosen retained
secretions. 't has been used in patients with chronic obstructive pulmonary disease and " and in
patients who have neuromuscular weakness with persistent pulmonary consolidation. )everal
case reports have demonstrated e?cacy in patients with neuromuscular weakness, but assisted
coughing was not used or compared in one study
14
E in another study, it proved to be a valuable
addition to assisted coughing techni>ues.
1<

Hi#h Fre4ue"cy &hest 5all Oscillatio" 1HF&5O3
The Vest
0
1Hill6Ro$3 a"d SmartVest
0
1Electro$ed3
5",# was 8rst pioneered by ,arwick and 5ansen and reported in 1KK1.
1L
)ince this initial
report, the technology has gained widespread acceptance in cystic 8brosis care.
1O
5",#
involves wearing a rubber vest that rapidly infates and defates, thereby oscillating the chest
wall. 5",# is generally administered <J minutes twice daily. The most recent "ochrane
1@
review of airway clearance in " did not 8nd one techni>ue signi8cantly better than any other. *n
advantage of 5",#, which is an automated therapy, is that the device does not tire, get bored,
get sore, or answer the telephone. *s long as the patient uses it regularly, it is as efective as
manual "$T. 'ts advantage is its consistency and reproducibility. 'ts ma=or disadvantage is its
cost, which can be substantial. * newer device, the )mart;est !-lectromed&, has a single hose
and is designed to be more portable, which is an advantage for patients and families who travel
or if the child has more than one home.
*nother advantage of 5",# over traditional "$T is that this therapy does not re>uire another
caregiver. 't is ideal for patients who live aloneE for teens, it fosters independence.
5",# is increasingly being used in other diseases in which there are chronic lower airway
secretions, such as bronchiectasis and chronic aspiration. *lthough it is not indicated in
neuromuscularly weak patients without lower airway secretions, it has been used in the setting
of pneumonia in this population. There are no published data on use of 5",# in patients with
neuromuscular weakness, and therefore no recommendation can be made for its use in this
population.
+echa"ical I"su7atio"6E2su7atio"
3echanical insuTation-exsuTation !3'--& replaces or augments cough clearance when the
muscles of coughing have been weakened or paraly9ed. 3'-- has been in use since the 1KOJs
when it was populari9ed during the polio epidemic. %uring that time, negative pressure
ventilators could sustain life during periods of respiratory muscle insu?ciency, but patients were
still developing pneumonias. The 8rst device made used a vacuum cleaner motor with a valve
that allowed one to apply either positive or negative pressure across the airway opening. *fter
the polio epidemic subsided, the large-scale use of 3'-- decreased in this country. 'n 1KK< %r
.ohn +ach partnered with the ..5. -merson "o !"ambridge, 3ass& to re-create this device, which
-merson called the in(exsu)ator. 't was redesigned !primarily for cosmetic and noise reasons&
and renamed the Cough*ssist
P
!the renaming likely took place because most users
mispronounced its name&. )ince its reintroduction, 3'-- has gained increasing acceptance in
patients with all forms of neuromuscular weakness. * role for 3'-- has been demonstrated in
preventing morbidity in this patient population.
1Q
The *merican Thoracic )ociety has published a
consensus statement regarding respiratory care in %uchenne muscular dystrophy that advocates
for the use of 3'-- in this disease
1R
E a similar pro=ect is currently under way for patients with
spinal muscular atrophy that also supports 3'--. The critical advantage of 3'-- over all the
devices listed is that it augments the expiratory phase of coughing. *ll other therapies rely on
passive recoil of the respiratory system in patients with impaired cough clearance. 3'-- is the
only currently available therapy that assists the expulsive phase of coughing, which is critical in
airway clearance.
Su$$ary
3any new technologies are available to aid in secretion mobili9ation. )election will depend on
indication, patient preference, and social factors like the availability of a caregiver and the
patient:s ability to cooperate with therapy. $atients with impaired mucociliary clearance and
normal cough clearance !in " and bronchiectasis, for example& will bene8t from the handheld
secretion mobili9ation devices as well as 5",#. These devices, however, will not help a patient
whose main problem is impaired cough clearance. or these patients, 3'-- is the mainstay of
aiding airway clearance. %uring acute illnesses !pneumonia& in this population, there is a role for
other therapies such as intrapulmonary percussive ventilation.
Jonathan Finer! "#! is associate professor of pediatrics# +ivision of Pulmonology# Children,s
-ospital of Pitts"urgh.
The products reviewed in this article represent only a sampling of the secretion clearance devices
available. The opinions expressed by the author do not refect those of ./ maga9ine.
Refere"ces
1. 5esond 8J, Schwen# 9F, 7hoas :, &eaudry P!, Coates .;. <ediate and long%ter effects of chest /hysiothera/y in
/atients with cystic fi"rosis. J Pediatr. 1=>4'1)4:34>%3*(.
(. 8onstan 29, Stern 6C, 5oershu# CF. :fficacy of the Flutter device for airway ucus clearance in /atients with cystic fi"rosis. J
Pediatr. 1==*'1(*?3 Pt 1@:+>=%+=4.
4. Aondor 2, $iBon P., 2utich 6, 6e"ovich P, Orenstein 52. Co/arison of Flutter device and chest /hysical thera/y in the
treatent of cystic fi"rosis /ulonary eBacer"ation. Pediatr Pulmonol. 1==='(>:(33%(+).
*. $ewhouse P., 9hite F, 2ar#s J!, !onic# 5$. 7he intra/ulonary /ercussive ventilator and flutter device co/ared to standard
chest /hysiothera/y in /atients with cystic fi"rosis. Clin Pediatr. 1==>' 4C:*(C%*4(.
3. Patterson J:, &radley J2, !ewitt O, &rad"ury <, :l"orn JS. .irway clearance in "ronchiectasis: a randoized crossover trial of
active cycle of "reathing techni1ues versus .ca/ella. Respiration. ())3'C(:(4=%(*(.
+. Dols#o 7., 5iFiore J, Chat"urn 6;. Perforance co/arison of two oscillating /ositive eB/iratory /ressure devices: .ca/ella
versus Flutter. Respir Care. ())4' *>:1(*%14).
C. 2c<lwaine P2, 9ong ;7, Peacoc# 5, 5avidson .A. ;ong%ter co/arative trial of /ositive eB/iratory /ressure versus oscillating
/ositive eB/iratory /ressure ?flutter@ /hysiothera/y in the treatent of cystic fi"rosis. J Pediatr. ())1'14>:>*3%>3).
>. :l#ins 26, Jones ., Schans C. Positive eB/iratory /ressure /hysiothera/y for airway clearance in /eo/le with cystic fi"rosis.
Cochrane Database Syst Rev. ())*'?1@:C5))41*C.
=. 6au J;. 7orniainen 2. Co"ining a /ositive eB/iratory /ressure device with a etered%dose inhaler reservoir syste using
chlorofluorocar"on al"uterol and hydrofluoroal#ane al"uterol: effect on dose and /article size distri"utions. Respir Care. ())):
*3:4()%4(+.
1). Sorenson !2, Shelledy 5C. ..6C clinical /ractice guideline. <nterittent /ositive /ressure "reathingE())4 revision F u/date.
Respir Care. ())4'*>:3*)%3*+.
11. 2ar#s J!, !are 8;, Saunders 6., !onic# 5$. Pulonary function and s/utu /roduction in /atients with cystic fi"rosis: a /ilot
study co/aring the Percussive7ech !F device and standard chest /hysiothera/y. Chest. ())*'1(3:13)C%1311.
1(. &irn#rant 5J, Po/e JF, ;ewars#i J, Stegaier J, &esunder J&. Persistent /ulonary consolidation treated with intra/ulonary
/ercussive ventilation: a /reliinary re/ort. Pediatr Pulmonol. 1==+'(1:(*+%(*=.
14. 7oussaint 2, 5e 9in, Steens 2, Soudon P. :ffect of intra/ulonary /ercussive ventilation on ucus clearance in duchenne
uscular dystro/hy /atients: a /reliinary re/ort. Resp Care. ())4'*>:=*)%=*C.
1*. 9arwic# 9J, !ansen ;A. 7he long%ter effect of high%fre1uency chest co/ression thera/y on /ulonary co/lications of
cystic fi"rosis. Pediatr Pulmonol. 1==1'11:(+3%(C1.
13. Fin# J&, 2ahleister 2J. !igh%fre1uency oscillation of the airway and chest wall. Respir Care. ())('*C:C=C%>)C.
1+. 2ain :, Prasad ., Schans C. Conventional chest /hysiothera/y co/ared to other airway clearance techni1ues for cystic
fi"rosis. Cochrane Cystic Fi"rosis and Aenetics 5isorders Arou/. Cochrane Database Syst Rev. ())3 Jan (3'?1@:C5))()11.
1C. &ach J6, <shi#awa G, 8i !. Prevention of /ulonary or"idity for /atients with 5uchenne uscular dystro/hy. Chest.
1==C'11(:1)(*%1)(>.
July 899:
THE A''ER;Y
ASTH+A
&O))E&TIO)
By Joseph Fahhou$! +%
A co$i"atio" of #e"etic predispositio" a"d e",iro"$e"tal factors ca" tri##er asth$a
i" patie"ts with aller#ies
*sthma is a common chronic disease in the (nited )tates and worldwide. *ccording to the 4JJ<
National 5ealth 'nterview )urvey,
1
there were an estimated 4J.Q million adults diagnosed with
asthma, a prevalence of K.QA, and R.K million children diagnosed with asthma, a prevalence of
14A. The same survey reported 1.Q million asthma-related emergency department visits,
O11,JJJ hospitali9ations, 14.K million outpatient o?ce visits, and L,4@1 deaths in 4JJ4. %espite
advances in knowledge of the pathophysiology and etiology of asthma, the availability of new
medications, and the introduction of new formulations and drug-delivery methods, asthma is still
a life-threatening disease. *sthma is a leading cause of absence from work and school. 't is a
signi8cant economic burden on health care, and it afects >uality of life negatively, limiting
patients: activity levels and imposing psychological stress on their families.
*sthma is a complex, variable disease. )ymptoms can vary from cough alone !in cough-variant
asthma& through inability to inhale deeply enough to chest tightness, whee9ing, and respiratory
distress. )ome patients sufer from fre>uent symptoms and signi8cantly limited physical
activities, but maintain normal lung function. #thers may have mild symptoms with signi8cant
decreases in lung function, but bronchodilators may reverse the associated obstruction.
*sthma is the result of interaction between complex genetic factors and the environment.
3edicine is =ust beginning to understand how genetic predisposition afects the manifestations
and severity of asthma and the individual:s response to pharmacotherapy. ;ariable degrees of
infammation are present in the airways of asthma patients. The infammation leads to reversible
airway obstruction and airway hyperresponsiveness.
*llergies trigger airway infammation in approximately KJA of asthma patients,
4
but this may be
less true of older patients. *n inhaled allergen reaches the immune cells in the lung. Through a
chain of steps, a speci8c immunoglobulin - !'g-& is produced. The allergen-speci8c 'g- then binds
to tissue mast cells and basophils for long periods6until it comes in contact with the same
allergen again, which results in the activation of the mast cells and basophils in the lung.
The infammatory process can be divided into early and late responses. 'n the early phase,
histamine, tryptase, and cysteinyl leukotrienes !among other mediators& are released, causing an
immediate decrease in forced expiratory volume in 1 second !-;1&, followed shortly by the
recovery of lung function. 'n the late phase, eosinophils are recruited to the lung tissue, in
addition to other types of cells, and chronic infammation begins !and goes on for years&. The
chronic infammation gets a boost every time a new exposure occurs, and it persists even when
asthma enters clinical remission.
<
-xacerbations represent an acute increase in an existing, chronic infammation of lung tissue
!igure&. *irway infammation can be triggered by exposure to allergensE air pollutants !such as
dust, rubber particles, and o9one&E tobacco smoke, whether inhaled actively or passivelyE irritants
and sensiti9ers in the workplace !including fumes, cleaners, detergents, and saniti9ers&E and
bacterial and viral infections.
"old air and exercise can also trigger symptoms, especially if the patient:s asthma is
suboptimally controlled. -xercise tolerance usually improves along with asthma control.
*sthma severity is described using four categories. -ach category is determined using the
patient:s single most severe feature, whether it involves diurnal or nocturnal symptoms,
pulmonary function, or peak fows.
O
The de8nition of asthma control is still being debated, but
the goals of therapy, as stated by the National *sthma -ducation and $revention $rogram -xpert
$anel 7eport
4O
published in 1KKQ, are to2
G prevent symptoms,
G maintain near-normal lung function,
G maintain normal activities,
G prevent exacerbations,
G provide therapy with the lowest incidence of side efects, and
G meet patient expectations.
'n other words, clinicians should strive to provide asthma control that gives patients normal or
near-normal lives. -ach patient has individual expectations, and each patient:s asthma is
diferent, so treatment should be tailored for each individual. 'n a telephone survey of asthma
patients, uhlbridge et al
O
found that QQ.<A of patients had moderate-to-severe persistent
disease. The same survey also showed that fewer than 1JA of () patients are in the mild
intermittent category. The ma=ority have persistent asthma and should be using controller !anti-
infammatory& medications, as recommended in the guidelines of the () National 5eart, Fung,
and +lood 'nstitute !N5F+'&.
L

*sthma is a dynamic diseaseE even patients in the mild category are at risk for severe
exacerbations and death. -xacerbations also occur with the best management. )temple et al
@
analy9ed < years: claim data for @,<JJ asthma patients and found that patients moved in and out
of control. #f the OQA who were in control in the 8rst year, O<A lost control in the second or third
year, as indicated by oral steroid use, emergency-department visits, hospitali9ation, or increased
use of short-acting b-agonists.
The search continues for the perfect tool to assess or predict how well asthma is controlled.
3easuring exhaled nitric oxide or sputum eosinophils seems promising, but each method has
limitations. Neither test has reached clinical utility in o?ce practice. 'n the o?ce setting, patients
should be asked about their use of rescue medications, functional status, missed work or school,
fre>uency of diurnal and nocturnal symptoms, and emergency-department or urgent care visits.
'nformation on self-reported control and lung-function measurement should be obtained by either
peak-fow monitoring or o?ce spirometry. *n asthma-control survey has been developed
commerciallyE it consists of 8ve >uestions and is available in two versions !for patients older and
younger than age 14&.
Acute Asth$a +a"a#e$e"t
-xacerbations are accompanied by increased airway infammation. The severity of exacerbation
refects the degree of airfow obstruction. )ymptoms and signs correlate poorly with the degree
of airfow restriction. #nly the peak expiratory fow rate !$-7& or -;1, rather than clinical signs
and symptoms, should be used to assess the severity of airfow obstruction and the patient:s
response to treatment in the emergency department, the clinician:s o?ce, or the patient:s home.
"hildren younger than Q years of age are usually incapable of performing these maneuvers
reliably. They should be assessed using clinical signs and symptoms.
3ost exacerbations are mild or moderate and are treated in outpatient settings. *ccording to an
*ustralian survey,
Q
only 4A of total exacerbations resulted in hospitali9ation or death. -ven
though death from asthma is rare, it still claims about O,JJJ lives per year in the (nited )tates.
)everal risk factors have been associated with asthma mortality. +lack men living in inner cities
have the highest case-fatality rate, as well as the highest rates of previous mechanical
ventilation and recurrent hospitali9ation. $sychological disorders and noncompliance are also
associated with increased risk. ewer than OJA of patients who experience life-threatening
episodes have these risk factors, however.
R
3ost asthma deaths occur at home, and access to an
emergency department is a good predictor of survival.
K

The N5F+' guidelines
L
de8ne a moderate exacerbation as an -;1 or $-7 of OJA to RJA of the
predicted or personal-best value, with a severe exacerbation indicated by results of less than
OJA. These measurements are not needed for cyanotic, confused, or exhausted patients. $ao4 is
usually normal in mild and moderate exacerbations, and $aco4 is normal to low. 5ypoxemia
results from ventilation-perfusion mismatching, which occurs in severe exacerbations.
5ypercarbia !$aco4 of more than LJ mm 5g& generally develops only when the -;1 is less than
4OA of the predicted value.
*rterial blood gases are not routinely assessed in asthma exacerbations. "hest radiographs are
obtained only for patients with suspected complications such as pneumonia, congestive heart
failure, pneumomediastinum, or pneumothorax.
'nhaled b4-agonists are 8rst-line therapy. 3etered-dose inhalers !3%'s& used with spacers are as
efective as nebuli9er therapy, if used correctly by patients. The dose of b4-agonist needed to
reverse an asthma attack varies, depending on the degree of the obstruction and the response to
the initial treatment. Typically, four to eight pufs from an 3%' with a chamber are needed. The
pufs should be given one at a time. Nebuli9ing three to four units of li>uid b4-agonist,
intermittently or continuously, is as efective. The continuous method saves the 7T time and does
not sub=ect the patient to increased side efects.
)ubcutaneous epinephrine or intravenous terbutaline may be indicated for some patients !for
example, those who have excessive coughing or who are too weak to inspire ade>uately&. *dding
ipratropium bromide to a b4-agonist is superior to using a b4-agonist alone, especially in severe
exacerbations.
1J

$atients re>uire hospitali9ation or die not because of bronchospasm, but due to signi8cant
infammation. 'nstituting anti-infammatory therapy early in the course of emergency-department
management is, therefore, essential. #ral corticosteroids should be administered early, within
the 8rst hour, but how much should be given is uncertain. There is no clear evidence
demonstrating more e?cacy for high !versus moderate& doses.
The use of methylxanthines !such as theophylline& as additions to b4-agonists has declined in
acute asthma management, since evidence favoring their use is inade>uate, at best.
11
The need
for assisted ventilation increases as the -;1 or $-7 decreases below 4OA of the predicted
value. -ndotracheal intubation is associated with complications, of courseE noninvasive positive-
pressure ventilation !N$$;& has been shown to reduce the likelihood of intubation, decrease work
of breathing, and improve oxygenation.
14
N$$; is an attractive alternative to intubation when
aggressive medical management fails.
'o"#6Ter$ +a"a#e$e"t
$harmacological maintenance treatment, also referred to as controller medication, has evolved.
*nticholinergics such as atropine and other belladonna alkaloids were 8rst-line treatment until
the early 1KQJs. Now, a long-acting form is available as tiotropium bromideE it has a place in the
long-term treatment of chronic obstructive pulmonary disease,
1<
but is not yet part of asthma
management. 'soproterenol, salbutamol, and terbutaline have been used since the 1K@Js for
bronchodilation. 'soproterenol was widely used until it was linked to the possibility of increased
asthma mortality.
1L
)hort-acting b-agonists were initially used on a scheduled daily basis, as
controller and rescue medications. Now, they are used only as needed. 'n the past decade, two
long-acting b4-agonists !F*+*s&, formoterol and salmeterol, were introduced and used as
controller medications. *dding F*+*s to inhaled corticosteroids !'")& improved asthma control
better than increasing the dose of '").
1O
This led to the production of a futicasone-salmeterol
combination in the (nited )tates. F*+*s should be used in combination with '"), not alone, as
controller therapy.
)everal types of polymorphism of the b4-agonist receptor have been identi8ed. 'ndividuals with
one polymorphism in particular do not respond to b4-agonists as well as individuals with other
polymorphisms.
1@

'") treatment is recommended as 8rst-line therapy for persistent asthma because it has been
most efective in decreasing symptoms, exacerbations, emergency-department visits, and
hospitali9ations, as well as in improving lung function and reducing mortality.
1Q,1R
Feukotrienes are released during the infammatory process in the airways. They cause
bronchoconstriction and fuel infammation, and may not be blocked by '"). )everal leukotriene
modi8ers are being used as controller medications. Uileuton works by blocking the production of
leukotrienes, while 9a8rlukast and montelukast are receptor blockers. They are more efective
than placebo, but less efective than '").
1K
*dding a leukotriene modi8er to an '") regimen is
more efective than increasing the dose of '"), but the combination of F*+*s and '") is most
efective.
4J
The long-term safety of '") and systemic exposure to '") are ma=or concerns. The
safety of low-dose '") is well established. $rolonged use of medium-to-high doses of '") is
accompanied by increased incidence of side efects such as oral candidiasis, hoarseness, and
osteoporosis.
41
The bene8ts of long-term '") therapy appear to outweigh the associated risks.
*fter asthma control is initially gained, the '") dose should be tapered to the lowest level that
maintains asthma control. "ombination therapy can be used to achieve control at a lower '")
dose.
'ndividual responses to any controller medication vary signi8cantly. )9efer et al
44
examined
variations in response to futicasone and montelukast among children with mild-to-moderate
persistent asthma. They found that OA of children responded well to montelukast aloneE 4<A, to
futicasone aloneE and 1QA, to both medications6but OOA did not respond signi8cantly to either
medication. Iounger children with shorter asthma duration responded more favorably to
montelukast, while patients with more severe asthma and higher levels of infammatory markers
responded better to futicasone.
Benetic inheritance is probably the determining factor in the varying therapeutic response to
diferent agents. The time may come when it will be possible to select suitable medications for
each patient after analy9ing individual genetic polymorphisms that predict the response to
therapy. 3eanwhile, '") treatment remains the foundation of asthma treatment for the near
future.
3ometasone recently became available, and ciclesonide is expected to be approved by the ()
ood and %rug *dministration soon. )everal antibodies have been developed against speci8c
mediators of allergic infammation and are under investigation. The anti-'g- antibody
omali9umab is being used to treat patients with moderate and severe asthma. Treated patients
have been able to use lower doses of '") while maintaining asthma control and experiencing
fewer exacerbations.
4<
)till, the clinical e?cacy of the available antibodies has fallen below the
levels initially hoped for, providing added evidence of the complexity of asthma.
$harmacotherapy is one aspect of disease management. * more di?cult aspect is persuading
patients to carry out clinical recommendations. *s for all chronic conditions, patient adherence to
therapy is lower than it is for acute illnesses.
4L
Fack of adherence and incorrect use of medication
pose more challenges in clinical management than choosing the appropriate regimen. -ducating
patients about the disease, its triggers, the early recognition of exacerbations, and, most
important, the correct use of medication is essential. )uccessful management starts with
establishing a relationship and good communication, leading to partnership between the provider
and the patient. The current restraints on health care delivery allow less time to be spent with
patients and, as a result, less time for education. 'mproving adherence is also hampered by the
mounting 8nancial pressure on patients due to increasing insurance co-payments. Time spent
educating patients and creating a partnership pays good dividends, however, and this is one of
several signi8cant parts for nurses, 7Ts, and other medical personnel to play in successful
asthma management.
&oseph !ahhoum# 0+# is clinical assistant professor of medicine and pediatrics# +epartment of
0edicine# 1niversity of /ennessee -ealth 2cience Center# 0emphis.
Refere"ces
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())('1++:1)**%=.
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