April 23, 2014

Respiratory Therapists: Key Players in Asthma Care

Carole Dorr, RT

Carole Dorr, RT, is a Registered Therapist at Lehigh Valley Hospital in Allentown, Pennsylvania. Lois Wessel, CFNP, ACU’s Associate Director for Programs and asthma project co-director, interviewed Carole to get a sense of her role in asthma care and education as part of a transdisciplinary health care team.

Q. What kind of training do respiratory therapists receive?

A. Graduation from an accredited Respiratory Therapy Program is required to become a Respiratory Therapist (RT); more recently many RTs have a bachelor’s degree from a four-year college. Management positions usually require a master’s degree as well. All states except Alaska and Hawaii require reparatory therapists to be licensed. There are over 300 RT accredited RT program in the country.

Students study anatomy and physiology, pathophysiology, chemistry, physics, microbiology, pharmacology and math, as well as courses that focus on diagnostic procedures and tests, equipment, patient assessment, clinical practice guidelines, care in hospitals and rehabilitation facilities, health promotion, disease prevention, and medical record keeping.

Additionally, many RTs including myself are certified asthma educators.

Q. Describe the types of patients you see in your setting:

A. In the hospital, we follow patients with any number of respiratory illnesses including COPD, bronchitis, CF, pneumonia, asthma, lung cancer, neuromuscular diseases, trauma and post-operative patients with complications.

In addition to the inpatient setting, the RTs on our team rotate through outpatient high-risk prenatal and pediatric clinics, providing clients with asthma trigger management, asthma education, and working as part of the care team to implement asthma action plans (AAP).

This week, in the prenatal clinic, I saw a pregnant mom with a young child. I was able to work with both of them and discuss ways to keep their asthma well controlled, including appropriate use of medication and trigger reduction in the home.

Q. What is the role of RTs in providing asthma care?

A. It’s huge. We start with a complete assessment of the patient, including their asthma history and get a sense of how well controlled it is. In an acute situation, we make a quick assessment and make protecting the patient’s airway our top priority. Often we will adjust medications and initiate specialty therapies, utilizing our department’s protocols, to immediately treat the exacerbation. Then we continue to follow and assess these patients, adjusting their treatment and educating them utilizing the NHLBI Guidelines. Typically, by the time they leave our hospital they understand how asthma affects their body and how to use their medications properly, they can identify their triggers and have learned how to control them. They have also learned how to monitor their peak flows and use the results to implement their personal AAP.

Q. How do you function as part of a healthcare team?

A. Clinicians see us as important resources and an integral part of the team. They consult us early and defer to us often, as we are very specialized and have unique knowledge to provide care to patients and families. They include us in team meetings regarding patients and listen to our recommendations. We involve the whole team because we need to make sure everyone is providing and reinforcing the same information.

In our prenatal clinic, we have medical residents in training. I work closely with the residents on how to provide appropriate asthma care and education to the clients. As part of the team, I share my knowledge of asthma medications, use of peak flow meters and spacers, asthma trigger reduction, and answer questions. We discuss cases continually, so that the residents will become effective advocates for appropriate asthma education.

We also work with the case managers who are usually social workers. We know that if a patient can’t afford medication, they will not be able to control their medical problems. So the caseworkers help find drug assistance programs, alternative drugs, and other important resources for our patients. Everyone does their part to make things work for the benefit of the patient.

Q. How do you use the Asthma Action Plan in your work?

A. I always have color copies of the Asthma Action Plan with me. I give them to patients and encourage them to take them to their providers, (along with their peak flow charts) when they go for follow up visits. When I see patients with acute asthma, I ask them if they have an Asthma Action Plan. I’m surprise at the number of them who don’t, so I empower the patient to give the plans to their provider to fill in.

I find it is important to have color copies of the Asthma Action Plan because the analogy of a stop light is something almost everyone can understand—green is good, yellow is caution, and red means stop and make a new plan. It is one of the most culturally valuable tools in asthma education and it is underutilized. It also empowers patients to know how to control their asthma and how to use their plan to make changes if it starts to get out of control. This is a key piece of patient self-management that we are encouraging physicians and patients to work out together.

Q. How to do provide education on appropriate use of asthma inhalers?

A. I’ve seen so many people sick because they have the right drug and they are using it the wrong way. I’ve seen them use their inhalers on their chests or turn it the wrong way. Unfortunately, the majority of patients we see still do not use spacers with their MDIs! So providing devices with teaching, repetition and repeat demonstration is key. I encourage them to bring their inhalers to every medical visit and show the providers how they are using them. The problem is that the providers sometimes don’t have the time to watch them use their inhalers or never think to ask.

Q. How do you provide asthma trigger management?

A. If someone is admitted to they hospital for asthma, they are a captive audience with time to listen. If they have gotten so out-of-control that they need hospitalization, they are often open to hearing about trigger management. We do have linguistically appropriate resources (in approximately 12 languages) to hand out on trigger management, as well.

I recently saw a 20-year-old having his sixth hospital admission for the year, and he didn’t know his triggers. This took time, but we broke down his life style and were able to pinpoint the things that caused his asthma to flare up and talk about how to avoid them.

Q. Describe what you do with regards to smoking cessation for your patients who smoke or who are exposed to second hand smoke?

A. In our facility, all of the Respiratory Clinical Specialists are trained as smoking cessation consultants. We went through a day-long seminar and were given special tools on how to categorize severity, provide feedback to patients, and engaged in role playing to learn how to provide appropriate support and education to our patients who smoke.

It is our goal that we engage all patients, especially those with lung diseases, in smoking cessation. I know if we are successful, I will be out of a job, but I have seen the devastating problems related to smoking in both children and adults.

Q. How do you tailor your education to meet the linguistic and health literacy needs of your clients?

A. We have a native Spanish speaker in our group who will typically work with our Latino patients. He has been trained in medical interpretation and has been approved to provide care in Spanish. This is an invaluable resource for us. We also use telephonic language lines and analyze our materials to make sure they are written in a language and at the level our patients understand.

Our group of Clinical Specialists wrote an educational book on asthma to give to our patients. The book includes a colored AAP and pictures to illustrate techniques. For example, we use these visuals to teach patients how to use inhalers. It is written in simple terms because we know that once you spend a lot of time talking about the history, the symptoms, and the triggers, people are tired and can’t take in much more. The booklet serves as a reminder of key points for them to refer to once they are discharged. It is available in both English and Spanish. We encourage patients to follow up with their primary care providers to ask questions and fine-tune their plans.

This column appeared in the the February 2012  ACU newsletter, Clinician & Community.

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