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asthma

Adjunct Therapies to Treat Dyspnea in Adult Patients With Moderate to Severe Asthma

Volume 54 - Issue 1 - January 2014

Authors:

Eran Sykes, MA, BSN, RN, MS/FNP, Lisa Morrow, MSOM, LAc, BSN, RN, MS/FNP, and Kathryn Daniels, RN, BSN, MS/FNP

Citation:

Consultant. 2014;54(1):36.

 

ABSTRACT: Evidence supports that acupressure helps alleviate dyspnea in various pulmonary diseases and the use of acupressure may be particularly beneficial for adults with moderate-to-severe asthma. Primary care providers who have a grounded understanding of complementary and alternative medicine (CAM) can more appropriately identify patients who may be candidates for a referral to adjunct therapy for their dyspnea. Knowledge-based collaboration between biomedical providers and non-allopathic providers can also improve the patient’s adherence and compliance to asthma medications. This article will focus on the benefits and applications of acupressure in family primary care settings.
 

Asthma is a chronic illness that is a physical, emotional, and financial burden to all those affected. Each day, 9 people die from this cumbersome disease1,2 and the prevalence of asthma continues to increase in the United States. In 2001, there were 20.3 million cases reported and in 2010, that number increased to 25.7 million.2 In New York City, 1 in 8 people over the age of 18 were diagnosed with asthma as compared to the national rate of 1 in 12 adults.1 While asthma is an incurable obstructive airway disease, symptoms can be controlled and the patient’s quality of life can be improved. 

The frequency of asthma exacerbations, hospital admissions, and emergency room visits indicate that current treatment regimens are not sufficient. While medications are necessary, patients may experience major side effects. In addition, medication costs and the lack of a perceived need for intervention leads to medication non-adherence.3 Poorly controlled asthma can be attributed to environmental factors such as air pollution and cockroach feces,4 lower socioeconomic statuses, and low levels of literacy.2 While the majority of health care programs guarantee care for children, the same is not true for adults.2 

Adjunct therapy may potentiate the effects of asthma medications and decrease exacerbations, thus leading to lower doses of medication therapy and a reduction in adverse effects. 

NEXT: Complementary and Alternative Medicine

 

COMPLEMENTARY AND ALTERNATIVE MEDICINE

Complementary and alternative medicine (CAM) is a therapeutic discipline that encourages an individualistic approach, focusing on a patient’s feelings and energy balance to help prevent, treat, and control disease.5 CAM has been used worldwide as a stand-alone and adjunct therapy for centuries and uses multiple modalities—including herbal remedies, acupuncture, acupressure, and meditation—to heal patient ailments. 

CAM providers must attend schools that are accredited by a national body. Similar to nursing, regulation guidelines and scope of practice are regulated by each individual state. However, family nurse practitioners can help refer appropriate patients to CAM providers.

CAM has received some resistance from the healthcare community in the United States, which may be attributed to the primary care provider’s lack of understanding. Topaz et al6 found that biomedical providers generally have a positive attitude towards holistic medicine, but lack the practical knowledge to practice or refer patients to CAM providers. However, 86% of patients in the United States are using CAM methods to supplement their primary care, and often not informing their healthcare providers.7 

Currently, there are no guidelines that mention CAM treatment modalities as an option. As such, integrative medicine may not be as easily accepted in evidence-based practices. Primary care providers (PCPs) are hesitant to refer or educate patients about CAM treatments due to lack of guidelines and insurance reimbursement. Randomized clinical trials of CAM are difficult to conduct because non-allopathic providers base their treatment on the individual needs of their patients.5 Similarly, there are no standard guidelines for the use of CAM because therapy is tailored to the culture, social, and mental needs of each patient. 

acupuncture
Photo Credit: Kathryn Daniels RN, BSN, MS/FNP

NEXT: Acupuncture and Dyspnea

 

Acupressure

Acupressure is a non-invasive form of CAM with minor side effects, such as dizziness, skin reactions, and headaches.8 Studies suggest that acupressure can help treat multiple symptoms related to common discomforts and illnesses. One clinical trial of 100 women in labor found significant differences in the pain score and duration of labor between the control and experimental groups.8,9 Another randomized trial of 146 adults with chronic low back pain found that after a period of 4 weeks and 6 months respectively, acupuncture better reduced pain as compared to physical therapy.10 

Given the low cost of acupressure, it is a recommended treatment in cases of acute vertigo.11 In fact, sea-bands, a popular method to reduce motion sickness, vertigo, nausea, and vomiting, work by putting pressure on the Nei-Kuan point of the wrist. In a systematic review, Lee at al provided evidence for the efficacy of acupressure for vomiting and nausea associated with chemotherapy, radiation, surgery, acute myocardial infarction, and motion sickness.8 In addition, acupressure has been found to be helpful in the treatment of chronic obstructive airway disease (COPD).12 Many of these studies face limitations, including a small sample size, low quality, and/or do not prove patient-centered outcomes, that need to be addressed to create evidence-based practice guidelines.13 

Dyspnea

Similar to COPD, symptoms of asthma can be incapacitating and negatively impact your patient’s quality of life. Dyspnea can be acute or chronic and is the primary reason patients with asthma visit their primary care provider.8 It limits a patient’s activity level, leads to hospitalization, is costly, and difficult to manage. Dyspnea is associated with other symptoms including increased blood pressure, respiratory rate, and heart rate.8 Dyspnea is often exacerbated by the anxiety induced from the sensation of not being able to breathe.

Studies have found that the use of acupressure as an adjunct therapy to COPD regimens is effective in reducing dyspnea in patients with this chronic obstructive airway disease.12,14 Maa et al collected data from 2 separate studies to conclude that daily acupressure, at 5 different points, improved quality of life and reduced dyspnea in patients with chronic obstructive asthma and bronchiectasis.15,16 In a study of 41 patients suffering from chronic obstructive asthma, acupressure in combination with standard care was found to have a 6.57-fold increase in quality of life versus standard care alone.15 

In another study with 52 patients, Tsay et al found statistically significant data to indicate that daily acupressure decreased heart rate, blood pressure, anxiety, respiratory rate, and dyspnea in patients on mechanical ventilation support.17 A clinical trial of preoperative anxiety for patients undergoing abdominal surgery noted the effects of acupressure on decreasing anxiety, heart rate, blood pressure, and respiratory rate before surgery were statistically significant.18 

NEXT: Treatment Plans

 

A TREATMENT PLAN

Three acupressure points—HT7, PC6, and LI4—were deemed the least complicated for patients to learn and perform correctly.8 Practitioners and Family Nurse Practitioners (FNPs) can use the Figure as an example of a potential CAM acupressure protocol that can be self-administered by capable patients. A CAM practitioner would customize the protocol for each individual patient after an initial evaluation. The collaboration between the CAM practitioner and the primary care provider should result in a well-monitored and efficacious treatment plan for the patient. 

The FNP and practitioner can then follow-up with the patient, assess for symptom improvement, and decide whether to re-assess the current management. As a result, the patient stays informed and is able to participate in their own wellness with improved adherence to their treatment plan and clinical improvement.

Asthma patients can benefit from integrating acupressure into their current regimen. Take these 2 scenarios: A post-surgery asthma patient may benefit from preventative acupressure while on bed rest to reduce the risk of an asthma exacerbation or a patient in the emergency department experiencing an asthma exacerbation could apply acupressure to reduce acute symptoms during a nebulizer treatment.  

In each of the above cases, CAM practitioners must personalize the acupressure points prescribed to address the specific needs of each patient and the practitioner and FNPs must advocate for collaboration and information on behalf of the mutual patient—and ideally improve patient adherence and compliance through increased dialogue. 

Ultimately, CAM providers can teach patients to properly self-administer their acupressure protocols. Asthma patients suffering from dyspnea who self-administer acupressure, will have similar outcomes to other patients who use acupressure to help treat their conditions, including a reduction in stress, anxiety, heart rate, respiratory rate, blood pressure, dyspnea, and less asthma exacerbations. 

dyspnea
Figure. Adjunct Therapy for Asthma Patients: An example of CAM provider protocol including easily self-administered acupressure points. 

NEXT: Primary Care Takeaways

 

Primary Care Use

The CAM approach involves understanding the patient’s energy balance, personal feelings, and individual social and cultural context. Clinicians without CAM training should refer patients to a licensed and experienced CAM provider to maximize results and minimize risk. Consider using FNPs as the primary contact for the CAM provider.  

Keep in mind that while the cost in seeking CAM would initially be greater due to consultation fees, eventually patients can self-administer individualized acupressure therapy. And as exacerbations are prevented, the number of missed days of work will decrease and your patient will save on hospital visits, copays, and the cost of medication. Providers can also learn to incorporate adjunct therapy into their practice to enhance patient outcomes, increase patient’s quality of life and lower health care costs. 

Research has proven that acupressure is beneficial to patients who suffer from dyspnea and its associated symptoms. However, more comprehensive studies are needed to provide evidence-based practice guidelines. Until then, physicians and FNPs should consider referring their adult patients with moderate-to-severe asthma who suffer from dyspnea to a CAM practitioner specializing in acupressure. Specific measures such as respiratory rate, anxiety, heart rate, and blood pressure can be used to prove the efficacy of acupressure in asthma patients.

 

Eran Sykes, MA, BSN, RN, MS/FNP, has recently completed her Master's in Nursing at Columbia University. She looks forward to continuing at Columbia in the DNP program, and starting her practice as a family nurse practitioner.

Lisa Morrow, MSOM, L.Ac, BSN, RN, MS/FNP, is a student in the FNP/DNP nursing program at Columbia as well as a licensed acupuncturist with 7 years experience. She looks forward to innovative ways of enhancing your well being from the combined perspectives of Eastern and Western medical arts.

Kathryn Daniels, RN, BSN, MS/FNP, recently completed her Master’s in Nursing at Columbia University as a family nurse practitioner. Her experience in research began at Dana Farber Cancer Institute where she worked as a Clinical Research Coordinator for 2.5 years before going back to school for nursing.

References:

  1. Public Health Information Groups Center for Community Health New York State Department of Health. New York State asthma surveillance summary report. 2009. http://www.health.ny.gov/statistics/ny_asthma/pdf/2009_asthma_surveillance_summary_report.pdf. Accessed November 15, 2013.
  2. Moorman, JE, Akinbami LJ, Bailey CM, et al. National surveillance of asthma: United States 2001‐2010. National Center for Health Statistics. Vital Health Stat. 2012;3(35). http://www.cdc.gov/nchs/data/series/sr_03/sr03_035.pdf. Accessed November 15, 2013.
  3. McHorney CA, Spain CV. Frequency of and reasons for medication non-fulfillment and non-persistence among American adults with chronic disease in 2008. Health Expect. 2011;14(3):307-320.
  4. Corburn J, Osleeb J, Porter M. Urban asthma and the neighbourhood environment in New York City. Health Place. 2006;12(2):167-179.
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  6. Topaz M, Johnson A, Pinilla R, et al. Primary care providers’ attitudes and beliefs about patients’ complementary and alternative medicine use for asthma self-management: an exploratory study. J Asthma Allergy Educators. 2012;3(6):255-263.
  7.  Jong MC, van de Vijver L, Busch M, et al. Integration of complementary and alternative medicine in primary care: what do patients want? Patient Educ Couns. 2012;89(3):417-422.
  8. Lee EJ, Frazier SK. The efficacy of acupressure for symptom management: a systematic review. J Pain Symptom Manage. 2011;42(4):589-603.
  9. Hamidzadeh A, Shahpourian F, Orak RJ, et al. Effects of LI4 acupressure on labor pain in the first stage of labor. J Midwifery Women’s Health. 2012;57(2):133-138.
  10. Hsieh LL, Kuo C, Yen MF, Chen TH. A randomized controlled clinical trial for low back pain treated by acupressure and physical therapy. Prev Med. 2004;39(1):168-176. 
  11. Alessandrini M, Napolitano B, Micarelli A, et al. P6 acupressure effectiveness on acute vertiginous patients: a double blind randomized study. J Altern Complement Med. 2012;18(12):1121-1126.
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  15. Maa SH, Sun MF, Hsu KH, et al. Effect of acupuncture or acupressure on quality of life of patients with chronic obstructive asthma: a pilot study. J Altern Complement Med. 2003;9(5):659-670.
  16. Maa SH, Tsou TS, Wang KY, et al. Self-administered acupressure reduces the symptoms that limit daily activities in bronchiectasis patients: pilot study findings. J Clin Nurs. 2007;16(4):794-804.
  17. Tsay SL, Wang JC, Lin KC, Chung UL. Effects of acupressure therapy for patients having prolonged mechanical ventilation support. J Adv Nurs. 2005;52(2):142-150.
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