Diagnosis
Allergic asthma is diagnosed by the presence of both asthma and a year-round allergen. In light of the abundance of recent data on allergic asthma and its prevalence, it is essential that asthma patients know their allergic triggers. Nurse practitioners are ideal providers of this education.

The National Asthma Education and Prevention Program (NAEPP) expert panel recommends allergy testing for patients with persistent asthma who require daily pharmacologic therapy.¹³ Options for allergy testing include skin (in vivo) testing and laboratory (in vitro) testing. Skin testing is most often performed in a specialty setting. Laboratory testing involves analyzing a blood sample for the presence of IgE. Systems available for the lab are radioallergosorbent testing (RAST) or ImmunoCap, a registered trademark of Pharmacia Diagnostics AB.

Patient Education
Thorough patient education should be provided as soon as the results of allergy testing or IgE analysis are available. This education should emphasize avoidance of specific triggers and implementation of environmental controls. Strategies are discussed in the sections below.

Dust Mites
Dust mites may be the most common cause of year-round allergies. Because dust mite allergy is so prevalent, patient education should begin with a thorough discussion about the facts. Patients often need reassurance that the presence of this allergy is not a reflection of their housekeeping practices or cleanliness in general. In most areas of the world, dust mites are in every house, no matter how carefully or thoroughly cleaned.

Because the majority of our time in the home is spent in the bedroom, it is the best place for initiating environmental control. Studies show that more dust mites live in the bedroom than anywhere else in the home. Specific strategies to limit dust mite exposure include the following:

• Encase pillows, mattresses and box springs to create an allergen barrier.
• Wash all bedding and blankets once a week in hot water (at least 130º F).
• Remove wall-to-wall carpets in bedrooms, and leave floors bare.
• Remove fabric curtains and upholstered furniture.

Pollens
Allergy and asthma patients also require education about pollens. Plants that are wind-pollinated are often the cause of allergic reactions. Likely culprits of pollens are spring trees, grasses, weeds and ragweed. Plants that are pollinated by insects are usually not an important cause of allergies.

While it is difficult to avoid pollens, a number of strategies are available to reduce exposure. Reduction measures include the following:

• Avoid activity on dry, windy days. Instead, plan activities after rain.
• Keep home and automobile windows closed. Run air conditioners to filter the air.
• Shower after outdoor activities. Put on clean clothes afterward.
• Dry laundry in dryers during pollen season. Avoid hanging clothes outside.
• Track daily pollen counts, and avoid outdoor exposure when pollen counts are high. Pollen count reports, available in most areas of the country through media outlets and the Internet, reflect how many grains of plant pollen are in a certain amount of air during a set period of time (usually 24 hours).

Molds
Molds are common allergic triggers and grow indoors as well as outdoors. Indoor growth has no definite seasonal pattern. Teach patients that indoor molds are often found in areas with excess moisture, such as kitchens, bathrooms and basements.

Outdoor molds are seasonal, first appearing in early spring. They grow in every climate and region. Many outdoor molds grow on rotting logs and fallen leaves, in compost piles and on grasses and grains. Unlike pollens, molds do not die with the first killing frost. Most outdoor molds become dormant during the winter. In the spring, they grow on vegetation killed by cold weather. Mold counts are likely to change quickly depending on the weather. Certain spore types reach peak levels in dry, breezy weather. Some need high humidity, fog or dew to release spores.

Prevention strategies to reduce mold include the following:

• Use a dehumidifier or air conditioner to maintain relative humidity below 50% and keep temperatures cool.
• Vent bathrooms and clothes dryers to the outside.
• Operate bathroom and kitchen vents while bathing and cooking.
• Remove decaying debris from the yard, roof and gutters.

Putting It Into Practice
A recent survey found that 88% of asthma patients believed their asthma was under control. But 61% of them had to catch their breath while running upstairs, 50% had to stop exercising midway through their regimen, and 48% are awakened at night by their asthma.¹⁴ These results prove that too many patients with asthma overestimate their asthma control and believe that a compromised level of existence is to be expected. NPs must alter that way of thinking.

If a patient's asthma is properly controlled, he or she should be able to participate fully in most activities. The first necessary step in reshaping the prevalent school of thought is patient education. Patients require a good understanding and working knowledge of asthma, its treatment, its triggers and particularly its connection to allergies. The treatment of asthma often necessitates the treatment of an allergy, and the treatment of an allergy often necessitates the treatment of asthma.

Karen Rance is a pediatric nurse practitioner and certified asthma educator who works at Tidewater Pediatric Consultants in Virginia Beach, Va. The author has declard no real or perceived conflicts of interest that relate to this educational activity.

To learn about another precursor to asthma, don't miss the sidebar about atopic dermatitis on the next page.

References
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