
==== Front
Tunis Med
Tunis Med
Tunis Med
La Tunisie Médicale
0041-4131
2724-7031
Tunisian Society of Medical Sciences

37682277
Article
Éducation thérapeutique du patient asthmatique aux urgences: intérêt chez l’adolescent et l’adulte jeune
Impact of online therapeutic education on asthma control in youth: an emergency department studyHebaieb Fatma 1
Arfaoui Rayène 1
Hmaïssi Rania 1
Gzara Sofiène 1
Aissa Sonia 1
1. Service d’Urgence, Hôpital Mahmoud El Matri Ariana / Faculté de Médecine de Tunis, Université Tunis El Manar.
2 2023
05 2 2023
101 2 306312
2022
https://creativecommons.org/licenses/by-nc-nd/4.0/ This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-nd/4.0/
RESUME

Introduction : L’asthme est une pathologie respiratoire chronique très répandue qui touche principalement les jeunes. Sa prise en charge vise à prévenir la survenue d’exacerbation et assurer une activité quotidienne normale. Objectif : Evaluer l’impact de l’éducation thérapeutique en ligne initiée aux urgences sur le niveau de contrôle de l’asthme. Méthodes : Etude prospective menée sur six mois. Inclusion des asthmatiques âgés de 14 à 35 ans. Le niveau de contrôle de l’asthme était évalué selon les recommandations de la GINA avec une réévaluation à trois mois après éducation thérapeutique en ligne. Résultats : N=75, 18% adolescents, âge moyen=24 ans et sex-ratio=0,56. Un niveau d’étude supérieur était noté dans 73% des cas et un bon niveau socio-économique dans 48%. 55% n’avaient aucune connaissance des mécanismes physiopathologiques. La dernière exacerbation a été classée modérée dans 71%. L’humidité était le facteur d’exacerbation le plus fréquent (76%). Une amélioration significative du contrôle de l’asthme a été observée après l’éducation thérapeutique (p<.0,001) avec une corrélation positive avec : genre féminin (p=0,048), bonne connaissance des mécanismes physiopathologiques (p=0,001) et classification légère de la dernière exacerbation (p=0,039). Le sexe masculin et le déclenchement de l’exacerbation par l’humidité étaient des facteurs indépendants influençant négativement l’évolution du contrôle après l’éducation thérapeutique. Conclusion : Le service d’accueil des urgences est un lieu de consultation fréquent pour les patients asthmatiques. Transmettre des messages éducatifs à partir des urgences et émettre un programme d’éducation thérapeutique en ligne a fait preuve de son efficacité

ABSTRACT

Introduction: Asthma is a widespread chronic respiratory disease. It affects all age groups, mainly youth. Its management aims to prevent exacerbations and ensure normal daily-life activity. Current international recommendations attach particular importance to the therapeutic education to improve asthma control and reduce emergency room visits. Aim: To assess the impact of online therapeutic education for youth asthmatics initiated in the emergency department on the level of asthma’s control. Methods: Descriptive-evaluative study conducted over six months including asthmatics aged 14 to 35 years old living in Ariana. Asthma control was evaluated according to the 2019 Global Initiative for Asthma recommendations with a reassessment at three months after online therapeutic education. Results: N=75; 18% of patients were adolescents, sex-ratio = 0.56. University education was noted in 73% of cases and high socioeconomic status in 48% of subjects. 55% of participants had no basic knowledge of the asthma’s pathophysiology. Moderate classification of the last exacerbation was noted in 71% of patients and humidity was the most common exacerbation trigger (76%). A significant improvement in asthma control was observed after therapeutic education (p <0.001) with a positive correlation with female gender (p=0.048), basic knowledge of asthma’s pathophysiology (p=0.001) and mild classification of the last exacerbation (p=0.039). Male gender and humidity as exacerbation trigger were independent factors negatively influencing control outcome after therapeutic education. Conclusion: The emergency department is the referral unit of the management of asthmatics with acute events. This represents an important opportunity to share educational messages that have proven effective using an online model.

Mots clés

Asthme
Education
Adolescent
Adulte jeune
Urgences
Keywords

Asthma
Education
Adolescent
Young adult
emergency
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pmcINTRODUCTION

Asthma is a chronic respiratory condition that is widely spread throughout the world

Its prevalence is increasing in different age groups especially in youth ( 1 , 2 ).

It constitutes the most frequent chronic disease in childhood (1).

It often limits the daily activity of patients, reduces their quality of life and represents a heavy burden for individuals and their families with high direct and indirect costs ( 3 , 4 ).

Asthma control is a relatively recent concept that evolves beyond the usual notion of disease severity

It may be described as controlling the residual manifestations of asthma under treatment, thus providing a dynamic concept to facilitate therapeutic decisions.

To improve the asthma outcome, facilitate symptom control and reduce emergency department (ED) visits, other therapies and non-drug strategies have been considered. Global Initiative for Asthma (GINA) insist on the value of educational strategies and personalized action plan ( 3 )

Therapeutic education in asthma aims to guarantee the best possible quality of life by offering patients autonomy with the acquisition and maintenance of necessary skills to use their treatment optimally and manage their chronic disease ( 3 ).

Our study was interested to assess the impact of online therapeutic education provided by ED team on the level of asthma control in adolescents and young adults and to describe the influence of the different personal factors on the effectiveness of the education program

METHODES

Study design and setting

Prospective, descriptive-evaluative study conducted over a six-month period from January to June 2020, in a polyvalent ED in Ariana governorate.

Study population

Patients aged 14 to 35 years old with known asthma living in Ariana who presented successively to our ED for exacerbation or answering the online questionnaire during the study’s period.

Through social networks (Outlook, Instagram and mainly Facebook), known asthmatics, living in Ariana, had responded to the form shared online, as well as to the interrogation made by telephone.

The diagnosis of known asthma was based on a combination of clinical and paraclinical arguments, mainly spirometry.

As sa non-inclusion criterion, we decided on asthma of primary diagnosis in the ED.

Exclusion criteria were patients followed for mental illness for risk of misunderstanding or interpretation of therapeutic education and patients lost to follow-up during the study

Study protocol personal history

Patient demographics, including socioeconomic status and education level, known asthma history and background therapy, comorbidities, risk factors for poor asthma outcomes, and exacerbation triggers were recorded.

The socio-economic status was based on the most used indicators: education, occupation and income ( 5 ).

clinical evaluation

The emergency physician noted the classification of asthma exacerbation severity into 3 classes: mild, moderate, and severe based on the current international recommendations.

It should be noted that, in view of the first wave of SARSCOV2 epidemic, peak expiratory flow was not considered in the classification of exacerbation in patients consulting the ED.

The level of asthma control was assessed according to the 2019 GINA recommendations ( 3 ).

Optimal control of asthma meets the following criteria: no or minimal daytime symptoms, no night waking due to asthma, no or minimal activity limitation, no or minimal medication use, no exacerbation and normal lung function ( 3 ).

Well controlled asthma is defined as all criteria met, partly controlled asthma as one or two criteria per week, and uncontrolled asthma as three or more criteria per week.

For patients who filed the online form, they were called and provided the information necessary to classify the severity of the last asthma exacerbation and assess their asthma control.

therapeutic education program

After completing the questionnaire (in the ED/online), patients were contacted by email and telephone, for possible correction or clarification of received answers.

One or more video messages were sent to them containing a clear explanation of the use of the inhalation device.

These messages varied depending on the inhalation system that was prescribed for each case. Thus, each patient received a different email containing one or more explanatory video clips.

Therefore, 3 video clips were filmed with a Samsung NX 1000 digital camera:

- Video 1 explaining the handling of a metered dose inhaler

- Video 2 explaining the handling of a dry powder inhaler system like Diskus

- Video 3 detailing the handling of a dry powder inhaler system type aerosolizer.

Patients had to confirm that they had received and studied the manuals provided.

. A second phone call was then made. Three months later, a third telephone call was necessary to evaluate the condition of each included patient, the questionnaire is thus completed by the investigator.

The verification of post-education asthma control level was in September 2020.

Attached is the internet link of the video sequences filmed: https://www.youtube.com/user/22rayene/videos.

statistical analysis

The Mac Nemar test was used to compare frequencies of paired groups and in case of invalidity, we resorted to the binominal distribution properties.

A p value< 0.05 was considered significant in all statistic tests.

We have classified the investigated cases according to the results of our analysis into groups: Group 1: Patients who had maintained good control or became well controlled after the education program, Group 2: Patients who had improved asthma control without becoming well controlled and those who failed to improve their asthma control 3 months after the education program.

To identify risk factors independently related to the event, we conducted a multivariate analysis in logistic regression stepwise descending.

The multivariate analysis allowed the calculation of adjusted Odds Ratios, measuring the role of each factor.

ethical considerations

The local ethics committee of Mahmoud El Matri in Ariana approved the study protocol on December 3, 2019 with the IRB registration number 42/2019.

The patients had to sign an informed consent, based on complete, precise, properly conveyed and understood information, before being included.

The confidentiality of patients’ medical and personal data was respected.

RESULTS

Personal history and clinical evaluation

Seventy-five patients were enrolled. Figure1 illustrates the flow diagram for study participants. They had an average age of 24 years and showed a female predominance (64%). Fifty-five patients (73%) had university education among them were 16 health care professionals (21%), including physicians, dentists, pharmacists, and paramedical staff. Twelve patients had controlled asthma (16%), forty-one patients had partly controlled asthma (55%) and twenty-two patients had uncontrolled asthma (29%). Moderate classification of the last exacerbation was noted in 71%. Humidity was the most common exacerbation trigger (76%).

Figure 1. Flow diagram for study participants.

Table 1 shows the characteristics of patients prior to the therapeutic education.

Table 1 : Personal history and clinical evaluation

blanc_space

	Characteristic of population

	Results

	
Age, years

	24,3 ± 10

		
Age groups

	Adolescent

Young adult

	14 (19%)

61 (81%)

	
Sex-ratio (M/F)

		0,56

	
Socioeconomic status

		High socioeconomic status

Middle socioeconomic status

Low socioeconomic status

36 (48%)

35 (47%)

4 (5%)

	
Family stability (adolescent)

		Married parents

Divorced parents

12 (86%)

2 (14%)

	
Marital status (young adults)

		Single

Married

Divorced

47 (77%)

13 (21%)

1 (2%)

	
Education level

		Primary education

Secondary education

University education

2 (3%)

18 (24%)

55 (73%)

	
Basic knowledge of the asthma’s pathophysiology

		41 (55%)

	
Tobacco, active smoker

		26 (31%)

	
Controller medications for asthma: types of inhalers

		Metered dose inhalers

Dry powder inhalers

71 (95%)

4 (5%)

	
Comorbidities

		Infant asthma

Gastroesophageal reflux

Pulmonary tuberculosis

Atopic terrain

25 (33%)

15 (20%)

1 (1%)

57 (76%)

	
Prior asthma-related events

		ED visit once a year

ED visits ≥ twice a year

Hospitalization for asthma exacerbation

ICU stay for severe asthma exacerbation

42 (56%)

23 (31%)

6 (8%)

1 (1%)

	
Severity of last asthma exacerbation

		Mild

Moderate

Severe

9 (12%)

53 (71%)

13 (17%)

	
Circumstances of asthma exacerbation

		Exposure to environmental allergens

Humidity

Season change

Cold air

Environmental change

Presence of animals

Exercise

Hearty meal

53 (71%)

57 (76%)

56 (75%)

38 (51%)

45 (60%)

23 (31%)

33 (44%)

9 (12%)

	
Asthma control on initial examination based on GINA 2019

		Well controlled asthma

Partly controlled asthma

Uncontrolled asthma

12 (16%)

41 (55%)

22 (29%)

	
GINA: Global Initiative for Asthma

			

Asthma control

Asthma control was compared before and 3 months after therapeutic education.

The figure 2 and table 2 illustrate the distribution of patients according to changes in level of control before and 3 months after the education program.

The percentage of patients with uncontrolled or partly controlled asthma had decreased from 84% to 31%.

That of patients with well controlled asthma had improved from 16% before therapeutic education to 69% after (p< 0.001).

No deterioration in asthma control was observed after the therapeutic education program.

Figure 1. Flow diagram for study participants.

Table 2 : Asthma control level before and 3 months after therapeutic education

Characteristic of population

	Well controlled asthma

	Partly controlled asthma

	Uncontrolled asthma

	
Prior to therapeutic education

	12

	41

	22

	
3 months after therapeutic education

	52

	23

	0

	
p<0,001 Mc Nemar Test: p<0,001

	

Factors that affect the evolution of asthma control after the education program

Female gender, basic knowledge of the mechanisms of asthma’s physiopathology, humidity, and inhalation of allergens as exacerbation-triggers factors, and mild classification of the last exacerbation were significantly associated with the evolution of asthma control after therapeutic education.

Table 3 presents a summary of the analysis of factors that may influence the outcome of asthma control after the education program.

Adolescents’ family stability, young adults’ marital status, types of inhalers, comorbidities and prior asthma-related events did not influence the evolution of asthma control after education program.

Multivariate regression analysis revealed that humidity (OR=10.68; 95% confidence interval, 1.32 - 86.05; p=0.008) and gender (OR=2.69; 95% confidence interval, 0.976 - 7.42; p=0.048) were factors independently related to improvement in asthma control with therapy education.

After calculating the adjusted Odds Ratios, it can be concluded that:

• Factors that improved the level of control after this program were:

- Female gender (p=0.048; OR=2.69)

- Basic knowledge of the mechanisms of bronchial obstruction (p< 0.001; OR=73.3)

- Mild classification of last exacerbation (p=0.008; OR=3.35)

• Factors negatively influencing the evolution of post education asthma control were:

- Humidity as exacerbation trigger (p=0.008; OR=10.68)

- Exacerbation of asthma after exposure to environmental allergens (p=0.039; OR=3.84).

DISCUSSION

Our study shows that therapeutic education is an efficient approach to optimize asthma control in adolescents and young adults.

Sixty-nine percent of patients had well-controlled asthma after the education program compared to 16% at the beginning of the study

None of included patients had poor control after the therapeutic education, while 29% were uncontrolled prior to it.

Gender, presence of basic knowledge of the asthma’s pathophysiology, exacerbation-inducing factors as humidity or inhalation of allergens and mild classification of the last exacerbation were significantly associated with well evolution of asthma control after therapeutic education.

According to GINA, asthma control is assessed by the patient’s ability to manage asthma symptoms, to reduce or remove them by treatment.

Disease control has two main areas of action: symptom control and risk factors for future poor outcome, particularly asthma flare-ups ( 3 )

Asthma control remains poor, worldwide (6-12).

Many studies have analyzed the impact of the education program on asthma control ( 13 - 17 ).

Boulet and al ( 14 ) reported that in the year following the therapeutic education program for enrolled patients, the number of unscheduled medical visits related to respiratory problems decreased significantly (from 137 to 33 visits; p=0.002).

There was an observable rise in the proportion of patients with well-controlled asthma which increased from 52 before the therapeutic education program to 90 one year later (p<0.001) (14)

In the comparative study of Arikan and al, one hour of education for children with uncontrolled asthma in the presence of their parents did not improve asthma control at 1 and 3 months, although the Asthma Control Test score was higher in the education group compared to the control group (15).

This study is in the only case found in the literature that did not report a significant impact of therapeutic education program. However, they found a significant difference between the two groups regarding school absenteeism: 0.1±3 for the first group vs 2±4 for the second (p=0.006) ( 15 )

Ali and al in 2019 reported that therapeutic education had a positive impact on the level of asthma control: the number of cases with well-controlled disease increased from 28 patients (32%) to 44 patients (50%) after therapeutic education (p=0.0043) (16)

The visits to the EDs decreased after education (42 visits before education versus 20 visits after the education program; p=0.0002); the number of ED visits per patient per year decreased to 0.86 before and 0.44 after education (p<0.01) ( 16 ).

The Gallefoss and al study (17) evaluated the life’s quality of 78 asthma patients compared therapeutic education program group to a control group, reported a statistically significant decrease in daytime symptoms, nighttime events, limitation of activity due to asthma per week and consequently a better control (17).

Our study confirmed the importance of therapeutic education and its impact on asthma control.

The percentage of our patients with poor or partial control decreased from 84% before therapy education to 31% afterwards.

The proportion of patients with well-controlled asthma increased from 16% to 69% (p< 0.001).

). In addition, we aimed to assess the impact of different personal factors on the effect of the education program on asthma control.

Tada and al. noted that therapeutic compliance was better in older subjects compared to younger subjects (18) and recent literature reported that asthma control was more difficult in adolescents (18,19)

Gemicioglu and al found that asthma control and adherence were similar in elderly and newly diagnosed young asthma patients, although the follow-up rate was lower in younger patients ( 20 ).

In our study, there was no evidence of an impact of age on the evolution of asthma control after the education program.

Selberg and al in 2019 evaluated the difference in both genders concerning asthma control and didn’t find a statistically significant difference ( 21 )

In our study, female gender was an independent factor related to good asthma control with an OR of 2.69.

This is a unique finding that wasn’t reported in the literature.

Analyses studying patients’ knowledge of their asthma disease prove the positive impact of this knowledge on the evolution of asthma ( 22 , 23 )

Indeed, good education of asthma and its mechanism leads to a 25% reduction in work absenteeism, 36% fewer EDs visits, 40% fewer hospitalizations and fewer night wakings due to asthma ( 23 ).

Our study reflects patients’ lack of knowledge of asthma: only 54.7% of patients had a minimal pathophysiological awareness.

Although the level of education did not influence the evolution of asthma control after therapeutic education, basic knowledge of the asthma’s pathophysiology was significantly involved in the disease control (p< 0.001).

Scientific analyses assessing the impact of asthma exacerbation triggers on the evolution of asthma control after therapeutic education are exceptional.

In our study, patients with humidity and allergens inhalation as exacerbation triggers have more difficult asthma control even after therapeutic education.

Humidity had an independent negative influence on the evolution of asthma control after education and this result wasn’t reported in the literature.

The classification of the last exacerbation was also significantly involved in the good evolution of asthma control after therapeutic education (p=0.008).

No article reported a similar result. Our data and literature findings indicate poor asthma control despite available medical resources. They confirm the useful role of therapeutic education in the asthma management.

Online therapeutic education has been found effective, with a significant impact on controlling this disease.

It is available, repeated, and unlimited.

A new concept, appreciated by our young study population, that under certain circumstances may be necessary or even indispensable such as the first wave of COVID19 pandemic.

limitations

- Although we insisted to our best ability on understanding the usage steps of inhaler and on asking clarifying questions, we did not have the opportunity to check this in a face-to-face, as the therapeutic education was done by correspondence during the COVID pandemic19.

- Selection biases were related to self-selection of patients on social networks and to the proportion of health professionals representing 21% of our sample.

Conclusion

Therapeutic education should be an integral part of asthma treatment in adolescents and youth. Our study highlighted the contribution of ED in therapeutic education and preventive approach.

Additional efforts are needed for males’ therapeutic education and a special emphasis should be placed to avoid humid environments among asthmatics.

The establishment of a national platform of asthma school in Tunisia, multidisciplinary, accessible, free, and available from the ED presentation is therefore essential.
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