Introduction to the Yellow Zone: Stressing Variability in Perception of Dyspnea, Real World Nonadherence and Proposed Mechanism of Dose Escalation

Identification and management of acute loss of asthma control is extremely important, as not recognizing and treating a potential asthma attack could lead to a more severe situation and a visit to the emergency room, hospitalization, or in worst-case scenarios, death. Asthma as a disease is difficult to predict, as the patient and the environments are always changing. However, clinicians and patients both need to be prepared for the worst-case scenarios and determine what treatment approach works best for managing asthma exacerbations. A practice parameter for clinicians, derived from the “traffic light” model (i.e., green, yellow, and red zones) is called the “yellow zone,” which indicates when patients are having an asthma exacerbation or have lost control of managing their asthma symptoms and requires additional treatment to regain control.

John J. Oppenheimer, MD, FACAAI, from Rutgers Medical School and Pulmonary and Allergy Associates in Cedar Knolls, New Jersey, stressed the very real challenges in treating patients with asthma throughout his presentation “Introduction to the Yellow Zone—Stressing Variability in Perception of Dyspnea, Real World Nonadherence and Proposed Mechanism of Dose Escalation.” Challenges include: patients not adhering to their daily treatment regimen; patients adjusting their medication on their own without physician oversight; patients not perceiving symptoms readily; and the need for more data for making appropriate yellow zone treatment recommendations.

A common problem with helping patients maintain control of their asthma is non-adherence to treatment plans, with one study showing that 6%-44% of patients fail to fill their initial prescription. Another study indicates that inhaled corticosteroids are used as directed less than 50% of the time.² Therefore, in treatment failures, physicians should consider non-adherence as a possible cause.

One solution for handling worst-case scenarios and exacerbations is an asthma action plan for the patient to follow. Asthma action plans have been shown to reduce symptoms and emergency use of healthcare resources as well as improving asthma-specific quality of life, as patients tend to feel less anxious about how asthma will affect their daily activities. Dr. Oppenheimer cautioned that research by Partridge et al. shows that patients without asthma action plans tend to adjust their medications on their own when they notice an increase in symptoms and often times the adjustment is inappropriate.

 Dyspnea, or difficulty breathing, represents another challenge in patients presenting with asthma, which is often an indicator that patients may have an asthma attack. However, dyspnea is not readily measured in patients with asthma, and there are some patients that are not able to perceive dyspnea. The “poor” or “low” perceivers can quickly enter the yellow zone without warning; thus, these patients need to be educated about how to monitor their asthma symptoms more closely (specifically, with a peak flow meter).

“Poor perceivers of dyspnea are at a higher risk of death and less likely to know how severe their asthma is—as a clinician it is your responsibility to make sure you know who these patients are and that they can use a peak flow meter,” urged Dr. Oppenheimer.

Dr. Oppenheimer ended with the call for more research and data to determine what the best approach is for managing patients with asthma in the yellow zone. Currently, there is no perfect measure of asthma control. In the coming years, the use of computer learning could help develop composite scores for patients to determine their risk for asthma exacerbations. The best thing to do at present, Dr. Oppenheimer noted, is to instruct patients to escalate asthma therapy when there is a loss of asthma control—preferably as it relates to the patient’s specific asthma action plan.

Citations
1. World Health Organization 2003. Available at: http://www.who.int/ chronic_conditions/en/adherence_report.pdf Accessed May 16, 2007.
2. Walders N. J Pediatr. 2005;146:177-182.
3. Partridge BMC. Pulmonary Medicine. 2006;6:13.