Asthma

Aims of asthma care

To recognise asthma
To abolish symptoms
To restore and maintain best possible long term airway function
To reduce the risk of severe attacks
To enable normal growth in children
To minimise absence from school or work
To encourage the use of agreed self-management plans

Goals

Recognition of basic symptoms of asthma
Distinction between preventers and relievers
When to call for help with worsening symptoms
Correct use of chosen inhaler device

Other considerations

Education of general population, especially teachers, by liaison with other members of the PHCT eg school nurse, health visitors.

school workshops
health workshops in the community, etc.

This protocol proposes a step-wise management plan for patients with asthma. This involves early use of preventive treatment, and treatment tailored to the (changing) needs of the individual. Successful management involves a partnership with the patient (and family). A distinction is made between active, quiescent and chronic asthma.

The asthma register

The asthma register is maintained on the practice computer. When a new diagnosis of asthma is made, it is entered on the patient's computer record. A search is defined to detect those patients who receive asthma medication, but in whom the asthma disease code is missing.

Call and recall

Priority is given to patients whose asthma is poorly controlled. This is determined by a program which detects patients who are over-using their reliever inhalers. Patients with active asthma are called to the asthma clinic, and priority is given to patients with night-time symptoms (this is determined by attaching a questionnaire to their repeat prescription for reliever medication.

Patients with quiescent asthma are not called. (Active asthma is present when a patient has had ANY prescription for asthma in the last year - quiescent asthma is symptom free, using no medication)

Education of newly-diagnosed patients

Height/weight > optimum PEF.
Reversibility/exercise test if appropriate.
Asthmatic history and record possible trigger factors.
Other medical history and drugs - possible interaction. i.e. Aspirin, Beta-blockers + NSAID's (eg Ibuprofen).
Asthma state - present.
Brief explanation of asthma (at this stage careful not to overwhelm patient with info).
Instruct in inhaler technique, using inhaler device which patient feels most comfortable with.
Instruct in PEF. and give home monitoring sheet and PEF. meter and treatment card.
Give P.A.L.
Make appointment for return in 1 month.
consider desired areas of understanding

Continuing education

First follow-up visit

Check home monitoring chart and control.
Check inhaler technique.
Further education - ask if any questions! Effect of drugs and if on preventer as well as reliever the importance of not stopping preventer.
Make next appointment. P.A.L.
consider desired areas of understanding

Six-monthly/yearly visit (frequency depends on severity)

Height if relevant
Weight if relevant
PEF and review peak flow diary
Past asthmatic history and home monitoring
Check present treatment/compliance/inhaler
If difficulties with type of inhaler - change
Educate
- Cause and action of disease
- Trigger factors - avoidance/or alter treatment before contact with trigger factors.
- Importance of preventers
- Interpretation of PEF and action
- Emergency action
- Drugs, eg. NSAID's, Beta-blockers
- Lose weight/stop smoking. (other family members who smoke).
- consider desired areas of understanding

Self -management plan

Patients on Relievers only: beta2 agonists or Atrovent may increase inhaler to up to 20 puffs per day. If symptoms persist or inhaler effective for less than 4 hours to contact G.P. ?to commence steroids.
Patients on Relievers and Preventers:
- If drop in P.E.F. of 30% - double preventer dose
- If drop in P.E.F. of 50% start oral steroids and inform Doctor. Prednisolone, child 20-30mg., adult 30-60mg. Continue inhaled steroids. If reliever works for less than 4 hours contact Dr.
- If P.E.F. <50% of baseline
  - increasing breathlessness
  - can't speak
  - can't move
  call Doctor urgently or 999 to Berwick Infirmary

Patients who use self-management plan must:

have written instructions: use proforma
have action levels for PEFR recorded in their notes
have a PEF meter
have regular review

Clinical procedures

For more detail of the stepped management plan see the summary of the latest BTS guidelines

Short Course Oral Steroid Treatment: Short courses of oral steroid treatment may be needed for exacerbations of asthma at any step to gain control. Such courses may be indicated when any of the following pertain:
- Symptoms and PEF progressively deteriorate day by day
- PEF falls below 50% of patient's best
- Sleep is disturbed by asthma
- Morning symptoms persist until mid-day
- Maximum non-oral steroid medication is not working
- Emergency nebuliser or injected bronchodilators are needed
Patients should be given 30 to 60mg of prednisolone daily (the higher dose if already taking maintenance oral steroid treatment). This dose should be maintained until two days after full recovery when it may be stopped or tapered down.
Short courses or oral steroid treatment may be started on the initiative of the patient under pre-arranged circumstances according to written guidance .
Inhaled Anti-inflammatory Agents: Patients needing to use their bronchodilator inhaler more than once daily or who have night time symptoms, require regular inhaled anti-inflammatory treatment. The treatment options include inhaled corticosteroids, inhaled sodium cromoglycate (5 to 20mg four times daily) and nedocromil sodium (4mg twice daily).
Inhaled steroids are the agents of choice and should be started at a dose of beclomethasone dipropionate (BDP) or budesonide 100-400 micrograms twice daily every day. Patients with persistent symptoms (especially nocturnal), a continuing need for inhaled bronchodilators or suboptimal peak flow may need to start at a higher and more frequent dose of inhaled steroid to achieve control. The daily dose may need to be increased from time to time in response to changes in symptoms and PEF. For example: The dose of inhaled steroid might be doubled for one week with the onset of upper respiratory infection.
Patients who have not responded to cromoglycate or nedocromil should receive inhaled steroids as above.
Preventer treatment can be tailed off if patient has been totally asymptomatic for at least 6 months. Inhaled steroids should be tailed off over several weeks, rather than stopping abruptly. Seasonal asthmatics may only need seasonal treatment. A peak flow diary is a useful management tool.
Guidelines for the Safe Use of Nebulised Bronchodilators Initial assessment: Before considering nebulised bronchodilators:
- the diagnosis should be reviewed and confirmed
- other methods of drug administration should have been explored
- the patient should be complying with anti-inflammatory treatment
- increased bronchodilation without unacceptable side-effects should be demonstrated
- an initial home trial for three weeks with PEF monitoring should be undertaken
Supervision:
- verbal and written instruction should be given to the patient on the method and frequency of use, the action to be taken in the event of deteriorating asthma, and when to attend for follow-up.
- supervision should normally involve attendance at the Asthma Clinic or home visiting by an appropriate member of the PHCT.

Staffing

Practice nurses are appropriately trained via the Stratford Asthma Diploma Course. The Practice maintains its connection with the GP in Asthma Group (BNC is a member of the GPIAG) In-practice educational sessions relating specifically to asthma are held at intervals.

Referral policy

Referral should be considered for:

diagnostic difficulties
- the elderly and smokers or ex-smokers with wheeze in whom diagnosis may be difficult
- those with unexplained persistent cough
those with possible occupational asthma
patients with asthma who present a problem in management, eg:
- patients who have recently been discharged from hospital
- patients with catastrophic, sudden severe (brittle) asthma
- those with continuing symptoms despite high dose inhaled steroids
- those being considered for long term nebulised broncho-dilators
- pregnant patients with worsening asthma
- patients whose asthma is interfering with their lifestyle

In general, it is inappropriate for patients with chronic asthma to be followed up for long periods in hospital outpatient clinics where:

the physician has no special interest in the condition
patients are seen by members of junior staff who receive no specialist training in the condition or who rotate through the post at frequent intervals.

Criteria for Emergency Admission

Any life-threatening features
Any features of a severe attack which persists after initial treatment
PEF 15-30 minutes after nebulisation lt40% of predicted or of best (&lt200L/min)
A lower threshold for admission is appropriate in patients:
- seen in the afternoon or evening rather than earlier in the day
- with recent onset of nocturnal or deteriorating symptoms
- with previous severe attacks - especially where the onset was rapid
- where there is concern over their assessment of severity of symptoms
- where there is concern over social circumstances and/or relatives' ability to respond appropriately

Record -keeping

Problem-orientated asthma proforma in conspicuous position in the patient's record, detailing continuing care and self-management plan.
Computer record of:

diagnosis
asthmatic attacks
all prescriptions
prescription of PEF meter (recall marker)
satisfactory inhaler technique (recall marker)
attendance at asthma clinic (recall marker)
peak flow readings (numeric marker)
FEV1 for patients with chronic severe asthma (numeric)

Audit

Audit of outcome is most telling - and often most difficult!

Acute asthma attacks
Night visits for asthma attacks
Hospital admissions
% of patients on prophylactic therapy
Use of oral steroids
Adherence to self-management plans
Sleep disturbance and daytime symptoms
Time lost from school or work