Asthma

 

Asthma is a chronic respiratory condition associated with airway inflammation and hyper-responsiveness.  The disease is heterogeneous, with different underlying disease processes and variations in severity, clinical course, and response to treatment.  Asthma is characterized by symptoms including cough, wheeze, chest tightness, and shortness of breath, and variable expiratory airflow limitation, that can vary over time and in intensity.  Symptoms can be triggered by factors including exercise, allergen or irritant exposure, changes in weather, and viral respiratory infections.  Asthma UK reports that 5.4 million people in the UK are receiving treatment for asthma, including 1.1 million children (1 in every 11) and 4.3 million adults (1 in every 12), with approximately 160,000 people in the UK being diagnosed with asthma each year

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Diagnosis

  1. Undertake a structured clinical assessment to assess the initial probability of asthma. This should be based on:
    1. a history of recurrent episodes (attacks) of symptoms, ideally corroborated by variable peak flow when symptomatic and asymptomatic
    2. symptoms of wheeze, cough, breathlessness and chest tightness that vary over time
    3. recorded observation of wheeze heard by a healthcare professional
    4. personal/family history of other atopic conditions (in particular, atopic eczema/dermatitis, allergic rhinitis)
    5. no symptoms/signs to suggest alternative diagnoses
  2. Compare the results of diagnostic tests undertaken whilst a patient is asymptomatic with those undertaken when a patient is symptomatic to detect variation over time
  3. Carry out quality-assured spirometry using the lower limit of normal to demonstrate airway obstruction, provide a baseline for assessing response to initiation of treatment and exclude alternative diagnoses.  (Airway obstruction is confirmed by a forced expiratory volume in 1 second (FEV1) < 80% of the predicted value and FEV1/forced vital capacity (FVC) ratio < 70%)
    1. Obstructive spirometry with positive bronchodilator reversibility increases the probability of asthma
    2. Normal spirometry in an asymptomatic patient does not rule out the diagnosis of asthma

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Distinguish asthma from COPD, based on:

  1. Smoking history - almost always present in people with COPD
  2. Age - usually older than 35 years of age for COPD
  3. Chronic productive cough - common with COPD; uncommon with asthma
  4. Breathlessness - progressive with COPD; variable with asthma
  5. Variability of symptoms - common with asthma; uncommon with COPD
  6. Night time wakening with wheeze and breathlessness - common with asthma; uncommon with COPD

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If asthma and COPD cannot be distinguished based on clinical features, consider the following:

  1. A large response (greater than 400 ml) to bronchodilators or prednisolone (30 mg orally per day, for 14 days) is characteristic of asthma
  2. If FEV1 and the FEV1/FVC return to normal with drug therapy, clinically significantly COPD is not present
  3. Significant diurnal or day-to-day variability of serial peak flow measurements suggest asthma
  4. If doubt still remains, refer the person for a specialist's opinion

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In patients with a high probability of asthma:

  1. Record the patient as likely to have asthma and commence a carefully monitored initiation of treatment (typically six weeks of inhaled corticosteroids)
  2. Assess the patient's status with a validated symptom questionnaire, ideally corroborated by lung function tests (FEV1 at clinic visits or by domiciliary serial peak flows)
  3. With a good symptomatic and objective response to treatment, confirm the diagnosis of asthma and record the basis on which the diagnosis was made
  4. If the response is poor or equivocal, check inhaler technique and adherence, arrange further tests and consider alternative diagnoses

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Monitoring

In adults, the following factors should be monitored and recorded in primary care:

  • symptomatic asthma control
  • lung function assessed by spirometry or by PEF
  • asthma attacks, oral corticosteroid use and time off work since last assessment
  • inhaler technique
  • adherence
  • bronchodilator reliance
  • possession of and use of a self-management plan/personal action plan

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Supported self-management

  1. All people with asthma (and/or their parents or carers) should be offered self-management education, which should include a written personalised asthma action plan and by supported by regular professional review
  2. Prior to discharge, inpatients should receive written personalised asthma action plans, given by healthcare professionals with expertise in providing asthma education
  3. Adherence to long-term asthma treatment should be routinely and regularly assessed by all healthcare professionals within the context of a comprehensive programme of accessible proactive asthma care

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Non-pharmacological management

  1. Parents with asthma should be advised about the dangers of smoking, to themselves and to their children with asthma, and be offered appropriate support to stop smoking
  2. Weight-loss interventions (including dietary and exercise-based programmes) can be considered for overweight and obese adults and children with asthma to improve asthma control
  3. Breathing exercise programmes (including physiotherapist-taught methods) can be offered to people with asthma as an adjuvant to pharmacological treatment to improve quality of life and reduce symptoms

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Pharmacological management

  1. Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique, and eliminate trigger factors
  2. Inhaled corticosteroids are the recommended preventer drug for adults and children for achieving overall treatment goals
  3. The first choice as add-on therapy to inhaled corticosteroids in adults is an inhaled long-acting β2 agonist, which should be considered before increasing the dose of inhaled corticosteroids
  4. If asthma control remains suboptimal after the additional of an inhaled long-acting β2 agonist then the dose of inhaled corticosteroids should be increased from low dose to medium dose in adults or from very low dose to low dose in children (5-12 years), if not already on these doses

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Inhaler devices

  1. Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique
  2. Prescribe by hand to ensure the patient receives the same device on each occasion (a number of preparations have the same generic name)
  3. Generic prescribing of inhalers should be avoided as this might lead to people with asthma being given an unfamiliar inhaler device which they are not able to use properly
  4. Check technique on each occasion - never assume a patient has good technique
  5. Use the pharmacy services such as Medicine Use Reviews to reinforce messages on technique
  6. Review high use of short-acting β2 agonist in line with the recommendation from the National Report on Asthma Deaths

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NOTE In children, a pDMI and spacer are the preferred method of delivery of β2 agonists and inhaled corticosteroids.  A face mask is required until the child can breathe reproducibly using the spacer mouthpiece.  Where this is ineffective a nebuliser may be required

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Management of acute asthma (in adults)

  1. Refer to hospital any patients with features of acute severe or life-threatening asthma
  2. Give controlled supplementary oxygen to all hypoxaemic patients with acute severe asthma titrated to maintain an SpOlevel of 94-98%.  Do not delay oxygen administration in the absence of pulse oximetry but commence monitoring of SaO2 as soon as it becomes available
  3. Use high-dose inhaled β2 agonists as first-line agents in patients with acute asthma and administer as soon as possible.  Reserve intravenous β2agonists for those patients in whom inhaled therapy cannot be used reliably
  4. Give steroids in adequate doses to all patients with an acute asthma attack

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Management of acute asthma (in children)

  1. Children with life-threatening asthma or SpO<94% should receive high-flow oxygen via a tight-fitting face mask or nasal cannula at sufficient flow rates to achieve normal saturations of 94-98%
  2. Inhaled β2 agonists are the first-line treatment for acute asthma in children
  3. Give oral steroids early in the treatment of acute asthma attacks in children

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Management of acute asthma (all patients)

It is essential that the patient's primary care practice is informed within 24 hours of discharge from the emergency department or hospital following an asthma attack.  Ideally this communication should be directly with a named individual responsible for asthma care within the practice, by means of secure email

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Management of difficult asthma

Patients with difficult asthma should be systematically evaluated, including:

  • confirmation of the diagnosis of asthma, and
  • identification of the mechanism of persisting symptoms and assessment of adherence to therapy

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Asthma in pregnancy

  1. Women should be advised of the importance of maintaining good control of their asthma during pregnancy to avoid problems for both mother and baby
  2. Counsel women with asthma regarding the importance and safety of continuing their asthma medications during pregnancy to ensure good asthma control

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Occupational asthma

NOTE In patients with adult onset, or reappearance of childhood asthma, healthcare professionals should consider that there may be an occupational cause

Adults with airflow obstruction should be asked:

  • Are you better on days away from work?
  • Are you better on holiday?

Those with positive answers should be investigated for occupational asthma

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Distinguishing Asthma from COPD

The following table listing clinical features of both asthma and COPD can be used to distinguish between the two conditions:

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Blood tests / Phlebotomy

If your practice does not have a practice nurse who is trained to take bloods, you can refer a patient to the Pathology Department at East Kent Hospitals for a blood test (find details here)

Alternatively, Buckland Hospital (Dover) and the Royal Victoria Hospital (Folkestone) both operate a walk-in service where no appointment is necessary, except for if the patient requires a Glucose Tolerance Test (GTT).  In the event that a GTT is required, please call 01304 222552 (for Buckland) and 01303 854484 (for Royal Victoria) to arrange a suitable appointment

Please ensure that the patient remembers to take with them their blood test form to the walk-in centres

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Spirometry

In combination with undertaking structured clinical assessment of the patient's signs and symptoms, GPs should carry out quality-assured spirometry.  Spirometry is performed in primary care and must be carried out by suitably trained nurses accredited to ARTP standards.  Please click on the Spirometry map register for a full list of those practices where spirometry is being undertaken to the accredited standard

Further information:

Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

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