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Continuing professional development

Asthma update: recommendations for


diagnosis, treatment and management
PHC700 Kaufman G (2012) Asthma update: recommendations for diagnosis, treatment and
management. Primary Health Care. 22, 4, 32-39. Date of acceptance: January 24 2012.
Correspondence

Abstract

gerri.kaufman@york.ac.uk

Asthma is a chronic inflammatory disorder of the airways associated with a high level of morbidity. In the UK,
much of the responsibility for asthma management rests in primary care. Diagnosing asthma requires careful
clinical history taking and support for the diagnosis, using spirometry and measures of peak expiratory flow rates.
A stepwise approach should be used in the treatment of asthma. The main strategy for reducing the burden
of asthma is a shift in emphasis from acute management to long-term care and supported self-management.
Structured asthma reviews should be undertaken by competent professionals, using a patient-centred approach
that enables self-management and addresses symptom control, inhaler technique and adherence.

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PHC JUNE 2012 32-39.indd 32

Conflict of interest
None declared

Aim and intended learning outcomes


The aim of this article is to provide an overview
of the management of asthma in adults. The
time outs should be used to investigate local
asthma management arrangements.
After reading this article you should be able to:
Determine whether current asthma
management arrangements are justified.
Re-affirm the presenting signs and symptoms
of asthma to evaluate patients histories
and the challenges they may later face.
Re-examine the arrangements available to
support patients psychological needs.
Determine what might help patients
manage their condition better.

Overview

Time out

In the UK, respiratory disease generates 24 million


primary care consultations and 51 million prescriptions
annually. Diseases associated with the respiratory
system, including asthma, account for more
consultations than any other illness. An estimated
5.4 million people are receiving treatment for asthma in
the UK, including 1.1 million children and 4.3 million
adults (Asthma UK 2004). Despite the availability of
evidence-based guidelines and effective treatments,
achieving asthma control can be troublesome for most
people who have the disease (Haughney et al 2008).
Poor asthma control significantly affects the quality
of life of patients and their families (Sarver and Murphy
2009). Asthma morbidity is associated with lost time
from work and school as well as increased rates of
hospital admission and urgent care visits (Haughney et al
2008, Rees 2010). While mortality rates associated
with asthma have declined, 1,131 deaths were reported
in 2009 (Rees 2010). On average in the UK, three
people every day die from asthma (Asthma UK 2004).
The specific causes of poor control are linked to incorrect
diagnosis, comorbid rhinitis, poor inhaler technique, poor
adherence to treatment and poor response to treatment
(Haughney et al 2008). Addressing the causes of poor
control and providing better care for asthma sufferers
could avoid 75 per cent of hospital admissions and up
to 90 per cent of deaths (Greener 2010). Individualised
care, regular education and support are needed
(Cornforth 2010) to empower people with asthma
to have full quality of life (Haughney et al 2008).

Gerri Kaufman is lecturer


in health sciences,
pathway leader for BSc
health and social care
practice and continuing
professional development
lead, University of York

Review the asthma management challenges in


your practice:
How many adult patients with asthma do
you see on a weekly basis?
What percentage of asthma presentation
problems could have been forestalled or
limited with better patient education?
Summarise the complexity and variation
of patients needs: managing medication,
avoiding asthma triggers, and dealing with
the stress of living with asthma.

Keywords
Asthma, asthma
management, respiratory
care, allergens

These keywords are based on


the subject headings from
the British Nursing Index.
This article has been
subject to double-blind
review and checked using
anti-plagiarism software.
For related articles visit our
online archive and search
using the keywords

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22/05/2012 16:21

What is asthma?
There is no gold standard definition of asthma
(McMurray 2010), but there is consensus on
the main pathological, physiological and clinical
features of the disease (Bateman et al 2008).
Asthma is a chronic inflammatory disorder of the
airways most commonly caused by allergic triggers
(Box 1). In sensitised individuals this results in
inflammation and swelling of the lining of the airways,
increased mucus secretion and constriction of airway
smooth muscle (McMurray 2010, Kaufman 2011).
These reactions cause the airways to become narrow
and irritated which makes it difficult to breathe and
causes one or more of the following symptoms:
Wheeze.
Breathlessness.
Chest tightness.
Cough (especially at night).
Variable airflow obstruction.

Policy trends
Primary care is at the forefront of transforming asthma
management with the development of proactive
nurse-led services. The Quality and Outcomes
Framework (QOF) was introduced in 2004 as part of the
new General Medical Services contract to pay GPs for
their performance (Department of Health (DH) 2004).
Table 1

Box 1 Triggers associated with asthma


Indoor allergens domestic mites, animals, cockroaches, fungi
Outdoor allergens pollens, fungi
Indoor and outdoor air pollution
Weather changes
Active and passive smoking
Occupational sensitisers
Chemicals
Irritants such as household sprays and paint fumes
Dust
Foods and additives
Emotions such as stress
Respiratory infections
Parasitic infections
Drugs for example paracetamol and non-steroidal inflammatory drugs
Exercise
(Scullion 2005, Douglass and Holgate 2010, Rees 2010, Kaufman 2011)

The scheme encourages accurate diagnosis,


maintenance of disease registers and the proactive care
of people with long-term conditions, including asthma,
by providing financial incentives to achieve targets
across a range of clinical indicators (Table 1). The QOF
approach to improving quality has been criticised as a
tick box exercise. There is evidence that the process
has encouraged proactive care with the potential to

Quality and Outcomes Framework indicators for asthma

Records

Indicator

Rationale

The practice can produce a register


of patients with asthma, excluding
patients with asthma who have been
prescribed no asthma-related drugs in
the preceding 12 months.

A register of patients who require follow up is a pre-requisite for structured asthma


care. Proactive structured review as opposed to opportunistic or unscheduled review
is associated with reduced exacerbation rates and days lost from normal activity.

Initial
The percentage of patients aged eight
management and above diagnosed as having asthma
from April 1 2006 with measures of
variability or reversibility.

National and international guidelines emphasise the importance of demonstrating


variable lung function to confirm the diagnosis of asthma. Variability of peak
expiratory flow (PEF) and forced expiratory volume (FEV1), either spontaneously over
time or in response to treatment is a characteristic feature of asthma.

Ongoing
The percentage of patients with asthma Many people who smoke start at a young age. Asking young people about smoking
on an annual basis is therefore justified. The risk of persisting asthma is increased
management between the ages of 14 and 19 years
when smoking is started in teenage years.
in whom there is a record of smoking
status in the preceding 15 months.
The percentage of patients with asthma Benefits of structured care have been demonstrated for patients with asthma.
who have had an asthma review in the Proactive structured review, as opposed to opportunistic or unscheduled review, is
preceding 15 months.
associated with reduced exacerbation rate and days lost from normal activity.
Recording morbidity, PEF levels, inhaler technique and current treatment is
associated with good care. The promotion of self-management skills is a common
theme of good structured care.
National and international guidelines recommend the use of standard questions for
monitoring asthma.
The QOF suggests use of the Royal College of Physicians three questions (Box 2) as
an effective way of assessing symptoms.
Adapted from Quality and Outcomes Framework Guidance for GMS Contract 2011/12 (NHS Employers and British Medical Association 2011)

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Continuing professional development


Table 2

Key elements of a comprehensive clinical history

Presenting problem

Symptoms specifically, cough, wheeze, breathlessness, chest tightness.


Symptom variability is an indicator of asthma.
Symptom severity how often symptoms occur, nocturnal wakening, exercise limitation.
Provocation of symptoms by specific triggers.

Medical history

Including any history of asthma in childhood and details of any atopy such as eczema and rhinitis.

Medicines the patient is taking

Ask about prescribed and over-the-counter medicines, and herbal and homeopathic remedies.
Non-steroidal anti-inflammatory drugs, aspirin and beta blockers can exacerbate asthma. Chronic cough
caused by angiotensin converting enzyme (ACE) inhibitors can mimic less well controlled asthma.

Family history

Any history of asthma or atopy should be identified.

Social history

Should include information about hobbies and pets as these may be triggers. Information about
occupation is important to exclude triggers in the occupational environment. Individuals who are
symptom free away from work should be referred and investigated for occupational asthma.

Smoking behaviour

Cigarette smoking is associated with persistent asthma.

Response to any treatment already


trialled for respiratory symptoms
(Kaufman 2011)

Statistics
When completing time out 1, did you
draw on information from a local register
of patients with long-term conditions?
How can such a register help you plot
the changing asthma management
workload? Do such statistics help you
argue for particular asthma initiatives?

History taking
Study Table 2 and determine your strengths
and shortfalls in clinical history taking.
Discuss with colleagues whether they can
identify any weaknesses in their history
taking. Discuss what needs to be addressed.

Spirometry

Diagnosis
History taking is like playing the role of detective,
searching for clues and collecting information without
bias (Kaufman 2008). The significance of a careful
clinical history is highlighted by Epstein et al (2008)
who point out that an accurate history can provide
80 per cent or more of the clues for diagnosis
(Table 2). In addition to a comprehensive clinical
Table 3

history it is also important to obtain objective


support for the diagnosis (British Thoracic Society
and Scottish Intercollegiate Guidelines Network
(BTS and SIGN) 2011). This is confirmed through
the use of spirometry and peak expiratory flow
(PEF) measurement (BTS and SIGN 2011).

Time out

2
Time out

improve outcomes (Worth et al 2011). The scope


for primary care practitioners to develop services for
patients with asthma, and other long-term conditions, is
likely to increase as a result of policy trends (DH 2009)
that are shifting services from secondary to primary care.

The preferred test for the diagnosis and monitoring


of asthma is spirometry, which measures lung
volumes and airflow, allowing clear identification
of airflow obstruction (BTS and SIGN 2011). The
financial rewards provided by QOF have enabled
most UK general practices to invest in spirometers.
Concerns have been expressed that this initiative
has not been supported by adequate staff training.

Recommendations for patient management linked to probability of diagnosis

High probability: diagnosis of asthma likely

Intermediate probability: diagnosis uncertain

Low probability: other diagnosis likely

A trial of treatment is recommended for


patients who fall into this category. Treatment
should be based on a stepwise approach and
continued if the response is positive. Further
investigations or referral are recommended in
the absence of a response to treatment.

For patients in this category differential


For patients in this category, a trial of
diagnosis needs to be considered and
treatment is recommended if measurement
of lung function suggests airway obstruction. appropriate treatment or referral initiated.
In the absence of airway obstruction, patients
may require further investigations or referral
as appropriate.

(British Thoracic Society and Scottish Intercollegiate Guidelines Network 2011)

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A national survey revealed that only 12 per cent


of nurses undertaking spirometry had completed
accredited training and fewer than half (49 per cent)
of those diagnosing and managing chronic obstructive
pulmonary disease (COPD) had undertaken specialist
training (Upton et al 2007). It is essential to adhere
to published standards for diagnostic spirometry in
primary care (Levy et al 2009). These emphasise
the importance of using appropriately calibrated
and serviced spirometers that should only be used
by trained professionals with accredited, up-to-date
skills, and who have the ability to interpret results
correctly (Worth et al 2011). Poor spirometry
technique and incorrect interpretation of results
can lead to incorrect diagnosis and potentially
inappropriate treatment (Kaufman 2011).

Peak expiratory flow

Peak expiratory flow

Time out

In contrast to spirometry, peak expiratory flow (PEF)


is a simple test of lung function that estimates
the maximum flow of air achievable from a forced
expiration, starting from a position of maximum lung
inflation (Booker 2007). PEF can be a useful test for
the assessment of variability, one of the main features
of asthma. Multiple PEF measurements should be
taken over a period of at least two weeks (BTS and
SIGN 2011). This requires the patient to keep a diary
and measure PEF in the morning and at night. Any
medications taken, symptoms experienced or factors
relevant to triggering symptoms should be documented.
Normal daily variations in airway size are
exaggerated in patients with asthma. Significant
variability is present if peak flow readings vary by
20 per cent or more (BTS and SIGN 2011).

What part do spirometry and peak


flow readings play in the diagnosis and
assessment of asthma in your practice? If you
measure peak expiratory flow, do you secure
readings over a period of two weeks and
compare them to estimated readings for the
individual? What might you say to a patient
when they ask why the readings could vary?

The BTS and SIGN (2011) guideline refers to the


concept of probability in making a diagnosis of
asthma. After the initial consultation and objective
measurement of lung function the practitioner
is provided with three options (Table 3).

Treatment
The BTS and SIGN (2011) guideline advocates a
stepwise approach to asthma management, and its
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PHC JUNE 2012 32-39.indd 35

tables give advice on drug classes and possible doses


(Table 4). It is important that the patient commences
treatment at the step most appropriate to the initial
severity of their asthma so that early control is achieved.
Treatment should be stepped up when required and
down when control is good (BTS and SIGN 2011).
Short-acting beta agonists The BTS and SIGN guideline
(2011) recommends a short-acting beta-agonist, as
required, as the first line treatment for mild intermittent
asthma. Short-acting beta-agonists include salbutamol
or terbutaline taken by inhalation (Barnes 2008,
Rees 2010). These drugs have a bronchodilator effect
and relieve the symptoms of chest tightness and
breathlessness (Scullion and Holmes 2010).
Inhaled corticosteroids For patients who continue
to experience symptoms while using a short-acting
beta-agonist, it is recommended that an inhaled
corticosteroid be added (BTS and SIGN 2011). Inhaled
corticosteroids include beclometasone dipropionate,
budesonide and fluticasone propionate. These drugs
play an important role in reducing inflammation in
the airways (Douglass and Holgate 2010) and are
Table 4

The main medications used in asthma, and their place in the stepwise
approach to asthma management

Step

Medications

Step 1: Mild
Inhaled short-acting beta2 agonist as required for example,
intermittent asthma salbutamol or terbutaline.
Step 2: Regular
preventer therapy

Add inhaled steroid 200-800mcg/day.


Start at dose of inhaled steroid appropriate to severity of
disease.

Step 3: Initial
add-on-therapy

Add inhaled long-acting beta2 agonist (LABA)


for example, salmeterol or formoterol.
Assess response and continue LABA if response good.
Benefit from LABA but control still inadequate, continue
LABA but increase inhaled steroid to 800mcg/day (if not
already on this dose).
If control is still inadequate, introduce trial of other
therapies for example, leukotriene receptor antagonist or
SR theophylline.

Step 4: Persistent
poor control

Consider trials of increasing inhaled steroid up to


2,000mcg/day.
Addition of a fourth drug: a leukotriene receptor
antagonist or SR theophylline.

Step 5: Continuous
or frequent use of
oral steroids

Use daily steroid tablet in lowest dose providing adequate


control.
Maintain high dose inhaled steroid at 2,000mcg/day
Consider other treatments to minimise the use of steroid
tablets.
Refer patient for specialist care.

(British Thoracic Society and Scottish Intercollegiate Guidelines Network 2011, Kaufman 2011)

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Box 2 Royal College of Physicians: three questions


In the past month
Have you had difficulty sleeping because of asthma symptoms
(including cough)?
Have you had your normal asthma symptoms during the day
(cough, wheeze, chest tightness or breathlessness)?
Has your asthma interfered with your usual activities
(housework, work, school)?
(Pinnock et al 2010)

considered the most effective preventative therapy in


asthma (Rees 2010).
Long-acting beta-agonists The stepwise approach
(BTS and SIGN 2011) advocates the introduction of a
long-acting beta-agonist, if symptoms are not controlled
with regular use of a short-acting beta-agonist and an
inhaled corticosteroid. Long-acting beta-agonists play a
role in relaxation of the airways (Douglass and Holgate
2010) and include the drugs salmeterol and formoterol.
Long-acting beta-agonists should be discontinued
if there is no response, and the dose of inhaled
corticosteroid increased (BTS and SIGN 2011).
Leukotrine receptor antagonists For patients who
experience persistent poor asthma control, the addition
of a fourth drug, such as, a leukotriene receptor
antagonist or a methylxanthine may be beneficial.
The leukotriene receptor antagonists, which include
montelukast and zafirlukast, have a role to play in
reducing inflammation, mucus production, oedema and
bronchoconstriction (Barnes 2008, Kuebler et al 2008,
Rees 2010). The leukotrines can be effective in patients
with aspirin- or exercise-induced asthma but, overall,
patients seem to differ in their response to these drugs
(Barnes 2008).
Methylxanthines Methylxanthine theophylline is
an effective bronchodilator that may also have
anti-inflammatory properties (Rees 2010). However, the
drug has a narrow therapeutic index which means that
the toxic dose is only a little higher than the effective
dose, and toxic levels can cause fatal side effects
(Anwar 2008). Consequently, the plasma levels of
theophylline need to be monitored carefully.
Oral corticosteroids For some patients with very severe
asthma, where control cannot be achieved with a
combination of the medicines described above, regular
long-term oral corticosteroids may be required (BTS
and SIGN 2011). Given the risk of systemic side effects
with long-term oral corticosteroids, patients with poorly
controlled asthma should be referred for specialist care
before proceeding to these drugs (BTS and SIGN 2011).
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Stepped approach

Time out

Continuing professional development

Review with colleagues whether a stepped


approach to drug therapy with patients is
employed in your practice. If it differs from
what has been summarised here, why do
colleagues approach medication differently?
One of the influences could be the
knowledgeable and the assertive healthcare
consumer. Asthma management consultations
should accommodate what the patient has to
say as well as what evidence supports.

Continuity of care and education


A strategy for reducing the burden of asthma is a shift
in emphasis from acute management to long-term
care and supported self-management which should
reduce exacerbations, hospital admissions, morbidity
and mortality (Pinnock et al 2010). Asthma clinics in
primary care, or the provision of asthma reviews as
part of routine appointments, are convenient ways of
delivering care. However, there is limited evidence that
asthma reviews in themselves improve outcomes.
What happens during the review consultation is
what matters (BTS and SIGN 2011). Routine asthma
reviews must be performed to a high standard and
carried out by a practitioner with specialist asthma
training (Cornforth 2010). The frequency of asthma
reviews will vary according to the severity of the
disease (BTS and SIGN 2011). Asthma reviews
in primary care should incorporate three steps:
Assess asthma control so that care can be targeted
appropriately.
Respond to the assessment by identifying reasons for
poor control and make appropriate adjustments to
the management strategy.
Explore patients ideas, concerns and expectations,
and enable self-management to guide on-going
control (Pinnock et al 2010).
Assessing control Asthma control is defined as the
degree to which the goals of therapy are obtained as
reflected in the maintenance of normal lung function
with reduced symptoms and exacerbations (Ellis 2009,
Pinnock et al 2010). In primary care, asthma control
is normally assessed on the basis of symptoms, in
conjunction with an examination of the patients record.
The use of specific morbidity questions such as the
Royal College of Physicians (RCP) three questions
(Box 2) (Pinnock et al 2010, BTS and SIGN 2011)
or other reliable tools, including the Asthma Control
Questionnaire (Cornforth 2010) can be helpful in
elucidating the presence of symptoms.
Occasional symptoms (on two or fewer days per
week) may be acceptable. However, any nocturnal
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Review and control

Time out

Reflect on your local practice approach to


asthma reviews and control. Are standard
questions used and do they cover control
in consistent depth? Review the purpose of
the questions. Questions are deployed not
just to gather information. Which ones seem
essential?

Adjustment of management If assessment suggests that


control is suboptimal, the reasons should be considered
and addressed. Causes for poor control can be linked
to incorrect diagnosis, inhaler technique and adherence
and the effect of co-existent asthma and rhinitis
(Pinnock et al 2010).
Incorrect diagnosis If symptoms do not improve as
expected after starting asthma medication, it may be
appropriate to reconsider the diagnosis (Corrigan 2011).
A number of differential diagnoses such as COPD in a
smoker, gastro-oesophageal reflux that triggers a cough,
obesity or heart failure may be responsible for the
symptoms the patient is experiencing and account for
the apparent poor control (Pinnock et al 2010).
Comorbid rhinitis There is a link between asthma
and rhinitis with both diseases co-existing in
75 to 80 per cent of patients (Haughney et al 2008,
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PHC JUNE 2012 32-39.indd 37

Pinnock et al 2010). Patients with asthma and


concomitant rhinitis are more likely to be hospitalised
for their asthma, and more likely to visit their GP over a
12-month period than those without rhinitis (Price et al
2005). Treatment of concomitant allergic rhinitis is
associated with significant reductions in risk of urgent
care treatment and hospitalisation for asthma and
should be investigated as comorbidity in all patients
with uncontrolled asthma (Pinnock et al 2010).

Psychological problems

Time out

wakening or activity limitation should be considered as


suboptimal control and management should be revised.
In addition to exploring symptoms, the patients
record can also be evaluated to determine symptom
control (Pinnock et al 2010). Records should be
evaluated for medication use, acute exacerbations or
asthma hospital admissions (Cornforth 2010). Frequent
use of reliever inhalers (short-acting beta-agonists)
implies poor control, and intermittent requests for
preventer treatment (inhaled corticosteroids) suggests
a need to address patients perceptions of, and
fears about, the use of corticosteroids (Pinnock et al
2010). Overuse of short-acting beta-agonist drugs is
associated with asthma deaths (Cornforth 2010), and
any patient requesting more than one or two inhalers
per month should have their management reviewed.
It is also important to remember that the occurrence
of an acute exacerbation is evidence of poor control
(Pinnock et al 2010). Objective measurement of lung
function (spirometry or PEF) can be performed as part of
an asthma review (Cornforth 2010), but it is important
to remember that a one-off reading is of limited value
in the assessment of a variable condition. If the patient
is well-controlled, a PEF can provide an up-to-date best
reading for use in an action plan (Pinnock et al 2010).

Write a one paragraph summary of your


practice approach to helping patients with
the psychological challenges associated with
asthma. To what extent are psychological
problems on the review agenda and why do
these seem important for patients asked to
self-medicate and sustain an active lifestyle?
If psychological matters are not routinely part
of your review, why do you think this is? Are
you confident about suitable questions to
ask? Do you know who you might refer to or
confer with, if problems are identified?

Anxiety and depression A patients adoption of at-risk


behaviours such as smoking and poor adherence
may be explained in part by co-existing psychological
problems (Thomas et al 2011). There is no consensus
on whether routine screening for anxiety and depression
should be initiated for asthma patients. This is accepted
practice in other long-term conditions such as COPD,
diabetes and ischaemic heart disease. However, further
research is required to determine whether this practice
is worthwhile for asthma patients (Thomas et al 2011).
Primary care practitioners must maintain a high index
of suspicion for depression and anxiety among asthma
patients (Greener 2010) particularly those with less
than optimal control and in whom poor adherence and
risk-taking behaviour are evident (Thomas et al 2011).
Inhaler technique Poor inhaler technique can markedly
reduce the proportion of drug that reaches the lung
and is a well-documented cause of suboptimal asthma
control (Chrystyn and Price 2009). A number of devices
are available for the administration of inhaled therapies
(Kaufman 2011) including:
Spacers.
Pressurised meter dose inhalers (MDIs).
Breath actuated devices.
Dry powder devices.
To optimise inhaler use, healthcare professionals need
to consider the interaction between the inhaler, drug
and patient when initiating treatment (Chrystyn and
Price 2009). The choice of device may be determined
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Continuing professional development


by the choice of drug and different patients are likely
to have different requirements no single device will
satisfy the needs of all (Kaufman 2011). Preferences
for inhaler device should be discussed, because the
choice of device preferred by the patient can make a
positive difference to disease control. If a patient cannot
use a particular device another should be tried. It is
essential to provide practical training when a device
is first prescribed and inhaler technique should be
reviewed at every asthma consultation. Unless patients
have a significant cognitive impairment, most can learn
to use an inhaler device correctly (Kaufman 2011).
Different devices have advantages and limitations,
for example MDIs are quick to use and easy to
transport. However, two of the most crucial errors with
MDIs are failure to co-ordinate inhalation with actuation
of the device, and inhaling the aerosol too quickly
(Corrigan 2011). Difficulty with co-ordination can be
overcome by using a breath-actuated device or a spacer.
The problem of rapid inhalation can be improved by
training (Corrigan 2011). Dry powder inhalers require
very rapid and forceful inhalation for best use. Failure
to inhale deeply and forcibly at the start of inhalation
results in the generation of drug particles that are
too big to enter the lungs. Additionally, if the patient
does not inhale fast enough or long enough, not all
of the dose is emitted (Haughney et al 2008).
Teaching and checking inhaler technique should
be undertaken by competent professionals. This helps
to avoid the more subtle problems with technique
going unnoticed which can reduce delivery of inhaled
drugs by as much as 90 per cent (Corrigan 2011).
Assessing adherence Prescribed treatments are effective
only if taken. Patients are more likely to under-use
than over-use treatment (BTS and SIGN 2011).
Non-adherence is an important problem in asthma
management, particularly in relation to the use of
inhaled corticosteroids (Haughney et al 2008). Issues
with adherence are multi-faceted and challenging
for healthcare professionals (Chrystyn and Price
2009). However, interventions designed to improve
communication between patients and healthcare
professionals achieve better adherence (BTS and SIGN
2011). The National Institute for Health and Clinical
Excellence (NICE 2009) has produced guidance on
medicine adherence. The guideline discusses the
concept of patient-centred care, and sets out a range of
strategies that can be used to enhance communication
between healthcare professionals and patients, and
involve patients in decisions about their medicines. It
also sets out strategies that can be used to support
adherence and review medicines, and emphasises that
treatment and care should take into account patients
individual needs and preferences. In relation to asthma
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this involves understanding, recognising and responding


to patients perspectives on asthma and its treatment
(Chrystyn and Price 2009).
It is crucial to understand the patients health and
illness beliefs because many negative and untrue
perceptions exist, particularly in relation to the use
of steroids for example, that inhaled steroids can
cause addiction, weight gain and excessive hair growth
(Cornforth 2010). Providing non-judgemental feedback,
clearly explaining why the patient needs an inhaled
corticosteroid, as well as addressing any concerns about
long-term side effects, dependence and long-term use
can help to provide patients with a better understanding
of the disease and allay anxieties (Chrystyn and
Price 2009, Cornforth 2010). Recognising and
responding to patient partiality for example, choosing
treatment that aligns with their preferences (Chrystyn
and Price 2009) and providing simple written
instructions and reminders of when to use medication
(BTS and SIGN 2011) can improve adherence.
Supporting self-management The Grade A
recommendation from the BTS and SIGN (2011)
clinical guideline on asthma management states
that: Patients with asthma should be offered
self-management education that focuses on individual
needs, and be reinforced by a written personalised
action plan. Many of the issues that hamper good
asthma control are related to a misunderstanding
of the condition, under-estimation of the benefits
of regular inhaled therapy and anxieties about the
side effects of treatment (Pinnock et al 2010).
Consequently, the importance of patient education
for effective asthma management and prevention is
widely emphasised. Self-management education is
a multi-faceted intervention that varies considerably
in the way that programmes are constructed. The
BTS and SIGN (2011) clinical guideline provides
an example of the main components (Box 3).
The provision of self-management education
that includes a written action plan can reduce
hospitalisations, unplanned consultations, nocturnal
symptoms and time lost from work. It can also
improve self-efficacy and asthma-related quality of life
(Cornforth 2010, Pinnock et al 2010). Personalised
asthma action plans should be a major component
in any asthma education plan and should be formed
in collaboration with the patient. Patients may
require different degrees of autonomy in relation
to self-management which highlights the need to
determine patients preferred roles for participation
in care, and to reflect their wishes in any action plan
(Cornforth 2010). Personalised action plans can be
either symptom- or peak-flow-led, or both. The optimum
way of monitoring asthma is to recognise the presence
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22/05/2012 16:21

Conclusion
Asthma is an inflammatory disorder of the airways
that is a significant source of morbidity and mortality
worldwide. In the UK, asthma care constitutes a large
proportion of primary care activity and policy trends

Box 3 Main components of a self-management programme


Structured education that is reinforced with a written personal action plan.
Specific advice about recognising loss of asthma control. This may be assessed
by peak-flow, by symptoms or both.
Actions to take if asthma deteriorates, that are summarised as two or three
action points. These should include, seeking emergency help, commencing
oral steroids (which may include provision of an emergency course of tablets)
recommencing or temporarily increasing inhaled steroids, as appropriate to
clinical severity.
Adapted from British Thoracic Society and Scottish Intercollegiate Guidelines Network (2011)

are shifting care closer to home. The emphasis on


structured and proactive care is likely to increase scope
for the development of asthma services. Evidence-based
guidelines must underpin approaches to diagnosis,
prescribing, continuity of care and education. Promoting
patient self-management coupled with competent
professional review has a significant role to play in
improving health outcomes for asthma sufferers.

Practice profile

Time out

of asthma symptoms alongside peak flow (Cornforth


2010). Portable meters for the measurement of PEF
can be obtained on NHS prescription (Booker 2007,
Douglass and Holgate 2010). In some individuals,
changes can occur in peak flow before the onset of
acute symptoms and early detection of an exacerbation
can allow appropriate treatment to be given (Kaufman
2011). Personalised action plans advise patients on
when and how to modify medications (for example,
increasing inhaled steroids or commencing oral steroids)
and how to access help in response to worsening
symptoms (Cornforth 2010, Pinnock et al 2010).
The challenge for primary care is to implement
evidence-based recommendations. Studies consistently
demonstrate that self-management education is poorly
implemented (Pinnock et al 2010), with time and
resources cited as barriers to routine care for patients
with asthma. Asthma reviews must be carried out by
appropriately trained professionals with the ability to
assess control and make appropriate adjustments to
treatment (Pinnock et al 2010). Recognition of the
inter-relationship between competent professional
reviews and patient self-management is essential to
improve health outcomes for patients with asthma.

Now that you have completed the article,


you might like to write a practice profile of
between 750 and 1,000 words.
Go to the Primary Health Care website:
www.primaryhealthcare.net and follow the
link to the Learning Zone for information on
how to make a submission.

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