Jaqui Walker. An asthma review, at least annually, for all people with asthma is an important way of ensuring good asthma control is achieved.

Transcription

1 INSIGHT... a JCN learning zone feature The importance of an asthma review at least annually is clearly evidenced by guidelines and, importantly, was highlighted in the National Review of Asthma Deaths report as an opportunity for assessment and education that could help prevent asthma deaths (Royal College of Physicians [RCP], 2014). Community nurses are in an ideal position to ensure that all patients with asthma have reviews. This article aims to clearly set out what these should include, give practical advice as to how to carry out an asthma are important. KEYWORDS: Asthma Asthma review Asthma deaths Self-management The National Review of Asthma Deaths (NRAD), led by the Royal College of Physicians (RCP, 2014) and run by a consortium of asthma professionals and patient groups investigated the circumstances surrounding 195 deaths from asthma between 1 February 2012 and 30 January The NRAD report, Why asthma still kills, published in May 2014, was pivotal in changing the way asthma is managed. Martyn Partridge, professor of respiratory medicine in London, explained that although some of the findings were new, others had been emphasised for decades, but perhaps now there are new systems (e.g. computerised Jaqui Walker, general practice nurse, Allanpark Medical Practice, Stirling; GPN education advisor, NHS Education for Scotland (NES) and freelance medical writer Asthma review: what we need to cover and why Jaqui Walker An asthma review, at least annually, for all people with asthma is an important way of ensuring good asthma control is achieved. prescribing) that can help to address them. Overall, he called for a shake-up, more training and monitoring, and an end to the complacency that has arisen regarding this common condition (RCP, 2014). Perhaps one of the most important findings from the NRAD report for both nurses and those living with asthma to consider is that it is not just severe asthma that kills although 39% of the people who had died in the NRAD report did have severe asthma, 49% were classed as moderate and 9% mild asthma, and only 43% were being managed in secondary or tertiary care (RCP, 2014). An asthma review, at least annually, for all people with asthma is an important way of ensuring good asthma control is achieved. ASTHMA REVIEW Guidelines recommend that patients with asthma should have a regular, professional review (British Thoracic Society/ Scottish Intercollegiate Guidelines Network [BTS/SIGN], 2016; National Institute for Health and Care Excellence [NICE], 2017; Global Initiative for Asthma [GINA], 2018). This was also a key recommendation from the NRAD 2014 report, which found no evidence that 43% of the people who died had had an asthma review in the last year (RCP, 2014). In this article, the different parts of an asthma review are explored, along with practical advice around how to deliver this in a busy clinical setting. With practice, a personal asthma action plan (PAAP), a discussion around triggers and how to avoid them, a review of medication, including adherence, side-effects and inhaler technique, a measure of asthma control and life style advice can all be incorporated into the review, with signposting to other resources that will assist the patient in effective self-management. In this way, nurses can show patients the value of the annual review and equip them with the tools they need to manage their condition appropriately. Self-management education and personal asthma action plan (PAAP) Our continued failure to provide meaningful support as patients self-manage their condition needs to be rectified, and where this needs to be modified to address issues of literacy or psychological comorbidity, we need to do JCN 2018, Vol 32, No 5 59

2 so to ensure that good care is equally available to all. (Professor Martyn Partridge, RCP, 2014) A person with asthma may be with the nurse for a review for only 20 minutes a year, the rest of the time they need to manage their asthma themselves selfmanagement education and a written PAAP are therefore vital. In the NRAD 2014 report, only 23% of the people who died had a PAAP, which is now considered a key recommendation for asthma care (BTS/SIGN, 2016; NICE, 2017; GINA 2018). BTS/SIGN (2016) recommend brief simple education linked to the patient goals. Writing the PAAP can take place in partnership with the patient, as the different elements of the asthma review are discussed and then given to the patient at the end of the consultation. Where possible, a copy for the patient s notes is useful. Peak flows can be included as a guide for worsening asthma, or symptoms alone can be used. The PAAP, downloadable from Asthma UK has green, amber and red zones, and this system can be used to help educate patients as to: How they should feel when their asthma is well controlled How to know when they are Facts... Asthma is a long-term respiratory condition affecting more than five million people in the UK and costing the NHS around 1 billion per year (International Study of Asthma and Allergies in Childhood [ISAAC], 2011). losing control of their asthma (amber), or having an asthma attack (red) How and where to seek help. This is vital so that patients and their family can recognise worsening asthma and quickly access appropriate care. A patient having an asthma attack should not, for example, wait to see their GP for an urgent appointment, but should get straight to hospital where full emergency resources are available. Triggers Triggers that could exacerbate asthma were only recorded for approximately half of the patients investigated in the NRAD report. Helping people to recognise their triggers and agreeing ways to minimise their impact is an important part of an asthma review. Asthma UK ( uk/advice/triggers) lists triggers on their website and these can be used to prompt discussion with patients, including: Weather Animals Emotions Food Dust mites Mould and fungi Pollution Sex Stress and anxiety Colds and flu Chest infection Alcohol Exercise Female hormones Indoor environment Pollen Recreational drugs Cigarette smoke. For each of these triggers, Asthma UK includes detailed advice as to how to help reduce the impact, e.g. being aware of when hay fever may have an effect and getting medication for this. In the author s clinical experience, encouraging people to access and make use of this resource will be beneficial to their asthma management and control. Remember... PAAPs help patients to become engaged in and motivated about their own care. Providing them with information and education also encourages them to take responsibility for their health. Adherence If our patients do not always take medication as we advise, is that their fault or our failure to involve them in a process of shared decision-making? If the patient fails to attend for a review or to collect a repeat prescription, is it because our processes, methods of followup or their convenience was suboptimal, or indeed, was it the quality of the consultation and the expertise experienced that failed to impress? (Professor Martyn Partridge, RCP, 2014) It is estimated that around 50% of people with asthma on long-term therapy fail to take their inhalers as prescribed (GINA, 2018). The BTS/SIGN 2016 guidelines recommend asking patients about adherence to their asthma medication, as well as checking any prescribing data that is available. There are many reasons why patients do not take their medicines as prescribed, and exploring these in a nonjudgmental way is vital. BTS/SIGN (2016) suggest that the person s attitudes to medicines, as well as physical barriers to adherence, can play a role. In the author s clinical experience, an open question that shows you already understand the problem can be useful, i.e: Many people struggle to remember their inhalers every day, even though this is important. In a week out of the 14 planned doses of your inhaled steroid (preventer) medication, how many do you think you actually take? In 2015, 1,468 people died from asthma in the UK; the highest number of annual deaths in over 10 years (Asthma UK; about/media/news/asthma- deaths-in-england-wales-hit-10- year-peak/). This question makes it easier for the patient to admit to and 60 JCN 2018, Vol 32, No 5

3 quantify the problem. It also leads into an easy joint discussion of how this important issue can be resolved: Can you think of ways to help increase the number of doses you remember to take? Other people have tried e.g. alarm on phone, keeping it somewhere where they can see it (although not in reach of children), finding a way to include it within a morning and bedtime routine (although dry powder inhalers should not be stored in damp conditions, such as a bathroom). Inhaler technique Inhaler technique should be checked at every opportunity and at least annually (RCP, 2014; BTS/ SIGN, 2016; NICE, 2017; GINA, 2018). Many patients and healthcare professionals struggle to use an inhaler correctly (GINA, 2018). Various resources are available to help with inhaler technique; most pharmaceutical companies have materials to help with the devices they make and asthma charities have videos that patients and healthcare professionals can watch (mylifemylungs, Asthma UK). Symptomatic asthma control It is important to assess for current symptoms of cough, wheeze, breathlessness and chest tightness, and where suboptimal control is identified immediate action needs to be taken to improve asthma control (RCP, 2014; BTS/SIGN, 2016; NICE, 2017; GINA, 2018). Validated questionnaires, such as the asthma control questionnaire (ACQ) or the asthma control test (ACT), are recommended to monitor asthma control (GINA, 2018), as well as spirometry or peak flow (NICE, 2017). One of the main differences between the tests is that the ACQ requires a spirometry reading, whereas the ACT score is purely a set of questions and can be carried out without any equipment and given to the patient to fill out before the review. Numerical asthma control scores are more sensitive to changes in asthma control than categorical symptom control tools, such as the RCP three questions tool (GINA, 2018). Under use of preventer medication was a feature in the NRAD 2014 report, with evidence of less than the recommended number of preventer medications being prescribed in 80% of those who had died. The GINA 2018 report stresses the importance of assessing the patient s future risk of having an exacerbation, even when their asthma control is currently good. This will help the patient to understand the importance of controlling their asthma. If changes are made to an individual s asthma treatment, this will need to be reviewed in terms of symptoms, exacerbations, sideeffects, patient satisfaction and lung function to assess if the change has been effective (GINA, 2018). History of asthma attack The NRAD 2014 report found that 47% of those who died had experienced a previous hospital admission for asthma and 21% CASE REPORT had attended a hospital emergency department for asthma in the last year. Discussing this and helping the individual reduce the risk of a further attack is an important part of the review. Preventer therapy The BTS/SIGN (2016) guidelines remove the previous step of just a short-acting beta agonist (SABA) for asthma and state that other than for short-lived, infrequent wheeze, all patients with asthma need regular preventer therapy with a low-dose inhaled steroid. NICE (2017) also recommends regular inhaled corticosteroid (ICS) maintenance therapy for those that need it and state that with infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone. NICE (2017) advises that symptoms three times a week or more, or that cause waking at night will need regular ICS preventer therapy. The GINA 2018 report points out that there is insufficient evidence for using a SABA on its own, and that this should only be used in patients who have short episodes of daytime symptoms less than twice a month, that do not cause night wakening, and only in people with normal lung function. Liz is 28 years old with a busy job and children aged five, two and one. She was diagnosed with asthma as a child, which has been controlled until recently when she has started experiencing increased shortness of breath and wheeze. Liz saw her community nurse for a continence assessment and during the discussion it became appararent that her asthma was not being controlled, leaving her at risk of an asthma attack. What could you do at this stage? A basic assessment of adherence to her current inhalers, inhaler technique and her understanding of how to recognise an asthma attack is important. It may be something as simple as helping Liz to remember to take her inhalers, or explaining how preventer therapy works and why she needs to take it regularly. Perhaps a comorbidity or stress is having an impact on her asthma control? This simple input could prevent a lifethreatening asthma attack. What follow-up would Liz need? A full asthma review and arrangement for follow-up should be made. JCN 2018, Vol 32, No 5 61

4 It is important that nurses are aware of the advice from their local area and that they understand and use local drug formularies. Under use of preventer medication was a feature in the NRAD 2014 report, with evidence of less than the recommended number of preventer medications being prescribed in 80% of those who had died. Another important recommendation is that longacting beta agonists (LABAs) are prescribed in combination inhalers with an ICS (RCP, 2014), as this avoids the danger of patients using the LABA alone and not controlling the inflammation experienced with asthma with an ICS. Bronchodilator reliance Over use of SABA to relieve symptoms is a clear sign of uncontrolled asthma. The NRAD 2014 report found that 39% of the people who died of asthma had been prescribed 12 or more shortacting reliever inhalers in the year before they died, and 4% had been prescribed more than 50. Oral steroid use in last year Assessing oral corticosteroid steroid use in the last year is important (BTS/SIGN 2016), both as a sign of uncontrolled asthma and due to their potential to cause sideeffects. Both long-term, high-dose inhaled steroids and also frequent use of short-term oral steroids can cause systemic side-effects, such as easy bruising, increased risk of osteoporosis, cataracts, glaucoma and adrenal suppression (GINA, 2018). Patients requiring frequent Practice point oral steroids for exacerbations or high-dose inhaled steroids should be referred to secondary care. Impact on the individual During assessment, nurses should also try to gain an understanding of the impact that asthma has on the individual in terms of time off work, school and their ability to enjoy social events, exercise and hobbies, as this will give clues to current asthma control. Smoking cessation It is important to make people aware of the dangers of smoking and second-hand smoke for both adults and children and to offer smoking cessation support (BTS/ SIGN, 2016; GINA, 2018). Weight loss The BTS/SIGN (2016) guidelines recommend weight loss interventions, such as diet and exercise to help overweight children and adults improve their asthma control. Comorbidities GINA (2018) suggests considering how rhinitis, rhinosinusitis, gastroesophageal reflux, obesity, obstructive sleep apnoea, depression and anxiety can all contribute to asthma symptoms, quality of life and asthma control. It is important that nurses are aware that psychological and mental health issues can impact on asthma control and increase the risk of an asthma attack (RCP, 2014). The GINA report provides further guidance on managing patients with comorbidities. Breathing exercises Breathing exercises can be helpful as an adjuvant to medication and can help to reduce a person s symptoms and improve quality of life (BTS/SIGN, 2016). In the author s clinical experience, teaching breathing exercises on their own, or using a spacer and SABA can be particularly helpful where stress and anxiety are a trigger for asthma. Occupational exposure There are a number of occupations INSIGHT... for individual e-learning and CPD time Having read this article, why not go online and take your individual learning further by testing your knowledge of this topic in the INSIGHT section of the FREE JCN e-learning zone ( If you answer the accompanying online questions correctly, you can download a certificate to show that you have completed this JCN e-learning unit on asthma reviews. Then, add the article and certificate to your free JCN revalidation e-portfolio, as evidence of your continued learning safely, securely and all in one place: www. jcn.co.uk/revalidation that can trigger asthma. These include baking, food processing, spray painting, welding, soldering, metalwork, woodwork, laboratory animal work, health and dental care, chemical processing, manufacturing of textiles, plastics, rubber, farming and other jobs with exposure to dust and fumes (BTS/SIGN, 2016). All patients with occupational asthma need to be referred to secondary care (BTS/SIGN, 2016). This is because the prognosis of occupational asthma is improved by early objective diagnosis and the avoidance of any further exposure to the occupational trigger, and because occupational asthma has implications for employment. The importance of checking a patient s inhaler technique cannot be overemphasised. No matter what drugs are prescribed and how concordant the patient is, if they are not using their inhaler correctly, a reduced amount of drug may be delivered to the lungs. Referral Secondary care referral is suggested as patients move up the asthma guidelines treatment strategies and should be considered in patients not responding to therapy and at risk of side-effects, or who have risk factors for an asthma-related 62 JCN 2018, Vol 32, No 5

5 death (BTS/SIGN, 2016), such as over reliance on SABA, under use of ICS, poor recognition of uncontrolled asthma, previous hospitalisation, or lack of attention to trigger factors etc (RCP, 2014). Is it definitely asthma? Asthma responds to asthma treatment and if this is not happening it is important to consider the diagnosis. Does the patient have a smoking history? Do they need lung function tests or referral to another member of the primary or secondary healthcare team? TRAINED, UP-TO-DATE PRACTITIONERS As many members of the primary care team should be trained to carry out a competent asthma review as possible. Asthma is a common condition throughout the age range; it can be well controlled for most people with appropriate input, but, if left uncontrolled, can result in unnecessary and preventable death. In the author s clinical opinion, if more nurses are aware of the importance of asthma reviews, this increases the chances of patients accessing care and ensures that the whole team understand the basic principles of good asthma management. The NRAD report identified that a lack of knowledge and implementation of UK asthma guidelines by healthcare professionals played a part in nearly half of the avoidable asthma deaths (RCP, 2014). Thus, it is vital to take time to read and be aware of the key recommendations from the guidelines. The NRAD recommends that those carrying out annual asthma reviews should have specialist asthma training (RCP, 2014). CONCLUSION The long-term goals of asthma management are to achieve good symptom control, and to minimise future risk of exacerbations, fixed airflow limitation and side-effects of treatment. The patient s own goals regarding their asthma and its treatment should also be identified. GINA, 2018 Achieving goals of good asthma management requires knowledge, understanding and good communication skills (GINA, 2018). Patient education is a major part of the asthma review and this should be carried out with care to match the individual s health literacy. Teach back, where you ask the patient to repeat back any instructions, is a good way to check understanding (GINA 2018). This article has looked at the areas that need assessing for an effective asthma review. A wealth of evidence and resources is available to help improve asthma control. It is up to us, as practitioners, to help our patients and their families benefit from this with competent, safe asthma care. JCN REFERENCES Asthma control test. Available online: Asthma UK. Asthma action plan. Available online: manage-your-asthma/action-plan Asthma UK. Asthma triggers. Available online: triggers Asthma UK. Available online: www. asthma.org.uk/about/media/news/ asthma-deaths-in-england-wales-hit- 10-year-peak/ British Thoracic Society/Scottish Intercollegiate Guidelines Network (2016) British guideline on the management of asthma. Available online: SIGN-153-british-guideline-on-themanagement-of-asthma.html Global Initiative for Asthma (2018) Global Strategy for Asthma Management and Prevention. Available online: International Study of Asthma and Allergies in Childhood (ISAAC) Key points Guidelines recommend that patients with asthma should have a regular, professional review. A person with asthma may be with the nurse for a review for only 20 minutes a year, the rest of the time they need to manage their asthma themselves self-management education and a written PAAP are therefore vital. A patient having an asthma attack should not wait to see their GP for an urgent appointment, but should get straight to hospital where full emergency resources are available. If more nurses are aware of the importance of asthma reviews, this increases the chances of patients accessing care and ensures that the whole team understand the basic principles of good asthma management. The Global Asthma Report 2011; International Study of Asthma and Allergies in Childhood and the International Union against Tuberculosis and Lung Disease (The Union). Available online: ac.nz/resources/global_asthma_ Report_2011.pdf Mylungsmylife. Available online: mylungsmylife.org National Institute for Health and Care Excellence (2017) Asthma: diagnosis, monitoring and chronic asthma management. National guidance [NG] 80. NICE, London. Available online: Royal College of Physicians (2014) Why asthma Still Kills. The National Review of Asthma Deaths (NRAD). RCP, London. Available online: ac.uk/projects/outputs/why-asthmastill-kills GPN 2018, Vol 4, No 5 63