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Managing adult asthma in primary care

Sharon Haggerty
RN DipHE BSc(Hons) MSc
Community Respiratory Nurse Specialist
Pallion Health Centre
Sunderland
E:sharon.haggerty@suntpct.nhs.uk

In 2003 the BTS and SIGN joined together to produce a joint asthma guideline for the first time.(1) The new guideline informs the GMS contract and provides revised advice on the management of patients of all ages in both primary and secondary care. However, for most healthcare professionals the majority of their asthma patients fall into the adult bracket.
Around 3.7 million adults are currently being treated for asthma in the UK, which equates to 1 in every 13 people.(2) Of the 1,300 people in England and Wales who died of asthma in 2002, only 5% were under 25 years, while nearly three-quarters were over the age of 55 years.(3) The treatment of adult asthma therefore equates to a large draw on health service resources and healthcare professionals' time.
This article provides an overview of adult asthma that considers the key treatment issues, discusses the latest guidance to healthcare professionals, and examines the role of the nurse in optimising asthma care.

Asthma diagnosis
Asthma is a chronic inflammatory disease of the airways causing recurring episodes of cough, wheeze, chest tightness and shortness of breath. As a variable disease, symptom severity is intermittent, often worsening at night, and is frequently provoked by trigger factors such as exercise. Asthma should be considered in a patient if there is evidence of reversible and variable airflow ­limitation - this can be measured using a peak expiratory flow (PEF) meter in any of the following ways:(1)

  • PEF increases more than 15%, 15-20 minutes after inhalation of a short-acting b(2)-agonist.
  • PEF varies more than 20% from morning ­measurement to subsequent measurement 12 hours later in patients taking a bronchodilator (more than 10% in patients not taking a bronchodilator).
  • PEF decreases more than 15% after six minutes of running or other exercise.

Some of the symptoms of asthma are shared with diseases of other systems, including other respiratory conditions, such as COPD (chronic obstructive pulmonary disease). Objective tests should therefore be used to confirm a diagnosis of asthma before long-term therapy is commenced.(1)
While asthma is viewed as a common childhood condition, symptoms can occur at anytime in life. Occupational asthma may account for about 10% of adult-onset asthma and is the most common industrial lung disease in the developed world.(1) Therefore healthcare professionals should always be suspicious that there may be an occupational cause for patients with adult-onset asthma. Confirmation of the link between work and asthma is possible through a variety of techniques, the most appropriate often being serial measurements of PEF. The aim of managing occupational asthma is to identify the cause and remove the worker from exposure itself - not ­necessarily removing them from their occupation.

Management and review
Asthma can impact considerably, and often unnecessarily, on a patient's quality of life. The Living and Breathing - Putting Patients First in Asthma research confirmed that patients frequently underestimate how well their symptoms are being controlled - 90% believed that their asthma was under control, yet two-thirds of these experienced symptoms at least two to three times a week.(4) When shown the GINA (Global Initiative for Asthma) guideline goals on how well asthma should be controlled, patient satisfaction dropped from 58% to 33%.(4) Healthcare professionals should be aiming for the following results from treatment:(2)

  • Minimal symptoms during day and night.
  • Minimal need for reliever medication.
  • No exacerbations.
  • No limitation of physical activity.
  • Normal lung function.

Nurses can and should continue to play a key role in achieving these goals through regular patient review. This provides a valuable opportunity to assess asthma control and establish whether current treatment options are working for the individual.
Regular review is associated with favourable outcomes, including reduced work absence, reduced exacerbation rate and improved symptom control.(4) It is also considered that primary care reviews undertaken by nurses with a diploma in asthma care can achieve better outcomes. The Living and Breathing research supported this by emphasising the importance of continuity of care - patients need to maintain contact with someone with whom they are comfortable,(4) and in many cases it is the nurse who provides the familiar face for their asthma care.
The National Asthma Campaign's Patient Charter highlights the need for regular review, recommending that patients should be reviewed at least once a year (see Box 1). In addition, the GMS contract now provides an extra incentive by awarding practice points for those who have had their asthma reviewed within the last 15 months. Using tools such as the Royal College of Physicians' "Three key questions" (see Box 2)(5) will help to achieve an accurate understanding of the patients' symptoms, ensuring effective communication.

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Treatment options
Pharmacological treatment for asthma remains centred on the use of short-acting and long-acting bronchodilators and inhaled steroids. The BTS/SIGN stepwise approach provides the definitive guide to asthma treatment and is based on the premise of achieving early control, stepping up treatment when symptoms deteriorate, but also remembering to step down when control is good.(1)
In a change from previous versions, step 3 now recommends the addition of long-acting b-agonists as the first-choice add-on therapy rather than higher-dose inhaled steroids.(2) The addition of long-acting b-agonists has also been shown to be equally effective through combination inhalers that deliver inhaled steroid and long-acting b-agonist in a single device.(2) Two combination treatments are available - Symbicort (eformoterol and budesonide; AstraZeneca) and Seretide (salmeterol and fluticasone; Allen & Hanburys). These incur only a single prescription charge and for some patients may offer compliance benefits.(5) Symbicort allows for adjustable dosing (in line with their GP's/nurse's advice), enabling patients to adjust the dose within a range of one to four inhalations a day in response to the variable nature of their condition. Research from the ASSURE study shows that transferring patients from fixed to adjustable dosing of eformoterol and budesonide has been estimated to result in an annual reduction in healthcare costs of £66 per patient,(6) while using 16% less drug.(7) In addition, adjustable dosing may complement the requirements of self-management and personalised asthma action plans.

Personalised asthma action plans
The BTS/SIGN guideline positions asthma action plans as one of the most effective interventions available in the routine management of asthma, and they are endorsed with a Grade A recommendation.(1) Yet currently the use of written action plans is minimal - a study by the National Asthma Campaign found that they are used by only 3% of people with asthma.(2) Practice nurses are ideally positioned to drive this recommendation to ensure patients are provided with the necessary guidance in the management of their condition.
Action plans are individually tailored, written plans, designed to help a patient to manage their asthma more effectively. They provide patients with information about when and how to use routine and emergency treatments, and how to monitor their peak flow, and to encourage them to make appropriate decisions to manage their asthma and prevent symptoms deteriorating.
One of the key challenges that healthcare professionals face in asthma management is poor patient compliance and concordance. Both adults and children with asthma commonly underuse preventer medication and overuse reliever medication, usually as a result of misunderstanding their treatment. Using action plans as part of a self- management education programme can address these issues and has been shown to reduce unscheduled primary care visits, hospitalisations and days off work.(8,9)
Providing patients with an action plan enables them to feel like an active participant in their treatment and empowers them to take control of their own condition by stepping up or down treatment depending on symptoms. It is particularly important for patients to fully understand the role their various inhalers play in the treatment of their asthma. Enabling the patient to alter the dose of their treatment without always needing to seek healthcare advice allows nurses and GPs to deal with other patients.(10) A 2002 Cochrane review has shown that patients managing their asthma by self-adjustment of their medications using a written asthma action plan have better lung function than those whose medications are adjusted by a doctor.(9)

Conclusion
Asthma management provides primary care with an important challenge, as reflected by the inclusion of the asthma quality marker in the GMS contract. It also presents an opportunity for nurses to develop their role within the practice team.

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The BTS/SIGN guideline offers clear and comprehensive guidance on the management and treatment of asthma, but thorough implementation remains a major obstacle. There remains much work among healthcare professionals to ensure that the step 3 recommendation is heeded and to improve uptake of personalised asthma action plans. Successful asthma management is based on the partnership and communication between patients and the healthcare team, with the patient taking an active role in the management of their own care. Nurses can play a pivotal role in improved asthma outcomes by empowering people with asthma to be proactive, ensuring wider implementation of written asthma action plans, and undertaking regular review of patients.

References

  1. BTS/SIGN. British guideline on the ­management of asthma. Thorax 2003;58(S1):i1-94.
  2. NAC. Out in the open. A true picture of asthma in the United Kingdom today. National Asthma Campaign Asthma Audit 2001. Asthma J 2001;6(3):Supplement.
  3. The Global Initiative for Asthma. Pocket guide for asthma management and prevention. London: National Institute of Health, National Heart, Lung and Blood Institute; 1998.
  4. Living and breathing - putting patients first in asthma. Key ­findings and ­analysis of a nationwide survey of asthma patients. London: Munro & Forster; 2001.
  5. Seretide and Symbicort in asthma ­management. Drug Ther Bull 2002;40(8):62-4.
  6. Price D, et al. Budesonide/ formoterol with an adjustable ­maintenance plan costs less and is as effective as fixed dosing. Paper presented at ERS Conference, Stockholm; 2002.
  7. Ind P, et al. Patient-managed adjustable dosing of budesonide/ formoterol is ­similarly well ­tolerated to fixed dosing. Poster presented at ERS Conference, Stockholm; 2002.
  8. Abramson MJ, et al. Are asthma medications and management related to deaths from asthma? Am J Respir Crit Care Med 2001;163:12-8.
  9. Gibson PG, et al. Self-­management education and regular ­practitioner review for adults with asthma (Cochrane review). In: The Cochrane Library. Issue 2. Oxford: Update Software; 2002.
  10. Price D, Wolfe S, on behalf of the NAC Needs Analysis Group. Greater ­expectations? Delivery of asthma care: patients' use of and views on healthcare ­services, as ­determined from a nationwide ­interview survey. Asthma J 2000;5:141-4.

Resources
British Thoracic Society
W:www.brit-thoracic.org.uk
General Practice Airways Group
W:www:gpiag.org

Further reading
Rees J, Kanaber D. ABC of asthma. London: BMJ Publishing Group; 2001.