A primary care nurse’s quick guide to…
Asthma and allergy
Key learning points:
1. Asthma is a very common long-term condition involving inflammation of the airways and is associated with atopy and allergies
2. Diagnosis is via clinical assessment of symptoms, triggers (including allergens) risk factors and history, and – likely to become increasingly important – lung function tests
3. Management in primary care aims for symptom control via self-management, including allergen avoidance and a step-wise approach to pharmacological treatment
4. Primary care nurses can help to ensure asthma is taken seriously, and can provide education on what to do when a person has an asthma attack
Both asthma and allergy are such well-recognised terms that they perhaps belie the complications and intricacies of diagnosis and management, as well as the potentially serious consequences including death and impact on quality of life.
Many asthma patients are managed in primary care, and the Primary Care Respiratory Society UK (PCRSUK) recommends a core set of skills for nurses in the setting.1,2
With that in mind, here’s a quick guide to asthma and allergy and your role in it.
Definition and prevalence
Asthma is a long‑term condition characterised by inflammation of the airways in the lungs, causing narrowing. Allergic asthma results from excess immunoglobulin E (IgE) produced in response to environmental allergens (sometimes called aeroallergens) such as house dust mites, pollen, moulds and animal fur and feathers.3,4
The National Institute for Health and Care Excellence (NICE) says that asthma is the most common long-term condition. It quotes Asthma UK’s figures that 5.4 million people in the UK, including 1.1 million children (one in 11), are receiving treatment for asthma. Data from the Health and Social Care Information Centre’s latest (2014-15) Quality and Outcomes Framework report put prevalence at 3.4 million in England, 6% of the population.3,5,6
The causes of asthma – why an individual develops the condition – are not well understood, though it is likely to be a combination of factors, both genetic and environmental. A personal or family history of atopy, including eczema, food allergy and allergic rhinitis, is one risk factor for developing the condition.3,7
Spotting the signs and symptoms
The classic symptoms of asthma are breathlessness, chest tightness, coughing and wheezing.3
Guidelines from the British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) state that the probability of these symptoms indicating asthma is increased if they:
· Are frequent and recurrent.
· Are worse at night and in the early morning.
· Occur in response to, or are worse after triggers including: exercise; cold or damp air; emotions or laughter; allergens such as animal fur.
· Occur apart from with colds.
· Occur after taking aspirin or ß-blockers.8
As well as a personal or family history of allergic conditions, other clinical features that increase the probability of an asthma diagnosis include:
• Widespread wheeze heard on auscultation (listening to the chest).
• Otherwise unexplained peripheral blood eosinophilia (high eosinophil count in the peripheral blood).8
NICE states that healthcare professionals should ensure that new diagnoses of asthma have been made in accordance with the BTS/SIGN guideline.3
· An initial clinical assessment based on the above symptoms and probability factors, as well as those that reduce the likelihood of asthma.
· For adults, spirometry.
The patient should be classified as having a high, intermediate or low probability of asthma.8
Although aeroallergens are recognised triggers for asthma symptoms, draft NICE guidance indicates that the institute will advise against skin-prick tests for these and IgE as diagnostic tests for asthma.9
Self-management and pharmacological treatment
Patients assessed as having an intermediate or high likelihood of asthma should be managed as if they have the condition, to confirm or reject the diagnosis.10
The aim of asthma management is good symptom control – characterised by no symptoms, normal lung function and no exacerbations – via a combination of self-management and pharmacological treatment. Self-management includes trigger avoidance.4,11 Allergy UK advises patients with allergies to be especially careful because their attacks can be more severe.17
Pharmacological management is via a step-wise approach (detailed in the BTS SIGN guideline). It starts with an occasional relief bronchodilator – an inhaled, short-acting ß2agonist – and is stepped up or down according to control and as appropriate for adults or children. Healthcare professionals should ensure that patients know how to use their inhalers correctly.8
For some patients aged six years and over with severe persistent allergic asthma – defined as poor control despite eliminating allergens and optimising standard care – NICE recommends omalizumab (a monoclonal antibody that binds to IgE) as a possible additional treatment.4
Notes for primary care nursing
As a primary care practitioner, the most important thing you can do is take asthma seriously.12
Exacerbations remain common. There were more than 60,000 hospital cases with amain diagnosis of asthma in England in 2013-14, and asthma was part of the diagnosis in more than 1.3 million admissions. Patients who receive secondary care treatment for an acute exacerbation of asthma should be followed up by their GP practice within two working days.6,3
In 2014 in England and Wales, more than 1,100 deaths were registered with a primary cause of asthma. Many asthma deaths involve avoidable factors. In addition, psychological conditions such as anxiety and depression may be up to six times more common in people who have asthma than in the general population. People with asthma may experience reduced quality of life, with symptoms leading to fatigue and absence from school or work.4,6,13,14
NICE wants healthcare professionals to ensure that every asthma patient has a written, personalised asthma plan and receives a structured review of their asthma control at least annually. Both should cover exposure to trigger allergens. Every general practice should have a named, trained and qualified clinical lead for asthma care, and should keep a register of asthma patients.3,11
Primary care professionals in particular may be faced with questions from pregnant, breastfeeding and weaning parents about preventing asthma in their children. These patients should be advised on the many risks of smoking to their children, including increased risk of asthma. They should also be encouraged to breastfeed for its many benefits including potential protection against asthma. Allergen avoidance during pregnancy and breastfeeding is not recommended as a strategy for preventing asthma.8
Asthma UK has found that three-quarters of people wouldn’t know what to do if someone had an asthma attack.12 This finding represents a role for primary care nurses in the education of parents and carers, and for school and community nurses to provide training to teachers and other community staff members to ensure the safety of asthma patients in the settings for which they are responsible.
The future of practice
NICE is developing a guideline on asthma management, expected in June 2017, as well as one on asthma diagnosis and monitoring whose publication date is yet to be confirmed.9,15
The latter includes more emphasis on objective testing to support asthma diagnosis than the BTS SIGN guideline. This approach is supported by research published in the British Journal of General Practice in March, which concluded that overdiagnosis of childhood asthma is common in primary care and that only a small proportion of diagnoses are confirmed by lung function tests.11,16
Therefore we may see an increasing expectation of lung function tests to support asthma diagnosis, particularly in children.
• The Association of Respiratory Nurse Specialists, http://arns.co.uk, provides resources such as this inhaler device summary: http://arns.co.uk/wp-content/uploads/2015/03/Drugs-and-Devices-January-2016m.pdf
• PCRSUK http://www.pcrs-uk.org/homepageoffers resources including this document detailing recommended skill levels for primary care nurses delivering respiratory services: https://www.pcrs-uk.org/resource/Professional-development/nurse-skills-document
1. Managing asthma in primary care: putting new guideline recommendations into context. Mayo Clin Proc. 2009 Aug; 84(8): 707-717. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719524/(accessed 13 June 2016)
2. McArthur R. Skill Levels for Delivering High Quality Respiratory Care by Nurses in Primary Care. Primary Care Respiratory Society UK. 2007, revised 2015. https://www.pcrs-uk.org/resource/Professional-development/nurse-skills-document
3. Nice. QS25. Asthma. February 2013. https://www.nice.org.uk/guidance/qs25
4. Nice. TA278. Omalizumab for treating severe persistent allergic asthma. April 2013. https://www.nice.org.uk/guidance/ta278
5. Asthma UK. Asthma Facts and Statistics. https://www.asthma.org.uk/about/media/facts-and-statistics/(accessed 13 June 2016)
6. Primary Care Domain, Health and Social Care Information Centre. Quality and Outcomes Framework – Prevalence, Achievements and Exceptions Report England, 2014-15. HSCIC. V1.1. October 2015. http://www.hscic.gov.uk/catalogue/PUB18887/qof-1415-Report%20v1.1.pdf
7. NHS Choices. Asthma – Causes. http://www.nhs.uk/Conditions/Asthma/Pages/Causes.aspx(accessed 13 June 2016)
8. British Thoracic Society – Scottish Intercollegiate Guidelines Network. Sign 141. British guideline on the management of asthma. Healthcare Improvement Scotland. 2003, revised 2014. http://www.sign.ac.uk/pdf/SIGN141.pdf
9. Nice.GID-CGWAVE0640. Asthma diagnosis and monitoring draft scope for consultation 10 April to 8 May 2013. Draft. https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0640
10.Nice. CKS Asthma. Revised December 2013. http://cks.nice.org.uk/asthma#!topicsummary
11.McArthur R, Small I. A Quick Guide to the Routine Management of Asthma in Primary Care. Primary Care Respiratory Society UK. Version 4.0. 2008, revised 2015. https://pcrs-uk.org/sites/pcrs-uk.org/files/AsthmaGuide_FINAL_2015.pdf
12.Asthma UK. World Asthma Day: Time to take asthma seriously. https://www.asthma.org.uk/wad16/takeitseriously/(accessed 13 June 2016)
13.Thomas M et al. Asthma and psychological dysfunction. Prim Care Respir J. 2011 Sep;20(3):250-6. http://www.ncbi.nlm.nih.gov/pubmed/21674122
14.Levy M et al. Why asthma still kills – The National Review of Asthma Deaths. Royal College of Physicians. May 2014. https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
15.Nice. GID-CGWAVE0743. NICE guideline: Asthma management Final scope. Draft. https://www.nice.org.uk/guidance/indevelopment/gid-cgwave0743
16.Looijmans-van den AkkerI, van LuijnK, VerheijT. Overdiagnosis of asthma in children in primary care: a retrospective analysis. Br J Gen Pract.2016 Mar;66(644):e152-7. bjgp.org/content/66/644/e152
17.Asthma UK. Your asthma action plan. https://www.asthma.org.uk/globalassets/health-advice/adult-asthma-action-plan.pdf(accessed 14 June 2016)