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Asthma reviews in general practice



Key learning points:

  • People with asthma should have a structured review with a health professional who has specialist asthma knowledge at least once a year
  • Frequent use of short-acting bronchodilators indicates poor control and increased risk of asthma death
  • Inhaler technique, adherence to preventer therapy and diagnosis should be checked before stepping up therapy

An estimated 5.4 million people in the UK have asthma1 and are mostly looked after in primary care, so asthma forms a significant proportion of general practice workload. There is good evidence2,3 to suggest that morbidity and mortality are significantly reduced by a proactive approach to asthma care through regular reviews and strategies for supported self-management.
Current guidelines4 recommend reviews at least annually by a health professional with appropriate expertise. Despite this, the Royal College of Physicians (RCP)5 review of asthma deaths found that 43% of people who died from asthma had not had an asthma review in the last year and only 23% had a personalised asthma action plan (PAAP).
As recommended by guidelines, the UK quality outcomes framework (QOF)6 incorporates the standard that all individuals with asthma should receive an annual review. Primary care nurses with appropriate asthma education are ideally placed to carry out these reviews working with patients and their families. This article will consider the key components of an adult asthma review including assessment of control, inhaler technique, adherence to preventer medication and the development of PAAPs.

Assessing asthma control
Poor control results in people being unable to perform their usual daily activities including paid work, and results in more intensive use of NHS resources with increased consultations and hospital admissions. The current asthma guidelines4 define good control as having no symptoms, no exacerbations and normal or near normal lung function. The presence of intermittent symptoms (twice a week or less) is potentially compatible with good control but night-time symptoms indicate loss of control.
In order to assess asthma control, the nurse should consider the presence of symptoms and review clinical records. Frequent requests for reliever medication in the form of short-acting ß2 agonists suggest poor control4 and have been linked to asthma death.5 The nurse should also look at records for evidence of acute exacerbations in the last year such as use of oral steroids or emergency attendances or admissions. This can indicate an increased risk of future attacks even in the presence of current good control.2
Guidelines3 recommend using a structured approach to eliciting information about symptoms and that a recognised tool should be used to quantify their impact. The QOF requires that the RCP’s three questions7 (see table 1) are asked.
Other validated tools such as the Asthma Control Questionnaire (ACQ)8 or the Asthma Control Test (ACT)9 are available and can add a further dimension to the assessment. These both use a series of morbidity questions but the ACT includes a rating of overall control where a score of 20 or more indicates good control.
Although these can be administered during the review they have both been validated for self-administration. Some practices send them out for patients to complete at home and bring to the review while others may ask patients to complete the questions in the waiting room beforehand. It is important to consider where, when and how they are completed as this may affect the answers given.10
When reviewing the answers it is important that the nurse does not simply note the scores but uses the opportunity to explore underlying issues. Every person with asthma will have a different perception of their symptoms and the impact of their disease. Evidence11, 12 has consistently shown that patients and health professionals underestimate the importance of symptoms and their impact on daily life.
Nurses should also ask about smoking status. Smoking could indicate the presence of chronic obstructive pulmonary disease (COPD), either alongside the asthma, or possibly COPD that has been incorrectly diagnosed as asthma. Smoking also interferes with the action of inhaled corticosteroids (ICS) and smokers may require higher doses to get control.4
It is also useful to enquire about symptoms such as persistent runny or blocked nose. Rhinitis is a common co-morbidity in people with asthma. Although treating rhinitis has not been shown to improve asthma control, it may help to reduce the symptom burden.4
As part of the assessment of control, objective measures of lung function such as spirometry or peak expiratory flow rate (PEFR) should be considered.4 Reduced lung function values compared to previous best readings can indicate bronchoconstriction at that time or a longer-term decline warranting further assessment.4 It is important to remember that due to the variable nature of asthma a ‘normal’ reading may not rule out overall poor control and so lung function should always be considered in the context of the overall history taken at the review.

Adherence with preventer medication
It is widely recognised that irregular use of prophylactic ICS is an important reason for poor control and increases the risk of asthma death.4, 5 The nurse should encourage the individual to be open and honest about their use of regular medication. It can be useful to ask: “How often do you forget your ICS inhaler?” as this may give permission to be less than perfect. On the other hand, asking “How often do you take your ICS?” is more likely to make the patient restate the prescribed dose instead of disclosing what they really do.
Underuse of ICS can result in increased symptoms and poor control so this must be explored before therapy is stepped up.4 Increasing doses or adding in new medication will not tackle poor control if the medication is not taken as prescribed. So if poor adherence is identified the nurse will need to explore this with the patient to identify ways they can be supported.

Inhaler technique
Asthma treatments are delivered straight to the lung by inhalation, so correct use of an inhaler device is vital.13 Incorrect inhaler technique is common and is associated with poorer outcomes,13 so this element of care must be tackled during the review.
There are many different inhaler devices, varying in shape and size, containing a range of medications that require different techniques and different levels of manual dexterity. Nurses carrying out asthma reviews should ensure they are familiar with all the devices that are frequently prescribed in their area and options for individuals who are in difficulties. When working with a patient it is important that the nurse has practical experience in how the various devices work and is able to teach their correct use.

Assessment outcomes and treatment recommendations
If it is established that control is good there may be no need for any change. But it is still essential that the nurse works with the patient to ensure they understand how to spot deterioration. Their PAAP should outline how to respond if this occurs.  
Once good control has been established, the aim should be to use the lowest possible dose of medication to remain symptom free. Stepping down of medication is an often overlooked element of asthma management and many people are on higher levels of medication than they need.4 It is important, therefore, that nurses always consider the possibility of stepping therapy down.
Guideines4 recommend that any reduction should be slow, since patients deteriorate at different rates. A reasonable approach is to consider reducing ICS dose by 25-50% every three months, and check that control is maintained.
If control is poor, contributing factors should be considered and dealt with.4 It is important to review the basis on which the original diagnosis was made and to consider if poor control could be due to a previously unrecognised diagnosis such as COPD in a smoker or gastro oesophageal reflux as a cause of cough etc.
Development of new co-morbidities such as cardiac disease should also be considered as potential causes of increased symptoms and ruled out before adjusting asthma therapy.14 Changes to therapy may involve change of inhaler device, restarting regular ICS or adding in further medication but must be in line with current guidelines.4 If the nurse carrying out the review is not a prescriber, they will need to liaise with the patient’s GP about changes in treatment. If a new inhaler is required it is important that before prescribing the nurse teaches the patient to use the new device and confirms them as competent in its use.4

Development of PAAPs
British Asthma guidelines4 recommend that people with asthma should be offered individualised self-management education supported by a written action plan. The benefits of this approach are shown to include an improvement in quality of life and a reduction in hospital admissions, unplanned healthcare consultations, time lost from work and a decrease in night-time symptoms.4,15 Working in partnership with the patient enables the nurse to ensure that information can be tailored to the individual’s own needs and preferences.
Guidelines4 suggest that brief simple education focused on patient goals is likely to be the most acceptable. Systematic reviews16,17 have provided advice on the best format for effective asthma action plans, which include written information with two to three clear action points on what to do if the condition deteriorates.
There is no evidence4 to suggest superiority of using either symptoms or PEFR as triggers for action. The guidelines4 suggest that in adults either may be used or a combination of both.
Asthma UK18 produces a PAAP based on these principles, which can be ordered in print format directly from Asthma UK, downloaded from the website or accessed via EMIS web.
The PAAP should be discussed and completed in relation to the specific needs of the patient, given to the patient and also stored in their records. As asthma is a dynamic condition subject to variation and change, it is important that that this PAAP is not seen as a static document but as one that should be reviewed and modified in light of any changes.

Tackling non-attendance at reviews
If nurses can create an atmosphere in which the patient feels valued and listened to, rather than part of a tick-box exercise, attendance at reviews will be valued and patients will be more likely to attend. But not all people will be willing to attend a pre-arranged appointment for a review,19 so it may be necessary for nurses to opportunistically review an individual’s asthma when they attend for other reasons.
By reviewing repeat prescriptions the nurse can identify patients using high levels of bronchodilators. And a tool such as the RCP three questions7 could identify patients who may be poorly controlled, so the nurse could suggest a full review. While a telephone review cannot check inhaler technique there is evidence to suggest that they can help to identify those with poor control who can be encouraged to attend for a more detailed review.20

Conclusion
Asthma reviews in primary care are an important part of improving control and reducing morbidity and mortality.
Primary care nurses are ideally placed to ensure these reviews are carried out effectively. The key aim should be to enable people with asthma to be symptom free (or at least to have minimal symptoms) enabling them to participate fully in all aspects of their daily life.
Successful asthma reviews need to assess control in order to target care appropriately; identify reasons for poor control and adjust therapy accordingly; to explore individuals’ own attitudes to their asthma in order to provide supported self-management to maintain control. In order to achieve these outcomes, nurses carrying out reviews need to have accessed appropriate training and be familiar with current evidence-based guidelines.

References
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2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2016. ginasthma.org (accessed 16 August 2016).
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16. Gibson PG, Powell H, Wilson A, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews, 2002.
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18. Asthma UK. Asthma Action Plans, 2016. asthma.org.uk/professionals (accessed 16 August 2016).
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20. Pinnock H, Bawden R, Proctor S et al. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. British Medical Journal 2003;326 (7387):477-479.