ASTHMA GUIDELINES

2012 UPDATE

What guidelines do we have available to follow for asthma

1) Asthma GP monitoring Guideline

2) Asthma Diagnosis Guideline

3) Acute asthma management guideline

4) Asthma Stepwise management

Asthma Guidelines 2012

The 2012 guidelines for Asthma have been written to improve

the way we care for our asthma patients.

The first part of the guidelines sets out the requirements of a good annual review.

A Good Review

NHS Calderdale, NHS Kirklees and NHS Wakefield DistrictPrimary Care asthma monitoring /annual review for adults

History

Number of exacerbations since last seen in clinic

Work days lost since last seen in clinic

Referral to stop smoking service

Emergency Department attendance since last seen in clinic

Atopy – triggers identifiedExercise symptoms

Is there a record of reversibility?

Emergency asthma admission since last seen in clinic

Is there any suggestion of occupational asthma?

Flu vaccination recorded in last 12 months, if appropriate

Nebulised bronchodilators required since last seen in clinic

Smoking status recorded Peak flow meter at home – ensure technique satisfactory

Last oral steroid use Stop smoking advice given

Assessment of Asthma Control

There are a number of validated tools that canbe used to assess asthma control.

The asthma control test can be found at http://www.asthmacontroltest.com and is an excellent tool for use with adult patients.

Assessment/examination

Height, Weight, Body Mass Index, consider need for blood tests e.g.. IgE RAST if appropriate and will change management of co ndition,

Spirometry Record at each review record FEV1 and FVC as % predicted and FEV1/FVC ratio

If spirometry is not available record Peak Expiratory Flow PEF where possible using patients own peak flow meter to record

Discuss and record current medication Assess concordance and understanding Drug side-effects (current) and potential risks (eg. Steroid-induced osteoporosis)Issue steroid safety cards for patients on step

4 & 5 of Stepwise Management of Asthma

Beclometasone or Budesonide 1000mcg twice daily

* via spacer device or Fluticasone 500mcg twice daily via spacer device

Assess inhaler technique at every review:Is device appropriate?Is there a need for spacer / spacer replacement (how long in use)?

Step up/down treatment as needed in response to assessment. If control is achieved and maintained, after 12 weeks inhaled cortico steroid therapy should be reduced (dose decreased by 25-50%) to the lowest step that maintains control

Assess *SABA use / overuse (record reliever – free days and number of puffs used a day)

Assess and record us of OTC */herbal medications

Consider referral to Community Pharmacist for further support with medication either through a New Medicines Service assessme nt or a Target Medicines Use Review

Medication review

Assess patient’s understanding of how to recognize worsening asthma (symptoms and *PEF) and what action to take

Assess and address patients needs for education

Assess understanding of action to take in an emergency Consider referral to Expert Patients Programme

Agree interval for asthma follow-up Written self management/action plan given or updated

Asthma Care Plan

OTC – Over the Counter, * PEF- Peak Expiratory Flow , * SABA – Short-acting beta2-agonist

Enquiries to:Group responsible for development: NHS Kirklees in collaboration with NHS Wakefield District, Mid Yorkshire NHS Hospitals Trust and Calderdale and Huddersfield Hospital Foundation Trust (Kirklees Sector).

Royal College of Physicians 3 Questions- ( minimum QOF requirement)

1 Have you had difficulty sleeping because of your asthma symptoms(including cough)?

2 Have you had your usual asthma symptoms during the day (cough,wheeze, chest tightness)?

3 Has your asthma interfered with your usual activities (work, sex,housework, exercise)?

Routine review in primary careThe Sign/BTS Asthma Guidelines 2009 state there is strong evidence that proactive clinical review of people with asthma improves clinical outcomes, with those reviews that include discussion and use of a written self management plan being of greatest benefit.

Proactive reviews are associated with reduced exacerbation and days lost from normal activity, as opposed to unstructured or opportunistic review. Outcomes are similar whether reviews are conducted by a Practice Nurse or GP with the best outcomes achieved with those clinicians with asthma management training. Identification of patients at high risk is recommended. Telephone review has been shown to be a suitable option for those patients who fail to attend for routine reviews.

Routine management of Asthma

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Offer at least annual review to all those on the asthma registerTime taken: approximately 20- 30 minutesConducted by healthcare professional with appropriate educationAim: To identify if asthma is CONTROLLED or UNCONTROLLEDand take action.

Primary care asthma Review

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Prioritisation of care

Prioritise those at greatest risk of attack

• Proactive recruitment to attend for asthma assessment• Telephoning resistant ‘DNA’ (Did Not Attend) patients to assess control and encourage attendance• Priority / same-day appointments for those with deteriorating symptoms who are ‘At risk’• Consider telephone assessments• Liaison with community pharmacists, schools, school nurses and community colleagues e.g. community nurses

SIGN Definition of Factors Contributing to ‘AT RISK’

• Previous near-fatal asthma

• Previous admission for asthma in the past year (including Accident & Emergency)

• Requiring three or more classes of medication

• Heavy use of short acting B2 agonist

•‘ Brittle asthma'

*How to identify of those at greatest risk – computer searches

• Previous near-fatal asthma

• Hospital attendance with asthma attack in past 2 months (including Emergency Department attendances)

• Presentation with asthma attack in primary care in past 2 months

• Two or more courses of oral steroids and/or antibiotics in past 6 months

•Heavy use of short-acting B2agonist (> 3 canisters in 6 months)

•DNA asthma clinic or excepted from QOF

•Repeated days off school or work with Asthma

•.Brittle asthma’

• Identification via regular computer searches and reviews of medical records• Placement on an ‘At risk’ register for Asthma• System devised to ‘flag up’ risk and prioritise attendance

The next guideline looks at diagnosis of asthma patients

We are going to look at this new guideline with particular attention to reversibility

Included on this guideline is the variability required and how to calculate that variability

Quite often a nurse is presented with a patient who has been reversed by a GP and commenced medication such as Ventolin.

Athma Diagnosis

Management of acute asthma in adults requires varying levels of treatment the next guideline sets out the most appropriate treatment for level of exacerbation.

Spacer, Nebuliser, Oxygen?

SpO2 level?

How much prednisolone?

NHS Kirklees and Wakefield DistrictGuidelines for the management of acute asthma in adults in general practice

Many asthma deaths are preventable. Factors leading to poor outcome include:•Failure by clinical staff to objectively assess severity•Patients or relatives failing to appreciate severity•Under-use of corticosteroids

1. Assess (Determine severity) : Record Peak expiratory flow rate (PEFR), heart rate, respiratory rate, oxygen saturations (SpO2) and complete a clinical examination.

2. Treat (According to severity)3. Reassess (Response to therapy)4. Educate & Follow-up

ACUTE SEVEREMODERATEMILD LIFE THREATENING

PEF <33% best or predicted PEF 33-50% best or predicted PEF >50-75% best or predicted PEF >75% best or predicted

• SpO2 ≥ 92%• Speech normal• Respiratory rate <25/min• Pulse <110bpm

• SpO2 ≥ 92%• Speech normal• Respiratory rate <25/min• Pulse <110bpm

• SpO2 ≥ 92%• Can’t complete sentences• Respiratory rate ≥25/min• Pulse ≥110bpm

• SpO2 < 92%• Silent chest, cyanosis • Poor respiratory effort• Exhaustion• Bradycardia

Treat at home / in surgery and assess response 999 – Admit IMMEDIATELY

1. β2 bronchodilator: eg salbutamol

Via spacer device (2 puffs initially, and 2 puffs every 2 minutes according to response up to maximum of 10puffs)

1. β2 bronchodilator eg salbutamol

Via spacer device (4 puffs initially, and 2 puffs every 2 minutes according to response up to maximum of 10puffs)

2. Prednisolone 40mg (7days)

RE-ASSESS (after 30minutes)

Clinical improvement and PEF >/= 60% allow home

•PEFR <60%•No clinical improvement•Requires second nebuliser•Concern over social circumstances•Patient unable to monitor / assess own condition • Previous near fatal attack

RE-ASSESS (after 30minutes)

Stable or improved and PEF >/=75% then allow home

PEF <75% or clinical deterioration then manage according to severity

1. Oxygen (Target SpO2 94-98%)

2. Salbutamol 5mg via a nebuliser preferably oxygen driven.

If no nebuliser available give via spacer device (4 puffs initially, and 2 puffs every 2 minutes according to response up to maximum of 10puffs).

3. Prednisolone 40mg

Prior to discharge (including following an Emergency Department attendance) ensure:

1 Patient is taking a regular inhaled corticosteroid2 Inhaler technique is checked and is satisfactory3 Medicines are explained and understood by the patient and/or carer4 A written Self Management Plan is provided5 Treatment is in accordance with BTS and Local guidelines and appropriate to severity of condition6 Smoking cessation is discussed and recorded if appropriate7 An Asthma UK ‘After your asthma attack’ leaflet is provided8 Discuss and address potentially preventable contributors to recent exacerbation

All patients should be reviewed by GP or practice nurse within 48hrs of acute treatment , or discharge from hospital including discharge from the Emergency Department

On discharge - Educate & Follow up

Admit if any:Life threatening featureFeatures of acute severe asthma after initial treatmentPrevious near fatal asthma attack

Lower threshold for admission if:Afternoon or evening attackRecent nocturnal symptoms or hospital admissionPrevious severe attacksPatient unable to assess own condition or concern over social circumstances

Admitting to hospital

Admit If:

The stepwise management reflects the guidance given on management of asthma as outlined by the British Thoracic Society as shown in the BNF

This year the layout has been changed to a more user friendly step up step down chart

Stepwise management

Good Control

Good Control

Good Control

NHS Kirklees, NHS Calderdale and NHS Wakefield DistrictStepwise management of asthma for adults ‘An inhaler is only as good as the technique and concordance of the patient using it’

STEP 1:Occasional

relief of symptoms As

required inhaled short-

acting B2

agonist (All patients must

have)

STEP 2:Inhaled

corticosteroid (ICS)

Beclometasone or Budesonide200mcg* twice

daily(Qvar

100mcg**twice daily)

STEP 4:High dose

inhaled corticosteroid

Beclometasone or Budesonide 1000mcg twice

daily* via spacer

device or Fluticasone 500mcg twice

daily via spacer device

STEP 5:

Use daily steroid tablets in the lowest

dose providing adequate

controlMaintain high dose ICS at

2000mcg/day.* Consider other treatments (as

mentioned above) – 6 week trial period, stop

if no improvement in

symptoms. Refer patient for

specialist care

STEP 3:Long acting B2 agonist (LABA)

Formoterol 12mcg twice daily orSalmeterol 50mcg twice daily – 4

week trial initially

Beclometasone or Budesonide 400mcg twice daily* 3 month trial

If already on this dose and sub optimal control of symptoms, proceed

to next step

Oral Leukotriene Receptor Antagonist:

3 month trial

Sequential trial (3 months each) of:

Oral MR Theophylline e.g. Uniphyllin, titrate dose to the

therapeutic rangeSlow-release B2 agonist tabletsNo clinical trials indicating which of these is the best option. BTS/SIGN

asthma guidelines (2009) also support Symbicort SMART regimen in selected

patients

Poor control

Poor Control Poor

control

Good Control

Poor control

Poor Control Poor

controlGood

Control

Poor control

Poor Control Poor

controlGood

Control

Poor Control

Poor Control

Poor control including

exacerbation of asthma requiring

oral corticosteroids in the last 2 years

Poor Control

Issue Steroid safety cards

for step 4 & 5

Good Control

* For Budesonide and certain Beclometasone inhalers (see overleaf) ** Qvar, Fostair, Fluticasone need lower dose for equivalence (see overleaf)

Step 3 consider referral to Respiratory Specialist: IF Doubt about diagnosis; Asthma disrupts lifestyle ; Possible food allergy; Consideration of nebulised therapy; Consideration of maintenance prednisolone; Past asthma admission; Second opinion; Anaphylaxis; Pregnant women with worsening asthma; Asthma threatening employment; Suspected occupational asthma;

Sub optimal control: any of the below criteria• Using reliever more than 3

times weekly• Symptomatic more than 3

times weekly• Waking one night a week• Two or more courses of

rescue oral steroids in past 6 months

Inhaled corticosteroid (ICS) therapy risks:

High dose ICS (1600mcg/day beclemetasone equivalent or Flixotide 1000mcg/day) is associated with a greater risk of systemic side effects including adrenal suppression, decrease in bone mineral density, cataracts and glaucoma, diabetes mellitus and adverse psychological and behavioural effects

Goals of asthma therapy:• Maximise asthma control• Minimise number of asthma

exacerbations• Minimise treatment side

effects

Reducing treatment:

Step down should be considered

• After 12 weeks if control is achieved (and after every subsequent 12 week period).

• If control is maintained, therapy should be reduced (dose decreased by 25-50% each time) to the lowest step that maintains control

• When on combination ICS & LABA, the preferred option is to reduce does of ICS by 50% while continuing LABA. If control is maintained further reductions in ICS should be made until ona low dose, when the LABA may be stopped

• After stepping down review in 12 weeks and step up again if symptomatic

Group responsible:

Enquiries to:

Published:

Review due: (unless clinical evidence base changes)

Notes

• Select the least costly product that is suitable for an individual, within its marketing authorisation• Patient Education

- Each patient should have a clear understanding of how to recognise and deal with deterioration- An individual self-management plan is essential- Patients should have a basic understanding as to how their medication works

• Rescue courses of steroids may be required at any stage to gain control and stabilise the condition. Prednisolone 40mg once daily for at least 5 days and until recovery of PEFR and symptoms• A rescue course of steroids may indicate the need to increase regular treatment to the next step• LABA should not be used without ICS

Combination inhalers:

• Should NOT be used before step 3 of asthma therapy• May improve compliance over the combined use of the individual components as separate inhalers

Dose of inhaled corticosteroids (ICS): Table below adapted from BTS/SIGN asthma guidelines (updated

January 2012) shows equivalent doses of ICS:

Steroid, name, inhaler device and trade name

Equivalent dose

Beclometasone 200mcg

* Clenil Modulite pressurised aerosol inhaler (PAI)

200mcg

Dry Powder Inhalere.g. Easyhaler, Pulvinal, Asmabec Clickhaler, Cyclocaps

200mcg

* Qvar (PAI, Autohaler or Easi-Breathe) 100mcg

Fostair$ 100mcg

Budesonide 200mcg

Dry Powder Inhalere.g. Easyhaler, Budelin Novoliser, Pulmicort Turbohaler & Symbicort

200mcg

Fluticasone 100mcg

Pressurised aerosol inhalere.g. Flixotide Evohaler & Seretide$ Evohaler 100mcg

Dry Powder Inhalere.g. Flixotide Accuhaler, Flixotide Diskhaler & Seretide$ Accuhaler

100mcg

Mometasone 100mcg

Ciclesonide 100 – 150mcg

• Must be prescribed by brand name

$ Combinations with long acting B2 agonists (LABA): Take care prescribing these as the relative amounts of steroids and LABA differ depending on the particular product chosen.

Information on inhaler technique is available at:http://www.medicines.org.uk/guides/pages/how-to-use-your-inhaler-videoshttp://www.asthma.org.uk/how-we-help/teachers-and-healthcare-professionals/health-professionals/interactive-inhaler-demo/

For telephone review or persistent DNA’s Consider referral to a community Pharmacist for inhaler technique review as part of a targeted Medicines Use Review or New Medicine Service review.Smoking is a major trigger factor for asthma and a significant cause of poor control, reducing exposure to cigarette smoke is essential Stop Smoking advice and avoidance is vital.Manage gastro-oesophageal reflux & rhinitis as clinically appropriate, there is however, a lack of evidence that this will improve asthma control

Despite best efforts or not lots of asthma patients attend casualty costing over £50 simply for walking through the A+E doors.

Follow up all A+E attendances

Have the respiratory/asthma A+E reports passed over and get them in to see you for a Self Management Plan and Emergency Rescue Pack issuing (if needed) or to change their inhalers as per the stepwise guidelines

A&E attendances

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