The Problem with Asthma Ruth McArthur, Practice Nurse/Trainer
Getting the diagnosis right!
Asthma or COPD? History taking is key Both are inflammatory conditions with different mechanisms & mediators Diagnostic tests help confirm the diagnosis in both
Sometimes patients don t fit in boxes They have more than one disease They have shared common risk factors They have shared presenting symptoms The patient has never read the textbook
Confirming the diagnosis
Treatment trials In adults a 6-8 week trial of 200mcg of inhaled beclometasone (or equivalent) twice daily Or In patients with significant airflow obstruction there may be a degree of inhaled corticosteroid resistance and a treatment trial with 30mgs of oral prednisolone for 2 weeks is preferred (rarely given in children) BTS/SIGN Guideline on the Management of Asthma, April 2014, revised edition : available from http://www.britthoracic.org.uk/portals/0/clinical%20information/asthma/guidelines/asthma_fullguideline_2014.pdf
The modern asthma paradox Greater understanding of pathogenesis Wide range of evidence based interventions Greater awareness of importance of prevention Proliferation of evidence based guidelines Improved health professional education Better educated patients and general public Undetected disease : case finding Poorly controlled and monitored disease Continued unacceptable levels of morbidity Unnecessary mortality Avoidable use of emergency care & hospital admissions crisis! Acute exacerbations still feature
Problems: The Health Care Professional Inadequate understanding of disease aetiology Not making the diagnosis early enough Inaccurate assessment of disease severity Poor or unstructured communication with patients Lack of time Holgate et al, 2006 BMC Pulmonary medicine 6(suppl 1):S2
Some possible explanations Patients and families not recognising symptoms of asthma Patients treat asthma as an acute episodic illness rather than a chronic disease HCPs assume patients will put aside their own beliefs, concerns & goals to follow the treatment plan Lack of emphasis on what really works in patient education: we frequently give information but concentrate less on how we deliver the messages.
Problems: The patient Underestimates symptoms Under usage of prophylaxis Tolerates poor symptom control Has low expectations of therapy Confused/lacks knowledge of correct drug Poor adherence. Holgate et al, 2006 BMC Pulmonary medicine 6(suppl 1):S2
Recognising symptoms Asthma symptoms are variable, patients and their family members, need to recognise symptoms and adjust medications at home according to the clinician and patient s assessment.
Worsening symptoms Needing more and more reliever treatment Waking at night with coughing, wheezing, shortness of breath or a tight chest Having to take time off work because of asthma symptoms Feeling that they cannot keep up with their normal level of activity or exercise
Symptoms on activity 3x week
Night symptoms x1 week
Reasons for poor asthma control Patients with asthma and rhinitis: treating allergic rhinitis lowers the risk of attending accident and emergency departments and of being hospitalized for asthma Cigarette smoking may reduce effectiveness of inhaled corticosteroids Exposure to allergens Treating allergic rhinitis in patients with co-morbid asthma: the risk of asth-ma-related hospitalizations and emergency department visits. Crystal-Peters J et al. J Allergy Clin Immunol 2002;109:57-62. Influence of cigarette smoking on inhaled corticosteroid treatment in mild asthma. Chalmers GW et al. Thorax 2002;57:226-230
Assess asthma control RCP 3 Questions 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 or breathlessness)? 3) Has your asthma interfered with your usual activities (eg housework or work)? British Thoracic Society-Scottish Intercollegiate Guideline Network. British Guideline on the Management of Asthma. Revised April 2014
Asthma control test 1 During the past 4 weeks: 1. How often did your asthma prevent you from getting as much done at work, school or home? 2. How often have you had shortness of breath? 3. How often did your asthma (wheezing, coughing, chest tightness, shortness of breath) wake you up? 4. How often have you used your reliever inhaler? 5. How would you rate your asthma control?
Other indicators to assess control: Frequent prescriptions
NRAD A UK initiative, funded by NHS England Scottish Government Multi-disciplinary multi-agency steering group Run by Royal College of Physicians (London) Commissioned to an investigative team RCP Why asthma kills. Report of the NRAD May 2014
NRAD Report 2014 Range of people who died 4-97yrs 69% diagnosed > 15yrs Most common trigger of attacks: Respiratory tract infections, followed by hay fever/allergic rhinitis, and other allergic factors such as foods and drugs 6 of the patients who died had a history of anaphylaxis 41% had a history of allergy In children/young people age 10-19yrs 78% died between May and September supporting earlier research that most deaths occur during the summer months due to allergy
Key findings Can be sub-divided into Medical and professional care Prescribing and medicines use Patient factors, perception of risk of poor control
Medical and professional care Personalised Asthma Action Plans were held by 23% of those studied No review in the previous year in 43% of those studied Exacerbation risk factors documented in half of those studied Severe asthma present in 39%, moderate in 49%, mild in 9% (not always documented and likely to be inaccurate) Avoidable death if guidelines applied in 46% Divided into: lack of expertise (17%) lack of knowledge (25%) RCP Why asthma kills. Report of the NRAD May 2014
Prescribing and medicine use Excess reliever prescribing: 39% of those with accessible records had received >12 SABA in previous 12 months, 6 people >50 Under-prescribed preventers: 38% fewer than 4/12months, 80% fewer than 12 (or full dose) Inappropriate use of LABA: 14% of those studied were on LABA by single component inhaler, 5 people on LABA but no ICS RCP Why asthma kills.report of the NRAD May 2014
What is frequent use of a reliever? 2 or more canisters per month = >10-12 puffs OD, defined as a marker of poorly controlled asthma
Inhaled Corticosteroid use and the prevention of death from asthma ICS = Inhaled corticosteroid. Suissa S, et al. N Engl J Med. 2000;343:332-336.
NRAD Recommendations Every hospital and GP practice should have a designated named clinician for asthma services Better monitoring of asthma control, where loss of control is identified, immediate action is required, treatment change and follow-up Better education for nurses, doctors, patients and carers to make them aware of risks, the need to be able to recognise signs of poor control and know what to do during an attack All patients should be provided with a personal action asthma plan (PAAP), which helps them to identify if their asthma is getting worse and tells them what to do and when to access medical help.
Actions during a review Record triggers in the medical records and PAAP Review control at each asthma review Inhaler technique should be routinely undertaken and documented Non-adherence should be identified and monitored Smoking record should be documented and support for smoking cessation Urgent review for all with more than 12 short-acting reliever inhalers in the previous 12 months Patients should not be prescribed a long acting beta agonist alone (should be in combination with an inhaled corticosteroid Royal College of Physicians (2014) Why Asthma Still Kills The National Review of Asthma Deaths
Background Excellence in medical treatment is worthless if the patient doesn t take the medicine Compliance is closely linked to clinician communication and patient education Most clinicians believe they are good communicators, but most patients feel clinician communication and education is inadequate.
Impact on Patients There are discrepancies between expectations and patients satisfaction with the doctor/nurse-patient relationship: Patients would like to receive more clear explanations about possible side effects and risks of their medicines Patients would like to be consulted with regard to the choice of the inhaler device Partridge et al, Prim Care J,20011
Fears about asthma medicines Research from 445 families with a child with asthma: 39% Believe medicines are addictive 36% Believe medicines are not safe to take over a long period of time 58% Believe regular use will reduce effectiveness Wasilewski Y, Clark NM, Evans D, Levison MJ, Levin B, Mellins RB. Factors associated with emergency department visits by children with asthma and implications for health education. American Journal of Public Health, 86(10): 1410-1415, October 1996.
Address adherence as a routine part of care instead of waiting for your patients to fail! We need to view adherence along a continuum without a succeed or fail mentality If they feel more supported they will be more honest Agree coping strategies together that are achievable What systems do you have at home to help you remember to take your medicines? Have you been taking all your medicines?
Patient acceptance: making the link1,2 Accepting they are an individual who requires medication may be difficult for some people and therefore: May avoid activities that bring on symptoms Think about the disorder and its treatment I don t think my asthma affects my ability to play sport... I just prefer playing in goal to running around the field 1. Juniper, 2003; 2. Rollnick et al, 2005
Patient acceptance: making the link1,2 Where the benefits of treatment are not immediate or obvious, patients can become ambivalent This is a particular problem for preventive treatment What s the point of taking my brown inhaler? 1. Juniper, 2003; 2. Elwyn et al, 2003
Patient involvement in decision making Patient involvement is particularly important for managing long-term conditions 1 Patient involvement increases the effectiveness of treatment and improves outcomes 2 4 Treatment should be based on negotiated agreement 4 1. Department of Health, 2006; 2. Weston WW. CMAJ 2001; 165: 438 439. 3. Towle A, Godolphin W. BMJ 1999; 319: 766 771; 4. Elwyn et al, 2003
Time and other barriers Professionals trained in communication do not take significantly longer when seeing patients 1 Suggesting/providing resources and information increases likelihood of patient involvement 2 Poor control of asthma leads to increased emergency attendance and consultation time 3 Participants given appropriate education about their condition make more effective use of healthcare resources, requiring fewer consultations, A&E attendances and hospital admissions, and greater use of pharmacy services 4 1. Cabana et al. 2Department of Health, Self Care 2006. 3.Barnes PJ et al. Eur Respir J 1996; 9: 636 642. 4. Commission for Healthcare Audit and Inspection. Clearing the air, 2006.
Concordance Four most important factors influencing compliance: Clinician/patient relationship Patients understanding of disease Current beliefs and perception of illness Active role in illness management Mork, Van Ganse, Osman, 2003 Primary Care Respiratory Journal
Poorly controlled asthma Check inhaler technique Eliminate triggers Compliance with therapy check computer prescriptions? Smoking status Review the diagnosis Step up therapy.
Vital variants in asthma The drug The device The patient treatment Important to get them all right!
Inhaler technique Up to 90% of patients show incorrect inhaler technique in clinical studies Techniques are significantly improved by brief instruction by trained HCP However, 25% of patients have never received verbal inhaler instruction Only 11% of patients receive follow-up assessment and education Basheti A et al, Patient Edu Councs 2008 Jul; 72 (1): 26-33
Examples of poor technique www.simplestepseducation.co.uk
Types of Inhaler Device? Think of inhalers in 2 categories: Aerosol: Liquid medication or Dry powder preparation Effectiveness of the inhaler depends on: Patient co-ordination Particle size Effect of resistance of inhaler device MDI < DPI Inspiratory Flow www.simplestepseducation.co.uk
So how would YOU inhale? Quick test of how you would inhale through commonly-used devices 1. MDI 2. Dry Powder Inhaler (DPI) Need to: 1. Simulate resistance of device 2. Measure speed of inhalation www.simplestepseducation.co.uk
How would you breathe in for these? www.simplestepseducation.co.uk
How about these? www.simplestepseducation.co.uk
Inhaler technique Check at each review Check before increasing medication
What makes a good asthma review Is asthma knowledge correct? Assess asthma control RCP OR ACT questionnaires Enquire about reliever/oral steroid use Enquire about associated symptoms and/or new triggers eg Rhinitis, house move, occupation Smoking status Check peak flow rate. - Compare with previous best
Asthma self management education and written action plans Cochrane review demonstrates use of patient education and self-management associated with: Reduction in unscheduled GP visits Reduction in number of patients who were hospitalised Reduction in number of days off work or school Reduction in nocturnal asthma Improvements in compliance and reduction in deaths also demonstrated Gibson PG, Couglan J, Wilson AJ et al. Cochrane Library 2000 Abramson MJ, Bailey MJ, Couper FJ et al. Am J Respir Crit Care Med 2001
Self management support will one size fit all? To be activated to be effective self managers our patients require a high level of knowledge, skills and confidence Around 40% of patients are likely to need additional support to self manage successfully By increasing activation step by step our patients can experience small successes and steadily build confidence in their ability to self manage Hibbard et al Health Serv Res 2005 Hellmans M abstract PCRJ 2012
Educate and support patients nd practice team to reduce risk of admission patients and
So that s the challenge... Do we know who our patients are? Do we tell them about their disease? Do we ask them about the impact of their disease? Do we know how best to treat them? Do we tailor their treatment to meet their individual needs? Do we encourage self management?
Goals of asthma management No/minimal symptoms No/minimal serious attacks Require little reliever medication Have productive, physically active lives Have normal or near normal lung function
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