A Quick Guide to the Routine Management of Asthma in
Transcript Of A Quick Guide to the Routine Management of Asthma in
Date of Preparation: June 2008 Modified: August 2015 Version 4.0
A Quick Guide to the Routine Management of Asthma in Primary Care
P IETY U K
E R E S PIR
RIMARY CAR ATO RY S O C
Primary Care Respiratory Society UK
Formerly known as General Practice Airways Group
Adapted from the 2014 BTS/SIGN Guideline for the Management of Asthma and incorporating NICE guidance on inhaled steroids, NICE Quality Standard for asthma and the recommendations of the RCP National Review of Asthma Deaths
A Quick Guide to the Routine Management of Asthma in Primary Care
Authors Ruth McArthur Practice Nurse, East Kilbride, National Training Coordinator (Scotland) for Education for Health
Iain Small GP, Peterhead Contributors The PCRS-UK wishes to thank Dr Robin Carr, Dr Stephen Gaduzo, Dr Steve Holmes, Dr Duncan Keeley, Dr Hilary Pinnock and Jane Scullion in the review and editing of this revision. Contributors to original publication Stephanie Austin, Andrew Brown, Dr Steve Holmes, Dr Raja Ramachandram, Jane Scullion, Dr Iain Small and Stephanie Wolfe
Edited on behalf of the PCRS-UK by Professor Mike Thomas
P IETY U K
E R E S PIR
RIMARY CAR ATO RY S O C
About PCRS-UK
Serving primary care for over two decades
The Primary Care Respiratory Society UK (PCRS-UK) is the UK-wide professional society supporting primary care to deliver high value patient centred respiratory care. Our ultimate vision is “optimal respiratory health for all” which we seek to achieve through:
• Campaigning to influence policy and set standards in respiratory medicine, relevant to primary care nationally and locally: the voice of primary care in respiratory medicine
• Educating primary care health professionals to deliver and influence respiratory care • Open access to best practice, evidence based clinical guidance and resources, produced
by primary care respiratory experts for primary care • Membership scheme to support the respiratory professional development and empower
primary care health professionals to provide and commission high value, patient-centred care • Promoting and disseminating real life primary care research in respiratory conditions to support policy and education activities
Our scientific journal, npj: Primary Care Respiratory Medicine, flagship annual national primary care conference and Quality Award underpin our research, campaigning and education work.
The PCRS-UK is a membership organisation. To learn more about the full range of membership services and programmes or for information on how to join please visit our website at http://www.pcrs-uk.org.
Address for correspondence: PCRS-UK, Unit 2 - Warwick House, Kingsbury Road Curdworth, Warwicks, B76 9EE Telephone: +44 (0)1675 477600 Facsimile: + 44 (0)121 336 1914 Email: [email protected] Website: http://www.pcrs-uk.org
The Primary Care Respiratory Society UK is a registered charity (Charity No: 1098117) and a company registered in England and limited by guarantee (Company No: 4298947) VAT Registration Number: 866 154309.
The PCRS-UK is grateful to GSK for providing an educational grant to support the original publication of this document
Copyright 2015 Primary Care Respiratory Society UK. All rights reserved. Details correct at the time of publication This publication and the individual contributions in it are protected under copyright of the PCRS-UK. See http://www.pcrs-uk.org/website-terms-and-conditions for a list of terms and conditions of use of PCRS-UK publications
Notice: No responsibility is assumed by the publisher for any injury or damage to persons or property as a matter of products liability, negligence, or otherwise, or from any use or operations of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in medical sciences, in particular, independent verification of diagnoses and drug dosages should be made.
Content
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Aim of asthma management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Diagnosis of asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Diagnosis in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Diagnosis in adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Monitoring asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Patient education and self-management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Pharmacological management of asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Primary Care Review - Organisation and delivery of care . . . . . . . . . 19 Difficult asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Asthma in adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Guidance for healthcare professionals on inhaled corticosteroids in adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 PCRS-UK Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Introduction
More than 3.4 million people in the UK are currently being treated for asthma1 yet despite proven treatments there remains a high morbidity from this condition with rising numbers of emergency admissions. Many of these could be avoided with the correct management.
We still have deaths from asthma with 46% of cases having avoidable risk factors identified in the National Review of Asthma Deaths.2 It is therefore important that healthcare professionals offer the best available management tailored to individual patients’ needs. Guidelines can assist us in our care management and treatment of this common problem.
This ‘Quick Guide’ to the routine management of asthma in primary care is based on the British Thoracic Society (BTS) and Scottish Intercollegiate Guideline Network (SIGN) British Guideline on the Management of Asthma, May 2008, revised edition published October 20143 https://www.brit-thoracic.org.uk/guidelines-and-qualitystandards/asthma-guideline/ supported by the recommendations of the Royal College of Physicians National Review of Asthma Deaths2 and the guidance published by NICE on the use of inhaled steroids in the management of asthma TA131 and TA1384 and the NICE Quality Standard for Asthma.5
This Quick Guide also takes into consideration the approach proposed by NICE in the draft guideline on the diagnosis and monitoring of asthma6 it recently put out for consultation. At various points we allude to what NICE recommended for your information.
It is intended as an ‘aide memoire’ for primary care health professionals.
The PCRS-UK is grateful to BTS/SIGN for permitting the adaptation of figures and text from the Guideline to support this publication. Additional tools and resources including slides and case studies to support the guideline are also available on the BTS website available at http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
1
Aim of asthma management
The aim of asthma management is disease control, this is defined as: • No daytime symptoms • No night time symptoms due to asthma • No need for rescue medication • No exacerbations • No limitations on activity including exercise • Normal lung function - in practical terms FEV1 and/or PEF >80% predicted or best
with minimal side effects4,7
2
Diagnosis of asthma
The NICE Quality Standard for Asthma statement 1 recommends that all people with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance.5 The approach proposed more recently by NICE6 put greater emphasis on objective testing to support diagnosis than BTS/SIGN does. This is important where diagnosis is uncertain. This is a direction of travel that clinicians may want to consider. The range of objective tests that NICE suggested includes: spirometry, bronchodilator reversibility testing, FeNO (fractional exhaled nitric oxide) testing and bronchial hyperresponsiveness challenge testing with histamine and methacholine. Importantly, NICE pointed out that there is no single gold standard objective test for asthma and suggested it can be useful to do more than one.
3
Diagnosis in children (See Figure 1, Page 7)
Spirometry and peak flow recording can be hard in younger children, but should be attempted and recorded in all if possible. Focus the initial assessment in children suspected of having asthma on: • Presence of key features in the history and examination • Careful consideration of alternative diagnoses
Clinical features that increase the probability of asthma • More than one of the following symptoms - wheeze, cough, difficulty breathing,
chest tightness: o particularly if these are frequent and recurrent; o are worse at night/early morning o occur in response to are worse after exercise or other triggers such as exposure
to pets, pollens, cold or damp air, or with emotion, laughter o occur apart from colds • Personal history of atopic disease • Family history of atopic disease and/or asthma • Widespread wheeze heard on auscultation • History of improvement in symptoms or lung function in response to adequate therapy
The diagnosis of asthma in children aged under 5 yrs is a clinical one. It is based on recognising a characteristic pattern of episodic symptoms in the absence of an alternative explanation. Confirmation by objective demonstration of peak flow or spirometry reversibility is desirable in children old enough to perform these tests. Where diagnostic doubt persists referral for specialist assessment using tests for airway inflammation should be considered.
With a thorough history and examination, a child can usually be classified into one of three groups:
High probability of asthma - diagnosis of asthma is likely • Start a trial of treatment • Review and assess response after an agreed period, no longer than 3 months • Reserve further testing for those with poor response
4
A Quick Guide to the Routine Management of Asthma in Primary Care
P IETY U K
E R E S PIR
RIMARY CAR ATO RY S O C
Primary Care Respiratory Society UK
Formerly known as General Practice Airways Group
Adapted from the 2014 BTS/SIGN Guideline for the Management of Asthma and incorporating NICE guidance on inhaled steroids, NICE Quality Standard for asthma and the recommendations of the RCP National Review of Asthma Deaths
A Quick Guide to the Routine Management of Asthma in Primary Care
Authors Ruth McArthur Practice Nurse, East Kilbride, National Training Coordinator (Scotland) for Education for Health
Iain Small GP, Peterhead Contributors The PCRS-UK wishes to thank Dr Robin Carr, Dr Stephen Gaduzo, Dr Steve Holmes, Dr Duncan Keeley, Dr Hilary Pinnock and Jane Scullion in the review and editing of this revision. Contributors to original publication Stephanie Austin, Andrew Brown, Dr Steve Holmes, Dr Raja Ramachandram, Jane Scullion, Dr Iain Small and Stephanie Wolfe
Edited on behalf of the PCRS-UK by Professor Mike Thomas
P IETY U K
E R E S PIR
RIMARY CAR ATO RY S O C
About PCRS-UK
Serving primary care for over two decades
The Primary Care Respiratory Society UK (PCRS-UK) is the UK-wide professional society supporting primary care to deliver high value patient centred respiratory care. Our ultimate vision is “optimal respiratory health for all” which we seek to achieve through:
• Campaigning to influence policy and set standards in respiratory medicine, relevant to primary care nationally and locally: the voice of primary care in respiratory medicine
• Educating primary care health professionals to deliver and influence respiratory care • Open access to best practice, evidence based clinical guidance and resources, produced
by primary care respiratory experts for primary care • Membership scheme to support the respiratory professional development and empower
primary care health professionals to provide and commission high value, patient-centred care • Promoting and disseminating real life primary care research in respiratory conditions to support policy and education activities
Our scientific journal, npj: Primary Care Respiratory Medicine, flagship annual national primary care conference and Quality Award underpin our research, campaigning and education work.
The PCRS-UK is a membership organisation. To learn more about the full range of membership services and programmes or for information on how to join please visit our website at http://www.pcrs-uk.org.
Address for correspondence: PCRS-UK, Unit 2 - Warwick House, Kingsbury Road Curdworth, Warwicks, B76 9EE Telephone: +44 (0)1675 477600 Facsimile: + 44 (0)121 336 1914 Email: [email protected] Website: http://www.pcrs-uk.org
The Primary Care Respiratory Society UK is a registered charity (Charity No: 1098117) and a company registered in England and limited by guarantee (Company No: 4298947) VAT Registration Number: 866 154309.
The PCRS-UK is grateful to GSK for providing an educational grant to support the original publication of this document
Copyright 2015 Primary Care Respiratory Society UK. All rights reserved. Details correct at the time of publication This publication and the individual contributions in it are protected under copyright of the PCRS-UK. See http://www.pcrs-uk.org/website-terms-and-conditions for a list of terms and conditions of use of PCRS-UK publications
Notice: No responsibility is assumed by the publisher for any injury or damage to persons or property as a matter of products liability, negligence, or otherwise, or from any use or operations of any methods, products, instructions or ideas contained in the material herein. Because of rapid advances in medical sciences, in particular, independent verification of diagnoses and drug dosages should be made.
Content
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Aim of asthma management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Diagnosis of asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Diagnosis in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Diagnosis in adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Monitoring asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Patient education and self-management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Pharmacological management of asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Primary Care Review - Organisation and delivery of care . . . . . . . . . 19 Difficult asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Asthma in adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Guidance for healthcare professionals on inhaled corticosteroids in adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 PCRS-UK Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Introduction
More than 3.4 million people in the UK are currently being treated for asthma1 yet despite proven treatments there remains a high morbidity from this condition with rising numbers of emergency admissions. Many of these could be avoided with the correct management.
We still have deaths from asthma with 46% of cases having avoidable risk factors identified in the National Review of Asthma Deaths.2 It is therefore important that healthcare professionals offer the best available management tailored to individual patients’ needs. Guidelines can assist us in our care management and treatment of this common problem.
This ‘Quick Guide’ to the routine management of asthma in primary care is based on the British Thoracic Society (BTS) and Scottish Intercollegiate Guideline Network (SIGN) British Guideline on the Management of Asthma, May 2008, revised edition published October 20143 https://www.brit-thoracic.org.uk/guidelines-and-qualitystandards/asthma-guideline/ supported by the recommendations of the Royal College of Physicians National Review of Asthma Deaths2 and the guidance published by NICE on the use of inhaled steroids in the management of asthma TA131 and TA1384 and the NICE Quality Standard for Asthma.5
This Quick Guide also takes into consideration the approach proposed by NICE in the draft guideline on the diagnosis and monitoring of asthma6 it recently put out for consultation. At various points we allude to what NICE recommended for your information.
It is intended as an ‘aide memoire’ for primary care health professionals.
The PCRS-UK is grateful to BTS/SIGN for permitting the adaptation of figures and text from the Guideline to support this publication. Additional tools and resources including slides and case studies to support the guideline are also available on the BTS website available at http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
1
Aim of asthma management
The aim of asthma management is disease control, this is defined as: • No daytime symptoms • No night time symptoms due to asthma • No need for rescue medication • No exacerbations • No limitations on activity including exercise • Normal lung function - in practical terms FEV1 and/or PEF >80% predicted or best
with minimal side effects4,7
2
Diagnosis of asthma
The NICE Quality Standard for Asthma statement 1 recommends that all people with newly diagnosed asthma are diagnosed in accordance with BTS/SIGN guidance.5 The approach proposed more recently by NICE6 put greater emphasis on objective testing to support diagnosis than BTS/SIGN does. This is important where diagnosis is uncertain. This is a direction of travel that clinicians may want to consider. The range of objective tests that NICE suggested includes: spirometry, bronchodilator reversibility testing, FeNO (fractional exhaled nitric oxide) testing and bronchial hyperresponsiveness challenge testing with histamine and methacholine. Importantly, NICE pointed out that there is no single gold standard objective test for asthma and suggested it can be useful to do more than one.
3
Diagnosis in children (See Figure 1, Page 7)
Spirometry and peak flow recording can be hard in younger children, but should be attempted and recorded in all if possible. Focus the initial assessment in children suspected of having asthma on: • Presence of key features in the history and examination • Careful consideration of alternative diagnoses
Clinical features that increase the probability of asthma • More than one of the following symptoms - wheeze, cough, difficulty breathing,
chest tightness: o particularly if these are frequent and recurrent; o are worse at night/early morning o occur in response to are worse after exercise or other triggers such as exposure
to pets, pollens, cold or damp air, or with emotion, laughter o occur apart from colds • Personal history of atopic disease • Family history of atopic disease and/or asthma • Widespread wheeze heard on auscultation • History of improvement in symptoms or lung function in response to adequate therapy
The diagnosis of asthma in children aged under 5 yrs is a clinical one. It is based on recognising a characteristic pattern of episodic symptoms in the absence of an alternative explanation. Confirmation by objective demonstration of peak flow or spirometry reversibility is desirable in children old enough to perform these tests. Where diagnostic doubt persists referral for specialist assessment using tests for airway inflammation should be considered.
With a thorough history and examination, a child can usually be classified into one of three groups:
High probability of asthma - diagnosis of asthma is likely • Start a trial of treatment • Review and assess response after an agreed period, no longer than 3 months • Reserve further testing for those with poor response
4