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Management of chronic asthma in adults
GP Registrar, Merchant Street Practice, Tower Hamlets, London
E-mail: pannahussain{at}hotmail.com
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Abstract |
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 TOP Abstract The GP Curriculum and...Aims of treatmentReviews and monitoringSevere asthma symptoms and...Drug therapySpacersDrugsAdd-on therapyReferences |
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Asthma is a chronic inflammatory disease of the airways. It is characterized by recurrent episodes of dyspnoea, wheeze and cough caused by reversible airways obstruction. Three factors are responsible for the airways narrowing: bronchial muscle contraction, mucosal swelling/inflammation and increased mucous production (Fig. 1). About 10–15% of the UK population have asthma and the number appears to be growing although there is some difficulty understanding why. It affects 1 in 20 adults and 1 in 10 children. Approximately 5.1 million people are currently being treated for asthma in the UK.
Primary care management GPs in training must learn how to manage primary contact with patients who have a respiratory problem, coordinate care of respiratory patients with other primary health-care professionals and apply the guidelines for emergency admission of patients with an acute exacerbation of asthma, to help reduce preventable deaths. The knowledge base Respiratory problems are the most common reason for general practice consultation and emergency medical hospital admission. The management of asthma is a key competence for general practice. GPs in training should be involving patients fully in the management of their respiratory condition, for example negotiate a patient self-management plan for asthma in partnership with the patient. Specific problem-solving skills A GP in training must be able to use knowledge of the relative prevalence of respiratory problems to aid diagnosis. They should recognize that there are groups of patients that are at higher risk of acquiring respiratory infection. GPs in training should be able to explain the role of serial peak flow measurement, reversibility testing and spirometry in the diagnosis of asthma and intervene urgently when patients present with a respiratory emergency. Community orientation and a holistic approach GPs in training must understand the current population trends in the prevalence of allergic and respiratory conditions in the community. They should appreciate the importance of the social and psychological impact of respiratory problems on the patient's family, friends, dependants and employers.
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Aims of treatment |
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TOPAbstractThe GP Curriculum and...Aims of treatmentReviews and monitoringSevere asthma symptoms and...Drug therapySpacersDrugsAdd-on therapyReferences |
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The aims of asthma treatment are:
- To control the disease and minimize impact on activities of daily living
- To prevent exacerbations and hospitalizations related to poorly controlled asthma
- To control asthma symptoms by regularly reviewing treatment so that the lowest possible dose of inhaled steroid is used and treatment is stepped down
A GP or a nurse with specialist training can manage most asthma in primary care. Good-quality asthma care is rewarded in the Quality and Outcomes Framework. A register should be kept of all asthma patients to enable follow-up and facilitate audit, recording of an asthma review, smoking status and cessation advice in the last 15 months and influenza vaccination during the previous winter (Table 1).
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Control of asthma is defined as
- No day-time symptoms
- No night-time awakening because of symptoms
- No need for rescue medication
- No exacerbations
- No activity limitation including exercise
The fact that someone is prescribed a medicine does not necessarily mean that this medication has been dispensed by the pharmacist or is actually being taken. It is important to try and ascertain the patient's current treatment and compliance. Recording asthma ‘steps’ is helpful in both the assessment and management of asthma patients (Table 2).
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Reviews and monitoring |
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Patients should be reviewed at least annually or more frequently if treatment is being stepped up or down.
- Check symptoms since last being seen using objective measures such as the revised Jones morbidity index or the Royal College of Physicians' 3 questions (Box 1)
- Record patient's smoking status and ask about smoking in other household members
- Medication review with the patient
- Offer influenza and pneumococcal vaccination to all patients with asthma
- Review objective measures of respiratory function, for example peak expiratory flow rate (PEFR)
- Check inhaler technique. If a patient is unable to use a device satisfactorily, an alternative should be found.
- Discuss management goals, patient education and set a date for the next review. Formulate written action plans that indicate when asthma is worsening and action to be taken in those circumstances.
| Box 1. Objective measures of asthma symptoms: morbidity categories correlate with lung function The Revised Jones Morbidity Index: During the last 4 weeks:
RCP 3 questions: In the last month:
NO to all questions = low morbidity 1xYES answer = medium morbidity Two or three YES answer = high morbidity Note: These questionnaires are not designed for use during an acute attack.
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The Revised Jones Morbidity Index is reproduced with permission from Dr Kevin Jones. RCP questions Copyright © 1999 Royal College of Physicians. Reproduced with permission.
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Severe asthma symptoms and depression |
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Around 2.6 million people have severe asthma symptoms in the UK and it is estimated that as many as a third of people with a long-term medical condition experience symptoms of depression.
As health professionals, we need to ensure that, as well as supporting people with asthma to manage their symptoms effectively, they also consider the psychological effects of living with asthma.
Common symptoms of depression in people with long-term conditions include:
- Persistent sadness that lasts for more than 2 weeks
- Lack of interest in family and other close relationships
- Change in eating habits—eating more or less than usual
- Change in habits—sleeping more or less than usual
- Loss of energy/fatigue
- Sense of hopelessness/helplessness
- Lack of interest in taking medicines/managing illness
- Missing doctor's appointments/sleeping
- Worsening of chronic illness symptoms (which can signal an increased vulnerability to depression)
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Drug therapy |
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The model of modern treatment is expressed in the new edition of the British Thoracic Society/Scottish Intercollegiate Network British Guideline on the Management of Asthma published in the May 2008 issue of Thorax. A stepwise approach to drug treatment should be used (Fig. 2). Treatment should be guided by the initial severity of symptoms and started at the most appropriate step. The aim is to gain symptom control early and then to step down treatment.
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Stepping down treatment should be gradual at intervals of more than 3 months because different patients deteriorate at different rates. Patients should be placed on the lowest dose of inhaled steroid controlling symptoms. When the dose of steroid is stepped down, it should be reduced by 25–50% each time.
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Spacers |
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A spacer is a large plastic container with a mouthpiece at one end and a hole for the aerosol inhaler at the other (Fig. 3). Spacers only work with an aerosol inhaler. Spacers are important because they help to direct the delivery of the treatment to the lungs, resulting in:
- Less oro-pharyngeal side effects with inhaled steroids used with a spacer
- No need to coordinate actuation with inhalation
- There is more time for evaporation of propellant so a larger amount of active drug is deposited in the lungs
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Choice
Most spacers are of large volume, around 750 ml, made of plastic and they are inconvenient to carry around. Smaller spacers exist but are probably less effective although this is disputed. Large spacers usually have a valve system (Nebuhaler and Volumatic) that permits the drug to stay in suspension while it is inhaled. The dose may be reduced by accumulation of electrostatic charge so that the drug is absorbed on to the plastic. This can be avoided by periodic washing of the device in soapy water or detergent. Aero chambers are widely available, easy to use and portable.
Use of spacer devices
As soon as the inhaler is actuated, the drug should be inhaled from the spacer immediately because the effect of the drug is short lived. To prevent build-up of electrostatic charge, which can affect drug delivery, spacers should be washed and air dried weekly. They should also be replaced 6–12 monthly.
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Drugs |
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Short-acting beta-2 agonists
Short acting beta 2 agonists, such as salbutamol and terbutaline, cause relaxation of bronchial smooth muscle. They have a duration of action of 3-5 hours. Inhaled preparations are more effective than oral preparations. Prescribe as 1-2 puffs as needed. Advise patients to seek help if symptoms are not controlled or return within three hours. If a patient is using bronchodilators more than once daily, consider commencing prophylactic treatment. Using bronchodilators alone in this situation is associated with worsening of asthma and even asthma deaths. Patients using large amounts of bron chodilator (more than one cannister per month or more than 10-12 puffs per day) are poorly controlled and should have their prophylactic medication reviewed. Nebulizer treatment should be considered if high doses of inhaled steroids are needed.
Inhaled corticosteroids
Inhaled corticosteroids are very effective preventers for achieving treatment goals. They need to be used regularly for maximum benefit. Symptoms are alleviated 7–10 days after treatment is initiated. If patients are on high-dose steroids, ensure that they carry a ‘steroid card’. Inhaled steroids may be beneficial even for patients with mild asthma. Consider if
- The patient has had an asthma exacerbation in the past two years
- Using beta-2 agonists greater than three times per week
- Has symptoms greater than three times per week or nocturnal symptoms greater than one night per week
Oral steroids
These are often started at a high dose (40–50 mg od for five days or until necessary) to ease a severe or prolonged attack of asthma. Steroid tablets are good at reducing the inflammation in the airways. For example, a severe attack may occur in association with a cold or chest infection.
Many patients are worried about taking steroid tablets. However, a short course of steroid tablets is unlikely to cause side effects. Most of the side effects caused by steroid tablets occur if they are taken on a long term basis (more than several months) or if the patient has taken frequent short courses of high doses of steroid.
Steroid cards should be carried at all times by patients who are on oral steroids or high-dose inhaled steroids. These cards inform other practitioners that a patient is on steroids and also give the patient advice regarding use of steroids and the risk of infection.
| Box 2. Withdrawal of corticosteroids The CSM has recommended that gradual withdrawal of systemic corticosteroids should be considered in those whose disease is unlikely to relapse and have
Systemic corticosteroids may be stopped abruptly in those whose disease is unlikely to relapse and who have received treatment for 3 weeks or less and who are not included in the patient groups described above. During corticosteroid withdrawal, the dose may be reduced rapidly down to physiological doses (equivalent to prednisolone 7.5 mg daily) and then reduced more slowly. Assessment of the disease may be needed during withdrawal to ensure that relapse does not occur.
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Add-on therapy |
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Longer acting beta-2 agonists (LABA)
Inhaled preparations of long-acting beta-2 agonsists (LABA), such as salmeterol 50-100mcg bd, improve both symptoms and measured lung function. They are particularly useful for night-time symptoms. Slow-release tablets have a similar effect but side effects are greater. Their usual duration of action is 12 hours. LABA should not be used for the relief of acute attacks.
It is recommended that for most individuals, LABA inhalers should not be used alone, but in combination with steroid inhalers in those asthmatics who are not well controlled by steroid inhalers alone. This may be a more effective alternative to increasing the corticosteroid dose. A series of clinical trials has shown that inhaled LABAs, salmeterol and formoterol, when administered to patients who are already taking inhaled corticosteroids but whose asthma is poorly controlled, may produce greater improvements in pulmonary function and symptom control than would be obtained by doubling the dose of inhaled corticosteroid.
Combinations of a LABA and a inhaled corticosteroid are now available in single inhalers that combine steroids and a long-acting beta-2 agonist. For example, Seretide contains salmeterol and fluticasone and Symbicort contains formoterol and budesonide.
Theophylline
Theophylline improves lung function and symptoms. However, it has a narrow therapeutic range and toxicity and side effects are common. Side effects include cardiovascular symptoms, gastrointestinal disturbance and central nervous system symptoms. The optimum plasma concentration is 10-20 mg/l. Prescribe slow-release theophylline by brand name as different branded preparations vary in their bioavailability.
Leukotriene receptor antagonists
Leukotriene receptor antagonists, such as Montelukast, provide relief from symptoms and decrease exacerbations. They may be particularly useful for patients with concomitant symptoms of chronic rhinitis
Sodium cromoglycate and nedocromil sodium
There is some evidence that sodium cromoglycate and nedocromil sodium are effective for asthma management in adults. Nedocromil sodium is probably more effective than sodium cromoglycate.
Delivery of inhaled medication
Drug delivery by inhalation of aerosols or powders has the advantages of achieving high drug concentrations in the airways and reducing the risk of systemic adverse effects. A variety of delivery devices are available:
- Pressurized metred dose inhalers (pMDIs)
- Breath actuated pMDIs (e.g. Autohaler)
- Dry powder inhalers such as Accuhaler, Diskhaler, Rotahaler, Spinhaler and Turbuhaler
Whichever device is chosen, its use should be explained carefully to the patient and the patient's technique checked regularly.
Nebulizers
Nebulizers are not available on NHS prescription in England and Wales. Nebulizers convert a solution of medication into aerosol form to allow easy inhalation. They are used to deliver higher doses of drug in a shorter period of time than is possible with inhalers. Indications for the use of a nebuliser include:
- Acute asthma exacerbations and/or regular treatment of asthma
- Antibiotic treatment—for patients with chronic respiratory infections, for example bronchiectasis and cystic fibrosis
- Palliative care—to help treatment of breathlessness and cough
Buying a Nebulizer
If hospital consultants decide that a nebulizer is necessary, they can apply for NHS funding to provide one, but they may not always get the funding. This means that some people have to buy their own nebulizer. If patients do have to buy one, most manufacturers sell them by mail order. They can also provide information about a local agent who will supply them. Pharmacists may also be able to order them, but they may only offer one model. If patients are considering buying a nebulizer, they ought to discuss this with their GP or hospital consultant. It is important that patients have their nebulizer serviced regularly, so this needs to be looked at before buying. Other factors that should be considered when buying a nebuliser include:
- Does the price quoted include everything that is needed? Some may charge extra for postage and packing or for parts such as mouthpieces or masks
- Nebulizers are not exempt from value added tax (VAT). However, if a patient has been recommended to buy a nebulizer by their doctor, they can qualify for VAT exemption. The manufacturer can explain how patients can claim VAT at zero rate for their nebulizer. Pharmacies and GP surgeries that order nebulizers are not usually exempt from VAT
- Patients need to make sure that they are clear about how often the compressor needs servicing and how often the filters, tubing and other parts need changing
- How heavy is the nebulizer, what are the running costs, how big is it and how long is the warranty for?
Non-pharmacological measures
- In all cases, when reviewing the treatment of a patient with asthma, it is important to consider non-pharmacological measures that may help.Smoking—smoking may exacerbate or trigger symptoms of asthma and patients should be advised to stop
- Weight—there is some evidence to suggest that weight reduction in obese patients results in better controlled asthma
- Allergen avoidance—there is little evidence that decreasing house dust must expose results in clinical improvement. If patients would like to try, advise complete barrier bed coverings, removal of carpets, removal of soft toys, washing linen at high temperatures, acaricides to soft furnishings and dehumidification. Air ionizers have not been shown to have any beneficial effect.
Complementary therapies
Many patients try complementary therapies and medicines, such as yoga, acupuncture, homoeopathy, hypnosis, and Buteyko and other breathing techniques. There is little scientific evidence, however, that complementary treatments are effective on their own. It is better to see these therapies as ‘complementary’—working alongside conventional medicines—rather than ‘alternative’. If a patient is interested in trying one of the many complementary treatments available, they should discuss it with their GP but it is important to stress that they do not stop taking their normal asthma medicine.
Of those treatments mentioned, trials have shown that Buteyko breathing technique, which specifically focuses on control of hyperventilation, shows benefit in terms of reduced symptoms and bronchodilator usage but has no effect on lung function. It may be considered to help patients to control the symptoms of asthma. There has been inconclusive or variable benefit shown with acupuncture and herbal or Chinese medicines.
Patient education
All patients who have asthma should receive self-management education. The ‘Be In Control’ asthma action plan from Asthma UK can be downloaded directly from their website: www.asthma.org.uk/control. It can also be obtained by contacting the organization directly.
It is important to focus on individual needs. Include information about features which indicate that asthma is worsening and what to do under these circumstances. Each patient should have a personalized asthma action plan. Asthma plans are effective at decreasing morbidity and health costs from asthma.
Home monitoring of PEFR in combination with an asthma action plan can be useful for patients with brittle asthma, severe asthma or those patients who perceive their symptoms poorly. A PEFR diary kept 1–2 weeks before a review can be extremely valuable. Variability greater than 20% indicates inadequate control requiring intervention either by changing inhaler device or medication as appropriate.
Acute management of asthma
It is important to recognize an acute asthma exacerbation. Diagnosis is usually straightforward in patients presenting with typical features of uncontrolled asthma such as difficulty breathing, wheezing and cough. Occasionally, the presentation can be less clear.
Receptionists in a surgery are often the first point of contact for patients with a history of asthma who present with respiratory symptoms or worsening asthma symptoms. These patients need to be booked in to see a doctor or asthma nurse urgently. Receptionists should receive training to recognize such patients. Once patients are seen by a doctor or asthma nurse, the diagnosis needs to be confirmed. In patients with a diagnosis of asthma, poor asthma control is indicated by respiratory symptoms, particularly at night or during exercise with or without a history of poor response to the usual medication.
Assessment should include (see Tables 3 and 4):
- The patient's level of distress—difficulty in breathing, difficulty in speaking, exhaustion and level of consciousness
- clinical examination—pulse, respirations, use of accessory respiratory muscles, presence of cyanosis, auscultation of the lungs and lung function (PEF and spirometry)
- pulse oximetry—can be used to grade the severity of the attack and guide treatment
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Key points
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References |
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TOPAbstractThe GP Curriculum and...Aims of treatmentReviews and monitoringSevere asthma symptoms and...Drug therapySpacersDrugsAdd-on therapyReferences |
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British Lung Foundation. www.lunguk.org.
British Society for Allergy and Clinical Immunology. www.bsaci.org.
British Thoracic Society Scottish Intercollegiate Guidelines Network. British Guideline on the management of asthma. Thorax (2008) 63((suppl 4)):iv1–121.
General Practice Airways Group. www.gpiag.org.
Levy M, Pearce L. Asthma. Rapid reference series (2004) Elsevier Ltd. ISBN 0-7234-3360-7.
Lynch J, Simon C. Oxford General Practice Library: Respiratory problems (2007) Oxford: Oxford University Press. ISBN 9780019857137–7.
Masoli M, Fabian D, Holt S, Beasley R. Global Initiative for Asthma (GINA) Program. The global burden of asthma: executive summary of the GINA Dissemination Committee report. Allergy (2004) 59(5):469–78. [Medline].[CrossRef][Web of Science][Medline]
National Asthma Campaign. www.asthma.org.uk.
RCGP GP Curriculum statement 15.8: Respiratory problems. Access via www.rcgp-curriculum.org.uk/PDF/curr_15_8_Respiratory_problems.pdf [date last accessed 11.11.2008].
Simon C, Everitt H, Kenrick T. Oxford Handbook of General Practice (2005) Oxford: Oxford University Press. ISBN 978019856581–9.
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