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Traps for the unwary in asthma management

Good asthma control is achievable but needs constant vigilance, says Dr Chris Woodforde

Although asthma management in the UK remains generally good there are several pitfalls for the unwary.

Here we highlight five.

1 Failure to step down asthma therapy.

2 Failure to manage exacerbating factors.

3 Inhaler device choice and technique not checked.

4 Not recognising poor control.

5 Failure to detect and manage coexistent conditions.

New guidelines from the BTS say GPs should aim for no or minimal asthma-related symptoms. Each of the five steps of asthma management based on medication prescribed consists of progressively more additions to therapy (see box).

Minimum treatment should be used to achieve adequate control and then reviewed every three months.

Commonly, patients may be placed on a higher therapy step but are not stepped down subsequently.

This can result in excessive and unnecessary medication and a waste of resources.

Barriers to stepping down

 · Patient's unwillingness to reduce medication they feel helps them.

 · GP's unwillingness to precipitate a worsening of a patient's asthma control. GPs may be wary of imposing extra work (increased surveillance/ reviews) on an already overloaded system.

 · Persistence of triggers.

 · Difficulty accessing chest clinic services (unsuitable times for patients).

Overcoming barriers

 · Find an appropriate acceptable therapy step for each patient.

 · Ensure compliance with therapy and trigger factor avoidance, including smoking cessation.

 · Agree review date with the patient/ carer, document in notes, give patient written reminder slip.

 · Explain to patients why therapy review is needed.

 · Offset any additional prescription charges by offering the patient multiple inhalers on one script (only one charge per item).

 · Implement a recall system.

Exacerbating factors

Trigger factors are well documented and should be discussed with every patient. A record can be made of all identified triggers and a discussion had about exposure reduction at each review.

All asthma patients who smoke or are exposed to smoke regularly should be identified and their smoking status recorded. There is evidence these patients require more asthma therapy, generally have poorer control and may go on to develop COPD in later life.

It is important smoking histories are recorded ­ 15 or more pack years may indicate a risk of developing COPD. One pack year represents a whole year of smoking one pack (20 cigarettes) daily (see below). Advice and support through smoking cessation programmes should be targeted at all respiratory patients who continue to smoke. This may further improve control and reduce risk of hospital admission.

Pack year calculator

Pack years = number of cigarettes smoked a day divided by 20 multiplied by years smoked at this level

Example: smoker of 10 cigarettes per day for 20 years has 10 pack years.

Inhaler device technique

Simply giving a patient an inhaler device does not improve asthma control per se, they have to use it correctly. Twelve different inhaler devices containing various therapeutic agents are used in the UK with several different types of spacers available.

It is important an appropriate inhaler device is chosen with the patient. Inhalers may be presented in a user-friendly way in a foam-padded photographic case our practice has dubbed the SMART box.

It is imperative to demonstrate the correct technique for a particular device and give the patient a pictorial information leaflet.

Inhaler technique should be quickly rechecked, documented and corrected at every consultation.

Failing to recognise poor control

Poor asthma control often results in overuse of short-acting medication and poor quality of life and runs the risk of significant disability or even death. It may not be obvious, patients have a tendency to under-report symptoms and their impact.

Poor control is more likely

if there is:

 · Inadequate review of prescribing

 · Poor patient/carer knowledge of asthma and its basic management

 · Poor interest in respiratory health by primary care practitioners

 · Inadequate chest clinic review time

 · Little/no regular audit of asthma care

 · Poor recall/chaser system for defaulters

Three simple questions suggested by the royal college can rapidly and easily assess symptom control. These have been adapted for use in the Tayside score ­ most can now be coded into Read codes permitting audit and comparative assessment from visit to visit.

Coexistent conditions

Most patients diagnosed with asthma may have other conditions that can interfere with asthma control.

Rhinitis The atopic triad of asthma, eczema and rhinitis is well known;

30 per cent of asthma patients have significant rhinitis. It is not well detected or managed. Asthma patients may endure excessive respiratory medication if coexistent rhinitis is not correctly managed. The ARIA guidelines provide a useful reference guide (see box).

Asthma and COPD Practitioners and patients often confuse these. Spirometry and reversibility trials will distinguish the difference.

Obesity There is an increasing threat of significant health problems with a raised body mass index. Spirometry can assist in excluding this from the diagnosis. Height, weight and BMI should be recorded at each formal respiratory review.

Reflux Although said not to influence asthma control, coexistent reflux can cause irritating cough mistaken for poor asthma control. Investigative gastroscopy may be required to exclude other pathologies.

Pitfalls in asthma management require constant vigilance. Good asthma control is not hard to achieve with the majority of patients but requires surveillance, organisation, patience and persistence. Success is reflected in patients' comments and abilities rather than residual disability.

References

ARIA guidelines (2001). Allergic rhinitis and its impact on asthma initiative

Asthma guidelines supplement (2003). Primary Care Respiratory Journal General Practice Airway Group (GP/AG)

British Thoracic Society (2003). The British Guidelines on Asthma Management.

Thorax 58 (2003) (Supp · 1)

Hoskins G et al. The Tayside Asthma Management Initiative. Health Bulletin. March 1998;56:586-91

Pearson MG, Bucknall CE. Measuring clinical outcome in asthma. London: Royal College of Physicians, 1999

BTS 2003 asthma guidelines

Step Therapy

recommendation

5 (Continuous or frequent Use daily oral steroids

use of oral steroids) (lowest dose)

Maintain high-dose

inhaled steroids

4 (Persistent poor control) Trial of high-dose inhaled

steroids or

Trial of leukotriene

antagonist or

SR theophylline or

SABA tablet

3 (Add-on therapy) Add long-acting beta-2

agonist

2 (Regular preventor Add inhaled steroid up

to therapy) 800mcg daily

1 (Mild intermittent asthma) Inhaled short-acting

beta-2 agonist

PRN

Trigger factors in asthma ­

avoidance advice

Allergens: house dust mites, animal hairs, feather pillows, moulds in bathrooms

Avoid exposure to animal hairs (cats and dogs), cover mattress with allergen-proof covers; use synthetic pillows. Wash pillowcases, sheets and blankets at least weekly. Keep bathrooms clean to avoid mould build-up. Have wooden floors instead of carpets.

Irritants in the air: tobacco smoke, household sprays, paint, petrol and perfumes

Avoid: tobacco smoke, sprays, paints, perfumes and other strong fumes.

Outdoor allergens: pollens released from grasses and trees

Avoid excessive outdoor exposure at these times.

Weather changes: extreme cold or hot weather

Avoid excessive outdoor exposure at these times.

Infections: viral infections.

Strong emotions: over-excitedness and upset.

Certain medicines: NSAIDs, aspirin,

beta-blockers; over-the-counter therapies

Avoid these drugs in asthma.

Exercise: running for the bus, playing football, etc.

Questions to assess symptom control

In the past week (or month)

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

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

 · Has your asthma interfered with your usual activities (housework, work/ school)?

ARIA guidelines to managing

allergic rhinitis (abridged)

Symptoms

Rhinorrhea, nasal obstruction, nasal itching, sneezing

Intermittent if

Persistent if >four days/weeks and

>four weeks per year

Management

 · Allergen avoidance

 · Pharmacological treatment (antihistamines, intranasal corticosteroids)

 · Specific immunotherapy

 · Education

 · Surgery

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