ASTHMA MANAGEMENT Jackie Sheppard ASTHMA NURSE SPECIALIST (ADULTS) 2012
Asthma statistics Differential diagnosis Can we predict asthma deaths? Classification Types of asthma Inflammatory process How is asthma diagnosed PEFR what is it and how to do it! Management Uncontrolled asthma Summary of interventions Inhaler technique Role of Asthma Nurse Case study Outcomes
Asthma: The facts • 5.2 million suffer from asthma in the United kingdom. • 1 in 6 with severe asthma report weekly attacks. • Hospital admissions due to asthma are 1 every 7.5 minutes. • 1,400 deaths per annum 90% preventable • The North West incidence is 65% higher than the in the South of the country. Asthma UK (2007) Asthma Services. House of commons Debate (2006)
WHAT IS ASTHMA?‘It is chronic inflammation of bronchial airwaytissue secondary to allergens or other stimuli’ • Swelling of the airways • Excess mucus production • Bronchoconstriction • Wheezing on expiration
Types of Asthma • Atopic or not? • Brittle asthmatics sudden onset no real signs most need intubation • Pregnancy induced/symptoms worse or better • Menstrual • Occupational • Seasonal • Exercise induced
Nuts Pollen /Grasses Infection Cold weather Smoking Food intolerance Pets Exercise Contributing factors
Allergic rhinitis 80 % of asthmaticsmay suffer from co existing allergic rhinitis. Which is hay fever persistent outside the hay fever season. An American study showed that effectively treating those pts with rhinitis reduced their hospital admissions by 50%.
The inflammatory process • Immunoglobulin's (IgE) destabilize mast cells in the airway. Releasing group of chemicals including prostaglandins, histamines and leukotrienes. • Leukotrienes function as chemical mediators causing constriction of the airways (bronchospasm). Leukotrienes attract white blood cells called eosinophills which also release major chemical mediators exacerbating the inflammatory process. • 1000 times more powerful than histamines or prostaglandins.
IgE-dependent releaseof inflammatory mediators Allergens IgE FceRI Immediate release Granule contents: Histamine, TNF-, Proteases, Heparin Over hours Cytokine production: Specifically IL-4, IL-13 Over minutes Lipid mediators: Prostaglandins Leukotrienes Mucus production Eosinophil recruitment Sneezing Nasal congestion Itchy, runny nose Watery eyes Wheezing Bronchoconstriction
Summary of the allergic inflammatory cascadein patients with IgE-mediated asthma B lymphocyte Allergic inflammation:eosinophils and lymphocytes Allergic mediators -switch Plasma cell Release of IgE Allergens Asthma exacerbation Mast cells Basophils
How is Asthma diagnosed • Diagnosis is dependent on recording of peak flows first thing in the morning and in the evening. • Diurnal variation of 12-15% or more is indicative of an Asthma diagnosis. • Good history taking including family history of asthma, eczema, hay fever/rhinitis • Detailed spirometry • Reversibility testing • Manitol challenges • Trial of inhaled or oral steroids
Maximum flow rate during a forced expiration. Indicator of airflow obstruction PEFR are different for everyone. They are based on age, sex and height Useful in diagnosis and monitoring of asthma and diurnal variation Not as useful in COPD PEFR! What is it?
SIGNS OF UNCONTROLLED ASTHMA • Coughing at night/early morning (Why?) • Increased use of bronchodilator/reliever medication. • Drop in peak flow PEFR diurnal variation. PEFR – BEST OR PREDICTED THEN DIVIDE BY THE HIGHEST NUMBER AND TIMES 100 E.G 300-400=100 100/400=0.25 X100=25 Therefore variation is 25% and pt has Asthma diagnosis
Differential diagnosis • Pts with COPD • Bronchiectisis • Pulmonary embolism • Cardiac involvement – CCF • Pneumonia • LRTI and secondary bronchial hypereactivity • Vocal cord dysfunction - sudden onset pt unable to speak • In children: Croup - infection of larynx • Bronchiolitis
Previous near fatal asthma Admission in last year Needing 3 classes of asthma medication Repeated A/E attendances Brittle asthma Heavy Beta 2 use Non compliance with Tx or monitoring Failure to attend Appts Self discharge 2012 the RCP are undertaking a enquiry into asthma deaths Psychiatric illness Tranquiliser use Denial Alcohol/drug misuse Learning difficulties Employment issues Income problems Childhood abuse Domestic, marital or legal stress Obesity Can we predict death?
Classification of Asthma • Mild/moderate PEFR 50-75% best or predicted, no symptoms of severe asthma. • Severe PEFR 33-50% best or predicted, rr >25/min,hr>110/min/inability to complete sentences in one breath. • Life-threatening PEFR <33%best or predicted, Spo2 <92%, cardiovascularly unstable, exhaustion, cyanosis, normal CO2. • Near fatal raised CO2 and requiring mechanical ventilation.
Management of Asthma BTS guidelines • Step 1: Mild intermittent asthma. Inhaled short acting B2 agonist prn. If using more than 2 times a week or has night time symptoms should move to step 2. • Step 2: Regular preventer therapy. Add inhaled steroid 200-800mcg per day. 400mcg is appropriate dose. • Step 3: Initial add on therapy. Add in long acting B2 agonist and increase inhaled steroid to 800mcg. If no benefit from long acting B2 stop. Trial of leukotriene receptor antagonist or theophylline.
Step 4: Persistent poor control. Increase inhaled steroid to 2000mcg/day. Addition 4th drug e.g. theophylline, B2 tablet. • Step 5: Continuous or frequent use of oral steroids. Use steroid tablets daily. Maintain high dose inhaled steroid at 2000mcg/day. Refer to specialist care. Patients should be moved up and down the steps to improve and maintain control as needed. BTS Guideline on the Management of Asthma Revised version (2011)
Management Mild exacerbation • PEFR on admission • Know the patients BEST/Predicted • If PEFR 75% or > administer usual bronchodilator/nebulised Salbutamol 5mg via O2 • Note 10 puffs of usual Salbutamol is equivalent to a nebuliser • Resp rate <25bpm, pulse <110bpm, SpO2>95% • Pt should be able to talk in full sentences • Monitor and review in 20-30 mins • Consider prolonged observation if nebulised bronchodilator given • If PEFR>75% consider discharge with Prednisalone 40-50mg 5-7 days. Check inhaler technique • Inform pt to see Gp within 2 days from discharge • Consider stepping up pts treatment as per BTS guidelines • Refer to Asthma nurse via CWS, bleep 6168 or ext 63973 BTS Guidelines Revised version May 2011
Moderate Exacerbation • PEFR 50-75% Predicted/Best • Spo2 >95% • Resp rate <25bpm, pulse <110bpm • Speech normal • Administer 5mg Salbutamol via O2 • Repeat PEFR 20-30mins • Give prednisalone 40-50mg orally • If PEFR <50% treat as Severe exacerbation • Consider discharge if PEFR>75% & pt is stable • Check inhaler technique • Step up patients treatment if indicated as per BTS • Ensure 40-50mg Prednisalone given for 5-7 days • Inform pt to see Gp within 2 days & fax letter to GP • Refer to Asthma Nurse via CWS or Bleep 6168 or leave message on ext 63973 if pt has been discharged
Severe Exacerbation • PEFR 33-50% Predicted/Best • Resp rate >25bpm, pulse 110bpm • Unable to complete full sentences • Using accessory muscles • High concentration O2 to keep SpO2 >95% • If SpO2 <92% this is a life threatening sign ABG needed • O2 driven nebulised salbutamol 5mg • Add in Atrovent 0.5mg if no improvement • 40-50mg oral prednisalone IV hydrocortisone if vomiting or unable to take oral. Iv Magnesium if not improving • Review in 20-30mins • Repeat PEFR if <33% treat as life threatening • Continue with back to back nebulisers consider iv bronchodilators • Prolonged period of observation/ ICU review if needed • Discharge only if PEFR>75% and all other observations are within normal limits
Life threatening(one or more of below) • PEFR <33% Best/predicted • Resp rate <10bpm • Pulse <50bpm • Cyanosis • Reduced GCS • Silent chest • SpO2 <92% • If <92% ABG needed if Co2 ^ this is a near fatal exacerbation potential intubation • ICU opinion if any of the above • Administer high concentration O2 • Nebulised salbutamol 5mg & atrovent 0.5mg • Iv hydrocortisone 100mg • Back to back nebuliser • Iv bronchodilator after discussion with senior • Consider iv magnesium 2g after discussion with senior • CXR,U&E,FBC
Summary of interventions • Know the patients Best/predicted PEFR • Ensure PEFRs measured before and after treatment • Does the patient need their treatment stepping up? • Ensure pt off nebulised therapy 24hrs • Ensure regular preventer inhalers are continued in addition to nebulisers with the exception of atrovent/tiotroprium/salbutamol • Can the patient use their inhalers? • Has the patient got 40-50mg Prednisalone for 5-7 days? • Fax letter to Gp advice pt to see Gp in next 48hrs • Is the patient registered with a local Gp? • Have you informed Asthma nurse of patients admission/discharge?
Why assess inhaler technique? • 65 % of patients do not use them effectively. • Those who have ‘good’ technique will receive 20% at lungs. • 80% will end up on the oropharynx. • Ensures patients are not over medicated unessesarily.
What effects inhaler technique? • Inspiratory flow. This is the amount of effort the pt exerts on inspiration. • Dexterity • Pt lack of drug knowlegde • Pt lack of understanding of disease process • Type of inhaler pt has been given
Dry powder Aerosol Types of inhaler
Inhaled drugs Bronchodilators (step 1 BTS) There action is short acting providing immediate relief within 5 mins. Lasting for approx 4 hrs or Long acting to prevent symptoms occuring action last 12 hrs. They act on the beta 2 receptors in the lungs relaxing smooth muscle thereby reducing bronchoconstriction
Types of bronchodilator • Salbutamol (short acting) • Terbutaline (short acting) • Salmeterol (long acting) • Fomoterol (long acting) Side effects include tachycardia, hypokaleamia in excessive use, tremors
Anticholinergics These are long acting and reduce muscle contraction and reduce mucus in the bronchi. Onset of action 30-60 mins Duration of action -3-6 hours or 24hrs Used for COPD and chronic asthma • Types include ipratroprium and tiotroprium Side effects include • Hoarse voice,dry mouth, cough
Preventers Corticosteroids (step 2 BTS) A group of anti-inflammatory drugs similar to the hormone cortisol. Need to be taken twice a day even when well. Side effects include • Osteoporosis • Diabetes • Oral thrush
Types of corticosteroid • Beclomethasone • Budesonide • Fluticasone All aerosol steroid products should be used via a spacer device to avoid sore mouth and oral thrush!
Combination therapies Currently there are three combined therapies on the market. They combine a long acting beta 2 and steroid.(step 3 BTS) • Symbicort (Fomoterol/Budesonide) • Seretide (Salmeterol/Fluticasone) • Fostair (Beclomethasone/Fomoterol) Benefits include improved compliance Disadvantages are the steroid dose cannot be increased without increasing the long acting beta 2
Role of the Asthma nurse • Follow up patients who attend A/E. 1 in 5 see respiratory specialist. • 25% of patients will represent if not seen by a respiratory specialist. • Review patients on the wards and in clinic. • Step up patients therapy according to symptoms and manage them on the appropriate step of BTS guidelines.
Increase the number of Personal Asthma Action Plans (PAAP) only 16% have action plans. £1.20 cost per plan. • Patients without PAAP are 4 times more likely to have an attack needing admission. • Patient education. 80% asthma patients will have signs of their asthma worsening days before they get admitted. Asthma Services. House of commons debate (2006) British lung foundation Supporting people with long term conditions (DOH 2006) Asthma UK (2006)
Goals • Reduction in hospital admissions. • Decrease in the use of acute/critical care beds. • Saving money. • Increase patients knowledge of their condition. • Preventing avoidable deaths.
Case study True events