Managing asthma in general practice

This Clinical Update outlines the practice nurse’s roles in asthma management, including device use, spirometry and models of care.

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Introduction

ASTHMA is predominantly managed in general practice¹ and practice nurses are in an excellent position to complement the medical management of asthma by GPs.

Practice nurses can be vital members of the asthma management team, providing aspects of patient care including self-management education, spirometry and instructions on inhaler use.

Asthma in Australia

More than two million Australians have a current asthma diagnosis.¹ The prevalence of asthma in Australia is relatively high by international standards, although it has decreased slightly in children and young adults in recent years.

About one in eight or nine children (11%-13%) and about one in 10 adults (10%-12%) have asthma.

In 2007, asthma killed 385 Australians, mainly older adults.² While this suggests that asthma management messages are getting across to younger adults and carers of children with asthma, it reinforces the need for increased vigilance, particularly among older Australians.

Management principles

Asthma is a chronic inflammatory disorder of the airways for which the cornerstone of management is appropriate medication. Education, self-monitoring, regular medical review and a written asthma action plan have been shown to reduce morbidity and mortality.³

A team approach to care for chronic diseases has been shown to improve health outcomes for patients and to reduce the disease’s economic burden.

Using the Asthma Cycle of Care and other chronic disease management initiatives (including GP Management Plan and Team Care Arrangement), practice nurses can play a key role in delivering best practice evidence-based care (see Box 1).

Role of the practice nurse

The role of the practice nurse will depend on his or her experience, training, practice structure and available time.

The following points outline the potential role of the practice nurse in asthma management based on his or her skills and experience.

1. The basic role
The core elements of the basic role of practice nurses in general practice includes:

• checking inhaler device use
• providing smoking cessation information
• providing written asthma information.

2. The desirable role
A practice nurse with more experience, training and/or opportunities may carry out activities listed above and additionally be able to:

• explain about asthma and its treatment
• conduct spirometry
• provide self-management education
• discuss smoking cessation
• explain the use of a written asthma action plan.

3. The advanced role
A practice nurse with advanced skills in asthma management may follow a specialised asthma and respiratory model of care.
This would include, in addition to the activities outlined above, the skills to:

• take a detailed history
• assess asthma severity
• assess current asthma control
• assess trigger factors and discuss avoidance strategies
• assess respiratory health status including conducting spirometry
• document current medications including device use and adherence
• collaborate with GP to develop a written asthma action plan.

Models of care
There are various models of care for asthma and respiratory education in general practice. These models include:

1. Opportunistic – as requested by GP or patient
2. Scheduled appointments – direct appointment with a practice nurse
3. Designated asthma and respiratory clinic conducted by specialist nurse – formal program in place with allocated appointments.

Asthma medications

Medical management of asthma aims to achieve and maintain optimal asthma control with best possible lung function and minimal side-effects.³

There are three main types of medication available: relievers, preventers and symptom controllers, plus combination medications.

Relievers

Reliever medications have a direct bronchodilator effect and relieve the symptoms of asthma. They are the mainstay drugs for the acute relief of asthma symptoms. Relievers include salbutamol (Ventolin, Asmol) and terbutaline (Bricanyl).

All patients with asthma should have some form of reliever medication.³

Preventers

Preventer medications have anti-inflammatory properties and are generally taken regularly to reduce symptoms and exacerbations.³

Preventers include oral montelukast (Singulair) and inhaled corticosteroids (ICS) such as beclomethasone (Qvar), budesonide (Pulmicort), fluticasone (Flixotide) and ciclesonide (Alvesco).

Oral corticosteroid medications are potent anti-inflammatory agents reserved for use in acute or very severe chronic asthma.

Symptom controllers

Symptom controllers produce prolonged bronchodilation for up to 12 hours. These agents are usually taken on a regular basis together with an ICS.³

The addition of these agents to ICS improves lung function and symptoms and reduces exacerbations more effectively than increasing the dose of ICS alone.

Combination medications

Combination medications consist of a preventer and a symptom controller in a single inhaler device.³ Combination medications are budesonide plus eformoterol (Symbicort) and fluticasone plus salmeterol (Seretide). Symbicort can be used as both preventer and reliever under the SMART regime.

Inhaler delivery devices

Medications used to treat asthma are usually administered by inhalation. However, evidence suggests that up to 90% of patients are misusing their inhalers.⁴

Inhaler misuse results in poor medication delivery and reduced lung deposition. These in turn can lead to poorer health outcomes, more frequent and longer hospital stays, and an increased dependence on medication.⁴

Practice nurses have a vital role to play in checking and regularly reviewing patient inhaler device use. Inhaler technique can be significantly improved by brief instruction from an appropriate person.⁴

Types of inhalers

Two different methods of inhalation are commonly used: metered-dose inhaler (MDI) with or without the use of a spacer, or dry-powder inhaler.

Provided the devices are used correctly, there is no evidence of long-term clinical advantage of one device over another. The inhaler should be age and skills appropriate for the patient. Nebulisers should no longer be used routinely in asthma management (see Box 2).

Spacers
Spacers are used with MDIs to increase the deposition of medication and reduce the oral complications of ICS.
Spacers are recommended for:

• All patients on ICS
• All children
• All adults with limited coordination.³

Figure 1 shows appropriate medication delivery devices for children of different ages. Figure 2 shows a patient using a spacer.

 

Figure 2: Using a metered-dose inhaler with large volume space.

 

Improving technique

Regardless of the type of inhaler, patients are unlikely to use the device correctly unless they receive clear instruction, including a demonstration (see Box 3).⁴

Inhaler demonstration videos – for health professionals and their patients – are available via the National Asthma Council Australia and Asthma Foundation NSW websites, and from the Lung Health Promotion Centre at the Alfred Hospital in Victoria.

Spirometry

Spirometry is the lung function test of choice to:

• diagnose asthma and COPD
• assess asthma severity and control
• monitor treatment effectiveness.

This test can be performed by most adults and by children older than seven years (see Figure 3). Peak flow measurement is not an appropriate substitute for full spirometry.

Figure 3: Patient performing spirometry

 

Spirometric measurements are usually taken both before and after administration of a short-acting beta-agonist (bronchodilator). The results can help to:

• diagnose airflow limitation
• measure the degree of airflow limitation
• monitor the effects of treatment
• demonstrate the presence and reversibility of airflow limitation to the patient
• provide objective feedback to the patient about the presence and severity of asthma and/or COPD
• provide an effective aid to encourage patients to quit smoking.

Spirometry in general practice

The National Asthma Council Australia recommends that all doctors managing asthma should have access to and use a spirometer.³

A suitably trained practice nurse can perform spirometry on behalf of the doctor as part of MBS item numbers 11506 and 10997. Comprehensive spirometry training for those performing the test is recommended and regular refresher updates are essential (see Box 4).

Summary

Practice nurses are integral members of the asthma care team, utilising their advanced skills in chronic disease management, clinical care and self-management education.

The practice nurse role includes education about asthma and its treatment, smoking cessation advice, checking and reviewing device technique and conducting spirometry. An essential element is ensuring all patients with asthma have a current written asthma action plan and know how to use it.

Box 1: Key elements of the Asthma Cycle of Care

1. Document diagnosis and assessment of asthma severity and level of asthma control
   
2. Review the patient’s use of, and access to, asthma-related medication and devices
   
3. Provide a written asthma action plan
   
4. Provide asthma self-management education
   
5. Review the written asthma action plan.

Box 2: Spacers versus nebulisers³

Nebulisers should no longer be used routinely in asthma management unless there are special circumstances or co-morbidities. Compared to nebulisers, an MDI plus large-volume spacer:

• is as effective
• has fewer side-effects
• is more convenient
• is more cost effective.

Nebulisation should be reserved for patients with severe or life-threatening asthma requiring continuous salbutamol and oxygen.³

Box 3: Tips for teaching correct inhaler use

1. Make sure your own knowledge of correct technique is up to date, and you know the errors commonly made with the different inhalers
2. Ensure the inhaler is appropriate for the patient. Where possible, avoid giving the patient multiple inhaler types, as this can cause confusion
3. Ask patients to show you how they use their inhaler. Most patients don’t know that their technique is incorrect
4. Give patients verbal instruction – not just a leaflet. The manufacturer’s instructions alone are not sufficient to teach the correct technique
5. Provide a physical demonstration, via either a video or one-on-one instruction
6. Repeat instruction regularly. Patients’ technique can deteriorate as soon as three months after education.

Box 4: Asthma resources

National Asthma Council Australia
Australian Asthma & Respiratory Educators Association (AAREA)
Australian Government Department of Health and Ageing
Asthma Foundations Australia
Lung Health Promotion Centre

This update is by Judi Wicking, RN, BNsg, GradCertAsthmaEd, project manager and asthma educator, and Siobhan Brophy, BOptom, GradCertsArts(Comms), communications manager, National Asthma Council Australia.

The authors have no disclosures.

References available on request.