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Asthma UK (2018) describes asthma as a common chronic lung condition affecting

4.3 million adults in the UK, at an estimated cost of one billion a year. Alongside the economic burden are the human factors, as living with a chronic respiratory disease places a burden on day-to-day living with people striving to manage cough, wheeze, and shortness of breath. For some, asthma may also be life-threatening. Every day in the UK, the lives of three families are devastated by the death of a loved one due to an asthma attack — sadly, many of these deaths are preventable. The

Adult asthma: what community nurses should know

National Review of Asthma Deaths (NRAD) found that many of those who died were being treated for mild-to-moderate asthma, and 50% of those that died had not had an asthma review by their nurse or GP in the previous year (Royal College of Physicians [RCP], 2014).

The majority of routine asthma care is carried out in primary care by nurses; these consultations present key opportunities to enhance the lives of people with asthma and prevent the suffering caused by premature asthma deaths.

There are comprehensive guidelines available to guide the practitioner through the evidence base. However, the National Institute for Health and Care Excellence’s most recent update of asthma guidelines has sparked debate (NICE, 2017). The guidelines contain some discrepancies in recommendations in comparison to the widely used British Thoracic Society (BTS) and Scottish Intercollegiate Guidelines Network (SIGN) asthma guidelines (BTS/SIGN, 2016). Although the methodology used to develop both guidelines is broadly the same, NICE uses health economic modelling to appraise the literature. In addition, NICE (2017) does not include guidance on inhaler devices, management of acute asthma attacks, occupational asthma, or management of asthma in pregnancy (White et al, 2018).

There are concerns that multiple guidelines create uncertainty for clinicians and lead to inconsistencies in care. The key differences between the guidelines for the care of adult patients centre around:

DiagnosisTreatment at diagnosisIntroduction of leukotreine receptor antagonists (LRTA)Maintenance and reliever treatment (MART)Treatment beyond combined inhaled treatment.

Readers may wish to consult the Primary Care Respiratory Society-UK’s (PCRS-UK, 2017) briefing document and White et al’s (2018) paper, which provide detailed analysis of the key differences between the guidelines and offer practice-based advice for healthcare professionals.

Shirley Pickstock, trainee advanced clinical practitioner, Shrewsbury and Telford NHS Trust

RESPIRATORY CARE

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‘The majority of routine asthma care is carried out in primary care by nurses; these consultations present key opportunities to ehance the lives of people with asthma...’

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RESPIRATORY CARE

Asthma is influenced by a complex interaction of genetic and environmental factors, which result in airway inflammation and responsiveness (Booth, 2016). Eosinophils, mast cells, neutrophils, B, T cells, and immunoglobulin E (IgE) are all involved in cellular infiltration. IgE and raised eosinophils are found in the blood during an inflammatory response. The inflammatory response results in contraction of smooth muscle in the airways, leakage of blood vessels, and mucus production, which produce the symptoms of cough, wheeze, and breathlessness experienced by patients (Bourke and Burns, 2015; Figure 1).

Asthma can present at any time in a person’s life. Adult-onset asthma differs from childhood asthma in that it is more often non-atopic, can be severe, and has a lower remission rate. The diagnosis of asthma is a clinical one, as there is not yet a gold standard diagnostic test. Both guidelines agree that no one symptom, sign, or test is diagnostic. However, the BTS/SIGN guideline differs in its use of probabilities when considering an asthma diagnosis (White et al, 2018).

Gathering a careful history is integral when clinicians are considering probability and recognising patterns. Asthma is characterised by the presence of more than one symptom of wheeze, breathlessness, cough, and variability in airflow obstruction (BTS/SIGN, 2016; NICE, 2017).

Tests, such as measurements of diurnal peak flow variability (symptoms which are worse at night or in the early morning) and demonstration of airflow obstruction on spirometry (lung function testing), influence the probability, but do not offer a definitive asthma diagnosis. The measurement of eosinophils and IgE in the blood may demonstrate evidence of inflammation in the airways. NICE (2017) suggests that these tests should only be undertaken once a diagnosis of asthma has been made.

Another objective test is the measurement of fractional nitric oxide (FeNO) concentration in exhaled breath. This is a non-invasive, easy and safe method of measuring airway inflammation (Dweik et al, 2011). SIGN/BTS (2016) have acknowledged that a positive FeNO test suggests the presence of eosinophilic inflammation increasing the probability of asthma. However, the NICE (2017) guideline recommends that FeNO testing is used in all people with suspected asthma as a primary investigation. This is currently not widely available in primary care and therefore raises economic challenges in terms of the provision of this service at local level. FeNO levels in the breath can be lowered by effective asthma treatment with inhaled corticosteroids (ICS). Therefore, measuring FeNO in the breath once people have started ICS may be misleading. There is also concern that the lack of availability in primary care may delay diagnosis and cause an increase in referrals to secondary care. Further research is needed to ascertain how to achieve the greatest value of including FeNO in the diagnostic pathway (PCRS-UK, 2017).

The role of spirometry as an objective measurement of airflow obstruction is pivotal in both sets of guidelines. However, PCRS-UK (2017) highlights the false negatives that occur at points in time when the patient is asymptomatic and will blow normal spirometry. Spirometry testing does offer

objective confirmation of airflow obstruction, with a lower forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio and peak expiratory flow (PEF) in comparison to a patient’s normal or predicted parameters, if measured during symptomatic presentation (SIGN/BTS, 2016; NICE, 2017). BTS/SIGN (2016) recommend using the lower limit of normal (LLN) for FEV1/FVC ratio in comparison to the fixed ratio of 70% recommended by NICE (2017). This is to avoid over-diagnosis in the elderly and under-diagnosis in children. Both SIGN/BTS (2016) and NICE (2017) recommend further research on the diagnostic accuracy of objective tests.

Spirometry testing is easy to perform and is often undertaken in primary care. However, if performed or interpreted incorrectly, it can lead to a misdiagnosis and delayed and/or unnecessary treatment. NHS England (2016) recently published guidance on the level of training practitioners should receive before undertaking diagnostic spirometry. A national register aims to ensure that those performing spirometry are competent to do so. Many nurses working in primary care are now trained, or in the process of training

Remember...

Lung function tests should always be quality assured, as while spirometry is easy to do, it is also easy to get wrong (Booth, 2016).

muglan

Normal airway Asthma airway

Figure 1. Normal and narrowing airways found in asthma.

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RESPIRATORY CARE

Figure 2. Asthma management in adults. This figure is reproduced from BTS/SIGN British Guideline on the management of asthma by kind permission of the British Thoracic Society (BTS/SIGN, 2016).

Consider monitored initiation of treatment with low-dose inhaled

corticosteroid (ICS)

Regularpreventer

Low dose ICS

Initial add-on preventer

Add inhaled long-acting beta2-agonist (LABA)

to low dose ICS (normally as a

combination inhaler)

Infrequent,short-lived wheeze

Additional add-on therapies

No response to LABA — stop LABA and

consider increased dose of ICS

If benefit from LABA but control still inadequate —

continue LABA and

increase ICS to medium dose

If benefit from LABA but control still inadequate,

continue LABA andICS and consider trial of

other therapy — LRTA, S-R theophyline, LAMA

Short-acting beta2 agonists as required — consider moving up if using three doses a week or more

High-dose therapies

Consider trials of:Increasing ICS up to

high dose

Addition of a fourth drug, e.g. LTRA, sustained release (SR)

theophylline, beta agonist tablet, LAMA

Refer patient forspecialist care

Continuous orfrequent use of

oral steroids

Use daily steroid tablet in the lowest dose

providing adequate control

Maintain high dose ICS

Consider other treatments to

minimise use of steroid tablets

Refer patient forspecialist care

Asthma — suspected Asthma — diagnosedDiagnosis and

assessmentEvaluation: assess symptoms, measure lung function, check inhaler technique and adherenceAdjust dose, update self-management plan, move up and down as appropriate

Move up to improve control as needed

Move down to find and maintain lowest controlling therapy

to a high standard in spirometry (Loveridge, 2016).

The BTS/SIGN (2016) asthma guideline states that a 400ml increase in FEV1 upon reversibility testing would strongly suggest asthma. Patients undertaking reversibility testing need to take their bronchodilator after the baseline test — normally 4x10mcg salbutamol as single puffs via a spacer or 2.5mg salbutamol via a nebuliser (Primary Care Commissioning [PCC], 2013).

In adults with obstructive spirometry, an improvement in FEV1 of 12% or more in response to either beta-2 agonists or corticosteroid treatment trials, together with an increase in volume of 200ml or more, is regarded as a positive test. A serial peak flow diary may be helpful in eliciting diurnal variation (BTS/SIGN, 2016; NICE, 2017).

The following factors suggest

a high probability of asthma when considering a diagnosis:

Patients that suffer episodic symptoms of wheeze, breathlessness, chest tightness and cough triggered by viral infection or allergen exposure with asymptomatic periodsSymptoms triggered by beta blockers or non-steroidal anti-inflammatoriesWheeze heard on physical examination by a healthcare professionalPersonal or family history of eczema or rhinitis (atopy).(BTS/SIGN, 2016).

ASTHMA MANAGEMENT

The aim of asthma management is control of the disease. Complete control is defined by BTS/SIGN (2016) as no daytime symptoms, no night-time awakening due to asthma, no need for rescue medication, and no asthma attacks.

Patients would suffer no limitations on activity, including exercise, and would demonstrate normal lung function (in practical terms FEV1 and/or PEF >80% predicted or best). This would be achieved with minimal side-effects from medication. However, patients may not share the same goals. Healthcare professionals should consider lifestyle and the economic costs of prescribed medication, as these are important in terms of patient concordance. PCRS-UK (2017) recommends a patient-centred approach with reviews carried out by a healthcare professional with current and appropriate training in asthma and the skills to negotiate treatment goals and plans with patients.

NICE (2017) recommends the use of a recognised tool for assessment of asthma control. The three question of the Royal College of Physicians (RCP) is widely used,

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with alternatives including the asthma control questionnaire, and asthma control test or mini asthma quality of life questionnaire (Tidy, 2016).

In terms of pharmacological management, the 2016 BTS/SIGN guideline (Figure 2) recommends the initiation of treatment with low-dose inhaled corticosteroids (ICS), with short-acting beta agonists (SABA) alone only being used in very few cases of occasional short-lived wheeze. However, NICE (2017) still advocates the use of SABA alone in its treatment algorithm, although acknowledging that this would only be applicable for a small number of patients. It is of note that the NRAD report demonstrated that a proportion of asthma deaths occurred in patients prescribed SABA only (RCP, 2014).

The most significant difference between the guidelines is the recommendation of first-line add-on treatment to low-dose ICS in adults with insufficient control. NICE (2017) recommends a LRTA, whereas BTS/SIGN (2016) recommends a ICS/LABA combination. LRTA is an oral therapy taken at night and is the most cost-effective, although head-to-head comparisons favour ICS/LABA as the more clinically effective treatment (Chauhan et al, 2014). The issues for consideration when prescribing, include patient

preferences for tablets or inhaled therapy and that the immediate clinical benefit derived from a LABA may influence adherence to treatment (White et al, 2018).

Use of a MART regimen reduces the number of attacks in adults. While the guidelines suggest that MART is a viable option, they differ in the recommended target group. NICE favours introduction of MART when low dose ICS/LABA is ineffective in asthma control, while BTS/SIGN (2016) recommend introducing MART in a patient with a history of asthma attacks on medium dose ICS or ICS/LABA. Whatever prescribing decisions are made, the importance of maintaining asthma control to prevent unnecessary exacerbations and potential hospital admissions is paramount.

Lareau and Hoder (2011) found that the knowledge and skills of healthcare professionals in providing education and instruction in the use of inhalers is variable. There are pictorial graphs of the wide range of inhaled therapy available on line and helpful categorisation of inhaled corticosteroids by dose listed in the BTS/SIGN (2016) guideline. The decision of the prescriber will be influenced by the evidence base as well as local formularies and consideration of patient lifestyle and choice. Although local health

economics and availability may affect decision-making, unless the patient is confident and competent in use of their individual device it is a false economy.

This is emphasised in a systematic review by Sanchis et al (2016), which showed that over a quarter of patients were unable to use their device correctly. In general, inhalers fall into four categories: Pressurised metered dose

inhalers (pMDIs), spacer devices can be used to enhance the delivery of medication from a pMDI

Breath actuated inhalers (pMDI breath-actuated)

Dry powder inhalers (DPIs) Soft mist inhalers (SMI).

The correct inhaler technique differs for each and considerations such as patient coordination, dexterity, eyesight and an assessment of inspiratory flow rate are all integral to any prescribing decisions. Patients or carers need to understand how to clean their device and to recognise when it is empty (Yawn et al, 2012).

Furthermore, flow rates differ between devices. For example, pMDI inspiration is slow and deep, whereas the DPI requires faster inspiration to ensure deposition in the airways and optimise drug availability. Inspiratory flow rates can

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be estimated with the use of training devices, which are now widely available; nurses can also use these to demonstrate inhaler techniques to patients during consultations (Hickey, 2014).

The use of a peak expiratory flow (the maximum rate of airflow) enables patients to measure PEF against their normal parameters and assess response to inhaled therapy. It is a universally understood measure and is used to assess baseline, monitor diurnal variations and to assess the severity of asthma exacerbations and response to therapeutic interventions (NICE, 2017).

There is good evidence that the use of supported self-management for people with asthma, including a personal asthma action plan (PAAP), reduces emergency use of healthcare resources and improves markers of asthma control (Stonham, 2017). Asthma UK action plans and resources can be downloaded from their website (SIGN/BTS, 2016).

The majority of asthma is managed in primary care; however, there may be a need for referral for investigations and specialist advice. Around 12% of people have refractory asthma. This means that they have difficulty breathing almost all of the time and often have potentially life-threatening asthma attacks, even though they are on high doses of medication (Asthma UK, 2018).

Patients with an unclear diagnosis, suspicion of occupational asthma, those with a poor response to treatment and all patients who have suffered a severe, or life-threatening attack should be referred for specialist advice. Other red flag indicators for secondary referral are unexpected clinical signs such as finger clubbing, persistent non-variable breathlessness and restrictive spirometry (SIGN/BTS, 2016).

In terms of managing refractory asthma, both guidelines agree that referral to specialist services is needed when patients are still uncontrolled on high dose ICS, LABA, LRTA and

theophyllines. The BTS/SIGN (2016) guideline documents the treatment options, such as introduction of a LAMA. NICE has approved advanced therapies such as anti-IgE monoclonal antibody, which is initiated by a specialist and usually administered in secondary care by subcutaneous injection every two or four weeks. Other options for severe asthma are anti-interleukin monoclonal antibody and bronchial

(PHE, 2015) found that e-cigarettes are significantly less harmful than tobacco. However, Asthma UK (2018) recommends caution to people with asthma with regards to the use of flavourings to lessen the risk of an allergic reaction.

The recognition of a severe or life-threatening attack in primary/community care and admission for hospital management is possibly the most straightforward aspect of managing a patient with asthma. Assessment includes a review of presenting clinical features, i.e. severe breathlessness (including too breathless to complete sentences in one breath), tachypnoea, tachycardia, silent chest, cyanosis, or collapse. The assessment should include measurement of the patients PEF rate and oxygen saturations with pulse oximetry. Patients with any feature of a life-threatening or near-fatal asthma attack or a severe asthma attack that does not resolve after initial treatment should be admitted to hospital. Admission may also be appropriate when peak flow has improved, but concerns remain about symptoms, previous history or psychosocial issues, as patients with severe asthma and one or more adverse psychosocial factors are at risk of death (BTS/SIGN, 2016).

In the author’s professional opinion, it is vital that nurses use their skills of engagement with patients to build a rapport and establish trust, as this encourages the provision of individualised, meaningful care. A review of the processes, i.e. ease of appointments for full-time workers, introduction of telephone consultations, collection of repeat prescriptions and the quality of care that is provided may serve to improve access to asthma patients and increase skills and expertise that ultimately save lives. A study by Pinnock et al (2005) has shown that telephone reviews are an economic and effective means of providing ongoing support and advice for people with asthma, allowing triaging with risk questions, which prompt face-to-face review, although telephone consultations are not specifically recommended by BTS/SIGN (2016).

‘The BTS/SIGN (2016) guideline recommends a structured asthma review, which includes identification of triggers, inhaler technique, and review of control. The psychosocial aspects of chronic disease should be explored and lifestyle advice, including smoking cessation and weight reduction, should be advised for some patients.’

thermoplasty, however, these are not included in the 2017 guideline, although all approved by NICE (White et al, 2018).

The management of co-existing allergic rhinitis is an important consideration when treating asthma, as it more difficult to treat asthma successfully if upper respiratory tract inflammation is not adequately controlled (Brozek et al, 2016).

The BTS/SIGN (2016) guideline recommends a structured asthma review, which includes identification of triggers, inhaler technique, and review of control. The psychosocial aspects of chronic disease should be explored and lifestyle advice, including smoking cessation and weight reduction, should be advised for some patients. Smoking exacerbates asthma symptoms and is associated with poorer response to ICS and increased risk of exacerbation. Nurses are best placed to identify, support and signpost patients who are ready to make a quit attempt. Patients may ask the advice of their nurses regarding the use of e-cigarettes. The evidence review by Public Health England

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KEY POINTS Asthma is a common lung condition affecting many patients in the community.

Asthma reviews offer opportunities to build therapeutic relationships.

The aim of asthma management is control of the disease.

It is vital that patients are educated in how to use their inhaler device correctly.

Use of supported self-management for people with asthma, including a personal asthma action plan (PAAP), reduces emergency use of healthcare resources and improves markers of asthma control.

JCN

CONCLUSION

Asthma is a complex and challenging disease to manage. However, the benefits for patients of striving to achieve their own goals of asthma control and prevent life-threatening attacks requiring hospital admissions are immense. The recent controversy over multiple and contradictory asthma guidelines is challenging for clinicians. However, guidelines are designed to be used alongside clinical experience and knowledge of the individual patient. The advice of specialists in asthma care can be accessed where necessary as clinicians collaborate across the health sectors to achieve the best possible outcomes for their patients.

REFERENCES

Asthma UK. (2018) Asthma facts and statistics. Available online: www.asthma.org.uk/about/media/facts-and-statistics/ (accessed 14 December, 2017)

Booth A (2016) Routine management of asthma in primary care. Respir Care Today 1(1): 26–31

Bourke S, Burns P (2015) Respiratory Medicine: Lecture notes. Wiley-Blackwell, Oxford

British Thoracic Society, Scottish Intercollegiate Guidelines Network

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(2016) British guideline on the management of asthma. Edinburgh: SIGN. (QRG 153). Available online. www.sign.ac.uk (accessed 14 December, 2017)

Brozek JL, Bousquet J, Agache I, et al (2016) Allergic rhinitis and its impact on asthma guidelines — 2016 revision. J Allergy Clin Immunol 140(4): 950–8

Chauhan BF, Ducharme FM (2014) Addition to inhaled corticosteroids of long-acting beta2-agonists versus anti-leukotrienes for chronic asthma. Cochrane Database Syst Rev :CD003137.doi:10.1002/14651858.CD003137.pub5

Dweik RA, Boggs PB, Erzurum SC, et al (2011) An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FENO) for clinical applications. Am J Respir Crit Care Med184(5): 602–15

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Loveridge C (2016) Competence and confidence in diagnostic spirometry. JGeneral Practice Nurs 2(5): 18–19

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National Institute for Health and Care Excellence (2017) Asthma: diagnosis, monitoring and chronic asthma management. NICE, London. Available online: www.nice.org.uk/guidance/ng80 (accessed 14 December, 2017)

Pinnock H, McKenzie L, Price D, et al (2005) Cost-effectiveness of telephone or surgery asthma reviews: economic analysis of a randomised controlled trial. Br J Gen Pract55(511): 119–24

Primary Care Respiratory Society-UK (2017) Briefing document: Asthma guidelines. Available online: https://pcrs-uk.org/sites/pcrs-uk.org/files/BriefingAsthmaGuidelines_V3.pdf(accessed 14 December, 2017)

Primary Care Commissioning (2013) AGuide to Performing Quality Assured Diagnostic Spirometry. PCC, London

Public Health England (2015) E-cigarettes: an evidence update : A report commissioned by Public Health England. PHE, London

Royal College of Physicians (2014) Nationalreview of asthma deaths. RCP, London. Available online: www. rcplondon.ac.uk/projects/national-review-asthma-deaths

Sanchis J, Gich I, Pedersen S (2016) Systematic review of errors in inhaler use: has patient technique improved over time? Chest 150:

Stonham C (2017) Shared decision-making, patient-centred care and PAAPs can seem challenging. Respir Care Today 2(1): 16–20

Tidy C (2016) Asthma. Available online: https://patient.info/doctor/asthma-pro#ref-7

White J, Paton J, Niven R, Pinnock H (2018) Guidelines for the diagnosis and management of asthma: a look at the key differences between BTS/SIGN and NICE. Thorax. Available online: http://thorax.bmj.com/content/thoraxjnl/early/2018/01/02/thoraxjnl-2017-211189.full.pdf

Yawn BP, Colice GL, Hodder R (2012) Practical aspects of inhaler use in the management of chronic obstructive pulmonary disease in the primary setting. Int J Chron Obstruct Pulmon Dis 7: 495–502