thunderstorm asthma - murray phn...2017/08/18 · thunderstorm asthma supported by the department...

Asthma Best PracticeFor Professionals Supported by the

Department of Health andHuman Services (Vic)

ThunderstormAsthma

Thunderstorm Asthma

Supported by the Department of Health and Human Services (Vic)

Introductions…

• In your workbooks

– Copy of slides

– National Asthma Council Australia resources

– Evaluation form

Thunderstorm Asthma


References• The November 2016 Victorian epidemic thunderstorm asthma

event: an assessment of the health impacts. The Chief Health

Officer’s Report, 27 April 2017

• State Government Victoria, Review of response to the

thunderstorm asthma event of 21-22 November 2016, April 2017

• National Asthma Council Australia (NAC) Australian Asthma

Handbook Version 1.2 www.asthmahandbook.org.au

• Also

– NAC Information paper “thunderstorm asthma”, soon to be

released

– Asthma in Australia 2011

– Global Initiative for Asthma (GINA) 2017

http://www.asthmahandbook.org.au/

http://www.asthmahandbook.org.au/

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Objectives

• Describe the phenomena of thunderstorm asthma

• Define who is at greater risk of thunderstorm asthma

• Apply current, evidence – based best practice of

asthma and allergic rhinitis to professional practice

• Describe the importance of written asthma action

plans and how to use them

• Implement emergency asthma management and

asthma first aid

Please close your eyes !

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BUSY !!What other words come to mind?

Would you and your workplace be able to cope?

Thunderstorm asthma –an unprecedented

emergency

Thunderstorm Asthma


History in Australia

• 1984: 11November Melbourne

• 1987: 8 November Melbourne

• 1989: 29-30 November Melbourne

• 1990: Tamworth NSW

• 1997: 30 October Wagga Wagga NSW

• 1998: Newcastle NSW


• 2010: Canberra ACT



• 2016: 21 November Melbourne – 9 deaths

Several incidents have also be recorded internationally

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Spring rainfall 2016

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Emergency ambulance calls

6pm 12mn

Peak between 7-7.15pm

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Hotspots of emergency calls

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Respiratory presentations to Victorian Emergency Departments, 2001-2016

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Comparison of six 12 hour surge periods ofemergency ambulance calls to

Emergency Services Telecommunications Authority (ESTA)

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Asthma related deaths in Victoria,21-30 Nov 2013-2016

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When and why……….

• Occurs during the rye grass pollen season

–Between October and December (majority in Nov.)

• Large pollen grains rupture

–One hypothesis is moisture in the cloud fragments the pollen into smaller particles

• Smaller starch particles are inhaled into the very small airways

• Larger particles are usually filtered in the nose

G B Marks et al. Thorax 2001;56:468-471

Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved

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Rupture of rye grass pollen

https://www.deakin.edu.au/students/faculties/sebe/les-students/airwatch

With permission from Associate Professor Cenk Suphioglu, Deakin University Geelong

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Type of thunderstormVisual representation of one hypothesis for the mechanism of thunderstorm asthma

UpdraftDowndraft

Outflow

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The challenges are….

• Being largely invisible

• Being geographically dispersed and

widespread

• Having a rapid onset

• Being unfamiliar or unknown, with less

practiced response protocols

Thunderstorm Asthma


Proposed pre conditions:

• High concentrations of allergenic material:

– mainly rye grass pollen also could be fungi and/or dust

• Thunderstorm outflow

• Respirable sized particles (<10microns)

• Exposure of people who are sensitive to the relevant allergen – can be either allergic rhinitis and/or asthma

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Who is at risk?

• Allergy to ryegrass pollen

• Allergic rhinitis (with or without known asthma)

• Asthma (especially if poorly controlled)

• Those not taking asthma preventer (inhaled corticosteroid (ICS))

• Exposed to open air before and during thunderstorm in pollen season

• Living in an area prone to high pollen counts, historically South Eastern Australia

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Asthma Australia survey

N = 3,396 responses (Self reported) from people “affected” by the thunderstorm asthma event.

• 79% experienced an asthma “attack”

• Hay fever (allergic rhinitis)– 92% suffered from hay fever

– 60% were treating hay fever

• History of asthma– 40% no previous diagnosis of asthma

• Asthma & hay fever– Over half had both

• Asthma first aid awareness– 53% of people with asthma were aware of first aid steps

– 25% of people not diagnosed were aware of asthma first aid

• Asthma diagnosis and experiencing an asthma attack– 73.5% had been prescribed a preventer

– Only half were taking it daily in the lead up to the 21st Nov 16

• Asthma Action Plans– 28% yes; 57% no, 15% never heard of one

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Be prepared!

“if you wheeze or sneeze

be proactive for spring”

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How can thunderstorm asthma be prevented?

• Good asthma control– Use regular preventer if prescribed

• Good allergic rhinitis control– Regular intranasal corticosteroid

• Written Asthma Action Plan

• Education– Understanding of risk factors, having reliever and

knowing how to use it, avoid breathing outdoor air during a thunderstorm

• Know asthma first aid

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4 groups of risk

• Current asthma

• Ever asthma

• Seasonal allergic rhinitis - no asthma

• No seasonal allergic rhinitis, no asthma

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Risk group – current asthma

• Manage as per current asthma guidelines

• Ensure correct use of inhalers, check adherence of preventers

• Seasonal preventer use: commence 6 weeks prior to pollen season

• Always carry reliever

• Current Written Asthma Action Plan

• Review for allergic rhinitis and treat if present

• Warn against being outdoors during thunderstorms in grass pollen season

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Risk group – any history of asthma

• Review for allergic rhinitis– If present, treat with intranasal corticosteroids 6 weeks prior to and

throughout pollen season

• Evaluate need for inhaled corticosteroids (ICS)– Consider allergies, seasonality of symptoms, how long since last

asthma episode, severity of previous asthma, other medical, psychological and social factors

• Explanation of how to recognise asthma symptoms and what to do– Carry a reliever and know how to use it, ensure correct device use (see

NAC videos www.nationalasthma.org.au/health-professionals/how-to-videos)

– Provide Asthma First Aid information (and spare for child minders)


https://www.nationalasthma.org.au/health-professionals/how-to-videos

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Risk group – allergic rhinitis but never asthma

For people with allergic rhinitis but no history of asthma at any stage:

• Identify those allergic to grass pollens– Treat with intranasal corticosteroids (INCS) beginning 6 weeks before and

throughout pollen season

• Manage allergic rhinitis as per current guidelines

• Explanation of how to recognise asthma symptoms and what to do– Carry a reliever and know how to use it, ensure correct device use (see

NAC videos www.nationalasthma.org.au/health-professionals/how-to-videos)

– Provide Asthma First Aid information


If no response to treatment consider referral for possible immunotherapy

https://www.nationalasthma.org.au/health-professionals/how-to-videos

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Allergic rhinitis treatment

• Intranasal corticosteroids (INCS)– Most effective medication for controlling symptoms

– Also effective for ocular symptoms associated with allergic rhinitis

– May also help with asthma symptoms

• Antihistamines– Mild allergic rhinitis

– Children who cannot tolerate INCS

• Montelukast (Singulair® and generics)– Those with concurrent asthma

– Young children

– Children who cannot tolerate INCS

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Allergic rhinitis treatment cont’d.

• Antihistamine nasal spray may be used in combination with INCS

• Allergen avoidance

– Important to confirm allergen

• Specific allergen immunotherapy (desensitisation)

– Sublingual or subcutaneous immunotherapy

– Can modify allergic immune responses

• Oral corticosteroids should be avoided

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Specialist referral

• If no response within 3-4 weeks of treatment trials

• Symptoms persistent, severe or unresponsive

• Continuing poor asthma control despite regular

preventer medication

• Other allergic diseases present (e.g. severe eczema)

• Food or occupational allergy suspected

• Complications such as resistant obstruction, sinus

disease, anosmia, ear problems and persistent purulent

discharge

• If immunotherapy is contemplated

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Thunderstorm asthma preventionin adults with grass pollen allergy

Regular INCS Regular ICS Written asthma action plan

Thunderstorm avoidance

Allergic rhinitis *

Asthma

Asthma and allergic rhinitis

* Patient with allergic rhinitis should have a written allergic rhinitis plan.

See ASCIA website: www.allergy.org.au

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Others

• People without either asthma or allergic

rhinitis are at very low risk

• Reassure them their risk is low

• Encourage to learn Asthma First Aid so

they can help others

Supported by the Department of Health and

Human Services (Vic)

Asthma Overview

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Diagnosis

• Based on:– History: personal and familiar (first degree relatives)

– Physical examination

– Diagnostic testing (e.g. spirometry)

– May include treatment trial (e.g. assess response to an inhaled bronchodilator)

– Diary card may be helpful

Make sure the diagnosis is right!

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Diagnostic testing

• Spirometry

– To assess airway function

– Pre and post bronchodilator testing to assess reversibility

– Can be used in older children and adults

– May be normal if asthma well controlled at time of testing

– Peak flow is no substitute or spirometry

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Asthma is more likely if:

• Symptoms are:– Recurrent or seasonal

– Worse at night or in the early morning

– Triggered by exercise, irritants, allergies or viral infections

– Rapidly relieved by an inhaled bronchodilator (SABA)

• Symptoms began in childhood

• FEV1 or PEF lower than predicted, without other explanation

• Eosinophilia or raised blood IgE level, without other explanation

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Steps in the diagnosis of asthma in adults

Steps in the diagnosis of asthma in children

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Alternative diagnosis

• Exclude non-asthma causes of wheeze or cough– Cough can be predominant symptom of asthma but extremely

rare to be the only symptom

• Consider:– Recurrent non-specific cough especially in children

– Other respiratory conditions e.g. uncontrolled allergic rhinitis, bronchiectasis, COPD, hyperventilation/dysfunctional breathing, inhaled foreign body, vocal cord dysfunction

– Cardiovascular disease e.g. chronic heart failure, pulmonary hypertension

– Co morbid conditions e.g. obesity

– Other causes of cough e.g. postnasal drip, enlarged thyroid, side-effects of medications

– Exercise-induced respiratory symptoms – is it ‘normal huff and puff’?



Asthma Management

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Management principles

• Asthma is a chronic disease– Needs ongoing care

– Not just about treating asthma attack

– Ongoing self-management education▪ Asthma Action Plans

• Need to consider– Lifestyle issues

– Medical management

– Comorbidities

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Lifestyle issues

• Smoking cessation

• Eliminate passive exposure

• Identify triggers

– Avoidance strategies

• Healthy well balanced diet

– ideal body weight

• Exercise regime/activity levels

• Stress management

– Anxiety/stress may trigger and/or increase asthma

symptoms

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Medical management

• Goal is to achieve and maintain:– Optimal asthma control

– Best possible lung function

– Minimal side effects

– Lowest effective dose

– Reduce risk of flare ups

• Most appropriate regimen determined by:– Pattern of symptoms

– Severity of symptoms

– Asthma control

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Asthma control

• Involves both:

– Assessment of recent asthma symptom

pattern and severity, reliever use and effect on

activities

– Assessment of risk factors for future adverse

events e.g. past flare ups, life threatening

asthma, adverse effects of treatment

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What is good asthma control?

• Daytime symptoms ≤2 days per week

• Reliever use ≤2 days per week

– Excluding before exercise

• No limitation of activities

• No symptoms during the night or on waking

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Reasons for poor asthma control

• Medication related issues– Incorrect device technique, poor adherence to preventer

therapy, preventer dose too low, medication interaction

• Uncontrolled trigger exposure– Rhinitis/allergen exposure, workplace/hobby exposure

to chemicals, continued smoking

• Limited knowledge of asthma and self

management– Potential denial

• No asthma action plan or regular asthma review

• Diagnostic issues:– It’s not asthma

– Mixed diseaseConsider a Medication Management Review if patient is on multiple medications

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Step up – Step down principles

• Aim of medication management is to maintain good asthma control with the lowest effective dose of ICS

• Step up if asthma not well controlled

• Step back when asthma well controlled

• Need to consider– Potential risks e.g. previous serious events/hospitalisations

– Severity of asthma

– Treatment-related adverse effects

– Achieved therapeutic benefits

– Patient’s wishes

• Once asthma well controlled, review 3-6 months

Thunderstorm Asthma


Step up – Step down principles cont’d

• Carefully check:

– adherence

– inhaler technique

– exposure to triggers

– the possibility that symptoms are due to comorbid or alternative diagnoses (e.g. uncontrolled allergic rhinitis or rhinosinusitis, de-conditioning, obesity, cardiac disease or upper airway dysfunction)

• Consider referral if nil response

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Step up step down……Adults Children

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Step down process

• Consider stepping down when well controlled for >3months– Not when about to travel or unwell

• Step down ICS dose– Aim for minimum effective dose

– Decrease by approx. 25–50% each time

• Withdraw LABA for at least 3 weeks– Advise to take SABA when needed

• Always symptom control and lung function

• Regular review

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Assess medication adherence

• Consider medication under-use for failure to control asthma symptoms

• Check patient’s prescribing records

• Discuss with patient any barriers to adherence– Lack of understanding of roles of medications

– Cost

– Device preference

– Where do they keep their preventer

• Adherence often poor in the adolescent and older persons

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Inhaler devices• Up to 90% of people use their devices incorrectly

• 22–56% of health care providers have never received any formal education on device usage

• Clear instruction and physical demonstration is essential

• Correct technique is not maintained unless instructions are repeated regularly

“matching the right inhaler to the right patient is key to ensuring effective therapy and good compliance”

Roche N,& Dekhuijzen R Journal of Aerosol Medicine & Pulmonary Drug Delivery Vol29, Number 0, 2016

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Consequences of incorrect device use

• Associated with poor asthma symptom control

• Reduced deposition of medication in the lungs– Increased risk of oral side effects of ICS

• Loss of short-acting beta2 agonist (SABA) effect

• This can lead to:– increased medication usage

– poorer asthma symptom control

– greater burden on medical services• 50% increased risk of hospitalisation

• Increased emergency department visits

– reduced quality of life

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Asthma review

• Recall patient for regular assessment

including updating their asthma action plan

• Self management education

• Highlight the important principles of chronic

disease management

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Exploring patient perceptions and guiding self-management

• Patients with asthma should be offered self-management education:

– focused on individual needs

– reinforced with a personalised written action plan

• Better self-management + regular review

= improved asthma outcomes

.

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Education

• Every asthma consultation is an opportunity

– Review

– Reinforce

– Extend knowledge

– Extend skills

• Education is a process not a single visit

• Must be appropriate to the patient’s level of understanding of their condition, educational status, age, language and culture

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Remember

• Before introducing further treatment

– Check device technique

– Check adherence

• Medication

– Lowest effective dose to minimise side effects

• When on multiple inhaled medications aim for consistent devices

– Less variety of devices = Less room for error



Asthma Action Plans

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Written asthma action plans

For all patients with asthma

• Improve asthma control

• For every 8 plans written, one unscheduled GP visit is saved

• For every 20 plans written, one hospital admission is spared

• Reduces mortality due to asthma

• Reduce days absent from work/school.

• Reduce emergency presentations to general practice

• Reduce hospital presentations and admissions

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Action plans help the patient/carer:

• Recognise worsening asthma

– Increased symptoms, especially waking from sleep

– Increased use of reliever medications

– Falling or variable peak flow readings

• Respond appropriately

– Adjust medication

– When to see a Dr

– When to call an Ambulance

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• Despite evidence of benefits ownership is low2011-2012

• 24.6% Australians with asthma (all ages)

• 40.9% children 0-14yrs

• Uptake is poor despite national guidelines’ recommendation for well over 20 years!

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Must:• Be personalised

• Be in language the patient understands

• Provide advice about modification of treatment

according to symptoms

• Contain emergency steps

• Include useful contact numbers

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Australian Asthma Handbook:Written asthma action plan overview

www.asthmahandbook.org.au/management/action-plans

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Asthma action plans

National Asthma Council

Royal Children’s Hospital

http://www.rch.org.au/clinicalguide/forms/Asthma_Action_Plan/

GP Computer software

http://www.rch.org.au/clinicalguide/forms/Asthma_Action_Plan/

http://www.bpsoftware.com.au/

http://www.zedmed.com.au/

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Targeted asthma action plans

Culturally appropriate

– for Indigenous Australians

Medically appropriate

– for SMART regimen



Acute asthma

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Acute asthma

• Primary assessment

– Mild/Moderate, severe or life-threatening

• History

• Management

• Follow up

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Rapid primary assessment

Mild/Moderate Severe Life-threatening

Can walk

Speak whole sentences in

one breath

(for young children: can

move around, speak in

phrases)

Oxygen sat >94%

Any of:

Use of accessory muscles

of respiration, tracheal tug,

subcostal recession

(abnormal breathing)

Unable to complete

sentences in one breath

due to dyspnoea

Obvious respiratory

distress

Oxygen sat 90-94%

Any of:

Reduced consciousness or

collapse

Exhaustion

Cyanosis

Poor respiratory effort,

soft/absent breath sounds

Oxygen Sat <90%

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History

• Precipitating factors of respiratory distress

– URTI

– Allergen exposure

– Food allergy

• Duration and severity of symptoms

• Medication history

– Response to bronchodilator (last used & how much)

– Any preventer use – check adherence

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Management at home –follow WAP

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Management at General Practice

• Salbutamol MDI via a spacer– Adult or child 6 years or older: 4–12 puffs

– Child <6 years: 2-6 puffs

• Repeat 20-30mins or sooner if

necessary

• Maintain oxygen saturation– Adults: 92–95%

– Children: at least 95%

• Nil response– Call ambulance 000

– Nebulised salbutamol only if patient unable to

breathe through spacer

– Consider commencement of oral

corticosteroids

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When is it an emergency?

• Severe respiratory distress– Use of accessory muscles

– Impaired speech due to dyspnoea

– Oxygen saturation <94%

• Reliever response is not immediate and not sustained for at least 3 hours

• Worsening of symptoms despite treatment

• Asthma action plan indicates the need for urgent medical care

• Call an Ambulance 000

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Emergency management of life threatening attack

• Oxygen driven salbutamol via continuous nebulisation– ≥6 years 5mg nebule

– 0-5 years 2.5mg nebule

• Maintain oxygen saturation– Adults: 92–95%

– Children: at least 95%

• Arrange immediate transfer to emergency department

• If poor response to salbutamol add inhaled ipratropium bromide

• When dyspnoea improves, consider changing to salbutamol via MDI plus spacer or intermittent nebuliser

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Primary care (GP) follow up

• Review previous flare up/attack and ascertain any lessons learnt

• Identify trigger factors

• Review medication regimen

– Has reliever on hand

– Assess if preventer indicated and check adherence

– Check device use

• Provide a follow up written asthma action plan for home use

• Review self management and action plan use

• Use spirometry to monitor lung function

• Review and modify the treatment plan as necessary

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Pharmacy/Community first aid protocol

1. Give 4 separate puffs of

SABA via spacer

2. Take 4 breaths per puff

3. Wait 4 minutes

4. If symptoms persist, repeat

steps 1-3

If still no improvement, call ambulance

and continue steps 1-3 until help arrives

Short Acting beta2 agonistSymbicort only if on SMART protocol

(lower strengths)

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Review reliever device use

• MDI alone– Ventolin, Asmol

• MDI and spacer– Ventolin, Asmol

• Turbuhaler– Bricanyl, Symbicort (if on SMART protocol)

• Autohaler– Airomir



Proactive approach is the key…..…How do we prepare?

Thunderstorm Asthma


What to do if a thunderstorm is forecast in spring

• Always carry a blue reliever puffer

• If prescribed, take daily preventer as instructed

• Know the signs of worsening asthma and the asthma first aid steps

• If any signs of asthma follow a personal asthma action plan or if no personalised WAP then follow the asthma first aid steps

• If asthma symptoms are rapidly worsening, call 000 and state having an asthma attack

• For those with known sensitivity to pollen and get allergic rhinitis stay inside on high pollen and windy days, and just before, during and after a thunderstorm

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At your clinic

• Be aware of thunderstorm asthma forecast

• Ensure bronchodilators are in date and have adequate supply

• Have a supply of spacers

• Have a clinic policy for patients presenting with an asthma flare up/attack– For all staff, including medical receptionists, practice nurses

and general practitioners to know their responsibilities

– Train all staff in asthma first aid and have chart on display

• Utilize recall systems for people with asthma to have regular review of their asthma

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At your pharmacy

• Ensure adequate supply of bronchodilators

• Maintain adequate supply of spacers

• Have a pharmacy policy for patients presenting with an asthma flare up/attack

– For all staff, including pharmacy assistants, dispensing technicians and pharmacists to know their responsibilities and prioritise these patients

– Train all staff in asthma first aid and have chart on display

– Know which GP clinics are open and able to assist if appropriate

• For patients requesting hay fever medications, ask about asthma symptoms. Suggest GP review if asthma symptoms are identified.

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Thoughts to consider….

• Does your clinic/workplace have an Emergency Asthma Plan Policy– Who has responsibility for different aspects of care

– Is there a consistent approach to emergency asthma management

– Does everyone in the practice know where a reliever is kept

• Refer to Australian Asthma Guidelines 2017

www.asthmahandbook.org.au

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In summary• Be proactive leading up to spring

– Don’t wait for something to happen

• Ensure correct diagnosis of asthma and/or allergic rhinitis– Know and understand management of triggers

• Address both lifestyle and medical management of asthma and

allergic rhinitis– Take preventer every day if prescribed particularly before and throughout

pollen season, ideally start before 1st September (the first day of Spring), but

make sure everyone is started by 1st October (AFL/NRL grand final weekend)

• All people with asthma to have a current Written Asthma Action

Plan and know how to use it

• Awareness of Asthma First Aid for all

• Have access to a “reliever” and know how to use it

State Government “Public Health Campaign” early Spring Asthma Australia COACH Program: 1800 ASTHMA

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Questions ?



www.nationalasthma.org.au

Ph: 1800 032 495

National Asthma Council AustraliaAustralian Asthma Handbook

thunderstorm asthma - murray phn...2017/08/18 · thunderstorm asthma supported by the department...

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