1. 2012 UPDATE

2. What guidelines do we have available to follow for asthma 1) Asthma GP monitoring Guideline 2) Asthma Diagnosis Guideline 3) Acute asthma management guideline 4) Asthma Stepwise management

3.  The 2012 guidelines for Asthma have been written to improve the way we care for our asthma patients. The first part of the guidelines sets out the requirements of a good annual review.

5. Routine review in primary care The Sign/BTS Asthma Guidelines 2009 state there is strong evidence that proactive clinical review of people with asthma improves clinical outcomes, with those reviews that include discussion and use of a written self management plan being of greatest benefit. Proactive reviews are associated with reduced exacerbation and days lost from normal activity, as opposed to unstructured or opportunistic review. Outcomes are similar whether reviews are conducted by a Practice Nurse or GP with the best outcomes achieved with those clinicians with asthma management training. Identification of patients at high risk is recommended. Telephone review has been shown to be a suitable option for those patients who fail to attend for routine reviews. Routine management of Asthma Named healthcare professionals with appropriate qualifications Ongoing training and educational support Offer at least annual review to all those on the asthma register Time taken: approximately 20- 30 minutes Conducted by healthcare professional with appropriate education Aim: To identify if asthma is CONTROLLED or UNCONTROLLED and take action. Primary care asthma Review Clinical audit and evaluation Prioritisation of care Prioritise those at greatest risk of attack Proactive recruitment to attend for asthma assessment Telephoning resistant ‘DNA’ (Did Not Attend) patients to assess control and encourage attendance Priority / same-day appointments for those with deteriorating symptoms who are ‘At risk’ Consider telephone assessments Liaison with community pharmacists, schools, school nurses and community colleagues e.g. community nurses SIGN Definition of Factors Contributing to ‘AT RISK’ Previous near-fatal asthma Previous admission for asthma in the past year (including Accident & Emergency) Requiring three or more classes of medication Heavy use of short acting B2 agonist ‘ Brittle asthma' * How to identify of those at greatest risk – computer searches Previous near-fatal asthma Hospital attendance with asthma attack in past 2 months (including Emergency Department attendances) Presentation with asthma attack in primary care in past 2 months Two or more courses of oral steroids and/or antibiotics in past 6 months Heavy use of short-acting B2 agonist (> 3 canisters in 6 months) DNA asthma clinic or excepted from QOF Repeated days off school or work with Asthma.Brittle asthma’ Identification via regular computer searches and reviews of medical records Placement on an ‘At risk’ register for Asthma System devised to ‘flag up’ risk and prioritise attendance

6.  The next guideline looks at diagnosis of asthma patients  We are going to look at this new guideline with particular attention to reversibility  Included on this guideline is the variability required and how to calculate that variability  Quite often a nurse is presented with a patient who has been reversed by a GP and commenced medication such as Ventolin.

8.  Management of acute asthma in adults requires varying levels of treatment the next guideline sets out the most appropriate treatment for level of exacerbation.  Spacer, Nebuliser, Oxygen?  SpO2 level?  How much prednisolone?

9. Many asthma deaths are preventable. Factors leading to poor outcome include: Failure by clinical staff to objectively assess severity Patients or relatives failing to appreciate severity Under-use of corticosteroids 1.Assess (Determine severity) : Record Peak expiratory flow rate (PEFR), heart rate, respiratory rate, oxygen saturations (SpO 2 ) and complete a clinical examination. 2.Treat (According to severity) 3.Reassess (Response to therapy) 4.Educate & Follow-up ACUTE SEVEREMODERATEMILDLIFE THREATENING PEF <33% best or predicted PEF 33-50% best or predicted PEF >50-75% best or predicted PEF >75% best or predicted SpO 2 ≥ 92% Speech normal Respiratory rate <25/min Pulse <110bpm SpO 2 ≥ 92% Speech normal Respiratory rate <25/min Pulse <110bpm SpO 2 ≥ 92% Can’t complete sentences Respiratory rate ≥25/min Pulse ≥110bpm SpO 2 < 92% Silent chest, cyanosis Poor respiratory effort Exhaustion Bradycardia Treat at home / in surgery and assess response999 – Admit IMMEDIATELY 1. β 2 bronchodilator: eg salbutamol Via spacer device (2 puffs initially, and 2 puffs every 2 minutes according to response up to maximum of 10puffs) 1. β 2 bronchodilator eg salbutamol Via spacer device (4 puffs initially, and 2 puffs every 2 minutes according to response up to maximum of 10puffs) 2. Prednisolone 40mg (7days) RE-ASSESS (after 30minutes) Clinical improvement and PEF >/= 60% allow home PEFR <60% No clinical improvement Requires second nebuliser Concern over social circumstances Patient unable to monitor / assess own condition Previous near fatal attack RE-ASSESS (after 30minutes) Stable or improved and PEF >/=75% then allow home PEF <75% or clinical deterioration then manage according to severity 1.Oxygen (Target SpO 2 94-98%) 2. Salbutamol 5mg via a nebuliser preferably oxygen driven. If no nebuliser available give via spacer device (4 puffs initially, and 2 puffs every 2 minutes according to response up to maximum of 10puffs). 3. Prednisolone 40mg Prior to discharge (including following an Emergency Department attendance) ensure: 1 Patient is taking a regular inhaled corticosteroid 2 Inhaler technique is checked and is satisfactory 3 Medicines are explained and understood by the patient and/or carer 4 A written Self Management Plan is provided 5 Treatment is in accordance with BTS and Local guidelines and appropriate to severity of condition 6 Smoking cessation is discussed and recorded if appropriate 7 An Asthma UK ‘After your asthma attack’ leaflet is provided 8 Discuss and address potentially preventable contributors to recent exacerbation All patients should be reviewed by GP or practice nurse within 48hrs of acute treatment, or discharge from hospital including discharge from the Emergency Department On discharge - Educate & Follow up Admit if any: Life threatening feature Features of acute severe asthma after initial treatment Previous near fatal asthma attack Lower threshold for admission if: Afternoon or evening attack Recent nocturnal symptoms or hospital admission Previous severe attacks Patient unable to assess own condition or concern over social circumstances Admitting to hospital Admit If:

10.  The stepwise management reflects the guidance given on management of asthma as outlined by the British Thoracic Society as shown in the BNF  This year the layout has been changed to a more user friendly step up step down chart

11. Good Control Good Control Good Control NHS Kirklees, NHS Calderdale and NHS Wakefield District Stepwise management of asthma for adults ‘An inhaler is only as good as the technique and concordance of the patient using it’ STEP 1: Occasional relief of symptoms As required inhaled short- acting B 2 agonist (All patients must have) STEP 2: Inhaled corticosteroid (ICS) Beclometasone or Budesonide 200mcg* twice daily (Qvar 100mcg**twice daily) STEP 4: High dose inhaled corticosteroid Beclometasone or Budesonide 1000mcg twice daily * via spacer device or Fluticasone 500mcg twice daily via spacer device STEP 5: Use daily steroid tablets in the lowest dose providing adequate control Maintain high dose ICS at 2000mcg/day.* Consider other treatments (as mentioned above) – 6 week trial period, stop if no improvement in symptoms. Refer patient for specialist care STEP 3: Long acting B 2 agonist (LABA) Formoterol 12mcg twice daily or Salmeterol 50mcg twice daily – 4 week trial initially Beclometasone or Budesonide 400mcg twice daily* 3 month trial If already on this dose and sub optimal control of symptoms, proceed to next step Oral Leukotriene Receptor Antagonist: 3 month trial Sequential trial (3 months each) of: Oral MR Theophylline e.g. Uniphyllin, titrate dose to the therapeutic range Slow-release B 2 agonist tablets No clinical trials indicating which of these is the best option. BTS/SIGN asthma guidelines (2009) also support Symbicort SMART regimen in selected patients Poor control Poor Control Poor control Good Control Poor control Poor Control Poor control Good Control Poor control Poor Control Poor control Good Control Poor Control Poor Control Poor control including exacerbation of asthma requiring oral corticosteroids in the last 2 years Poor Control Issue Steroid safety cards for step 4 & 5 Good Control * For Budesonide and certain Beclometasone inhalers (see overleaf) ** Qvar, Fostair, Fluticasone need lower dose for equivalence (see overleaf) Step 3 consider referral to Respiratory Specialist: IF Doubt about diagnosis; Asthma disrupts lifestyle ; Possible food allergy; Consideration of nebulised therapy; Consideration of maintenance prednisolone; Past asthma admission; Second opinion; Anaphylaxis; Pregnant women with worsening asthma; Asthma threatening employment; Suspected occupational asthma; Sub optimal control: any of the below criteria Using reliever more than 3 times weekly Symptomatic more than 3 times weekly Waking one night a week Two or more courses of rescue oral steroids in past 6 months Sub optimal control: any of the below criteria Using reliever more than 3 times weekly Symptomatic more than 3 times weekly Waking one night a week Two or more courses of rescue oral steroids in past 6 months Inhaled corticosteroid (ICS) therapy risks: High dose ICS (1600mcg/day beclemetasone equivalent or Flixotide 1000mcg/day) is associated with a greater risk of systemic side effects including adrenal suppression, decrease in bone mineral density, cataracts and glaucoma, diabetes mellitus and adverse psychological and behavioural effects Inhaled corticosteroid (ICS) therapy risks: High dose ICS (1600mcg/day beclemetasone equivalent or Flixotide 1000mcg/day) is associated with a greater risk of systemic side effects including adrenal suppression, decrease in bone mineral density, cataracts and glaucoma, diabetes mellitus and adverse psychological and behavioural effects Goals of asthma therapy: Maximise asthma control Minimise number of asthma exacerbations Minimise treatment side effects Goals of asthma therapy: Maximise asthma control Minimise number of asthma exacerbations Minimise treatment side effects Reducing treatment: Step down should be considered After 12 weeks if control is achieved (and after every subsequent 12 week period). If control is maintained, therapy should be reduced (dose decreased by 25-50% each time) to the lowest step that maintains control When on combination ICS & LABA, the preferred option is to reduce does of ICS by 50% while continuing LABA. If control is maintained further reductions in ICS should be made until ona low dose, when the LABA may be stopped After stepping down review in 12 weeks and step up again if symptomatic Reducing treatment: Step down should be considered After 12 weeks if control is achieved (and after every subsequent 12 week period). If control is maintained, therapy should be reduced (dose decreased by 25-50% each time) to the lowest step that maintains control When on combination ICS & LABA, the preferred option is to reduce does of ICS by 50% while continuing LABA. If control is maintained further reductions in ICS should be made until ona low dose, when the LABA may be stopped After stepping down review in 12 weeks and step up again if symptomatic Group responsible: Enquiries to: Published: Review due: (unless clinical evidence base changes)

12. Notes Select the least costly product that is suitable for an individual, within its marketing authorisation Patient Education - Each patient should have a clear understanding of how to recognise and deal with deterioration - An individual self-management plan is essential - Patients should have a basic understanding as to how their medication works Rescue courses of steroids may be required at any stage to gain control and stabilise the condition. Prednisolone 40mg once daily for at least 5 days and until recovery of PEFR and symptoms A rescue course of steroids may indicate the need to increase regular treatment to the next step LABA should not be used without ICS Notes Select the least costly product that is suitable for an individual, within its marketing authorisation Patient Education - Each patient should have a clear understanding of how to recognise and deal with deterioration - An individual self-management plan is essential - Patients should have a basic understanding as to how their medication works Rescue courses of steroids may be required at any stage to gain control and stabilise the condition. Prednisolone 40mg once daily for at least 5 days and until recovery of PEFR and symptoms A rescue course of steroids may indicate the need to increase regular treatment to the next step LABA should not be used without ICS Combination inhalers: Should NOT be used before step 3 of asthma therapy May improve compliance over the combined use of the individual components as separate inhalers Dose of inhaled corticosteroids (ICS): Table below adapted from BTS/SIGN asthma guidelines (updated January 2012) shows equivalent doses of ICS: Steroid, name, inhaler device and trade name Equivalent dose Beclometasone200mcg * Clenil Modulite pressurised aerosol inhaler (PAI) 200mcg Dry Powder Inhaler e.g. Easyhaler, Pulvinal, Asmabec Clickhaler, Cyclocaps 200mcg * Qvar (PAI, Autohaler or Easi-Breathe)100mcg Fostair $ 100mcg Budesonide200mcg Dry Powder Inhaler e.g. Easyhaler, Budelin Novoliser, Pulmicort Turbohaler & Symbicort 200mcg Fluticasone100mcg Pressurised aerosol inhaler e.g. Flixotide Evohaler & Seretide $ Evohaler100mcg Dry Powder Inhaler e.g. Flixotide Accuhaler, Flixotide Diskhaler & Seretide $ Accuhaler 100mcg Mometasone100mcg Ciclesonide100 – 150mcg Must be prescribed by brand name $ Combinations with long acting B 2 agonists (LABA): Take care prescribing these as the relative amounts of steroids and LABA differ depending on the particular product chosen. Information on inhaler technique is available at: http://www.medicines.org.uk/guides/pages/how-to-use-your-inhaler-videos http://www.asthma.org.uk/how-we-help/teachers-and-healthcare- professionals/health-professionals/interactive-inhaler-demo/ For telephone review or persistent DNA’s Consider referral to a community Pharmacist for inhaler technique review as part of a targeted Medicines Use Review or New Medicine Service review. Smoking is a major trigger factor for asthma and a significant cause of poor control, reducing exposure to cigarette smoke is essential Stop Smoking advice and avoidance is vital. Manage gastro-oesophageal reflux & rhinitis as clinically appropriate, there is however, a lack of evidence that this will improve asthma control

13.  Despite best efforts or not lots of asthma patients attend casualty costing over £50 simply for walking through the A+E doors.  Follow up all A+E attendances  Have the respiratory/asthma A+E reports passed over and get them in to see you for a Self Management Plan and Emergency Rescue Pack issuing (if needed) or to change their inhalers as per the stepwise guidelines