Asthma Management for nurses in General Practice

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Asthma Management for nurses in General Practice

• Maria McKinnon
• Asthma Educator
• HARP
• Hospital At Risk Program
• June 2007

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OUTLINE

• What is asthma?
• Triggers
• Types of Medications
• Importance of adherence
• Correct Device Use
• Spacers
• Asthma First Aid Plan
• Asthma Action Plan
• Asthma cycle of Care
• Empowering your patients to self manage their
  asthma

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ASTHMA

• Asthma is a chronic inflammatory disorder of the
  airways
• in which many cells play a role.
• with widespread but reversible airflow
  obstruction
• an associated increase in the bronchial
  hyper-responsiveness to a variety of stimuli
  (NHLBI1997)

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ASTHMA
Constriction of the muscle wall

• If not treated will lead to airways
• remodelling

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• Important to explain there are 2 processes
• 1. Constriction on the outside of the
  bronchioles which bronchodilators e.g. Ventolin
  relieves .
• 2. Inflammation,swelling and mucus production
  inside the bronchioles in response to a trigger
  factor
• Ventolin only treats the symptoms
• Ventolin does not work on the inside of the
  bronchioles and stop the inflammation.

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Symptoms of Asthma

• Possible iintermittent wheezing
• Cough, particularly at night and early in the
  morning
• Chest tightness
• Chest discomfort
• Shortness of breath

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Cycle of unstable asthma
Unstable asthma
ED Presentation
Non-adherence
Prescribed medication
No perceived effect

• Asthma Education needed to stop the cycle

Incorrect device use
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TRIGGERS

• Bronchial infections
• Allergens HDM, cat, mould,
• Changes in air temp/weather
• Chronic rhinosinusitus post nasal drip
• Drugs Beta blockers, NSAIDS, aspirin
• Emotion stress, laughter
• Exercise

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TRIGGERS

• Food additives
• Gastro - esophageal reflux
• Hormones premenstrual or pregnancy exacerbations
• Irritants Smoke (passive active), odours
  bleaches, perfumes
• Job Occupational (dust, fumes).

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Medications

• 1. RELIEVERS - Bronchodilators e.g. Ventolin
• 2. PREVENTERS - Anti-inflammatory e.g. Flixotide
• 3. SYMPTOM CONTROLLERS - Long acting beta2
  agonist e.g. Oxsis
• 4. COMBINATION - medication e.g. Seretide and
  Symbicort

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Relievers (blue/grey)

• Salbutamol (Ventolin, Airomir, Asmol, Epaq)
• Terbutaline (Bricanyl)
• Bronchodilators (Short acting beta2 agonists)
• Acute relief of asthma symptoms
• Prevent exercise induced asthma
• Effective within a few minutes lasts for 4 to 6
  hours.
• Shakiness or palpitations may occur.

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Relievers

• Ipratropium bromide (Atrovent)
• Bronchodilator
• Anticholinergic
• Relieves smooth muscle contraction
• Reduces mucus production
• Tiotropium (Spiriva)
• (Long acting for COPD only)
• Theophylinne (Nuelin )
• Bronchodilator
• Narrow therapeutic index (difference between
  therapeutic toxic is small)
• Provides little additional bronchodilatation when
  maximal doses of beta2 agonists have been given

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PREVENTERS

• Steroid and non steroid
• Prevents symptoms by treating airway inflammation
• Improves lung function
• Need to be taken every day even if feeling well
• Do not provide immediate relief of symptoms. Tell
  pts it can take a few weeks to work

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Inhaled corticosteroids

• Beclomethasone diproprianate
• Budenoside
• Fluticasone propionate
• Tell Pts to always rinse mouth with water and
  spit it out after any corticosteroids to prevent
  thrush

• - Qvar
• - Pulmicort
• - Flixotide

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Ciclesonide (Alvesco)

• New corticosteriod
• For children over 12 years and adults.
• Ultra-fine deposition aerosol which may
  facilitate intrapulmonary deposition.
• Does not need to be shaken before use.
• Once a day ONLY
• Except before first use of the MDI, or if not
  used for a week, release 3 puffs away from you
  into air to check it is working properly

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Preventers

• Inhaled non-steroidal anti-inflammatory
• Leukotriene Antagonists Singulair Blocks the
  effect of leukotrienes (inflammatory mediator)
• Mild disease or aspirin sensitivity
• Non steroidal
• Tablet taken once a day
• Treatment response variable
• Intal, (Neocromil sodium) Tilade (Sodium
  cromoglycate )
• Non-steroidal anti trigger
• Stabilises prevents mediator release from mast
  cells
• Used prior to exposure to allergen or exercise
• Taken QID
• Mouthpiece easily blocked wash plastic part daily

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Symptom Controllers

• Serevent (Salmeterol)
• Foradile, Oxis (Eformoterol)
• Long-acting bronchodilator
• Lasts for 12 hours
• Taken twice daily
• Used for
• 1. Nocturnal asthma
• 2. Exercise symptom control
• 3. Maintenance treatment of asthma

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Combination MedicationInhaled corticosteroids
and long-acting beta2 agonists

• Seretide
• Combines Flixotide and Serevent
• Symbicort
• Combines Pulmicort and Oxis
• Increases compliance
• Lasts for 12 hours

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Symbicort and SMART

• Symbicort Maintenance and Reliever Therapy
• Use Symbicort 100 or 200 BD day as a preventer
• Also use Symbicort one inhalation PRN as a
  reliever( instead of Ventolin)
• Up to 6 reliever inhalations in a day
• See Symbicort Asthma Action Plan

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Puffer technique

• 1. Remove the cap from the mouthpiece
• 2. Shake the puffer.
• 3.Breathe out slowly and gently. Place the
  mouthpiece in your mouth.
• 3. Tilt the chin
• 4. Begin to breathe in through your mouth, and
  at the same time press the top of the puffer.
  Continue to breathe in SLOWLY AND DEEPLY until
  your lungs are full
• 5. Hold your breath for 5-10 seconds
• 6. Breathe out gently. If you are taking a second
  puff shake the puffer again and repeat steps 2-5

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WHY YOU MUST SHAKE BETWEEN PUFFS AND DO ONE PUFF
AT A TIME

• You must shake MDI before each actuation to give
  correct mix of propellent and medication as one
  is heavier than the other
• Multiple puffs into a spacer decrease small
  particle emission by
• a third for 2 puffs
• and half for 5 puffs
• Therefore you do not receive the correct dose
• Slader et al 2002 Pharmacist
• Exception is Alvesco as it has a very fine pre
  mixed solution

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Priming devices

• Ventolin, Flixotide Alvesco MDIs If a new
  inhaler OR if you have not used the MDI for one
  week spray one dose into the air before use to
  mix properly and check it working.
• Seretide Spray 3 times until counter at back of
  MDI says 120
• Symbicort Turbuhaler before first use need to
  twist to the left and to the right 3 separate
  times to prepare the turbuhaler

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SPACERS - WHY

• Remove the need for coordination of acuation and
  inhalation
• Increase delivery to lower airways
• Reduces local and systemic side effects
• As effective as an nebuliser.
• Maximum benefit faster 60 mins with Spacer
• 90 mins nebuliser.
• See Cochrane www.Cochrane.org/airways

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SPACERS
ABLE
SPACER
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SPACERS

• All children must use a spacer when using MDI's
• lt3 year olds - small volume spacer with face
  mask
• 3-6 year olds small volume spacer, with a mask
  until they are able to have a good seal around
  the mouth piece.
• gt6 year olds - large volume or ABLE spacer
• All adults should use a spacer with an MDI

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MDI Spacer

• Remove cap of MDI SHAKE
• Insert into spacer
• Place lips around mouthpiece
• Press down on canister to release one dose
• Take 3-4 smaller breaths
• 6. Hold breath for 5-10 seconds
• 7. Repeat steps 1-6 for further doses
• Cleaning
• To reduce static the spacer needs to be cleaned
  in warm water with a little detergent. Then drip
  dried. NOT rinsed or wiped dry.
• Wash every 2-4 weeks

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Common mistakes

• Incorrect timing of actuation
• Failure to shake MDI before EACH puff need to
  mix propellent and medication
• Failure to do ONE PUFF AT ATIME
• Failure to hold breathe for 5-10 seconds after
  actuation

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Turbuhaler

• Remove cover
• Hold upright (NB to get correct dose)
• Turn base anticlockwise
• Turn base to Clockwise left until you hear a
  click
• Breath out away from turbuhaler
• Place mouth around mouthpiece
• Breathe in QUICKLY AND DEEPLY
• Remove Turbuhaler before breathing out.
• Repeat steps 2-8 for furthers doses
• Replace cover
• First time need to do step 2 to 4 x3 times the
  first 2 turns get it ready for loading. The third
  turn of base in both directions loads the dose

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Accuhaler

• 1. Open the accuhaler by placing your thumb in
  the thumb grip, rotate it fully until it clicks
• 2. Slide the lever until it clicks, this prepares
  the dose ready for inhalation
• 4. Breathe out away from the accuhaler
• 5. Put the mouthpiece to your lips
• 6. Breathe in Steadily and Deeply through your
  mouth
• 7. Remove the accuhaler from your mouth and hold
  your breath for 10 seconds
• 8. Breathe out slowly
• 9. Repeat steps 3-8 for further doses
• 10.Close by using the thumb grip to rotate the
  cover until it clicks back into place.

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AUTOHALER (Qvar)

• Remove mouth piece cover
• Hold upright and click Red lever up
• Breathe out normally
• Place device between lips
• Breathe in SLOWLY and deeply
• Keep breathing despite click
• Hold breath for 5-10 seconds
• Click Red lever back in place and replace
  mouthpiece cover.

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Peak flows

• PEAK FLOWS
• Need to be charted over a week when patient is
  well to get average range.
• Can be useful to access a pattern of asthma the
  severity of asthma
• Peak flows are not always reliable
• Effort dependent. Beware!
• Technique can be unreliable

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Empowering your patient

• Teach the patient to self manage through
  education
• What is asthma
• How the different medications work
• Correct device use and care, check their
  technique
• Importance of adherence
• Signs and symptoms of the different stages of
  asthma
• Utilizing the written Asthma Action Plan
• Asthma First Aid 4x4x4x4

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ASTHMA ACTION PLANS

• Get Dr to write out Action Plan Mandatory for
  Asthma Cycle of Care
• Go through plan with the patient
• Different types of mediations eg which is their
  preventer, reliever and combination medicine.
• Signs and symptoms of severity
• If you need a reliever more than 3 times a week
  you need a preventer.
• If you need Ventolin 3 hourly see Dr for
  Prednisalone and review ( reception staff to make
  apt ASAP)
• If you can only speak in sentences not well. If
  can only say one word go to hospital.
• Asthma First Aid Plan

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Asthma First Aid Plan 4 x4x4

• Sit the person down, Stay Calm
• Get out spacer have 4 separate puffs of Ventolin
• Wait 4 minutes
• If no better have another 4 separate puffs
• Wait 4 minutes
• If no better ring 000 and go to hospital
• repeat steps whilst waiting if necessary

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Asthma Cycle of Care

• Very easy and achievable
• Must be an Accredited practice and registered for
  the Asthma PIP.
• Visit I Patient presents with exacerbation or
  for a script. Doctor follows steps and writes up
  Asthma Action Plan
• Doctor makes review appointment within 12
  months
• Nurse if trained, can assist

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• Pt education What is asthma,differences between
  asthma medications, NB of adherence
• Checking correct device use and care.
• Trigger factors how to identify and manage
• Spirometry
• Walk patient through Asthma Action Plan
• Peak flows
• Set up recall list
• Book in for long 2nd consult
• Letter for patients with date for 2nd visit pt to
  write in diary, palm pilot, calendar when get
  home

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• Remind patients to bring their medications and
  devices to check their technique
• If performing spirometry No bronchodilators 4
  hours before spirometry or combination medication
  12 hrs before.
• Phone or mail reminder to pt to return for 2nd
  visit
• Claim SIP of 100

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SIP payments

• Visit one Usual item number depending on length
  of the visit
• Visit 2 Special Item number depending on length
  of visit
• GP Attendance
• Level B 2546 Out of surg consult 2547
• Level C 2552 Out of surgery consult 2553
• Level D 2558 out of surgery 2559
• For Non- Referred attendances see MBS book

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Northern HARP Asthma Service

• If you do not have the time available
• Would like FREE spirometry
• Would like your pt to have a FREE spacer
• Refer to us
• We fax spirometry results and interview report to
  practice
• Ring 8345 5336
• Fax [phone]
• Leave a message if office unattended
• Mondays and Wednesdays at Northern Hospital
• Tuesdays at Broadmeadows Health Service

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REFERENCES

• National Heart lung Blood Institute Report, USE
  1997.
• A/ Professor Frank Thien, Alfred Hospital, 2004
• National Asthma Strategy Goals Targets.
  NAC,19944. Lung Health Promotion Centre at the a
  Alfred, 2004
• 5. Dr J. Hayes, TNH 2003
• Asthma Management Hand book, NAC, 2006
• Introductory course in Asthma Education. Lung
  health Promotion Centre
• Acknowledgements
• Lucy Keatley Kylie Thitchener