Management tools

teaching patients self management skills

Self management is a way of empowering patients to take control of their own condition. Evidence suggests that this is best achieved in partnership with a health professional, normally a primary care practitioner. This partnership must build on a trusting relationship, with ease of communication in both directions. Valuable input can also be provided by practice nurses, asthma educators and other members of the primary care team.

self management plans

A self management plan is flexible, individualised, and negotiated between the doctor and the patient. Self management plans are only effective in the context of regular medical review and systematic asthma education, i.e. they are part of a package which should be delivered in the primary care setting. Click here to read the seven steps to help you implement a self management plan for your patient.

While a complete self management plan may only be necessary for those with moderate or severe asthma, everyone with asthma needs to know what to do in an emergency, and where possible these instructions should be written down.

This update on the approaches to self management includes background information on asthma, the way to introduce appropriate medications, the role of long-acting beta-agonists (LABAs) and the use of combination medications.

Asthma and inflammation

The hallmark of asthma is an inflammation of the airways which is present all of the time. Associated with this is mucosal oedema, excess mucus production and thickening of the submucosal layer leading to substantial narrowing of the airways. On top of this the airway smooth muscle is hypertrophied and over-active, leading to an increased sensitivity of the airways to stimuli such as exercise, temperature change and allergen exposure.

Assessing asthma control

Many people with asthma play down their symptoms and/or become tolerant of them, reducing their level of activity to compensate. Many do not appreciate that their asthma could be under better control.

Asthma control should be assessed quantitatively using the following questions:

Do you use a reliever on most days of the week?
Any night-time waking or reliever use ?
Any limitation of physical activities?

High risk patients

Some patients with asthma are at greater risk of mortality and severe life threatening asthma attacks than others. Characteristics which suggest a higher risk include:

admission to hospital within the last 12 months
previous history of admission to ICU or loss of consciousness during an attack
active psycho-social problems, particularly anxiety and depression
variable peak flow rates with morning dipping
more than two courses of prednisone in the last 12 months
recent emergency nebulisation requirement
poor access to primary care services/low socio-economic group

Compliance/adherence

The most common explanation for failure to achieve good asthma control is a gap in the educational process such that the patient does not accept the need for regular anti-inflammatory preventive therapy. It is essential that the doctor addresses any concerns or fears about side effects before assuming that the patient will comply with therapy.

Once established on treatment, adherence to the regimen should be checked frequently in an open and non-judgemental fashion. Patient views and attitudes/beliefs should be taken into account if adherence is not maintained. Simple suggestions such as reducing dose frequency, linking taking medication to other activities such as tooth-brushing, etc, may be helpful.

Asthma medications - relievers

The main short-acting beta-agonist relievers are salbutamol and turbutaline. These drugs should only be used as required. Patients should be aware that if their reliever is not working, this means that their asthma is out of control, and further medical advice and an increase in anti-inflammatory therapy will be required. Those patients who remain symptomatic in requiring frequent doses of short-acting beta-agonists and who are on adequate doses of inhaled steroids (greater than 800 mcg BDP/BUD daily or fluticasone 500 mcg daily) should be started on a long-acting beta-agonist - formoterol or salmeterol. Under no circumstances should patients be instructed to take short-acting beta-agonists on a QID regimen. Patients should be educated to understand that an escalating requirement for short-acting beta-agonists is a danger sign.

Oral beta-agonists are almost never indicated as the side effect profile is substantially inferior to inhaled medications.

Asthma medications - LABAs

Long-acting beta-agonists have revolutionised asthma control and have a well-established efficacy and safety profile. The institution of long-acting beta-agonists will reduce symptoms, improve quality of life and reduce the frequency of both mild and more severe exacerbations. Long-acting beta-agonists are not associated with any serious safety concerns.

Formoterol is a rapid onset long-acting beta-agonist which is well tolerated and available in dry powder formulations. It is important that patients do not take excessive doses of this on a PRN basis. The usual dose is 6 mcg twice daily but some patients may need 12 mcg twice daily particularly to protect against exercise-induced symptoms.

Salmeterol is a slower onset long-acting beta-agonist which should be taken as a twice daily regimen to maintain asthma symptoms under control. The usual dose is 50 mcg twice daily. Extra doses are almost never indicated.

Neither drug should be used in isolation - ie all patients on these medications must be on an inhaled corticosteroid.

In the event of an exacerbation, the safest approach is for the patient to take extra doses of their short-acting reliever.

Asthma medications - inhaled corticosteroids

Inhaled corticosteroids are the mainstay of anti-inflammatory therapy. In most patients the initial dose of ICS should be around 400 mcg BDP/BUD, or 250 mcg fluticasone, in a twice daily regimen. For those with very severe initial symptoms a higher dose of initial therapy may be indicated. The usual maximal dose for BDP is 2000 mcg, for BUD 1600 mcg, and for fluticasone 1000 mcg.

Beclomethasone and budesonide are equivalent microgram for microgram in terms of their clinical effect and the main issue is to introduce the patient to a delivery device that they are comfortable with and can use readily. Their inhaler technique should be checked on a regular basis.

Fluticasone is a more potent inhaled corticosteroid and should be used in half or less of the equivalent dose of BDP/BUD.

Asthma medications - combination agents

Patients who have been on an inhaled corticosteroid for some time and who require a long-acting beta-agonist to maintain asthma control should be considered for a switch to a combination medication. Symbicort (formoterol and budesonide) is available in the turbuhaler for all patients on Special Authority. Seretide, a combination of salmeterol and fluticasone, is not currently funded by Pharmac but may be available in the future.

It is interesting that all research has shown some benefits in terms of adherence and clinical effectiveness when using the combined preparation compared to the two agents delivered through separate devices.

Patients on combination agents who suffer a severe exacerbation should be instructed to double the dose of their combination agent in the first instance, but if symptoms do not improve a course of prednisone is mandatory and in that instance they should revert to the use of short-acting beta-agonists for reliever requirements. Patients should not use excessive doses of combination agents because of the risk of beta-agonist side effects.

When to measure peak flow

Not everyone will want or need to measure their peak flow on a regular basis. However, it is important to obtain peak flow information in the following circumstances :

Diagnosis of

asthma
exercise-induced asthma
occupational asthma

Monitoring asthma status - when

measuring response to therapy
establishing an asthma self management plan
weaning off oral steroids
asthma is unstable
back titrating inhaled corticosteroids

and prior to routine consultation

Home monitoring

when symptoms develop/deteriorate eg after an upper respiratory tract infection
when asthma is unstable
for poor perceivers of airflow obstruction (define after initial diary)
for those who wish to follow an asthma self management plan based on PEFR
when back titrating inhaled corticosteroids

A diary of peak flow values twice-daily for two weeks is recommended.

As different brands of peak flow meter may vary in their absolute results, the asthma self management plan details must be based on the use of a single brand of meter. Peak flow meters should be checked for accuracy against a new meter of the same make every 12 months.

Spirometry will be needed if a diagnosis of airflow obstruction is needed for immediate diagnosis or assessment of severity.

Referral to Specialist

Patients who may benefit from seeing a specialist include those for whom any of the following apply:

poor response to treatment with uncontrolled symptoms
possible occupational asthma
frequent steroid courses or apparent steroid dependency
after a hospital admission or life-threatening attack
where the diagnosis is in doubt eg possible coincident COPD or bronchiectasis