An Update on Asthma management and using Action Plans to support patient care'.

1. An Update on Asthma management and using Action Plans to support patient care'. HUH & CCG joint presentation 5th July 2013

2. An Update on Asthma management and using Action Plans to support patient care'. • Asthma care is still not optimal • Still seeing many patients in ED without ICS. • Some not registered with GP • Repeat attenders & …….

3. HUH adult asthma ED visits

4. HUH adult asthma admissions

5. 2012 ED study results • 71 pts had no allocated GP on EPR • 51 pts asked for supply of inhalers (not seen for exacerbation!) • 47 pts were not on ICS • ICS status was unknown for 282 pts • 119 pts were repeat attenders (2 or more)

6. KEY MESSAGES FROM ASTHMA AUDIT CONSORTIUM MEETINGS (2012) • 50% of A&E or admission are children - either definite asthma or viral wheeze. • Care is variable within and between primary and secondary care. Need for an urgent care pathway to provide guidance on the management of acute asthma in primary and secondary care for adults and children.

7. KEY MESSAGES FROM ASTHMA AUDIT CONSORTIUM MEETINGS (2012) • Patients not being followed up after an exacerbation/admission • Some patients are ‘hard to reach’-do not attend appointments and non-concordance with medication. Need some outreach for this group to follow up exacerbations and admissions and do some preventive work.

8. KEY MESSAGES FROM ASTHMA AUDIT CONSORTIUM MEETINGS (2012) • Need for Asthma action plans-advice about how to recognise and manage/prevent exacerbation based on symptoms and peak flow. •   Inhaler technique.-a Hackney you tube video on CCG website would be a good idea!

9. ADULT ASTHMA URGENT CARE PATHWAY HOMERTON UNIVERSITY HOSPITAL AND C&H CCG Based on CHARM guidelines 2008,SIGN guidelines 2012 and Map of Medicine 2012

10. Initial assessment

11. Mild/moderate exacerbation • Able to speak and walk easily • PEFR – 50 – 75% best or predicted • HR< 110 • RR < 25 • SATS>92% • No features of acute severe asthma

12. Management of mild/moderate exacerbation • Salbutamol via large spacer device( up to 10 puffs) • Repeat PEFR after 5 – 10 mins • If PEFR > 75% best or predicted : • Salbutamol 2 puffs via spacer as required. • Prednisolone 30 - 40mg daily for 7d and continue inhaled steroids via spacer . Continue oral steroids longer if patient still remains symptomatic and PEFR has not achieved its target. • Quadrupling ICS may be appropriate for some patients with mild exacerbation as per the action plan. • Provide written asthma action plan • Review by GP/PN in 48 hours or sooner if needed • Consider rescue steroids

13. Management of Mild/moderate exacerbation • If PEFR still <75% treat as severe exacerbation

14. Acute severe exacerbation (any one of the below) • Inability to complete sentences in one breath • PEFR 33-50% of best or predicted • HR > 110 • RR > 25

15. Management of Acute severe asthma • Salbutamol 5mg via nebuliser (via oxygen) and repeat if necessary. • Repeat PEFR after 15 min • If PEFR >50 - 75% treat as mild/moderate exacerbation • If PEFR = 33-50% then review risk factors for admission and discuss with A&E consultant • May need to attend A&E or be admitted • Arrange to review 48 hrs after admission or A&E attendance

16. Life- threatening asthma – any one of the following with acute severe asthma • Silent chest • Altered conscious level including coma • Exhaustion • Cyanosis • Poor respiratory effort • Arrhythmia • Hypotension • PEFR <33% • SATS<92%, normal PaCO2

17. Near fatal asthma • Raised PaCO2 and/or requiring mechanical ventilation. • A previous history of this is useful in the initial assessment of the patient in order to stratify further management. Patients with a history of near fatal asthma require hospital admission.

18. Management of life -threatening asthma • Salbutamol via nebuliser 5mg via oxygen driven (flow rate 6 to 8 lit). Repeat and offer back to back therapy if required. • Prednisolone 40-50mg stat dose • Call ambulance and arrange admission

19. Risk factors for life-threatening asthma • Previous near-fatal episodes • Previous admissions in the past year or frequent A&E attendance • Step 4 or above • Heavy use of salbutamol • Brittle asthma • Severe mental illness • Use of major tranquillisers • Alcohol or substance misuse • Learning disability • Non compliance with treatment and monitoring • Pregnancy • Already on steroids • Adverse social circumstances

20. Admit to hospital • Life threatening features • Features of acute severe asthma present after initial Rx • P/H of near fatal asthma • Lower threshold for admission if: afternoon or evening attack, recent nocturnal symptoms or hospital admission, previous severe attacks, recent nocturnal symptoms or hospital ad.mission, previous severe attacks

21. Post –exacerbation review • All patients should have a review 48 hrs after discharge and 1 week after exacerbation (sooner if needed) • The review provides an opportunity to: • Alter medication (step up if needed) • Provide asthma action plan • Consider rescue steroids • Review risk factors for life –threatening asthma • Provide stop smoking advice • Arrange post- bronchodilator spirometry (after 6w) if you suspect COPD.

22. Problems • Not being registered with GPs • Patients who find it difficult to get to their GP visits in normal working hours • Noncompliance to medications • Poor asthma knowledge due to no asthma education - due to work load of practice nurses • Poor allergy control • Missing GP asthma appointments • Lack of coordinated asthma care

23. Suggestions • Review your practice – a database for asthma and look at the profiles. Look out for those requiring too many SABAs and oral steroids. • Look at guidelines • Asthma review by doctors and nurses; particularly those who are uncontrolled. • Asthma action plan (see next slide) for all. • Step 4 asthmatics to be reviewed at least once in the local asthma clinic. • Training for nurse practitioners.

25. Thank you for listening