Non-acute Asthma in Adults; Management Flashcards
Practice point
Treat all asthmatics with ICS
An anti-inflammatory reliever (AIR) inhaler can be used to achieve rapid relief and maintain control in mild to severe asthma.
Māori and Pacific peoples are far more likely to be dispensed salbutamol alone. The use of salbutamol alone without an inhaled corticosteroid (ICS) is no longer recommended.
Request non-acute respiratory assessment
following a severe exacerbation or hospitalisation.
Find ways to tailor your asthma care to the needs of patients who are likely to experience barriers to equitable asthma outcomes e.g., Māori and Pacific peoples:
. Provide flexible scheduling and reminders according to patient need.
-Flexible scheduling and reminders
-Use acute presentations (to urgent care, the emergency department,
and hospital admissions) to prompt a personal invitation for a follow-
up.
-Consider scheduling extended consultations to prioritise the
relationship with the patient and facilitate shared decision making
with rangatahi, whānau, and those who have been disconnected from
healthcare.
-Offer personalised reminders or support to get to appointments.
-Audit patients to identify those at risk of severe and fatal asthma
enabling targeted extra care.
. Book reviews and vaccines in advance.
. Offer flu vaccination opportunistically.
. Ask about and assist with any difficulties accessing medical care and medication.
-Offer targeted funded care and outreach services to all patients who
qualify, particularly Māori and Pacific Island patients.
-Complete disability allowance forms.
-Recommend applying for a high use health card when appropriate.
-Consider back pocket prescription for emergency supply of oral
steroids.
-Encourage the use of a single pharmacy to take advantage of the
prescription subsidy scheme.
-Consider linking to a funded long-term condition pharmacy service
(e.g. Medicines Adherence Support Service (MASS), Medicines Use
Review (MUR) services, medication review services offered by some
PHOs) if available.
. Request respiratory nurse services for community-based specialist nursing, support, and education.
. Consider an audit to identify patients at risk of severe or fatal asthma and any variation in prescribing rates of ICS or AIR according to ethnicity.
Encourage
smoking cessation.
Together with the patient, choose and implement a stepwise medication plan:
. Anti-inflammatory reliever (AIR) therapy
. Traditional ICS and SABA therapy
Encourage self-management at every review:
. Ask about their inhaler use – when, why, how, and how often they use and forget it.
. Check inhaler technique.
. Update their asthma action plan and ensure they understand it.
. Endorse regular physical exercise and healthy nutrition to maintain a healthy and active lifestyle.
. Support them to achieve and maintain a smoke-free environment.
Provide education:
. Asthma education resources
. Trigger avoidance;
- Avoiding or protecting against workplace exposure is essential.
- Unflued gas heaters can worsen asthma – support the patient to
source electric heat pumps where possible.
-Hand and cough hygiene protect against respiratory infections.
. Asthma in sports;
- Exercise-induced asthma is generally a symptom of poor asthma
control.
-Some athletes develop bronchospasm at high intensity exercise but
do not otherwise show evidence of asthma e.g., rowers, swimmers,
cross-country skiers. Differentiation between this situation and
asthma should be undertaken by a respiratory specialist.
-Elite athletes should be aware of the anti-doping requirements for
asthma medications for their sport. See NZ Formulary – Drugs and
Sport
. Respiratory nurse services for community-based support and asthma education.
If suspected occupational asthma, arrange specialist treatment through ACC:
. Lodge a gradual process ACC claim – See Check the Type of Claim You’re Lodging.
. Request non-acute respiratory assessment – access private ACC-funded services where available.
Address allergen fears and risks:
. Offer advice about dust, cats, food, and mould;
-House dust mites – The available avoidance strategies are labour-
and cost-intensive, and don’t significantly alter asthma control.
-Cats – The evidence supporting cat removal for asthma control is still
unclear.
-Food sensitivities and allergies – Unlikely to affect asthma control
unless there is associated anaphylaxis.
-Mould – There are no trials available looking at effect of reduction in
fungal allergen levels on asthma control, but reducing exposure may
be worthwhile.
. Manage risks e.g., anaphylaxis, aspirin sensitivity, or nasal polyposis.
-Food-related anaphylaxis (a risk for fatal asthma)
-Sensitivity to aspirin or non-steroidal anti-inflammatory drugs
-Inhaled allergens – Nasal polyps may indicate significant exposure
-Consider requesting non-acute immunology assessment. Treatment
options are often time consuming and expensive and may include:
..sublingual or subcutaneous allergen immunotherapy for
confirmed inhaled IgE allergies.
..aspirin desensitisation to treat NSAID and aspirin hypersensitivity.
..epipen to manage anaphylaxis.
Consider arranging further support, especially for Māori and Pacific peoples, to minimise barriers to good asthma control:
. Social and housing support, funding, and advocacy
. Fitness and lifestyle support
. Respiratory physiotherapy for breathing techniques – if chronic
breathing dysfunction suspected due to an over-reliance on relievers
when PEFR is reasonable
If ongoing poor control despite good management, consider further steps:
. Consider alternative diagnoses and co-morbidities, particularly if there
are atypical findings.
. Request respiratory nurse services for community-based specialist
nursing, support, and education.
. If uncertain about management, consider seeking respiratory advice.
. Request non-acute respiratory assessment if the clinical picture is
unusual, or for possible medical management add-ons.
. If appropriate, request non-acute immunology assessment for
possible aspirin desensitisation or allergen immunotherapy.
