Transcript Management of Acute severe asthma

An Update on Asthma management
and using Action Plans to support
patient care'.
HUH & CCG joint presentation
5th July 2013
An Update on Asthma management and
using Action Plans to support patient care'.
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Asthma care is still not optimal
Still seeing many patients in ED without ICS.
Some not registered with GP
Repeat attenders & …….
HUH adult asthma ED visits
Admission year
No
2006
1260
2007
1114
2008
1020
2009
1065
2010
1078
2011
645
2012
551
HUH adult asthma admissions
Admission year
No admitted
LOS
2006
205
4.11
2007
170
4.00
2008
163
3.78
2009
145
3.74
2010
183
4.02
2011
119
2.94
2012
131
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)
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.
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.
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!
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
Initial assessment
Initial assessment of exacerbation
Mild/moderate
Acute severe
Life threatening
Near fatal
Mild/moderate exacerbation
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Able to speak and walk easily
PEFR – 50 – 75% best or predicted
HR< 110
RR < 25
SATS>92%
No features of acute severe asthma
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
Management of Mild/moderate
exacerbation
• If PEFR still <75% treat as severe exacerbation
Acute severe exacerbation (any one
of the below)
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Inability to complete sentences in one breath
PEFR 33-50% of best or predicted
HR > 110
RR > 25
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
Life- threatening asthma – any one of the
following with acute severe asthma
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Silent chest
Altered conscious level including coma
Exhaustion
Cyanosis
Poor respiratory effort
Arrhythmia
Hypotension
PEFR <33%
SATS<92%, normal PaCO2
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.
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
Risk factors for life-threatening
asthma
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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
Admit to hospital
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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
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.
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
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.
ASTHMA ACTION PLAN
Name:
NHS/Hospital No:
D.o.b:
Date
YOUR ASTHMA TREATMENT:
Preventer
Additional Preventer
Reliever
Asthma Tablets
Other
Best/predicted PEFR:---------WHEN
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YOUR ASTHMA IS UNDER CONTROL:
Breathing good
No cough OR wheeze
Sleeping well
Good peak flow (>80%) >…….
IF YOU
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GET WORSE:
Wheezy /Breathless
Chest tight
Coughing a lot
Waking up in the night
Hard to exercise or to do daily activities
Peak flow worse (60-80%) ---- to ----
ASTHMA ATTACK/ EMERGENCY:
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Very wheezy/ breathless
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Inhalers not working
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Peak flow much worse (<60%) <-------
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Take preventers regularly
Use reliever when needed
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Use a spacer to take your inhalers
Take reliever 2 puffs 4 times a day
Increase your preventer to .. … puffs twice a day for
one to two weeks
Take rescue course of steroid tablets (prednisolone) if
you have them and phone your GP.
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Phone GP( or Out of Hours GP) as soon as possible
Take 2 puffs of reliever every 2 minutes using a spacer
up to a maximum of 10 puffs
IF YOU FEEL FAINT OR FRIGHTENED OR ARE FINDING IT DIFFICULT TO SPEAK CALL 999 OR ASK
SOMEONE TO DO THIS FOR YOU
GP PRACTICE NAME……………………………………….TELEPHONE NUMBER OF GP: . . . . . . . . . . . . . .
EMERGENCY GP (WHEN SURGERY IS CLOSED): . . . . . . . . . . . . . . . .
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HOW TO KEEP YOUR ASTHMA UNDER CONTROL – USEFUL INFORMATION
Take your inhalers regularly-make sure you don’t run out or stop taking them .
The preventers (not the relievers) are meant to stop you having asthma attacks and keep your asthma under
control.
If you do run out – order an emergency prescription from your GP/local chemist rather than going to A&E for this.
Please call your GP surgery if you are concerned about your asthma.
Check your peak flow 1-3 times per week.
Use a spacer to take your inhalers if possible especially if you are a bit wheezy.
Watch out for times when your asthma is worse (when you have a cold or hay fever or if you are allergic to
animals) and follow the advice above.
Have an asthma check- up at your GP practice once a year – this will help to keep your asthma under control.
Have a flu injection once a year.
Don’t smoke-ask your GP or nurse for help to stop smoking.
Name of the Health Professional:
Thank you for listening