Managing adults with asthma in primary care: the four-stage consultation

Patients who have been diagnosed with asthma (see: “A specified increase in lung function following bronchodilation is no longer required for a diagnosis of asthma”) should have their level of symptom control and exacerbation risk assessed at Stage one of each consultation.¹

As patients often under-report their symptoms, the five-question Asthma Control Test (ACT) is recommended.¹ The ACT asks patients to rate:¹

• Any limitations at work, school or home
• The frequency of any dyspnoea
• The frequency of any night waking
• Their frequency of reliever medicine use
• Their own assessment of symptom control

Each question is scored from 1–5, with higher scores indicating good control and lower scores indicating poor control. A total score of 20–25 indicates the patient’s asthma is well-controlled and their treatment is appropriate; a score of 16–19 indicates partial control and prompts consideration of whether treatment is sufficient; a score of 5–15 indicates poor control and the need for intensification of treatment.¹

The asthma control test is available from: www.asthmacontrol.co.nz

Review any lung function tests

If the patient is performing peak flow monitoring or if spirometry is available in the practice, these measurements can be helpful in assessing asthma control and determining if a change in treatment is indicated.

Assess asthma severity

Asthma severity is determined by the level of treatment required for the patient to maintain good control. For example, mild asthma is well controlled with infrequent use of a short-acting beta₂-agonist (SABA) or with a standard daily inhaled corticosteroid (ICS) dose.⁷ Moderate asthma requires a “step up” in treatment to achieve good control, e.g. replacing an ICS with a combination ICS/long-acting beta₂-agonist (LABA) inhaler.⁷ Severe asthma is when symptoms are uncontrolled despite the patient being adherent to optimal treatment, taken correctly.¹

Information on ICS treatment is available in: “Inhaled corticosteroids for adults with asthma” and information on stepping up to a LABA is available in “Adding a LABA to asthma treatment for adults”.

Assess the future risk of exacerbations

Assessing the risk of future adverse outcomes is a new and important feature of the Asthma Guidelines. Patients with an increased exacerbation risk may require a step up in treatment, e.g. those with:¹

• SABA use greater than one canister per month
• The need for long-term or repeat courses of oral corticosteroids
• Under use or poor adherence to ICS treatment
• A history of sudden asthma exacerbations
• A history of unplanned consultations, emergency department visits or hospital admissions

Further information on assessing asthma exacerbation risk is available in: “Adding a LABA to asthma treatment for adults”

Consider if the patient has any treatable traits

The concept of “treatable traits” is new to the New Zealand Asthma Guidelines. This refers to the recognition and management of overlapping disorders, co-morbidities, environmental and behavioural factors to improve asthma care. This approach is most likely to benefit patients with asthma who have poor respiratory health despite optimal asthma treatment.

Disorders that may overlap with asthma

Overlapping respiratory disorders that may exacerbate symptoms in patients with asthma include, chronic obstructive pulmonary disease (COPD), allergic bronchopulmonary aspergillosis (ABPA), bronchiectasis and dysfunctional breathing, i.e. breathing too deeply and/or too rapidly.¹ Patients with features of COPD may benefit from treatment with a long-acting muscarinic antagonist (LAMA).¹ ABPA can progress to bronchiectasis and is suggested by worsening asthma and a productive cough with mucus plugs and fever.⁸ Diagnosis of ABPA involves chest X-ray or CT scan, allergy skin testing and/or blood tests.⁸ Chest physiotherapy and the prompt use of antibiotics for exacerbations are the mainstays of bronchiectasis management. Dysfunctional breathing is generally managed by a physiotherapist with breathing retraining techniques.

Further information on bronchiectasis is available from: www.bpac.org.nz/BPJ/2012/september/bronchiectasis.aspx

Manage co-morbidities to improve quality of life

Chronic rhinosinusitis is associated with an increased frequency of asthma exacerbations.⁹ Intranasal corticosteroids may reduce the symptoms of asthma in patients with chronic rhinosinusitis,⁷ e.g. intranasal fluticasone 100 micrograms (two sprays of 50 micrograms) into each nostril every morning, increasing to twice daily if required.¹⁰ A saline sinus rinse may remove sticky secretions from the upper airways in patients with upper airway disease.

Patients with asthma who are obese may have respiratory symptoms that are harder to control.⁷ They are also less likely to respond to ICS treatment, compared with lean individuals with asthma.¹¹ A reduction in weight of 10% or more is likely to result in improved respiratory symptoms.¹¹

Gastro-oesophageal reflux disease (GORD) is often present in patients with asthma and is associated with an increased frequency of exacerbations.⁹ This may be due to microaspiration of gastrointestinal secretions during sleep.⁹ Prescribing a proton pump inhibitor (PPI) will improve symptoms of GORD, and therefore in theory reduce asthma exacerbations. However, a PPI has no effect on lung function.¹²

Further information on the treatment of GORD is available from: www.bpac.org.nz/BPJ/2014/June/gord.aspx

Environmental factors that may exacerbate asthma

Consider factors in the patient’s environment such as occupational exposure to irritants, smoking and the use of medicines such as aspirin, other non-steroidal anti-inflammatory medicines and beta-blockers, which may be contributing to ongoing asthma symptoms despite optimal pharmacological treatment.¹

Assess behavioural factors

The New Zealand Asthma Guidelines emphasise the importance of checking and demonstrating inhaler technique and assessing treatment adherence at Stage two of every consultation.¹ A collaborative approach between practice nurses, pharmacists and general practitioners ensures that key asthma education messages are repeated in different ways from multiple sources.

The use of a spacer with a metered dose inhaler (MDI) is strongly recommended for the routine administration of ICS, ICS/LABA and SABA during acute exacerbations.¹ Patients can be instructed to:^{1, 3}

• Remove the cap of the inhaler, shake and insert it into the spacer
• Administer one dose of the medicine at a time into the spacer, followed quickly by an inhalation
• Medicine can be inhaled by either taking one deep, slow breath and holding it for ten seconds or by taking five or six tidal breaths

Spacers which fit all subsidised pressured MDIs in New Zealand are subsidised under Practitioners Supply Order (PSO). These e-chamber spacers are made from anti-static material and do not have to be primed before use.

Peak flow monitoring is not routinely required

Peak flow monitoring may be incorporated into the self-management plan of any patient with asthma who wishes to record their lung function. However, this approach is now generally only recommended for patients with severe asthma or for those with an impaired ability to perceive worsening airflow limitation.^{3, 7}