Asthma Management Handbook

Comprehensive review when asthma is not controlled by preventer treatment

Recommendations

Offer a comprehensive asthma review for patients with asthma that is not well controlled despite treatment.

Note: This is especially important for patients with difficult-to-treat asthma: asthma that is not well controlled despite stepped-up preventer treatment (medium-dose inhaled corticosteroid plus long-acting beta2 agonist in adults, or high-dose inhaled corticosteroid in children).

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

If possible:

  • book a long appointment so you have time to listen to the person’s experiences, concerns and thoughts about their asthma and their medication
  • arrange a consultation with an asthma educator.
How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

More information

Living with asthma

People’s experiences of asthma

More than three-quarters of Australians with asthma describe their general health as ‘good’ to ‘excellent’.1 However, the experience of living with asthma differs between individuals.

Experiences of asthma reported in research studies are diverse. They include:2

  • frightening physical symptoms experience as ‘panicky’, a sensation of ‘choking’, ‘breathing through a straw’, ‘suffocating’ or ‘drowning’
  • feeling judged by others (family, employers/colleagues)
  • self-judgement (e.g. believing that asthma is not a legitimate reason for absence from work)
  • fearing dependency on medications
  • fearing or experiencing side effects from medication
  • fearing unpredictability of asthma symptoms that could occur while out
  • wishing to be ‘normal’.

Living with severe asthma

Studies of adults with severe asthma have identified frequently reported needs and goals, including:3

  • achieving greater personal control over their conditions by gaining knowledge about symptoms and treatment. This included receiving more information about asthma from health professionals.
  • being able to ask questions without feeling rushed during consultations
  • being involved in making decisions about their treatment
  • striving for a normal life.

People with severe asthma report a range of problems, including:34

  • troublesome adverse effects of oral corticosteroids (e.g. weight gain, ‘puffy face’, anxiety, irritability and depression) – these can affect social relationships and cause some people reduce or stop their use
  • feelings of panic and fear of asthma symptoms – some people avoid activities and situations due to severe asthma
  • emotional distress
  • stigma
  • restrictions on social life or ability to play with children
  • restrictions on everyday activities including chores or leisure activities
  • effects on working life, including absences or the need to change occupation or give up work
  • being misunderstood by other people, who expect the person’s asthma to be readily controlled as for milder asthma
  • a sense of lack of support from their healthcare providers, including the perception that doctors did not have time to discuss asthma.

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Health system initiatives that support asthma care

Chronic Disease Management Medicare items

Patients with asthma are eligible for Chronic Disease Management Medicare items.5 These include:

  • Preparation of a GP Management Plan (Item 721)
  • Review of a GP Management Plan (Item 732)
  • Coordination of Team Care Arrangements (Item 723) for patients who need ongoing care from a multidisciplinary team of at least three health or care providers
  • Coordination of a Review of Team Care Arrangements (Item 732)
  • Contribution to a multidisciplinary care plan being prepared by another health or care provider (Item 729)
  • Contribution to a multidisciplinary care plan being prepared for a resident of an aged care facility (Item 731).

GPs can be assisted by practice nurses, Aboriginal and Torres Strait Islander health practitioners, Aboriginal health workers and other health professionals.5

Asthma cycle of care

The Asthma cycle of care is an Australian Government initiative to support primary care health professionals (GPs, other medical practitioners and trainees) to provide asthma care. It is implemented through the Practice Incentives Program (PIP) Asthma Incentive and applies to the clinical care of people with moderate-to-severe asthma, generally defined as people with (any of):6

  • symptoms on most days
  • use of preventative medication
  • bronchodilator use at least three times per week
  • hospital attendance or admission following an acute asthma flare-up.

The Asthma cycle of care involves at least two asthma-related consultations within 12 months for a patient with moderate-to-severe asthma, of which at least one visit is a planned asthma review. Each consultation includes:

  • documenting the diagnosis, assessing asthma severity and assessing level of recent asthma symptom control
  • reviewing the patient’s use of and access to asthma medicines and inhaler devices
  • providing a written asthma action plan (or documented alternative, if the patient is unable to use a written action plan)
  • providing asthma self-management education
  • reviewing the written or documented asthma action plan.

The Personally Controlled eHealth Record System

The eHealth record is an electronic record for a patient that contains a summary of their health information. Patients can choose to register for an eHealth record. Authorised healthcare professionals can access a patient’s record and upload information to the record if their healthcare organisation has registered for the eHealth record system.

Health system initiatives for Aboriginal and Torres Strait Islander people

Health system initiatives to support the care of Aboriginal and Torres Strait Islander people include:

  • Health Assessment Medicare items
  • The Indigenous Chronic Disease Package
  • The Asthma Spacer Ordering System.
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Assessing risk factors for adverse asthma outcomes in adults

Predicting poor asthma outcomes

As well as assessing recent asthma symptom control, it is necessary to assess each patient’s risk of future asthma events or adverse treatment effects. (Recent asthma symptom control and risk of adverse events are both components of overall asthma control.)

Table. Risk factors for adverse asthma outcomes in adults and adolescents Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/40

Table. Management of risk factors for adverse asthma outcomes in adults

Risk factor

Clinical action †

Any risk factor for flare-ups

Check patient has an appropriate action plan

Carefully check inhaler technique and adherence, and identify any barriers to good adherence

Review frequently (e.g. every 3 months)

Hospitalisation or ED visit for asthma or any asthma flare-up during the previous 12 months

Ask about triggers for flare-ups, and lead time

History of intubation or intensive care unit admission for asthma

Ensure action plan recommends early medical review when asthma worsens

Hospitalisation or ED visit for asthma in the past month

Emphasise importance of maintaining regular ICS use after symptoms improve

Confirm that patient has resumed using SABA only when needed for symptoms

High SABA use (>3 canisters per year)

Check lung function

If SABA use appears to be habitual, investigate causes and consider alternative strategies, e.g. short-term substitution of ipratropium for SABA

Long-term high-dose ICS

Consider gradual reduction of ICS dose if symptoms stable

Monitor regularly (e.g. assessment of bone density, regular eye examinations)

For local side-effects, ensure inhaler technique is appropriate

Poor lung function (even if few symptoms)

Consider 3-month trial of higher ICS dose, then recheck lung function

Consider referral for detailed specialist investigation

Sensitivity to unavoidable allergens (e.g. Alternaria species of common moulds)

Refer for further investigation and management

Exposure to cigarette smoke (smoking or environmental exposure)

Emphasise the importance of avoiding smoke

Provide quitting strategies

Consider increasing ICS dose (higher dose of ICS likely to be necessary to control asthma)

Refer for assessment of asthma–COPD overlap

Difficulty perceiving airflow limitation or the severity of exacerbations

Regular PEF monitoring

Action plan should recommend early review and measurement of lung function

No current written asthma action plan

Provide and explain written asthma action plan

† In addition to actions applicable to all risk factors

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Poor clinical control, as indicated by frequent asthma symptoms and frequent reliever use, is a very strong predictor of the risk of flare-ups in the future. Any asthma flare-up during the previous 12 months indicates higher risk of flare-up over the next 12 months. A history  of artificial ventilation due to acute asthma, and admission to an intensive care unit due to acute asthma have been associated with increased risk of near-fatal asthma,7 but there is not enough evidence to indicate how long this risk may persist over a person’s lifetime. Other risk factors indicate increased probability of future flare-ups or accelerated decline in lung function, independent of the person’s level of recent asthma symptom control.89

Other factors may increase a person’s risk of treatment-associated adverse effects. The most important of these are prescription of high dose treatment and frequent courses of oral steroids.

People with risk factors need more frequent asthma review, a carefully tailored written asthma action plan, and close attention to adherence and correct inhaler technique.

Inflammatory markers

Inflammatory markers, such as sputum eosinophil percentage or exhaled nitric oxide, are used in research and for managing severe asthma in patients attending secondary or tertiary care. Elevated sputum eosinophil levels and, to a lesser extent, elevated exhaled nitric oxide, are associated with increased risk of flare-ups. At present, treatment based on inflammatory markers is not recommended for routine use in primary care.

The value of inflammatory markers is being evaluated:

  • Adjusting asthma treatment by monitoring exhaled nitric oxide does not reduce the rate of flare-ups or improve asthma control in adults and children, compared with adjusting treatment according to clinical symptoms or spirometry, based on a meta-analysis of randomised controlled clinical trials.10 However, many of the studies were not optimally designed to answer this question,11 and some comparator regimens did not match current recommended treatment options.
  • In some studies, asthma treatment algorithms based on monitoring sputum eosinophil counts reduced flare-ups, compared with control-based management.12, 13 However, most studies assessing treatment guided by sputum eosinophilia have been conducted in selected populations in a few research centres, and therefore may not apply to the general community population. Assessment of sputum inflammatory cells is not generally available at present even in secondary care.
  • Limited evidence14 suggests that patients whose symptoms do not match their degree of eosinophilic inflammation may benefit more from treatment monitoring using sputum eosinophil count than other patients.
  • Monitoring inflammatory markers might enable safer down-titration of maintenance inhaled corticosteroid doses.

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Culturally secure asthma care for Aboriginal and Torres Strait Islander people

Primary care services can aim to deliver healthcare that is culturally secure. However, only the Aboriginal or Torres Strait Islander person themselves can determine whether their care is culturally safe or respectful.15

Making the healthcare system a secure environment for Aboriginal and Torres Strait Islander peoples involves cultural respect, which involves not only respecting cultural difference but recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander peoples.16

Cultural awareness (or ‘cultural sensitivity’) among individual health professionals involves sensitivity to the similarities and differences between different cultures to enable effective communication with members of another cultural group.17

Training in cultural awareness and  ‘cultural safety’ is available for non-Indigenous health professionals who provide healthcare for Aboriginal and Torres Strait Islander people.

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Involvement of Aboriginal and/or Torres Strait Islander health workers and health practitioners in asthma care

Aboriginal and Torres Strait Islander health workers and Aboriginal and Torres Strait Islander health practitioners can provide self-management education for people with asthma and parents of children with asthma. Culture-specific programs may be more appropriate than mainstream programs for Aboriginal and Torres Strait Islander people.18

An education program (three sessions) conducted by Aboriginal and Torres Strait Islander health workers in primary health care in  the Torres Strait region reduced the number of school days missed due to wheezing among school-aged children, and increased carers’ knowledge of asthma, the contents of the child’s written asthma action plan, and where the written asthma action plan was kept.19 However, it did not reduce the rate of asthma flare-ups, compared with children whose families did not participate.19

Aboriginal and Torres Strait Islander health workers and practitioners can provide health care services that are reimbursable through Medicare.520

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Confidentiality issues for adolescents

Adolescents’ concerns about confidentiality prevent them using health care services, especially if substance use is likely to be raised. Adolescents are more likely to disclose information about health risk behaviours, and are more likely to return for review, if they know that confidential information will not be revealed to their parents or others.21

When adolescents are accompanied by parents or carers, health care providers should consider seeing the adolescent alone for part of each consultation.21

Health professionals should discuss confidentiality and its limits with adolescents.21 Adolescents are more willing to communicate honestly with healthcare professionals who discuss confidentiality with them.22

Health professionals need to clearly explain which personal health information can be confidential and which must be shared with parents, and keep parents informed.

Health care providers should advise adolescents that they can obtain their own Medicare card once they turn 15.21

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References

  1. Reddel, H. K., Sawyer, S. M., Everett, P. W., et al. Asthma control in Australia: a cross-sectional web-based survey in a nationally representative population. Med J Aust. 2015; 202: 492-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25971575
  2. Pickles, K., Eassey, D., Reddel, H. K., et al. "This illness diminishes me. What it does is like theft": A qualitative meta-synthesis of people's experiences of living with asthma. Health Expect. 2018; 21: 23-40. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/28768067/
  3. Eassey D, Reddel HK, Foster JM et al. "...I've said I wish I was dead, you'd be better off without me": A systematic review of people's experiences of living with severe asthma. J Asthma 2018: 1-12. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29617182
  4. Foster JM, McDonald VM, Guo M, Reddel HK. "I have lost in every facet of my life": the hidden burden of severe asthma. Eur Respir J 2017; 50: Available from: https://www.ncbi.nlm.nih.gov/pubmed/28931662/
  5. Australian Government Department of Health. Chronic Disease Management (CDM) Medicare Items. Australian Government, Canberra, 2013. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement
  6. Australian Government Medicare Australia. Practice Incentives Program Asthma Incentives Guidelines – August 2011. Medicare Australia, Canberra, 2011. Available from: http://www.medicareaustralia.gov.au/provider/incentives/pip/forms-guides.jsp#N10068
  7. Turner MO, Noertjojo K, Vedal S, et al. Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med. 1998; 157: 1804-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9620909
  8. Thomas M, Kay S, Pike J, et al. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J. 2009; 18: 41-49. Available from: http://www.nature.com/articles/pcrj200910
  9. Osborne ML, Pedula KL, O'Hollaren M, et al. Assessing future need for acute care in adult asthmatics: the Profile of Asthma Risk Study: a prospective health maintenance organization-based study. Chest. 2007; 132: 1151-61. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1085456
  10. Petsky HL, Cates CJ, Li A, et al. Tailored interventions based on exhaled nitric oxide versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev. 2009; Issue 4: CD006340. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006340.pub3/full
  11. Gibson PG. Using fractional exhaled nitric oxide to guide asthma therapy: design and methodological issues for asthma treatment algorithm studies. Clin Exp Allergy. 2009; 39: 478-490. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19260871
  12. Taylor DR, Bateman ED, Boulet LP, et al. A new perspective on concepts of asthma severity and control. Eur Respir J. 2008; 32: 545-554. Available from: http://erj.ersjournals.com/content/32/3/545.long
  13. Petsky HL, Cates CJ, Lasserson TJ, et al. A systematic review and meta-analysis: tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils). Thorax. 2012; 67: 199-208. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20937641
  14. Haldar P, Pavord ID, Shaw DE, et al. Cluster analysis and clinical asthma phenotypes. Am J Respir Crit Care Med. 2008; 178: 218-224. Available from: http://ajrccm.atsjournals.org/content/178/3/218.full
  15. National Aboriginal Community Controlled Health Organisation. Creating the NACCHO Cultural Safety Training Standards and Assessment process. A background paper. National Aboriginal Community Controlled Health Organisation, Canberra, 2011. Available from: http://www.csheitc.org.au/wp-content/uploads/2015/11/CSTStandardsBackgroundPaper-NACCHO.pdf
  16. Australian Health Ministers' Advisory Council Standing Committee for Aboriginal and Torres Strait Islander Health Working Party. Cultural respect framework for Aboriginal and Torres Strait Islander health, 2004 -2009. Department of Health South Australia, Adelaide, 2004. Available from: http://www.sapo.org.au/pub/pub2142.html
  17. Thomson N. Cultural respect and related concepts: a brief summary of the literature. Australian Indigenous Health Bulletin. 2005; 5: 1-11. Available from: http://citeseerx.ist.psu.edu/viewdoc/summary?doi=10.1.1.499.6685
  18. Bailey EJ, Cates CJ, Kruske SG, et al. Culture-specific programs for children and adults from minority groups who have asthma. Cochrane Database Syst Rev. 2009; Issue 2: CD006580. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006580.pub4/full
  19. Valery PC, Masters IB, Taylor B, et al. An education intervention for childhood asthma by Aboriginal and Torres Strait Islander health workers: a randomised controlled trial. Med J Aust. 2010; 192: 574-9. Available from: https://www.mja.com.au/journal/2010/192/10/education-intervention-childhood-asthma-aboriginal-and-torres-strait-islander
  20. Australian Government Department of Health and Ageing. Medicare Health Assessment for Aboriginal and Torres Strait Islander People. Australian Government, Canberra, 2013. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycareATSIMBSitem715
  21. The Royal Australasian College of Physicians Joint Adolescent Health Committee. Confidential Health Care for Adolescents and Young People (12–24 years). The Royal Australasian College of Physicians, 2010. Available from: http://www.racp.edu.au/
  22. The Royal Australasian College of Physicians. Routine adolescent psychosocial health assessment. Position statement. The Royal Australasian College of Physicians, Sydney, 2008. Available from: http://www.racp.edu.au/fellows/resources/paediatric-resources