Asthma Protocol –

Aims

The aims of asthma care in the practice are to reduce asthma-related morbidity & mortality, reduce absence from work or school, & to promote effective education & self-management for patients with asthma.

Objectives

Ø  To recognise the symptoms of asthma & initiate appropriate treatment.

Ø  To encourage compliance with therapy & good inhaler technique.

Ø  To invite all patients with “active” asthma for at least once-yearly review at the asthma clinic

Ø  To maintain an accurate asthma register, with a mini register for patients with severe asthma.

Ø  To encourage the use of written self-management plans in all patients, particularly those with more severe asthma.

Identification of target population & diagnosis

Diagnosis in children is generally based on a history of recurrent episodes of wheeze associated with upper respiratory tract infections, persistent nocturnal cough or exercise-induced wheeze or cough. In adults, in addition to a suggestive history, it is desirable to obtain some objective evidence of reversibility of airways obstruction. This may be done by twice daily measurement of peak expiratory flow rate period, before & after a therapeutic trial of oral steroids, or before & after an inhaled beta-2 antagonist. Spirometry may also be considered. Greater than 15% reversibility of peak flow rate supports a diagnosis of asthma.

The Asthma Register

Once diagnosis has been made by a GP, patients are read-coded and entered on the computer register. Patients on treatment are systematically invited to the Asthma Clinic. The mini register if patients with more severe asthma includes those who have previously been admitted to hospital because of asthma, or who required nebulised therapy, or who have needed one or more courses of oral Prednisolone. Case notes for these patients are given to the Practice Nurse to encourage early review after an obvious symptomatic deterioration.

Action at first consultation.

A record is made of the following details: Age of asthma diagnosis, family history, personal history of eczema, hay fever, urticaria or ‘wheezy bronchitis’; environmental factors including occupation, bedding/pillows, animal contacts or smoking: present clinical stat, including presence of persistent or episodic wheeze and nocturnal or exercise induced wheeze or cough. A baseline peak-flow reading is taken, & the predicted value based on the height of the patient calculated. An appropriate inhaler is selected & technique demonstrated. The distinction between relief and prophylactic medication is explained and according the level of understanding of the patient, a self-management discussed, whereby he or she is encouraged to try and achieve an optimum level of control

Frequency and content of review

All patients with “active” asthma (i.e. on regular prophylaxis or symptoms within past 12 months) will be offered at least once-yearly review at asthma clinic.

All patients with sub-optimal control of asthma, especially those who have nocturnal symptoms or who are on the list of previously nebulised or hospitalized, or rescue course of steroids will be invited to the asthma clinic and offered regular review until symptoms controlled. Frequency of follow up depends on the severity of symptoms.

Patients with “inactive” asthma, i.e. no symptoms or prescribed medication for the past year will not be invited to the asthma clinic.

Emergency Nebulised therapy

All patients who are nebulised within the surgery should have a pre-nebulised peak flow and O2 saturation and a post nebulised peak flow and O2 Saturation recorded. If no improvement as per British Thoracic Society guidelines or who present late admission to hospital should be considered.

Clinical Management of asthma

Stepped care is based on the British Thoracic Society Guidelines for asthma care. Stepping down of preventative treatment will be considered where appropriate, according to these guidelines.

Asthma education and self-management

The purpose of self-management plans are as follows:

§  To enable patients with asthma achieve better control of their condition and step up treatment without always having to consult a Doctor or a Nurse

§  To improve patient understanding & compliance with treatment.

They are most likely to be used properly if adequate time is spent in educating patient at time of diagnosis. This is easiest if an early appointment is given for the asthma clinic. Educational booklets are available. Although it is desirable that all patients with asthma have some understanding of self-management, the initial aim is to target those with moderate or severe asthma to offer self-management by peak-flow monitoring. Mild asthmatic patients will be offered symptom –based self-management plans.

Ss/December 2007