Asthma Guidelines, Primary Care (33)

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Diagnosis

There is no definitive test for asthma.

Diagnosis is by clinical assessment.

• Nocturnal, exercise and / orallergy induced.

• Wheeze heard on auscultation.  If asthma thought likely, then use trial of treatment (e.g. six weeks ICS) to confirm.

• More than one of: episodic breathlessness; wheeze; cough; chest tightness.

• Spirometry or peak flow measurements can aid diagnosis, but may need repeated for variation. Normal results do not exclude asthma.

• If diagnosis uncertain, then refer (see Box F).

Assessing control

People with asthma under-report symptoms.

Use a validated questionnaire, e.g.: RCP 3 Questions

• Have you had difficulty sleeping because of your asthma symptoms - including cough?

• Have you had your usual asthma symptoms during the day - cough, wheeze, chest tightness or breathlessness?

• Has your asthma interfered with your usual activities - housework, work, school etc?

Stepwise management

A. Compliance

Under-use of preventive therapy is common - review prescriptions ordered, address patient concerns regarding steroids.

Check Inhaler technique to make sure patient can use their inhaler / change as required. Use Personal Asthma Action Plan as a tool.

B. Self-management – personal asthma action plan

Click for NHSGGC Asthma self-management plan

• Grade A evidence; offer to all, but particularly those who are poorly controlled.

• Written and personalised, focusing on patient’s needs and preferences. Brief, simple education linked to patient goals likely to be most effective - “If we could make one thing better with your asthma, what would it be?”

• May be based on symptom or PEFR - latter not essential. A process not an event.

C. Categorisation of ICS by dose (abbreviated from SIGN 153)

Preferred choices highlighted, refer to NHSGGC Inhaler Device Guide.

D. Annual review

• Assess control of symptoms using agreed tool – RCP 3 questions.

• Review therapy including inhaler technique.

• Frequency of exacerbations / oral steroids / A&E, OOH contacts and acute admissions.

• Peak flow (percentage of best).

• Personal Asthma Action Plan – See Box B above

• Smoking cessation

• Consider steroid side effects in patients on high dose inhaled steroid (see C above). Consider DEXA referral for osteoporosis if on high dose inhaled steroid for 10 years or oral steroid for >3 months in the last year, and 10 year risk of major fracture >10%.
Use Qfracture risk calculator or FRAX.

E. Complicating problems in asthma

• Rhinitis - control may improve asthma control.

• GORD - worth treating if present.

• Infection - confirm with sputum culture if recurrent infection suspected - most asthma exacerbations do NOT require antibiotics.

• Obesity - may contribute to poor control.

• Smoking - associated with usual issues plus reduced effect of inhaled steroid.

• Dysfunctional breathing.

F. Hospital Referral

• Diagnostic uncertainty:

- Symptoms without variation in PEFR or spirometry.

- Poor response to treatment, following adequate trial of treatment.

- Possible causative agent, especially occupational.


• Poor control

- Frequent exacerbations.

- Persisting symptoms / frequent exacerbations despite additional add-on therapies.

G. Checking Inhaler Technique

See NHSGGC Patient Information Leaflets

MDI / Breath actuated MDI:
Preparation (shake inhaler, breathe out)
Co-ordinate activation (unless breath activated MDI)
Slow, steady inhalation
Breath-hold for 10 seconds
Wait 30 seconds before repeating.

Spacer: Breathe in immediately after activation
Single puff of inhaler
Breathe in slowly
Either breath-hold for 10 seconds or tidal breathe in and out of mouthpiece 5 times
Wait 30 seconds before repeating, even if multi-dosing.

Dry Powder: Fast, deep inhalation.

Last reviewed: 06 August 2018

Next review: 05 November 2020

Author(s): Nigel Pexton

Version: Version 3

Approved By: Medicines Utilisation Subcommittee of ADTC

Document Id: 33