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The management of exacerbations of acute asthma in primary care

There are more than five million people with asthma in the UK (National Asthma Campaign, 2001). Many patients, including those with mild asthma, will at some point experience a deterioration in their asthma control and the severity of this will vary.

Abstract

VOL: 100, ISSUE: 06, PAGE NO: 48

Dave Burns, BA, CertEd, RGN, RNT, is senior lecturer, Edge Hill College, and national training manager, Respiratory Education and Training Centre, University Hospital Aintree, Liverpool

 

There are more than five million people with asthma in the UK (National Asthma Campaign, 2001). Many patients, including those with mild asthma, will at some point experience a deterioration in their asthma control and the severity of this will vary.

In 1990, about 2,000 patients died from exacerbations of asthma. This figure has fallen to about 1,400 in recent years (NAC, 2001). Disturbingly, 80-90 per cent of these deaths were preventable; factors included poor routine care, non-compliance and failure of health care professionals to appreciate the seriousness of the situation (British Thoracic Society and Scottish Intercollegiate Guidelines Network, 2003).

Overview
Asthma is a chronic inflammatory condition of the airways. It can occur at any age, with the highest incidence occurring in childhood. It is characterised by atopy (allergy), although patients developing the condition in later life tend not to have evidence of atopy.

The major pathophysiological changes are bronchoconstriction, oedema of the airway wall, and mucus hypersecretion. These lead to the symptoms of breathlessness, wheeze, tight chest and cough.

Mild inflammatory changes persist even with apparently well-controlled disease, hence the need to adhere rigorously to treatment regimens that are based on inhaled corticosteroids, to which other treatments can be added as required.

Inhaled steroids are important, as the suppression of the inflammation as well as reducing symptoms, protects against acute exacerbations. Unfortunately, like many chronic diseases, adherence to treatment can be difficult.

When is asthma out of control?
Conventionally, a drop in peak-flow readings, which measure peak expiratory flow (PEF), has been considered a good guide in assessing symptoms of asthma. Tattersfield et al (1999) showed the pattern of peak-flow readings in the days before and after an acute exacerbation.

In the study there was a general fall in peak-flow reading five to seven days before an acute asthma attack. This fall became more pronounced in the two to three days before the attack.

Unfortunately, not all patients have peak-flow meters, and there is evidence that even when they do, they do not use them (Cote et al, 1998). However, if they are taught the importance of their appropriate use, PEF can be a good indicator of asthma control.

An increase in symptoms may be a better measure, but again there is evidence that shows patients have a poor perception of dyspnoea (Kendrick et al, 1993).

It is therefore important to ask patients to consider their asthma control in the context of their daily lives - in other words, to recognise when asthma is limiting their normal activities such as housework, sport or work.

Recently published guidelines on asthma management (BTS/SIGN, 2003) classify poor asthma control in adults in three ways (Box 1). Readers are referred to the guidelines for specific details for children.

What factors lead to poor control?
The BTS/SIGN guidelines identify a number of factors that are related to the disease itself or to psychosocial factors. Disease-related factors include heavy use of beta2 agonists, patients taking three or more classes of medication, and previous admission for asthma (particularly in the past year). Psychosocial factors include non-compliance, self-discharge from hospital, denial, alcohol/drug misuse, obesity and income problems.

Management of exacerbations
The new guidelines devote seven pages to managing asthma exacerbations across a range of ages and in a number of settings. This article aims to draw together the main points in relation to asthma exacerbations in primary care. Box 2 shows general points of management.

Moderate asthma exacerbation

Initial treatment for adults may be administered either at home or in the surgery. First-line management is administration of a bronchodilator (either salbutamol or terbutaline) via: an oxygen-driven nebuliser (preferable to an air-driven nebuliser as it reduces the risk of hypoxia); through an air-driven nebuliser; or via a metered-dose inhaler and spacer.

Salbutamol 5mg or terbutaline 10mg should be given to adults via the nebuliser. If a nebuliser is not available, one puff of bronchodilator via a metered-dose inhaler (MDI) and a spacer should be given 10-20 times.

Children (aged two to five years) should be treated with two to four puffs of bronchodilator administered via spacer and face mask; subsequent dosage is then two puffs every two minutes, up to a maximum of 10 according to the response.

A key treatment in any exacerbation is administration of steroids. For adults, the recommended dose is 40-50mg of prednisolone for at least five days, or until recovery. Tailing treatment off is unnecessary as it is a short course.

Soluble prednisolone 20mg for three days should be considered for children aged two to five years. A dose of 30-40mg of prednisolone should be considered for children over five years of age. Treatment should normally continue for three days or until improvement is achieved.

Following on from this initial treatment, it is important to assess the patient’s response. Adults who show a good response - for example, their symptoms settling, and PEF of more than 50 per cent - can be sent home with either their usual or increased inhaled therapy, plus a course of oral steroid tablets.

Adult patients who fail to respond to treatment, have even one feature of acute severe asthma after initial treatment, or have had a previous incidence of near fatal asthma, should be referred to hospital.

Also, hospital admission should be considered where the attack has occurred in the afternoon or evening, where there has been a recent hospital admission, previous severe attacks, or there is concern regarding the patient’s ability to assess his or her own condition or social circumstances.

Children in both age groups (two to five, and five to twelve) who show a good response can continue with up to 10 puffs of beta2 agonist but no more than once every four hours.

If oral steroids are prescribed, these should be continued for at least three days, and a follow-up clinic visit should be arranged. Children who do not respond should be admitted to hospital. The thresholds for admission are similar to those for adults.

It is important to stay with any patient who is to be admitted to hospital until the ambulance arrives, provide written assessment and referral details, and continue beta2 agonist administration via oxygen-driven nebuliser in the ambulance.

Acute severe asthma
Adult patients who meet this criterion should automatically be considered for admission to hospital (Box 1). Treatment is essentially the same as for moderate asthma, although hydrocortisone 100mg may be given intravenously in place of oral prednisolone. While the intravenous route is no more effective than the oral route, it may be necessary where the patient is nauseous and/or vomiting. Give 40-60 per cent oxygen if available.

Children should be given inhaled therapy as recommended for the treatment of a moderate asthma attack. While soluble prednisolone is a consideration in moderate exacerbations, its administration is essential for acute severe asthma.

The guidelines offer no advice on time scales for assessing adult responses to treatment, but children of both age groups (two to five and five to twelve) should be assessed 15 minutes after administration of a beta2 agonist. If there has been a poor or no response to beta2 agonists, admission to hospital should be arranged.

Life-threatening asthma
Admission should be arranged as a matter of urgency for all age groups. In addition to the inhaled treatments referred to earlier, ipratropium (0.25mg for children and 0.5mg for adults) should be added as it has a marked additive effect on bronchodilation when administered with a beta2 agonist.

For children aged under two years, and those aged two to five, intravenous hydrocortisone may be given in place of soluble prednisolone at this stage. As with all stages, nebulised bronchodilators administered via an oxygen-driven nebuliser should be continued in the ambulance on the way to the hospital.

Important points in care
It is important to ensure that all drugs are administered as prescribed. Doses may need to be repeated if vomiting occurs. Ensure that face masks stay in place, particularly when used by children - parents can help to ensure this. Explanation of the various treatments can provide reassurance. Close and accurate monitoring of the exacerbation is vital, as it will help gauge the response to treatment, guide further interventions and also help dictate whether admission to hospital is required.

Aftercare
Where possible, factors that may have led to the exacerbation should be identified and discussed with the patient. Those admitted to hospital should be referred to a specialist nurse or consultant. In addition, the guidelines state that patients should be referred to their own GP or practice nurse within two working days.

All patients should have their inhaler technique checked as there is evidence that many patients cannot use their device adequately. If this is the case, a device that the patient can use should be prescribed.

Patients should be provided with an asthma action plan, detailing signs to look for when their asthma is out of control, and appropriate actions to take such as when to obtain further help. This is important because many experts agree that the evidence supporting the use of asthma action plans is overwhelming.

Tettersell (1993) found that while 78 respondents to a postal survey stated they were confident they could manage an exacerbation of their asthma, when tested only 21 of these were deemed to be safe to do so. Educating patients to identify when their asthma is out of control, what to do in these circumstances and when to obtain further expert help are the keystones of asthma management.

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