VOL: 96, ISSUE: 37, PAGE NO: 43
Caia Francis, BSc, MSc, is a project coordinator/research nurse, Division of Primary Health Care, University of Bristol, and a member of The Nursing Times Good Practice Network. For GPN details, tel: 020 7383 5865
‘I didn’t know my asthma could be this good. I didn’t know that I could feel this well. I thought that was how my asthma was. I thought that was how it should be.’
‘I didn’t know my asthma could be this good. I didn’t know that I could feel this well. I thought that was how my asthma was. I thought that was how it should be.’ These words were spoken by a 14-year-old schoolboy, James Turner. James was one of a group of 450 children who agreed to participate in a research project in the Bristol area. James’ case illustrates some key issues about asthma management, education and how chronic illness is perceived by the individual. It also shows how working collaboratively with the school, GP and practice nurse can produce positive results. The aim of the project was to see if children, aged 11 to 16 would find an asthma review at their school, during school hours, more beneficial than one at their GP’s surgery. Children of secondary school age appear to fall through the asthma care net since they are notoriously poor at attending reviews or other heath-related consultations (Jacobson and Wilkinson, 1994). They can, therefore, experience high levels of asthma-associated morbidity (Strachan et al, 1994). Over a third of children with asthma miss more than one week of school per year, with 8% missing more than a month (National Asthma Campaign, 1999). This could be reduced by giving appropriate asthma advice (Charlton et al, 1992) given by appropriately trained health professionals (NARTC, 1999), working towards structured care, adherence to management guidelines with systematic review of medication, inhaler technique and compliance (Neville et al, 1996). By providing asthma care at schools it is hoped that children will improve their asthma management. Six secondary schools agreed to participate in the research project. Four out of the six schools had an asthma clinic run by a suitably qualified nurse.
The case of James Turner
I first met James at an asthma clinic at his school. I could hear James coming along the corridor long before I saw him because he was audibly wheezy. He came into the room with some trepidation, because he was not sure what to expect. I undertook the usual baseline assessments, which included: - Height: (to calculate, among other things, predicted peak expiratory flow rate); - Actual peak expiratory flow rate: (best of three); - Level of symptoms associated with asthma, coughing, wheezing, chest tightness and shortness of breath (experienced in the last week); - Whether or not he smoked; - The medication prescribed and his compliance with medication regime; - Assessment of his asthma inhaler device technique; - Trigger factors for his asthma. His peak expiratory flow was 50% of his predicted value, hence the wheeze and other associated symptoms. James’ airways were obviously quite obstructed at that time by the disease process of asthma. Due to smooth muscle contraction around the airways, at any one time the lumen airways may be partially blocked by mucus, and there may be inflammation occurring in the airway tissue as a result of oedema and cellular infiltration and bronchospasm. James explained that this was ‘normal’ and he just came to school and got on with his life. We discussed his medications, which consisted of a steroid inhaler and salbutamol. I felt that the dose for his inhaled steroid was rather low. Compliance with prescribed therapy is a particular problem with asthma medication (Cochrane, 1999), but James assured me that he took his as prescribed. I had no access to the practice records so was unable to check on the number of repeat prescriptions issued, which would have given me a rough indication of compliance. James was using his salbutamol three to four times a day, but quite clearly this was not giving him adequate relief. I suggested he double up on the number of puffs he took of his inhaled steroid, in line with the British Thoracic Society guidelines (1997), and keep a peak-flow diary. His inhaler technique was adequate, but with advice and education this improved. Every three to four months James had needed to attend the A&E department of the local teaching hospital to have nebuliser therapy. I advised him to see his GP to discuss other forms of medication. A recorded copy of my consultation with James was sent to his GP and a letter sent home to his parents suggesting that they make an appointment for James to see his GP. I felt that James should not be in school with such a poor peak expiratory flow rate. His teacher informed me that James was usually wheezy, that it was quite difficult to have someone at home with him during the day and that at least at school there was always someone there to keep an eye on him. James was quite happy with this arrangement. I saw James a week later with his peak-flow diary, which indicated a large diurnal variation, with peak flow falling to 40% of his predicted value - his asthma was still no better. It turned out that James had not been to see his GP because of difficulties attending the appointments. He was still ‘doubling up’ on his inhaled steroid and using his salbutamol three to four times a day. I telephoned James’ GP on his behalf and discussed the possible options. His GP was also concerned about James and had no idea that his asthma was so bad or that he routinely required nebulisation three to four times a year at A&E. We both felt that other methods should be tried to improve James’ asthma. James was fully informed of this conversation and his parents were once again advised to take him to see his doctor. I made an appointment to see James a week later. Although this meant that he would miss three lessons in three weeks, I felt that the severity of his asthma would justify the action taken. It was frustrating to observe a child who could not receive appropriate treatment for his asthma purely because he could not easily access his GP. James’ asthma had been bad in the last week, and although he had had a day off sick, he managed to see his GP. He was now on a short course of oral steroids, a higher concentration of inhaled steroids and had the chance to talk about his asthma with his doctor and practice nurse, both of whom had given him support and encouragement to attend the school clinic and become involved in all school activities. It had taken a month, several telephone calls, many letters and much persuasion to get James to this stage, but the battle wasn’t yet won. James and I still had work to do in terms of allergen avoidance, inhaler techniques, education about asthma and how his drugs worked. During this time I also provided asthma education and advice to the school personnel so they understood that children who were audibly wheezy required intervention. Hopefully, they gained more information about asthma, its treatment and effect upon individuals. I saw James every month or so for the next three months and his asthma improved. He knew how his drugs worked, why he should take them, and how to recognise the signs when his asthma was deteriorating. We worked out a management plan, which James found useful, and his GP agreed that he needed to remain on a higher maintenance dose of his inhaled steroids at least during the winter. Six months later, I saw James playing football, with no obvious signs of his asthma. He played the whole match, and when he stopped he said the magic words, ‘I didn’t know I could feel this good’. James is just one young person in a large research project. His case illustrates how asthma care at school can benefit some children’s asthma. This research project is due for completion in December 2000. If providing asthma care in school proves successful this kind of service could be extended as a means of providing care for young people with other chronic conditions, which could be run by school nurses, practice nurses or health visitors. - The patient’s name has been changed