VOL: 97, ISSUE: 34, PAGE NO: 49
Linda Pearce, MSc, RN, RCM, NPracDip, is respiratory specialist nurse, West Suffolk Hospital, Bury St Edmunds
There are 3.4 million people in the UK with asthma. A small proportion of these - an estimated 5% - are difficult to treat due to breakthrough symptoms despite best current therapy.
There are 3.4 million people in the UK with asthma. A small proportion of these - an estimated 5% - are difficult to treat due to breakthrough symptoms despite best current therapy. To have some symptoms while taking asthma medication is not unusual. The Asthma Insights and Reality in Europe Study [AIRE] (Rabe et al, 2000) showed that one in four asthma patients experienced symptoms every day or on most days and that nearly a third (28%) woke at night at least once a week because of them. However, most of these patients do not fall into the ‘difficult to treat’ category. They are grouped mainly in steps one to three of the British Thoracic Society’s guidelines on asthma management (British Thoracic Society, 1997), and their treatment consists of regular preventative therapy with low doses of inhaled steroids plus bronchodilator therapy as it is needed. Much attention has been focused on these patients in recent years, with an emphasis on good inhaler technique and correct use of therapies, with the result that many are gaining better understanding and control of the disease process. Patients with ‘difficult to treat’ asthma reside at the more severe end of the British Thoracic Society (1997) guidelines at management steps four and five. These are high-risk patients who are in danger of near-fatal episodes of asthma. They present repeatedly at both primary and secondary level, are on full medication and still encounter problems. They require intensive input from both community and hospital-based respiratory teams, including respiratory nurse specialists and practice nurses. Their medication will usually include high doses of inhaled steroids plus short- and long-acting bronchodilators as required. On top of this they may need additional anti-inflammatory agents, such as a leukotriene antagonist, theophylline, inhaled anti-cholinergic, and regular courses of oral steroids to treat the underlying inflammatory response that characterises asthma. ‘Difficult to treat’ patients fall into two groups: - Type one brittle asthma is associated with a higher incidence of psychiatric, psychological and social issues and the frequency of denial is greater. Large variations in peak flow readings can be observed both during the day and night; - With type two brittle asthma, asthma rapidly becomes severe, often within just a few minutes and with no warning. Both types of asthma can result in near-fatal asthma attacks or death (Ayres et al, 1998). Each year there are approximately 90,000 admissions to hospital due to asthma in the UK (Partridge et al, 1997). There are more than 1,500 deaths from asthma per year in the UK (Registrar General for Scotland et al, 2000). The total cost of asthma to the NHS is estimated at more than 700m per year, more than half of which is spent on ‘difficult to treat’ patients (Office of Health Economics, 1997). In addition, the value of lost productivity is thought to be in region of 1,139m for the same year (Office of National Statistics, 1997). The toll their disease places on these patients is unreported but must include many working days lost as well as reduced performance capacity and sleep disturbance. Research has shown that a variety of factors may exacerbate asthma and that dealing with them may help to tackle asthma more effectively. Much asthma is allergic in nature, or can be triggered by common allergens, such as house-dust mites, pollen or cat dander. In ‘difficult to treat’ asthma other factors may need to be taken into account. These psychosocial factors can sometimes contribute to poor disease control (Harrison, 1998; Miller and Barber, 1999). Ayres et al (1998) showed that doctors, asthma nurses and patients all have differing opinions as to what constitutes a ‘bad asthma day’. Nurses described symptoms such as a tight chest or nocturnal wakening and environmental factors such as pollution, hot weather and humidity. GPs also listed symptoms such as cough, wheeze and shortness of breath. Perhaps not surprisingly, patients focussed on restrictions in their everyday lives, such as not being able to go to the pub, for a meal or being unable to play sport (Price et al, 1999). Other strategies to improve asthma management among these ‘difficult to treat’ patients have looked at how care is delivered (Box 3). Only a few years ago there was little evidence to support any of the various models currently in place because evaluative trials had not been performed. All that could be said was that specialist care seemed to be better than care provided by staff with no specialist training (Droogan and Bannigan, 1997). In recent years a clearer picture has been emerging of what is and what is not useful. One study has shown that a nurse-led home management training programme for children admitted to hospital with acute asthma reduces subsequent readmissions (Madge et al, 1997). The teaching package included advice on how to manage attacks, written information, subsequent follow-up, telephone advice and oral steroid tablets and instructions on how to use them. A further study by Wesseldine et al (1999) focussed on achieving the same outcome but with fewer resources so that it could be implemented by staff with basic training. Three other analyses are equally supportive of the role of respiratory-trained nurses in improving education and control in asthma. The effects of specialist hospital-based nurses have been studied in both adults and children who attended A&E (Levy et al, 2000; Smith et al, 2000). Advice to adults on how to recognise and manage uncontrolled asthma and when to seek medical assistance had wide-reaching benefits. Not only did patients manage their attacks more appropriately, they also gained better control of symptoms, had fewer days off work and fewer consultations with health professionals during the six-month follow-up period (Levy et al, 2000). The interventions of an asthma nurse among children led to improved management and discharge planning, although this did not translate into any improvements in use of therapies or inhaler technique (Smith et al, 2000). In the community, patients who attended a practice nurse-run asthma clinic have shown better overall compliance with more use of preventative therapy and less reliance on relief medication in line with the British Thoracic Society guidelines (Dickinson et al, 1998). What emerges from these studies is an emphasis on education at every available opportunity. Although a visit to A&E with an exacerbation of asthma is not an ideal time to educate patients, it is a time when the patient’s attention is focused on their disease. Education at this time could improve self-management techniques so that next time the patient’s condition worsens they can regain control themselves, without having to attend A&E (Dickinson et al, 1998). An education package could include advice on the following: - Why regular preventive treatment is important; - What symptoms suggest worsening asthma; - What to do when symptoms worsen; - When to use oral steroids; - When to seek assistance. Videos as well as written and verbal information can be used. There are several new therapies targeted specifically at patients with ‘difficult to treat’ asthma. These include selective phosphodiesterase inhibitors, cytokine antagonists and an anti-IgE therapy, omalizumab, targeting the allergic events leading to the inflammatory process in asthma. The place of these new therapies in this difficult patient group will need to be assessed in clinical practice, but they may offer additional options to the clinician.