Remote Primary Health Care Manuals

Asthma in adults

  • Chronic, often allergic inflammation of airway walls causing
    • Narrowing of airways, bronchospasm (tightening of airway wall muscles)
    • Inflammatory oedema and increased mucus production 
  • Symptoms come and go

  • Not all wheeze or shortness of breath is asthma

Consider asthma if

  • Variable shortness of breath with exercise or physical activity
  • Cough or wheeze (whistling sound on breathing out) — usually with respiratory infection
  • Sensitive to irritants, allergic symptoms, eg sneezing, watery eyes
Red Flags — Urgent Medical Consult
  • Severe, rapidly increasing shortness of breath
  • Silent chest (may indicate severe asthma)
  • Drowsiness — may indicate CO2 retention (slow breathing), severe hypoxia, low BP (shock)
  • Reduced consciousness, collapse, exhaustion
  • Unable to talk 

Diagnosis

  • Confirmed by history or presence of typical symptoms combined with reversible airflow obstruction on spirometry if  FEV1  and FEV/FVC are reduced on spirometry then improve by more than 12%  AND at least 200mL of FEV1 after 4 puffs of salbutamol (400microgram) via spacer
  • Normal spirometry does not exclude asthma

Managing an asthma attack

Do

  • Use Table 7.15 to assess severity (how bad it is)
    • Do not stop oxygen to do pulse oximetry 
    • If person is in more than one severity category record the higher (worse) category as overall level
    • If not sure if it is mild or moderate — treat as moderate

Table 7.15 Rapid assessment of severity

Mild Moderate Severe Life-threatening
  • Alert
  • Can walk
  • Can finish a sentence in one breath
  • RR less than 25 breaths/min
  • Pulse less then 110 beats/min
  • Can only speak a few words in one breath
  • Can't lie flat due to shortness of breath — sitting hunched forward
  • RR 25/min or more
  • Pulse 110 beats/min or more
 Any of these findings:
  • Use of accessory muscles of neck or intercostal muscles or ‘tracheal tug’ during inspiration or subcostal recession (‘abdominal breathing’)
  • Unable to complete sentences in one breath due to dyspnoea
  • Obvious respiratory distress (trouble breathing)
  • O2 sats
    90–94%
 Any of these findings:
  • Reduced consciousness or collapse
  • Exhaustion (severe tiredness)
  • Cyanosis (turning blue)
  • O2 sats less than 90%
  • Very hard to breathe, soft or absent breath sounds

Severe and life-threatening asthma

Do first

  • Sit person up — use wheelchair to move them
  • Start oxygen if O2 sats less than 92% and titrate to target oxygen saturation of 93–95%
    • Do not over-oxygenate to avoid risk of hypercapnia (CO2 retention)
  • Give salbutamol nebulised as needed — 5mg AND ipratropium nebulised as needed — 500microgram — can mix with salbutamol
  • Nebulisers have high risk of transmitting infection. Wear full PPE
  • Urgent medical consult 
  • Give prednisolone oral — adult 50mg, single dose OR if oral route not possible give hydrocortisone IV — 100mg, every 6 hours
  • If poor response consider — magnesium sulfate IV diluted in a compatible solution as a single IV infusion — 10mmol (2.5g) over 20 minutes
  • If severe or unresponsive — give adrenaline (epinephrine) IM — adult 0.5mg
  • Check RR, O₂ sats, pulse every 15 minutes. If getting better — try using spacer or reduce nebuliser frequency to half hourly
    • AVPU, RR, O₂ sats, pulse, BP, Temp — work out REWS
    • Can give prednisolone oral — 50mg, once a day for 5 days

Moderate and mild asthma

Ask

  • Onset — how many days have they been sick
  • Wheeze or cough, what makes them worse — dust, smoke, pollen, grass, recent cold or flu
  • Symptoms of chest infections (URTI/LRTI)
  • Contacts who are sick 
  • Medicines they have already used to manage attack, do they use a spacer
  • Adherence to regular medications
  • Coexisting heart or lung disease
  • Smoking status and exposure to second hand smoke
  • Do they have an asthma action plan, have they followed it
  • Previous hospitalisations for asthma especially intensive care admissions

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • Head-to-toe exam with attention to  
    • Breathing — rib recession, accessory muscle use. Listen to front and back of chest for wheeze, air entry 

Do

  • FEV1 or PEFR
  • Treat according to moderate or mild asthma
  • If temp more than 38.5°C — medical consult

Moderate asthma

  • Give reliever
    • Salbutamol puffer with spacer — 100microgram/dose (4–12 puffs) OR terbutaline inhaler — 500microgram/dose (6 puffs)
    • Repeat every 20 minutes for 1 hour (total of 3 doses) if needed
  • Check response 10–20 minutes after third dose
  • May need oxygen to target O2 sats 93–95% 
    • Nasal cannula 2–4L/min OR mask 5–10L/min
  • Medical consult
  • Give prednisolone oral — adult 50mg, single dose OR give hydrocortisone IV — adult 100mg — can repeat after 6 hours
  • If not better — may need to ADD magnesium sulfate IV diluted in a compatible solution as a single IV infusion — 10mmol (2.5g) over 20 minutes
  • If better — keep in clinic for 1 hour. When stable
    • Make management plan with doctor. Update asthma action plan and give copy to patient
    • Advise to use reliever — salbutamol puffer with spacer — 100microgram/dose (2–4 puffs) every 4 hours 
      OR terbutaline inhaler — 500microgram/dose (1–2 puffs) repeat every 4 hours
      OR usual reliever
    • Give prednisolone oral — adult 50mg, once a day for 4 more days
    • Send home then review every day
    • Medical follow-up next visit

Mild asthma

  • Give reliever
    • Salbutamol puffer with spacer — 100microgram/dose (4–12 puffs) OR terbutaline inhaler — 500microgram/dose (4 puffs)
  • If person has been sick for a few days or on regular preventer treatment — give prednisolone oral — adult 50mg, single dose
  • Check response to treatment after 20 minutes
  • If not better — treat as moderate asthma
  • If better — keep in clinic for 1 hour. When condition stable
    • Advise to use reliever every 4 hours — salbutamol puffer with spacer — 100microgram/dose (2 puffs)
      OR terbutaline inhaler — 500microgram/dose (1 puff) repeat every 4 hours
      OR usual reliever
    • Advise what to do if symptoms get worse
    • Record in asthma action plan and give copy to person
    • Send home then review next day
  • If more than 1 attack in last year — medical consult to check and revise asthma action plan

Managing ongoing asthma

Asthma management is adults in based on

  • Confirmation of diagnosis — symptoms, medicines used, spirometry
    • If diagnosis made elsewhere — get results
  • Education
    • Make sure person understands and can manage asthma, including how to use devices and make a bush spacer — See Spacer devices for respiratory medicines
    • Provide advice about smoking, healthy eating, physical activity, healthy weight and immunisation
  • Assessment of symptoms and control 
    • Reassessing asthma control regularly — increase or decrease preventive therapy based on this
  • Monitoring (PEFR or spirometry) — achieve and maintain best lung function
  • Triggers identified and avoided including fire, e-cigarettes and tobacco smoke
  • Managing comorbid conditions that affect asthma or contribute to respiratory symptoms
  • Asthma action plan developed and reviewed regularly

Table 7.16 Levels of asthma symptom control

Level of control Features — over 4 week period
Good control

All of

  • Daytime symptoms — 0–2 days/week
  • Need to use reliever — 0–2 days/week*
  • Able to carry out all activities
  • No symptoms during night or on waking
Partial control

1 or 2 of

  • Daytime symptoms — 3–7 days/week
  • Need to use reliever — 3–7 days/week*
  • Any limitation of activities
  • Any symptoms during night or on waking
Poor control

3 or 4 of

  • Daytime symptoms — 3–7 days/week
  • Need to use reliever — 3–7 days/week*
  • Any limitation of activities
  • Any symptoms during night or on waking

* Not including reliever used for prevention before physical activity

Management — key points

  • Manage by level of symptom control — Table 7.16 and Table 7.17
  • Most important medicines for asthma control are relievers (eg salbutamol) and inhaled corticosteroids (ICS)
  • Regular follow up is important to assess control and adjust (increase or decrease) treatment
    • Effect of change in ICS dose usually reached in 4 weeks
    • If ICS started at high dose for acute attack with newly diagnosed asthma — reduce after 2 weeks if now good control
    • If partial or poor control — adjust ICS dose every 4 weeks until good control
  • If partial or poor control despite high dose ICS — may need Long Acting Bronchodilator (LABA), eg salmeterol
  • Do not use LABA without ICS — always use combination LABA/ICS device
  • Check inhaler technique regularly and when changing treatment 

Table 7.17 Management by level of control

Level of control Management
All
  • Use reliever for symptoms and before physical activity if needed
Newly diagnosed (irrespective of control)
  • If stable — start low dose ICS — Table 7.19
  • As needed low-dose budesonide-formoterol or beclometasone-formoterol
  • If acute attack or poor control at diagnosis with or without prednisolone — consider short course of high dose ICS
Good control
  • Reduce ICS to lower dose if stable for 2–4 months — aim to stop if minimal symptoms 
  • Below patients need to stay on an inhaled steroid
    • Asthma symptoms twice or more in past month
    • Waking due to asthma symptoms once or more during the past month
    • Asthma flare-up in the past 12 months
Partial control
  • Increase ICS to higher dose — Table 7.19
  • If on maximum dose ICS — change from ICS alone to combined ICS/LABA
  • Check for and address causes and triggers
  • Review inhaler technique
  • If ongoing partial control on maximum dose ICS/LABA — medical/specialist review
Poor control
  • Review inhaler technique and talk with person about adherence
  • Reconsider asthma diagnosis and confirm symptoms are not due to something else — bronchiectasis, COPD, heart failure, RHD
  • Increase ICS to higher dose — Table 7.19
  • If on maximum dose ICS — add combination ICS/LABA
  • If ongoing poor control on maximum dose ICS/LABA — medical/specialist consult

Follow-up care

  • If good control — review once a year
  • If partial or poor control — review every 4 weeks
  • If frequent or persistent asthma — 3 monthly until symptoms well controlled
  • Medical follow-up after any hospital admission

Ask

  • How often do they get symptoms — cough, wheeze, waking at night
  • Does asthma stop them doing usual physical activities or work
  • How often do they use their reliever
  • Are there any problems with medicines
  • About causes, eg smoke exposure, dust, allergies

Check

Do

  • Assess level of control and adjust treatment if needed
  • Review and update asthma action plan
  • Give advice on avoiding triggers, eg avoid exposure to smoke

Asthma medicines

Table 7.18 Asthma medicines

Used as Medicine type Examples
Reliever — relief of symptoms


 Bronchodilator
  • Salbutamol
  • Terbutaline
  • Ipratropium — for severe or life-threatening asthma, also used for exacerbations of COPD 
Reliever + maintenance — relief of symptoms in mild asthma without regular ICS Bronchodilator + inhaled corticosteroid (ICS)
  • Budesonide-formoterol 
Preventer — prevents symptoms happening Inhaled corticosteroid (ICS)
  • Beclometasone
  • Budesonide
  • Ciclesonide
  • Fluticasone propionate
Preventer — prevents symptoms happening Oral
  • Montelukast
Combined therapy — preventer and long-acting reliever together ICS + long-acting beta2 agonist (LABA)
  • Budesonide + formoterol
  • Fluticasone furoate + vilanterol
  • Fluticasone propionate + formoterol
  • Fluticasone propionate + salmeterol

Table 7.19 Total daily doses of inhaled corticosteroids (ICS) for adults

Inhaled corticosteroid Low dose (microgram) Medium dose (microgram) High dose (microgram)
Beclometasone 100–200 microgram 250–400 microgram More than 400 microgram
Budesonide 200–400 microgram 500–800 microgram More than 800 microgram
Ciclesonide 80–160 microgram 240–320 microgram More than 320 microgram
Fluticasone fuorate N/A 100 microgram 200 microgram
Fluticasone propionate 100–200 microgram 250–500 microgram More than 500 microgram

Inhaled therapy devices

  • All metered dose inhalers/MDIs (puffers) work best with a spacer — See Spacer devices for respiratory medicines
    • Have person show you their puffer and spacer techniques
    • Check they know how to make a bush spacer
  • Bronchodilators (relievers) work as well with puffer and spacer as with nebuliser — except in severe or life-threatening attacks
    • Salbutamol 100microgram/dose puffer 8–12 puffs = salbutamol 5mg nebulised
  • Other devices are available — find device person prefers or works best for them
  • Dry powder inhalers (DPIs), eg turbuhaler, accuhaler, Ellipta
    • Can get blocked in very humid climates
    • Need to be able to take a big enough breath to make work — Ellipta doesn't need as big a breath to activate as the others

Asthma action plan

Every person needs written asthma action plan — make sure they understand it

  • Keep copy at home and in file notes

Illustrated Aboriginal asthma action plans are available online — includes

  • What to do when
    • Person well
    • Asthma bit worse or they get a cold or chest infection
    • Asthma severe
  • How often they need regular reviews, medical follow-up, specialist reviews
  • When to collect medicines and have immunisations