Dealing with emergencies in general practice Asthma exacerbations

Many clinicians will at some point have to assist a patient who is having an acute asthma exacerbation. In this article we focus primarily on the immediate treatment of the asthma exacerbation via accurate assessment and immediate management, as well as touching on longer-term management including avoidance of further exacerbations

Gemma, age 29, is a patient at the surgery. She was last seen three months ago for her asthma review when everything seemed to be in order. However, she attends morning surgery as an emergency complaining of shortness of breath and a tight chest; she checked her peak flow this morning and it was 230. She is not sure what her usual peak flow reading is. She has taken her reliever three times already since 6am but does not feel much better. You are asked to see her as you are the asthma nurse and your immediate impression is that Gemma is suffering from an acute asthma attack.

ASSESSING CONTROL

In the event of an acute asthma exacerbation the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) guidelines¹ suggest that these observations are carried out:

• Pulse rate and rhythm
• Respiratory rate
• Oxygen saturations
• Peak flow measurement

It may also be useful to record the temperature in case of an infective exacerbation.

However, the immediate initial assessment will be carried out as soon as the nurse sees Gemma. A quick glance will give important information on the presence of dyspnoea, tachypnoea, pallor or cyanosis or the inability to speak in sentences; further assessment will swiftly identify other key features of concern such as accessory muscle use, tachycardia or hypoxia. If Gemma seems to be suffering from features of an acute, severe asthma exacerbation then immediate action should be taken to stabilise her and, if necessary, admit her.

The nurse was able to ascertain fairly quickly that Gemma was able to speak in sentences and did not seem to be distressed. She therefore carried out the objective measurements suggested by BTS/SIGN. In Gemma's case she recorded the following findings:

• Pulse rate of 112bpm with a regular rhythm
• Respiratory rate 26 per minute
• Oxygen saturations 97% at rest on air
• Peak flow measurement 220 (best PEFR in the past 2 years is 460)
• Temperature 36.8 — normal

In accordance with BTS/SIGN this is consistent with an acute severe exacerbation. An acute severe exacerbation is defined as one where the patient is found to have any one of the following:

• PEFR between 33-50% of best PEFR (or predicted if best not known)
• Respiratory rate ≥25/min
• Heart rate ≥110/min
• Inability to complete sentences in one breath
• Accessory muscle use

GETTING CONTROL

It is important at this stage to bring Gemma's symptoms under control in order to avoid worsening symptoms and a potentially life-threatening exacerbation. This will be done initially by delivering high dose inhaled bronchodilators (beta2 agonists) such as salbutamol via a pressurised metered dose inhaler and spacer. Salbutamol can be given at a dose of 4-10 puffs and the dose can be repeated as required until Gemma's condition improves. Failure to respond to high dose bronchodilators is an indication that the diagnosis may be incorrect or that the patient is at risk of life threatening asthma and should be admitted.

According to BTS/SIGN the features of life threatening asthma include:

• Altered conscious level
• PEFR <33% best or predicted
• Oxygen saturations <92%/cyanosis
• Silent chest
• Hypotension
• Exhaustion
• Arrhythmia
• Abnormal arterial blood gases as assessed in hospital

Patients who present with any of these signs and symptoms will require high dose bronchodilators via oxygen driven nebuliser and immediate transfer to hospital. A flow rate of 6 l/min should be used for most nebulisers. Where oxygen cylinders are used, a high flow regulator should be in situ.¹ Close observation will be required to monitor for signs of respiratory or cardiac arrest, in which case life support interventions will be needed as discussed in the previous article on this subject.² Intramuscular (IM) methylprednisolone may be administered by ambulance or secondary care staff.

Once Gemma's condition improves, oral steroids should be prescribed and taken as soon as possible to maintain the improvement and restore best possible lung function as soon as possible. Oral steroids work within a few hours of being taken. A dose of 40-50 mg prednisolone daily should be given for at least 5 days or until the patient has recovered.

MAINTAINING CONTROL

Any exacerbation is an opportunity to look at what has gone wrong and identify opportunities to improve overall control by recognising and treating worsening asthma quickly. Follow up is essential to ensure the patient has fully recovered and also to ensure possible causes of the exacerbation are identified. (See Setting a new benchmark for asthma care, Clinical/Primary Care Essentials) The recent Asthma Quality Standards publication from NICE³ was the subject of some controversy when it suggested that any patient suffering from an asthma exacerbation that required input from the out of hours or emergency services should be reviewed in the practice within 2 working days. Some clinicians thought this was unattainable and unnecessary but soon after an acute exacerbation can be a good time to discuss strategies to avoid a recurrence in the future.

One of these strategies will be to encourage Gemma to have a self-management plan, or asthma action plan, which encourages her to develop an increased awareness of any changes in symptoms as a way of alerting her to deteriorating control. Gemma can also do this by monitoring her peak expiratory flow readings as a way of identifying a reduction in her usual lung function. Asthma action plans allow patients to recognise and act upon any deterioration early enough before a more severe exacerbation results. The BTS/SIGN guidelines endorse the use of asthma action plans, especially for someone like Gemma who has suffered an exacerbation in the past.¹

As well as having a personalised, written action plan there are other ways in which control can be monitored both in and away from surgery. These include the Royal College of Physicians 'Three Questions'⁴ and the Asthma Control Test (ACT).⁵ This test, along with personalised information and guidance about an individual's asthma, is also available online from www.myasthma.co.uk or as an app for smart phones and tablets. Gemma decides to sign up for this free app as it suits her lifestyle.

Recently the COPD and Asthma Outcomes Strategy⁶ suggested that practices maintain asthma risk registers, identifying people at increased risk of an asthma exacerbation. This concept has been addressed via Asthma UK's online Triple A test, where factors that increase the risk of an asthma attack are measured, rather than looking at measures of good control.⁷ This test, like others, has advantages and disadvantages but Gemma was able to use it to look at her asthma exacerbation risk and think about how to reduce her overall risk in the future.

It may be that Gemma's current therapy is inadequate. Asthma is an inflammatory condition and requires adequate doses of inhaled corticosteroids to treat this underlying inflammation — a dose of between 200-800mcg of beclometasone or equivalent is recommended in the BTS/SIGN guidelines. If the condition is inadequately treated on this, however, it may be necessary to step up treatment. Key areas that should be addressed before automatically stepping up treatment include:

• Checking inhaler technique
• Ensuring understanding of and adherence to current prescribed medication regimen
• Identifying and addressing untreated co-morbidities such as allergic rhinitis

Once these areas have been covered, Gemma may need to step up her treatment to step 3 of the BTS/SIGN guidelines by introducing a long acting beta 2 agonist within a combination inhaler. As she is over 18 she may benefit from using one inhaler as both maintenance therapy and reliever — both Fostair and Symbicort are licensed to be used this way.⁸

Any changes in her asthma management should include Gemma at every step — she should be central to decisions about her treatment, choice of device, and development of an action plan. Ongoing reviews should be tailored to suit her future asthma control.

CASE STUDY — SAM

Sam is 10 years old and is normally fit and well. However, he attends surgery with his mother one afternoon complaining of cough and marked wheeze. His mother had been asked to collect him as he had become unwell after playing rounders on the school playing field. She had brought him straight to surgery as it is next door to the school. Sam is not known to have asthma but there are elements of his presentation that make the nurse suspicious that asthma could be the diagnosis here. The diagnosis of asthma is a clinical one where the presence of typical symptoms in the absence of other possible explanations will lead to consideration of asthma as the underlying cause. Clinicians are asked to decide, based on the history and presentation, whether there is a high, intermediate or low probability of asthma being the diagnosis.¹ The nurse decided that the primary objective at this stage was to determine whether urgent action was required to stabilise Sam before taking a further history and making a more in-depth assessment.

As previously mentioned, the immediate visual assessment will often give important clues to the severity of the exacerbation. Objective measurements should also be carried out and a record kept of conscious level, level of breathlessness and wheezing, pulse rate, respiratory rate and accessory muscle use. PEFR and pulse oximetry should also be recorded. At the earliest opportunity, where possible and practical, a good history should be taken. All of this information should be documented, ideally at the time but if the patient is acutely unwell, as soon as possible once they have been stabilised.

On examination, Sam was short of breath, tachypnoeic and tachycardic. There was an audible expiratory wheeze.

The asthma nurse uses her AGM for asthma again.

ASSESS CONTROL

The BTS/SIGN guidelines include a checklist for assessing the severity of an exacerbation in children. For children aged over 5 such as Sam, the features which suggest a severe acute exacerbation include:

• Oxygen saturations of <92%
• PEF 33-50%
• Cannot complete sentences in one breath or too breathless to talk or feed
• Pulse >125 (>140 in 2 to 5 years)
• Respiration >30 breaths/min (>40 in 2 to 5 years)

In Sam's case his SATs were 98%, he was unable to perform PEFR and there was no previous record as he had no history of asthma. His pulse rate was 98bpm and his respiratory rate was 30. He had an audible wheeze and was finding it hard to speak in sentences. He was very anxious, as was his mum. The school had said that Sam had begun to cough and wheeze when playing rounders on the freshly mown playing field. Although Sam's sister had asthma, Sam had no history of this condition. However, he was known to suffer from hay fever. On the basis of this information the nurse felt that Sam should be treated as an acute severe asthma exacerbation — first presentation.

GET CONTROL

Immediate management involved administration of 4 puffs of salbutamol, increasing by 2 puffs every 2 minutes up to 10 puffs. If Sam had not responded to 10 puffs of salbutamol, he should have been admitted. However, Sam responded quickly to this treatment and was much better within 5 minutes.

In line with BTS/SIGN oral steroids were prescribed to avoid a more serious exacerbation. Children over 5 years can be given 30-40 mg of prednisolone whereas younger children — age 2 to 5 years — can be given 20mg. Treatment for just 3 days is often all that is required.

MAINTAIN CONTROL

As in the case of adults, Sam should be monitored and reviewed and a decision should be made about ongoing education and therapy. A diagnosis of asthma seems likely based on his presentation and history and treatment with an appropriate dose of inhaled corticosteroid with or without additional therapy should be considered. Device choice will require careful consideration too. An action plan should be developed and the practice should aim to work with Sam's school to ensure seamless, ongoing care throughout.

In summary, patients who suffer from asthma exacerbations require swift assessment to determine the severity. Early control of symptoms is vital and treatment with high dose short acting bronchodilators and oral steroids will help to bring about an early resolution of symptoms and help to avoid a more serious and even life-threatening exacerbation. All patients who exacerbate should be reviewed soon after the exacerbation and consideration should be given to developing an asthma action plan with them. Ongoing support should be offered to ensure control is regained and maintained.

REFERENCES

1. BTS/SIGN (2012) British Guideline on the management of asthma Available at http://www.brit-thoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/sign101%20Jan%202012.pdf Accessed May 2013

2. Bostock-Cox B. Emergencies in general practice. Practice Nurse November 2012;42(17):22-25

3. NICE (2013) Asthma Quality Standards Available at http://publications.nice.org.uk/quality-standard-for-asthma-qs25 Accessed May 2013

4. Thomas M, Gruffydd-Jones K, Stonham C, Ward S, Macfarlane TV. Assessing asthma control in routine clinical practice: use of the Royal College of Physicians '3 Questions'. Prim Care Respir J 2009; 18: 83—88.

5. Asthma Control Test (2004) Available at www.myasthma.org or via http://www.asthma.org.uk/media/2316174/asthma_control_test_english.pdf Accessed May 2013

6. COPD and asthma outcomes strategy (2011) Available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_128428.pdf Accessed May 2013

7. Triple A test (2012) — available at http://www.asthma.org.uk/get-involved/our-campaigns/the-triple-a-avoid-asthma-attacks-campaign/ Accessed May 2013

8. Electronic Medicines Compendium: Fostair MART. Available at http://www.medicines.org.uk/emc/medicine/21006/SPC/Fostair+100+6+inhalation+solution/ Accessed May 2013

9. Electronic Medicines Compendium: Symbicort SMART. Available http://www.medicines.org.uk/emc/medicine/4820/SPC/Symbicort+Turbohaler+100+6%2c+Inhalation+powder./ Accessed May 2013