Assessing asthma control

Asthma is assessed in two ways:

1-Symptom control

It is assessed by checking your symptoms and issues in the day, when you are doing things or exercising o sleeping and whether you need the blue inhaler of have wheeze frequently. If this is the case the asthma is not well controlled.

 

 

There is a different questionnaire which we sometimes use for younger people.

Asthma_Control_Test_Form

2- Peak Flow readings

Important to take a full deep breath and blow out as hard and fast as you can.

Best of 3 readings

Asthma causes a tightness of the airways and makes it hard to breath out fast.

A peak flow reading which allows us to see how hard you can blow out from a full breath in. It is always the best of 3 readings.

It may be that your technique is poor and the readings are not accurate reflection of your ability to blow out.

As the natural size of the airway changes according to the time of day it is imprtant that you note whether it is an am, lunch or evening reading. COPD causes a more flat variation.

How to measure your peak flow

The first time your peak flow is measured, you’ll be taught how to do it by a doctor or nurse. After this they may advise you to carry out the test regularly at home using your own peak flow meter.

To measure your peak flow:

  • find a comfortable position, either sitting or standing
  • reset your peak flow meter so the pointer is pushed back to the first line of the scale – this is usually 60
  • hold the peak flow meter so it’s horizontal and make sure that your fingers are not obstructing the measurement scale
  • breathe in as deeply as you can and place your lips tightly around the mouthpiece
  • breathe out as quickly and as hard as you can
  • when you’ve finished breathing out, make a note of your reading

This should be repeated 3 times, and the highest of the 3 measurements should be recorded as your peak flow score.

If you’re monitoring your asthma at home, you may have a diary or chart to record your score.

You can download a peak flow diary (PDF, 2.2Mb) from the Asthma UK website if you don’t have one.

https://queensbowersurgery.co.uk/wp-content/uploads/2016/11/diurnal.jpg

 

There are predicted peak flow charts which give an indication of what you should be compared with your sex and height.

http://peakflow.com/top_nav/normal_values/index.html

 

 

Actions If not controlled

Monitor asthma control at every review. If control is suboptimal:

  • confirm using prescribed treatment in line with the recommendations on assessing adherence in the NICE guideline on medicines adherence
  • review  inhaler technique. A spacer can help with the medicine reaching the lungs if the coordination of releasing the gas in some inhalers and the timing of breathing in is poor. Poor technique can mean just 5% reaches the lungs versus 15% with a good technique
  • review if treatment needs to be changed
  • ? occupational asthma (see recommendation 1.1.10) and/or other triggers, if relevant.

If your asthma is not well controlled, checking your technique is important.

Inhaler technique – see below or

https://queensbowersurgery.co.uk/?page_id=5230

If it is a poor technique, then learning the correct technique or using a spacer (if a pressurised inhaler is being used) to ensure the medicine is going into your lungs.

 

 

 

 

aerochambers

 

 

Alternatively a change of device may be suggested.

If your technique is fine and you are not controlled changing the amount or type of medicine is the next step.

Sometimes other reasons may cause you to feel short of breath e.g. weight, anaemia, heart problems

 

This information lets us make a care plan –

 

Within a self-management programme, there may be an increased dose of steroids for 7 days to adults (aged 17 and over) who are using an steroid in a single inhaler, when asthma control deteriorates. This my be if there is isolated wheeze without signs of infection. When increasing ICS (INHALED STEROID) treatment:

  • we consider quadrupling the regular ICS dose
  •  not exceed the maximum licensed daily doseOtherwise we may feel steroid (prednisolone tablets) are necessary if your asthma is poorly controlled.

BD=twice daily

In the orange zone you can see oral steroids (prednisolone) are mentioned. These are many times the strength of the inhaler which works only

where it is needed. The steroid tablet has to go through your whole body to get to your lungs.

These should not be used frequently due to the effect on bone strength, blood sugars, blood pressure etc. and are backups for people with severe asthma/copd.

 

THE MEDICINES THAT ARE GIVEN ARE PRESCRIBED ACCORDING TO THE SEVERITY OF YOUR CONDITION

AND THE RISKS VS BENFITS OF THE MEDICATION.

If things are not controlled your technique should be considered before  we consider increasing the dose or changing to a stronger device.

When you are given a stronger inhaler with asthma, you are in the main asked to discontinue other inhalers apart from the reliever.

If in doubt ask.

Types of active ingredients in inhalers ( These last three are often now days mixed in different combinations)

Short acting beta-agonists that open up the wind-pipe. They are for short term relief. If they are frequently needed or there are symptoms they are not sufficient or the technique is poor.e.g. ventolin

Steroid inhalers component to damp down the soreness and regular usage reduces the soreness and irritibility of the airways reducing the  triggering of asthma. e.g. clenil

Long acting beta-agonists that open up the airways for longer ( when steroid inhalers do not control asthma) e.g. salmeterol, ingredient in fostair,seretide. These rely on regular use

Antimuscarinic drugs (generally used for COPD/not asthma) such as tioptopium which relax the muscles in the airways which would normally close it up. e.g. tiotropium, braltus. These rely on daily use.

 

Relievers

Salbutamol\Ventolin (occasionally short acting ipratropium is used)

2 puffs inhaler as needed normally, 5-10 puffs if very tight (can be used with spacer)   LEAFLETVIDEO 

Infrequent, short-lived wheeze SABA as required 1st choice: Salbutamol MDI 100 micrograms/ inhalation: 2 puffs as required +/- spacer

 

Image result for easibreath

 

2nd choices: Salamol® Easibreathe MDI 100 micrograms/ inhalation: 2 puffs as required  LEAFLET \ VIDEO

Or Bricanyl ® Turbohaler (Terbutaline) 500 micrograms / inhalation 1 puff as required LEAFLET \VIDEO 

Preventers

ICS doses and their pharmacological strengths vary across different formulations. In general, people with asthma should use the smallest doses of ICS that provide optimal control for their asthma, in order to reduce the risk of side effects.

For adults aged 17 and over:

  • less than or equal to 400 micrograms budesonide or equivalent would be considered a low dose
  • more than 400 micrograms to 800 micrograms budesonide or equivalent would be considered a moderate dose
  • more than 800 micrograms budesonide or equivalent would be considered a high dose.

For children and young people aged 16 and under:

  • less than or equal to 200 micrograms budesonide or equivalent would be considered a paediatric low dose
  • more than 200 micrograms to 400 micrograms budesonide or equivalent would be considered a paediatric moderate dose
  • more than 400 micrograms budesonide or equivalent would be considered a paediatric high dose.

Clenil

Image result for clenil inhaler

1st choice: Clenil Modulite® (CFC-free BDP) MDI 100 micrograms/ inhalation +/- spacer 2 puffs BD LEAFLET \ VIDEO 

Combination inhalers

OR QVAR® Easibreathe (CFC-free BDP) MDI 50 microgram/inhalation 2 puff BD LEAFLET \ VIDEO

 

Mixed Preventers(steroid)  with Long acting relievers (instead of Preventers) 

 

Low dose steroid

Image result for fostair

 

Fostair® 100/6 MDI +/- spacer LEAFLET \ VIDEO 

or

NEXThaler 1 puff BD LEAFLET \ VIDEO 

OR
Flutiform® 50/5 MDI +/- spacer 2 puffs BD  LEAFLET \ VIDEO 

 

OR

Symbicort® 200/6 turbohaler 1 dose BD LEAFLET \ VIDEO ( Remember to twist whilst vertical)
OR

DuoResp Spiromax 160/4.5, 1 dose BD  VIDEO 

 

Medium dose steroid

 

Fostair® 100/6 MDI +/- spacer or NEXThaler 2 puffs BD (£356)
OR
Flutiform® 125/5 MDI +/- spacer 2 puffs BD (£340)
OR:
Symbicort® 200/6 turbohaler 2 doses BD (£340)
OR
DuoResp Spiromax 160/4.5, 2 doses BD (£339)

 

 

Maintenance and reliever therapies (SMART / MART):
• Symbicort® , Fostair® or DuoResp® can be used for both maintenance and relief medication instead of a separate
short – acting beta-agonist inhaler for selected patients who have seen a benefit with a long acting beta agonist,
but are still not controlled following initial add-on therapy.

Use of the reliever inhaler is then discouraged under normal circumstances

 

 

 

All inhalers

With all inhalers you should check that there is no foreign body in the mouthpeice to pevent choking on anything unexpected.

 

Sit upright to let you take a good breath in.

All inhalers require you to empty your lungs before you take your inhaler to give room for the medicine.

All inhalers require you to hold the medicine in your lungs to work. Ideally upto 10 seconds.

 

Use the cover to protect the mouth peice when not in use.

Powdered inhalers versus Pressurised inhalers

The big differences are –

The coordination of your breathing needs to be ok as you need to press the inhaler to release the gas just after you start breathing in

The pressurised inhalers need energy to give heat to be used to change the liquid to a gas.

Hence shaking it is important and

giving time between puffs (so that the inhaler can reheat with heat from the surroundings).

This is why multi-puffs (Several puffs in one go) is a bad idea.

 

The gas comes out over 3-5 seconds and therefore you should take a longer breath in than with the powdered inhalers. 

and continue to breath in slow and steady for upto 5 seconds.

 

If you cannot manage this spacers are also used.

 

The powdered inhalers rely on energy from your breath to break up the powder and hence the breath in needs to be sharper and quicker.

The timing is not so important as you are effectively sucking the powder into your lungs. For some inhalers you need to breath in quite hard.

 

 

mdi

Checklist for metered dose inhaler use

1 Stand or sit upright when using your inhaler.
2 Remove the inhaler cap.
3 Hold the inhaler upright and shake 4 or 5 times.
4 Breathe out fully.
5 Place the mouthpiece between your teeth without biting and form a good seal around it with your lips.
6 Breathe in through your mouth and press the canister down at the same time to release a puff of medicine.
7 Continue to breathe in slowly and deeply for 3-5 seconds.
8 Hold your breath and take the inhaler from your mouth.
9 Continue to hold your breath for 10 seconds or as long as is comfortable. Breathe out slowly.
10 If your doctor has told you to take two puffs, wait 30 seconds then repeat steps 3 to 9.
11 Replace the cap straight away to keep out dust.

Common problems

Common mistakes that people make with metered dose inhalers include:

  • Not standing, sitting or holding the inhaler upright.
  • Not shaking the inhaler before using it.
  • Inhaling too sharply, at the wrong time or not deeply enough.
  • Not holding your breath long enough after breathing in the contents.
  • Taking several puffs without waiting between them.
  • It can be difficult to tell when the inhaler is empty.

 

Useful tips

  • Practice in a mirror, if you see a ‘mist’ from the top of the inhaler or the sides of your mouth you should start again.
  • If your inhaler contains a corticosteroid rinse your mouth out with water after your dose.
  • A spacer device used with your inhaler could help with any co-ordination problem, help the medication reach the lungs and reduce any side effects.
  • Always read the patient leaflet provided with your inhaler for any specific instructions.
  • Speak to your nurse or pharmacist if you experience problems using your inhaler.

Other videos

https://www.asthma.org.uk/advice/inhaler-videos/

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