This essay is to examine the care 22 year old woman who attended for an annual review having been treated with prednisolone due to a chest infection 2 months ago. The annual review took place in a GP’s surgery in the North West of England.
The professionals involved in his care were a Nurse Practitioner and a Practice Nurse who is undertaking a level 5 Asthma course.
NICE Guidelines were used to assess and implement further care and treatment.
The main points that will be covered in this essay are how NICE guidelines have been implemented to manage the control of her symptoms and achieve the best possible pulmonary function with minimal side effects.
The essay will explore the importance of promoting self-management of the condition. During the case study four main areas will be identified as being important, information, self-monitoring, regular asthma reviews and a written personal action plan. The effectiveness of the use of a self-management plan has been evaluated in improving overall asthma care, in studies it appears that self-management education in over sixteen year olds results in reduced hospitalisation, A+E visits, unscheduled GP visits and less days lost through illness from school or work, 1.
There are several strategies required for successfully management of asthma. The first is ensuring the correct diagnosis has been made. Management of asthma, this involves the use of medications to treat both the inflammation and therefore the symptoms, advice about avoiding triggers and education about the disease and it’s management.
The woman had attended for her annual review, she had been diagnosed as having asthma 12 months ago following a structured history of her symptoms and spirometry reversal, FeNO testing wasn’t available at the time of her diagnosis.
The first stage of the annual review is to ascertain the patient’s history and current asthma status. This is an extremely important part of the review to understand the nature of the condition at present. ‘Due to the fact that Asthma is so variable a patient with a long standing diagnosis of asthma can find that the condition can vary in nature this can mean that the frequency of symptoms and the triggers can change over time’ 2. As there is currently no gold standard test available to diagnose asthma 3, history taking was conducted following NICE guidelines on components of a structured interview. The patient’s history showed that she has had a moderate exacerbation recently, following an upper respiratory viral infection, which was treated with oral steroids prednisolone 40mg daily for 5 days.
A patient centred consultation was conducted, the aims of this were to explore the patient’s understanding of her condition and the problems she is confronted with on a daily basis. It also enables the patient to negotiate and contribute to her personal action plan. Fradd (1996) observes that negotiation is about encouraging involvement in the decision making process, to promote concordance. 4
The patient was weighed and height measured, her BMI was 24, within normal limits. Her peak Flow was measured which was 75% of her best.
The interview was carried out according to NICE guidelines, Asthma control will be monitored at every review. Confirmation of the person’s adherence to prescribed treatment. Inhaler technique to be reviewed and treatment change if necessary. Other triggers or presence of occupational asthma established if relevant. 5
The consultation was conducted using open questions and closed questions only when necessary. This gives the patient longer to talk about their symptoms and the effect they have on their daily life.
At the time of the review the patient is currently prescribed medication at step 1 of the step wise approach management, it was a short acting beta-2-agnonist (SABA) as required. She presented in surgery describing symptoms of a cough with no mucous production. The cough occurred during the night, waking her and disturbing sleep nightly, and in the morning on waking. A wheeze was described, how it sounds and how it feels were explored. Intermittent shortness of breath was also described, particularly on exertion. This was preventing her from doing many household activities which she was finding distressing as she was reliant on her husband. She was struggling to walk up a flight of stairs and was sleeping downstairs alone most nights.
It would appear at this stage of the interview that Asthma was not well controlled and is having a significant impact on her own and her husband’s lives.
The next stage of the interview process is to establish why her condition isn’t well controlled and what trigger factors may be present. She appeared to have a runny nose and itchy eyes, she described a feeling of having mucous at the back of her throat. She currently takes no medication for allergic Rhinitis. On examination her nasal passages were inflamed. She describes this as something she suffers with on a yearly basis but her symptoms are better during the colder months.
In conclusion it would appear that this patient has an exacerbation of Asthma and has allergic rhinitis. It indicates that asthma is atopic and would benefit from treatment of allergic rhinitis with a steroidal nasal spray, along with cetirizine that she is currently taking, world allergy. Org say that nasal steroid treatment improves both allergic rhinitis symptoms along with symptoms of asthma, reducing bronchial hyperresponsivness. 6
The use of Ventolin was explored, it became obvious that only 50% of prescriptions had been collected and that Ventolin was being used 4-5 times per day at least 3 days per week. It was only being used when the patient felt that it was absolutely necessary. At several points during the interview the patient mentioned that she was frightened of becoming addicted to certain medications. She spoke about it in relation to simple analgesia both oral. It was suggested to her, using paraphrasing, that addiction seemed to be a fear for her. She spoke of the fact that her father is an alcoholic and that she is frightened of becoming addicted to any medication.
In accordance with NICE guidelines pragmatic thresholds to define asthma were used prior to initiating any further medication, these proved this patient has uncontrolled asthma. She has 3 days a week with required use of a SABA for symptomatic relief, 7. Which means that, in accordance with NICE guidelines, an inhaled corticosteroid (ICS) is offered as first line therapy. This could prove challenging for this patient due to her existing fears and beliefs. In BMC pulmonary medicine they described how further questioning as to what a patient’s goals and aspirations asthma control and the impact on her life is necessary to explore further beliefs and concerns about treatment. 8
The ICS that was prescribed was Clenil Modulate 250mcgs, in accordance with local guidelines, to be used as prophylactic management. THE ICS was started at the dose appropriate to the severity of asthma symptoms and will be adjusted to the lowest effective dose at which the symptoms can be controlled.
A spacer had never been used by this patient. When inhaler technique was reviewed it appeared to be poor. Inhaler technique is extremely important in control of symptoms. Incorrect inhalers technique is very common and has not altered over the past 40 years. 9
Poor inhaler technique lowers drug delivery into the inflamed and constricted airways. Therefore, leading to poor disease control. This in turn will lead to increased exacerbation of symptoms and an increase in admissions. In 2014 the National review of Asthma Deaths (NRAD) reported that misunderstandings and misuse of inhalers was thought to have contributed to a significant number of deaths registered for England and Wales. 10
Education as to optimal inhaler technique was demonstrated. It has been recognised that education is of vital importance in promoting self-care and therefore concordance it has been described as: a key challenge for health care professionals to engage patients in self-management behaviours with optimal adherence to appropriate treatment. 11
Assessment of inhaler technique is done at every assessment with demonstration of correct inhaler technique. The patient’s technique was poor, she didn’t prime her inhaler and had never used a spacer. It has been shown that inhaler technique is assessed and demonstrated at every visit because it does deteriorate over time. 12
Education and concordance go hand in hand and are inextricably linked. NICE has outlined Key priorities when involving adults in decisions about taking medication, one of which is to offer education and information.12 to provide education a discussion was initiated to assess how ICS have been shown to reduce both the morbidity and mortality of asthma and because of this are the cornerstones of symptom management. They control the inflammation, oedema and basement membrane thickening having the potential to treat the disease rather than simply modify the symptoms as bronchodilators do. Assurance was offered about the non-addictive nature of ICS’s and that the lowest dose would be used to control asthma symptoms once control had been achieved, in accordance with NICE guidelines. Education as to why control, is so important was given. The aims of asthma management are to improve symptoms and prevent deterioration. 13
An excellent definition of asthma control was described by Cockroft and Swystun. They defined asthma severity as the minimum medication required to achieve asthma control. Control is defined as a lack of symptoms, ability to lead a normal life, almost normal lung function and lack of morbidity from the disease. 14 The aim of the use of the ICS and its importance in asthma control was discussed with the patient. She agreed that it was important to her to remain symptom free and to lead her normal active life. Not only is the change in her medication important in enabling her to achieve her goals, self-care will be a priority. There is extensive information evidencing the importance of promoting self-management and maintenance of it by the patient, its importance is emphasised in different guidelines. 15, 16. Side effects of ICS were explained and we agreed that she would have a drink of water after using her ICS to reduce the taste in her mouth if it is a problem for her.
Self-management can lead to a reduction of exacerbations. It improves markers of control of asthma, reducing symptoms and reducing employment days lost to sick leave. It also improves quality of life, which is an agreed goal for the patient. It has been suggested that the impact of asthma control is greater when self-management education is given within a comprehensive programme of proactive and accessible asthma care.17 and is supported by regular asthma reviews 18. To promote and re-inforce self-management a Personal Asthma Action Plan (PAAP) was negotiated and agreed with the patient. In accordance with NICE guidelines a written personal action plan can improve outcomes for people with asthma, such as efficacy, knowledge and confidence. Nice guidelines 2017
A written PAAP reminds people of what their medication is, when and how to take it. The aim of it is to help them to recognise when control of their condition is deteriorating and what action to take. The PAAP used was one from Asthma,org’s website.
It was suggested to the patient that she could choose as whether she monitors control by monitoring her symptoms, using peak flow readings or a combination of both. She chose to use symptom control.
The patient admitted that she can be very forgetful thus she decided to set a reminder twice daily on to her smart phone. She also chose to link it with activities that she carries out every day to aid recall.
There are three parts or zones in the PAAP. The first is a green zone that is a reminder of all medication prescribed, this includes Clenil Modulate as a Preventer inhaler, Ventolin as a reliever inhaler, both to be used with an Ablespacer. The patient admitted that she can be very forgetful and decided to set a reminder twice daily on to her smart phone. She also chose to link it with activities that she carries out every day to aid recall.
Cetirizine and Beclometasone nasal spray were added. A reminder to be aware of inhaler technique is also included. Details were added for www.asthma.org.uk to watch their Asthma inhaler videos, this will enable the patient to remain vigilant about her inhaler technique. Identification of triggers is important to add. As pollen seems to be a trigger for her management of allergic rhinitis was added and when and how to use her nasal steroidal spray. Other triggers were discussed but at this moment in time the patient doesn’t believe that she has any.
The next zone is a yellow one. This describes deterioration in symptoms, tightness of the chest, wheezing, coughing, breathlessness, waking at night, interference with usual daily activities. Use of reliever inhaler more than 3 or more times per week. The patient recognises that this part of the PAAP is extremely important. It is this part that will assist her in remaining in control of her symptoms. Because asthma is unpredictable and varies in nature it was explained to the patient what actions to take when she recognises she is in the yellow zone. The use of the reliever inhaler during this period of time can reduce inflammation in the airways an agreement was reached as to how many doses of the reliever inhaler could be used until symptoms have gone, this is to prevent an asthma attack occurring and may need to be used for a few days. It was agreed that she would contact the surgery. As a surgery we don’t offer rescue packs so this wasn’t discussed. The patient was advised to avoid any asthma triggers wherever possible.
The final zone is the red zone. This is when the reliever inhaler is not helping and symptoms are worse. What to do in an Asthma attack was outlined and added to the PAAP.
The patient understood the necessity for the PAAP and for her change in medication. She had a goal to remain symptom free to enhance hers and her husband’s lives. A date was agreed for a follow up review.
When the patient returned, she was symptom free, she was living her life in the independent manor she had made her goal. Her husband was happier as he was worry free about his wife and could now do things that were important to him. She was taking her medication as prescribed and using both inhalers and spacer as prescribed. Her allergic rhinitis was controlled and not affecting her asthma symptoms. She uses her PAAP regularly and has agreed to use it to maintain control. She is now considering regular exercise as a way of managing her asthma to aid pharmacological control.
This conclusion this essay is about a patient who attended an annual asthma review. She believed her asthma symptoms were well controlled however throughout the course of the interview it became apparent that her symptoms were deteriorating and, as indicated by the Peak flow measurement that she was experiencing moderately acute asthma.
The health professionals took a detailed history of her symptoms both as she believed them to be and as they were interpreted by the health professionals.. By use of good communication skills the Health Professionals were able to uncover some fears that she had with regards to addiction and medication and to allay these fears to promote concordance with pharmacology. Had the patient not been able to express this fear and have it answered satisfactorily she may well have not complied with any treatment.
By using NICE guidelines the health professionals were able to structure the interview and therefore advice an increase in medication, and ICS.
A PAAP was devised as a joint agreement between the patient and the health professional. This enabled the patient to re-call what was discussed during the review and effectively self-manage her condition on leaving the surgery. The PAAP also enables her to recognise any deterioration in symptoms and to act accordingly.
The patient now has a quality of life which she hasn’t had for a few months, as does her husband. They both feel like individuals within their relationship as opposed to one being extremely reliant on the other.
This patient leads a busy life and may not always be able to attend reviews, now her asthma is controlled it has been agreed that telephone reviews can used. Having flexible access to professional advice is an important part of self-management. 19
