Jo Riley

Brief Outline:

Lead Reparatory Nurse, Churchill Hospital, Oxford

Background:

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A specialist nurse talks about why it might take time to find the right medication.

So the sorts of treatments we’d start somebody on would be inhaled treatments and one of the key things with inhaled treatments is getting good inhaler technique. So we may start somebody on an inhaler and they are not perhaps responding as well as we’d expect and the first thing we would then look at is: Have they got good inhaler technique? Have they been taught to use the inhaler correctly? If they have and they’re still not getting full response, they are getting some benefit but still getting some symptoms then we may need to step the treatment up adding in different drugs or increasing the dose of the treatments in the inhalers. So for some people you might hit on the right dose straight away for other people you might need to increase doses over a few times before you get to the right dose to get the asthma under control.

And does that involve patients returning to see you at different intervals to check up how that is going?

Yes and we would expect that we would see a patient perhaps every six weeks or so depending on how symptomatic they are. If somebody came to see us straight away with a very severe attack then we might want to see them within a few days to make sure that is settling down and perhaps see them a little more frequently until they are a bit more stable but for somebody who is stepping up treatment we’d normally try a treatment for about six to eight weeks and then get them to come back to see how they have responded to the treatment and if they are still having symptoms then try a new inhaler or an increase in dose and then bring them back again, again about 6 to 8 weeks later until we’ve got the condition stable.

A specialist nurse describes the variety of inhaler devices and how different types suit different needs.

You were talking about inhaler technique earlier can you just say a little bit about because there are difference devices at the moment. There are different types of inhalers.

Yes. We use lots of different devices for people with asthma. Ideally we should be checking whether somebody can use the particular device that we are recommending but also if possible offering a choice of different devices that might be more suitable to the patient’s lifestyle.  So vaguely the two different types of devices we have are either devices that are what we call, ‘the metered dose inhalers’ or puffers which are where the patient compresses the inhaler down and a spray or mist of inhaler comes out and the patient has to breathe that down into their lungs. With those sorts of devices the patient often has to co-ordinate being able to press and breathe in at the same time and should breathe in with slow gentle breaths so that they carry that mist or that spray as far down into the lungs as possible. And they can be quite difficult devices to use because of getting the co-ordination right and getting the timing right. We can use those devices in spacers as we mentioned earlier and that can help with co-ordination because you don’t have to press and breathe at exactly the right time with the spacer device and so that can make it a little bit easier to use. 

The other devices we have are called, ‘dry powder devices’. There are lots of different dry powder devices. We’ve got turbohalers and accuhalers and clickhalers that are different types of devices that have powder in them and the patient twists or primes the device and then has to breathe in quite forcibly to take the powder down into the lungs. The different devices suit different people. Some people prefer one device over another. Sometimes it’s that a particular drug comes in a particular device and that’s the particular drug that is better for that person’s asthma. So there are lots of different reasons why we might choose one device over another.

Certainly if somebody had difficulty in operating one particular type there are options for them to have.

Yes there are lots of different devices and we mustn’t forget that there are people. We often think of asthma in younger people but there are older people with asthma who perhaps don’t have the dexterity to be able to press an inhaler. So somebody may have arthritis or rheumatism and not be able to press an inhaler down. And we have devices that we can put on inhalers to adapt them to make them easier to press the inhaler or we have different devices that we can use. It may be that somebody is younger and has poorer co-ordination or just somebody who wants something that fits better with their lifestyle. So lots of different devices that we can choose, so not always having to stick to the device that has been the first one that has been chosen.

A specialist nurse explains what an asthma action plan is.

What are asthma care plans or action plans?

Asthma action plans usually are a plan often a written plan that advises the patient on what they should do under normal circumstances with their asthma but also about what to look out for when their asthma is going out of control and what action they should take as a result of that. And they can be very simple plans. If somebody doesn’t feel confident to want to take control of their asthma just with simple advice about the sorts of things to look out for that would suggest that they ought to go and seek advice right through to quite complex plans that give patients lots of information about what they can do in an emergency, when they should start taking their steroids, when they can change their own treatment according to the plan.

One would also expect in the plan to see advice around the sorts of things like prevention of their asthma so avoiding triggers if there are particular triggers that we know are a particular problem to that patient.

Does everybody have an asthma plan or is that optional? How does that work?

In an ideal world that ought to be. Everybody with asthma ought to have an action plan. I truly believe that it’s the way forward for people to understand their asthma is that they have a plan that tells them what they should do under normal circumstances and what they can do to help themselves in the future. But unfortunately not everybody has action plans either because they’ve not been offered one or perhaps because they have been offered one but haven’t wanted to take that up or that the healthcare professional seeing them doesn’t know how to draw up an action plan for the patient.

I would hope, that people would feel confident to go to their practice nurse or to their GP or whoever manages their asthma and say, ‘I’d like a written action plan so I know what to do with my asthma’.

And so should they take those extra medications themselves if they know they are having an attack or is that something that somebody else would need to help them with?

It should be done as rapidly as possible and would again suggest why it’s important to have an action plan because the action plan would guide them as to what they should do in the event of an attack and how much they should increase the treatment by. So we wouldn’t suggest that somebody without an action plan should just go increasing their treatment but if they’ve got either verbal or written guidance as to what to do and they’ve got the treatments to take then they should follow the advice that they’ve been given but also being aware to seek medical attention if the symptoms are becoming uncontrollable.
 

A specialist nurse describes an asthma crisis and when someone should seek medical advice.

Not everybody has what you might term an ‘asthma crisis’ but what happens when you do have one? What does it involve? How would you know you were having one?

With a crisis with asthma the airways become much more inflamed, often very rapidly. So somebody may have a response, a reaction to something that they are allergic to that they have a very severe response to. It could be that they’ve had a lot of things irritating the airways at one time so lots and lots of irritants in the air or it could be that there’s lots of, maybe they have had a cold or a viral infection that can suddenly trigger off the asthma. And what happens in those circumstances is that the person will start to feel much more breathless than normal. 

Very often their blue inhaler won’t work so they try their reliever inhaler or their blue inhaler and they don’t get good response to that and they feel progressively more breathless. These attacks can come on sometimes over a day or two but sometimes can come on very, very rapidly and the person will feel very wheezy, breathless and struggle. And we often tell people to watch out for whether they are able to move around or talk and if somebody is not able to talk properly so they are talking in broken sentences and only can say a few words at a time then that would indicate a very severe attack. And in those circumstances the most important thing is to seek an increase in treatment. So with the slowly progressing attack then increasing their preventative treatment, increasing their reliever treatment and often starting a course of steroids will get the attack under control if they’ve got so severe that they can’t talk properly they should seek medical advice very quickly.

And in terms of seeking medical attention do you mean actually going to A&E in some circumstances or what would that involve, just going to the doctor?

Yes again it very much depends on how severe the attack is and how well the attack is coming under control. So somebody who is perhaps feeling more breathless, blue inhaler is not working so much but is able to walk and talk we would suggest that they go down to their GP and seek advice from the GP or practice nurse. But if somebody’s attack was so severe that they were too breathless to walk and talk properly then we would advise that they call for help immediately so going to A&E and preferably not driving themselves in a car in case the attack gets worse on the way, so usually calling an ambulance so that they can get there with some medical advice.

A specialist asthma nurse describes what her role is in providing asthma management.

In a GP practice usually the patient may go and see the GP initially but then be referred to see the Asthma Nurse or a specialist nurse. What is her/his role? How does that fit in to the general system?

These days practice nurses often specialise in lots of different long term conditions and if the practice nurse has got specialist knowledge in asthma then they are often able to manage the patient’s asthma long term.  So practice nurses will often be more expert in assessing inhaler technique, assessing whether somebody is on appropriate treatment, to give lifestyle advice, help draw up self-management plans and generally monitor the asthma and be able to advise the person with asthma under any special circumstances they might come across. So if they are wanting to go on holiday abroad and wondering what they should do about their asthma, can they take backup medication, then the practice nurse is often the best person to go and ask about that.

Does every practice have a specialised asthma-assigned nurse or not?    

Not necessarily some practices will have practice nurses who have some knowledge around asthma and may be trained in order to assess inhaler technique but may not have the specialist advice to go on and give further information around self-management. But in many practices now there is often a practice nurse who is more specialised in asthma and is able to give that level of advice.

When someone has poorly controlled asthma that is not responding well to normal treatments they may be referred to a respiratory consultant.

In what circumstances would somebody go to see a respiratory consultant or have out-patient treatment?

There are a number of reasons why somebody might go to a respiratory consultant. It may be that the asthma isn’t well controlled on conventional treatment and we have very good national guidelines that give us a sort of stepwise approach to how we might treat asthma. And if we are not under control at one step then we step up to the next level of treatment. And often once we’ve stepped up to different inhaled devices and using maybe one or two different drugs in an inhaler and somebody is still not controlled then they may then get referred to a respiratory consultant for advice over whether we want to add in maybe some tablet therapy. Some people in the community, you might have a GP who has got a special interest in asthma or a practice nurse who has done more asthma training who would be confident to step people up a little bit further. But very often there comes a point where somebody will say, ‘Actually I am not getting good control over the asthma at this stage so I want further specialist advice.’ So that would be one reason why we might refer somebody. It may be that somebody is having lots and lots of flare ups and having frequent courses of steroid tablets, possibly even every time they come off the steroids having another flare up and needing to go back on the steroid. And again that would be another time where somebody might be referred for some specialist advice to see a respiratory consultant. 

And then there are people who have very severe asthma that is not brought under control by the guideline treatments we have available to us. And there are one or two specialist treatments particularly an injectable treatment called omalizumab (Xolair) which is only available under respiratory consultant control. And that’s only used in people who have very severe, highly allergic asthma where the asthma isn’t controllable under other circumstances and that would be assessed by a respiratory consultant who would possibly ensure that all the other treatments are being used appropriately, that there isn’t something else that is causing the asthma to be poorly controlled before they are then assessed to go on to that level of treatment.

A specialist nurse talks about the importance of regular asthma reviews.

And you talked early about the fact that people should go for regular reviews. How regular and what happens at a review?

Ideally asthmatics should go for a review at least once a year and in addition to that should go and be reviewed at their practice if they have ever had an admission to hospital with their asthma or if they’ve had an exacerbation or a flare up of their asthma. So their asthma should be reviewed after that time to see whether or not the treatment that they were on prior to that flare up was appropriate. So the reviews can be more often than a year but at a very minimum asthma should be reviewed on an annual basis. 

At the review the nurse or the doctor who is carrying out the review should review whether the patient is on appropriate medication, whether they are taking their medication appropriately. So have they got good inhaler technique? Have they had many flare ups that year. So is there any idea that they might need their asthma treatment stepping up but also looking at whether their asthma has been well controlled over that time and if their asthma has been very well controlled and they are on a high level of treatment could the treatment be stepped down. And so they may advise that under very well controlled asthma that the treatment is reduced. In those circumstances we would often recommend that the treatment is reduced and then reviewed again three months later to ensure that it hasn’t then set the asthma back out of control again.