Respiratory: Asthma
This Clinical Information Sheet (CIS) has been developed to assist RACF staff, medical practitioners and relevant professionals (pharmacists, allied health clinicians) involved in the management of residential aged care patients with asthma. It addresses issues that may occur in RACF, particularly:
Diagnosis of RACF residents newly presenting with asthma; Ongoing management of residents with asthma; and Initial management of residents experiencing an acute asthma attack.
This CIS covers:
This clinical information sheet is a guide only. It should be used with consideration to the:
Resident’s preferences, existing medical care plans, and advance care plan; Health professional’s role, knowledge, preferences and professional experience; Policies and resources available within the RACF; Requirements of local professional registration and regulatory bodies; and Relevant local legislation.
About Asthma
Forty percent of Australians have respiratory signs and symptoms that are consistent with asthma at some stage during life [1]. Asthma rates as one of the top 10 reasons for a visit to a GP [1] and as many as 40% of asthmatics are admitted to an emergency department each year with acute asthma [2]. Mortality is highest in the very young and the very old, and prompt recognition and management of symptoms of an acute asthma attack is essential to a positive clinical outcome [2, 3].
Asthma is a chronic inflammatory disorder of the airways that causes episodes of breathlessness, wheezing, coughing and chest tightness. An episode of asthma is associated with airway obstruction caused by contraction of the airway smooth muscle and swelling of the airway walls. The airway becomes more susceptible to various stimuli that cause an inflammatory response, e.g. exercise, cold air, cigarette smoke, allergens [1-4]. Airflow obstruction that occurs in asthma is reversible either spontaneously or with treatment, although reversibility may be incomplete in older adults [3].
Characteristics of Asthma
Signs and symptoms of asthma include [1, 2, 4, 5]:
Signs and symptoms of asthma are:
Recurrent, variable and intermittent; Often worse at night or in the early morning; Regularly provoked by specific triggers such as exercise, allergens (e.g. house dust mite, pollens, pets and moulds), irritants or infections [1, 2, 4, 5].
Assessment
Diagnosis
Diagnosis is based on history, physical examination, spirometry and peak expiratory flow monitoring. Asthmatics frequently have a history of allergic disorders such as rhinitis, sinusitis, or respiratory symptoms related to medications, e.g. aspirin, non-steroidal anti-inflammatory drugs, or allergens [1, 3-5]. Respiratory function tests are helpful in diagnosis and monitoring of the resident’s progress and response to therapy.
Spirometry
Spirometry is a diagnostic procedure to measure lung function. The volume of air expired in 1 second from the lungs (FEV1) or total volume of air expired as fast as possible (FVC) measure lung function. Results are compared to the resident’s previous best values, or to predicted values for his or her age range [1, 3-5]. The resident’s FEV1 or FVC are also measured following treatment with bronchodilators or corticosteroids to measure response of airways to asthma treatment. Lower than predicted values, values that decrease throughout a session, and values that improve following medication therapy are consistent with a diagnosis of asthma [1, 3-5].
Whilst spirometry is a valuable diagnostic tool it is often difficult for older adults to perform due to poor technique and coordination, general weakness and muscle wasting or severe airflow restrictions. Comparing FEV1 or FVC to the resident’s previous best values rather than predicted values is recommended in older adults [3].
Peak Expiratory Flow Measures
Peak expiratory flow (PEF) measures the maximum airflow that can be generated during forced expiration. It is used to detect presence or absence of airflow obstruction by detecting variation from the individual’s previous best value. Peak flow monitoring is most useful when multiple readings are taken over time, rather than isolated measures of PEF [1, 3, 4, 6]. Review of the resident’s medication regime is indicated if PEF is 15-20% below the resident’s own predicted values[6].
Although useful for individuals who have intermittent symptoms [1], the sensitivity and specificity of peak flow monitoring has not bee established in older adults [3]. Age-related factors such as rigidity of the chest wall, muscle weakness and reduction in coordination may influence PEF in older adults [3]. Peak expiratory flow monitoring requires effort and cooperation by the individual [3], therefore its use in dementia is unlikely to be reliable.
If a resident is performing PEF, it is important that it is done on a daily basis with the same PEF meter. Peak flow measuring should be conducted first thing in the morning, prior to medications [1, 4, 6].
Classification of Asthma
Classification of asthma helps to determine the long-term management strategy for the resident’s asthma. Throughout the asthmatic individual’s lifespan classification of his or her asthma may be stepped up or down, depending upon response to therapy and ongoing history of the disease.
Asthma is classified as mild if [1, 3-5]:
Signs and symptoms of an acute asthma attack occur less than twice per week; Nocturnal signs and symptoms occur less than twice per month; The resident has no symptoms between episodes of exacerbation; and Pre-treatment PEF is >80% of the resident’s predicted value.
Asthma is classified as moderate if [1, 3-5]:
Signs and symptoms of acute asthma attack occur more often than twice per week; Signs and symptoms affect the resident’s sleep and activity less than 1 time/week; Chronic signs and symptoms requiring relieving medication occur daily or every other day; and Pre-treatment PEF is 60-80% of the resident’s predicted value or is variable by 20-30%.
Asthma is classified as severe if [1, 3-5]:
Signs and symptoms occur almost continuously; Exacerbation occurs frequently; The resident awakens from asthma at night frequently; The resident restricts his or her activity; and Pre-treatment PEF is <60% of the resident’s predicted value or is variable by 20-30%.
Special Considerations in the Elderly
Asthma in older adults can be a continuation of disease that commenced at a younger age, or newly diagnosed in later life. Diagnosis and detection of asthma in older adults is complicated by the need to distinguish between other diseases with similar presentations, e.g. chronic obstructive pulmonary disease, acute myocardial infarction, and to differentiate between normal ageing and disease processes. Although triggers for asthma are the same in all age groups, older adults are less prone to airborne allergens but more likely to have an adverse effect from medications [3]. Older adults may have age related lung changes that contribute to asthma, e.g. reduced muscle strength, increased chest wall rigidity, or reduce the older adult’s awareness of asthma signs and symptoms. Older adults may also have age-related changes that influence their compliance with treatment or ability to initiate treatment, e.g. arthritis, dementia [3]. Due to co-morbidity, e.g. COPD, CV disease, older adults with asthma often have earlier thresholds at which they require medical supervision or treatment in an acute hospital for asthma exacerbation [3].
Management
Management Goals
In older adults, goals of asthma management are harder to reach as airway obstruction may not be completely reversible and optimal lung function may not be attainable [3]. The resident’s GP should establish goals of therapy in consultation with the resident and/or his or her representative. Treatment of asthma in older adults aims to [3]:
Achieve a desired quality of life; Optimise pulmonary function; Control cough and nocturnal signs and symptoms; Prevent emergency admissions to hospital; Avoid aggravating other diseases; and Minimise medication side effects.
Asthma Management Plan
The management of asthma focuses on preventive medication, ongoing objective assessment, avoiding environmental triggers, and clear instructions for management of symptoms and acute exacerbations [1, 3-5].
It is recommended that all residents have a documented asthma management plan. The Reference Cards include an Asthma Management plan adapted for use in residential aged care from the Asthma 3+ Visit Plan education [7]. Peak Flow measurements, where appropriate, and prescribed medication are documented by the GP in the resident’s record and medication chart.
Ongoing Assessment
Regular monitoring of the resident’s signs and symptoms is essential in the long term management of asthma [1-5]. It is recommended that older adults with asthma be reviewed by their GP at least every 3-6 months, even if the asthma is diagnosed as mild. Decrease in lung function can be insidious and needs prompt attention, however in older adults a decrease in lung function is often mistaken for normal ageing [3]. Every 3-6 month the GP should interview the resident (or carers) regarding signs and symptoms; conduct a clinical examination; and evaluate objective assessments of lung function, e.g. peak flow readings or spirometry [3].
Signs and symptoms that the resident’s asthma is not well controlled include [1, 3-5]:
Nocturnal or early morning waking with wheeze or cough; Increase in coughing that produces sputum; Increase in use or, or decreased response to reliever medications; Decreased tolerance of activity; and Change in intensity of dyspnoea.
Education
All residents with a diagnosis of asthma should be educated to report symptoms to RACF staff as soon as they occur. RACF staff should be provided with ongoing education on the assessment and management of asthma, use of medications related to the treatment of asthma, and the importance of contacting emergency services as soon as possible if a resident is experiencing a severe exacerbation of asthma (See the Asthma Management Reference Card).
Environmental Strategies
Ongoing management of asthma includes identifying specific triggers for asthma avoiding exposure to triggers [1, 3-5]. Allergens are a common asthma trigger [1, 3-5], although older adults are less prone to environmental allergens than younger asthmatics [3]. House dust mite, pollens, pets and moulds are the most common environmental allergens that trigger asthma. Allergy testing can assist in identifying if an individual’s asthma is likely to be triggered by allergens [1, 3-5], however its usefulness in older adults is questionable as older adults generally have a lowered response on skin prick tests [3]. If a resident’s asthma is known to be triggered by environmental allergens, strategies to reduce exposure should be implemented.
Asthma Cycle of Care
The Federal Government has funded the Asthma Cycle of Care as an incentive for the GP to see the patient over a period of twelve months to improve asthma management. The Asthma Cycle of Care replaces the Asthma 3+ Visit Plan. The Asthma Cycle of Care incorporates diagnosis and assessment, spirometry, development of a written asthma management plan, ongoing review of this plan, and education [7].
Asthma medications are used to either prevent or relieve signs and symptoms of asthma. Residents diagnosed with mild asthma are likely to be prescribed a reliever medication only. Residents with moderate-severe asthma are likely to be prescribed at least one preventer medication as well as a reliever medication [3].
Reliever Medications
Reliever medications provide relief from acute asthma symptoms within minutes and provide ongoing relief for up to 4 hours. They are generally prescribed on a PRN (as required) basis for signs and symptoms of asthma. Short acting beta2-agonists are the most effective reliever medications as they cause smooth muscle relaxation of the airways within minutes [1, 2, 4, 5, 8, 9]. However, some of the side effects of short acting beta2-agonists (e.g. salmutamol, terbutaline) are arrhythmias, hypokalaemia and increased blood pressure, and therefore the use of these medications by residents with cardiovascular disease should be carefully monitored [3].
Ipratropium bromide (an anticholinergic bronchodilator) is a reliever medication used more often in chronic obstructive pulmonary disease than asthma [1, 4, 8, 9]. The effect of it is much slower than short acting beta2-agonists. Despite having a slower onset than short acting beta2-agonists [1, 4], Ipratopium bromide has been shown to have significant benefit for older adults. Due to fewer systemic side effects this medication is recommended as the reliever medication of choice for older adults with concurrent cardiovascular disease [3]. Ipratropium bromide is as effective as inhaled beta-2- agonists in maintenance therapy of COPD. It is also indicated for severe asthma with a short-acting beta-2-agosnist. Tiapropium has a longer duration of action than ipratropium bromide allowing once daily dosing. Anticholinergic adverse effects, e.g. dry mouth, occur more often than with ipratropium bromide [9, 10].
Theophylline has an anti-inflammatory effect as well as a being a bronchodilator. It is not recommended for use in older adults unless absolutely necessary, due to a very narrow therapeutic range, and toxicity [1, 3, 5, 9].
In Australia, all reliever medications are packaged in a blue/grey container [8]. It is important that RACF staff monitor the use of all reliever medications, as increased use or a decreased response to medication, is an indication that the resident’s asthma is getting worse and requires review by the GP [1].
Preventer Medications
Preventer medications help control inflammation in the airways. The most commonly used preventer medications are inhaled corticosteroids, e.g. fluticasone propionate; beclomethasone dipropionate. Their use has been shown to lead to a reduction in number of asthma exacerbations and emergency hospital admissions [2]. The most common adverse effects from inhaled corticosteroids are oral candidiasis and throat hoarseness. Residents should be encouraged to use a spacer for administering corticosteroids and to rinse the mouth well after each dose [1, 3-5, 8, 9]. Residents on large doses on inhaled corticosteroids are at risk of osteoporosis as corticosteroids cause a decrease in bone mineralisation. Calcium supplements and regular screening for osteoporosis are recommended for individuals at risk [1, 3]. Other inhaled preventive medications include anti allergy agents excluding corticosteroids, e.g. sodium cromogylcate; nedocromil sodium, and leukotriene receptor anatagonists, e.g. montelukast sodium.
Systemic Corticosteroids
Oral corticosteroids, e.g. prednisolone, are prescribed to treat persistent and/or acute exacerbations of asthma and if used promptly may avoid emergency department admission [4]. If the resident previously had stable asthma, oral corticosteroids usually have an effect within 3-4 hours and therefore treatment should be initiated as soon as possible [1, 4, 5, 9]. Initially a large dose (25-50mg daily) is administered, followed by a tapering course over 5-10 days. Systemic corticosteroids may aggravate cardiovascular disease [3] and if used over a long period the risk of diabetes mellitus or osteoporosis increases significantly [3, 4].
Immunisation
It is highly recommended that elderly people with asthma be immunised against pneumonia and influenza [1, 3-5]. See the Clinical Information Sheets Respiratory: Influenza and Respiratory: Pneumonia for further information.
Adverse Effects of Medication
The RACF pharmacist should review all medications annually. Adverse reactions to medication increase with age and as many as 10% of emergency department admissions of older adults with asthma are related to adverse medication effects [3]. The pharmacist should check for medication interactions, e.g. non-potassium sparing diuretics and beta2-agonists, as well as the prescribing of medications that are known to exacerbate asthma, e.g. aspirin, non-steroidal anti-inflammatory drugs [3].
Procedure for Managing an Acute Exacerbation of Asthma
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Procedure for Managing an Acute Exacerbation of Asthma
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1. |
Sit the resident down, remain calm and provide the resident with reassurance [1, 4, 5].
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2. |
Assess the resident’s signs and symptoms, and if the resident regularly uses a PEF meter, take the resident’s PEF [1, 4, 5].
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3. |
Check the resident’s care plan and medication orders. If the resident’s GP has recorded a clinically appropriate care plan to follow in the event of the resident having an exacerbation of his or her asthma, follow the GP’s care plan.
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4. |
Following assessment, determine the degree of severity of the resident’s asthma [1, 5]:
Mild Attack
PEF >75% of resident’s best predicted value
No physical exhaustion
HR < 100/min<
No central cyanosis
Oximetry (if available) >95% on air
Wheeze intensity is variable
Able to talk in sentences
Waking at night or decreased ability to perform activities due to asthma
Cough, breathlessness, or chest tightness present
Moderate Attack
PEF 50-75% of resident’s best predicted value
No physical exhaustion
HR 100-120/min
No central cyanosis
Oximetry (if available) 92-95% on air
Wheeze intensity is moderate-loud
Able to talk in phrases
Waking at night or decreased ability to perform activities due to asthma
Cough, breathlessness, or chest tightness present
Severe Attack
PEF <50% of resident’s best predicted value
Physical exhaustion
HR >120/min
Central cyanosis present
Oximetry (if available) <92% on air
Wheeze intensity is often quiet
Able to talk in words only
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5. |
If the resident is assessed as having a severe exacerbation call an ambulance immediately and continue management until emergency services arrive [1, 4, 5].
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6. |
Administer oxygen 8L/min via a facemask [1, 4, 5]. |
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7. |
Initial treatment:
Mild-Moderate Attack [1, 5] administer either:
Single nebuliser treatment of a short-acting beta2-agonist (nebulise with oxygen); or 4 puffs of a a short-acting beta2-agonist from an MDI with a spacer. Treatment may be repeated every 4 minutes for a maximum of 3 treatments if required.
Severe Attack [5] administer either:
Nebuliser treatment of a short-acting beta2-agonist (nebulise with oxygen) every 15-30mins until ambulance arrive; or 4 puffs of a short-acting beta2-agonist from an MDI with a spacer. Treatment may be repeated every 4 minutes until ambulance arrives.
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8. |
Follow up treatment: Reassess the resident’s symptoms and/or PEF every 60 minutes for at least 4 hours [1, 5].
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9. |
If resident has a good response to initial treatment evidenced by PEF >80% of personal best, absence of respiratory symptoms and response to treatment is sustained for 4 hours:
Continue 2-4 puffs a short-acting beta2-agonist from an MDI with a spacer every 4 hours for 24-48 hours as required. Contact the resident’s GP within 48 hours to organise a review of the resident’s asthma[5].
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10. |
If the resident has an incomplete response to initial treatment evidenced by PEF 50-80% of personal best, persistent wheezing, shortness of breath or chest tightness:
Continue 2-4 puffs a short-acting beta2-agonist from an MDI with a spacer every 4 hours for 24-48hours as required. Contact the resident’s GP or locum GP within 24 hours to organise a review of the resident’s asthma; and The resident should commence oral steroids unless there is a contraindication .
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11. |
If the resident has a poor response to initial treatment as evidenced by PEF <50%, severe distress, continued wheezing, shortness of breath, cough and chest tightness and response to treatment is not sustained beyond 2 hours:
The resident has a severe exacerbation of asthma. Administer treatment for severe exacerbation as outlined in step 7. Contact an ambulance immediately [1-5].
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12. |
Document the event and the treatment given and communicate it to other staff members according to the RACF policy.
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Residents at High Risk of an Asthma-related Death
The following residents are at a high risk of an asthma-related death and should be reviewed by their GP as soon as possible following an exacerbation [1, 4, 5]:
Past history of sudden severe exacerbations; Past history of admission to intensive care or intubation for asthma; More than 1 hospital admission or more than 2 visits to the emergency department for asthma in the past 12 months; Admission to hospital or emergency department visit for asthma within the past 30 days; Use of more than 2 cannisters of a short-acting beta2-agonist in the past 30 days; Recent or current use of oral steroids for asthma; and Multiple medical diagnoses, particularly chronic obstructive pulmonary disease or cardiovascular disease.
Sources of Information
Where to go for more information
Asthma Foundation of Victoria.
The Asthma Foundation of Victoria is a community-funded, not-for-profit organisation that provides advice, counselling, education and training to people with asthma, their carers, health professionals, first aiders and the community.
The Asthma Foundation of Victoria provides innovative training programs, a wide range of information sheets and brochures, the helpline and an informative website.
Contact: 9326 7088, or 1800 645 130 (Helpline)
Website:http://www.asthma.org.au/
National Asthma Council
The National Asthma Council Australia is a non-profit organisation, which serves aims to create awareness in the community about asthma and provide information about asthma. The organisation provides information about asthma for health professionals, asthmatics, and the general community.
Contact: (03) 8699 0476 or 1800 032 495 (Hotline)
Website: http://www.nationalasthma.org.au/index.htm
Pulmetrics
Pulmetrics is a mobile spirometry service that provides measurement and interpretation of spirometry on residents referred by their GP. Pulmetrics provide on-site spirometry if at least 6 residents are booked for the service. Residents are bulk-billed so there is no out-of-pocket expense for either the resident or GP and the results provide the GP with objective assessment data on the resident’s lung function.
Contact: (03) 9842 5347 or 0410 538 410
References
National Asthma Council Australia, Asthma Management Handbook 2002. 2002, Canberra: Commonwealth Government Department of Health and Ageing. J Sims, Guidelines for Treating Asthma. Dimensions of Critical Care Nursing, 2003. 22(6): p. 247-250. National Institutes of Health (National Heart Lung and Blood Institutes), Considerations for Diagnosing and Managing Asthma in the Elderly. 1996, New York: U.S. Department of Health and Human Services. Scottish Intercollegiate Guidelines Network and British Thoracic Society, British guidelines on the management of asthma. 2003, London: SIGN and BTS. National Institutes of Health (National Heart Lung and Blood Institutes), Practical guide for the diagnosis and management of asthma. 1997, New York: U.S. Department of Health and Human Services. Joanna Briggs Institute, Aged Care Practice Manual. 2nd ed. 2003, Adelaide: JBI. National Asthma Council Australia, Partnership for Asthma Care. 2002, Canberra: Commonwealth Government Department of Health and Ageing. Asthma Australia, Asthma medications and delivery devices. 2003, Canberra: Asthma Australia. eTG, Therapeutic Guidelines: Respiratory, in http://www.tg.com.au (accessed August 2006), eTG. 2006 F Bochner, ed. Australian Medicines Handbook 2004 2004, Hyde Park Press: Richmond, SA. National Asthma Council Australia, Partnership for Asthma Care. 2002, Canberra: Commonwealth Government Department of Health and Ageing.
Levels of Evidence
The guideline has been developed using the process outlined in Chapter 5 of the the GP and Residential Aged Care Kit.
This clinical information sheet is based on recommendations stemming from level I evidence produced by the National Asthma Association Australia and level I evidence produced jointly by Scottish Intercollegiate Guidelines Network and British Thoracic Society. Level IV evidence produced by the National Heart Lung and Blood Institutes, USA specific to asthma in the elderly augments this information. The information sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (eg. NBV, RCNA, ANF) overseeing the aged care industry in Victoria, Australia.
The information presented is developed from level I evidence produced by the National Asthma Association Australia, Scottish Intercollegiate Guidelines Network and British Thoracic Society, as well as level IV evidence produced by the National Heart Lung and Blood Institutes, USA specific to asthma in the elderly.
The following table outlines the level of evidence of each reference:
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Reference |
Year |
Level of Evidence* |
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1. |
National Asthma Council Australia |
2002 |
Level I evidence |
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2. |
J Sims |
2003 |
Level IV C evidence |
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3. |
National Institutes of Health (National Heart Lung and Blood Institutes) |
1996 |
Level Iv C evidence |
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4. |
Scottish Intercollegiate Guidelines Network and British Thoracic Society |
2003 |
Level I evidence |
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5. |
National Institutes of Health (National Heart Lung and Blood Institutes) |
1997 |
Level IV C evidence |
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6. |
Joanna Briggs Institute |
2003 |
Level IV C evidence |
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7. |
National Asthma Council Australia |
2002 |
Level IV C evidence |
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8. |
Asthma Australia |
2003 |
Level IV C evidence |
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9. |
eTG |
2006 |
Level IV C evidence |
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10. |
F Bochner |
2004 |
Level IV C evidence |
Literature was identified through a standardised search for systematic reviews and clinical guidelines published by relevant health organisations; and ‘clinical guidelines’ and ‘practice guidelines’ in CINAHL & MEDLINE databases and HONcode search engine. Literature was evaluated according to relevance to residential aged care patients, and strength of evidence using the NHMRC (1995) [11] scale for randomised control data and lower levels of evidence when RCT is not available. The scale was adapted by adding a level of evidence (level V) for non-referenced material, e.g. developed in local RACFs. Prescribing information is consistent with the Australian Therapeutic Guidelines, at the time of writing.
Applicability of information
This Clinical Information Sheet has been developed with consideration to legislation and any requirements of or recommendations from professional registration groups or regulating bodies (e.g. NBV, RCNA, ANF) overseeing the residential aged care industry in Victoria, Australia. Readers outside Victoria, Australia are advised to review the material in the context of their local legislation and health system regulations.
This Clinical Information Sheet was developed using the process outlined in Section 5, and is provided under the terms of the disclaimer in Section 1 of the GP and Residential Aged Care Kit.
GP and Residential Aged Care Kit: http://nwmdgp.org.au/pages/after_hours/
For more detailed or up to date information than is provided in this CIS, please refer to cited sources and current literature.
Reference Cards for Respiratory: Asthma
The following reference cards are designed to be used in conjunction with the Respiratory: Asthma Clinical Information Sheet. Because the evidence base and availability of national guidelines for clinical care and multidisciplinary service delivery is rapidly changing, we strongly recommend that the these Reference Cards be regularly reviewed and revised as with Clinical Information Sheets.
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Reference Cards:
Asthma Management Reference Card
Acute Asthma Management Plan
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