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Sample Topic: Asthma

Asthma : Last revised in December 2013


Lifestyle advice

What information is needed in self-management education and action plans?

  • Give all people with asthma self-management education and a written action plan.
  • At each review, repeat education and advise on:
    • Taking medication and avoiding known trigger factors.
    • Recognizing poor asthma control (worsening symptoms or peak flow readings) and early signs of an exacerbation (sudden persistent worsening symptoms).
    • Presenting for follow up annually or more frequently if symptoms are not controlled.
  • A typical asthma action plan should include:
    • When to increase treatment (as defined by symptoms or peak expiratory flow rate).
    • How to change treatment in case of deterioration and when to go back to maintenance medication.
    • When to seek medical help.

Additional information

  • Tailor self-management education and written action plans to the needs of the individual. Such plans may be particularly helpful in some high-risk people with a history of insidious deterioration of asthma, poor perception of deteriorating breathing, and poor adherence to medication, and in people with frequent exacerbations. Provide such people with a ‘crash course’ of oral corticosteroids and instructions, preferably in writing, on when to start treatment:
    • Advise people that poor asthma control may be suggested by:
      • Worsening symptoms (cough, wheeze, breathlessness), especially at night or during exercise.
      • Worsening peak expiratory flow rate (PEFR) compared with previous readings.
    • Advise people with worsening symptoms for a couple of days or a decrease in PEFR to initiate their personalized action plan. This plan should be based on the person’s current medication, history, and severity of an exacerbation. Consider the following approach:
      • If a person’s PEFR is > 75% (best or predicted), advise regular use of a short-acting beta2-agonist for 1–2 days until symptoms improve. If there is no benefit, start a course of oral prednisolone.
      • If a person’s PEFR is 50–75% (best or predicted), advise starting a course of oral prednisolone with regular use of their short-acting beta2-agonist. If no benefit is seen after 1–2 days, seek medical help.
      • If a person’s PEFR is < 50%, advise starting a course of oral prednisolone along with regular use of their short-acting beta2-agonist and seek medical help.
  • Examples of asthma action plans are available online from the National Asthma Campaign (www.asthma.org.uk).

Basis for recommendation
These recommendations are based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].

  • Studies vary widely in populations, setting, and disease severity. One approach cannot be assumed to be successful in all circumstances. Less evidence is available from primary care settings, and results are less consistent. Overall, self-management education packages appear to be effective, but no one individual component is consistently shown to be effective in isolation. A consistent finding in many studies has been improvements in people’s self efficacy, knowledge, and confidence [SIGN and BTS, 2011].
  • Increasing low-dose inhaled corticosteroids (ICS) by as much as fourfold at the beginning of an exacerbation may be suitable for some people on low doses of maintenance ICS, but doubling ICS during an exacerbation has not been shown to provide benefit and is no longer recommended [SIGN and BTS, 2011].

Smoking: What advice should I give someone with asthma?

  • Advise smokers with asthma to stop smoking and provide them with the appropriate help. For more information, see the Prodigy topic on Smoking cessation.
  • Advise people with asthma to, as far as possible, avoid exposure to tobacco smoke. For parents who smoke and have a child with asthma, this means either stopping smoking (the best option), or not smoking in the same room as the child (or, preferably, not smoking in the house).
  • Parents and parents-to-be who smoke should be advised about the many adverse effects of smoking on themselves and their children. They should be offered appropriate support to stop smoking.

Basis for recommendation
These recommendations are based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].

  • The evidence suggests that exposure to tobacco smoke in the home contributes to increased wheezing in infancy, increased risk of persistent asthma, increased severity of childhood asthma, and that starting smoking as a teenager increases the risk that asthma will persist. Active smoking in asthma results in worsening symptoms and decline in lung function, and it may inhibit the short-term response to inhaled or oral corticosteroids (although the mechanism of this effect is not certain) [Thomson et al, 2004].

Vaccinations: What advice should I give someone with asthma?

  • Advise all people with asthma and parents looking after children with asthma that an influenza and a pneumococcal vaccination is advisable if asthma is severe and requires hospital admission or frequent use of corticosteroids.
  • Influenza vaccination is recommended for all people older than 6 months who have required hospital admission for an exacerbation of asthma, or who need continuous or frequently repeated use of inhaled or oral corticosteroids. For more information, see the Prodigy topic on Immunizations – seasonal influenza.
  • Pneumococcal vaccination is recommended in the following groups:
    • People (of any age) whose asthma is so severe that they require continuous or frequent repeated use of oral corticosteroids (i.e. at a dose equivalent to 20 mg or more of prednisolone daily).
    • Children weighing less than 20 kg, a dose prednisolone of 1 mg or more per kilogram body weight per day, for more than a month.
    • Note that pneumococcal vaccine is now part of the childhood immunization programme — see www.dh.gov.uk. For more information, see the Prodigy topic on Immunizations – pneumococcal.

Basis for recommendation
These recommendations are based on government policy as discussed in the ‘Green Book’, published by the Department of Health [DH, 2006a].

  • A yearly influenza vaccination does not appear to protect people from exacerbations or improve asthma control [GINA, 2006].

Allergen avoidance: What advice should I give someone with asthma?

  • Advise all people with asthma and parents looking after children with asthma to avoid (if possible) known trigger factors, especially at times when asthma is poorly controlled.
  • Advise all adults to report promptly any worsening asthma control during work.
  • The person with asthma should identify trigger factors, where possible, by noting worsening symptoms or decreasing peak expiratory flow rates (PEFR) during exposure to certain situations. Some triggers cannot be avoided (for example air pollution, weather, viral illness), but at times of poor asthma control, it is prudent to do so if possible. Uncontrolled asthma is more sensitive to possible trigger factors.
  • Dust mites: sensitization to house dust mite is an important risk factor for the development of asthma, however in the absence of benefit from domestic aeroallergen avoidance, it is not possible to recommend it as a strategy for preventing childhood asthma. Overall, measures to decrease house dust mites have not been shown to have an effect on asthma severity. If a household member shows evidence of house dust mite allergy and wishes to try mite avoidance, strategies include complete barrier bed-covering systems, ensuring that susceptible children do not sleep in a lower bunk bed, removal of carpets or soft toys from beds, high-temperature washing of bed linen, application of acaricides (chemical agents that kill mites) to soft furnishings, and good ventilation.
  • Animal allergens, particularly cat and dog allergens, are potent inducers of asthma symptoms. Many experts recommend the removal of pets from the home of allergic people with asthma, but the reported effects are inconsistent.
  • Food and food additives (for example sulphites found in wine, beer, processed potatoes, shrimps) as an exacerbating factor for asthma are uncommon and occur primarily in young children. Do not recommend food avoidance unless there is a proven allergy, and then only with the supervision of a dietitian, especially in children.
  • Air pollutants (ozone, nitrogen oxide, acidic aerosols) and occasional weather changes have been associated with asthma symptoms and exacerbations, although there is no evidence to support a link between exposure to air pollutants and the induction of allergy. There is no need to recommend avoidance in people with stable asthma. Advise people with poorly controlled asthma who are troubled by outdoor triggers to minimize exposure, such as by not doing strenuous exercise or smoking in cold weather, low humidity, or times of high air pollution.
  • An occupational trigger will usually worsen asthma at work, and improvements will occur when the person is away from the work environment. Identify people with occupational triggers early and refer them to a respiratory specialist.

Basis for recommendation
These recommendations are based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011]:

  • Allergen avoidance: the evidence that reducing allergen exposure can reduce morbidity and mortality is tenuous. In uncontrolled studies, children and adults have shown some benefit from exposure to very-low-allergen environments. However, the benefits cannot be necessarily attributed to allergen avoidance. Larger, well-designed studies of combined-allergen avoidance strategies in different groups are needed [GINA, 2006; SIGN and BTS, 2011].

Weight reduction, diet, and exercise: What advice should I give someone with asthma?

  • Advise overweight people that a healthy diet and regular exercise will help with weight reduction and improve asthma control:
    Advise people (if possible) to take 30 minutes of exercise to increase their heart rate at least five times weekly. For more information on weight loss, see the Prodigy topic on Obesity.
  • Exercise — no specific exercise regimen can be recommended apart from that needed to adopt a healthier lifestyle (30 minutes of exercise to increase heart rate at least five times weekly). Advise people about precautions against exercise-induced asthma.
  • Diet — no specific dietary recommendation can be given to people with asthma apart from a balanced diet, or a low-fat diet for people needing to lose weight. Observational studies in both adults and children have consistently shown that a high intake of fresh fruit and vegetables is associated with less asthma and better lung function. No intervention studies have yet been reported.

Basis for recommendation
These recommendations are based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011]:

  • Weight reduction, diet, and exercise: the evidence is limited and based on small numbers of people with asthma. Weight reduction appears to improve asthma control, lung function, and symptoms in obese people. However, no convincing trial evidence shows that any specific diet or specific exercise regimen improves asthma control or symptoms [GINA, 2006; SIGN and BTS, 2011].

Comorbidities: What advice should I give someone with asthma?

  • Advise all people with asthma and parents looking after children with asthma to report symptoms of conditions that could worsen asthma, such as rhinitis, sinusitis, gastro-oesophageal reflux disease, and sleep apnoea.
  • Explain that such symptoms as facial pain, nasal symptoms, indigestion, and snoring suggest co-existing conditions that may worsen asthma and need treatment.

Basis for recommendation
These recommendations are based on the British guideline on the management of asthma: a national clinical guideline [SIGN and BTS, 2011].

  • Associated conditions, such as sinusitis, rhinitis, and gastro-oesophageal reflux disease, worsen asthma control. However, there is no conclusive evidence that managing these conditions results in significant clinical improvements in asthma symptoms.

Driving: What advice should I give someone with asthma?

  • For both group 1 (car or motorcycle) or group 2 (lorry or bus) entitlement:
    • The Driver and Vehicle Licensing Agency (DVLA) need not been informed unless attacks are associated with disabling giddiness, fainting, or loss of consciousness.
    • If the DVLA need to be notified, advise the person that it is their responsibility to do so.
  • The latest information from the DVLA regarding medical fitness to drive can be obtained at www.gov.uk/government/publications/at-a-glance.

Basis for recommendation
This information on medical rules is from the Driver and Vehicle Licensing Agency’s guidance for medical practitioners, At a glance guide to the current medical standards of fitness to drive [DVLA, 2011].