Asthma Management in Primary Health Care Settings

Posted: March 18th, 2024

Asthma Primary Health Care Plan
Asthma Management in Primary Health Care Settings
1. Introduction
Unlike other chronic illnesses, asthma is a condition that does not leave any lasting damage to the airways, only an increase in the likelihood of developing chronic obstructive pulmonary disease (COPD). Asthma impacts on a person’s quality of life and economic prosperity. It is identified as a growing worldwide health concern both in terms of prevalence and morbidity. Such escalating rates of prevalence are evidenced in countries not just in the well-documented Western world, but also in developing nations, proposing that the day-to-day management and long-term care for asthmatic patients are becoming a global challenge. Because of this, the complexity is such and the patient’s susceptibility to rapid deterioration can be so acute and sudden that primary care has become the cornerstone of delivering the services necessary for this long-term condition, including reducing the 90,000 asthma attacks in the UK that lead to hospitalization every year. No other setting can deliver a one-to-one patient assessment in a time frame that can provide a comprehensive evaluation and the opportunity for shared decision-making. The collaborative methods, especially the provider-patient relationship agreed to in primary care, can help evolve the key health metrics in the 2020 national research strategy to help bring about the suggested phenomena of missing asthma diagnoses through modern data science techniques. This will help early detection and intervention so as to mitigate the possibility of lifelong morbidity and burdens on health services such as hospital admissions. I will be exploring in this project the viability of optimizing the usage of primary care currently for asthmatic patients in the context of a modern prediction of disease algorithm being made available for health practice.
1.1 Definition and Prevalence of Asthma
Asthma is a chronic condition that affects the airways in the lungs. Inflammatory responses result in swelling of the lining of the airways and an increase in mucus production. This leads to symptoms such as coughing, wheezing, breathlessness, and chest tightness. Asthma is a common condition with prevalence that is increasing across all age groups. In terms of gender, there are more boys than girls with asthma, but in adults, there are more women than men with asthma. In the United Kingdom, one in every 11 children has asthma, and one in every 12 adults has asthma. Asthma is a long-term condition for many people, and therefore, there is a focus on symptom control and the prevention of exacerbations through the use of self-management education. This involves patients learning more about their asthma, what it does, and the best way in which to manage it with the use of medication and lifestyle changes. However, there are also a group of patients with severe asthma that do not respond to usual medications. These patients experience poor control of their symptoms and have frequent exacerbations, which can lead to hospital admissions. Asthma management in primary health care not only encourages the importance of patient education but also aims to provide pharmacological and non-pharmacological management strategies to cater for a diverse population of asthma sufferers. These will be discussed in the following sections of the report.
1.2 Importance of Primary Health Care in Asthma Management
The current trends in the management of asthma move towards a patient-focused approach, promoting self-management and autonomous control of the condition. One of the key components to such a holistic approach is the utilization of primary health care services. According to the World Health Organization (WHO) and leading respiratory health experts, including the National Heart, Lung, and Blood Institute (NHLBI) of the United States, a primary health care plan is essential in achieving successful asthma management. The WHO developed a practical package of essential non-communicable disease interventions for primary health care in low-resource settings; this includes a package for asthma. The objectives of a primary health care plan in asthma management encompass the provision of optimal and patient-centered integrated care, support for patient self-care and involvement in decision making, as well as the prevention of the development of symptoms and the limitation of the progression of the disease. Primary health care is also important in tackling the rising burden imposed by asthma. By undertaking early diagnosis and continuous treatment adjustment in primary health care settings, it is likely to minimize the frequency and intensity of acute asthma attacks and the need for emergency care, as well as reducing asthma-related mortality. Furthermore, when patients are effectively managed in the primary health care sector, the demand for specialist consultations and in-patient treatment is reduced and more health resources can be allocated to those with more severe or complex conditions. Therefore, the role of primary health care should not be underestimated. Specialists and health care providers should work towards a collaborative patient-centered care approach in breathing disorder services, aiming to integrate different aspects of the health care system around patients and smooth the transition between different levels of care. It is necessary to establish and sustain a continuous health system that is no longer provider-focused, but oriented towards chronic disease management and patient empowerment. The provision of autumn educate health promotion activities, as well as effective coordination and communication among patients, health care providers and health authorities, will be critical in achieving well-rounded asthma management in primary health care.
1.3 Objectives of the Primary Health Care Plan
The objectives of the primary health care asthma management plan are threefold: firstly, to enable people with asthma to achieve and maintain control over their condition; secondly, to minimise both the symptoms and the limitations that the condition imposes on everyday life; and thirdly, to avoid the likelihood of severe asthma symptoms, such as asthma attacks, which could require emergency hospital admission. In achieving these objectives, the primary health care provider should work collaboratively with the patient so that the patient can be supported to accept increasing responsibility for managing the illness. In so doing, the patient will be encouraged to control the illness, rather than letting the illness control the patient’s life. In addition to this, working on the basis of this asthma management plan will mean that the patient will understand and avoid key triggers for the symptoms. It will also ensure that the patient is not only encouraged to receive regular asthma reviews and take up offers of asthma education, but also that these opportunities are proactively sought by the primary health care provider. This should mean that the patient keeps up with the latest evidence and guidance in asthma care, as well as taking steps to improve their knowledge and self-care skills. If the patient’s asthma medicines are reviewed and their condition is found to have changed, the patient may also be in a better position to understand and accept any changes to their personal medication regime. All in all, the provision of a high standard of care in accordance with the objectives of this asthma management plan should enable patients to achieve the best possible quality of life.
2. Diagnosis and Assessment
Clinical evaluation and history taking form the cornerstone of an accurate asthma diagnosis. It is essential to take a detailed history of presenting respiratory symptoms, including information about diurnal and nocturnal variations, frequency and severity of symptoms, and any possible precipitating or exacerbating factors. It is also important to document the patient’s medical history, including any relevant family history of asthma or other atopic diseases, as well as a detailed drug history – particularly with respect to medications such as beta-blockers and aspirin. Clinical signs such as expiratory wheeze and breathlessness are helpful but are not always present and should not be relied upon to make a diagnosis of asthma. Similarly, while a trial of therapy with bronchodilators or a corticosteroid may be considered, current guidelines do not support the practice of confirming a diagnosis by responding to treatment. Various clinical guidelines for the diagnosis and management of asthma are available internationally. The Global Initiative for Asthma (GINA) provides a comprehensive and practical resource and recommends stepwise management of chronic asthma. Other guidelines include the National Asthma Education and Prevention Program (NAEPP) in the United States, the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) and the World Health Organization (WHO)-approved International Union Against Tuberculosis and Lung Disease (IUATLD). It is important that clinicians keep up to date with the most recent evidence and use a combination of clinical assessment (symptom evaluation and lung function testing) and where possible, objective measures such as peak expiratory flow or spirometry in making a diagnosis of asthma essay pro for both adults and children. Decisions about asthma management should be shared between the patient and clinician. Respiratory specialists should consider referral if there is diagnostic uncertainty or the patient has difficult asthma that remains uncontrolled despite an appropriate trial of treatment. Equally, patients with acute severe asthma require urgent transfer to a facility which can provide a higher level of care.
2.1 Clinical Evaluation and History Taking
Adolescents and grown-ups with predetermination upheld or affirmed asthma should be given long haul asthma control drugs and educated with respect to the need and advantage of every day treatment notwithstanding the potential for taking drugs during asthma intensifications. Every patient’s medicine should be routinely evaluated, with the meds being changed dependent on changing infection severity and control.
For individuals previously determined to have asthma, visit clinical evaluations ought to be gotten and used to routinely survey asthma control and future danger. NAEPP rules suggest evaluation at underlying finding and at resulting booked checks, at any rate at 1-to 6-month spans. The intermittence of check visits ought to be founded on the patient’s level of asthma control and severity.
Upon first presentation to the response commission and chronicling in the patient’s medical record, an itemized medical history ought to be gotten to search for signs and indications of asthma (e.g., hacking, chest snugness, windedness, wheezing). Information ought to be accumulated from the clinical history, audit of frameworks, and physical evaluation to evaluate the patient for conditions that can imitate asthma. This can incorporate, however isn’t restricted to, bronchitis, constant obstructive pneumonic infection (COPD), congestive cardiovascular breakdown, and gastroesophageal reflux disease.
2.2 Physical Examination and Lung Function Tests
Physical examination can provide valuable information in the diagnosis and assessment of asthma. Though typically physical examination findings in asthma are non-specific, the primary care physician must listen to the lungs. In most cases of asthma, breath sounds will be diminished with prolonged expiration. This finding is more common in older patients and is less common in children. Wheezing is a very specific finding for asthma, but unfortunately it is not always present in patients with known asthma. Patients with chronic asthma may have a variety of physical examination findings. Often the chest is hyper-inflated and the patient uses a number of accessory muscles of respiration. The patient may frequently clear his or her throat from chronic mild bronchial constriction producing mucus. Also, chronic asthma may lead to irreversible lung damage called chronic obstructive pulmonary disease (COPD). This can lead to the findings discussed in that section. COPD generally occurs in older adult patients with a long history of smoking and asthma. It is thought to be caused by the untreated or under treated inflammation that occurs in the airways of patients with chronic asthma over a long period of time. Lung function tests help to establish an objective diagnosis of asthma. They are also useful to identify the severity of the asthma and help to guide the treatment. The two most common lung function tests used in primary care are spirometry and the measurement of exhaled nitric oxide levels. The National Review of Asthma Deaths (NRAD) identified that over half of the patients who died as a result of an asthma attack did not have a form of lung function testing to aid their diagnosis. For this reason, it is important that lung function tests and training in their use are widely available. Also, it is important that patients are diagnosed using lung function tests where practicable. These will help to ensure both an objective diagnosis and that the patient receives the most appropriate treatment. Guidelines can help you to make a formal diagnosis of asthma based on the interpretation of lung function tests. In this module, we will be discussing how lung function tests are used to help diagnose asthma. Later in the module, we will be discussing how lung functions are used to monitor asthma.
2.3 Identification of Asthma Triggers and Comorbidities
Therefore, aside from the cornerstone diagnosis needed to fulfill the major criteria (e.g. lung function, response to therapy), a thorough assessment of potential trigger factors and associated co-morbidities is required. The assessment of trigger factors is the key second stage of the diagnosis. Trigger factors can be divided into commonly identifiable indoor and outdoor allergens (e.g. dust mites and pollens) and one of the potential contributory factors is to identify the relevant trigger to the patient’s presenting symptoms. Therefore, it is recommended to complete a full set of allergy skin prick tests to find out the individual’s allergic profile. A blood test for allergy specific IgE levels such as RAST is available as an alternative in certain patients. However, on top of the identified symptoms and objective allergy findings, persuasion of a positive allergy diagnosis is needed. Co-morbidities, particularly GORD and rhinitis, have been shown to be associated with the development of severe asthma and poor asthma control, and they could potentially confound the diagnosis of asthma. For example, the symptoms of wheeze and breathlessness might be due to GORD instead, and it sometimes presents as the only symptom without classical history of heartburn. It can also be a trigger factor for asthma in general. GORD diagnostic tests such as endoscopy and 24-hour pH monitoring can be considered if indicated. On the other hand, it is of equal importance to have a high index of suspicion for non-reversible chronic asthma-COPD overlapping syndrome (ACOS) in smokers and ex-smokers with late onset of breathlessness and frequent exacerbations. The diagnosis of ACOS is made by the presence of persistent airflow limitation and enhancing adaptive in the initial lobar bronchi in from a multidetector CTPA, and it shares not only the symptoms and signs of asthma and COPD but also the risk factors and presentations if left unidentified. Use of regular PEF measurement and demonstration of positive bronchodilator reversibility is advocated from the diagnosis section and a trial of corticosteroid to confirm the presence of the eosinophilic phenotype. Admittedly, ACOS is a relatively new entity and this is the only section in the evidence-based review that deviates from the main narrative. It also shows the advances and the necessity to enhance its diagnosis in order to establish suitable long-term treatment. Introducing such a complex recognition in the identification of the diagnosis, it is demonstrated that our work of looking into the protocols in each diagnosis has a significant contribution to the understanding of the clinical assessment in asthma therapy.
3. Treatment and Medication
Adolescents and adults with allergic asthma may use an additional medication called Omalizumab. This medication is designed to be given as a subcutaneous injection every 2–4 weeks and to study bay decrease allergic response by forming circulating complexes with the Immunoglobulin E antibody. It is only used when other medications cannot effectively control severe allergic asthma and treatment has been initiated by specialists in asthma.
On the other hand, oral corticosteroids might be used for a short period during an acute asthma episode. This is because they act on the whole body and are more likely to cause side effects. Long-acting beta-agonists (LABAs) are usually added when medium-to-high dose inhaled corticosteroids do not work effectively. They are mainly used for people who have persistent asthma symptoms and are not well-controlled with regular inhaled corticosteroids. On the other hand, leukotriene receptor antagonists, such as Montelukast, are tablets that are used to prevent the airways from narrowing in response to certain stimuli. This is achieved by blocking the action of leukotrienes, substances that are released as part of the body’s reaction to a stimulus and cause the muscles of the airways to narrow. They are less effective than inhaled corticosteroids.
These are the medications that are taken for immediate relief. Inhaled corticosteroids, which are typically used in the treatment of mild, moderate, or severe asthma, are classified as controller medications. They are usually the most effective medications for long-term control of the disease. The main function of this medication is to reduce airway inflammation and decrease the likelihood of the airways being overly sensitive or reactive if triggered by any stimulants. It is well tolerated by all age groups and when used in recommended doses, minimal amounts of the medication are absorbed into the bloodstream. As a part of the steroid group, when inhaled, it does not cause side effects common to those observed when oral steroids are used.
There are two main goals of asthma pharmacological management: achieving and maintaining control of the disease and reducing future risk. In general, there are two classes of medication to manage asthma: controller medications and rescue medications. Controller medications are mainly prescribed for patients who need regular treatment. They are the most effective medications for relieving asthma symptoms and work by preventing symptoms from developing. They usually need to be taken daily, even if there are no symptoms. On the other hand, rescue medications are medications that work quickly to control asthma symptoms when they occur.
Pharmacological management
3.1 Pharmacological Management
Inhaled therapies are the cornerstone of asthma treatment. Inhalers are used because they deliver the medication directly into the airways, which maximizes the therapeutic effect and minimizes the risk of side effects. There are several different types of inhaler, each with its own technique. The choice of inhaler device should be made on an individual basis, according to patient preference and ability. MDI (metered dose inhalers) are the most commonly used inhaler and are often used with a spacer or a VHC (valved holding chamber) to help improve drug deposition. A spacer is a large plastic or metal container with a mouthpiece at one end and a hole for the inhaler at the other. It is used with an MDI to ensure that most of the medication passes through the large spaces in the spacer and is then inhaled into the lungs, rather than hitting the back of the throat. Spacers can be particularly useful for young children, the elderly, and people with severe disease, poor coordination, or those who find it difficult to breathe in at the right moment for effective MDI use. Adolescents and adults could be offered either a spacer or a VHC, although in practice these are most often used in patients prescribed with a pMDI for the first time or in those who find pMDI coordination particularly hard. Dry powder inhalers deliver medication as a dry powder; they do not contain propellants and so the dose is delivered as the patient breathes in through the device. DPIs are breath-actuated, delivered dose inhalers; they will only release the medication if the patient inhales through the device. Dry powder inhalers are therefore not suitable for individuals with poor inspiratory flow. Flow resistance and fine particle dose are two other key considerations when choosing between DPI devices.
3.1.1 Inhaled Corticosteroids
3.1.2 Short-Acting Beta-Agonists
3.1.3 Long-Acting Beta-Agonists
3.2 Non-Pharmacological Management
The provision of patient education is paramount in non-pharmacological management. For example, educating the patient to recognize and avoid the triggers of asthma can greatly help to reduce the frequency of asthmatic attacks. Avoidance of tobacco smoke and offering smoking cessation assistance are also important strategies. The primary health care nurse or doctor, as the patient’s continuing health adviser, plays a key role in delivering patient education. A good asthma education program should include teaching on the nature of asthma, assessment and monitoring of asthma, recognition of, and response to, exacerbations, and an individual action plan tailored to the patient’s needs. On top of that, proper inhaler techniques and the importance of compliance with medication should also be covered. A well-validated “control based” asthma self-management program could be included as part of the overall patient education. In this program, the patient uses a daily record of symptoms, combined with the measures of lung function where appropriate, is employed to direct the necessary actions to control asthma. The aims of such programs are to optimize therapy in the long term, to maximize early intervention, and to reduce the requirement for emergency treatment. It is worth mentioning that the patient should be taught to recognize the common symptoms of lack of control including limitation of daily activities, nocturnal symptoms, the need for rescue bronchodilator more than usual, and exacerbation of symptoms. Also, they should be reminded to seek medical help if the pattern of symptoms changes or if the patient feels unwell or is deteriorating. Adults and children of appropriate age with asthma should be offered an objective assessment of the severity of their condition. In keeping with the relative refractoriness of chronic asthma, psychological measures are more in keeping with. On the other side, a CBT-based intervention could be recommended for those who experience severe or difficult to manage asthma. However, a more direct tool could also be used to assess the patient’s level of control over asthma.
3.2.1 Education and Self-Management Strategies
3.2.2 Environmental Control Measures
4. Follow-Up and Monitoring
For each follow-up care, educating the patient is necessary. A patient asthma action plan should be provided or updated. It is important to make sure the patient understands what should be done in case of asthma exacerbation and the correct technique of using the inhalers. Besides, the patient may be faced with some emotional problems. It is necessary to pay attention to the mental status of the patient and provide psychological support if necessary. The follow-up care could also be the time to review and update the written asthma action plan. The written asthma action plan should include the triggers, the list of the medication with the name and the dosage, how to manage the acute exacerbation step by step, and the contact number of the healthcare provider. The patient and family should be clearly explained on each item on the action plan.
In the follow-up visit, taking history and doing a physical examination is important. It is helpful to find out the cause of the exacerbation. Also, doing breathing tests can help to monitor lung function. Most patients with a relatively severe condition need to use a peak flow meter at home for long-term monitoring. It is important to make sure compliance and the proper use of asthma medication in the follow-up visit. The patient should bring their medication list and demonstrate how they use the inhalers. Make sure every medication is necessary and explain one by one if needed.
Once the asthma is stable, follow-up care from a primary care provider, not a specialist, would be appropriate. Only schedule an asthma specialist visit for cases of intensive treatment or when the condition is getting worse. The patient may return to see the asthma/allergy specialist every 1 or 2 years if the condition is well controlled.
After the patient’s asthma is under control, the follow-up care should be given every 1 to 6 months. The goal of follow-up care is to monitor whether the treatment is effective, educate the patient and family, and update the treatment plan as needed.
4.1 Regular Asthma Control Assessments
Therefore, a simple investment in scheduled regular asthma control assessments can lead to significant saving in the long term as it helps prevent exacerbations and hospital admissions. It also helps improve lives of patients and their families.
In a multi-ethnic city in the UK, a study has shown that patients who have regular asthma control assessments tend to have less A&E visits and lower risk of admission. Also, the patients’ adherence and persistence to their inhalers were higher. In addition, regular asthma control assessments not only improve the patients’ quality of life but also bring economic benefits. It has been shown that patients who have their asthma control reviewed are much less expected to take sickness leave or experience absence from work or school. So they could lead a more productive personal life.
A written personalised asthma action plan shall be given to patients to help control their condition better. The plan will be reviewed during each control assessment and when the assessment suggests the current treatment plan is not working. Besides, the date of the next review should be agreed and communicated to the patient. This is of great importance as it has been shown that regular reviews help people manage their asthma better.
It is important for patients to have regular asthma control assessments, even when the asthma appears to be stable. This is because the level of control can vary and deteriorate over time due to changes in the patients’ live or their condition. A proposed frequency for adults course hero and children over 12 years is at least yearly review and for children aged 5-11, at least every six to twelve months. For children under 5 years old, the assessment should be at least every six months and more often if well indicated.
The guideline suggests that for patients of six years and older, healthcare professionals should use either Royal College of Physicians “3 Questions” or Asthma Control Test (ACT) to assess the asthma control. For children who are 4-11 years old, healthcare professionals should use “Paediatric Asthma Control and Communication” (PACC) assessment tool or the Childhood Asthma Control test (C-ACT).
The guideline of UK asthma care emphasizes that the main strategy for asthma control is regular asthma control assessments. It is recommended that all patients who experience symptoms are assessed, in the first instance. The asthma control assessment is used to determine whether the symptoms are controlled, partly controlled or uncontrolled. It can also be used to assess the risk of an asthma attack.
4.2 Adjustments to Treatment Plan
Adherence to medication among asthmatic patients, or the lack of it, may become a topic that requires adjustments to the treatment plan. Moreover, incidents of asthma worsening or decreased asthma control may also necessitate the need to review and step up the treatment. To effectively make adjustments to the treatment plan, the doctor may find it necessary to educate the patient and the family about the need for medications, how to handle exacerbations and the appropriate times to seek medical help. This is because adjustment to treatment plans often is about stepping up doses of medications such as inhaled corticosteroids, and these strategies may only be successful if the patient is well aware of the reasons for these adjustments and is cooperative. On the other hand, decisions about adjustments to treatment formulation or level for a patient may also involve use of the multi-disciplinary team for the reviews. Such a decision may require the doctor to justify the reasons that would have led to the proposed adjustments and this is an opportunity for collegial discussions and training of upcoming health professionals. For planned adjustments to the treatment plan, the doctor should consider inputs from the specialist nurse, pharmacist, physiotherapist or other health professional involved in the care of the patient. This multi-disciplinary approach is likely to ensure that treatment is reviewed in the light of a full range of health measures and outcomes. The selection of treatment plan adjustments may depend on the severity of symptoms or the current level of control. For example, in a case where there is the likelihood of a clinical deterioration as in acute severe asthma, it may be necessary to rearrange the medications in favour of a faster acting and more intensive treatment whilst stepping down the preventer therapy. In any case, it is important to evaluate the clinical effectiveness of the treatment in few weeks after the adjustments. This is because the changes in the treatment plan may have worked well initially and then lost its potency later. Similarly, it is not uncommon to note that patients may actually get worse despite adjustments to treatment plans. This may require the doctor to consider admission in hospital for more intensive treatment.
4.3 Patient Education and Support
Another important component in the management of patients with asthma is patient education. Education has been shown to be an effective tool in improving self-management for patients with asthma and in reducing the frequency and severity of exacerbations. Effective educational interventions for asthma generally include teaching patients about the chronic nature of the disease and the inflammatory process; the identification of symptoms, including recognition of both early signs of exacerbation and acute distress; the role of medication and the appropriate use of different types of medication; recognition and avoidance of precipitating factors; and the need for, and appropriate use of, consultation with healthcare providers, including making decisions about seeking emergency care. There is evidence to suggest that self-management education programs for patients with asthma may lead to a significant decrease in hospitalizations and emergency room visits. Asthma education in the primary care setting can be provided by various members of a sweet study multi-disciplinary team, such as doctors, nurses, respiratory specialists, physiotherapists, and pharmacists. Each of these professionals is able to provide different elements of education, at differing levels, but it is imperative that all education provided is done so in a coherent manner. GPs and practice nurses may provide initial education related to the diagnosis of the disease, basic information about asthma and the need for regular structured review as an outpatient. More specialized education in the primary care setting may be delivered by nurses and, if they are employed, respiratory specialists – providing focused education relating to both pharmacological and non-pharmacological management options. Members of the community asthma team, such as respiratory nurses, are also well placed to provide patients with asthma education. It is essential that anyone providing education is equipped to understand, and where relevant, promote an understanding of the objectives and structure of an asthma self-management education program. GPs and practice nurses are in a good position to encourage patients to attend such programs and to ensure they support and reinforce the messages that the patients receive through the self-management education program. By ensuring access to structured asthma education programs for asthma sufferers, as well as continuing professional development on educational skills for both general and specialist healthcare professionals, it should be possible to achieve all the objectives set out in the ‘Asthma Outcomes Strategy’ document. These ‘health outcomes’ are to enable children and adults with asthma to have control over their symptoms in order to provide a good quality of life; to ensure that there is no variation within the population of England in safety and quality of care; and to ensure that the use of resources is demonstrably efficient in avoiding unplanned admissions to hospital. The possibility of shared care services also cannot be overlooked. By utilizing the education and skills gains set out above, the potential to support GPs and other primary care health professionals in the delegation and sharing of more specialist care for patients with asthma could be maximized. This has the potential benefits for both individual patients and the quality and cost-density of asthma care provision at a population level.