Assessing a patient with asthma

Garry McDonald is a pharmacist with a genuine passion for asthma. He is also on the PCRS Respiratory Leadership Practice Board and a Pharmacist Faculty member. During the Clinical Pharmacy Congress, he joined us in the MORPh Skills Theatre to discuss assessing an asthmatic patient. This podcast is taken from Garry’s input at the CPC. Garry’s engaging manner makes it interesting and easy to follow. The content is summarised below.

Garry’s history with asthma

Having suffered from croup as a child, Garry lived in an oxygen tent for four weeks at three years old. From then until the age of 14, he was back and forth to the GP regularly, trying every type of medicine you can imagine. When he was finally given an inhaler at the age of 16, nobody showed him how to use it. As a patient, he has still never been told how to use an inhaler to this day. He stresses that every patient should be shown how to use an inhaler correctly, even him with the level of expertise he now possesses.

What is an asthma attack?

Garry’s main message is that asthma kills. An attack can manifest as:

• Severe wheezing
• Constant coughing that won’t stop
• Very rapid, short breathing
• Tight chest
• Tight neck and chest muscles
• Using a lot of ancillary muscles like shoulders to breathe instead of breathing from the diaphragm, which can cause stiffness and soreness
• Difficulty talking, may only manage single words or syllables
• Feelings of anxiety and panic
• Sweaty face
• Blue lips
• Clubbing of the fingernails

What do the airways look like during an asthma attack?

When an asthmatic patient is having an asthma attack, their airway will be highly constricted due to constricted muscles. When an asthmatic person is not having an asthma attack, their muscles relax, and they think they don’t need to continue using their inhaler. However, their airway remains a lot smaller than it should be.

Asthma prevention

Garry reinforces the fact that smoking cessation is the biggest impact you can make on any patient’s life.  Half of all smokers will die from a smoking related illness. Inhaler technique and asthma monitoring are also important tools. He stresses the importance of looking at the whole patient. Are you doing everything you can for them? Why increase the dose of drugs if they are still smoking? We need to get the basics right first. Why throw more drugs at it when you can make a non-pharmacological intervention?

Garry advises pharmacists to look at the number of inhalers the patient is using. If the patient is using their inhaler more than twice a week, their asthma is not controlled. If they are using their inhaler more than three times a week, they are twice as likely to have an asthma attack. This is true irrespective of whether their asthma is mild, moderate or severe. If they are having to use it more than twice a week, it’s not working properly.

Lifestyle factors are also important and it is essential to remove the trigger if a patient has an allergy that triggers asthma. For example if a patient is triggered by cats, they can’t live with a cat. Weight management and education are also key factors. Support for asthma patients can be incredibly helpful. Garry would point them in the direction of Asthma UK who offer a variety of services including texting people every week to check in with them and see how their asthma is.

How do you know whether a patient has definitely got asthma?

Garry is keen to point out that there is no single diagnostic test. You have to look at the whole patient and paint a picture of the information you have got. Then, you look at the probability that the patient has asthma. For a diagnosis of asthma at least two of these symptoms should be present

• Wheeze
• Breathlessness
• Chest tightness
• Cough
• Variable airflow obstruction

Clinical tests can be used to establish the probability of asthma, but they don’t prove the diagnosis. The objective tests seek to demonstrate variable airflow obstruction and the presence of airway inflammation. The tests can give you false negatives and false positives, so you need to look at the whole picture.

Asthma changes with time and patients can grow out of it. Of all children that have asthma, 80% have allergic asthma. This reduces greatly in adults because people grow out of it as their immune system changes.

Probabilities

Listen to the full podcast to hear Garry talk about the SIGN Guidelines. He runs through the probability of asthma that can be established using clinical tests. If high probability is indicated, asthma should be diagnosed. When the probability is low, pharmacists should always hold back, look at the bigger picture and consider other things.

If the probability of asthma is in the middle, more tests will be needed. Pharmacists should look for reversible obstruction. If airway obstruction can be reversed, then it is probably asthma. He talks in some detail about the best ways to establish a diagnosis where the probability is initially unclear. When it comes to spirometry, he is keen that all pharmacists should carry out a spirometry themselves as a patient. This allows them to understand what it is like, as it is a very unpleasant test for the patient.

Garry mentions that if a patient has been triggered by a seasonal allergy, he would make an appointment to see them in 11 months’ time. That is to say one month before the trigger kicks in again. Allowing the pharmacist to get their medication sorted before the trigger hits next year.

Additional learning

For further input on asthma including inhalers and the green agenda, have a look at the free MORPh webinars. There are no subscription fees to join MORPh and no hidden costs for participants. If you are unable to make any of the webinars, check out our Education Platform where you can watch webinars in your own time.