Asthma Consult checklist – Review

Download Asthma Consult Checklist – Review

Explanatory notes and References

Explanatory notes:

  1. Including Asthma Score (Asthma Control Test), Primary care Asthma Control Screening and Asthma Control Questionnaire,3 the Test for Respiratory and Asthma Control in Kids (for children aged <5 years) and Childhood Asthma Control Test (for children aged 4–11 years).4
  2. Every 1–2 years for most people, but more often in the absence of good asthma control or presence of risk factors for accelerated loss of lung function.3
  3. Good control is defined as all of daytime symptoms ≤2 days/week and no limitation of daily activities and no symptoms during night/on waking and need for a SABA reliever ≤2 days/week. Partial control is defined as one or two of daytime symptoms >2 days/week and any limitation of daily activities and any symptoms during night/on waking and need for a SABA reliever >2 days/week. Poor control is defined as three or more of daytime symptoms >2 days/week and any limitation of daily activities and any symptoms during night/on waking and need for a SABA reliever >2 days/week.3
  4. Not including doses taken prophylactically before exercise, which should be recorded separately.3
  5. White cell differentiation count on peripheral blood is not currently recommended for asthma, but can be considered for severe asthma to help guide biologic therapy.3
  6. Medical history includes intubation or admission to an intensive care unit for asthma (ever), ≥2 hospitalisations for asthma over the last year, ≥3 emergency department visits for asthma over the last year, hospitalisation or emergency department visit for asthma over the last month, high-use of a SABA, history of delayed hospital presentation during flare ups, history of sudden-onset acute asthma and cardiovascular disease. Investigations include sensitivity to unavoidable allergens. Other factors include inadequate treatment, past side effects during oral corticosteroid use, no written asthma action plan, socioeconomic disadvantage, living alone, mental illness, use of alcohol or illegal substances and poor access to health care (such as living remotely).3
  7. Medical history includes chronic mucus hypersecretion and severe asthma flare ups in people not taking an inhaled corticosteroid. Investigations include poor lung function and eosinophilic airway inflammation. Other factors include smoking or environmental cigarette smoke exposure and occupational asthma.3
  8. Medical history includes long-term high inhaled corticosteroid use and frequent use of oral corticosteroids. Other factors include anxiety disorder or euphoria with oral corticosteroid use.3 For patients requiring long-term high-dose inhaled corticosteroids to maintain good asthma control, or who need frequent courses of oral corticosteroids, monitor bone mineral density and glucose metabolism and advise patients to have regular eye examinations, do regular weight-based physical activity, have adequate dietary intake and maintain adequate vitamin D levels.16
  9. By peers, employers, colleagues or family (for example, expectation that they should have ‘grown out of asthma’).5
  10. Including ethnicity, cultural beliefs, level of social support, comorbidities, mental health, healthcare provider factors (such as communication skills, teaching ability and time) and healthcare system factors (such as complexity of the health system).5
  11. Also consider asking about circumstances and timing of symptoms, assessing the risk of thunderstorm asthma, and consider whether there is food allergy or exposure to pet allergens, house dust mite, moulds or workplace triggers.6,7
  12. People with eczema commonly have or will develop other allergies, such as allergic rhinitis, asthma, food allergy or dust mite allergy. Managing eczema in infants may reduce the chance of developing food allergy. Children with eczema and/or food allergy can have false-positive allergy tests, leading to unnecessary food restrictions.7 Food allergy is a risk factor for life-threatening asthma flare ups.4
  13. A sign of allergic rhinitis.7
  14. Exercise and laughter can be asthma triggers, but should not be avoided.13
  15. Includes animal allergens, cockroaches, house dust mite, moulds, workplace allergens and pollens. Advise avoidance only if a patient is sensitised and it is practical and effective.13
  16. Including cold/dry air, fuel combustion, home renovation materials, household aerosols, moulds, workplace irritants, outdoor industrial and traffic pollution, perfumes/scents/incense, smoke (including bushfires, agricultural fires and indoor woodfires) and thunderstorms (in spring and early summer).13
  17. Aspirin and NSAIDs (in people with aspirin-exacerbated respiratory disease), beta-blockers, anticholinesterases, cholinergic agents, bee products (such as pollen and royal jelly) and echinacea.13
  18. Unavoidable, but manageable. Includes allergic rhinitis/rhinosinusitis, gastro-oesophageal reflux disease, nasal polyposis, obesity and upper airway dysfunction.13
  19. Unavoidable, but manageable. Includes extreme emotions, hormonal changes, pregnancy and sexual activity.13
  20. Influenza vaccination reduces the risk of influenza and pneumococcal vaccination reduces the risk of pneumococcal pneumonia. Patients with severe asthma should keep their flu vaccines up to date. For all other patients, follow national immunisation guidelines such as the Australian Immunisation Handbook.14
  21. Including medication names and doses, and when to take each dose.3
  22. When asthma is getting worse and substantially worse, and during an emergency.3
  23. Including treatment regimen, asthma severity, culture, language, literacy level and ability to self-manage.15
  24. Individual goals will vary, but could include: Encourage medicines to be taken as prescribed, improve adherence, identify or address barriers to asthma control or medication adherence, improve inhaler technique, confirm inhaler suitability, assess appropriateness of current treatment or preventer, determine whether prescribed preventer doses are effective, improve ability to self-manage, encourage use of written asthma action plans, confirm whether all symptoms are due to asthma, confirm a diagnosis, identify whether other conditions are present, identify whether there are any unidentified triggers, and encourage smoking cessation and avoidance.17
  25. Arrange more frequent follow-up for children with confirmed food allergy, poor asthma control, admission to hospital over the last 12 months, history of intubation for acute asthma, over-use of SABA reliever, frequent failure to attend consultations, abnormal spirometry findings, reversible expiratory airflow limitation on spirometry despite treatment, poor preventer adherence, poor inhaler technique, poor use of their written asthma action plan, significant parental psychological or socioeconomic problems, a carer not able to manage an asthma emergency, obesity, and exposure to clinically relevant allergens or tobacco smoke.4
  26. In addition to early post-acute assessment within 3 days of discharge.4

Key Australian Asthma Handbook resources:

  • Figure: Stepped approach to adjusting asthma medication in adults and adolescents.8
  • Figure: Stepped approach to adjusting asthma medication in children aged 6–11 years.9
  • Figure: Stepped approach to adjusting asthma medication in children aged 1–5 years.10
  • Table: Checklist for reviewing a written asthma action plan.3
  • Table: Considerations for choice of inhaler device type when prescribing inhaled medicines.12
  • Table: Considerations when choosing inhaler devices for older patients.12
  • Table: Definitions of ICS dose levels in adults.16
  • Table: Definitions of ICS dose levels in children.4
  • Table: Definition of levels of recent asthma symptom control in adults and adolescents (regardless of current treatment regimen).3
  • Table: Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen).4
  • Table: Management of risk factors for adverse asthma outcomes in adults and adolescents.3
  • Table: Options for adjusting medicines in a written asthma action plan for adults.3
  • Table: Risk factors for adverse asthma outcomes in adults and adolescents.3
  • Table: Sample questions for reviewing children.4
  • Table: Suggested questions to ask adults and older adolescents when assessing adherence to treatment.3
  • Table: Summary of asthma triggers.13
  • Table: Troubleshooting checklist.17
  • Table: Types of inhaler devices for delivering asthma and COPD medicines.11

References

  1. National Asthma Council Australia. Australian Asthma Handbook. Available at: asthmahandbook.org.au. Accessed March 2020.
  2. Asthma Initiative of Michigan. Primary care 15-minute asthma visit infographic. https://getasthmahelp.org/asthma-health-professional-main.aspx. Accessed March 2020.
  3. National Asthma Council Australia. Australian Asthma Handbook. Conducting asthma review at scheduled asthma visits. Available at: https://www.asthmahandbook.org.au/management/adults/reviewing-asthma/scheduled-asthma-visits. Accessed March 2020.
  4. National Asthma Council Australia. Australian Asthma Handbook. Planning and conducting routine asthma review for children. Available at: https://www.asthmahandbook.org.au/management/children/routine-asthma-reviews. Accessed March 2020.
  5. National Asthma Council Australia. Australian Asthma Handbook. Assessing patients’ adherence to asthma treatment. Available at: https://www.asthmahandbook.org.au/management/adherence/assessing-adherence. Accessed March 2020.
  6. Australasian Society of Clinical Immunology and Asthma. Eczema (atopic dermatitis). Available at: https://www. org.au/patients/skin-allergy/eczema. Accessed March 2020.
  7. National Asthma Council Australia. Australian Asthma Handbook. Assessing allergies to guide asthma management. Available at: https://www.asthmahandbook.org.au/clinical-issues/allergies/assessing-allergies. Accessed March 2020.
  8. National Asthma Council Australia. Australian Asthma Handbook. Managing asthma in adults. Available at: https://www. org.au/management/adults. Accessed March 2020.
  9. National Asthma Council Australia. Australian Asthma Handbook. Reviewing initial treatment in children aged 6 years and over. Available at: https://www.asthmahandbook.org.au/management/children/6-years-and-over/reviewing-initial-treatment. Accessed March 2020.
  10. National Asthma Council Australia. Australian Asthma Handbook. Reviewing initial treatment in children aged 1–5 years. Available at: https://www.asthmahandbook.org.au/management/children/1-5-years/reviewing-initial-treatment. Accessed March 2020.
  11. National Asthma Council Australia. Australian Asthma Handbook. Training patients in inhaler technique. Available at: https:// asthmahandbook.org.au/management/devices/inhaler-technique. Accessed March 2020.
  12. National Asthma Council Australia. Australian Asthma Handbook. Choosing an inhaler device to suit the individual. Available at: https://www.asthmahandbook.org.au/management/devices/device-choice. Accessed March 2020.
  13. National Asthma Council Australia. Australian Asthma Handbook. Considering triggers and comorbidities. Available at: https:// asthmahandbook.org.au/clinical-issues/management-challenges/triggers-comorbidities. Accessed March 2020.
  14. National Asthma Council Australia. Australian Asthma Handbook. Maintaining appropriate immunisation according to risk group. Available at: https://www.asthmahandbook.org.au/prevention/preventive-care/immunisation. Accessed March 2020.
  15. National Asthma Council Australia. Australian Asthma Handbook. Asthma action plans. Available at: https://www. org.au/resources/tools/action-plans. Accessed March 2020.
  16. National Asthma Council Australia. Australian Asthma Handbook. Planning asthma review and follow-up. Available at: https:// asthmahandbook.org.au/management/adults/reviewing-asthma/planning-reviews. Accessed March 2020.
  17. National Asthma Council Australia. Australian Asthma Handbook. Management challenges. Available at: https://www. org.au/clinical-issues/management-challenges. Accessed March 2020.