MODULE 7: ASTHMA EDUCATION AND SETTING UP AN ASTHMA CLINIC

COMPULSORY ASSIGNMENT
TO BE HANDED IN BEFORE: 9th September, 2022

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 ASSIGNMENT QUESTIONS

PATIENT NO 1
Mr X, aged 30, has an appointment at your clinic. This is the first time you have seen him. He says he is worried
about his chest. Using the acronym H.E.A.T, how would you determine if he has asthma?
(Possible marks 22)
One of your diagnostic tests confirms your suspicion that Mr X has Asthma
What medication would you recommend and what education would you give him?
(Possible marks 13)
TOTAL MARKS: 35

PATIENT NO 2
Vuyani, aged 10, a known asthmatic arrives with his Mom outside their appointment date at your morning clinic. He
is on Inflammide 200 μg BD and Asthavent 100 μg prn. They are upset and distressed and have been awake most of
the night because Vuyani’s chest was tight. He is coughing continually. How would you manage this acute severe
attack?
(40 Marks)
When the patient has stabilized, it is important to ascertain what might have contributed to the exacerbation in order
to try and prevent a recurrence. In this regard, what questions would you ask and what education would you offer?
(5 Marks)
TOTAL MARKS: 45

SOLUTION

PATIENT NO 1

A. Procedure for establishing a diagnosis of asthma:

 The acronym H.E.A.T. stands for History, (Physical) Examination, (Lung) Assessment, and
(Reversibility) Testing, and it describes the diagnostic algorithm followed in clinically establishing
a case of asthma. Briefly:
 “History” stands for the account of the symptoms given by the patient, including the
progression/worsening or recession/amelioration of these symptoms, as well as additional
information which help to contextualise the account of symptoms already obtained;
 “Physical examination” (progressed to only if the history had yielded a high index of
suspicion for asthma) involves an exploration of the patient’s anatomy by the health care
provider for discovery of positive signs indicative of asthma;
 “Lung assessment” mainly involves spirometry (a simple form of this is the peak expiratory
flow rate - PEFR - assessment);
 “Reversibility testing” involves a challenge test with a short-acting β-agonist (SABA);
 These last two items are frequently run together, and they constitute the basis of a clinical
diagnosis of asthma. They are administered if the history and examination strongly
suggests the presence of asthma.
 At first, I will ask Mr X what his concerns were with his chest, and if he has any specific symptoms
that had him worried like a cough or wheezing (inability to exhale optimally) or dyspnoea
(shortness of breath).
 If he indicates he has any of these specific symptoms (or has had in the recent past) I will proceed
to take a comprehensive history of the symptoms, endeavouring to elucidate the quality and the
pattern of these cardinal symptoms whilst carefully noting the onset and triggers for each
symptoms as well.
 While taking Mr X’s history, I will also obtain a history of allergenic/atopical responses (personal
and familial), comprehensive health and medical history (including history of respiratory disease
and medication use, especially aspirin), occupational history (especially if he has been exposed to
recognised triggers via his work) and lifestyle habits (like smoking) etc.
 If the history yield such positive points as being elucidated, I will carry out a physical examination
(of course obtaining the appropriate consent) as follows:
 Observe Mr X’s bearing and posture for such things as a barrel chest, and his skin for
eczema and other signs of atopy.
 Carefully his inspect nose, throat and upper airways for findings such as swollen and pale
nasal turbinates, nasal polyps and post-nasal drip
 Auscultate Mr X’s chest for wheeze (mostly expiratory and bilateral, diffuse in asthma) and
hyper-resonant percussion notes
 On finding the things indicated during the physical examination, I will proceed to lung function
testing (spirometry) to determine Mr X’s FEV1 and the FVC as well as their ratio (i.e. FEV1/FVC),
after which I will administer 200µg of Ventolin (salbutamol) via a metered dose inhaler, then
repeat the test (reversibility test).
 The expected baseline values for FVC in a normal male of Mr X’s age is between 4.5L –
5.5L, while the expected FEV1 is about 80% of the FVC (or an FEV1/FVC ratio of 0.8).
 So obtaining a value <0.75 for the FEV1/FVC ratio suggests obstruction.
 Administering a SABA should relieve the obstruction, thus after giving the patient the
salbutamol, I will administer the spirometry again (within fifteen minutes).
 If there is an increase of over 12% and an improvement of 200ml above the baseline FEV1,
then it is apparent Mr X has asthma.
 I may also request other, more specialised tests – such as a pin prick test, bronchial provocation
test, arterial blood gases, exercise stress testing etc – to appropriately characterise the asthma.
 I will definitely have ruled out differential diagnoses like upper respiratory dysfunction, chronic
obstructive pulmonary disease (COPD), gastric esophageal reflux disease (GERD), left ventricular
failure or vocal cord dysfunction syndrome (by requesting the appropriate tests as/or making the
appropriate referrals), and also ensured Mr X has no contraindications to undergoing spirometry –
 recent eye surgery, recent abdominal surgery, recent heart attack or an aneurysm in the abdomen,
thorax or cranium – before subjecting him to the lung function assessment.

B. After a positive diagnosis:

 The goals of clinical intervention in asthma are to
 Assess the severity of the asthma
 Achieve and maintain control of symptoms
 Maintain normal activity levels, including exercise
 Maintain pulmonary function as close to normal as possible
 Prevent asthma exacerbations
 Avoid/minimise adverse effects from asthma medications
 Prevent asthma mortality
 The first goal is an attempt to provisionally classify the asthma based on past presentation of
symptoms (sub-divided into day-time and night-time symptoms) and also based on the results of
the lung function test.
 This first goal also usually involves a continuation of the diagnostic process, and involves the
specialised testing already in the previous section – pin prick test (to test for allergic sensitivity, as
well as to determine the range of substances which elicit this allergic response), bronchial
provocation test and exercise stress testing in order to further refine the assigned label.
 The report on follow-up visits will also modify the diagnosis further and make possible a more
grounded classification of the asthma as intermittent or persistent.
 The other goals of clinical intervention come under the broad heading of asthma control. The
main methods of achieving this are by pharmacotherapy, patient education (including
advice/counselling on lifestyle modification) and regular monitoring.
 The rest of this answer will focus on prescription (pharmacotherapy) and education as directed in
the assignment task.

Prescription

 The gold standard of pharmacotherapy in asthma is a low-dose controller (for long-term control of
symptoms) prescribed along with a short acting reliever for emergencies/acute attacks, although
supplementary drugs may be prescribed to support the action of these two classes of drugs.
 Short-acting β2-agonists (SABAs) – salbutamol or fenoterol – are the drug of choice for a reliever,
and they are the recommended first line for asthma management; a controller becomes only
necessary if at the first month follow-up it the patient reports poorly controlled symptoms.
 Thus I would prescribe Mr X 200µg Asthavent (salbutamol), administered via a metered dose
inhaler (MDI) and large volume spacer (LVS), and schedule him for a four-week follow-up
appointment.
 The instruction will be to take the salbutamol prn for symptoms – typically dyspnoea/expiratory
flow limitation (with a recommendation to take two puffs only).
 At the follow-up, a validated measure such as the Asthma Control Test (ACT) or the Asthma
Control Questionnaire (ACQ) will usually be used to assess the control or otherwise of the asthma.
 Clinical measurements such as pulse oximetry and respiratory rate will also be taken for
comparison against baseline (and a blood gases profile may also be ordered, if so indicated by the
presenting severity of symptoms).
 If Mr X demonstrates good control of symptoms), then his asthma will be classed as intermittent.
Further advice/counselling on maintaining asthma control will be provided and the patient will be
scheduled for another appointment.
 If, however, he demonstrates poor control, I will proceed to investigate the reasons for this poor
control, taking care to inquire into inhaler technique and confounders.
 Where one or the other factor were found to be the culprit, the patient will be carefully counselled
and retrained (where poor inhaler technique is responsible), then another one month (or maybe
two weeks) appointment given for re-evaluation.
 Where neither confounders nor poor inhaler technique is found to be responsible for poor
symptom control, it means the Mr X has persistent asthma, and will thus require a controller
medication in addition to his reliever.
 My choice of a controller, based on the latest practice recommendations, will be a low-dose inhaled
corticosteroid (ICS) – budesonide (100 µg twice daily) or flucatisone (50µg twice daily) – delivered
via an MDI, except he happens to have severe allergic rhinitis, exercise induced asthma or aspirin
hypersensitivity, which case I will prescribe a modified.
 At the next follow-up, if the asthma control is still poor I will prescribe a long-acting β2-agonist
(LABA) in combination with the low-dose ICS.
 A good ICS+LABA agent will be seretide (salmeterol and fluticasone); I will prescribe the
100µg/50µg (also delivered via an MDI) to be taken twice a day.
 I will schedule Mr X for ongoing clinic visits for monitoring of symptoms and progress so as to
know if to step management up further to a medium/high dose ICS (with/without combination),
and whether to progress to Steps 4 and 5 of the recommended asthma management paradigm.

Education

 Achieving the goals of clinical intervention (and maintaining them) involve instituting preventive
and avoidance measures to prevent/limit exposure to allergens and pollutants, occupational
 exposure and triggers from foods and drugs (including vaccines) and amelioration of other
confounders such as co-morbidities (including obesity).
 It is also important for the patient to learn a good inhaler technique so as to be able to correctly
self-administer prescribed medications
 Since a patient’s health beliefs will affect their attitude to their diagnosis (and ultimately to
compliance with management), I will also attempt to modify the health beliefs through education.
 Thus, my first point of education for Mr X would be detailed investigation of his health beliefs in
general and attitude to asthma in particular. This will enable me develop a personalised approach
 Then, the education proper commences with information provided about his condition/diagnosis
(including the type of it, which information has gleaned from the tests and physical
examination/measurement already carried out) delivered in unambiguous and non-technical
language.
 Next point of education will be to spell out the general predisposing factors to attacks as well as
communicate the identified triggers from the history provided, and then to inform Mr X of the
need to make several lifestyle changes so as to minimise the triggering effect of the factors (or even
to eliminate it totally).
 Some of these proposed lifestyle changes may be radical, like having to stop smoking if he is a
smoker or having to lose weight if he is overweight, or changing jobs if there is positive history of
workplace exposure (and must be supported by extensive psychosocial education).
 If he demonstrated any comorbidies and/or is one medication (like aspirin) which predispose him
to airway constriction and/or inflammation, I will also counsel that he see the prescribing doctor in
order to switch medications and to also adhere to the medical management of the other condition
so as not to make the asthma worse.
 Then, I will provide general information about asthma medication, and specifically about the
medication that he is being prescribed (salbutamol) – its mechanism of action and expected side
effects (negligible to nil) and emphasise the need to take it correctly as directed.
 I will also instruct him in self-observation and basic self-monitoring to track symptoms (and to be
able to objectively indicate worsening of symptoms it that happens).
 Finally, I will instruct Mr X in a good inhaler technique (and I will also recommend he use a spacer
device).
 All the preceding information is at the initial presentation, so on follow-up visits I will reiterate the
lessons/counsels on preventive and avoidance measures to avoid triggers as well as assessment and
re-training of the inhaler technique, and also reinforce the habit of self-examination and
monitoring.
 All information provided to Mr X will be supplemented by written resources (e.g. flyers) reiterating
the most important points.
 A written management plan will also be provided to Mr X. This has the advantage of encouraging
self-management and of having a documented response algorithm which can be followed in a
crisis.

PATIENT NO 2

A. Management of acute severe attack in 10-year-old Vuyani who is a known asthmatic:

 The protocol for acute exacerbations in children involves first obtaining a quick history,
observation and the taking baseline measurements then pharmacological stabilisation (usually
as run-on procedures).
 In addition to the base history of the persistent cough, chest tightness, sleep disturbance and
medications already given (per the question), I would ask Vuyani’s mother about recent oral
corticosteroid intake as well as pin down the exact duration in hours of this recent
exacerbation. A positive history of recent oral corticosteroids and an attack duration of >12
hours constitute danger signs which will necessitate hospital admission.
 I will also observe/examine the Vuyani for alertness and auscultate the chest (drowsiness or
confusion and a silent chest constitute another cluster of dangerous signs pointing to a
requirement for hospital admission). I will also note the breathing pattern and
 The measurements to take are respiratory rate, pulse rate, oxygen saturation (via pulse
oximetry) and peak expiratory flow.
 If respiratory rate is above 40, pulse rate above 12o, oxygen saturation below 90% and PEF
below 2.5L or below 65% of predicted or previously achieved personal best value, (or any
combination of at least two signs from the above), it appears the child is having a severe
episode; the decision will be to refer the child to the hospital, otherwise I will proceed to
stabilisation.
 Stabilisation is achieved by administering
 Supplemental oxygen (intranasally if ≤5L or via face-mask if above 5L);
 High dose (>1000µg) short-acting β2-agonist (typically salbutamol) in conjunction with
ipratroprium bromide via nebulizer, giving 1 dose every 20 minutes over the next hour
 I may also administer a systemic corticosteroid.
 I will repeat prior measurements at the end of one hour of therapy. The outcome can demonstrated
either a moderate episode or a severe one
 A moderate episode is indicated by moderate symptoms, moderate retraction, PEFR
between 60-75% of predicted value/personal best, and stabilised vital signs + good
peripheral oxygen saturation.
  A severe episode is characterised by severe symptoms, severe retraction, use of
accessory muscles in breathing, PEFR <60% of predicted value/personal best and
elevated vital signs + poor oxygen saturation.
 The treatments are administered again over the next hour. If re-assessment show that the
response is still poor (characterised by severe symptoms and non-improvement of signs) or
incomplete (moderate to severe symptoms but with some improvement in signs), Vuyani will
have to be admitted to the hospital.
 But where Vuyani shows good response to treatment (cessation of symptoms, improved PEFR -
>75% over predicted/personal best value, improvement in vital signs + improved peripheral
oxygenation) and sustains this response for about 6o minutes, he will be discharged home.
 The discharge will be with the appropriate maintenance treatment (SABA, controller – a
combination drug, and oral corticosteroid) and comprehensive education as well an action plan
(which is well explained to both Vuyani and his mother) and a follow-up plan.

B. Post-stabilisation inquiry and education for Vuyani:

 The usual causes of asthma exacerbation attacks while on medication is traceable to one of
 Exposure to triggers
 Improper inhaler technique
 Reduced medication compliance
 Reduced dose efficscy
 Contraction of an illness/condition which acts as a confounder (e.g. a respiratory illness
or recent rapid weight gain)
 So first thing to do after stabilisation is ask Vuyani to demonstrate his inhaler technique. Then I
will measure his weight for comparison to the last measure taken.
 After this I will take a more detailed history in order to pin down if there was unwitting
exposure to triggers (including use of medications such as aspirin or beta blockers), reduced
medication compliance or a recent illness – respiratory, upper GI and so on.
 The key points of the education to be reiterated to Vuyani and his mother are:
 To avoid any and all known triggers of his asthma
 Teach the correct inhaler technique
 Emphasise a strict compliance with all prescribed medication
 Provide tips (especially to the mother) for recognising worsening asthma, and arrange
(again with the mother) the steps to request an earlier review (before a worsening
asthma breaks out into an open exacerbation).
 Provide written materials to support the above education.