Notes: Asthma Review (Family Medicine/Primary Care)

Establish rapport

1. Hello my name is Dr.______. How can I help you today? 
1. New complaint*
2. I came to renew my medications
2. Demographics: How old are you? What do you work? Are you married? Do you have any children? Who do you live with?
3. E: So is there anything else I can help you with today/you expect me to help you with?
4. I: What are your ideas about [insert complaint]?
5. C: What are your concerns today/is there anything worrying you about todays visit?

*NOTE: Refer to Respiratory Complaints post.

How to proceed in interview: 
1. Take a detailed history of new complaint if having any and then do asthma review.
2. Start with asthma review if patient only came for medications or reviewing results of a test)

Asthma review

1. Assessing asthma control
1. During these past week, how many times did you have an asthma attack? During these past 4 weeks? (>2x/week) *
2. During this past week, how many times did you use your asthma medications? During these past 4 weeks? (>2x/week) *
3. During this past week how many times did you wake up at night because of coughing or shortness of breath? During these past 4 weeks. *
4. Has it affected your activity this week? *
5. Ever been to hospital for asthma problem? When was the last time?
2. Assessing medications and adherence
1. What are the medications you use for asthma? 
2. What are the doses and timings of these medications? 
3. Assessing atopy 
1. a. Do you have itchy/runny nose? Itchy eyes? Rash on body? Food allergies?
2. b. Do you notice something specific causing the attacks? Dust, exercise, laughing, perfume, incense?
4. Assessing uncontrolled asthma
1. Do you know how to use the inhaler? Can you show me how you use it?
2. Allergens (already been asked above)
3. Inform patient: 
1. We may need to go up with the treatment by increasing dose. 
2. OR you must lower exposure to allergen and come back in 3 months. If it still uncontrolled, we may need to add another drug.

Controlled	Partially controlled	Poorly controlled
No *	1-2 *	3-4 *

Management

1. Investigations: 
1. If patient comes with a complaint, then do the investigations based on that.
2. Education: 
1. Try to stay away from allergens or exacerbating factors (such as perfume, incense)
2. Use inhaler correctly (links to youtube videos of instructions for device use):
1. Spacer: take 4 breaths after 1 puff, wait 4 minutes and take another 4 puffs (4x4x4 rule) (max 4)
1. MDI: can take up to 4-6 puffs (standard 1-2 puffs)
2. Nebulizer: breathe normally
3. Educate about medication adherence
4. Take puff of inhaler before exercise if exercise-induced
3. Referral: if needed, patient may go to ER
4. Follow up: see as fit based on the complaint and control of asthma. According to Murtagh's General Practice:
1. After starting ttx: 1-3 months later
2.  Thereafter: 3-12mo
5. Step-wise management:

ICS = inhaled corticosteroid

OCS = oral corticosteroids

LABA = long-acting beta agonist

SABA = short-acting beta agonist

	Reliever	Controller	Add-on therapy
Step 1	SABA
Step 2	SABA	Low dose ICS
Step 3	SABA or ICS/formoterol	Low dose ICS + LABA	Theophylline
Step 4	SABA or ICS/formoterol	Medium/high dose ICS + LABA	Tiotropium/ Theophylline LTRA
Step 6	SABA or ICS/formoterol	Low-dose OCS (refer)	Theophylline/ omalizumab (anti-IgE)

Stepping up and down drugs:

1. Down: if controlled for 3 months by slowly reducing dose and then keep patient on low dose ICS (do not completely withdraw).
2. Up (if exacerbations persist for 2-3mo despite controller): 
1. Assess: compliance, inhaler technique, modifiable risk factors (smoking, incense)

Facts about medications doctors love to ask about:

• ICS side effects are not wide spread like OCS:
• Oral thrush, dysphonia
• Therefore advise patient to wash mouth with water after use of ICS.
• Beta-agonist side effects:
• Tremors, tachycardia, hypokalemia
• Corticosteroids given in an acute attack do not need to be tapered (like the usual usage) because it is a very short period of use.

Managing asthma attack in primary care/clinic setting:

1. O₂ & SABA + corticosteroid oral in ER room
2. Vitals check & IV access
3. Call for ambulance and transfer to hospital
4. Tell hospital to arrange follow up in clinic within 1 week for patient

References
GINA Pocket Guide for Asthma Management and Prevention 2015

*NOTE: Refer to the latest guidelines available for management at the time you are reading this.