MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers i MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers Asma layout.indd 1 11/26/14 3:15 PM CONTENTS PAGE CHAPTER I MANAGEMENT OF ASTHMA 1 Topic 1 Management of Asthma at Primary Care level 41 Topic 2 Update on Management of Asthma and Assessment Tool 47 Topic 3 Assessment and monitoring asthma and clinical action plan 51 Topic 4 Management of Childhood asthma according to Malaysia CPG 63 Topic 5 Inhaler technique and pharmacotherapy in asthma management. 87 Topic 6 Application of Peak Flow Meter (PFM) and Spirometry in management of asthma 97 Topic 7 How to interpret Spirometry result CHAPTER II QUALITY ININATIATIVE OF ASTHMA 103 QAP ASTHMA “APPROPRIATE MANAGEMENT OF ASTHMA” CHAPTER III ASTHMA DSA PROJECTS 111 1. Management of bronchial asthma in health clinic: outcome & remedial measures conducted at Health Clinic Tampin since 2008 117 2. Improving QA asthma through a district specific approach - District Office Kuala Langat 123 3. Elevate the percentage of controlled bronchial asthma at Pendang District 133 4. Increase the implementation of Controlled Asthma among the asthmatic patient in Perlis 139 Appendix I ii MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers Asma layout.indd 2 11/26/14 3:15 PM CONTRIBUTORS Dr Kamaliah binti Mohamad Noh Dr Noraini binti Yusoof Deputy Director Public Health Physician Primary Care Sector Primary Care Sector Family Health Development Division Family Health Development Division Dato’ Dr Hj Abdul Razak Muttalif Dr Iskandar Firzada bin Hj Osman Respiratory Consultant Family Medicine Specialist Institute of Respiratory Medicine Health Clinic Jaya Gading, Hospital Kuala Lumpur Kuantan, Pahang Dr Norzila binti Mohamed Zainudin Dr Norsiah binti Ali Consultant Family Medicine Specialist Paediatric Institute Health Clinic Tampin, Hospital Kuala Lumpur Negeri Sembilan Dr Norhayati binti Mohd Marzuki Dr Nor Azila binti Mohd Isa Specialist Family Medicine Specialist Institute of Respiratory Medicine Health Clinic Telok Datuk, Hospital Kuala Lumpur Banting, Selangor Dr Fatanah binti Ismail Dr Junaidah binti Ishak Public Health Physician Public Health Physician Primary Care Sector Primer Officer, Perlis Family Health Development Division Pn Syuhadah binti Ahad Dr Nazma binti Salleh Pharmacist Public Health Physician Hospital Melaka Primary Care Sector Family Health Development Division Ruzita Bt Saad Nurse Health Clinic Pendang, Kedah. EDITORS 1. Dr Fatanah binti Ismail 3. Dr Natasya Nur binti Mohd Nasir Public Health Physician Medical Officer Primary Care Sector Primary Care Sector Family Health Development Division Family Health Development Division 2. Dr Nazma binti Salleh Public Health Physician Primary Care Sector Family Health Development Division iii MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers Asma layout.indd 3 11/26/14 3:15 PM INTRODUCTION Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation. Symptoms are triggered by viral infections (colds), exercise and allergen exposure, changes in weather, laughter, or irritants such as car exhaust fumes, smoke or strong smell trigger. The narrowing of the airways and increase in mucus production due to these trigger factors, will reduces the flow of air in and out of the lungs, resulting in an asthma attack. It is estimated that there are 300 million asthmatics globally. National Health Morbidity Survey 2006 showed a prevalence of adult asthma was 4.5% and childhood asthma up till 18 years old was 7.14%. Intermittent asthma among adult was 7.2% and persistent asthma has 25.8% while 68.1 % experience acute exacerbations of bronchial asthma. Level of asthma control among community is still low at 32.9% in a study done in Perak from 2007 till 2009. In a 2009 study done in Selangor, 93.8% of asthmatic patients did not perform the PEF test, 62.7% demonstrated a wrong inhaler technique and only 66.3 % patient knew the care plan for an acute asthma attack Therefore, there is an urgent need for the management and monitoring of asthmatic patient at the primary care level to be strengthened. Patient’s knowledge to manage their asthma is highly dependent on patient education given to them by the healthcare provider. In the primary care clinic the patient is handled by the primary health care team including doctors, nurses, assistant medical officer, pharmacist and assistant pharmacist. In service training of the primary health care team to maintain competency in managing asthma need to be conducted regularly at the implementation level. With the development of this module the training for providers at primary care setting will be facilitated. During the workshop and the course, all the physicians such as Respiratory Physicians, Family Medicine Specialist, Public Health Specialist, Pharmacist, and the paramedic shared their experiences and made initiatives in developing this module. Good practices, innovation and learning tools in implementation of asthma are shared in this module iv MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers Asma layout.indd 4 11/26/14 3:15 PM TOPIC 1 MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers 1 MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers Asma layout.indd 1 11/26/14 3:15 PM TOPIC 1: MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL TRAINING MODULE FOR HEALTH CARE PROVIDERS Learning objective • Definition and pathophysiology of asthma will be discussed in this chapter • The paramedic will be able to use clinical examination, investigation and assessment tools during triaging at the health clinic. MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL SLIDE 1 Outline 1. Definition 2. Pathophysiology 3. Outcome 4. Diagnosis 5. Classification 6. Management SLIDE 2 Definition Chronic lung heterogeneous disease characterised by recurrent/episodic/paroxysmal breathing problems & symptoms such as; • Breathlessness • Wheezing • Chest tightness • Coughing 2 MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers Asma layout.indd 2 11/26/14 3:15 PM SLIDE 3 Symptoms of asthma attack SLIDE 4 Definition Normal Lungs Asthma Lung 3 MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers Asma layout.indd 3 11/26/14 3:15 PM SLIDE 5 Pathophysiology • Chronic inflammatory disorder of the airways. (Host) • Airways are hyperresponsive; become obstructed (bronchoconstriction, mucus plugs, & increased inflammation) when exposed to various risk factors. (Host) • Common risk factors; allergens (house dust mites, animals with fur, cockroaches, pollens, molds), occupational irritants, tobacco smoke, respiratory (viral) infections, exercise, strong emotional expressions, chemical irritants, & drugs (aspirin & beta blockers). (Environment) SLIDE 6 Pathophysiology Airway lumen Ciliated epithelial cells Blood vessel Constricted Bronchioles Bronchial smooth muscle Mucous gland SLIDE 7 Outcome • Acute respiratory failure. • Irreversible airflow limitation (airways remodelling). • Troublesome symptoms night & day. • Limitations of physical activities / activities of daily living. 4 MANAGEMENT OF ASTHMA AT PRIMARY CARE LEVEL Training Module For Health Care Providers Asma layout.indd 4 11/26/14 3:15 PM SLIDE 8 Diagnosis Several ways: • Clinical symptoms & medical history. • Lung function measurement. • Trial of treatment; marked clinical improvement during the treatment & deterioration when treatment is stopped. Clinical symptoms & medical history; • Recurrent cough / wheeze / difficult breathing / chest tightness particularly at night or in the early morning or after exposure to risk factors or worsen at night (awaken the patient) & has eczema, hay fever, family history of asthma or atopic diseases. • Patients colds “go to the chest” or take more than 10 days to clear up. Clinical symptoms & medical history (<5 years); • Frequent episodes of wheezing – more than once a month. • Activity-induced cough or wheeze. • Cough particularly at night during periods without viral infections. • Symptoms that persist after age 3 years. • Symptoms occur or worsen in the presence of risk factors. • The child’s colds repeatedly “go to the chest” or take more than 10 days to clear up. • Symptoms improved when asthma medication is given. Physical examination in people with asthma; • Often normal • The most frequent finding is wheezing on auscultation, especially on forced expiration. Wheezing is also found in other conditions, for example; • Respiratory infections. • COPD. • Upper airway dysfunction. • Endobronchial obstruction. • Inhaled foreign body. Wheezing may be absent during severe asthma exacerbations (‘silent chest’). Lung function test / measurement; 1. Provide an assessment of the severity, reversibility, & variability of the airflow limitation (confirm diagnosis). 2. Spirometry; ↑ FEV1 > 12% & > 200 ml after bronchodilator (reversibility). 3. Peak Expiratory Flow (PEF); § Compared to previous best measurements using his/her own peak flow meter. § ↑ 60 L/min (> 20%) after bronchodilator (reversibility) or diurnal variation > 20% (2x daily, > 10%) (Variability). 5 MANAGEMENT OF ASTHMA AT PRIMARY