In this Issue November 2004

Asthma in the Later Years

The management of asthma in the older person may involve some special issues that require extra consideration with regard to diagnosis, other existing conditions and medications.

A Home Medicines Review should help to uncover any problems such as ACE inhibitor-induced cough or possible medication allergies.

The possibility also exists that the development or treatment of other diseases may have unmasked asthma. 

Establishing a diagnosis of asthma is important to prevent any confusion with other respiratory problems such as bronchitis, chronic obstructive pulmonary disease, heart problems, or post viral cough. 

Conditions that the older person may have could make their asthma more apparent. Treatment of conditions such as: 

• emphysema, bronchitis 

• hypertension, heart failure, cerebrovascular disease, myocardial infarction 

• arthritis, osteoporosis 

• glaucoma, cataracts 

• tremor, ecchymoses 

can influence asthma management or can make the asthma itself worse.

Even small gains made by good asthma management may help to improve quality of life.

Medication Management

The older person may need to cope with multiple medications and needs to be aware of medications that may trigger their asthma such as aspirin, NSAIDs and beta blockers (either orally or in eye drops).

Apart from choosing the most appropriate medication for asthma management in the older person, consideration must be given to the physical abilities required to use the range of delivery systems available. 
 

Clarity of Instructions

Extra guidance, explanation and review of all issues is necessary in educating the older person. Give clear written instructions in large print to the person and/or carer.

Vaccinations

Attention to vaccination and immunisation is particularly important for the older person with asthma and/or other respiratory diseases. 

• Pneumococcal immunisation every five years for all people 65 years and over. 
• Annual influenza vaccination is recommended for all people 65 years and over. 

For more information go to 

Asthma Management Handbook 2002

'Personal Best' Peak Flow

An article published in Thorax in November highlights the value of enlisting 'personal best' peak expiratory flow (PEF) values in Written Asthma Action Plans. Individualising a Written Asthma Action Plan on the basis of personal best PEF reduced hospital admissions and emergency room visits and improved PEF, while using predicted PEF reduced hospital admissions only.

The challenge for the person with asthma and their doctor sometimes is to actually establish the personal best peak flow, particularly when the person is seen only when their asthma is uncontrolled.

The research by Dr Reddel, Dr Marks and Dr Jenkins from the Woolcock Institute of Medical Research, Camperdown in New South Wales, shows that personal best PEF from two weeks of twice daily measurements reached a plateau very early after initiation of high dose budesonide in people with poorly controlled asthma.

These results mean that the action points for a PEF-based Written Asthma Action Plan can be determined within a short period of preventer medication treatment, even though other markers of asthma control such as average PEF or symptoms have not become stable.

Why is this important?

A person with asthma that is not controlled and who continues to have symptoms may be more motivated to return, allowing the determination of personal best PEF and inclusion of more 'acceptable' PEF action points in their Written Asthma Action Plan.

The authors note that personal best PEF must be carefully explained to the person with asthma so that they understand that their personal best PEF is calculated from two weeks of twice daily data rather than a single measurement.

Overall, the study underscores that just two weeks of PEF data and doctor visits within a realistic time frame provides the ability to produce a more 'user-friendly' Written Asthma Action Plan.

Useful Resources

The full article is featured on the Thorax website see

When can personal best peak flow be determined for asthma action plans?
(http://thorax.bmjjournals.com/cgi/content/full/59/11/922)

First Aid for Asthma

Asthma Management Handbook - Written Asthma Action Plans (Adult)

Asthma Management Handbook - Written Asthma Action Plans (Children)

Asthma Action Plans

Is it more than Asthma?

The Australian Lung Foundation launched the Australian and New Zealand COPD Reference Site on World COPD Day - November 17, 2004.

The site hosts the latest version of the COPD management guidelines, The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2004.

From the guidelines:

"Asthma and COPD are usually easy to differentiate. Asthma usually runs a more variable course and dates back to a younger age. Atopy is more common and the smoking history is often relatively light (eg, less than 15 pack-years). Airflow limitation in asthma is substantially, if not completely, reversible, either spontaneously or in response to treatment.

By contrast, COPD tends to be progressive, with a late onset of symptoms and a moderately heavy smoking history (usually > 15 pack-years) and the airflow obstruction is not completely reversible.

However, there are some patients in whom it is difficult to distinguish between asthma and COPD as the primary cause of their chronic airflow limitation. Long-standing or poorly controlled asthma can lead to chronic, irreversible airway narrowing even in non-smokers."

The site also has general practice patient management tools and other COPD resources. 

The Australian and New Zealand COPD Reference Site (http://www.copdx.org.au)

Research Funding Opportunities