Approach to consultations
Integrating disease control and device choice
Optimising disease control in a way which is acceptable and appropriate to the patient should always be the main goal of the consultation. Well controlled asthma has 1/3rd of the carbon footprint of asthma that is not controlled. Changing inhaler device may to a lower carbon inhaler device may also improve disease control if patients find the device easier to use.
Asthma conversations to improve care and reduce carbon: This one-page visual guide supports healthcare professionals to have better person-centred asthma reviews that empower patients to understand and manage their asthma, improve ICS adherence and integrate conversations on device choice based on a patient’s inhalation technique.
This 9-min video by Carol Stonham, Respiratory nurse practitioner and previous Executive Chair of the Primary Care Respiratory Society, is an excellent demonstration of how to integrate high quality and low carbon asthma care during an asthma review.
Consider the setting for the consultation. Appointments should in person, or by video if necessary, to assess inhaler technique. Confirming correct inhaler technique is an essential part of asthma review. If a new inhaler device is prescribed, then its use should be demonstrated and patients given a chance to practice. Videos and leaflets on inhaler technique are available here.
Asthma review templates can help to structure the consultation and prompt you to review and discuss important information. For the PCIT Asthma Template which can be downloaded for free onto your clinical system please register here.
You might also find the framework below useful for structuring your consultation.
Step 1: Current symptoms and triggers
How often do they have symptoms or alter behaviour to avoid the possibility of getting symptoms?
Do symptoms interfere with activities or sleep?
How often are they using their inhalers?
How many prescriptions have they had in the last 12 months? (look at prescribing data)
Are they aware of their asthma triggers? If not, can you explore with them what these might be?
Do they have a current personalised asthma action plan and have they needed to use it? Do they know what to do in an asthma attack?
Step 2: Current treatment
Which stage of the asthma treatment ladder are they at?
Do their symptoms or inhaler use suggest their asthma is not well controlled and they need to step up treatment to the next stage? Would a MART reginme be appropriate and aid symptom control?
Or are they symptom-free and would like to consider stepping down their treatment, if appropriate?
Step 3: Shared goal
How do they feel their current devices and regimen are working for them?
Is there anything they find challenging or would like to change?
Step 4: Questions to aid adherence with preventer therapy
- Has anyone explained to you what asthma is and how your inhalers work?
- Do you understand why it is important to take the preventer inhaler every day?
- Taking a medication regularly twice a day can be difficult to remember, many people miss odd doses. How often would you say you miss a dose?
- What would help you remember?
- For people in whom MART is an option:
- Would you be more likely to take your inhaler if you had one inhaler that combined the preventer and reliever?
- Are there any cost issues for you in having two separate inhalers? (consider MART if appropriate)
Step 5: Questions to help with device choice
- Show me how you use your inhaler? (Is the technique appropriate for the device they are on?)
- Do you use a spacer? (if they have an MDI inhaler)
- How often do you wash it?
- Will you use a spacer or would you prefer a device that doesn’t need a spacer?
- Do you struggle with knowing when inhaler empty?
- Would you prefer an inhaler with a dose counter?
- How important is it to you that your medication is also good for the environment?
- If there were an inhaler that treated your asthma but was kinder to the environment, would you think about swapping to it?
Do they want to change both their preventer and reliever, or just the preventer? Or, if appropriate, would they prefer to move to a MART regimen? Remember some patients may still need an emergency pack of SABA and spacer.
- NICE Patient Decision Aid: Inhalers for asthma
- Guide for healthcare professionals on reducing carbon footprint of inhaler prescribing
- For patients who want to know more about inhalers and the environment
- PrescQIPP Bulletin 295 Inhaler carbon footprint (at the end of the document is a table of DPI alternatives)
- Inhaler technique videos from Asthma UK
Remember (It sounds obvious but…) Patients may not want to change their device! They may or may not have reasons for this. This decision should be respected. Some patients may want to have more information or time before they decide.
Step 6: Discuss options in detail
Explain which devices and regimens you would suggest based on their asthma symptoms and preferences.
If considering a new device, show a placebo of it and explain how and when they would use it.
Step 7: Confirm new treatment
Confirm the patient’s decision and complete the prescriptions. Add ‘for NMS’ on the script note to alert the community pharmacy to do a new medication check. This will mean that patient is shown how to use their inhaler again and reinforces your consultations.
Confirm inhaler technique and provide a reference for this (leaflet or link).
Issue the patient with an updated personalised asthma care plan and go through this with them (leaflet or link).
Give information about how to tell when their inhaler is finished and how to dispose of them.
Step 8: Follow-up
Arrange a follow-up appointment in 4 – 6 weeks to review any change to the inhaler device. This could be face to face or a video call so inhaler technique can be assessed.