The just launched Asthma and Respiratory Foundation NZ child and adolescent asthma guidelines are designed to help nurses, doctors and other health professionals – delivering asthma care in the community to emergency departments – to provide simple, practical and evidence-based guidance for the diagnosis and treatment of asthma in children and adolescents up to 15 years of age.
The new guidelines – developed by a team of health professionals under the guidance of Professor Innes Asher – include a shift from the ‘medical’ focus of the previous guidelines* to taking a holistic look at the ‘big picture’ factors that influence asthma outcomes.
Debbie Rickard, a child health nurse practitioner at Capital & Coast DHB who helped develop the guidelines, said the new guidelines were not just medical and encompassed many other factors for health professionals “such as how to support families to manage their child’s condition, and looking at the big picture of factors that contribute to child asthma, such as housing, environment and barriers to accessing services”.
A quick reference guide to the new Guidelines was published last week in the latest New Zealand Medical Journal (NZMJ), which said that the new guidelines were informed by recent New Zealand reports describing the growing impact of asthma – especially on children – and the inequities suffered by Māori, Pacific peoples and low-income families.
Lorraine Hetaraka-Stevens, the National Hauora Coalition nurse leader who was also part of the guidelines team, said underpinning the new guidelines was eliminating inequities. She said they included a focus on workforce, systems and broader determinants that impact on asthma, such as income and housing. The guidelines, she believed, also enabled consistent standards of care, which could the work of a wide range of health professionals working in a variety of settings; for example, school-based nurses and rural health professionals.
Dr Stuart Jones, Medical Director of the Asthma and Respiratory Foundation NZ, agreed that addressing issues of social inequities is of paramount importance “if we are going to address the disparities in childhood respiratory illnesses and set all New Zealanders up with good lungs for life”.
“I think every child in New Zealand should have the right to be raised in a warm, dry, well-ventilated house, free of cigarette smoke and have good access to medical care,” said Jones.
David McNamara, respiratory paediatrician at Starship Children’s Health, said the guidelines were an important step in reducing disparities and improving outcomes for children with asthma and their whānau.
“The guidelines address the biggest challenges in asthma management: patient education, follow-up, motivation and improving adherence,” said McNamara. “By focusing on these we hope to lift the health and quality of life of children with asthma and reduce the burden of acute sickness and hospitalisation.”
Click here to download the full 33-page Asthma and Respiratory Foundation NZ child and adolescent asthma guidelines.
*The new guidelines are a complete update of the Paediatric Society of New Zealand’s Management of Asthma in Children aged 1–15 years, published back in 2005.
]]>At least 200,000 people or 15 per cent of the New Zealand population are thought to have the often undiagnosed condition, mainly caused by smoking, with symptoms including coughing, increasing phlegm and breathlessness.
The Asthma and Respiratory Foundation NZ is marking COPD Day by encouraging those who have been diagnosed to take part in pulmonary rehabilitation, a programme of exercise, education and support to learn to breathe – and function – at the highest level possible.
The seven reasons why pulmonary rehabilitation is good for COPD are:
1. It improves your exercise capacity! Get more done in your day.
2. It helps you learn about COPD and how to manage it! Don’t let breathlessness get in the way of having a good time.
3. Classes are fun! Get out of your house, meet new people and make new friends.
4. It’s good for everyone! People benefit regardless of how severe their breathlessness is. Even people on home oxygen can improve their exercise capacity and manage their breathing better.
5. Exercise is good for your sex life! Breathlessness doesn’t just happen when you’re hanging out the washing or going for a walk.
6. It helps you feel in control of your health and wellbeing. Take charge of your life.
7. It improves your quality of life! All of the above.
At higher risk of COPD are people over the age of 40, who have at any stage been a smoker or worked in a job exposing them to dust, gas or fumes. Visit your doctor if you fit in this category and experience coughing, increased phlegm or breathlessness.
Today (November 15) is World COPD Day.
Facts about COPD in New Zealand
Chronic obstructive pulmonary disease (COPD) in New Zealand:
Source: Asthma and Respiratory Foundation of New Zealand
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Shocked award winner Jess Tiplady flew back to Auckland this morning clutching an enormous bouquet of flowers, a beautiful trophy and an enormous certificate.
The 29-year-old, who became a primary health NP in April, was awarded NZNO Young Nurse of the Year 2017 at the organisation’s annual conference dinner at Te Papa last night.
The young NP is one of only four NPs under 35 and Tiplady (whose mother is Ngāi Te Rangi) is currently the youngest Māori nurse to have achieved NP status in New Zealand.
To become an NP by age 29, Tiplady has studied every year but one since first enrolling in nursing school. “It’s been a massive journey to get to here,” acknowledges Tiplady. She said she was shocked by her win, was very grateful, and felt the award was a reflection of how much others have helped her on her journey.
Kerri Nuku, NZNO’s kaiwhakahaere, said when presenting the award to Tiplady that she was a great example of a nurse making a positive contribution to health outcomes for New Zealand children living in poverty. “The impact on families living in overcrowded houses, with the associated infection, itch and discomfort of eczema, loss of sleep and potential for hospitalisation, is significant,” said Nuku.
Tiplady has worked for Manurewa’s Greenstone Family Clinic since graduating in 2001 with a conjoint degree in nursing and health sciences from the University of Auckland.
Primary health has been her passion from the start and she says becoming an NP followed on from that passion as it seemed to be a “really useful tool”.
Early on at her time at Greenstone, she looked at how she could make a difference and saw a niche in helping prevent eczema crises for children and their families. “We were seeing a lot of children with nasty skin infections, and not sleeping and some very distressed children and parents.”
Around five years ago she started providing a nurse-led clinic in eczema for children to provide a whole package of care to support parents and reduce the risk of eczema flare-ups and distress.
A year later she set up an asthma clinic for children with the aim of using the clinical guidelines for good asthma care in primary health to see whether a focused clinic could make a difference to hospital admissions for asthma.
Invitations to the asthma clinic was tied in with the annual reminder letter sent to all children on preventative inhalers that it was time for their free flu vaccine. “We altered our annual letter to say come in and have a 30-minute appointment with a nurse to have your annual asthma check-up,” said Tiplady. “It was kind of a ‘warrant of fitness’ going into winter.”
She said in 2015 its practice admission rates for children with asthma halved compared with previous years, but it was very difficult to prove whether that was due to the asthma clinic or other factors. “But I think what we have managed to do is establish a really good model of care where our children are getting what is considered to be the best practice package of care for their asthma.”
Tiplady said about 80-110 children under 16 are eligible for the asthma clinic each year. She said she and other nurses chased up children where there might be barriers to coming into the clinic or grabbed an opportunistic clinic appointment if the child came into the practice for another reason.
While the young NP really likes working with children and young people – and has a special interest in mental health – her scope is primary care and her day-to-day work involves seeing a cross-section of patients across the practice’s population.
She also offers fortnightly clinics in James Cook High School and Alfriston College, predominantly in sexual health.
Tiplady was a member of the first cohort of the pilot Nurse Practitioner Training Programme (NPTP) and was mentored by two GPs at the Greenstone clinic. She said a particular aspect of NPTP that was particularly helpful was having two protected clinic days a week to focus on transitioning from being a nurse to being an NP.
After so many years of study, she says the focus for the next year was consolidating her knowledge and establishing herself in her role as an NP. “And then looking at where else I can utilise those skills as an NP. The clinical role is most important to me but the NP hat also offers the opportunity to do research, teaching and mentoring so I will look at where I can contribute in those areas.”
The Young Nurse of the Award was set up to recognise and celebrate the work of nurses in the younger age group and to encourage younger nurses to demonstrate their commitment to the nursing profession. The winner is chosen for showing compassion or courage beyond what is expected in their role as a nurse and who has improved care or health outcomes for their patients through their commitment to care, leadership, research or quality.
Kerri Nuku said she also warmly congratulated runner-up Dana Smith from Dunedin Hospital general surgery. Smith was nominated by her colleagues for her work in the community with children with Crohn’s disease including volunteering at their annual camps,” said.
The judging panel consisted of a representative from Otago University Centre for Postgraduate Nursing Studies, previous years’ award winners, the Ministry of Health’s Chief Nursing Officer (or representative), and the NZNO president and kaiwhakahaere.
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Lead researcher Dr Caroline Shorter from the Department of Medicine at the University of Otago, Wellington (UOW) said it had been known for a long time that damp and mould made existing asthma worse but this was one of the first studies to show that mould may actually cause asthma to develop. The research also found the more mould, the more cases of asthma.
The study investigated the homes of 150 children who had visited their GPs for their first prescribed asthma medication, and compared them with the homes of 300 matched children who had never wheezed. The research, published in international journal Indoor Air, was funded by the Health Research Council of New Zealand and carried out by researchers from Otago’s He Kainga Oranga, Housing and Health Research Programme.
Shorter says the team found that mould and leaks were more likely to be found in the bedrooms and homes of children who had just started wheezing compared to the children who had never wheezed.
“The amount of mould present in the bedroom made a difference; the more mould, the greater the risk that children would start wheezing,” said the research fellow.
She said this was particularly concerning as surveys carried out by the Building Research Association of New Zealand and others indicated that around half of all New Zealanders have mould in their homes.
“We also have very high rates of asthma in New Zealand with 1 in 6 adults and 1 in 4 children reported to suffer from the condition,” said Shorter. “Worldwide prevalence of indoor mould is estimated at 10-30 per cent of homes, depending on climate and asthma rates are 1 in 20.”
“We urgently need to improve the quality of our children’s home environments”.
Dr Shorter’s research shows that it is important for dry homes to have ‘the basics’ sorted, for example:
She said moisture needed to be reduced in homes by using extractor fans, not drying clothes inside, and improving ventilation by opening windows often, even for just 10 minutes a day.
“Even with these measures mould can still grow, so we also need to frequently check for mould and remove it when we see it, particularly around windows, where condensation can increase mould growth,” she said
The next stage of the team’s research is to look in more detail at what types of mould might be important and what additional prevention measures could be used to keep mould at a minimum.
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The Foundation was responding to today’s New Zealand Herald report linking cold, damp and overcrowded homes with 30,000 children being hospitalised each year with housing-related diseases, including asthma, bronchiolitis and the third-world disease bronchiectasis that should be confined to people in their 80s.
Letitia O’Dwyer, Chief Executive of the Foundation, said currently reducing respiratory disease was not a Ministry of Health, district health board or “even a primary health organisation” target but the Foundation advocated that the next government should ensure a cross-portfolio target was set to help break down silos between health, housing, education and other related portfolios.
The cross-portfolio target it wanted acted on was: “Reduce emergency visits for acute respiratory illnesses by 20 per cent within the next five years”.
“It’s obvious that one organisation or agency cannot act alone to address poverty, unhealthy housing and inadequate basic health care,” said O’Dwyer. “There is a strong need for a government approach that ‘sees the bigger picture’ and works across all areas focusing on prevention.”
At present the Foundation was working with a healthcare provider in South Auckland to deliver respiratory health ‘action plans’ to schools in the area, with the aim of reducing the “disproportionate hospitalisation rates” of the people most at risk, said O’Dwyer.
The Foundation said its proposed national target should go across all of the following portfolios:
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The Sailor the Puffer Fish show has been taken to schools from Auckland to Wellington between May and July educating about 14,000 school children about asthma, tips on managing asthma and what to do in an emergency. The show was initiated by Asthma Waikato but has now been taken up by the Asthma and Respiratory Foundation. Schools that have hosted the show are being invited to become Asthma Friendly Schools. To qualify schools need an asthma policy and a first aid kit containing an up-to-date reliever inhaler. Schools interested in becoming a certified Asthma Friendly School can contact the Asthma and Respiratory Foundation NZ.
]]>The experienced aged care nurse is the general manager of the Selwyn Institute for Ageing and Spirituality, which initiated a pilot into using tablet-based telehealth technology to help older people living at home to manage their long-term conditions.
The case study Johnson-Bogaerts shared was of George, a man with heart failure (leading to multiple hospital admissions, COPD (chronic obstructive pulmonary disease) and hypertension.
As part of the pilot, George had access to a blood pressure monitor, pulse oximeter, thermometer and scales, which were connected by Bluetooth to a touchscreen tablet. He used the devices to take his ‘vitals’ daily, with the information digitally delivered to his telehealth nurse Sandi Milner.
During follow-up teleconferences on the tablet – to discuss missed out or out-of-range readings – Sandi found out that George had a problem with constipation, had little energy and had stopped gardening. She also found out that George – who had been advised to go on a low-salt diet – wasn’t sharing meals with his family and was trying to resolve his constipation by eating cornflakes.
Johnson-Bogaerts said the telehealth nurse guided George on how to check the salt content on the packaging of food, like his cornflakes, and shared advice on how to better manage his fluid and salt intakes. Sandi also suggested he try kiwifruit and he slowly started to introduce fruit and vegetables back into his diet and to eat with his family again.
Over six weeks he improved and over the four months he learnt to better control his symptoms. At the post-discharge check, George reported he was out in the garden planting vegetables, feeling better than he had felt in years and had had no hospital admissions.
Following the pilot, the telehealth-based chronic disease management programme is now being delivered by a joint venture between the Selwyn Foundation and Australian provider Feros Care, called Inviga. A second telehealth care pilot also got underway late last year, which involved retirement village residents having home-based video consultations with the on-site doctor.
]]>More information at https://cpd.whitireia.ac.nz.
]]>Is that an asthmatic wheeze or a smoker’s cough? Is it a ‘weak lung’ from a childhood disease or ‘twitchy’ lungs due to asthma?
Respiratory physician Jeff Garrett believes fixating on fitting respiratory patients into neat diagnostic boxes for asthma, chronic obstructive pulmonary disease (COPD) or bronchiectasis may not be as helpful as targeting the right treatment.
Taking a patient’s history can reveal whether the patient wheezes, coughs up phlegm, has ever smoked or gets breathless upon exercise. Testing lung function with a peak flow meter can tell you more – and a spirometry test even more again. Garrett believes that spirometry should be routinely available, but only half of those in general practice in New Zealand have access to it.
Bringing all the information together can give you a likely diagnosis and an indication of where the patient sits on the spectrum.
“But you can still end up with substantial overlap,” says Garrett, who is also clinical director of medicine at Middlemore Hospital and an asthma researcher. An example can be someone in their 60s who has experienced a lifetime of asthma and, over time, has developed fixed airways obstruction (i.e. COPD) due to ‘remodelling’of their airways.
“So which box do you put them in now – the COPD box or the asthma box?” he says.
Furthermore, about 20 per cent of people with smoking-related COPD will end up with bronchiectasis because of recurrent infections, and as many as 10–15 per cent of more severe asthmatics will develop bronchiectasis due to remodelling of their airways, resulting first in COPD, then in recurrent infections and bronchiectasis.
“So the diagnostic labels are pretty crude ways of classifying patients, though they still have their uses,” says Garrett.
The answer, Garret believes, is to spend less time trying to fit an asthma or COPD label onto patients and more time regarding people as having an inflammatory airways disorder.
“You need to think about such patients as having an airways disorder that is associated with inflammation – reddening and swelling.”
He believes the best way to identify what is causing the inflammation – and therefore which treatment is best – is to use a biomarker.
Canadian researchers in the 1990s developed a test that revealed the different types of inflammatory cells in patients’ airways. They developed an induced sputum test, where patients are given a very salty solution (hypertonic saline) by nebuliser that causes them to cough up sputum, which is tested to evaluate whether eosinophils, neutrophils or both cells are present. (Eosinophil levels rise in response to allergens and neutrophils in response to bacterial or viral infection or as a result of exposure to an irritant.)
Subsequent researchers, including Garrett, have found that when the sputum of asthmatics, or suspected asthmatics, is tested, around 40 per cent are found to contain eosinophils, 20 per cent neutrophils, 5–10 percent have both and about 30 per cent have few, if any, inflammatory cells (because they either have well-controlled asthma or don’t have asthma at all).
Further research has confirmed that the most helpful treatment for a respiratory patient with elevated eosinophil levels is inhaled steroids at a dose required to return eosinophils back into the normal range.
“Eosinophils dislike steroids and if used correctly and if targeted to the right part of the airway will usually lead to satisfactory control,” says Garrett.
However, if neutrophils are present instead (neutrophils are associated with COPD but also found in the airways of some people labelled as asthmatic) then Garrett says inhaled or oral steroids will make absolutely no difference. “If anything, they may make the situation somewhat worse.”
Garrett says the best treatment for the neutrophils group is to identify what is irritating the airways or to treat the bug or the condition that is causing the neutrophilic inflammation.
“These people tend to require antibiotics,” says Garrett. “If you continue to give inhaled or oral steroids to these people [with neutrophilic inflammation], you actually reduce the effectiveness of the antibiotic.
“Because the bugs that are down there love steroids, they will proliferate, so the worst thing you can do is to give steroids to somebody with neutrophilic inflammation.”
This group includes the 20 per cent of people labelled with asthma who don’t have eosinophilic inflammation and most COPD patients.
Research has found that the vast majority of COPD patients don’t have eosinophil cells in their airways. In fact, it is estimated that only about 10–15 per cent of people labelled as COPD have lung inflammation due to eosinophils.
But Garrett says that current audits suggest that as many as 70 per cent of COPD labelled patients in New Zealand are currently being prescribed inhaled steroids. “For two-thirds of those people, they are not getting any benefit from steroids and potentially the steroids are doing harm.
“The harm is that recent research has shown you can increase their risk of episodes of pneumonia, particularly if you give them high doses of steroids – for example, 500mcg Flixotide a day or doses of Pulmicort greater than 800mcg a day.”
COPD has been diagnosed in at least 200,000 New Zealanders (though it is thought there are another 300,000 who are undiagnosed). That is potentially a lot of money being invested in prescribing steroid inhalers that may be causing more harm than good. Garrett has estimated that up to $14 million a year is wasted on prescribing inhaled or oral steroids to patients who gain no benefit from them. This includes the 20 per cent or so of people labelled as having asthma, but who actually have small airways damage or bronchiectasis.
The gold standard for detecting whether there is airways inflammation, and whether steroids are the answer, remains the induced sputum test.
But Garrett says the test is largely limited to research laboratories (it is available privately in Auckland) and has not become standard clinical practice worldwide as it is time-consuming and reasonably costly. Consequently, researchers have sought an easier but less accurate test. A lot of time and effort was spent developing an expired nitric oxide test (simple breath test), which is reasonably good at identifying patients with eosinophilic inflammation, but not those with neutrophilic inflammation. The expired nitric oxide test is also artificially influenced by other factors, including smoking, and whether patients are on inhaled steroids at the time.
Research undertaken at Middlemore Hospital (and since validated by four other groups internationally) has revealed that the best surrogate for the induced sputum test – for predicting eosinophils in the airways – is a straightforward blood test using a white blood cell count differential.
Garrett’s team found that an eosinophil count of greater than 0.35 indicates an 80 per cent likelihood that eosinophils are present in the airways. So if a patient presents with bronchitis and blood test results show an eosinophil count of, say, 0.45, then a GP or NP could reasonably confidently prescribe inhaled or oral steroids.
Conversely, a Belgian group has found that if the eosinophil count is less than 0.25 there is a
76 per cent likelihood that neutrophils are present instead. In this situation steroids are unlikely to help and other treatment options like antibiotics and bronchodilators (non-steroidal inhalers that open the airways) should be considered.
Garrett says the simple blood test should be used by GPs and NPs whenever a respiratory patient presents with an attack of bronchitis. An English group used a simple cut off of 0.3 eosinophil levels to decide whether to use oral steroids for exacerbations of bronchitis in patients with COPD. They found if a patient with an eosinophil level of less than 0.3 was given Prednisone then the outcome was inferior to when antibiotics alone were used.
So rather than the knee-jerk reaction of sending a patient away with antibiotics and a course of the oral steroid Prednisone – that may hinder rather than help recovery – the health practitioner can use a straightforward blood count to target which patients will or won’t benefit from the addition of steroids.
Garrett says he sees plenty of patients admitted to Middlemore with bronchitis attacks who have been misprescribed oral steroids when they have low serum eosinophil counts.
“I go on my ward rounds stopping steroids left, right and centre for COPD patients with low eosinophil counts and have never seen anyone deteriorate as a consequence.”
The blood test can also be used by GPs and NPs when a patient first presents with asthma-like symptoms to better determine whether they have asthma or not.
“If you just take a patient history, measure their lung function and consider the blood test biomarker you will get it [asthma diagnosis]more right, more often,” says Garrett.
“Certainly if you are experienced at using blood tests then you get it right in between 80–90 per cent of cases when tested against the gold standard of an induced sputum test. We tested our respiratory physicians’ and nurse specialists’ ability to predict the inflammatory cell present and they were similar in their accuracy. It was mainly the mixed inflammatory subtypes, not surprisingly, where clinicians have the greatest difficulty.
“At the moment a lot of doctors are doing it by the flip of a coin – with about 50–60 per cent accuracy in predicting which inflammatory cell is present in the airways.”
Garrett adds that while on the one hand New Zealand is overprescribing unnecessary steroids for COPD patients, on the other hand it is underutilising inhaled steroids for some asthma patients. “We are not maximising their effect to control the inflammation.”
He says it doesn’t make sense to keep giving people bronchodilators (short-acting or long-acting symptom relievers) if you haven’t first done your best to control the inflammation. And, in the case of asthma patients, that means controlling the eosinophil inflammation by using inhaled steroids at the appropriate dose and frequency.
As it is Garrett says many people regard their steroid inhaler as a ‘preventer’ rather than ‘controller’ and if their asthma worsens, and they get an asthma attack, they reach for their ‘reliever’ inhaler thinking the ‘preventer’ has failed. Whereas, he argues, if their blood eosinophil count has increased above 0.35 they should be escalating their inhaled steroid dose.
He recommends that patients with suboptimal control of asthma (i.e. those who despite using 500mcg of Flixotide or 800mcg of Pulmicort remain symptomatic and with impaired lung function) should have a blood count. If the eosinophil count is high (i.e. greater than 0.35 x 109/L) then they should either double their inhaled steroid dose or switch to the most efficacious inhaler QVAR MDI. (Garrett says QVAR deposits 60 per cent of medication to the airways and to all the airways, as opposed to the other inhalers, which deposit only 15–20 per cent to the airways and only to the first few generations.
Steroid inhaler adherence remains a major issue for asthma patients with Garrett’s research indicating that 80 per cent of people hospitalised with asthma attacks are poorly compliant and that around 50 per cent of asthmatics within the outpatient clinic are poorly compliant.
He says nursing has a key role in helping people improve adherence through the use of education and, potentially, through the support of devices such as Nexus6’s Smartinhaler (a wi-fi-based system developed in Auckland that has been shown to improve adherence by 50 per cent).
A further 25 per cent of people have poor inflammation control as a result of poor inhaler technique, which he says can be remedied by instruction from a nurse, use of a spacing device or transfer to QVAR, which overcomes a lot of the effects of a poor technique.
Diagnosing a respiratory condition – even with the help of blood test biomarkers – is still not an exact science.
But Garrett says adding the biomarker to the lung function data and the information gathered from a full patient history data helps in more accurately placing the patient on the diagnostic continuum. This allows more accurate assessment of what is causing inflammation in the airways and better targeting of treatment.
“If we use the tools available to us better and target treatment more effectively we would have 90 per cent of asthmatic patients optimally controlled (as opposed to the 50 per cent estimated from telephone surveys) and at a lower cost,” believes Garrett. “And we would have a greater proportion of COPD patients on appropriate long-acting bronchodilators and far fewer on inhaled steroids.”
That may mean no steroids for some, more steroids for others and better-targeted treatment for all. And maybe more people able to breathe a big sigh of relief.
Eosinophils are the inflammatory white cells that rise in response to allergens or after certain viral infections. They are found in higher levels in sputum or blood when airways inflammation is due to an allergic response or after some viral infections.
BIOMARKER: A blood test that shows eosinophil levels greater than 0.35 indicates an 80 per cent chance that airways inflammation is eosinophilic and steroids are the treatment of choice.
Neutrophils are the most common inflammatory white blood cell and their main role is in fighting against bacterial or fungal infection, so neutrophil levels are elevated when inflamed lungs are fighting a bacterial infection. (Irritants and pollutants like tobacco smoke can also trigger neutrophilic inflammation, however, and are more strongly associated with COPD or with patients who have damaged their small airways.
BIOMARKER: If a blood test shows an eosinophil count of less than 0.25 then there is a 76 per cent likelihood that neutrophils are causing the inflammation, therefore inhaled or oral steroids should be avoided. The best treatment is to remove the cause of the irritation (i.e.stop smoking) and/or use antibiotics to combat the bacteria the neutrophils are fighting.
Chronic obstructive pulmonary disease* (COPD) is a term used to describe lung damage that makes breathing difficult, with tobacco smoking being the main cause in 70–80 per cent of cases. The two main types are emphysema and chronic bronchitis. COPD is the fourth most common cause of death in New Zealand after cancer, heart disease and stroke. It accounts for about 200,000 GP visits a year and more than 453,000 prescribed medications.
In New Zealand about one in four children and one in nine adults who have a cough or wheeze are diagnosed as having asthma*. (Garrett believes that childhood asthma is overdiagnosed and may be around half that rate). Asthma happens when airways become oversensitive and react to certain triggers by tightening up (bronchospasm), swelling (inflammation) and producing more mucus.
About 70–80 per cent of asthma in New Zealand is associated with allergies.
Bronchiectasis* is a condition caused by damaged airways, usually occurring in childhood and often leading to colonisation by pathogenic bacteria causing low grade inflammation, mucous production and repeated infections.
Asthmatic from age five, she was puffing on her blue inhaler up to six times a day.
But better medication and management means she hasn’t needed a relief inhaler for more than a decade.
The British-trained nurse is passionate about helping others get their asthma under control. She wants to get the message across that many more can be symptom-free.
“With the right support and education they can not only turn their asthma around but also turn their lives around,” says McNaughton. “So days off school or days off work become something in the past.”
The aim of the GASP tool is to standardise and speed up asthma clinical assessment and provide personalised best practice advice to the clinician for improving asthma management for each patient.
The tool calls on the expertise McNaughton has built from specialising in asthma for 20 of her 30 years of nursing.
She says common problems in asthma management include poor inhaler technique, not knowing what the different inhalers do and concerns about steroids. The result can be acceptance of asthma symptoms that can be controlled with the right medication and support.
It was her work in training other nurses to run nurse-led asthma clinics that prompted her to see how useful an online tool – that simplified calculations and prompted best practice advice – could be.
After moving to New Zealand in 2001, McNaughton started work first as a specialist practice nurse in Silverdale, north of Auckland, then soon after took up her current role as respiratory programme manager for the Harbour Health primary health organisation.
She still does one nurse-led respiratory clinic a week at Silverdale to keep her hand in, but her main focus is offering respiratory training to practices across the North Shore and urban Rodney area.
About 250 nurses have been through the Harbour Health’s GASP (Giving asthma support to patients) asthma course in the past eight years, leading to many nurse-led clinics across the district. McNaughton said the course built on the NZQA-accredited Asthma and Respiratory Foundation’s fundamentals course with additional components built in, like assessment and diagnosis of asthma/COPD (chronic obstructive pulmonary disease) and how to set up a nurse-led clinic.
Initially the nurses were trained in using a paper-based clinical assessment tool. But the paper tool had its limitations including it being difficult for McNaughton to audit what impact the assessment and clinics were having on patients’ asthma management.
The nurses were also reporting the paper tool was cumbersome. “I thought it would be really good if you could have it with a touch of a button.”
Working with Murray Speight, an IT specialist from Comprehensive Health Services, the pair spent two years developing the GASP tool. It had early support from the Asthma Foundation (of which McNaughton is an advocacy and education committee member) and in 2008 the pair emerged with the final model which has also won the foundation’s endorsement.
Use of the tool became part of Harbour Health’s respiratory training course and is used in its nurse-led clinics.
McNaughton says the decision support advice generated by GASP follows the New Zealand, British Thoracic Society and the GINA (Global Initiative for Asthma) asthma guidelines “to the letter”.
She says this means nurses and GPs using the tool are “all singing from the same song sheet” making it much easier to follow best practice guidelines that can otherwise end up sitting on shelves gathering dust.
The tool provides “decision support” advice to the nurse or GP about whether a patient is being over- or under-medicated and when education is needed to improve inhaler technique or to get better adherence to preventer use. At the push of a button the clinician can also print out advice to the patient on how to better manage their particular asthma triggers, be they animal hair, cold or pollen. The tool also enables input of spirometry readings to help assess whether the patient should be further tested for COPD. (A variation of GASP for use with COPD patients is currently under development.)
With calculations done automatically and personalised action plans printed out with the push of a button, the GASP tool’s aim is to free up more time for one-on-one education to improve a patient’s asthma management.
The tool has also given McNaughton the ability to audit what difference it makes to asthma management.
The audit covered 205 Harbour Health patients aged five to 64 years old, 12 months before and 18 months after starting to use the GASP tool.
It found hospital admissions declined by 76 per cent (21 per cent before GASP and five per cent after); exacerbations declined by 58 per cent over the 18-month period (down from 102 per cent to 43 per cent); and courses of oral corticosteroid decreased by nearly half (down from 86 per cent to 46 per cent courses).
The GASP tool was the overall winner of the 2009 Waitemata DHB Health Excellence Awards and the tool and training package have been sold to several other regions with interest also now coming from Australia and the States.
This month McNaughton and Speight are on a whistlestop tour of the United States promoting the GASP tool as one of the ten successful finalists in New Zealand Trade and Enterprise’s Focus on Health innovation challenge.
The success is welcomed, but McNaughton’s biggest hope is that GASP will help nurses help more patients with asthma to live a symptom-free life. ✚
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