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Table II. Spacers (Fig. 1) Spacers improve and enhance deposition in the airways. They overcome co-ordination and decrease local side-effects: thrush, hoarseness and cough. Spacers should not be shared among patients, and patients should be encouraged to bring them to each follow-up visit. All spacers should be primed when new and after washing; before using: wash in a mild detergent, air dry and actuate 4 or 5 doses of the most cost-effective asthma medication into the device. Optimal delivery is assured, when 20 minutes later, it is used for administration of medication. Spacer Colour/compatibility 4 years Technique Glaxohaler Mostly purple, With mask Without mask Remove valve near (GSK) (10) sometimes orange. mouthpiece. Place mask Used with most MDIs. over mouth and nose, with Difficult to put back together, mouth open and allow 5 if separated breaths per dose actuation. Shake in-between doses. Wash face after controllers Zerostat (Cipla) White, available with With face No face mask, Discourage hyperventilation, and mask and without valves mask – used directly particularly in older child. (11) Used with most MDIs. same ordered in mouth Shake in-between doses. Separates into 2 halves, separately Wash face after using mask/ easy to transport spacer for controllers. Neonate Orange. Used with
lasting up to 4 hours. If these are required frequently, the patient should seek medical help. During an acute attack, in lieu of a nebuliser, an SAB2, via MDI plus spacer may be used (20 puffs for adults and 10 puffs for children – one puff at a time). If there is no improvement refer to doctor for possible oral steroids. Longacting β 2 -agonists (salmeterol or formoterol), should only be used in conjunction with inhaled corticosteroids (ICS), and never administered to preschoolers. Sideeffects include tremor, palpitations, headaches and facial flushing. In the case of under-2-year-olds and the elderly, ipratropium bromide (e.g. Ipvent) may be prescribed. Beneficial effects are noted 30-40 minutes after administration and side-effects include dry mouth and constipation. Explain the actions of controllers Identify specific device to be used and the dose required (budesonide, fluticasone propionate or beclomethasone). Explain that if taken regularly, every morning and every evening, the inflammation in the airways which causes asthma symptoms will be reduced and this in turn should reduce the severity and frequency of acute attacks. Patients should not stop until they next see their doctor, even though symptoms are not present. Side-effects are rare but may include hoarseness or oral thrush. This may be overcome by using a spacer or regular rinsing of the mouth, after each ICS administration. Reassure patients that corticosteroids used for asthma are different from anabolic steroids used by athletes. The appropriate device should be demonstrated and checked. Always have a placebo available and demonstrate the device yourself, then ask patient to do so. Watch closely and discuss any concerns. Correct technique with inhaler is essential and adherence vital. Tables I and II and Figure 1 illustrate and outline device techniques and care. An emergency action plan should be written down, taking into account the patient’s lifestyle. Printed action plans are available at www.asthma.co.za Discuss a self-management plan. This should include the nature of asthma and how the patient can recognise signs and symptoms of worsening asthma. These include deterioration in peak flow (if meter is used), increase in diurnal variations, an increase in symptoms with more frequent use of bronchodilators, yet declining efficacy of same. Sleep disturbance and a decrease in exercise tolerance should also be recognised as signs of impending asthma deterioration. In addition, the patient should be told (and the plan written down) what action to take and where to go – even in the middle of the night, when to start prednisolone, how much, and how to avoid triggers (including smoking). Asthma symptom and adherence diary available at www.asthma.co.za Finally, and most importantly, make a follow-up appointment. On all subsequent follow-up visits adherence (how many times did you forget your medication), inhaler technique evaluation, and an exploration of possible different health beliefs and/or psychological issues should be addressed in order to achieve optimal control. CONCLUSION A trained enthusiastic allergy and asthma nurse can work together with the health team and patients in order to strive for improved control and quality of life for all patients. THE FUTURE It would be a great advantage to have an allergy course where nurses can be trained as allergy nurse practitioners, who will work in conjunction with allergists and also function at primary health clinics where specialists are not always available. They could work in pathology services where they can conduct basic allergy tests, e.g. skin-prick tests. These allergy nurse practitioners would also provide patient education in areas beyond specialist clinics and assist doctors to refer patients to the specialised centres when necessary. Acknowledgement We thank the authors of the National Asthma Education Programme Version 2011 which has been used for this article. We thank Prof Paul Potter for his invaluable assistance in the preparation of this article. Declaration of conflict of interest The authors declare no conflict of interest. References 1. Lalloo U, Ainslie G, Wong M, et al. Guidelines for the management of asthma in adults and adolescents. South African Family Practice 2007; 49 (5): 19-31. 2. Motala C, Green RJ, Manjra AI, et al. Guideline for the management of chronic asthma in children - 2009 update. S Afr Med J 2009; 99: 897-912. 3. Kling S, Goussard P, Gie RP. Treatment of acute asthma in children. Current Allergy & Clinical Immunology 2011; 24: 22-26. 4. Green RJ, Motala C, Potter PC, eds. ALLSA Handbook of Practical Allergy, 3rd ed. Cape Town: ALLSA, 2010: 17. Would you like to receive future copies of this journal Please contact our national office to be added to the mailing list. If you are interested in becoming a member of the Allergy Society of South Africa (ALLSA), please contact Mrs Ruwayda Adams for more details. ALLSA Office PO Box 88 Observatory 7935 Tel 021-447-9019 Fax 021-448-0846 Email mail@allergysa.org 144 Current Allergy & Clinical Immunology, August 2011 Vol 24, No.3
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