22 April 2020
Acute asthma during the pandemic: Our finest hour
Something really special today from Andrew Booth, one of our tutors and a Respiratory Nurse Specialist working in a GP practice. I must admit to watery eyes reading the last part!
There have been many ‘war’ references and comparisons during the current pandemic. Andrew discusses his experiences battling Covid-19 in primary care, and considers the risks to self-isolating patients, particularly those who are unable to obtain usual inhalers or access specialist services. As always, he shares useful practical tips, and challenges you to dish out the peak flow meters!
Andrew remembers one of the first people with COPD that he cared for as a student nurse, and pays tribute to the wonderful Captain Tom Moore. He talks about being inspired by his NHS colleagues and finally feeling worthy of the Thursday 8pm clap.
Please share this blog with your colleagues, and remember that when PCTC staff are on their doorsteps on Thursday evening we are clapping for all of you!
We’d love to hear your experiences, and any tips you’d like to share. You can email us on firstname.lastname@example.org, or just post on our Facebook page.
We’ll be featuring more from Andrew but you can also follow him on Twitter: @AODBooth
ACUTE ASTHMA DURING THE PANDEMIC: OUR FINEST HOUR
It almost feels like war. Only we’re battling Coronavirus, not an invading armed force. Queues for the shops, empty shelves, deserted streets. Every prescription I write feels like a ration-book token, and I wonder if my patient is going to get their inhaler. Our local pharmacy has run out of peak flow meters, which is completely my fault as I’ve been dishing them out left right and centre (I challenge you all to achieve the same feat!). And although they didn’t have an eight o’clock “clap” during the war, they did have Vera Lynn and Winston Churchill.
And rather than people hiding in bomb shelters, they’re self-isolating, sometimes with extreme and irrational consequences.
On Monday I phoned one lady as she had been ordering extra salbutamol for her 10-year-old son (more than three short-acting B2 agonists a year are an indicator of impending asthma attack). She was giving him Clenil, but he was still wheezing and getting breathless nearly every night. Despite this, she had stopped his Montelukast as she was too scared to go to the pharmacy to collect his prescription. I reassured her that as she was a young person with no underlying health problems, the risk of asthma attack was greater to her son if he didn’t get his meds, than the risk of Covid to her if she went to the pharmacy.
Wednesday lunchtime I spoke with a patient who was on maximum dose of Fostair plus Montelukast, yet still having daily chest tightness and difficulty breathing. She had originally responded to a text message asthma questionnaire, which told us she was using her reliever 14 times a day. It sounded like her concordance was good, all her prescription refills looked appropriate, and I’d already sent her text links to enable her to check her inhaler technique. Her eosinophil levels had recently been 0.39 (raised) and I was reassured by her home peak flows that were running between 320 to 380 (normally 420). Usually, I would have referred her to the difficult asthma service. But, unable to do this, I spoke with the senior respiratory nurse specialist at the hospital, who felt that the patient may benefit from a biologic (injectable monoclonal antibody therapy), and that the difficult asthma service could assess her for this once the pandemic restrictions were lifted. As the patient had experienced some heartburn and acid reflux, we agreed that treatment with Gaviscon after meals and before sleeping, would help protect her airway. And that I would try Tiotropium Respimat to see if this maintained her peak flow, and improved her symptoms (the Long-Acting Muscarinic Antagonist (LAMA) Tiotropium in a Respimat inhaler is licensed for more severe asthma, and the British Thoracic Society guidelines recommend is initiated only by specialist care.) I also made sure she had a self-management plan, plenty of safety-netting advice, and a standby course of prednisolone. I also made sure that she understood that she could take multiple doses of salbutamol through her spacer (10-12 puffs is equivalent to a 5mg nebule of salbutamol 1).
And then on Friday, I spoke with another patient in a similar situation. Maximum dose inhaled steroid / long-acting B2 agonist, unable to tolerate Montelukast, and on the last day of a second week of oral steroids. She was speaking in full sentences, but coughing constantly on the phone, and commented that oral steroids always made her feel better, but as soon as she stopped them her symptoms got worse. Another need for the difficult asthma service, I thought. She was needing salbutamol every four hours, and her peak flow was 120 to 150. If she had been in the surgery, I would have checked her sats, resp rate, and listened to her chest. But I realised she was in need of immediate medical attention, and advised her to go to A&E straight away. I told her to go now, as it was morning, and liable to be a little quieter.
She called me back a few hours later. A&E had nebulised her twice, taken bloods, reported on her chest X ray that was normal. Then discharged her saying that if she had another asthma attack, she was to go back to A&E. I’m now considering LAMA therapy for her too. But right now, it almost feels like she’s an unexploded bomb waiting to go off, and the bomb squad are unavailable.
I always seek feedback on cases like these from my GPs, and talk with other nurses in our team. At coffee on Friday, we chatted, and I looked round the room at us all sat two metres apart and felt a sense of pride. We’re all working differently, under difficult and changing times, yet we’re working cohesively together, drawing on the vast range of skills and experiences we have. I thought about my colleagues in hospital who are going through an even more torrid time, yet who are still available to answer my silly questions via phone or e-mail. And I thought about my wife’s nurse team in the community, and the massive, increasing workload they’re facing. And I think, “Wow. We really are amazing.”
Captain Tom Moore recently said: “I have fought during a war and they are now fighting in a war too.”2 I can’t compare what we’re all going through to the men and women who lost their lives seventy years ago. Yet I can take inspiration from that time, and in particular the words of Winston Churchill. At the start of the Battle of Britain, Churchill warned that “I have nothing to offer but blood, toil, tears and sweat.” And he told us we should keep on going; “We shall fight on the beaches, we shall fight on the landing grounds, we shall fight in the fields and streets, we shall fight in the hills; we shall never surrender.”
Professional people are laying down their lives to save lives. This time it is the blue of the NHS, but seventy years ago it was the blue of the Royal Air Force, of which Churchill said: “Never in the field of human conflict was so much owed by so many to so few.”
One of my very first experiences of looking after a person with COPD, was at Killingbeck Hospital in Leeds in the mid-eighties. I looked after a small, hunched figure of a man, with a terrible productive cough, who staggered around the ward in a hypoxaemic state. On his bedside table was a black and white framed photograph of an RAF pilot. I knew this was a pilot, as he had two wings on his uniform, next to a brace of medal ribbons. I asked the daughter to tell me who was this dapper young man in the photo, and she pointed to her father, gasping and wheezing his way back to bed. He was a Spitfire pilot during the Battle of Britain, had shot down over five German Messerschmitt fighters, and had received the Distinguished Flying Cross. He was a war hero. And here was me, a first-year student nurse charged with the responsibility of looking after him. I didn’t feel worthy.
During the Thursday eight o’clock “clap,” I’ve previously felt embarrassed, and not worthy of the applause that have been lauded by everyone to the NHS. But after this week, I feel a change, and I am inspired by one of my most favourite of Churchill’s speeches:
“Let us therefore brace ourselves to our duties, and so bear ourselves, that if the British Empire and its Commonwealth last for a thousand years, men will still say, ‘This was their finest hour’.”
- Advice for Healthcare Professionals Treating People with Asthma (adults) in relation to COVID-19. https://www.brit-thoracic.org.uk/document-library/quality-improvement/covid-19/bts-advice-for-healthcare-professionals-treating-patients-with-asthma/
- NHS Fundraiser Captain Tom Moore To Open Yorkshire Nightingale Hospital: https://www.england.nhs.uk/2020/04/nhs-fundraiser-captain-tom-moore-to-open-yorkshire-nightingale-hospital/