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What makes the Asthma Nurse a specialist nurse?

mauschen profile image

Yesterday, I had my first Asthma review since returning to the UK 18 months ago.

My peak flows were 325-300-300

The nurse said that these were fine and to continue taking my Relvar Ellipta but change from Salbutamol to Bricanyl

This nurse was also the diabetic, thyroid, HTN and HF specialist.

I don’t doubt her qualifications but even I know that my peak flows are not fine.

I had Covid in May 2020.

21 Replies

What is your normal Peak Flow?

mauschen profile image
mauschen in reply to floating_

I don’t know, I stopped measuring it years ago when I was diagnosed with poor gas diffusion at the alveoli

floating_ profile image
floating_ in reply to mauschen

I'd recommend you start keeping a diary of your PF values then because they're useful to look at to see if you're struggling. Peak flows are relativistic to yourself when you're doing objectively better. Get some data and then you'll be able to point out where things are going wrong! As an example, my normal PF is 470. Recently I've been around 200, this is around half of my normal peak. However, just having 200 on it's own when not in acute distress tells me nothing. But, 200 in comparison to 470 shows my lungs are struggling. Does this make sense?

Were you very symptomatic during the appointment?

Personally, I get on really well with my named asthma nurse, but maybe I'm just lucky in that regard.

mauschen profile image
mauschen in reply to floating_

My peak flows are always very low which is why I stopped checking them.I would get body plethysmographs done every 6 months which reassured me that my asthma was stable.

I don’t have a problem with the nurse, I just wondered how she could possibly be an expert in each specialty. Her disinterest confused me. Usually a specialist nurse is brimming with information and the latest evidence based medicine. I have been on Salbutamol and Relvar Ellipta since 2011 with very good effect.

I was not symptomatic during the visit so I was surprised when she changed my inhaler to Bricanyl. It seems like a bit of a knee jerk reaction?

My asthma nurse has taken me off Ventolin Accuhaler and I'm wondering if there's a move, nationally, to move away from Ventolin, as a brand. Bricanyl is also a beta-agonist but is supposed to be beneficial for longer than Ventolin (up to 6 hours according to the manufacturer). I would expect your AN to explain the differences between the two medicines, how to use in an emergency and adjust your asthma plan accordingly.

This may be a way to change to a dry powder inhaler - there is definitely a move away from aerosol inhalers because of their carbon footprint. And if this is the first turbo inhaler that you have, your asthma nurse would have demonstrated how to use the new inhaler.

The other possible motive is cost. Budgets are increasingly squeezed and cheaper options are being considered more than ever. But whatever the reason for the change, your AN should have been transparent about their decision.

mauschen profile image
mauschen in reply to Poobah

I have not been given an asthma plan and the Bricanyl inhaler prescription was sent to the chemist. I was on Pulmocort inhaler about 30 years ago.Bricanyl is a selective beta 2 - agonist so I will still need my salbutamol in an emergency

Poobah profile image
Poobah in reply to mauschen

Your experience sounds very poor. At the very least, an explanation about prescribing any new medication and an update asthma plan would be considered a basic requirement. You could complain to the practice manager.

mauschen profile image
mauschen in reply to Poobah

Personally, I would have preferred to have been initially assessed by a medical doctor. Then and only then, do I feel that I should have been passed to the nurse for annual review.

I should have said that my GP surgery has two asthma nurses and they couldn't be more different. They've both undertaken the requisite training but there's definitely a huge gap in knowledge - at least that's my experience. I always opt for the AN that I feel has proved to be the most effective for me and who's happy to discuss/explain her decisions.

Over the years I've seen a number of different ANs, and some are appear to be more interested in the subject than others. I have been able to establish where on the knowledge spectrum they fall, just by chatting about asthma phenotypes. I had one AN say, "asthma is asthma" and always had to get the pictorial poster of inhalers out to refer to it as I wasn't on what she called "the normal treatment" - I was on Ventolin & Symbicort. Others have been animated about additional training courses they were signing up for or eager to explore solutions when symptoms had become challenging and very supportive beyond an annual review. The tick box approach just makes me feel less than confident.

mauschen profile image
mauschen in reply to Poobah

At least you have a choice. You sound well clued up on your asthma. My concern is for those who don’t recognise when their asthma is becoming a problem. These people need a well qualified asthma nurse to guide them

My respiratory nurse is a Nurse Practioner so she is able diagnose and dispense medications, so higher qualified than a regular nurse, but not as high as a GP. She also runs her own clinic for minor ailments, which frees up the GPs. I was recently changed from Serdupla to Fostair as I was struggling in the summer months. She wanted me to go to a powder inhaler as lowering their Co2 footprint, but I had problems when they first came out so opted for the Fostair. Had to have another review 4weeks later to get the next prescription and it was then added to my repeats list.

My apologies, I'm not sure if I wandered off topic or even answered your question.

mauschen profile image
mauschen in reply to Collienut

No worries lolI expected the asthma nurse to be as you described, an expert in the field.

Being an expert takes time and experience. It also involves ongoing learning and updating skills. This is why I was confused because she is apparently an expert in 5 or more specialities?

Collienut profile image
Collienut in reply to mauschen

Hi Mauschen

The extra trading they do, is an extra degree to be come a Nurse Practitioner. So a Mini GP, trained in many subjects. 🤗.

My best PF sits at around 350 on a good day. You need to keep a chart of your daily flows to see if there is any drastic change. I use and find the Asthma Hub Appt very helpful.

I don’t keep a record of PF because I have another lung disease which makes PF irrelevant.in my case.I provided the nurse with a print out of PFT for the last 6 years but I am not sure if she could interpret them?

Lysistrata profile image
LysistrataAdministrator

If it's a GP nurse, there is a lot of variation and they are generally not the same as a clinical asthma nurse specialist in a hospital, or the nurses on the Asthma UK helpline who are very experienced and fully trained. Some surgeries will take the time to properly train an asthma nurse and actually send them on courses. Others will just tell a nurse they are the asthma/diabetes etc nurse but not actually provide proper training. Others will get the HCA to do asthma reviews on the computer. So it depends on the surgery!

In terms of your peak flow, she should have asked about your best - as floating has said, these numbers are no use in isolation and they have to be measured against yourself, not anyone else. I would expect a good nurse to be alert if they sound lower than your predicted, but I would also expect a good nurse not to stop there and to actually discuss it with you and try to work out what your best is. If you already know your numbers are always low then 325 might be fine for you, or it might be that peak flow isn't that useful for measuring your asthma. If that's the case the nurse should be giving you an action plan that works for you.

This post may be useful re peak flow: healthunlocked.com/asthmauk...

mauschen profile image
mauschen in reply to Lysistrata

Thank you for the information.I wasn’t given a plan, nor was my asthma discussed other than to tell me to try a Bricanyl turbohaler

Lysistrata profile image
LysistrataAdministrator

If it's a GP nurse, there is a lot of variation and they are generally not the same as a clinical asthma nurse specialist in a hospital, or the nurses on the Asthma UK helpline who are very experienced and fully trained. Some surgeries will take the time to properly train an asthma nurse and actually send them on courses. Others will just tell a nurse they are the asthma/diabetes etc nurse but not actually provide proper training. Others will get the HCA to do asthma reviews on the computer. So it depends on the surgery!

In terms of your peak flow, she should have asked about your best - as floating has said, these numbers are no use in isolation and they have to be measured against yourself, not anyone else. I would expect a good nurse to be alert if they sound lower than your predicted, but I would also expect a good nurse not to stop there and to actually discuss it with you and try to work out what your best is. If you already know your numbers are always low then 325 might be fine for you, or it might be that peak flow isn't that useful for measuring your asthma. If that's the case the nurse should be giving you an action plan that works for you.

This post may be useful re peak flow: healthunlocked.com/asthmauk...

mauschen profile image
mauschen in reply to Lysistrata

Thank for the information, much appreciated.I am astounded to hear that the nurses leading the chronic illness clinics have varying levels of education and competence.

Nurse led clinics are popping up all over the place and while many will be led by nurse experts in their field, others might not. This is of great concern.

In my opinion, there need to be a certain standard of education set for all nurses taking up this role. They should be monitored, evaluated and be on a separate part of the professional register.

I have asked myself that question quite a lot! Asthma reviews often feel like the clinician is ticking boxes on the computer, sometimes it feels like a check to see how many inhalers you are using without giving any alternatives when the AN said it was too many, despite my comment at the time to the AN that I was using them because I was struggling to breathe. Another AN advised me to use more of the preventer inhaler to try and avert a course of pred but my consultant said I should not do this and wrote to my surgery saying so. I have had a very disinterested AN who appeared to be totally bored by the whole thing. On the other hand I had a brilliant AN who understood Asthma and had a plethora of skills and knowledge and it came to light that she had previously worked for the British Lung Foundation. Sadly she left the Practice. I think that when a registered nurse works for a GP Practice there are gaps that need filling in the service so the nurse goes on a training course to skill them up in asthma but these can be variable in their quality but it allows them to take on the role of specialist nurse. I have to say though, this doesn’t just apply to ANs in GP surgeries, it also applies to GPs who may or may not have an interest in asthma as well as hospital doctors and nurses in A&E. I think you are right to say that many are not very familiar with the many types and presentations of asthma, though if anyone knows this to be incorrect I am happy to be wrong.

Please see my response to Lysistrata , I think we are on the same page.I remember being in hospital A&E many years ago, and a doctor said that my asthma was stable because my saturation level was 97%. He didn’t appear to know that we can have excellent saturation levels because in my case, I didn’t have a problem getting oxygen into my lungs but couldn’t get it out. Plus, I arrived by ambulance where I had been given 100% oxygen.

In A&E, the pressure on staff is immense. As long as I didn’t die … and I didn’t, I was happy with my care. Decisions need to be made very quickly and revised quickly. However, if nurses are being put into a position where they are taking on the roll of a doctor, for their own sake, they should be properly trained and not be manipulated into being responsible for all chronic illness… scary!

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