The National Asthma Council Australia (NAC) has released a new guideline to upskill pharmacists in thunderstorm asthma management.

The Thunderstorm Asthma: prepare your patients for spring resource is designed to help pharmacists identify and advise at-risk patients on thunderstorm asthma for which the greatest risk is between October and December, said Dr Jenny Gowan FPS, member of the NAC Guidelines Committee and PSA Victorian Branch Committee member.

With a La Niña event under way, increasing the likelihood of above-average rainfall which can lead to above-average grass growth and ryegrass pollen, the NAC’s evidence-based flowchart will help pharmacists take the necessary steps when requests are made for medicines for asthma and allergic rhinitis.

‘We urge every pharmacy to inform all of their staff about the flowchart so they know to direct patients to pharmacists to undertake the appropriate steps and then supply the appropriate medicines as required,’ Dr Gowan said.

Thunderstorm devastation

Jarrod McMaugh MPS, a Victorian-based specialist asthma pharmacist, was a student at Charles Sturt University in Wagga Wagga when one of Australia’s first documented thunderstorm asthma events occurred in 1997.

‘There had been a dry thunderstorm,’ he said. ‘Lightning micronises the pollen into even smaller pieces which can get quite deep in a person’s lungs.’

As a result, there were 215 emergency department (ED) presentations, 41 hospital admissions and 2 intubations.

Before that event, inhaled corticosteroids were restricted for asthma flare-ups, Mr McMaugh said. According to current Australian asthma guidelines, most adults and adolescents with asthma need to take at least the minimal dose of inhaled corticosteroid every day to stave off inflammation. 

Yet patients who have ‘mild’ asthma are often the ones who find themselves in trouble when thunderstorm asthma season rolls around.

‘All those individuals start to need salbutamol [or] far more comprehensive treatment,’ he said. ‘It’s very likely they will present to ED because their symptom-free condition has come back with a vengeance as they haven’t been treating it.’ 

History repeating

Fast forward almost 20 years, and Mr McMaugh was again in the middle of another horror thunderstorm asthma event – this time as a practising pharmacist.

In 2016, as a deadly thunderstorm asthma event hit Melbourne, the Coburg pharmacy he once owned was inundated with patients needing salbutamol. But the pharmacy quickly ran out and couldn’t source any more for days.

‘We had patients present who said they’d never had asthma or they hadn’t had asthma since they were a kid,’ he said.

‘Those people [are] now needing salbutamol because their unidentified or undertreated asthma flared up and they didn’t know how to use their inhaler properly either.’

People also presented in significant distress, with around four to five patients struggling to breathe.

‘The pharmacy is located in a medical centre, [so] we had people referred immediately upstairs for supportive therapy from GPs, then transferred to the hospital via ambulance due to the severity of the impact,’ Mr McMaugh said.

Identifying at-risk patients

The steps included in the NAC tool include warning patients about probable ryegrass pollen allergy and the risk of thunderstorm asthma.

When patients request antihistamines, nasal corticosteroids or even eye drops, this is an opportunity for pharmacists to probe their symptoms, Mr McMaugh said.

‘If they’re getting any kind of wheeze, that’s not normal,’ he said. ‘They should be referred on to their GP for review.’

The tool goes on to cover advice about avoidance steps for reducing the risk of exposure to thunderstorms as well as asthma first aid during grass pollen season, Dr Gowan said.

‘If [patients] present requesting a medicine for asthma, the steps cover warnings about the risk of thunderstorm asthma, advice about good asthma control, steps for avoidance of risk and asthma first aid,’ she said. 

‘The flowchart also recommends pharmacists ask if the patient has allergic rhinitis, worsening asthma symptoms during spring and [about] preventer use. 

‘If needed, the pharmacist can then provide the appropriate advice, or recommend a GP treatment review.’

Mr McMaugh, who also teaches in an asthma educator course at The Alfred Hospital, said learning how to use spirometry can also be helpful in identifying patients with asthma.

‘Let’s say you’ve got somebody who doesn’t think they’ve got asthma, but they seem to – based on the symptoms they present with,’ he said.

‘Spirometry can then be a handy tool to [offer]. You could say, “We’ve got this ability to do some testing that [might] demonstrate you have asthma so we can get you a referral”.’

How’s your inhaler technique?

Every time a person presents to a pharmacy asking for an inhaler, Mr McMaugh said it’s critical to go through the correct techniques and encourage use of a spacer.

But be prepared for some resistance from complacent patients who buy salbutamol on a regular basis. Mr McMaugh suggests pointing out that people don’t often realise how they use salbutamol isn’t going to help them.

‘If they’re getting any kind of wheeze, that’s not normal. They should be referred on to their GP for review.’

JARROD MCMAUGH MPS

‘[I’ll say] “I just want to make sure that you’ve got all those little tips and tricks that really help you get the best out of it”,’ he said.

It’s also worth advising patients that inappropriate use can leave them out of pocket.

‘[I’ll] explain, “It’s great that you use it all the time, but it’s such a waste of money if you’re not getting any benefit out of it. Let’s make sure you aren’t wasting your money”,’ he said.

Have an emergency asthma plan in place

All pharmacies, particularly those across South-Eastern Australia, should ensure they have an Emergency Asthma Plan Policy in place for patients presenting with an asthma flare up, Dr Gowan said. 

‘[Ensure] all staff are trained in asthma first aid and there are good supplies of reliever medications and spacers on hand, particularly for emergency use,’ she said.

Mr McMaugh suggests pharmacists have proforma asthma plans on hand, available through the NAC, for patients who don’t already have one.

Pharmacists can even help patients begin filling out the form, including detailing their current treatment and how they manage flare-ups. 

‘Use that as a trigger for a referral to [help] people understand that this is a serious matter and they need to follow up with their GP to get a plan in place,’ he said.

Befriend GPs who are passionate about asthma care

While Mr McMaugh said referring at-risk patients or those with mild asthma symptoms to their regular GP is fine, be sure to follow up in instances when the symptoms are dismissed or treatment is not promoted. 

‘It’s good to know the GPs in [your] area who have a passion for asthma and other respiratory conditions,’ he said.

When you encounter patients who are complacent or whose healthcare teams are blasé about their condition, you then have a useful referral point. 

‘[You could say] “I know you’ve got a GP but get this person to assess you because they take asthma seriously”,’ he said.

‘If they say it’s an otherwise unrelated condition that’s great, but if they think it could be asthma or that treatment is needed, take it seriously”.’