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Asthma Update
Clare AlexanderRSCH
March 2015
Asthma update
What is asthma (spirometry)
BTS guidelines
National review of Asthma deaths
Diagnostic pitfalls
What is AsthmaVariable, reversible airways
obstruction
Est. 3.4 million people have Asthma in the UK
Bronchoconstriction
Inflammatory cellular infiltrateMucus
SpirometryMethod of assessing lung function - patterns
How much “puff”/ “breath” you have
= FVC (Forced vital capacity
How quickly you can force your breath out – i.e. how much resistance?
= FEV1 (Volume (litres) of air expelled in first second of forced expiration
Ratio between resistance or obstruction and the amount of available “breath” – disease patterns
= FEV1/ FVC or FEV1 ratio
British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network
(SIGN)Revised guideline October 2014
Aim of Asthma Management
Complete control - defined as:
No daytime symptoms
No night time wakening due to asthma
No need for rescue medication
No asthma attacks
No exacerbations
No limitations on activity including exercise
Normal lung function (FEV1 +/ or PEF> 80% predicted or best)
Minimal side effects from medication
Treatment strategies
1. Supported Self Management
2. Non- pharmacological Management
3. Pharmacological Management
4. Adherence and Concordance
5. Difficult Asthma
6. Work related Asthma
1. Supported Self Management
Incorporating written personalised asthma action plans (PAAPs)www.asthma.org.uk/control (traffic lights)Based on symptoms +/or PEFRsSupported by regular professional review
Education – linked to patient goalsE.g. Trigger avoidance such as animals, smokingTrained professionalsCulturally appropriate In patients should all receive/ had reviewed PAAPs
www.asthma.org.uk/control
1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?
2. During the past 4 weeks, how often have you had shortness of breath?
3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain)
wake you up at night, or earlier than usual in the morning?
4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as salbutamol)?
5. How would you rate your asthma control during the past 4 weeks? EDUCATION!
Score
Patient Total Score
Copyright 2002, QualityMetric Incorporated.Asthma Control Test Is a Trademark of QualityMetric Incorporated.
Asthma Control Test™ (ACT)
2. Non- pharmacological Management
Smoking advice and support
Weight loss in overweight patients
Breathing exercise programs (often Physiotherapy lead, RSCH) – “dysfunctional breathing patterns” or hyperventilation.NIJEMEN questionnaire
Exercise
Do not recommend Physical and chemical methods to reduce house dust
mite – ineffective (& expensive). Diets of exclusion (e.g. milk, unless (rarely) clinically
identified – immunologist)
3. Pharmacological Management
The Stepwise Approach
1. Start treatment at the step most appropriate to initial severity
2. Achieve early control
3. Maintain control by:1. Stepping up as necessary
2. Stepping down when control good
Before initiating new drug therapy, check – adherence with existing therapies; inhaler technique & eliminate trigger factors
Adults
Adults
Adults
Adults
Adults
3. Pharmacological Management cont.
Combination inhalers recommended toGuarantee LABAs not taken without ICS Improve inhaler adherence
Stepping downSeverity of asthma, time on current dose,
beneficial effects achieved & pts preferenceSlowly – every 3 months – 25- 50% dose each time
Exercise induced asthma – most patients represents poorly controlled asthmaSABA immediately prior to exercise
Avoid prescribing different inhaler types i.e. powder devices vs aerosols.
4. Adherence and Concordance
Routinely & regularly addressed (accessible pro-active asthma care)
Computer repeat- prescribing systems (practical index)
Non- judgmental discussions
Alternative diagnosis OR Severe/ Brittle
e.g.
COPD
Bronchiectasis
GO reflux
Cardiac failure
Asthma not responding to maximum treatment
Symptomatic at BTS/Sign step 4/5
• Compliance• Symptoms out of proportion• Dysfunctional breathing
5. Difficult Asthma
6. Work related Asthma (& Rhinitis)
At least 1 in 10 cases of new or reappearance of childhood asthma in adult life are attributed to occupation.
Nasal symptoms
Prognosis of Ig-E associated occupational asthma improved by early identification and avoidance.
Objective measures (PEFR at least 4x day) – specialist referrals
High risk Baking, spray paint, lab animals, health & dental care, food
processing, metal / wood/ plastics/rubber, farming + dust
National Review of Asthma Deaths NRAD (2014)
Commissioned by: Healthcare Quality Improvement Partnership (HQIP)
On behalf of: NHS England, NHS Wales, Health and Social Care Division of the Scottish Government, Northern Ireland Department of Health Social Services and Public Safety
Delivered by: Clinical Effectiveness and Evaluation Unit of the Clinical Standards Department of the Royal College of Physicians
Overall aim of NRADTo understand the circumstances
surrounding asthma deaths in the UK, in order to
identify avoidable factors and
make recommendations for changes
to improve asthma care as well as patient self-management
(This was not a prevalence study – did not aim to determine the number of asthma deaths in the UK)
www.rcplondon.ac.uk/
nrad
NRADA multidisciplinary, confidential enquiry of
asthma deaths in Feb 2012 - Jan 2013 in the UK effectiveness of the management
of asthma (acute and chronic) Identify potential avoidable
factors Make recommendations for
changes - to reduce the number of preventable asthma deaths
NRAD
Method
Analysis of 195 people who died from asthma
374 local coordinators
297 hospitals
174 expert clinical assessors (primary and secondary care)
Location of Death
Patient DemographicsDuration of asthma (n=104) : 0-62 yrs (11 yrs)Age at diagnosis (n=102) : 10 mths – 90 yrs (37 yrs)Age at death (n=193) : 4 yrs – 97 yrs (58 yrs)Severity of asthma (n=155):
(classified by the Clinicians) Mild 14 (9%)
Moderate 76 (49%)
Severe 61 (39%)
‘Amount of treatment required to gain control of the asthma’
It is possible that many of those cases defined by their doctors as Mild or Moderate ….. were more severe
Key Findings & Recommendations
Use of NHS services
Medical and professional care
Prescribing and medicines use
Key Findings - use of NHS Services
87 of the 195 (45%) died without seeking medical help or before emergency care could be provided
112 (57%) were not recorded as being under specialist supervision
There was a history of previous hospital admission in 47%
19 (10%) died within 28 days of discharge from hospital
Primary care review of the 195 cases
(in the 12 months before death)
• 64 (33%) - no details on asthma diagnosis
• 70/102 - diagnosed > age of 15 • ? Late onset; ? Delayed diagnosis; ? Recurrence
• 84 (43%) - no record of asthma review 12 mths
• 37 (19%) - had assessment of asthma control
• 44 (23%) - had Personal Asthma Action Plans (PAAP)
• 112 (57%) - not under specialist supervision
www.rcplondon.ac.uk/
nrad
Key Findings - Medical and Professional Care
The majority of people (58%) who died were thought to have mild or moderate asthma
Avoidable factors were identified in 89 (46%) deaths
Exacerbating factors, or triggers, were documented in only half the people who died
Recommendations - Medical and Professional
CareAll patients should have written guidance in the form of
a personal asthma action plans (PAAP), describing triggers, how to prevent relapse and emergency action
Triggers and avoidable factors should be actively sought, and appropriate action taken
Management plans should reflect that the risk of asthma death is increased where there is significant concurrent psychological and mental health issues
All patients with asthma should have a regular structured review, undertaken at least annually
Recommendations - Patient factors, awareness of risk of
poor control
Patient self-management should be encouraged to reflect exposure to known triggers eg before hay fever season
History of smoking and/or exposure to passive smoke should be documented. Current smokers should be offered referral to a smoking cessation service
Parents and children should be educated on the ‘how’, ‘why’ and ‘when’ to use their asthma medications and know how to seek emergency help
Key Findings - Prescribing and medicines use
There was evidence of excessive prescribing of relievers, 6 patients being prescribed more than 50 short acting reliever inhalers in the year before death
There was strong evidence of under prescribing of preventer medications (ICS)
There appeared to be inappropriate prescribing of long- acting beta agonist, either as a single agent without inhaled corticosteroid
Excessive prescribing of Short Acting Beta-Agonist Bronchodilators
(SABAs) (n= 189/194 ; 97%)
Numbers of devices prescribed during final year (n=165)
• Range: 1 to 112; median of 10 inhaler devices• > 6 SABA : 92/165 (56%) inhaler devices• > 12 SABA : 65/165 (39%) inhaler devices• >50 SABA : 6 patients
www.rcplondon.ac.uk/
nrad
Excess need for reliever medication (SIGN/BTS) = Poor asthma control
Inadequate prescribing of Inhaled Corticosteroids (ICS)
ICS +/- Long Acting Beta-agonist Bronchodilator (ICS/LABA)
(n= 168/195 ; 86%)
Number of prescribed devices final year (n=128): Range: 1 to 54, median of 5 inhaler devices• < 4 ICS devices in 12 mths : 49/128 (38%) • < 12 ICS devices in 12 mths : 103/128 (80%)
www.rcplondon.ac.uk/
nrad
Recommendations - Prescribing and medicines
use
People with asthma who have been prescribed more than 12 short-acting reliever inhalers in the past 12 months should be invited for urgent review
Non-adherence with preventer inhaled corticosteroid should be monitored
Use of combination inhalers should be encouraged
Assessment of inhaler technique should be made at annual review and by the pharmacist whenever new inhaled devices are prescribed
Recommendations - use of NHS Services
Every NHS hospital and general practice should have a designated lead for asthma service
Follow up must be undertaken after every attendance at the emergency department or out-of-hours service
A standard national template should be developed to facilitate a structured review
Electronic systems should be developed urgently to alert clinicians to over use of short acting relievers or underuse of preventers
Major factors identified by panels(i.e. contributed significantly to the deaths, where different management would reasonably be expected to have affected the outcome )
www.rcplondon.ac.uk/
nrad
nDid not recognise high-risk status 21Lack of specific asthma expertise 17Did not perform adequate asthma review 16Did not refer to another appropriate team member 16Failure to take appropriate medication in month before death 15Failure to take appropriate medication in year before death 13 Over prescribed short acting beta agonist bronchodilator 13Poor or inadequate implementation of policy/pathway/protocol 13Lack of knowledge of guidelines 12Did not adhere to medical advice 10
Differential Diagnosis & Diagnostic pitfalls
Bronchiectasis (normal, obstructive or restrictive spirometry)
Vocal cord dysfunction (+/- normal spirometry at rest)
COPD – smoking > 20years (fixed obstructive spirometry)
Pulmonary fibrosis – progressive SOB and cough – HRCT scan (restrictive spirometry)
Cardiac failure (restrictive spirometry)
Bronchiectasis “Wet cough” , hard “casts” sputum production Recurrent infections
Poorly controlled asthma High resolution CT Scan Aspergillus Precipitins (IgG) and Aspergillus specific IgE and total
IgE – ABPA (Allergic bronchopulmonary aspergilosis) treatment with prolonged steroid (upto a year) plus itraconazole.
Treatment – Physiotherapy and airways clearance.• Bronchodilators• Prophylactic Antibiotic (> 3-4 infections in a year)