Asthma in Asthma in Primary CarePrimary Care

Dr. Zareen MohamedDr. Zareen Mohamed MBBS., M Med(singapore) DAA(cmcMBBS., M Med(singapore) DAA(cmc))

Consultant – Allergy and AsthmaConsultant – Allergy and AsthmaDr. Mehta’s HospitalsDr. Mehta’s Hospitals

Burden of DiseaseBurden of Disease

WidespreadWidespread 7% prevalence and rising7% prevalence and rising 73% managed by PCPs73% managed by PCPs

Allergic vs. non-allergic asthmaAllergic vs. non-allergic asthma 60% of asthmatics have allergic asthma60% of asthmatics have allergic asthma 90% of children with asthma also have 90% of children with asthma also have

allergiesallergies

IntroductionIntroduction

Many patients with asthma are treated in Many patients with asthma are treated in the primary care setting. The primary care the primary care setting. The primary care physician is therefore in a key position to physician is therefore in a key position to recognize poorly controlled asthma and to recognize poorly controlled asthma and to improve asthma management for these improve asthma management for these patients. patients.

However, current evidence continues to However, current evidence continues to show that, for a substantial number of show that, for a substantial number of patients, asthma control is inadequate for a patients, asthma control is inadequate for a wide variety of reasons, both physician-wide variety of reasons, both physician-related and patient-related related and patient-related

Presentation provides a specialist's Presentation provides a specialist's perspective on diagnosis, perspective on diagnosis, appropriate therapy, disease control appropriate therapy, disease control surveillance, and appropriate surveillance, and appropriate referral when necessary referral when necessary

Many patients overestimate their Many patients overestimate their level of disease control, often level of disease control, often tolerating substantial asthma tolerating substantial asthma symptoms and having low symptoms and having low expectations about the degree of expectations about the degree of control that is possible.control that is possible.

Patients also frequently exhibit poor Patients also frequently exhibit poor adherence to prescribed controller adherence to prescribed controller medicationsmedications

Additional patient-related factors Additional patient-related factors affecting asthma control include self-affecting asthma control include self-management abilities, smoking management abilities, smoking status, inhaler technique, ability to status, inhaler technique, ability to remember doses, access to remember doses, access to prescriptions, and costs of prescriptions, and costs of medication.medication.

Physicians have a tendency to Physicians have a tendency to underestimate the prevalence of underestimate the prevalence of asthma symptoms and to asthma symptoms and to overestimate the degree to which overestimate the degree to which their patients' asthma is controlled; their patients' asthma is controlled; therefore, they may not always therefore, they may not always prescribe adequate controller prescribe adequate controller medication therapy medication therapy

Physicians may also have an Physicians may also have an inadequate understanding of disease inadequate understanding of disease etiology or may not communicate etiology or may not communicate well with patients, and these well with patients, and these problems make it difficult to problems make it difficult to establish a pharmacotherapeutic establish a pharmacotherapeutic regimen that the patient is willing regimen that the patient is willing and able to follow and able to follow

National Asthma Education and National Asthma Education and Prevention Program (NAEPP) Prevention Program (NAEPP) updated guidelines for the diagnosis updated guidelines for the diagnosis and management of asthma and management of asthma

Asthma DiagnosisAsthma Diagnosis

Particularly important factors that Particularly important factors that should be addressed as part of the should be addressed as part of the medical history include the overall medical history include the overall pattern of symptoms (eg, perennial, pattern of symptoms (eg, perennial, seasonal, or both; continual, episodic, seasonal, or both; continual, episodic, or both; diurnal variations), or both; diurnal variations), precipitating factors (such as the precipitating factors (such as the presence of allergic triggers), and a presence of allergic triggers), and a family history of asthma, allergy, or family history of asthma, allergy, or other atopic disorders.other atopic disorders.

The guidelines recommend the use of a detailed The guidelines recommend the use of a detailed medical history, the results of a physical medical history, the results of a physical examination (focusing on the upper respiratory examination (focusing on the upper respiratory tract, chest, and skin), and the results of tract, chest, and skin), and the results of spirometryspirometry (for patients aged 5 years or older) in (for patients aged 5 years or older) in making the diagnosis. making the diagnosis.

Any additional studies necessary for excluding Any additional studies necessary for excluding alternative diagnoses or identifying other potential alternative diagnoses or identifying other potential causes of symptoms should also be performed (eg, causes of symptoms should also be performed (eg, chest radiography, specific blood tests).chest radiography, specific blood tests).

primary care physicians should refer patients to a primary care physicians should refer patients to a specialist for spirometry or allergy testing. specialist for spirometry or allergy testing.

Role of SpirometryRole of Spirometry

Correctly diagnosing asthma is the first Correctly diagnosing asthma is the first step toward attaining disease control. In step toward attaining disease control. In general, a diagnosis of asthma is general, a diagnosis of asthma is established if episodic symptoms of established if episodic symptoms of airflow obstruction or airway airflow obstruction or airway hyperresponsiveness are present, airflow hyperresponsiveness are present, airflow obstruction is at least partially reversible, obstruction is at least partially reversible, and alternative diagnoses are excluded. and alternative diagnoses are excluded.

““All that wheezes is not asthma.” All that wheezes is not asthma.”

Chevalier Jackson [1865-1958]Chevalier Jackson [1865-1958]

Several other conditions may coexist with asthma or Several other conditions may coexist with asthma or complicate the diagnosis or management of asthma. complicate the diagnosis or management of asthma. Cough-variant asthma, in particular, is easily Cough-variant asthma, in particular, is easily overlooked because chronic cough can be a sign of a overlooked because chronic cough can be a sign of a wide variety of health problems.wide variety of health problems.

Conversely, chronic cough may also be the principal Conversely, chronic cough may also be the principal (or only) manifestation of asthma, especially among (or only) manifestation of asthma, especially among young children. young children.

The diagnosis of cough-variant asthma is confirmed The diagnosis of cough-variant asthma is confirmed by a positive response to asthma medication, and by a positive response to asthma medication, and treatment should follow the usual stepwise approach treatment should follow the usual stepwise approach to asthma management. to asthma management.

Vocal cord dysfunctionVocal cord dysfunction Vocal cord dysfunction—characterized by Vocal cord dysfunction—characterized by

episodic dyspnea and wheezing caused episodic dyspnea and wheezing caused by intermittent paradoxical vocal cord by intermittent paradoxical vocal cord adduction during inspiration—often adduction during inspiration—often mimics asthma and can be difficult to mimics asthma and can be difficult to diagnose. diagnose.

A diagnosis is best made with indirect or A diagnosis is best made with indirect or direct vocal cord visualization during an direct vocal cord visualization during an episode, and treatment generally episode, and treatment generally consists of speech therapy and relaxation consists of speech therapy and relaxation techniques techniques

Other common comorbid conditions that Other common comorbid conditions that complicate the diagnosis of asthma are complicate the diagnosis of asthma are chronic sinusitis, gastroesophageal chronic sinusitis, gastroesophageal reflux disease, obstructive sleep apnea, reflux disease, obstructive sleep apnea, and respiratory tract infections. and respiratory tract infections.

ABPA(Allergic bronchopulmonary ABPA(Allergic bronchopulmonary aspergillosis) is often accompanied by aspergillosis) is often accompanied by symptoms similar to those of asthma symptoms similar to those of asthma and by elevated IgE levels.and by elevated IgE levels.

Churg-Strauss syndromeChurg-Strauss syndrome is another comorbid is another comorbid condition that should be considered in the condition that should be considered in the assessment of patients with difficult-to-control assessment of patients with difficult-to-control asthma.asthma.

It is a serious disorder characterized by It is a serious disorder characterized by eosinophilic inflammation of the respiratory eosinophilic inflammation of the respiratory tract and necrotizing vasculitis of small and tract and necrotizing vasculitis of small and medium vessels. medium vessels.

Laboratory results demonstrate eosinophilia, Laboratory results demonstrate eosinophilia, and symptoms include asthma, rhinosinusitis, and symptoms include asthma, rhinosinusitis, pulmonary infiltrates, peripheral neuropathy, pulmonary infiltrates, peripheral neuropathy, and skin, heart, or gastrointestinal and skin, heart, or gastrointestinal involvement. involvement.

MANAGING ASTHMAMANAGING ASTHMA

Once the diagnosis of asthma has been Once the diagnosis of asthma has been established, the focus shifts to established, the focus shifts to classifying asthma severity so that classifying asthma severity so that therapy can be initiated and to therapy can be initiated and to monitoring control over time so that monitoring control over time so that therapy can be adjustedtherapy can be adjusted

According to the new guidelines, According to the new guidelines, severity and control should be assessed severity and control should be assessed separately, but both are classified on separately, but both are classified on the basis of the domains of current the basis of the domains of current impairment and future riskimpairment and future risk

After disease severity has been After disease severity has been assigned, treatment can be initiated assigned, treatment can be initiated at the recommended step. If the at the recommended step. If the patient is already receiving asthma patient is already receiving asthma therapy, symptom control should be therapy, symptom control should be periodically monitored periodically monitored

Obstacles to asthma Obstacles to asthma controlcontrol

Ongoing occupational exposures, which Ongoing occupational exposures, which should be identified and eliminated when should be identified and eliminated when possible possible

Occupational history should be considered Occupational history should be considered for adults with uncontrolled asthma, for adults with uncontrolled asthma, especially if symptoms improve on especially if symptoms improve on weekends and holidays. weekends and holidays.

Exposure to Outdoor and Indoor AllergensExposure to Outdoor and Indoor Allergens

Patient related factorsPatient related factors

Physician related factorsPhysician related factors

Perhaps the environmental factor that Perhaps the environmental factor that contributes most to the development, contributes most to the development, persistence, and severity of asthma is persistence, and severity of asthma is viral respiratory infection viral respiratory infection

Asthma can also be exacerbated by Asthma can also be exacerbated by certain drugs, such as nonsteroidal certain drugs, such as nonsteroidal anti-inflammatory drugs and β-blockers. anti-inflammatory drugs and β-blockers.

Aspirin-sensitive asthma is frequently Aspirin-sensitive asthma is frequently associated with a genetic sequence associated with a genetic sequence variation and is relatively common in variation and is relatively common in Eastern Europe and JapanEastern Europe and Japan

Asthma may also be difficult to control Asthma may also be difficult to control in the presence of untreated in the presence of untreated gastroesophageal reflux disease gastroesophageal reflux disease

What does good asthma What does good asthma control look like? control look like?

Patients should be educated so that Patients should be educated so that they do not accept a certain level of they do not accept a certain level of ongoing symptoms, short-acting ongoing symptoms, short-acting inhaler use, and reduced activity as inhaler use, and reduced activity as “normal” for someone with asthma.“normal” for someone with asthma.

Any aspect of the patient's asthma Any aspect of the patient's asthma control does not meet these criteria, control does not meet these criteria, the patient does not have good the patient does not have good asthma control, and the clinician asthma control, and the clinician should consider changing the should consider changing the patient's asthma management plan. patient's asthma management plan.

Asthma Control TestAsthma Control Test The ACT is an easy-to-use questionnaire The ACT is an easy-to-use questionnaire

consisting of 5 questions, each scored by the consisting of 5 questions, each scored by the patient on a scale from 1 to 5, regarding patient on a scale from 1 to 5, regarding activity levels, frequency of daytime or activity levels, frequency of daytime or nighttime symptoms, rescue inhaler use, and nighttime symptoms, rescue inhaler use, and the patient's perception of asthma control the patient's perception of asthma control during the past 4 weeks. during the past 4 weeks.

The result is a total numeric score ranging The result is a total numeric score ranging from 5 to 25; a cutpoint score of 20 or higher from 5 to 25; a cutpoint score of 20 or higher generally indicates well-controlled asthma generally indicates well-controlled asthma (in conjunction with the physician's clinical (in conjunction with the physician's clinical assessment). assessment).

PharmacotherapyPharmacotherapy

Step 1Step 1

Mild Mild intermittent intermittent

asthmaasthma

Step 2 Step 2

Regular Preventer Regular Preventer therapytherapy

Step 3Step 3

Initial Add-On TherapyInitial Add-On TherapyStep 4Step 4

Persistent Poor Persistent Poor ControlControl

Step 5Step 5

Continuous or Continuous or frequent use of frequent use of

oral steroidsoral steroids

Inhaled short Inhaled short acting Bacting B22--agonistagonist

Prescribe Prescribe inhalers only inhalers only after the after the patient has patient has received received training in the training in the use of the use of the device and has device and has demonstrated demonstrated satisfactory satisfactory techniquetechnique

Add inhaled Add inhaled corticosteroid corticosteroid (ICS) (ICS) 200-800mcg/day 200-800mcg/day (BDP or equivalent)(BDP or equivalent)

Start dose of Start dose of inhaled inhaled corticosteroid corticosteroid appropriate to appropriate to severity of disease. severity of disease. 400mcg/day is an 400mcg/day is an appropriate dose appropriate dose for most patientsfor most patients

1.1. Add inhaled long-acting Add inhaled long-acting ß2-agonist (LABA) and ß2-agonist (LABA) and 2.2.

2.2. Assess control of Assess control of asthma:asthma:

good response to LABA good response to LABA - continue LABA- continue LABACombination inhalers Combination inhalers

should be considered in should be considered in those for whom LABA those for whom LABA are effective at are effective at controlling symptoms. controlling symptoms.

benefit from LABA but benefit from LABA but control still control still inadequateinadequate

- continue LABA and - continue LABA and increase inhaled steroid increase inhaled steroid dose to 800 mcg/day dose to 800 mcg/day BDP or equivalent BDP or equivalent (if (if not already on this not already on this dose)dose)

no response to LABAno response to LABA- stop LABA and increase - stop LABA and increase

inhaled steroid to inhaled steroid to 800mcg/ day.800mcg/ day. BDP or BDP or equivalentequivalent

If control still If control still inadequate, inadequate, institute institute trial of other therapies, trial of other therapies, leukotriene antagonist leukotriene antagonist or SR theophylline or SR theophylline receptorreceptor

Consider trials of:Consider trials of:

Increased dose of Increased dose of inhaled inhaled corticosteroid up corticosteroid up to 2000mcg/day to 2000mcg/day BDP or equivalentBDP or equivalent

Consider adding a Consider adding a fourth drug e.g. fourth drug e.g. leukotriene leukotriene receptor receptor antagonist, SR antagonist, SR theophylline or theophylline or

BB22-agonist tablet-agonist tablet

Use daily steroid Use daily steroid tablet in lowest tablet in lowest dose to provide dose to provide adequate controladequate control

Maintain high dose Maintain high dose inhaled inhaled corticosteroids at corticosteroids at 2000mcg/day (BDP 2000mcg/day (BDP or equivalent)or equivalent)

Consider other Consider other treatments to treatments to minimise the use of minimise the use of oral steroidsoral steroids

Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009: Amended 16/06/10http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf

Combination inhalersCombination inhalers Long acting beta-agonists (LABA) are the Long acting beta-agonists (LABA) are the

preferred first option for add-on therapy, usually preferred first option for add-on therapy, usually beyond an ICS dose of 400mcg Beclometasone beyond an ICS dose of 400mcg Beclometasone equivalent per day in adults and 200mcg per day equivalent per day in adults and 200mcg per day in children. in children.

Combination inhalers have the advantage, once a Combination inhalers have the advantage, once a patient is on stable therapy, of guaranteeing that patient is on stable therapy, of guaranteeing that the LABA is not taken without the inhaled steroid the LABA is not taken without the inhaled steroid

Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009:http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf

Combination of budesonide/formoterol Combination of budesonide/formoterol in a single inhalerin a single inhaler

In selected adult patients at Step 3 who are In selected adult patients at Step 3 who are poorly controlled or in selected patients at poorly controlled or in selected patients at step 2 (>400mcg BDP/day who are poorly step 2 (>400mcg BDP/day who are poorly controlled) the use of budesonide/formoterol controlled) the use of budesonide/formoterol in a single inhaler as rescue medication in a single inhaler as rescue medication instead of a short acting instead of a short acting ββ2-agonist, in 2-agonist, in addition to its regular use as a preventative addition to its regular use as a preventative (controller) treatment, has been shown to be (controller) treatment, has been shown to be effective. effective.

The regular daily dose of ICS may be The regular daily dose of ICS may be Budesonide 200mcg bd or 400mcg bdBudesonide 200mcg bd or 400mcg bd

Patients taking rescue budesonide/formoterol Patients taking rescue budesonide/formoterol once/day or more should have their treatment once/day or more should have their treatment reviewedreviewed

Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009:http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf

Regardless of the therapy step, long-Regardless of the therapy step, long-term management of asthma always term management of asthma always involves a balance between the involves a balance between the benefits of achieving the best symptom benefits of achieving the best symptom control possible (hence minimizing the control possible (hence minimizing the risks of uncontrolled asthma and the risks of uncontrolled asthma and the effect of asthma on the patient's well-effect of asthma on the patient's well-being) and the risks of adverse effectsbeing) and the risks of adverse effects—a balance recognized as part of the —a balance recognized as part of the risk domain of the updated guidelines. risk domain of the updated guidelines.

However, patients' concerns about long-However, patients' concerns about long-term corticosteroid use may affect their term corticosteroid use may affect their adherence to a prescribed regimen, and the adherence to a prescribed regimen, and the risks of systemic effects (eg, reduced linear risks of systemic effects (eg, reduced linear growth rate in children or lower bone growth rate in children or lower bone mineral density in adults) increase with mineral density in adults) increase with higher doses.higher doses.

Therefore, it is just as important to step Therefore, it is just as important to step down medication for patients with well-down medication for patients with well-controlled asthma as to step up medication controlled asthma as to step up medication for those with uncontrolled asthma. for those with uncontrolled asthma.

These findings concerning the risks of These findings concerning the risks of higher-dose ICS therapy point toward higher-dose ICS therapy point toward the potential advantages of adjunctive the potential advantages of adjunctive therapies for patients with poorly therapies for patients with poorly controlled asthma: for example, controlled asthma: for example, adding a LABA, a leukotriene modifier, adding a LABA, a leukotriene modifier, or theophylline to medium-dose ICS or theophylline to medium-dose ICS therapy at step 4 or adding therapy at step 4 or adding omalizumab therapy to high-dose ICS omalizumab therapy to high-dose ICS therapy plus a LABA at step 5. therapy plus a LABA at step 5.

For patients with allergic asthma, as For patients with allergic asthma, as indicated by positive results from a indicated by positive results from a skin test or in vitro RAST testing for skin test or in vitro RAST testing for individual aeroallergens, specific individual aeroallergens, specific allergen immunotherapy may be an allergen immunotherapy may be an appropriate adjunctive therapy when appropriate adjunctive therapy when a clear relationship exists between a clear relationship exists between asthma symptoms and allergen asthma symptoms and allergen exposure exposure

Evidence for improved asthma control Evidence for improved asthma control with immunotherapy is strongest when with immunotherapy is strongest when patients are affected by single patients are affected by single allergens, especially house dust mites, allergens, especially house dust mites, cat dander, or pollen.cat dander, or pollen.

A patient with persistent asthma that A patient with persistent asthma that may be associated with allergy should may be associated with allergy should probably be referred to an allergist for probably be referred to an allergist for skin-prick testing and consideration of skin-prick testing and consideration of immunotherapy, omalizumab therapy, immunotherapy, omalizumab therapy, or both. or both.

primary care physicians consider primary care physicians consider referral for patients who have referral for patients who have experienced more than 2 oral experienced more than 2 oral corticosteroid bursts per year or a corticosteroid bursts per year or a recent exacerbation requiring recent exacerbation requiring hospitalization, those who required hospitalization, those who required therapy at step 4 or higher to therapy at step 4 or higher to achieve adequate asthma control, or achieve adequate asthma control, or those with allergiesthose with allergies

Proper diagnosis and regular Proper diagnosis and regular assessment of asthma control are assessment of asthma control are key components of an effective key components of an effective management strategy, but improving management strategy, but improving control depends on recognition by control depends on recognition by both the patient and the physician as both the patient and the physician as to what constitutes good asthma to what constitutes good asthma control. control.

Trigger Trigger identification/control is identification/control is

primary management stepprimary management step ““For at least those patients with For at least those patients with

persistentpersistent asthma on daily medications, asthma on daily medications,the clinician should:the clinician should: Identify allergen exposuresIdentify allergen exposures Use the patient’s history to assess sensitivity Use the patient’s history to assess sensitivity

to seasonal allergensto seasonal allergens Use skin testing Use skin testing oror in vitro in vitro [blood] testing to [blood] testing to

assess sensitivity assess sensitivity to to perennialperennial indoor allergens indoor allergens

Assess the significance of positive tests in Assess the significance of positive tests in contextcontextof the patient’s medical history”of the patient’s medical history”

““Use skin testing Use skin testing oror in vitroin vitro testing to determine testing to determine the presence of specific IgE antibodies to the the presence of specific IgE antibodies to the indoor allergens to which the patient is exposed indoor allergens to which the patient is exposed year round.”year round.”

Allergy testing is the only reliable way to Allergy testing is the only reliable way to determine sensitivity to perennial indoor determine sensitivity to perennial indoor allergens.”allergens.”

For selected patients with asthma at any level of For selected patients with asthma at any level of severity, detection of specific IgE sensitivity to severity, detection of specific IgE sensitivity to seasonal seasonal or perennialor perennial allergens may be indicated as a allergens may be indicated as a basis for avoidance, or immunotherapy, or to basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.”characterize the patient’s atopic status.”

Allergy testing may be conducted along Allergy testing may be conducted along with pulmonary function testswith pulmonary function testsand other diagnostic evaluationsand other diagnostic evaluations11

In allergic asthma: In allergic asthma: Confirm atopy and identify specific allergic Confirm atopy and identify specific allergic

triggers for avoidance counseling, symptom triggers for avoidance counseling, symptom reduction, and control of severity and reduction, and control of severity and comorbid ARcomorbid AR

““Determining whether and how Determining whether and how allergies play a role in a patient’s allergies play a role in a patient’s

asthma asthma is an important part of the clinical is an important part of the clinical

picture.”picture.”

Indication fo omalizumabIndication fo omalizumab

““Omalizumab is indicated for adults Omalizumab is indicated for adults and adolescents (12 years of age and and adolescents (12 years of age and

above) with moderate to severe above) with moderate to severe asthma who have a positive skin test asthma who have a positive skin test or or in vitroin vitro reactivity to a perennial reactivity to a perennial allergen and whose symptoms are allergen and whose symptoms are

inadequately controlled with inhaled inadequately controlled with inhaled corticosteroidscorticosteroids

Lung Function Lung Function Measurement in AsthmaMeasurement in Asthma

Provides an assessment of severity Provides an assessment of severity of airflow limitation, its reversibility of airflow limitation, its reversibility and variabilityand variability

Provides confirmation of the Provides confirmation of the diagnosisdiagnosis

Provides complementary information Provides complementary information about different aspects of asthma about different aspects of asthma controlcontrol

Spirometry in AsthmaSpirometry in Asthma Diagnosis of asthma:Diagnosis of asthma:

Degree of reversibility of FEV1 should be Degree of reversibility of FEV1 should be >12% and >200ml from pre-bronchodilator >12% and >200ml from pre-bronchodilator valuevalue

Spirometry:Spirometry: Reproducible but effort-dependentReproducible but effort-dependent Pre- & post test lacks sensitivity esp. those on Pre- & post test lacks sensitivity esp. those on

treatment, so repeated testing at different treatment, so repeated testing at different visits is advisedvisits is advised

Proper instructions on maneuver must be Proper instructions on maneuver must be givengiven

PEF measurement in PEF measurement in AsthmaAsthma

Important in both diagnosis and Important in both diagnosis and monitoringmonitoring

Peak flow meters are relatively Peak flow meters are relatively inexpensive, portable, plastic and inexpensive, portable, plastic and ideal for use in home settings for day-ideal for use in home settings for day-to-day objective measurement of to-day objective measurement of airflow limitationairflow limitation

Can underestimate degree of airflow Can underestimate degree of airflow limitation particularly in severe caseslimitation particularly in severe cases

PEF measurement in PEF measurement in AsthmaAsthma

Can be helpful to confirm the Can be helpful to confirm the diagnosis of asthma:diagnosis of asthma: 60 L/min (or 20% or more pre-BD PEF) 60 L/min (or 20% or more pre-BD PEF)

improvement after inhalation of a improvement after inhalation of a bronchodilatorbronchodilator

A diurnal variation of >20% (with twice A diurnal variation of >20% (with twice daily readings >10%)daily readings >10%)

PEF measurement in PEF measurement in AsthmaAsthma

Can help to improve asthma control esp. in Can help to improve asthma control esp. in those with poor perception of symptoms:those with poor perception of symptoms: Self-monitoring using a PEF chartSelf-monitoring using a PEF chart

Can help to identify Can help to identify environmental/occupational causes of environmental/occupational causes of asthma symptoms:asthma symptoms: PEF daily or several times a day over periods PEF daily or several times a day over periods

of suspected exposure to risk factors (at home, of suspected exposure to risk factors (at home, workplace, during exercise or other activities)workplace, during exercise or other activities)

Diagnostic precision leads to Diagnostic precision leads to evidence-based medical careevidence-based medical care Improves patient careImproves patient care Creates better patient satisfactionCreates better patient satisfaction Provides more appropriate referralsProvides more appropriate referrals

Good asthma reviewGood asthma review

• Undertake structured proactive clinical reviews. Consider undertaking reviews by telephone for those patients who cannot attend regularly

• Maintain register of asthma patients

• Patient education and understanding of the role of medication is important to aid compliance and concordance. Use written asthma action plans

Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009:http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf

Patient education and Patient education and self-managementself-management

socially disadvantaged groups, adolescents and the elderlysocially disadvantaged groups, adolescents and the elderly

Provide self-management advice focusing on individual Provide self-management advice focusing on individual needsneeds

Give specific advice on recognising loss of asthma controlGive specific advice on recognising loss of asthma control

Summarise actions required if asthma control deteriorates Summarise actions required if asthma control deteriorates and include information on how to seek help, the role of and include information on how to seek help, the role of oral steroids and how to safely increase medicationoral steroids and how to safely increase medication

Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009:http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf

Self-management will only achieve Self-management will only achieve better health outcomes if the prescribed better health outcomes if the prescribed asthma treatment is appropriate and asthma treatment is appropriate and within recommended guidancewithin recommended guidance

Difficult asthma is often associated with Difficult asthma is often associated with poor adherence to maintenance poor adherence to maintenance treatment and coexistent psychosocial treatment and coexistent psychosocial morbiditymorbidity

Diagnosing asthma in Diagnosing asthma in primary careprimary care

IPCRG guidelines. IPCRG guidelines. Prim Care Respir Prim Care Respir J. J. 2006;15:202006;15:20––34. 34.

Compatible clinical historyCompatible clinical history Episodic or persistent dyspnoea, wheeze, Episodic or persistent dyspnoea, wheeze,

tightness, coughtightness, cough Triggers (allergic, irritant)Triggers (allergic, irritant) Risk factors for asthma developmentRisk factors for asthma development Consider occupational asthma for adults with Consider occupational asthma for adults with

recent onsetrecent onset

InvestigationsInvestigations::

Spirometry or peak expiratory flowSpirometry or peak expiratory flow Eosinophils, IgE levelEosinophils, IgE level Allergy testingAllergy testing Chest x-rayChest x-ray