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Comprehensive Guide to Understanding and Managing Asthma: Expert Insights and Effective Strategies

Dive into the world of asthma with Dr. Ian Clifton, Consultant Respiratory Physician, as he provides an overview of asthma including background, diagnosis, investigations, chronic asthma management, and a stepwise approach. Discover the importance of combined reliever/preventer therapy, patient education, and creating personalized management plans. Learn about acute and difficult asthma cases, the history, symptoms, examination, alternative pathways, investigations, chronic asthma management, and effective management plans, while understanding factors that affect drug delivery to the lungs. Explore the challenges, misuses of inhalers, allergen avoidance, and stress management strategies. Assess asthma control, understand management plans, and utilize various assessment tools. Join the discussion on patient expectations and the International Control of Asthma Symptoms survey findings. Enhance your knowledge and skills in managing asthma effectively.

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Comprehensive Guide to Understanding and Managing Asthma: Expert Insights and Effective Strategies

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  1. www.backtomedicalschool.co.uk

  2. 18th April • Understanding the ECG • Asthma • Heart failure • Inflammatory bowel disease Moor Allerton Golf Club

  3. www.backtomedicalschool.co.uk

  4. 6th June • Acute abdomen • Palliative care – the last few days • Itchy skin • A lump in the thyroid Moor Allerton Golf Club

  5. www.backtomedicalschool.co.uk

  6. Asthma Dr Ian Clifton Consultant Respiratory Physician Leeds Difficult Asthma Service

  7. Overview • Background • Diagnosis • History • Investigations • Chronic asthma management • Stepwise approach • Combined reliever / preventer therapy • Management plan • Patient education • Acute asthma • Difficult asthma

  8. Background

  9. Definition • GINA 2008 • Chronic inflammatory disorder of the airways • Airway hyper-responsiveness • Recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. • Variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment.

  10. Background • It is common • 5.4 million people in the UK currently receive asthma treatment • 1 in 5 households contain someone with asthma • 67,700 hospital admissions in 2004 • Cost of hospital admissions for asthma was £58.3 million in 2004

  11. Is it a problem? • During 2004 risk of hospital admissions for asthma were highest in North West SHA (30% higher) • Followed by Yorkshire & Humberside SHA (20% higher) • 10% of people with difficult asthma consume 50% of “asthma resources”

  12. Differences between practices within Leeds PCT HES data/QOF outcomes 2008/09

  13. History • Tend to be variable, intermittent, worse at night and provoked by triggers: • Wheeze • Shortness of breath • Chest tightness • Cough, particularly at night and early in the morning • Difficulty in sleeping • Chest pain • Vomiting

  14. History • Other atopic illness or family history • Hayfever • Eczema • Occupational history • Specific triggers • Drugs • Allergens • Exercise

  15. Examination • May be normal • Wheeze on auscultation of chest

  16. Symptoms worse at night & in the early morning Symptoms in response to exercise, allergen exposure & cold air Symptoms after taking aspirin or beta-blockers History of atopy Family history of atopy Wheeze heard on auscultation Otherwise unexplained low FEV1 or PEF (historical or serial readings) Peripheral blood eosinophillia Prominent dizziness, light-headedness, peripheral tingling Chronic productive cough in the absence of wheeze or breathlessness Repeatedly normal physical examination of the chest when symptomatic Voice disturbance Symptoms with colds only Significant smoking history (> 20 pack-years) Cardiac disease Normal PEF or spirometry when symptomatic Asthma Alternative

  17. Suggested Pathway

  18. Spirometry traces Volume – time traces Flow - volume traces

  19. Spirometry • Airflow obstruction • FEV1 / FVC < 70% • Reversibility testing • >400mL improvement in FEV1 (NICE/BTS) • >200mL improvement in FEV1 or FVC (ERS/ATS) • >12% improvement in FEV1 or FVC (ERS/ATS) • <10% or <200mL improvement probably not significant

  20. Investigations • Spirometry • PEF • CXR • Serum IgE / FBC • Airway hyper-responsiveness • Exhaled nitric oxide

  21. Chronic asthma management

  22. Aim of management • Assessing Asthma Control • Treating to Achieve Control • Monitoring to Maintain Control

  23. The process in more detail Crompton et al 2006

  24. Examples of ‘Poor’ Technique Date of Preparation: June 2012 UK/CPD/0012/12

  25. Factors determining drug delivery to lung

  26. How Frequently are Patients able to Use Inhaler Devices? Lenny J et al. RespMed 2000;94:496-500

  27. Misuse of Inhalers is Associated with Decreased Asthma Stability • AIS = Asthma Instability Score • 0: best asthma stability • 9: worst asthma stability Frequency distribution of the number of errors in inhalation technique (left axis) Asthma Instability Score (right axis) Giraud V. Eur Respir J 2002;19:246-51.

  28. The importance of inhalation Voshaar Tet al Pneumologie2001.

  29. Other issues • Allergen avoidance • Pets • Occupation • HDM • Stress • Is it asthma or other precipitating factors? • Reflux • Alternative diagnosis

  30. Management plans • Consistently beneficial • Standard written instructions • 2-3 action points • Based on symptoms and percentage best PEF • Increase inhaled steroid (60-80%) • Start oral steroid (50-60%) • Seek medical attention (<50%)

  31. Assessment of control • RCP 3 Questions • Juniper Asthma Control Questionnaire • Asthma Control Test • Spirometry • PEF • Exhaled nitric oxide

  32. Do patients have low expectations? • International Control of Asthma Symptoms (ICAS) survey 1 • 802 asthma patients: • 90% of patients expected to have symptoms as part of having asthma • 91% said they would consult their GP if they thought it was possible to live without asthma symptoms 1. Bellamy D, Harris T. Primary Care Respiratory Journal 2005 14, 252-258

  33. Are healthcare workers any better Prieto L et al. Journal of Asthma 2007: 44:461-467

  34. Step 1 • Short acting beta agonist alone

  35. Step 2 • Low dose inhaled corticosteroid 200-400mcg BDP per day Generally 400mcg BDP per day is usual dose Steroid conversions 100mcg beclomethasone 100mcg extrafinebeclomethasone 50mcg fluticasone 100mcg budesonide

  36. Step 3 • Add long acting beta agonist as combination therapy • Flutiform – Formoterol / Fluticasone (MDI) • Fostair – Formoterol / Beclomethsone (MDI) • Seretide – Salmeterol / Fluticasone (MDI/Accuhaler) • Symbicort – Formoterol / Budesonide (Turbohaler) • Other alternatives • Increase the inhaled corticosteroid • Add leukotriene antagonist • Add theophylineprepration

  37. Step 3 – LABA strategies • “Total Control” • Up-titration of inhaled steroid / LABA to gain control as per guidelines • “SMART” • Use of combination reliever / preventer to titrate inhaled steroids according to symptoms

  38. Window of opportunity to prevent exacerbations? Profile of 425 exacerbations % Change from day –14 Night-time symptoms 100 SABA rescue use Window of opportunity to increase anti-inflammatory? 80 …..… hypothetical outcome 60 40 20 0 –15 –10 –5 0 5 10 15 Days before and after an exacerbation Adapted from Tattersfield A et al. Am J Respir Crit Care Med 1999; 160:594-599

  39. Step 4 • High dose inhaled steroid up to 2000mcg BDP / day • Trials of / continue with • LABA • Leukotriene antagonist • Theophylline preparation

  40. Step 5 • As per step 4 • Regular / maintenance oral steroid • Steroid sparing agents • Anti-IgEtherepy

  41. Acute asthma

  42. Categories of acute asthma • Near fatal • Life-threatening • Acute-severe • Moderate asthma • Brittle asthma • Type I – prolonged wide PEF variability • Type II – sudden severe attacks on stable background

  43. Moderate asthma • Increasing symptoms • PEF >50-75% best or predicted • no features of acute severe asthma

  44. Acute-severe asthma • Any one of: • PEF 33-50% best or predicted • respiratory rate ≥25/min • heart rate ≥110/min • inability to complete sentences in one breath

  45. Life-threatening asthma

  46. Near-fatal asthma • Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

  47. Criteria for admission / discharge • Needs admitting • Life-threatening or near fatal attack • Acute-severe attack persisting after initial treatment • Potentially can be discharged • Patients with PEF > 75% 1hr after initial treatment unless other criteria • still have significant symptoms • concerns about compliance • psychosocial problems • physical disability or learning difficulties • previous near-fatal or brittle asthma • exacerbation despite adequate dose steroid tablets pre-presentation • presentation at night • pregnancy.

  48. Managment • Steroids • Predisolone 40mg od • Hydrocortisone 100mg qds • Needs at least 5 days treatment • Do need to taper unless on steroids for >3/52 • Bronchodilators • Beta agonists either via nebuliser or MDI+spacer

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