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Asthma Update

Asthma Update. Steve Holmes (GP, Park Medical Practice, Shepton Mallet). NICE quality stand. 1. People with newly diagnosed asthma have a diagnosis made in line with BTS/SIGN guidance. 2. Adults who have recently developed asthma are assessed for causes linked to their place of work.

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Asthma Update

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  1. Asthma Update Steve Holmes (GP, Park Medical Practice, Shepton Mallet)

  2. NICE quality stand • 1. People with newly diagnosed asthma have a diagnosis made in line with BTS/SIGN guidance. • 2. Adults who have recently developed asthma are assessed for causes linked to their place of work. • 3. People with asthma receive a written plan with details of how their asthma will be managed. • 4. People with asthma are given training in using their inhaler before they start any new inhaler treatment. • 5. People with asthma have a review of their asthma and its management at least once a year. • 6. People with asthma who have symptoms have an assessment of how well their asthma is controlled. http://guidance.nice.org.uk/QS25)

  3. 7. People with asthma who go to see a healthcare professional because their symptoms have worsened have their symptoms measured at the time of the appointment. • 8. People aged 5 years or older who see a healthcare professional with severe or life-threatening asthma are given oral or intravenous steroids within 1 hour. • 9. People admitted to hospital with a sudden worsening of asthma have a review by a member of a specialist team before discharge. • 10. People who received treatment in hospital or through out-of-hours services for a sudden worsening of their asthma see a healthcare professional in their own GP practice within 2 working days of treatment. • 11. People with asthma that is difficult to control are offered an assessment by a team that specialises in managing ‘difficult asthma’.

  4. Areas covered in this presentation • What is asthma? • Facts and figures • Aetiology (causes / triggers) • Diagnosis including differential diagnoses • Associated morbidities • Treatment / medication guidelines • Management of acute asthma • Adherence, concordance and all that stuff

  5. Definition of asthma – what did the experts say in 2003? “A chronic inflammatory disorder of the airways…In susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airways response to a variety of stimuli. Obstruction is often reversible either spontaneously or with treatment” British guideline on the management of asthma. Thorax 2003;58 (Suppl 1):i1–94.

  6. Definition of asthma – what did the experts say in 2012? • The diagnosis of asthma is a clinical one; there is no standardised definition of the type, severity or frequency of symptoms, nor of the findings on investigation. • Central to all definitions is the presence of symptoms (more than one of wheeze, breathlessness, chest tightness, cough) and of variable airflow obstruction. BTS & SIGN British Guideline on the Management of Asthma May 2008 Revised January 2012 http://www.brit-thoracic.org.uk/Portals/0/Guidelines/AsthmaGuidelines/sign101%20Jan%202012.pdf

  7. Facts and Figures

  8. Discussion Point • How common is asthma? • How many people die from asthma? • How many people are admitted?

  9. Facts and figures - prevalence • Asthma is the most common symptomatic long-term condition and has a known prevalence of 5.9% in QOF data. (UK population 62.1m; 3.65 million people with asthma on current treatment)1 • Asthma UK suggest 1.1 million children (1 in 11) and 4.3 million adults (1 in 12) in the UK are currently receiving treatment for asthma2 1 - NHS Information Centre, 2012 Quality Outcome Framework figures 2010-2011 2 –Asthma UK – accessed: http://www.asthma.org.uk/news-centre/facts-for-journalists/ on 31/7/2012

  10. Key Facts • In 2010 there were 1017 deaths attributed to asthma 1 • 68, 532 admissions for asthma from July 2010 – 2011 • 56.9% female • 40% were aged 16y or younger 1- The NHS Information Centre

  11. Cost implications of asthma • Direct healthcare costs associated with asthma are estimated as £1,000 million per year1 • GP prescriptions alone were estimated at £600 million per year in 20022 • 12.7 million lost working days per year3 • 80% of asthma expenditure is spent on 20% of people with most severe asthma4 1 – Asthma UK 2 – Department of Health. Prescription Cost Analysis 2004. 2004 3 - Department of Work and Pensions Income and Disability Income benefit days claimed. 2003. 4 - Chung F et al . Severe therapy resistant asthma. European Respiratory Monthly. 2003 23:313

  12. http://www.inhale.nhs.uk/think-pieces/commentary/asthma-data-tool-release.htmhttp://www.inhale.nhs.uk/think-pieces/commentary/asthma-data-tool-release.htm

  13. Discussion Point • What are the causes of asthma? • What can trigger an asthma attack?

  14. Aetiology Early-life predictors of adult asthma include: • parental asthma • sibling asthma/allergy • repeated early-life wheezing • maternal smoking during pregnancy and • post-natal exposure to tobacco smoke Piippo-Savolainen E, Korppi M. Long-term outcomes of early childhood wheezing. CurrOpin Allergy ClinImmunol. 2009;9:190-6.

  15. Triggers Adapted from Asthma UK Website (2013) • Allergens • Viral Infections (URTI) • Emotions • Exercise • Medication • Salicylates • NSAIDs • Betablockers • Air pollution • Diesel • Tobacco • Perfumes • Weather • “Start of school term”

  16. Triggers - Allergens Aeroallergens • House dust mites • Pollens • Tree Pollens • Grass Pollens • Weed Pollens • Animals • Cats, Dogs, Horses etc • Moulds

  17. Making a diagnosis of asthma

  18. Discussion Point • What is your routine practice in making a diagnosis of asthma? • What tips have you got to share? • What do you do if you are uncertain?

  19. Obstructive FEV/FVC <70% Normal FEV/FVC >70% Investigate and treat alternative diagnosis Trial of Treatment Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral Response? Response? Reconsider probable diagnosis Further investigation Yes No No Yes Asthma diagnosis confirmed Continue Rx Manage according to alternative diagnosis ADULT with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) Intermediate Probability Low Probability High Probability 20

  20. Patient with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) • 1)Symptoms (cough, wheeze, SOB or chest tightness): • worse at night and in the morning • in response to exercise, allergen exposure and cold air • after taking aspirin or beta blockers • 2) History of atopic disease • 3) Family history of asthma or atopic disease • 4) Widespread wheeze • 5) Evidence of airway narrowing • NB Normal spirometry when free of symptoms does not exclude asthma) High Probability 21

  21. Trial of Treatment Response? Yes Patient with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) High Probability Asthma diagnosis confirmed Continue Rx 22

  22. Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral No Patient with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) High Probability Trial of Treatment Response? Yes Asthma diagnosis confirmed Continue Rx 23

  23. Low Probability Patient with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) • Low probability equals: • Cough in the absence of wheeze or breathlessness • Prominent dizziness, light headedness, peripheral tingling • Repeatedly normal clinical examination even when symptomatic • No evidence of airway narrowing when symptomatic • Voice disturbance • Symptoms with colds only • Chronic productive cough • Significant smoking history (>20 pack years) • Cardiac disease High Probability Trial of Treatment Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral Response? Yes No Asthma diagnosis confirmed Continue Rx 24

  24. Investigate and treat alternative diagnosis Response? Yes Patient with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) Low Probability High Probability Trial of Treatment Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral Response? Yes No Asthma diagnosis confirmed Continue Rx Manage according to alternative diagnosis 25

  25. Reconsider probable diagnosis Further investigation No Patient with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) Low Probability High Probability Investigate and treat alternative diagnosis Trial of Treatment Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral Response? Response? Yes No Yes Asthma diagnosis confirmed Continue Rx Manage according to alternative diagnosis 26

  26. Obstructive FEV/FVC <70% Normal FEV/FVC >70% Patient with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) Intermediate Probability Low Probability High Probability Investigate and treat alternative diagnosis Trial of Treatment Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral Response? Response? Reconsider probable diagnosis Further investigation Yes No No Yes Asthma diagnosis confirmed Continue Rx Manage according to alternative diagnosis 27

  27. Trial of Treatment Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral Response? Yes No Asthma diagnosis confirmed Continue Rx Patient with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) Intermediate Probability Low Probability High Probability Obstructive FEV/FVC <70% Normal FEV/FVC >70% Investigate and treat alternative diagnosis Response? Reconsider probable diagnosis Further investigation No Yes Manage according to alternative diagnosis 28

  28. Patient with symptoms that may be due to asthma Clinical History and examination Spirometry (or PEF if spirometry not available) Intermediate Probability Low Probability High Probability Obstructive FEV/FVC <70% Normal FEV/FVC >70% Investigate and treat alternative diagnosis Trial of Treatment Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral Response? Response? Reconsider probable diagnosis Further investigation Yes No No Yes Asthma diagnosis confirmed Continue Rx Manage according to alternative diagnosis 29

  29. Diagnosing asthma– we might need to look further Objective evidence Spirometry or peak expiratory flow Bronchoprovocation test (methacholine challenge) Ancillary tests Chest x-ray Eosinophils, IgE level Allergy testing Exhaled nitric oxide Induced sputum eosinophils IPCRG guidelines. Prim Care Respir J. 2006;15:20–34.

  30. Clin Respir J 2013; 7: 204–213.

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