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

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

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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

33. 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

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

36. Step 1 • Short acting beta agonist alone

37. 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

38. 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

39. 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

40. 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

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

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

43. Acute asthma

44. 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

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

46. 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

47. Life-threatening asthma

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

49. 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.

50. 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