ASTHMA Dr Liz Gamble BRI
Diagnosis Clinical: wheeze, breathlessness, chest tightness, cough Variable airflow obstruction: peak flow chart, spirometry with reversibility to bronchodilators Airways hyper-responsiveness and inflammation are also components Symptoms and test results vary over time and with treatment
2 or more oral steroid courses in 12 months
Relvar Once daily Fluticasone furoate and vilanterol 92/22 for asthma or COPD, 184/22 for asthma only Fluticasone furoate is more potent: 92mcg od is roughly equivalent to 500mcg of FP For use at step 4 The name suggests reliever but it is a preventer
Tiotropium Tiotropium respimat is licenced for asthma 2 puffs once daily, 5mcg Step 4 option Short term studies
Single inhaler therapy (SIT) Symbicort maintenance and reliever therapy (SMART) 200/6 2p bd + prn max 12 puffs Fostair MART 100/6 1p bd +prn max 8 puffs Duoresp spiromax 160/4.5 1p bd + prn max 8 puffs Reduces exacerbations requiring oral steroids Weak evidence for reduced hospitalizations
Monitoring: RCP 3 questions In the last week/month: Have you had your usual asthma symptoms during the day? Have you had difficulty sleeping because of your asthma symptoms/cough? Has your asthma interfered with your usual activities (housework/work/school)? No to all = good control, yes to any needs action Remember: day/night/life
Learning from asthma deaths 1 There are more asthma deaths in the UK than other European countries Most deaths occur before reaching hospital Most deaths occur in those with chronically severe asthma Most who die have had Underuse of inhaled/oral steroids Inadequate objective monitoring National review of asthma deaths, RCP, 2014
Learning from asthma deaths 2 Some fatal attacks are triggered by NSAIDS or beta-blockers In those who died: PAAPs were underused There was heavy overuse of relievers Adverse psychosocial factors were often present Those who have had a near fatal attack should be under indefinite specialist monitoring Those who have had a severe attack should be under specialist monitoring for a year
National review of asthma deaths: key recommendations Encourage self-management (PAAPs) Smoking cessation Patients should have annual structured review Patients who have received >12 reliever inhalers in the last 12 months should be urgently reviewed Assess inhaler technique Monitor adherence Use combination inhalers Arrange follow-up after emergency attendance
ASTHMA CASES FOR DISCUSSION
Case 1 63 year old man Admitted to BRI in Nov 2016 with asthma exacerbation, previous admission Jan 16 Wheeze and PEFR response to bronchodilator Started Fostair MART (by RNS) Breathing no better, SOB & wheeze Prednisolone x 10 in last year, good response but deteriorates after completing course Nebuliser in hospital was magic Cough & sputum some mornings Ex-smoker
Case 1 - management Unable to remember usual treatment No combination inhaler issued for 4 months Response of symptoms and peak flow to treatment was typical of asthma Switched to once daily inhaler and encouraged to use regularly. When asthma control is poor always review compliance and inhaler technique
Case 2 69 year old lady Asthma since age 8 Salbutamol prn for 20 years SOB on hills, with dust/pollen FEV1 78% predicted post bd, FeNO 11 3x steroid inhalers: side effects Salbutamol X 1-2/week, no prednisolone or admissions
Case 2 - management Patient had stopped ICS, using only prn salbutamol Low levels of inflammation, no exacerbations
Case 3 52 year old woman admitted to BRI with SOB Asthma since age 16, last admission 2 yrs ago Had been using home neb qds for 3 days (bought herself) No cough, sputum, fever PEFR 250 (usual 450), wheezy chest Rx: sirdupla, phyllocontin, montelukast
Case 3 - management Home neb delayed treatment with prednisolone which may have prevented admission Patients requesting a nebuliser should be referred to secondary care for further assessment, to ensure that the diagnosis is correct and that preventer therapy is optimised
Case 4 59 yr old man, asthma since childhood, eczema, previous pneumonia, anaphyllaxis to nuts Wife runs horse stables (he is allergic to horses and avoids them) Wheezy but no cough, 3-4 exacerbations in the last year, recent joint pains and trapped nerve Rx: prednisolone 10mg, Relvar 184/22, salbutamol, co-codamol, ibuprofen, fexofenadine, (montelukast no benefit)
Case 4 Examination: chronic eczema, ulnar weakness L arm, otherwise normal CXR: nil focal FEV1/FVC 1.48/2.78 FEV1 46% predicted, obstructive ratio, eno 39 IgE 13203, RAST + aspergillus, cat, dog, HDM, peanut, grass ANCA + eosinophils 3.41
Case 4 - discussion Steroid dependent asthma with poor control Systemic symptoms Eosinophilia, high IgE, ANCA + Significant history of allergy/atopy + exposures Need to consider eosinophilic granulomatosis with polyangiitis (EGPA or Churg-Strauss syn) or Allergic bronchopulmonary aspergillosis (ABPA)
Case 5 23 year old student nurse Frequent asthma exacerbations with hospital admissions (8-10 per year, 1 ITU admission) Rx: Relvar 184/22, salbutamol, montelukast and aminophylline were unhelpful CXR normal IgE 77, eosinophils max 0.9
Case 5 - discussion Compliance issues addressed Seen by physio for control of breathing HRCT chest normal ANCA negative Lung function tests: consistent with asthma Treated with Omalizamab: no admissions during the 4 month trial period
Difficult to treat asthma Do they have asthma? Do they take their treatment (properly)? Is lifestyle/occupation contributing? Is it drug-induced? (NSAIDs, beta blockers) Is there another pathology? (bronchiectasis, COPD, rhinosinusitis, vocal cord dysfunction, psychological distress, reflux
Investigations Eosinophils, aspergillus serology, RAST, alpha 1 antitrypsin, theophylline level, immunoglobulins, ANCA CXR, CT ENT assessment: nasendoscopy, laryngoscopy Bronchoscopy, echocardiogram, psychiatric assessment
Key points 1 Spirometry is preferred for diagnosis All patients with asthma should be given a personalised self-management plan Check inhaler technique and review adherence to treatment Encourage smoking cessation Avoid obesity Measures to reduce allergens or dietary restrictions have not shown benefit
Key points 2 Tidal breathing is advised for using spacers Use oral steroids in all but mild exacerbations, increased ICS dose has not shown benefit Don t use LABAs without ICS (risk of death) Bronchial thermoplasty can be considered for patients with moderate to severe asthma Breathing exercises can be offered with drug therapy Refer patients if the diagnosis is in doubt or treatment response is poor
Audit/development points Do all your asthma patients have PAAPs? Are any asthma patients on LABA without ICS or separate inhalers? How many patients have had more than 12 salbutamol inhalers in the last year? Is inhaler technique checked as part of asthma reviews?
References https://www.brit-thoracic.org.uk/documentlibrary/clinical-information/asthma/btssignasthma-guideline-2016/ https://www.brit-thoracic.org.uk/documentlibrary/clinical-information/asthma/btssignasthma-guideline-quick-reference-guide-2016/ file:///c:/users/dellto~1/appdata/local/temp/ Why%20asthma%20still%20kills%20full%20repor t.pdf