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					 Lee Dobson

Torbay Hospital
 A brief history of asthma management
                                                                                                             2007
                                                                                                    2001    SMART
                                                                                       1996, 1997 Symbicort
                                                                                  Woolcock & Pauwels
                                          1990                                        Landmark
                                        Serevent                                       studies            Fostair
                                       introduced                1994                                   1999
                                                              Greening, Ind                           Seretide
                                                             Landmark study                      1997 launched
                                                                                                 Oxis
                                           1980s                                      1995 onwards
                                            Major                                        GINA
                                       developments
                                         in asthma
                       1969            management
                                                                     1991
                      Ventolin                                        The

                                 How are we doing?
                    introduced                                     β2 agonist      1993
   Late 60s                                                         debate       Flixotide
Bronchoscope                                             1972
                                                       Becotide                 introduced
                                                      introduced




                    1956            1965
                  3M launch          Intal
                   The MDI       introduced



    Early 1950s
        MDI
                                      Not Well-Controlled asthma (% of treated patients)
% Patients not Well Controlled




                                 80                                                       72
                                 70                                     61
                                 60     55                                                                   56
                                 50              45        45
                                 40
                                 30
                                 20
                                 10
                                  0
                                      Overall    UK      Spain        Italy          Germany             France

NHWS: A population-based cross-sectional survey conducted in 2006 in 2337 patients diagnosed with asthma in France (n=476),
Germany (n=486), Italy (n=223), Spain (n=227) and the UK (n=915)
Not Well-Controlled defined as Asthma Control Test score ≤19


                                                                       Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s
              Data includes 590,000 teenagers
              and 700,000 people over 651

                                                                Total
                                                             5.2 million1




                                                                                             Every 6 hours someone dies from asthma2
                                        Women
                   Men                2.9 million1
               2.3 million1




1. Where Do We Stand? Asthma in the UK Today. Published December 2004. Available at: http://www.asthma.org.uk/how_we_help [Accessed October 2006.]. 2. General
Register Office collated in Office for National Statistics mortality statistics for England and Wales; General Register Office for Scotland; General Register Office for Northern
Ireland collated by the Northern Ireland Statistics & Research Agency (2004).
          It is a myth that only severe                                                      Number of asthma deaths across
           asthma can prove fatal                                           100                   disease severity 2001–2003




                                                             Number of deaths
                                                                                75

          Asthma deaths occur across
                                                                                     53%
           disease severity with deaths                                         50


           occurring in those patients                                          25
                                                                                                 21%
           whose asthma is considered                                                                       16%        10%
           mild-to-moderate                                                     0
                                                                                     Severe    Moderately    Mild     Unknown
                                                                                                 severe

                                                                                                Asthma severity (%)    n=57



Harrison B et al. Prim Care Respir J 2005 Dec; 14: 303–13.
                                     8.0%

                                     7.0%                                    6.7%
% patients registered with asthma




                                                               6.2%                                       6.4%           6.5%
                                                                                            6.1%
                                     6.0%        5.7%


                                     5.0%

                                     4.0%

                                     3.0%

                                     2.0%

                                     1.0%

                                     0.0%
                                               England      NHS South     Torbay Care    Devon PCT      Plymouth     Cornw all &
                                                              West           Trust                    Teaching PCT Isles of Scilly
                                                                                                                        PCT



                                    Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/
                                                                                                         2006/07     2007/08
                                           8.0%

                                                                          6.8%6.7%
                                           7.0%
       % patients registered with asthma




                                                              6.2%6.2%                  6.2%           6.4%6.4%       6.5% 6.5%
                                                                                               6.1%
                                                  5.8% 5.7%
                                           6.0%
                                                                              2009         2010
                                           5.0%

                                           4.0%
                                                                   TCT         10198       10193

                                           3.0%                     SD          8276       8481
                                           2.0%

                                           1.0%

                                           0.0%
                                                  England     NHS South   Torbay Care   Devon PCT       Plymouth     Cornw all &
                                                                West         Trust                    Teaching PCT Isles of Scilly
                                                                                                                        PCT



Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/
   Asthma admissions increased by 30%
     45 more hospital admissions


• Average length of stay decreased by 39%
     From 3.8 days to 2.3 days

   Asthma bed days decreased by 21%
     122 fewer bed days




                  Source: NHS Information Centre: Hospital Episodes Statistics (HES)
            British Thoracic Society (BTS)
Scottish Intercollegiate Guidelines Network (SIGN)
           Definition of asthma

“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 airway response to a
variety of stimuli. Obstruction is often reversible, either
spontaneously or with treatment.”




                                  Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92
   The diagnosis of asthma is a clinical one

   There is no standardised definition, therefore, it is not
    possible to make clear evidence based
    recommendations on how to make a diagnosis

   Central to all definitions is the presence of symptoms
    and of variable airflow obstruction
   Base initial diagnosis on a careful assessment of
    symptoms and a measure of airflow obstruction

   Spirometry is the preferred initial test to assess the
    presence and severity of airflow obstruction (use PEF if
    spirometry not available)

    PEFR –   spirometry unavailable
             occupational
             monitoring
   >1 of the following: wheeze, breathlessness, chest
    tightness, cough, particularly if:
       worse at night and early morning
       in response to exercise, allergen exposure and cold air
       after taking aspirin or beta blockers
       Personal/family history of asthma/atopy
   Widespread wheeze heard on auscultation of the chest
   Unexplained low FEV1 or PEF
   Unexplained peripheral blood eosinophilia
   Prominent dizziness, light-headedness, peripheral tingling
   Chronic productive cough in the absence of wheeze or
    breathlessness
   Repeatedly normal physical examination of chest when
    symptomatic
   Voice disturbance
   Symptoms with colds only
   Significant smoking history (>20 pack-years)
   Cardiac disease
   Normal PEF or spirometry when symptomatic
   Without airflow              With airflow
    obstruction                   obstruction
    Chronic cough syndromes       COPD
    DBS                           Bronchiectasis
    Vocal Cord Dysfunction        Inhaled Foreign Body
    Rhinitis                      Obliterative Bronchiolitis
    GORD                          Large Airway Stenosis
    Heart Failure                 Lung Cancer
    Pulmonary Fibrosis            Sarcoidosis
   Start treatment at the step most appropriate to the initial
    severity of their asthma
   Aim is to achieve early control
   Step up or down with therapy
   Minimal therapy
Before initiating new drug therapy:
   Compliance
   Inhaler technique
   Eliminate trigger factors
Control of asthma, defined as:
       No daytime symptoms
       No night time awakening due to asthma
       No need for rescue medications
       No exacerbations
       No limitations on activity including exercise
       Normal lung function (FEV1 and/or PEF >80% predicted or
        best)


with minimal side effects.
Factors that should be monitored and recorded:
      Symptomatic asthma control using RCP ‘3 questions’, Asthma Control
       Questionnaire or Asthma Control Test (ACT)
      Lung function (spirometry/PEF)
      Exacerbations
      Inhaler technique
      Compliance (prescription refill frequency)
      Bronchodilator reliance (prescription refill frequency)
      Possession of and use of self management plan/personal action plan
Factors that should be monitored and recorded:
      Symptomatic asthma control using RCP ‘3 questions’, Asthma Control
       Questionnaire or Asthma Control Test (ACT)
      Lung function (spirometry/PEF)
      Exacerbations
      Inhaler technique
      Compliance (prescription refill frequency)
      Bronchodilator reliance (prescription refill frequency)
      Possession of and use of self management plan/personal action plan
 Component of action               Result            Practical Considerations
       plan
Symptom vs PEF trigger Similar effect
Standard written instruct Consistently beneficial
Traffic Light             Not better than standard
2-3 action points         Consistently beneficial    <80% - increase ICS
4 action points           No better                  <60% - oral steroids
                                                     <40% - urgent advice
PEF on %personal best     Consistently beneficial    Assess when stable,
PEF on % predicted        No better                  update every few years
ICS and steroids          Consistently beneficial    >400 – steroids
Oral steroids only        Unable to evaluate         200 – increase substant
ICS                       Unable to evaluate         Restart medication
Inhaler devices
   Prescribe inhaled short acting β2 agonist (SABA) as short
    term reliever therapy for all patients with symptomatic
    asthma

   Good asthma control is associated with little or no need for
    short-acting β2 agonist

   Using two or more canisters of β2 agonists per month or >
    10-12 puffs per day is a marker or poorly controlled asthma
    that puts individuals at risk of fatal or near-fatal asthma

   Patients with high usage of inhaled short-acting β2 agonists
    should have their asthma management reviewed
   Inhaled steroids are the recommended preventer drugs
    for adults for achieving overall treatment goals

   Consider inhaled steroids if any of the following:
       Using inhaled β2 agonist three times a week or more
       Symptomatic three times a week or more
       Waking one night a week
       Exacerbation of asthma in the last two years (adults and 5-12
        only)
   Adults:
     200-800mcg/day BDP*(reasonable starting dose
      400mcg per day for many adults)

       Start patients at a dose appropriate to the severity of
        the disease

       Titrate the dose to the lowest dose at which effective
        control of asthma is maintained
Steroid              Equivalent dose (mcg)
Beclomethasone CFC   400
Beclomethasone
Clenil               400
Qvar                 200-300
Fostair              200
Budesonide
Symbicort            400
Fluticasone
Seretide             200
Mometasone           200
Ciclesonide          200-300
   A proportion of patients may not be adequately
    controlled at step 2

   Check and Eliminate

   Adults and Children 5-12:
       First choice as add-on therapy is an inhaled long-acting β2
        agonist (LABA), which should be considered before going
        above a dose of 400mcg BDP* and certainly before going above
        800mcg
   Can’t miss their ICS      Different inhalers – different
                               deposition

   More convenient           Interaction occurs at single
                               cell level

   Increased compliance      Deposition varies from one
                               inhalation to the next

   Pathophysiology?
   If control remains
    inadequate…
   Still uncontrolled..

   Monitor -
     Blood pressure
     Diabetes
     Hyperlipidaemia
     BMD
   Steroid sparing medication
    - Methotrexate
    - Ciclosporin
    - Oral Gold



    Colchicine
    IVIG
    Subcutaneous Terbutaline
    Anti- TNF
   Stepping down therapy once asthma is controlled is
    recommended

   Regular review of patients as treatment is stepped
    down is important

   Patients should be maintained at the lowest possible
    dose of inhaled steroid

   Reductions should be slow, decreasing dose by ~25-
    50% every three months
   Miss BL         1984

   Admission Sep 2006

   Exacerbation asthma, PEFR 200 l/min (normal 450)

   Recent LRTI

   1 Admission to hospital this year, usual control
    adequate

   Known panic attacks – this different
   ? Regular meds – becotide

   At university, smokes!..moderate alcohol!

   Acute management?

   Steroids, ICS, ventolin, RNS, OPD
   Clinic October 2006

   Good recovery, still some SOBOE, started attending
    gym.

   Nocturnal symptoms – none

   Ventolin – three times per week.

   What to do?
   Lifestyle advice

   Compliance

   RNS - Management Plan, Education

   Pre-dose with ventolin

   LABA - Combination inhaler
 UK qualitative and quantitative study to evaluate patient understanding
 of their asthma and determine patient preferences regarding the delivery
 of asthma care and treatment.

  Patient preferences:
      Treatment as simple as possible
      Few inhalers
      Lowest dose of steroid to control symptoms
      Avoid hospitals when possible
      Minimise symptoms




Haughney J et al ERS 2006
                      Self-reported level of control by Not Well-Controlled patients
                40                                   37        40% of Not Well-
                                        34
                35                                            Controlled patients
                30                                           consider themselves
                25                                                 “Well” or
                                                                 “Completely
% Patients




                20
                15                                                Controlled”
                                                                                   11            11
                10             6
                  5
                  0
                       "Completely   "Well                       "Somewhat      "Poorly       "Not at all
                       Controlled" Controlled"                   Controlled"   Controlled"   Controlled"




        Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s
   Mrs TL             24/10/1984

   Clinic Jul 2006

   Asthma age 12

   2 x pregnancies – deteriorated during, brittle++ (Newcastle)

   BIH

   Night waking, morning dipping, wheeze, SOB – 10/40
   Guinea pig and rabbit, shop assistant.

   Bec 250 4 puffs bd, SV 4 puffs bd, ventolin and
    combivent prn.

   SaO2 98%, 2.69/3.58 (3.21/3.68).

   What to do?
   Write to chest consultant
   RNS review – management plan, education
   QVAR - Thrush
   Combination inhaler - tried
   ?LTRA
   ?Nebuliser
   Standby steroids
   Clinic Aug 2006

   Stable
   2.84/3.67 litres
   Plan – no change

   DNA…
   23-year old woman with history of childhood asthma

   Started fitness campaign but suffers from
    breathlessness on exertion

   At clinic, PEF normal
What advice would you give Laura?


What therapy would you recommend if a peak flow diary
showed a stable baseline but short lived dips after
running?
Remember to make an assessment of the probability of
  asthma.

Diagnose before treating – try to confirm diagnosis with
   objective tests before long term therapy is started.
   Increasing symptoms – some help from blue inhaler
   Interested in complementary therapy - Buteyko
   Husband noticed night time coughing – keeping him
    awake!

What would you advise Laura about complementary
treatments for asthma?


   Becomes pregnant.
What would you do now if she was:

(a) not distressed, slightly wheezy with respiratory rate of
    20 breaths/minute, pulse 100 beats/minute and PEF of
    390 L/minute?

(b) looks dreadful, cannot complete sentences, with very
quiet breath sounds on auscultation, respiratory rate 30
breaths/minute, pulse 120 beats/minute and PEF of 120
L/minute?
   No consistent evidence to support use of
    complementary or alternative treatments in asthma

   Continue usual asthma therapy in pregnancy

   Monitor pregnant women with asthma closely to
    ensure therapy is appropriate for symptoms.
   Mr DC          02/09/1969

   Clinic Apr 2004 - Exacerbation March 2004

   Known asthmatic (eczema) – control not so good
    recently (nocturnal symptoms, SOB, reliever ++, PEFR
    down).

   Symbicort 200/6 2 puffs bd

   Green sputum – cefalexin, prednisolone

   What to do?
   Question diagnosis?
     Recent CT scan, alpha-1-antitrypsin level N


   Increase dose Symbicort

   LTRA trial – previously negative

   Bisphosphonate
   Clinic June 2004

   Ig E > 15,000 RAST Aspergillus >4

   Probable Allergic Bronchopulmonary Aspergillosis
    (ABPA)

   Plan - Maintenance prednisolone (10mg), Itraconazole
   Clinic Sept 2004

   Symptomatic - Prednisolone <20mg

   SOB increasing

   PEFR <160 l/min, FEV1/FVC 1.42/3.75 (3.71/4.4)

   Plan – increase inhaled steroid
   Clinic Oct 2004

   Recent exacerbation

   1.11/3.12

   Plan – prednisolone 15mg od, nebuliser
   Clinic Jan 2005 onwards…

   Cramps

   PPI/H2 Antagonist – some benefit

   Not taking ICS! Compliance

   Deranged Liver function tests

   1.57/3.49

   Diabetes - ? Steroid induced

				
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