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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
