Asthma Update

Clare AlexanderRSCH

March 2015

Asthma update

What is asthma (spirometry)

BTS guidelines

National review of Asthma deaths

Diagnostic pitfalls

What is AsthmaVariable, reversible airways

obstruction

Est. 3.4 million people have Asthma in the UK

Bronchoconstriction

Inflammatory cellular infiltrateMucus

SpirometryMethod of assessing lung function - patterns

How much “puff”/ “breath” you have

= FVC (Forced vital capacity

How quickly you can force your breath out – i.e. how much resistance?

= FEV1 (Volume (litres) of air expelled in first second of forced expiration

Ratio between resistance or obstruction and the amount of available “breath” – disease patterns

= FEV1/ FVC or FEV1 ratio

British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network

(SIGN)Revised guideline October 2014

Aim of Asthma Management

Complete control - defined as:

No daytime symptoms

No night time wakening due to asthma

No need for rescue medication

No asthma attacks

No exacerbations

No limitations on activity including exercise

Normal lung function (FEV1 +/ or PEF> 80% predicted or best)

Minimal side effects from medication

Treatment strategies

1. Supported Self Management

2. Non- pharmacological Management

3. Pharmacological Management

4. Adherence and Concordance

5. Difficult Asthma

6. Work related Asthma

1. Supported Self Management

Incorporating written personalised asthma action plans (PAAPs)www.asthma.org.uk/control (traffic lights)Based on symptoms +/or PEFRsSupported by regular professional review

Education – linked to patient goalsE.g. Trigger avoidance such as animals, smokingTrained professionalsCulturally appropriate In patients should all receive/ had reviewed PAAPs

www.asthma.org.uk/control

1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?

2. During the past 4 weeks, how often have you had shortness of breath?

3. During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain)

wake you up at night, or earlier than usual in the morning?

4. During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as salbutamol)?

5. How would you rate your asthma control during the past 4 weeks? EDUCATION!

Score

Patient Total Score

Copyright 2002, QualityMetric Incorporated.Asthma Control Test Is a Trademark of QualityMetric Incorporated.

Asthma Control Test™ (ACT)

2. Non- pharmacological Management

Smoking advice and support

Weight loss in overweight patients

Breathing exercise programs (often Physiotherapy lead, RSCH) – “dysfunctional breathing patterns” or hyperventilation.NIJEMEN questionnaire

Exercise

Do not recommend Physical and chemical methods to reduce house dust

mite – ineffective (& expensive). Diets of exclusion (e.g. milk, unless (rarely) clinically

identified – immunologist)

3. Pharmacological Management

The Stepwise Approach

1. Start treatment at the step most appropriate to initial severity

2. Achieve early control

3. Maintain control by:1. Stepping up as necessary

2. Stepping down when control good

Before initiating new drug therapy, check – adherence with existing therapies; inhaler technique & eliminate trigger factors

Adults

Adults

Adults

Adults

Adults

3. Pharmacological Management cont.

Combination inhalers recommended toGuarantee LABAs not taken without ICS Improve inhaler adherence

Stepping downSeverity of asthma, time on current dose,

beneficial effects achieved & pts preferenceSlowly – every 3 months – 25- 50% dose each time

Exercise induced asthma – most patients represents poorly controlled asthmaSABA immediately prior to exercise

Avoid prescribing different inhaler types i.e. powder devices vs aerosols.

4. Adherence and Concordance

Routinely & regularly addressed (accessible pro-active asthma care)

Computer repeat- prescribing systems (practical index)

Non- judgmental discussions

Alternative diagnosis OR Severe/ Brittle

e.g.

COPD

Bronchiectasis

GO reflux

Cardiac failure

Asthma not responding to maximum treatment

Symptomatic at BTS/Sign step 4/5

• Compliance• Symptoms out of proportion• Dysfunctional breathing

5. Difficult Asthma

6. Work related Asthma (& Rhinitis)

At least 1 in 10 cases of new or reappearance of childhood asthma in adult life are attributed to occupation.

Nasal symptoms

Prognosis of Ig-E associated occupational asthma improved by early identification and avoidance.

Objective measures (PEFR at least 4x day) – specialist referrals

High risk Baking, spray paint, lab animals, health & dental care, food

processing, metal / wood/ plastics/rubber, farming + dust

National Review of Asthma Deaths NRAD (2014)

Commissioned by: Healthcare Quality Improvement Partnership (HQIP)

On behalf of: NHS England, NHS Wales, Health and Social Care Division of the Scottish Government, Northern Ireland Department of Health Social Services and Public Safety

Delivered by: Clinical Effectiveness and Evaluation Unit of the Clinical Standards Department of the Royal College of Physicians

Overall aim of NRADTo understand the circumstances

surrounding asthma deaths in the UK, in order to

identify avoidable factors and

make recommendations for changes

to improve asthma care as well as patient self-management

(This was not a prevalence study – did not aim to determine the number of asthma deaths in the UK)

www.rcplondon.ac.uk/

nrad

NRADA multidisciplinary, confidential enquiry of

asthma deaths in Feb 2012 - Jan 2013 in the UK effectiveness of the management

of asthma (acute and chronic) Identify potential avoidable

factors Make recommendations for

changes - to reduce the number of preventable asthma deaths

NRAD

Method

Analysis of 195 people who died from asthma

374 local coordinators

297 hospitals

174 expert clinical assessors (primary and secondary care)

Location of Death

Patient DemographicsDuration of asthma (n=104) : 0-62 yrs (11 yrs)Age at diagnosis (n=102) : 10 mths – 90 yrs (37 yrs)Age at death (n=193) : 4 yrs – 97 yrs (58 yrs)Severity of asthma (n=155):

(classified by the Clinicians) Mild 14 (9%)

Moderate 76 (49%)

Severe 61 (39%)

‘Amount of treatment required to gain control of the asthma’

It is possible that many of those cases defined by their doctors as Mild or Moderate ….. were more severe

Key Findings & Recommendations

Use of NHS services

Medical and professional care

Prescribing and medicines use

Key Findings - use of NHS Services

87 of the 195 (45%) died without seeking medical help or before emergency care could be provided

112 (57%) were not recorded as being under specialist supervision

There was a history of previous hospital admission in 47%

19 (10%) died within 28 days of discharge from hospital

Primary care review of the 195 cases

(in the 12 months before death)

• 64 (33%) - no details on asthma diagnosis

• 70/102 - diagnosed > age of 15 • ? Late onset; ? Delayed diagnosis; ? Recurrence

• 84 (43%) - no record of asthma review 12 mths

• 37 (19%) - had assessment of asthma control

• 44 (23%) - had Personal Asthma Action Plans (PAAP)

• 112 (57%) - not under specialist supervision

 

 

 

www.rcplondon.ac.uk/

nrad

Key Findings - Medical and Professional Care

The majority of people (58%) who died were thought to have mild or moderate asthma

Avoidable factors were identified in 89 (46%) deaths

Exacerbating factors, or triggers, were documented in only half the people who died

Recommendations - Medical and Professional

CareAll patients should have written guidance in the form of

a personal asthma action plans (PAAP), describing triggers, how to prevent relapse and emergency action

Triggers and avoidable factors should be actively sought, and appropriate action taken

Management plans should reflect that the risk of asthma death is increased where there is significant concurrent psychological and mental health issues

All patients with asthma should have a regular structured review, undertaken at least annually

Recommendations - Patient factors, awareness of risk of

poor control

Patient self-management should be encouraged to reflect exposure to known triggers eg before hay fever season

History of smoking and/or exposure to passive smoke should be documented. Current smokers should be offered referral to a smoking cessation service

Parents and children should be educated on the ‘how’, ‘why’ and ‘when’ to use their asthma medications and know how to seek emergency help

Key Findings - Prescribing and medicines use

There was evidence of excessive prescribing of relievers, 6 patients being prescribed more than 50 short acting reliever inhalers in the year before death

There was strong evidence of under prescribing of preventer medications (ICS)

There appeared to be inappropriate prescribing of long- acting beta agonist, either as a single agent without inhaled corticosteroid

Excessive prescribing of Short Acting Beta-Agonist Bronchodilators

(SABAs) (n= 189/194 ; 97%)

Numbers of devices prescribed during final year (n=165)

• Range: 1 to 112; median of 10 inhaler devices• > 6 SABA : 92/165 (56%) inhaler devices• > 12 SABA : 65/165 (39%) inhaler devices• >50 SABA : 6 patients

www.rcplondon.ac.uk/

nrad

Excess need for reliever medication (SIGN/BTS) = Poor asthma control

Inadequate prescribing of Inhaled Corticosteroids (ICS)

ICS +/- Long Acting Beta-agonist Bronchodilator (ICS/LABA)

(n= 168/195 ; 86%)

Number of prescribed devices final year (n=128): Range: 1 to 54, median of 5 inhaler devices• < 4 ICS devices in 12 mths : 49/128 (38%) • < 12 ICS devices in 12 mths : 103/128 (80%)

www.rcplondon.ac.uk/

nrad

Recommendations - Prescribing and medicines

use

People with asthma who have been prescribed more than 12 short-acting reliever inhalers in the past 12 months should be invited for urgent review

Non-adherence with preventer inhaled corticosteroid should be monitored

Use of combination inhalers should be encouraged

Assessment of inhaler technique should be made at annual review and by the pharmacist whenever new inhaled devices are prescribed

Recommendations - use of NHS Services

Every NHS hospital and general practice should have a designated lead for asthma service

Follow up must be undertaken after every attendance at the emergency department or out-of-hours service

A standard national template should be developed to facilitate a structured review

Electronic systems should be developed urgently to alert clinicians to over use of short acting relievers or underuse of preventers

Major factors identified by panels(i.e. contributed significantly to the deaths, where different management would reasonably be expected to have affected the outcome )

www.rcplondon.ac.uk/

nrad

nDid not recognise high-risk status 21Lack of specific asthma expertise 17Did not perform adequate asthma review 16Did not refer to another appropriate team member 16Failure to take appropriate medication in month before death 15Failure to take appropriate medication in year before death 13 Over prescribed short acting beta agonist bronchodilator 13Poor or inadequate implementation of policy/pathway/protocol 13Lack of knowledge of guidelines 12Did not adhere to medical advice 10

Differential Diagnosis & Diagnostic pitfalls

Bronchiectasis (normal, obstructive or restrictive spirometry)

Vocal cord dysfunction (+/- normal spirometry at rest)

COPD – smoking > 20years (fixed obstructive spirometry)

Pulmonary fibrosis – progressive SOB and cough – HRCT scan (restrictive spirometry)

Cardiac failure (restrictive spirometry)

Bronchiectasis “Wet cough” , hard “casts” sputum production Recurrent infections

Poorly controlled asthma High resolution CT Scan Aspergillus Precipitins (IgG) and Aspergillus specific IgE and total

IgE – ABPA (Allergic bronchopulmonary aspergilosis) treatment with prolonged steroid (upto a year) plus itraconazole.

Treatment – Physiotherapy and airways clearance.• Bronchodilators• Prophylactic Antibiotic (> 3-4 infections in a year)