Download Asthma

Lee Dobson
Torbay Hospital
A brief history of asthma management
2007
2001
SMART
1996, 1997 Symbicort
1990
Serevent
introduced
1969
Ventolin
introduced
Late 60s
Bronchoscope
1980s
Major
developments
in asthma
management
Fostair
1999
Seretide
1997 launched
Oxis
1995 onwards
GINA
1991
The
β2 agonist
debate
How are we doing?
1972
Becotide
introduced
1956
3M launch
The MDI
Early 1950s
MDI
1994
Greening, Ind
Landmark study
Woolcock & Pauwels
Landmark
studies
1965
Intal
introduced
1993
Flixotide
introduced
% Patients not Well Controlled
Not Well-Controlled asthma (% of treated patients)
80
70
60
50
40
30
20
10
0
72
61
55
Overall
45
45
UK
Spain
Italy
56
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
Men
2.3 million1
Women
2.9 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
asthma can prove fatal
Asthma deaths occur across
disease severity with deaths
occurring in those patients
whose asthma is considered
mild-to-moderate
Number of asthma deaths across
disease severity 2001–2003
100
Number of deaths

75
50
53%
25
21%
16%
0
Severe
Moderately
severe
Mild
Asthma severity (%)
Harrison B et al. Prim Care Respir J 2005 Dec; 14: 303–13.
10%
Unknown
n=57
% patients registered with asthma
8.0%
6.7%
7.0%
6.2%
6.0%
6.1%
6.4%
6.5%
5.7%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
England
NHS South
West
Torbay Care
Trust
Devon PCT
Plymouth
Cornw all &
Teaching PCT Isles of Scilly
PCT
Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/
2006/07
% patients registered with asthma
8.0%
6.8%6.7%
7.0%
6.0%
5.8% 5.7%
6.2%
6.2%6.2%
6.1%
2009
2010
6.4%6.4%
2007/08
6.5% 6.5%
5.0%
4.0%
TCT
10198
10193
3.0%
SD
8276
8481
2.0%
1.0%
0.0%
England
NHS South
West
Torbay Care
Trust
Devon PCT
Plymouth
Cornw all &
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
obstruction

With airflow
obstruction
Chronic cough syndromes
COPD
DBS
Vocal Cord Dysfunction
Rhinitis
GORD
Heart Failure
Pulmonary Fibrosis
Bronchiectasis
Inhaled Foreign Body
Obliterative Bronchiolitis
Large Airway Stenosis
Lung Cancer
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
plan
Result
Practical Considerations
Symptom vs PEF trigger Similar effect
Standard written instruct Consistently beneficial
Traffic Light
Not better than standard
2-3 action points
4 action points
Consistently beneficial
No better
<80% - increase ICS
<60% - oral steroids
<40% - urgent advice
PEF on %personal best
PEF on % predicted
Consistently beneficial
No better
Assess when stable,
update every few years
ICS and steroids
Oral steroids only
ICS
Consistently beneficial
Unable to evaluate
Unable to evaluate
>400 – steroids
200 – increase substant
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


More convenient


Increased compliance


Pathophysiology?
Different inhalers – different
deposition
Interaction occurs at single
cell level
Deposition varies from one
inhalation to the next

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 ~2550% every three months

Miss BL

Admission Sep 2006

Exacerbation asthma, PEFR 200 l/min (normal 450)

Recent LRTI


1984
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
40
35
30
% Patients
25
20
15
10
Self-reported level of control by Not Well-Controlled patients
37
40% of Not Well34
Controlled patients
consider themselves
“Well” or
“Completely
Controlled”
11
11
"Poorly
Controlled"
"Not at all
Controlled"
6
5
0
"Completely
"Well
Controlled" Controlled"
"Somewhat
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

Clinic Apr 2004 - Exacerbation March 2004

02/09/1969
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