Transcript Slide 1

Asthma Update
Clare Alexander
RSCH
March 2015
Asthma update
 What is asthma (spirometry)
 BTS guidelines
 National review of Asthma deaths
 Diagnostic pitfalls
What is Asthma
 Variable, reversible airways obstruction
Bronchoconstriction
Inflammatory
cellular infiltrate
Mucus
 Est. 3.4 million people have Asthma in the UK
Spirometry
Method 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 PEFRs
 Supported by regular professional review
 Education – linked to patient goals
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E.g. Trigger avoidance such as animals, smoking
Trained professionals
Culturally appropriate
In patients should all receive/ had reviewed PAAPs
www.asthma.org.uk/control
3.
Asthma Control Test™ (ACT)
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?
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!
Copyright 2002, QualityMetric Incorporated.
Asthma Control Test Is a Trademark of QualityMetric Incorporated.
Patient Total Score
Score
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.
2.
Stepping up as necessary
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 to
 Guarantee LABAs not taken without ICS
 Improve inhaler adherence
 Stepping down
 Severity of asthma, time on current dose, beneficial
effects achieved & pts preference
 Slowly – every 3 months – 25- 50% dose each time
 Exercise induced asthma – most patients represents
poorly controlled asthma
 SABA 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
5. Difficult Asthma
Alternative diagnosis OR Severe/ Brittle
• Compliance
• Symptoms out of proportion
• Dysfunctional breathing
e.g.
Asthma not responding
to maximum treatment
COPD
Bronchiectasis
GO reflux
Cardiac failure
Symptomatic at BTS/Sign
step 4/5
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 NRAD
To 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 selfmanagement
(This was not a prevalence study – did not aim to determine
the number of asthma deaths in the UK)
www.rcplondon.ac.uk/nrad
NRAD
A 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 Demographics
 Duration 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
Moderate
Severe
14 (9%)
76 (49%)
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 Care
 All 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 BetaAgonist Bronchodilators (SABAs)
(n= 189/194 ; 97%)
Excess need for reliever medication (SIGN/BTS) = Poor
asthma control
 Numbers of devices prescribed during final year (n=165)
• Range: 1 to 112; median of 10 inhaler devices
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> 6 SABA : 92/165 (56%) inhaler devices
> 12 SABA : 65/165 (39%) inhaler devices
>50 SABA : 6 patients
www.rcplondon.ac.uk/nrad
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 )
Did not recognise high-risk status
Lack of specific asthma expertise
Did not perform adequate asthma review
Did not refer to another appropriate team member
Failure to take appropriate medication in month before death
Failure to take appropriate medication in year before death
Over prescribed short acting beta agonist bronchodilator
Poor or inadequate implementation of policy/pathway/protocol
Lack of knowledge of guidelines
Did not adhere to medical advice
www.rcplondon.ac.uk/nrad
n
21
17
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13
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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)