1. Asthma: how to prevent readmission and death Simon Quantrill Consultant chest physician Whipps Cross Chest Clinic BMJ 1967:

3. Asthma: the challenges Death Readmissions/admissions Concordance, action plans, PEF Underestimation of severity Underdiagnosis BTS standards Financial penalties

4. Asthma: admissions to Whipps Cross

5. Prevention of exacerbation/admission/death – case history 53 year old woman, asthmatic, never smoker Joined GP practice in 1994, taking salb + beclo previously Resp symptoms August 1997 reviewed 4 times in 3 weeks, wheeze noted on examination October 1997 salbutamol PRN 2001 and 2002 cough – no treatment Dec 2005 chesty cough 8 weeks. 2 courses antibiotics. Feb 2006 wheeze – salbutamol restarted: diagnosis “viral-induced wheeze”. Next review Dec 2006 “asthma resolved suspect nocturnal wheeze only”. April 2008 exacerbation asthma – inhaled steroid added. May 2008 exacerbation asthma. October 2008 prescription for salbutamol 2p tds January 2009 died of acute asthma

6. Who dies of asthma and where? 1300 deaths annually in UK Median age >50 years old Median age of onset asthma 30 years Obese 30% Psychosocial factors 50% 80% ever admitted to hospital with asthma 18% previously ventilated 64% severe, 29% moderate, 7% mild asthma 50% never attended hospital respiratory clinic 90% died in community (inc 20% in A&E) 80% may be preventable (mixture of patient and healthcare professional factors) Sturdy PM. Thorax 2005;60:909-15, Burr ML. Thorax 1999;54:985-9, Rea HH. Thorax 1986;41:833-9.

7. Things we need to do for asthmatics 1.Get better at diagnosis

8. Asthma is underdiagnosed n=86/1155 (7%) with  FEV1 + symptoms Van Schayck C. Thorax 2000;55:562-5

9. Childhood asthma is markedly underdiagnosed Speight ANP. BMJ 1983;286:1253-6

10. Why is asthma underdiagnosed? To avoid parental anxiety Stigma attached to “asthma” word Because of the belief that “wheezy bronchitis” etc is a separate entity Because infective exacerbations are labelled as “chest infections” Because people don’t always complain to their doctor of chest symptoms Because doctors don’t always take careful histories To avoid a shed load of work eg detailed history, PEF recordings, lung function, time-consuming patient education To avoid a difficult conversation with people who don’t want to have asthma Because making a new diagnosis of asthma seems a big thing and the implications are big, eg need for long-term inhaled steroids Because lack of continuity of care in hospital means it will be someone else’s problem the next day

11. Improving asthma diagnosis: history Intermittent breathlessness, wheeze, cough Diurnal variation, esp worse at night or early am Reduction in exercise tolerance, ability to comfortably accomplish tasks Recurrent “chest infections” Association with hayfever, eczema Family history Smoking

12. Asthma diagnosis: examination Wheeze nearly always present at some point, but not always at first Wheeze nearly always = asthma (or other obstructive airways disease, eg COPD, bronchiectasis)

13. Asthma diagnosis: tests of airflow obstruction Peak flow monitoring -over at least 2 weeks -even better if during a “chest infection” Spirometry -will need at least two done some time apart -even better if during a “chest infection” or otherwise symptomatic -normal does not exclude asthma -beware of interpretation of FEV1/FVC ratio with raised BMI

14. Asthma is underdiagnosed: case history 64 yr female Breast cancer + lung mets Mild LLL pneumonia Crackles wheeze Oral steroids + nebs Seretide 500 1p bd PEF recordings

15. Peak flows are crucial to the diagnosis 75 yr old man, retired engineer, stopped smoking 15 years ago “Unwell for 5/52, coughing ++, white sputum, SOB on exertion” No improvement with amoxycillin “no past h/o COPD” O/e crackles on admission Wheezes and crackles thereafter Treatment: antibiotics, nebulised salbutamol, prednisolone Discharged after 6 days to finish course of antibiotics and chest clinic follow-up Diagnoses on discharge summary: “COUGH, BILATERAL BRONCHITIS, POSSIBLE COPD”

16. Asthma is underdiagnosed: case history 28 yr female, 23 weeks pregnant, admitted Nov 2011, cough, sputum, dyspnoea Wheeze noted on auscultation, 2 doses prednisolone and 5 nebs salbutamol given (Why did this patient not have PEFs recorded despite having bronchodilators and steroids) Diagnosis at discharge: “LRTI”, given co-amoxiclav Readmitted Jan 2012: 30/40, wheezy, PEF 175 Oral steroids + nebs Discharged on Symbicort Update May 2012: Symbicort SMART regime, FEV1 86% Sep 2012: Asthma Control Test 25/25

17. Things we need to do for asthmatics 1.Get better at diagnosis 2.Get better at severity assessment, and: 3.Treat accordingly by stepping therapy up and down

18. Asthma severity is underestimated and asthma is therefore undertreated POMS: 71% not-well controlled, 19% badly uncontrolled 80% satisfied with control and 76% thought well-controlled Disconnect between asthma control and perception of symptoms

20. Some asthmatics are poor perceivers of breathlessness Poor perceptionGood perception Presented to GP1 (6%)15 (94%) Did not present to GP8 (26%)23 (74%) Van Schayck C. Thorax 2000;55:562-5Histamine challenge test with Borg scores 9/47 were poor perceivers in this test

21. Poor perceivers are at higher risk of death and near-fatal asthma Poor perceivers (n=29) Normal perceivers (n=67) High perceivers (n=17) ED visits32814 Hosp admission2243 Near-fatal asthma1321 Death610 Magadle R. Chest 2002;121:329-3 n=113, stable asthmatic out-patients, breathing against increasing levels of resistance, + Borg score

22. Prevention of exacerbation/admission/death – case history 7 yr old, known asthma, seen in A+E triage ?asthma attack, prednisolone given, 3/7 cough worse at night, SOB, using salbutamol with improvement. Imp: URTI. Became worse and saw GP, given salbutamol and prednisolone 5/7 2/52 later, in A+E, wheeze, cough, SOB. “On steroid + salbutamol inhaler”. Wheeze noted. Imp: Unstable asthma. 10 puffs salbutamol + ipratropium given, + prednisolone. Home with “atrovent 2 puffs bd + salbutamol, GP to review asthma medication control”. 2/52 later, in A+E, cough, SOB, on “Atrovent (not used as expired), Seretide BD, (triage - Becotide)”. Wheeze + subcostal recession noted. Imp: resp tract infection exacerbating asthma ?poorly controlled (no steroid inhaler ?as a result of changing meds). Prednisolone and salb nebs given. “Advised to use atrovent inhaler + go home with prednisolone. Leaflet on asthma given. Advised to see GP asap for an asthma review, advice given on how to take inhalers.” 2/52 later collapsed at home after severe asthma attack, unresponsive to salbutamol. Asystolic cardiac arrest, pronounced dead in A+E. Medication: Ventolin PRN, Seretide (“green inhaler”) BD, Previously been on Becotide”.

23. Asthma steps management Notes: Step down if possible every 3-6 months Step boundaries are blurred Consider also exacerbations and lung function

24. Assessing asthma control: RCP 3 questions In the last month: Have you had difficulty sleeping because of your asthma? Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, or breathlessness)? Has your asthma interfered with your usual activities (eg housework, work, school etc) “No” to all = well-controlled asthma

25. Assessing asthma control: the Asthma Control Test

26. Better care is associated with fewer readmissions Slack R. Quality in Health Care 1997;6:194-8.

27. Things we need to do for asthmatics 1.Get better at diagnosis 2.Get better at severity assessment, and: 3.Treat accordingly by stepping therapy up and down 4.Do serial peak flows especially when chesty

28. Patients discharged with PEF variability >25% are more likely to relapse Udwadia ZF. J R Coll Phys Lon 1990;24:112-4.

29. Things we need to do for asthmatics 1.Get better at diagnosis 2.Get better at severity assessment, and: 3.Treat accordingly by stepping therapy up and down 4.Do serial peak flows especially when chesty 5.Educate inc inhaler technique, and: 6.Discuss action plan, and: 7.Rescue pack of prednisolone

30. Specialist nurse patient education reduces readmissions Two hospital specialist nurses in East London Patients reviewed in clinic within GP practice after discharge Inhaler technique PEF-based action plan (self- management plan) Supply of rescue OCS Griffiths C et al. BMJ 2004;328:144

31. PEF-based action plans reduce readmissions Osman LM. Thorax 2002;57:869-74

32. PEF-based action plans reduce admissions Cowie RL. Chest 1997;112:1534-8 n=150, prior A&E visit, 6 month study

33. Things we need to do for asthmatics 1.Get better at diagnosis 2.Get better at severity assessment, and: 3.Treat accordingly by stepping therapy up and down 4.Do serial peak flows especially when chesty 5.Educate inc inhaler technique, and: 6.Discuss action plan, and: 7.Rescue pack of prednisolone, PEF meter and diary 8.Advise see GP/asthma nurse next working day, and: 9.Book OPA with Specialist Nurse within 4 weeks (or consultant)

34. Follow-up within 30 days by a GP or respiratory physician is associated with fewer readmissions Sin DD. Am J Med 2002;112:120-5. N=25,256 COPD + asthma 85% GP, 15% Resp physician In asthma: 25%  readmissions

35. Prevention of admission, readmission and death due to asthma: what to do when you review patients next working day Therapy stepped up, eg beclo  Symbicort, or montelukast added Appropriate length oral steroids given, usually 10-14 days Rescue pack oral steroids given Inhaler technique checked, recorded and satisfactory Asthma education/compliance addressed Action plan given and understood PEF meter given and diary carding twice a day OPA booked for within 4 weeks with Specialist Airways Nurse/Chest Consultant