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Lee Dobson Torbay Hospital. Early 1950s MDI Early 1950s MDI 1956 3M launch The MDI 1956 3M launch The MDI 1965 Intal introduced 1965 Intal introduced.

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Presentation on theme: "Lee Dobson Torbay Hospital. Early 1950s MDI Early 1950s MDI 1956 3M launch The MDI 1956 3M launch The MDI 1965 Intal introduced 1965 Intal introduced."— Presentation transcript:

1 Lee Dobson Torbay Hospital


3 Early 1950s MDI Early 1950s MDI M launch The MDI M launch The MDI 1965 Intal introduced 1965 Intal introduced 1972 Becotide introduced 1972 Becotide introduced 1991 The β2 agonist debate 1991 The β2 agonist debate 1993 Flixotide introduced 1993 Flixotide introduced 1995 onwards GINA 1995 onwards GINA 1999 Seretide launched 1999 Seretide launched Late 60s Bronchoscope Late 60s Bronchoscope 1969 Ventolin introduced 1969 Ventolin introduced 1980s Major developments in asthma management 1980s Major developments in asthma management 1990 Serevent introduced 1990 Serevent introduced 1996, 1997 Woolcock & Pauwels Landmark studies 1996, 1997 Woolcock & Pauwels Landmark studies 2007 SMART 2007 SMART 1994 Greening, Ind Landmark study 1994 Greening, Ind Landmark study A brief history of asthma management How are we doing? 2001 Symbicort 1997 Oxis Fostair

4 Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s 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 Not Well-Controlled asthma (% of treated patients) % Patients not Well Controlled

5 Every 6 hours someone dies from asthma 2 Number of people living with asthma in the UK today Men 2.3 million 1 Total 5.2 million 1 Data includes 590,000 teenagers and 700,000 people over 65 1 Women 2.9 million 1 1. Where Do We Stand? Asthma in the UK Today. Published December Available at: [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).

6  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 Harrison B et al. Prim Care Respir J 2005 Dec; 14 : 303–13. Asthma severity (%) Number of deaths SevereModerately severe MildUnknown 10% 16% 21% 53% Number of asthma deaths across disease severity 2001–2003 n=57

7 2007/8 QOF Prevalence of Asthma Source: NHS Information Centre: The Quality Outcomes Framework (QOF),

8 QOF Prevalence of Asthma Source: NHS Information Centre: The Quality Outcomes Framework (QOF), TCT SD

9  Asthma admissions increased by 30%  45 more hospital admissions  Asthma bed days decreased by 21%  122 fewer bed days Source: NHS Information Centre: Hospital Episodes Statistics (HES) Average length of stay decreased by 39%  From 3.8 days to 2.3 days


11 British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN)

12 Definition of asthma Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92 “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.”

13 Diagnosis  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

14 Diagnosis  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

15 Following clinical assessment in adults

16 Features that increase the probability of asthma in adults  >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 FEV 1 or PEF  Unexplained peripheral blood eosinophilia

17 Features that lower the probability of asthma  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

18 Following clinical assessment in adults

19 Differential Diagnosis  Without airflow obstruction Chronic cough syndromes DBS Vocal Cord Dysfunction Rhinitis GORD Heart Failure Pulmonary Fibrosis  With airflow obstruction COPD Bronchiectasis Inhaled Foreign Body Obliterative Bronchiolitis Large Airway Stenosis Lung Cancer Sarcoidosis


21  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

22 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 (FEV 1 and/or PEF >80% predicted or best) with minimal side effects.

23 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

24 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

25 Component of action plan ResultPractical Considerations Symptom vs PEF trigger Standard written instruct Traffic Light Similar effect Consistently beneficial 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 >400 – steroids 200 – increase substant Restart medication


27 Inhaler devices

28  Prescribe inhaled short acting β 2 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 β 2 agonist  Using two or more canisters of β 2 agonists per month or > 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 β 2 agonists should have their asthma management reviewed


30  Inhaled steroids are the recommended preventer drugs for adults for achieving overall treatment goals  Consider inhaled steroids if any of the following:  Using inhaled β 2 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)

31  Adults:  mcg/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

32 SteroidEquivalent dose (mcg) Beclomethasone CFC 400 Beclomethasone Clenil400 Qvar Fostair200 Budesonide Symbicort400 Fluticasone Seretide200 Mometasone 200 Ciclesonide


34  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 β 2 agonist (LABA), which should be considered before going above a dose of 400mcg BDP* and certainly before going above 800mcg


36  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


38  If control remains inadequate…


40  Still uncontrolled..  Monitor - Blood pressure DiabetesHyperlipidaemiaBMD

41  Steroid sparing medication -Methotrexate -Ciclosporin -Oral Gold ColchicineIVIG Subcutaneous Terbutaline Anti- TNF

42  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


44  Miss BL1984  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

45 ?? Regular meds – becotide AAt university, smokes!..moderate alcohol! AAcute management? SSteroids, ICS, ventolin, RNS, OPD

46  Clinic October 2006  Good recovery, still some SOBOE, started attending gym.  Nocturnal symptoms – none  Ventolin – three times per week.  What to do?

47  Lifestyle advice  Compliance  RNS - Management Plan, Education  Pre-dose with ventolin  LABA - Combination inhaler


49 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 UK qualitative and quantitative study to evaluate patient understanding of their asthma and determine patient preferences regarding the delivery of asthma care and treatment.


51 Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s 40% of Not Well- Controlled patients consider themselves “Well” or “Completely Controlled” Self-reported level of control by Not Well-Controlled patients % Patients

52  Mrs TL24/10/1984  Clinic Jul 2006  Asthma age 12  2 x pregnancies – deteriorated during, brittle++ (Newcastle)  BIH  Night waking, morning dipping, wheeze, SOB – 10/40

53  Guinea pig and rabbit, shop assistant.  Bec puffs bd, SV 4 puffs bd, ventolin and combivent prn.  SaO 2 98%, 2.69/3.58 (3.21/3.68).  What to do?

54  Write to chest consultant  RNS review – management plan, education  QVAR - Thrush  Combination inhaler - tried  ?LTRA  ?Nebuliser  Standby steroids

55  Clinic Aug 2006  Stable  2.84/3.67 litres  Plan – no change  DNA…

56  23-year old woman with history of childhood asthma  Started fitness campaign but suffers from breathlessness on exertion  At clinic, PEF normal

57 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?

58 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.

59  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.

60 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?

61  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.


63  Mr DC 02/09/1969  Clinic Apr 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?

64  Question diagnosis?  Recent CT scan, alpha-1-antitrypsin level N  Increase dose Symbicort  LTRA trial – previously negative  Bisphosphonate

65  Clinic June 2004  Ig E > 15,000 RAST Aspergillus >4  Probable Allergic Bronchopulmonary Aspergillosis (ABPA)  Plan - Maintenance prednisolone (10mg), Itraconazole

66  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

67  Clinic Oct 2004  Recent exacerbation  1.11/3.12  Plan – prednisolone 15mg od, nebuliser

68  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

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