1. Asthma Diagnosis Prescribing Acute Management Tracey Bradshaw Respiratory Consultant RIE

2. Diagnosis Diagnosis The diagnosis of asthma is a clinical oneThe diagnosis of asthma is a clinical one Based on historyBased on history Symptoms, triggersSymptoms, triggers Variable airflow obstructionVariable airflow obstruction FEV1 or PEFFEV1 or PEF

3. Asthma, COPD or Both?

4. Asthma COPD Overlap Syndrome (ACOS) ACOS is characterized by persistent airflow limitation with several features usually associated with asthma and several features usually associated with COPD Worse outcomes compared with asthma or COPD alone GLOBAL INITIATIVE FOR ASTHMA, GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE

5. ACOS diagnosis GLOBAL INITIATIVE FOR ASTHMA, GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE Treat asthmatic component with ICS

6. Prescribing Right drug Right dose Right device

7. A stepwise approach

8. Right Drug Who needs Inhaled Steroids? Early Introduction of ICSEarly Introduction of ICS Significant inflammation in mild asthmaSignificant inflammation in mild asthma 1/3 mild asthmatics may have severe exacerbation1/3 mild asthmatics may have severe exacerbation Consider if any of the following:Consider if any of the following: Using inhaled β 2 agonist three times a week or moreUsing inhaled β 2 agonist three times a week or more Symptomatic three times a week or moreSymptomatic three times a week or more Waking one night a weekWaking one night a week Exacerbation of asthma in the last two yearsExacerbation of asthma in the last two years

9. Right dose In mild to moderate asthma, no benefit starting high dose ICS and stepping downIn mild to moderate asthma, no benefit starting high dose ICS and stepping down Start at dose appropriate to severityStart at dose appropriate to severity Reasonable dose 200mcg bdReasonable dose 200mcg bd *All doses in the guideline refer to beclometasone given via CFC-MDI

10. Right dose- Differences in ICS Potency Clenil : budesonide : fluticasone 1 : 1 : 2 In mcgs 200 : 200 : 100 At equivalent doses, efficacy is equal

11. Inhaled corticosteroid Equivalent dose (mcg) UK licence > 12 years Clenil (beclom)200Yes Fostair100> 18 years Seretide Evo100Yes Seretide Acc100Yes Symbicort200Yes* Flutiform10050,125 only * Up to 400/12 1 dose bd only Right Dose- ICS/LABA

12. Step 4/5Step 2 Seretide 250 Evo 2 puffs bd (2000) Seretide 500 Acc 1 puff bd (2000) Symbicort 400/12 2 puffs bd (1600) Step 3 Seretide 125 Evo 2 puffs bd (1000) Seretide 250 Acc 2 puffs bd (1000) Symbicort 400/12 1 puff bd (800) or Symbicort 200/6 2 puffs bd (800) Fostair 100/6 2 puffs bd (1000) Seretide 50 Evo 2 puffs bd (400) Seretide 100 Acc 1 puff bd (400) Symbicort 200/6 1 puff bd (400) BDP 250, 1 bd PLUS Formoterol 12, 1 bd Prescribe an ICS device equivalent to 400-500 mcg BDP/day Control ≥ 3 m Right Dose- Stepping Down Good control 3 months Minimise device changes Assess 3 monthly If control lost, step back up

13. Right Device Always check inhaler technique Prior to starting inhalers Before stepping up Remember Accuhaler and Evohaler are not interchangeable Accuhaler- salmeterol 50mcg/puff= 1 puff bd Evohaler- salmeterol 25mcg/puff= 2 puffs bd

14. Acute Management Recognise severity Immediate treatment Hospital referral

15. Severity- History Markers of risk of an adverse outcome in asthma Baseline severity Recent hospital admission Three or more regular medications Frequent ‘‘after hours’’ GP visits Psychosocial problems Previous ICU admission (ever) Acute severity Heavy use of b2-agonist Marked (>50%) reduction or variation in peak flow Precipitate asthma

16. ModerateSevereLife-threatening Speech normal Respiration <25 breaths/min Pulse <110 beats/min Cannot complete sentences Respiration  25 breaths/min Pulse  110 beats/min Silent chest, cyanosis, poor respiratory effort Bradycardia,dysrhythmia hypotension Exhaustion,confusion, coma Severity- Examination Speech, RR, pulse PEF, Pulse oximetry 50 – 80%33- 50%< 33% spO2 < 92%

17. Goals of Immediate Treatment Correction of hypoxemia- high flow oxygen Aim for SpO2 94-98% Rapid reversal of airflow obstruction- bronchodilators MDI + spacer equivalent to nebuliser (oxygen driven) ↑ frequency as well as ↑ dose → greater bronchodilation Reduction likelihood of recurrence of severe airflow obstruction- steroids 40mg for 5 days Routine antibiotics not indicated Inhaled corticosteroids?

18. Criteria for admission Any feature of a life-threatening or near fatal attack Any feature of a severe attack persisting after initial treatment Other considerations Ongoing significant symptoms Concerns about compliance Living alone/socially isolated Psychological problems Physical disability or learning difficulties Previous near fatal or brittle asthma Presentation at night Pregnancy

19. Summary Diagnosis Clinical History Airflow obstruction Acute management Recognise severity Immediate treatment Hospital referral Prescribing Right drug Right dose Right device