1. The Modern Management of Asthma: Getting it right
Dr Richard Russell
Senior Lecturer
Nuffield Department of Medicine
University of Oxford

2. Who am I? Dr Richard Russell Respiratory Consultant
Lymington New Forest Hospital
Clinical Director West Hampshire Integrated Respiratory Service
Senior Lecturer University of Oxford
Editor in Chief Int J COPD

3. Normal versus asthmatic airways

4. Airway inflammation in asthma
Fibrosis
Neutrophil
Mast Cell
Epithelial
shedding
Airways
constriction
and
Smooth muscle
hyperplasia
hypertrophy
Eosinophil
Antigen
Mucus
plug
Oedema
Macrophage
T-Lymphocyte
Goblet cell discharge
Plasma leak

5. Sites of airway remodelling
Epithelium & BM
Airway smooth muscle
Mucous glands E BM
Extracellular matrix
Small vessels
Large vessels
Cartilage LV EC SV C
BM = Basement membrane.

6. Improving asthma control
Patients who would benefit from a review of therapy
10,000
% patients not well controlled
8,000
6,000
54.6%
Number of patients at each step
4,000
55.4%
2,000
67.6%
(n = 15,649) 1 2 3 4 5
BTS guidelines steps
Figure produced by Russell R using data from Neville R et al. Eur Respir J 1999;14:

7. What are the wishes of asthma patients?
No ‘bad asthma days’
Free from restrictions on their life
PEF not important to patients (but still essential to monitor control and exacerbations)
Price D et al. Asthma J. 1999;4:74-8.

8. Treatment goal: to take control of asthma
No chronic symptoms
No asthma attacks
No emergency visits
Minimal need for quick relief (as needed) ß2-agonist
Maintain normal physical activity including exercise
Maintain lung function as close to normal as possible
Minimal (or no) adverse effects from medicine
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, Available from: [Accessed Dec 2016]

9. A stepwise approach
British Thoracic Society, Scottish Intercollegiate Guidelines Network. SIGN 153: British guideline on the management of asthma. A national clinical guideline 2016.

10. A stepwise approach

11. National Review of Asthma Deaths (NRAD)
Why asthma still kills
National Review of Asthma Deaths (NRAD)
Mark L Levy FRCGP
Clinical Lead, NRAD
Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

12. Multidisciplinary confidential enquiry panels
37 panel meetings
174 volunteer assessors
9 cases per panel
Two assessors per case
Panel assessment form
Consensus agreement
195/276 died from asthma
1000 panel recommendations
Major factors in 67% deaths potentially avoidable
Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

13. Mild / moderate asthma – 58% of those who died from asthma
It is possible that many of those cases defined by their doctors as mild or moderate…
…were more severe
Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

14. Primary care of the 195 cases (in the 12 months before death)
64 (33%) - no details on asthma diagnosis 84 (43%) - no record of asthma review 12 mths 37 (19%) - had assessment of asthma control 33 (17%) - given Personal Asthma Action Plans (PAAP) 112 (57%) - not under specialist supervision
Please present data in a clearer way (table?)
Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

15. Excessive GP prescribing of Short Acting Beta-Agonist Bronchodilators (SABAs)
Excess need for reliever medication (SIGN/BTS)
= poor asthma control
Numbers of SABA inhalers prescribed during final year
> 6: 92/165 patients
> 12: 65/165 patients (39%)
> 50: 6/165 patients (4%)
Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

16. Potential avoidable factors identified by panels in routine medical care and ongoing supervision and monitoring
Primary Care (n=195)
n (%)
Secondary Care (n=83)
One or more avoidable factors
137 (70)
24 (29)
Avoidable prescribing factor
92 (47)
12 (14)
Lack of adherence to guidelines
115 (59)
19 (23)
NRAD recommendation:
“Health professionals must be aware of the features that increase the risk of asthma attacks and death, including the significance of concurrent psychological and mental health issues.”
Table reproduced with permission from Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

17. Failure by doctors, nurses, patients and carers to identify risk – missed opportunities
Prescribing
Excess relievers; insufficient preventers
Health care utilisation
10% recent admission
21% ED
NRAD recommendations:
Electronic monitoring prescriptions; earlier specialist referral; follow-up; named clinician responsible in hospital and primary care
Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.

18. Guided self-management
The evidence…
“Education in asthma self-management which involves self-monitoring by either peak expiratory flow or symptoms, coupled with regular medical review and a written action plan improves health outcomes for adults with asthma.”
Gibson PG et al. The Cochrane Library, Issue 3, 2002.

19. Guided self-management
The recommendation…
“Every asthma consultation is an opportunity to review, reinforce and extend both the patient’s knowledge and skills.”
British Thoracic Society, Scottish Intercollegiate Guidelines Network. SIGN 153: British guideline on the management of asthma. A national clinical guideline 2016.

20. Guided self-management
The reality…
UK surveys
Survey of people with asthma in the UK 3%
Price et al, Asthma J 2000; 5: 141-4
Patients who had had an acute attack
28%
Pinnock et al. Asthma J 2000; 5: 130-2
Survey of 517 people with asthma throughout the UK
20%
Haughney et al. Prim Care Respir J 2004; 13: 28-35
had a written asthma action plan

21. Telephone asthma reviews

22. Guided self-management
What does an action plan look like?
Meta-analysis:
components of a written asthma action plan
“Individualised written action plans based on personal best PEF, using 2–4 action points, and recommending both ICS and OCS for treatment of exacerbations consistently improve asthma health outcomes”
Gibson PG, Powell H. Thorax 2004; 59: 94-9

23. Guided self-management
What does an action plan look like?
Asthma UK. Asthma Action Plan. [Accessed Dec 2016]

24. Inhaled corticosteroids are the anti-inflammatory treatment of choice
Outcome: Asthma control
Outcome: Best possible results
Reliever: Rapid-acting inhaled β2-agonist as needed
Controller
Daily inhaled corticosteroid
Daily long-acting inhaled β2-agonist
Plus (if needed)
Theophylline-SR
Leukotriene
Long-acting inhaled β2-agonist
Oral corticosteroid
When asthma is controlled, reduce therapy
Monitor
STEP 1:
Intermittent
STEP 2:
Mild persistent
STEP 4: Severe persistent
None
STEP 3:
Moderate
persistent
STEP down
Figure adapted from GINA Teaching Slide Set