Allwin Mercer

Dr Andrew Zurek

• 1 in 11 people are currently receiving

treatment for asthma (5.4 million people in the

UK)

• Every 10 seconds, someone is having a

potentially life-threatening asthma attack

• Every day three families are devastated by the

death of a loved one because of an asthma

attack

• Two thirds of asthma deaths could be prevented with better routine care

• Room for improvement in the care received by 83% of those who died

• Children’s care fared worse than adults in multiple aspects of care

For further information you can read the National Review at www.asthma.org.uk/nrad-

report

• 8 out of 10 people are not receiving care that meets the most basic clinical standards

• Significant variation in care across the UK

• Four out of five children are not receiving all elements of basic clinical asthma care

1) all of the time

2) sometimes

3) most of the time

4) never

How many of your patients are given a written

asthma UK action plan at every review

1) all my patients

2) some of my patients

3) what's an asthma action plan

4) never give a written asthma plan

Asthma UK wants to see local NHS decision-

makers ensure every person with asthma has a

written asthma action plan and is given care that

meets basic clinical standards.

WHAT CAN WE DO BETTER IN BERKSHIRE WEST?

• More effective asthma reviews & assessment

• Increase number of written Asthma action plans

• Smart ways of reviewing non attendees/high risk

EFFECTIVE REVIEW V 3 QUESTIONS

AND OUT!!

BTS/SIGN guideline structured review should include:

• ASSESSMENT of asthma symptoms

• measurement of lung function,spiro or PEAK FLOW

• REVIEW of exacerbations, oral steroid use and time off work

• CHECK INHALER TECHNIQUE – youtube

• assessing ADHERENCE (review number of prescriptions)

• adjustment of treatment (consider stepping up and down)

• bronchodilator reliance ( review number of prescriptions)

• REVIEW OF WRITTEN ASTHMA ACTION PLAN

• SMOKING status

• assessment of comorbidities

• review of diagnosis.

• PATIENTS TAKE HOME MESSAGE

Assessment of asthma control An assessment of asthma control should use a recognised tool

• Royal College of Physicians (RCP) 3 questions (Quick QOF)

• Asthma control questionnaire - 5 questions

• asthma control test or children's asthma control test

• mini asthma quality of life questionnaire or paediatric asthma

quality of life questionnaire

Asthma action plans

Email and text messaging Online asthma reviews Targeting at risk patients Encourage self management of asthma- action plans INHALER TECHNIQUE! INHALER TECHNIQUE ! YOUTUBE Asthma symptoms questionnaire before appointments Website links to www.asthma.org.uk www.breatheberkshirewest.org.uk

WHATS WORKING WELL IN BERKSHIRE

EXAMPLES OF GOOD PRACTICE

INNOVATIVE IDEAS

42 year old woman, recent SOB, wheeze & dry cough

Symptoms worst in early mornings and on exertion

Smokes 5 – 10 a day

Normal chest exam & spirometry

Rx 200 mcg Beclomethasone BD

6 weeks later symptoms no different

A. Perform reversibility testing with Salbutamol

B. Change inhaler to Fostair

C. Check inhaler technique & ask patient to keep a peak flow diary

D. COPD more likely so stop BDP and try Spiriva instead

If diagnostic uncertainty and airflow obstruction assess response to 400 mcg Salbutamol

In other patients assess response to 6-8 weeks of inhaled BDP (200 mcg BD)

Or after 2 weeks of prednisolone 30 mg OD

+ve result is > 400ml improvement in FEV1

Low sensitivity

Of little value if normal or near normal FEV1 pre-treatment

28 year old man 3 months progressive wheeze and chest tightness, present every day

Non smoker, seasonal rhinitis but no past history of asthma

Sister and mother with asthma

FEV1 3.0L

FVC 5.0L

FEV1 increases by 0.6L after Salbutamol

A. Rx Salbutamol PRN

B. Ask patient to keep a peak flow diary

C. Rx Beclomethasone 200 mcg BD

D. Rx Prednisolone 30 mg OD for 2 weeks

A. Enquire about triggers

B. Increase BDP dose to 400 mcg BD

C. Refer to ENT

D. Rx Fostair instead of BDP

No pets or obvious allergies except pollens

Has worked in a saw mill for last 9 months

Symptoms worse towards end of day & week

Improves at weekends

Ask adult onset asthma pts:

1. Are your symptoms better on days away from work?

2. Are your symptoms better on holiday?

if either yes:

Refer to chest clinic or occupational physician

Arrange serial PEF monitoring

◦ 4 times daily minimum

◦ Periods at and away from work (~ 3 weeks)

◦ Download from http://occupationalasthma.com/

Baker / pastry making

Spray painting

Healthcare / dentalcare

Metalwork / woodwork

Food processing

Soldering / welding

Lab animal work

Farming

Textile, plastic, rubber manufacture

Chemical processing

32 year old woman, 4 months pregnant

Asthmatic, previously well controlled with Clenil 100 2 puffs BD

Stopped Clenil after finding out she was pregnant

Presents with worsening breathlessness but able to talk in sentences

PEF 350 L/min (pre-pregnancy 420)

A. Rx Salbutamol inhaler QDS and arrange review in 2 days

B. Restart Clenil 100 2 puffs BD and review in 1 week

C. Rx Prednislone 40 mg OD for 5 days

D. Refer to A&E

A. Long acting β agonists

B. Theophyllines

C. Montelukast

D. Prednisolone

E. All of the above

Treat as normal asthma

Monitor women with symptomatic asthma more closely

Emphasize importance (to mother & baby) of maintaining good control with medication & treating asthma attacks in the usual way

36 year old man, asthmatic since childhood

Worsening symptoms, no change in home or work environment

Good inhaler technique and compliance

No improvement on switching to Fostair (from Beclomethasone 200 mcg BD)

A. Stop Fostair and Rx Beclomethasone 400 mcg BD

B. Switch to Flutiform 125 2 puffs BD

C. Rx Montelukast

D. Rx Spiriva Respimat

Inadequate control on

low dose ICS

Add LABA

Assess control

Good response •continue ICS /

LABA

Some improvement

•↑ ICS to 800mcg

No response •stop LABA

•↑ ICS to 800mcg

Still not controlled

Montelukast

Modified release Theophylline

Spiriva Respimat

Smoking advice & support

◦ locally 50% of adult asthma pts admitted to hospital are smokers

◦ Smoking reduces effectiveness of inhaled steroids

Advise weight reduction in obese patients

Refer for breathing exercises (physiotherapist-taught)

◦ Reduces respiratory rate and minute volume; promotes nasal diaphragmatic breathing

◦ Improves asthma symptoms and reduces bronchodilator use

25 year old woman with asthma since school

Unemployed, living alone, smoker

Recent treatment for depression & anxiety

3 hospital admissions & frequent A&E attendances with asthma attacks

Poor adherence with preventer therapy (Symbicort); using 1 Ventolin inhaler every 1 – 2 weeks

Worsening symptoms over last week, not sleeping well

Talking in sentences, respiratory rate 24, pulse 100, sats 96%

Diffuse expiratory wheeze throughout chest

PEF 200 L/min (usual 350)

A. Assess inhaler technique and advise to take additional Symbicort as per SMART regime

B. As above plus add modified release Theophylline

C. As in A plus Prednisolone 40 mg OD for 1 week

D. Give nebulised Salbutamol 5 mg, Prednisolone 40 mg and refer to hospital

Moderate Severe Life-threatening

Able to talk in sentences

Pulse < 110 Respiratory rate < 25

PEF > 50-75%

Can’t complete sentence

P ≥ 110 RR ≥ 25

PEF 33-50%

PEF < 33% Exhaustion or altered

consciousness Sats < 92%

Silent chest, cyanosis, poor respiratory effort

Refer pts with severe or life-threatening asthma to hospital

Give pts with severe or life-threatening features Prednisolone 40mg within 1 hour of presentation

Enquiry into all asthma deaths in UK for 1 year 2012-13

In 195 cases where asthma confirmed as principal cause of death:

◦ Inadequate treatment

◦ Inadequate objective monitoring

◦ Inadequate follow-up

◦ Widespread underuse of written action plans

◦ Inappropriate prescription of NSAIDs & β blockers

Primary care follow-up within 2 working days following admission, A&E attendance or unscheduled out-of hours visit

Secondary care follow-up after any admission or 2 A&E visits within 1 year

Refer to hospital asthma clinic if

◦ On step 4 or 5 treatment

◦ Required 2 courses of Prednisolone in the last year

Asthma reviews should be structured

Give all patients written action plans

Educate and encourage self-management ◦ http://www.asthma.org.uk/

Implement systems to target at risk patients

QUESTIONS WELCOME