Lee Dobson

Torbay Hospital
 A brief history of asthma management
2007
2001 SMART
1996, 1997 Symbicort
Woolcock & Pauwels
1990 Landmark
Serevent studies Fostair
introduced 1994 1999
Greening, Ind Seretide
Landmark study 1997 launched
Oxis
1980s 1995 onwards
Major GINA
developments
in asthma
1969 management
1991
Ventolin The

How are we doing?

introduced β2 agonist 1993
Late 60s debate Flixotide
Bronchoscope 1972
Becotide introduced
introduced

1956 1965
3M launch Intal
The MDI introduced

Early 1950s
MDI
 Not Well-Controlled asthma (% of treated patients)
% Patients not Well Controlled

80 72
70 61
60 55 56
50 45 45
40
30
20
10
0
Overall UK Spain Italy Germany France

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

Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s

 Data includes 590,000 teenagers
and 700,000 people over 651

Total
5.2 million1

Every 6 hours someone dies from asthma2

Women
Men 2.9 million1
2.3 million1

1. Where Do We Stand? Asthma in the UK Today. Published December 2004. Available at: http://www.asthma.org.uk/how_we_help [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).
  It is a myth that only severe Number of asthma deaths across
asthma can prove fatal 100 disease severity 2001–2003

Number of deaths
75

 Asthma deaths occur across

50 53%
disease severity with deaths
occurring in those patients 25
21%
whose asthma is considered 16% 10%
mild-to-moderate 0
Severe Moderately Mild Unknown
severe

Asthma severity (%) n=57

Harrison B et al. Prim Care Respir J 2005 Dec; 14: 303–13.

 8.0%

7.0% 6.7%
% patients registered with asthma

6.2% 6.4% 6.5%

6.1%
6.0% 5.7%

5.0%

4.0%

3.0%

2.0%

1.0%

0.0%
England NHS South Torbay Care Devon PCT Plymouth Cornw all &
West Trust Teaching PCT Isles of Scilly
PCT

Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/
 2006/07 2007/08
8.0%

6.8%6.7%
7.0%
% patients registered with asthma

6.2%6.2% 6.2% 6.4%6.4% 6.5% 6.5%

6.1%
5.8% 5.7%
6.0%
2009 2010
5.0%

4.0% TCT 10198 10193

3.0% SD 8276 8481

2.0%

1.0%

0.0%
England NHS South Torbay Care Devon PCT Plymouth Cornw all &
West Trust Teaching PCT Isles of Scilly
PCT

Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/
 Asthma admissions increased by 30%
 45 more hospital admissions

• Average length of stay decreased by 39%

 From 3.8 days to 2.3 days
 Asthma bed days decreased by 21%
 122 fewer bed days

Source: NHS Information Centre: Hospital Episodes Statistics (HES)

 British Thoracic Society (BTS)
Scottish Intercollegiate Guidelines Network (SIGN)
 Definition of asthma

“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.”

Diagnosis and natural history. Thorax 2003; 58 (Suppl I): i1-i92

 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
 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
 >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 FEV1 or PEF
 Unexplained peripheral blood eosinophilia
 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
 Without airflow  With airflow
obstruction obstruction
Chronic cough syndromes COPD
DBS Bronchiectasis
Vocal Cord Dysfunction Inhaled Foreign Body
Rhinitis Obliterative Bronchiolitis
GORD Large Airway Stenosis
Heart Failure Lung Cancer
Pulmonary Fibrosis Sarcoidosis
 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
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 (FEV1 and/or PEF >80% predicted or
best)

with minimal side effects.

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
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
 Component of action Result Practical Considerations
plan
Symptom vs PEF trigger Similar effect
Standard written instruct Consistently beneficial
Traffic Light Not better than standard
2-3 action points Consistently beneficial <80% - increase ICS
4 action points No better <60% - oral steroids
<40% - urgent advice
PEF on %personal best Consistently beneficial Assess when stable,
PEF on % predicted No better update every few years
ICS and steroids Consistently beneficial >400 – steroids
Oral steroids only Unable to evaluate 200 – increase substant
ICS Unable to evaluate Restart medication
Inhaler devices
 Prescribe inhaled short acting β2 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 β2 agonist

 Using two or more canisters of β2 agonists per month or >

10-12 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 β2 agonists

should have their asthma management reviewed
 Inhaled steroids are the recommended preventer drugs
for adults for achieving overall treatment goals

 Consider inhaled steroids if any of the following:

 Using inhaled β2 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)
 Adults:
 200-800mcg/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
Steroid Equivalent dose (mcg)
Beclomethasone CFC 400
Beclomethasone
Clenil 400
Qvar 200-300
Fostair 200
Budesonide
Symbicort 400
Fluticasone
Seretide 200
Mometasone 200
Ciclesonide 200-300
 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 β2
agonist (LABA), which should be considered before going
above a dose of 400mcg BDP* and certainly before going above
800mcg
 Can’t miss their ICS  Different inhalers – different
deposition

 More convenient  Interaction occurs at single

cell level

 Increased compliance  Deposition varies from one

inhalation to the next
 Pathophysiology?
 If control remains
inadequate…
 Still uncontrolled..

 Monitor -
Blood pressure
Diabetes
Hyperlipidaemia
BMD
 Steroid sparing medication
- Methotrexate
- Ciclosporin
- Oral Gold

Colchicine
IVIG
Subcutaneous Terbutaline
Anti- TNF
 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
 Miss BL 1984

 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

 ? Regular meds – becotide

 At university, smokes!..moderate alcohol!

 Acute management?

 Steroids, ICS, ventolin, RNS, OPD

 Clinic October 2006

 Good recovery, still some SOBOE, started attending

gym.

 Nocturnal symptoms – none

 Ventolin – three times per week.

 What to do?
 Lifestyle advice

 Compliance

 RNS - Management Plan, Education

 Pre-dose with ventolin

 LABA - Combination inhaler

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

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

 Self-reported level of control by Not Well-Controlled patients
40 37
34 40% of Not Well-
35 Controlled patients
30 consider
25 themselves “Well”
or “Completely
% Patients

20
15 Controlled”
11 11
10 6
5
0
"Completely "Well "Somewhat "Poorly "Not at all
Controlled" Controlled" Controlled" Controlled" Controlled"

Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s

 Mrs TL 24/10/1984

 Clinic Jul 2006

 Asthma age 12

 2 x pregnancies – deteriorated during, brittle++ (Newcastle)

 BIH

 Night waking, morning dipping, wheeze, SOB – 10/40

 Guinea pig and rabbit, shop assistant.

 Bec 250 4 puffs bd, SV 4 puffs bd, ventolin and

combivent prn.

 SaO2 98%, 2.69/3.58 (3.21/3.68).

 What to do?
 Write to chest consultant
 RNS review – management plan, education
 QVAR - Thrush
 Combination inhaler - tried
 ?LTRA
 ?Nebuliser
 Standby steroids
 Clinic Aug 2006

 Stable
 2.84/3.67 litres
 Plan – no change

 DNA…
 23-year old woman with history of childhood asthma

 Started fitness campaign but suffers from

breathlessness on exertion

 At clinic, PEF normal

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?
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.
 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.
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?
 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.
 Mr DC 02/09/1969

 Clinic Apr 2004 - 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?
 Question diagnosis?
 Recent CT scan, alpha-1-antitrypsin level N

 Increase dose Symbicort

 LTRA trial – previously negative

 Bisphosphonate
 Clinic June 2004

 Ig E > 15,000 RAST Aspergillus >4

 Probable Allergic Bronchopulmonary Aspergillosis

(ABPA)

 Plan - Maintenance prednisolone (10mg), Itraconazole

 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

 Clinic Oct 2004

 Recent exacerbation

 1.11/3.12

 Plan – prednisolone 15mg od, nebuliser

 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