Conducting an Asthma Review

Raj Gill

Physician Associate

National Review of Asthma Deaths UK

• 195 deaths from Asthma (Feb ‘12-Jan ’13)

• Key Findings:

• Only 16% were judged to have good care

• 1/5 had A+E attendance in previous year

• 39% were prescribed more than 12 reliever inhalers

• 5% patients were prescribed LABAs without an ICS

• 19% people had not been referred to specialist

National Review of Asthma Deaths UK

• 135 patients had their last review in Primary Care

• 27% had their asthma control assessed

• 42% had their medication use checked

• 71% had their inhaler technique checked

• Only 23% had written personal asthma action plan

• Recommendations:

• A structured annual review which records current control, records asthma triggers and monitoring of inhaler technique.

(Levy, M 2014)

Definition of Asthma

Asthma is a disease with many variations (heterogenous), usually characterised by chronic airways inflammation. Asthma has two key defining features:

• A history of respiratory symptoms such as: wheeze, shortness of breath, chest-tightness and cough that vary over time and intensity, AND

• Variable expiratory air flow Limitation

(GINA 2017)

Clarify Diagnosis

• When was the patient first diagnosed?

• Did the symptoms resolve and return?

How was the Diagnosis Made?

Primary Care

• Peak Flow Diary - 2 weeks 3 days >20% diurnal variation

• Spirometry –Reversible obstruction with incs in FEV1 12% and 200mls (BTS 2016)

Secondary Care• Bronchial Challenge testing

e.g methacholine challenge with 20% fall in FEV1

• Blood/Sputum Eosinophils • FeNO

Symptoms

• Episodic symptoms:

• Cough

• Shortness of Breath

• Wheeze

• Chest tightness

• Night time waking

• Symptoms of other atopic conditions

• Worsening of the symptoms with viral infections

Assess Asthma Control

• RCP Questions

Assess Asthma Control

Triggers

• Exercise

• Pollen

• Dust Mite

• Fur/feathers

• Smoking

• Pollution

• Emotions

• Weather

• Moulds/Fungus

• Viral infections

Measure current airflow limitation

• Peak Flow - Compare to predicted or patient’s

• Post Bronchodilator Spirometry – current level of obstruction and FEV1

Current Regime and Check Adherence

• What Step is the patient on ?

• What reliever inhaler are they using – how often are they using it?

• What preventer inhaler are they using – how often are they using it?

• Do they have an Personal Asthma Management Plan- are they following it?

• Are they Following twice daily dosing?

• Is their adherence determined by carer administration?

• Are they using any aids to help the remember to take?

Check Inhaler technique

https://www.youtube.com/watch?v=YTU4eM33XjgMDI without a Spacer

MDI with Spacer https://www.youtube.com/watch?v=JaAP9x4Y12k

New Regime/Personal Asthma Action Plan

Comorbidities/Modifiable risk factors

Old Step 1 - inhalers

Salbutamol

(Ventolin)

Terbutaline

(Bricanyl)

Old Step 2/Regular Preventer therapy

Beclomethasone

Clenil

Qvar

Fluticasone Propionate

Flixotide

Budesonide

Pulmicort

Are all steroid inhalers equivalent?

Clenil Qvar

Are all steroids Equivalent?

Steroid Name Steroid Dose Inhalers

Beclomethasone Standard Particle

200-250mcgs Clenil,

Beclomethasone Fine Particle 100mcgs Qvar, Fostair

Budesonide 200mcgs Pulmicort, Duoresp,Symbicort

Fluticasone Propionate 100mcgs Seretide, Flutiform, Sirdupla, Aerivio

Fluticasone Furoate 92mcgs Relvar

Old Step 3/initial add on therapy

Fixed Dose inhalers Flutiform Ingredients and Doses:

Fluticasone PropionateFormoterol 50/6125/6250/6

Positives3 strengthsLicenced above age 12Cost effective (cheapest LABA/ICS)

NegativesOnly comes as MDIFP extra potent +/-No MART

Seretide Fluticasone Propionate Salmeterol 50/6125/6250/6

First LABA/ICSLicenced from 5yo

Salmeterol slow acting FP extra potent Costly inhaler

Relvar Fluticasone Furoate Vilanterol 92/22184/22

Once daily dosing Licenced from 12yo

Once daily dosingVilanterol slow actingNo MDI

Maintenance Reliever Therapy Duoresp Ingredients/dosing

Budesonide Formoterol 160/4.5320/4.5

Positives MART 1-2 puffs BD upto8 doses in one day. Short period - 12 doses Easy device Cost effective

NegativesLicenced 18 above

Symbicort Budesonide Formoterol100/6200/6400/6

Dosing as above 100/6 licenced from 6yoNo MART for children

Poor device Cost

Fostair Beclomethasone fine particleFormoterol 100/6200/6

MDI and DPIMART 2 puffs BD upto 8 doses in one day Cost effective

DPI not licenced for MARTColour

References

• https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2014 accessed 01/05/2017

• https://www.brit-thoracic.org.uk/document-library/clinical-information/asthma/btssign-asthma-guideline-2016 accessed 01/05/2017

• http://ginasthma.org/2017-pocket-guide-for-asthma-management-and-prevention accessed 01/05/2017