A Clinical update in Asthma - [Download PPT Powerpoint]

Lee Dobson

Torbay Hospital

Early 1950sMDI

19563M launchThe MDI

1965Intal

introduced

1965Intal

introduced

1972Becotide

introduced

1972Becotide

introduced

1991The

β2 agonistdebate

1991The

β2 agonistdebate

1993Flixotide

introduced

1993Flixotide

introduced

1995 onwardsGINA

1999Seretidelaunched

Late 60sBronchoscope

1969Ventolin

introduced

1969Ventolin

introduced

1980sMajor

developmentsin asthma

management

1980sMajor

developmentsin asthma

management

1990Serevent

introduced

1990Serevent

introduced

1996, 1997Woolcock & Pauwels

Landmarkstudies

1996, 1997Woolcock & Pauwels

Landmarkstudies

2007SMART2007

SMART

1994Greening, Ind

Landmark study

1994Greening, Ind

Landmark study

A brief history of asthma A brief history of asthma managementmanagement

How are we doing?

2001Symbicort

1997Oxis1997Oxis

Fostair

5545 45

61

72

56

01020304050607080

Overall UK Spain Italy Germany France

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

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

Not Well-Controlled asthma (% of treated patients)

% P

atie

nts

not W

ell C

ontr

olle

d

Every 6 hours someone dies from asthma2

Men2.3 million1

Total5.2 million1

Data includes 590,000 teenagersand 700,000 people over 651

Women2.9 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 It is a myth that only severe asthma can prove severe asthma can prove fatalfatal

Asthma deaths occur Asthma deaths occur across disease severity across disease severity with deaths occurring in with deaths occurring in those patients whose those patients whose asthma is considered asthma is considered mild-to-moderatemild-to-moderate

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

Asthma severity (%)

Nu

mb

er

of

death

s

0

25

50

75

100

Severe Moderately severe

Mild Unknown

10%16%21%

53%

Number of asthma deaths across disease severity 2001–

2003

n=57

Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/

6.2%6.7%

6.1%6.4%

5.7%

6.5%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

England NHS SouthWest

Torbay CareTrust

Devon PCT PlymouthTeaching PCT

Cornw all &Isles of Scilly

PCT

% p

ati

en

ts r

eg

iste

red

wit

h a

sth

ma

Source: NHS Information Centre: The Quality Outcomes Framework (QOF), http://www.qof.ic.nhs.uk/

6.2%

6.8%6.4%6.2%

6.7%

6.1%6.4%

5.8%6.2% 6.5%

5.7%

6.5%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

England NHS SouthWest

Torbay CareTrust

Devon PCT PlymouthTeaching PCT

Cornw all &Isles of Scilly

PCT

% p

ati

en

ts r

eg

iste

red

wit

h a

sth

ma

2006/07 2007/08

2009 2010

TCT 10198 10193

SD 8276 8481

Asthma admissions increased by 30% 45 more hospital admissions

Asthma bed days decreased by 21% 122 fewer bed days

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

• Average length of stay decreased by 39% From 3.8 days to 2.3 days

British Thoracic Society (BTS)British Thoracic Society (BTS)

Scottish Intercollegiate Guidelines Network Scottish Intercollegiate Guidelines Network (SIGN)(SIGN)

http://www.occupationalasthma.com/images/btslogo.jpg

http://images.google.co.uk/imgres?imgurl=http://www.scottishdental.org/pbrn/images/sign.gif&imgrefurl=http://www.scottishdental.org/pbrn/education/sign83.htm&h=78&w=79&sz=3&hl=en&start=1&um=1&usg=__CuRXKi8ClJqu7-g8trN85FBXZs4=&tbnid=I7FoeH2sXopp7M:&tbnh=72&tbnw=73&prev=/images?q=Scottish+Intercollegiate+Guidelines+Network&um=1&hl=en

Definition of asthmaDefinition of asthma

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

“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.”

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 unavailableoccupational 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 obstructionChronic cough syndromesDBSVocal Cord DysfunctionRhinitisGORDHeart FailurePulmonary Fibrosis

With airflow obstructionCOPD

BronchiectasisInhaled Foreign BodyObliterative BronchiolitisLarge Airway StenosisLung CancerSarcoidosis

Start treatment at the step most appropriate to the Start treatment at the step most appropriate to the

initial severity of their asthmainitial severity of their asthma

Aim is to achieve early control Aim is to achieve early control

Step up or down with therapyStep up or down with therapy

Minimal therapyMinimal therapy

Before initiating new drug therapy:Before initiating new drug therapy:

ComplianceCompliance

Inhaler techniqueInhaler technique

Eliminate trigger factorsEliminate trigger factors

Control of asthma, defined as:Control of asthma, defined as:

No daytime symptomsNo daytime symptoms

No night time awakening due to asthmaNo night time awakening due to asthma

No need for rescue medicationsNo need for rescue medications

No exacerbationsNo exacerbations

No limitations on activity including exerciseNo limitations on activity including exercise

Normal lung function (FEVNormal lung function (FEV11 and/or PEF >80% predicted and/or PEF >80% predicted

or best)or best)

with minimal side effects.with minimal side effects.

Factors that should be monitored and recorded:Factors that should be monitored and recorded:

Symptomatic asthma control using RCP ‘3 questions’, Asthma Symptomatic asthma control using RCP ‘3 questions’, Asthma

Control Questionnaire or Asthma Control Test (ACT)Control Questionnaire or Asthma Control Test (ACT)

Lung function (spirometry/PEF)Lung function (spirometry/PEF)

ExacerbationsExacerbations

Inhaler techniqueInhaler technique

Compliance (prescription refill frequency)Compliance (prescription refill frequency)

Bronchodilator reliance (prescription refill frequency)Bronchodilator reliance (prescription refill frequency)

Possession of and use of self management plan/personal Possession of and use of self management plan/personal

action planaction plan

Factors that should be monitored and recorded:Factors that should be monitored and recorded:

Symptomatic asthma control using RCP ‘3 questions’, Asthma Symptomatic asthma control using RCP ‘3 questions’, Asthma

Control Questionnaire or Asthma Control Test (ACT)Control Questionnaire or Asthma Control Test (ACT)

Lung function (spirometry/PEF)Lung function (spirometry/PEF)

ExacerbationsExacerbations

Inhaler techniqueInhaler technique

Compliance (prescription refill frequency)Compliance (prescription refill frequency)

Bronchodilator reliance (prescription refill frequency)Bronchodilator reliance (prescription refill frequency)

Possession of and use of self management plan/personal Possession of and use of self management plan/personal

action planaction plan

Component of action plan

Result Practical Considerations

Symptom vs PEF triggerStandard written instructTraffic Light

Similar effectConsistently beneficialNot better than standard

2-3 action points4 action points

Consistently beneficialNo better

<80% - increase ICS<60% - oral steroids<40% - urgent advice

PEF on %personal bestPEF on % predicted

Consistently beneficialNo better

Assess when stable, update every few years

ICS and steroidsOral steroids onlyICS

Consistently beneficialUnable to evaluateUnable to evaluate

>400 – steroids200 – increase substantRestart medication

Inhaler Inhaler devicesdevices

Prescribe inhaled short acting Prescribe inhaled short acting ββ22 agonist (SABA) as short agonist (SABA) as short term reliever therapy for all patients with symptomatic term reliever therapy for all patients with symptomatic asthmaasthma

Good asthma control is associated with little or no need Good asthma control is associated with little or no need for short-acting for short-acting ββ22 agonist agonist

Using two or more canisters of Using two or more canisters of ββ22 agonists per month or agonists per month or > 10-12 puffs per day is a marker or poorly controlled > 10-12 puffs per day is a marker or poorly controlled asthma that puts individuals at risk of fatal or near-fatal asthma that puts individuals at risk of fatal or near-fatal asthmaasthma

Patients with high usage of inhaled short-acting Patients with high usage of inhaled short-acting ββ22 agonists should have their asthma management agonists should have their asthma management reviewedreviewed

Inhaled steroids are the recommended Inhaled steroids are the recommended preventer drugs for adults for achieving overall preventer drugs for adults for achieving overall treatment goalstreatment goals

Consider inhaled steroids if any of the following:Consider inhaled steroids if any of the following: Using inhaled Using inhaled ββ22 agonist three times a week or more 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 years (adults Exacerbation of asthma in the last two years (adults

and 5-12 only)and 5-12 only)

Adults:Adults: 200-800mcg/day BDP*(reasonable starting 200-800mcg/day BDP*(reasonable starting

dose 400mcg per day for many adults)dose 400mcg per day for many adults)

Start patients at a dose appropriate to the Start patients at a dose appropriate to the severity of the diseaseseverity of the disease

Titrate the dose to the lowest dose at which Titrate the dose to the lowest dose at which effective control of asthma is maintainedeffective 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 A proportion of patients may not be adequately controlled at step 2controlled at step 2

Check and Eliminate Check and Eliminate

Adults and Children 5-12:Adults and Children 5-12: First choice as add-on therapy is an inhaled long-acting First choice as add-on therapy is an inhaled long-acting ββ22 agonist (LABA), which should be considered before agonist (LABA), which should be considered before going above a dose of 400mcg BDP* and certainly going above a dose of 400mcg BDP* and certainly before going above 800mcgbefore going above 800mcg

Can’t miss their ICS

More convenient

Increased compliance

Pathophysiology?

Different inhalers – different deposition

Interaction occurs at single cell level

Deposition varies from one inhalation to the next

If control If control remains remains inadequate…inadequate…

Still uncontrolled..Still uncontrolled..

Monitor - Monitor -

Blood pressureBlood pressure

DiabetesDiabetes

HyperlipidaemiaHyperlipidaemia

BMDBMD

Steroid sparing Steroid sparing medicationmedication

-- MethotrexateMethotrexate

-- CiclosporinCiclosporin

-- Oral GoldOral Gold

ColchicineColchicine

IVIGIVIG

Subcutaneous TerbutalineSubcutaneous Terbutaline

Anti- TNFAnti- TNF

Stepping down therapy once asthma is Stepping down therapy once asthma is controlled is recommendedcontrolled is recommended

Regular review of patients as treatment is Regular review of patients as treatment is stepped down is importantstepped down is important

Patients should be maintained at the lowest Patients should be maintained at the lowest possible dose of inhaled steroidpossible dose of inhaled steroid

Reductions should be slow, decreasing dose by Reductions should be slow, decreasing dose by ~25-50% every three months~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

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

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

http://www.simpsonstrivia.com.ar/simpsons-photos/simpsons-trivia.gif

6

3437

11 11

0

5

10

15

20

25

30

35

40

"CompletelyControlled"

"WellControlled"

"SomewhatControlled"

"PoorlyControlled"

"Not at allControlled"

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

40% of Not Well-Controlled patients

consider themselves “Well”

or “Completely Controlled”

Self-reported level of control by Not Well-Controlled patients

% P

atie

nts

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?