Asthma Guidelines, Diagnosis and Management Alison Hughes Respiratory Specialist Nurse Solent NHS Trust

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.” Thorax 2003

More than five million people in the UK are being treated for asthma Many emergency admissions are believed to be avoidable Many people who die from asthma had well recognised identifiable risk factors

British Guideline on the Management of Asthma BTS/SIGN 2008 Updated 2011

The aim of asthma management is disease control- this is defined as: No daytime symptoms No night-time symptoms No need for rescue medication No limitations on activity, including exercise No exacerbations Normal lung function (in practical terms FEV 1 and/or PEF <80% predicted or best) with minimal side effects from treatment

Adult with symptoms that may be due to Asthma

Adults

Recommended daily doses

© Imperial College LondonPage 24 Assessment: Royal College of Physicians of London three questions Outcomes and audit. Thorax 2003; 58 (Suppl I): i1-i92 Applies to all patients with asthma aged 16 and over. Only use after diagnosis has been established. IN THE LAST WEEK / MONTH YES NO “Have you had difficulty sleeping because of your asthma symptoms (including cough)?” “Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?” “Has your asthma interfered with your usual activities (e.g. housework, work, school, etc)?” Date / / /

1.In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home? 2.During the past 4 weeks, how often have you had shortness of breath? 3.During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning? 4.During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as salbutamol)? 5.How would you rate your asthma control during the past 4 weeks? Score Patient Total Score Copyright 2002, QualityMetric Incorporated. Asthma Control Test Is a Trademark of QualityMetric Incorporated. Asthma Control Test™ (ACT)

Quality Outcome Framework (QOF) Current QOF indicators Asthma register Annual asthma review Confirmation of diagnosis Smoking status of year olds NO necessity to check inhaler technique or measure lung function No necessity to measure asthma control

What do patients care about? No bad asthma days No restriction on their life PEF is not important to patients

What do we care about? No chronic symptoms No asthma attacks or emergency visits Minimal need for quick relief (as needed) beta₂ agonists Patients can maintain normal physical activity, including exercise Lung function as close to normal as possible Minimal (or no) adverse effects from medicine

Medication £1 billion spent on respiratory drugs- not including antibiotics Respiratory items are the most expensive category in the BNF inhalers Relatively low volume of respiratory prescriptions Source: NHS information Centre

Inhalers Seretide (all) is the most expensive drug Seretide 250 evohaler is the most expensive individual item Symbicort 200 is the 5 th most expensive item Of the top 5 costliest drugs to the NHS, currently 3 are inhalers Source: NHS Information Centre

Barriers for using inhalers Sub optimal communication between HCP & patient Lack of opportunity to discuss fear of side effects Patients under-estimate the severity Over-estimate their level of control Technique

The most expensive inhaler is an inhaler not taken correctly Could cost 50p per puff! The right inhaler and the right technique is very important Devices such as the AIMS, in-check and 2-tone can help

Resources Self management materials available free from Asthma UK ‘Be in control’ ‘My asthma material’ Interactive inhaler demo

Asthma or COPD? Does the medication fit in with a diagnosis of asthma? Could the patient have COPD but believe it’s asthma? Portsmouth Hospital local guidelines Based on the NICE 2010 COPD guidelines

Differential Diagnosis

Questions