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 reportwww.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 guidelineBTS/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

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

WHATS WORKING WELL IN BERKSHIRE EXAMPLES OF GOOD PRACTICE INNOVATIVE IDEAS

Case 1  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

Would you… 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

Reversibility testing  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

Case 2  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

Do you… 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

Symptoms improve slightly, do you… A. Enquire about triggers B. Increase BDP dose to 400 mcg BD C. Refer to ENT D. Rx Fostair instead of BDP

On further questioning…  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

Occupational asthma  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

High risk jobs  Baker / pastry making  Spray painting  Healthcare / dentalcare  Metalwork / woodwork  Food processing  Soldering / welding  Lab animal work  Farming  Textile, plastic, rubber manufacture  Chemical processing

Case 3  32 year old woman, 4 months pregnant  Asthmatic, previously well controlled with Clenil 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)

Do you… A. Rx Salbutamol inhaler QDS and arrange review in 2 days B. Restart Clenil puffs BD and review in 1 week C. Rx Prednislone 40 mg OD for 5 days D. Refer to A&E

The following can be used in pregnancy… A. Long acting β agonists B. Theophyllines C. Montelukast D. Prednisolone E. All of the above

Asthma in pregnancy  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

Case 4  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)

Do you… A. Stop Fostair and Rx Beclomethasone 400 mcg BD B. Switch to Flutiform puffs BD C. Rx Montelukast D. Rx Spiriva Respimat

Non-pharmacological interventions  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

Case 5  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

Makes appointment in your asthma clinic…  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)

Do you……. 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

Assessing severity of asthma attacks ModerateSevereLife-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

NRAD  Enquiry into all asthma deaths in UK for 1 year  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

Follow-up & referral recommendations  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 ◦  Implement systems to target at risk patients

QUESTIONS WELCOME