Why Asthma Kills (and how I can prevent it) or… The five things I wish I didn’t know about asthma Dr Will Carroll Honorary Reader, Keele University Consultant Paediatrician, University Hospitals of the North Midlands

Advertisement - LfE excellentsupervision@uhnm.nhs.uk ‘And if you press that one, someone comes in and tells you what a good job you are doing’

Let me tell you a story… ‘Why do you speak to them in parables? ‘Because it is given unto you to know the mysteries of the kingdom of heaven, but to them it is not given. Therefore I speak to them in parables: because seeing they see not; and hearing they hear not, neither do they understand. Matthew 13:10

Over the next 50 minutes… A story... The five things Questions Asthma kills Salbutamol kills I don’t listen Parents worry about steroids Patients lie (and tell the truth) Questions

Joanna’s story

1. Asthma Kills 19 Recommendations Motherhood & Apple Pie? Organisation of Services Professional Care Patient factors Prescribing Organisation of NHS services Every NHS hospital and general practice should have a designated, named clinical lead for asthma services, responsible for formal training in the management of acute asthma. Patients with asthma must be referred to a specialist asthma service if they have required more than two courses of systemic corticosteroids (oral or injected) in the previous 12 months or require management using British Thoracic Society (BTS) stepwise treatment 4 or 5 to achieve control. Follow-up arrangements must be made after every attendance at an emergency department or out-of-hours service for an asthma attack. Secondary care follow-up should be arranged after every hospital admission for asthma, and for patients who have attended the emergency department two or more times with an asthma attack in the previous 12 months. A standard national asthma template should be developed to facilitate a structured, thorough asthma review. This should improve the documentation of reviews in medical records and form the basis of local audit of asthma care. Electronic surveillance of prescribing in primary care should be introduced as a matter of urgency to alert clinicians to patients being prescribed excessive quantities of short-acting reliever inhalers, or too few preventer inhalers. A national ongoing audit of asthma should be established, which would help clinicians, commissioners and patient organisations to work together to improve asthma care. Medical and professional care All people with asthma should be provided with written guidance in the form of a personal asthma action plan (PAAP) that details their own triggers and current treatment, and specifies how to prevent relapse and when and how to seek help in an emergency. People with asthma should have a structured review by a healthcare professional with specialist training in asthma, at least annually. People at high risk of severe asthma attacks should be monitored more closely, ensuring that their PAAPs are reviewed and updated at each review. Factors that trigger or exacerbate asthma must be elicited routinely and documented in the medical records and PAAPs of all people with asthma, so that measures can be taken to reduce their impact. An assessment of recent asthma control should be undertaken at every asthma review. Where loss of control is identified, immediate action is required, including escalation of responsibility, treatment change and arrangements for follow-up. Health professionals must be aware of the features that increase the risk of asthma attacks and death, including the significance of concurrent psychological and mental health issues. Patient factors and perception of risk Patient self-management should be encouraged to reflect their known triggers, eg increasing medication before the start of the hay fever season, avoiding non-steroidal anti-inflammatory drugs, or by the early use of oral corticosteroids with viral- or allergic-induced exacerbations. A history of smoking and/or exposure to second-hand smoke should be documented in the medical records of all people with asthma. Current smokers should be offered referral to a smoking-cessation service.        Parents and children, and those who care for or teach them, should be educated about managing asthma. This should include emphasis on ‘how’, ‘why’ and ‘when’ they should use their asthma medications, recognising when asthma is not controlled, and knowing when and how to seek emergency advice. Efforts to minimise exposure to allergens and second-hand smoke should be emphasised, especially in young people with asthma. Prescribing and medicines use All asthma patients who have been prescribed more than 12 short-acting reliever inhalers in the previous 12 months should be invited for urgent review of their asthma control, with the aim of improving their asthma through education and change of treatment if required. An assessment of inhaler technique to ensure effectiveness should be routinely undertaken and formally documented at annual review, and also checked by the pharmacist when a new device is dispensed. Non-adherence to preventer inhaled corticosteroids is associated with increased risk of poor asthma control and should be continually monitored. The use of combination inhalers should be encouraged. Where long-acting beta agonist (LABA) bronchodilators are prescribed for people with asthma, they should be prescribed with an inhaled corticosteroid in a single combination inhaler.

Not one more life Organisation 1. Named professional 2. Refer poor control 3. Follow up 4. Structured review 5. Monitor prescribing 6. National audit

Your responsibility Professional care Give everyone a plan At least annual review Document (& avoid) triggers Assess control Know risk factors

Patient factors Self management and trigger awareness Document smokers Educate – how, when and why? Help people to stop smoking

Prescribing 1. >12 reliever pMDI used per year? 2. Check inhaler technique 3. Non-adherence kills 4. Do not use LABA as separate inhalers

Pop quiz 1: Salbutamol A. 3 minutes B. 6 minutes C. 10 minutes How long after a nebulised dose of salbutamol would you see maximum bronchodilation? A. 3 minutes B. 6 minutes C. 10 minutes D. 15 minutes E. 30 minutes

Pop quiz 2: Salbutamol A. 10 minutes B. 30 minutes C. 60 minutes The plasma half-life of salbutamol in a 14-year-old is most likely to be? A. 10 minutes B. 30 minutes C. 60 minutes D. 120 minutes E. 240 minutes

Pop quiz 3: Salbutamol A. Headache B. Hypoglycaemia C. Hypokalaemia Which of the following is NOT a recognised side effect of salbutamol? A. Headache B. Hypoglycaemia C. Hypokalaemia D. Lactic acidosis E. Tachycardia

Pop quiz 4: Salbutamol A. Inhaled B. Intravenous Which method is likely to be the safest mode of administration to a child with poor oxygenation (saturations of 85%)? A. Inhaled B. Intravenous C. Nebuliser driven with air D. Nebuliser driven with O2 E. Oral Answer — D. 15 min. The maximum plasma concentra- tion is reached after 10 min and maximum broncho- dilator effect occurs after 12 – 15 min. 2. Answer C. 4 h. In adults, salbutamol has a half-life of approximately 4 h and it is thought to be similar in children although detailed studies are lacking. 3. Answer B. Hypoglycaemia. As a sympathomimetic, salbutamol has effects across several organ systems and administration leads to dose-dependent tachycar- dia, hyperglycaemia, hypokalaemia and tremor. Children may also suffer from headache, hyperactivity, muscle cramps and lactic acidosis. Lactic acidosis usually occurs as a result of a direct β 2-receptor-stimulated anaerobic glycolysis within skeletal muscle. 4. Answer D. Nebuliser driven with oxygen. There is no absolutely correct answer to this question, although oral salbutamol is undoubtedly incorrect. Nebulisers driven with air are also likely to cause harm as there will be a transient increase in ventila- tion/perfusion mismatching. In this child, it is import- ant to give oxygen and therefore guidelines and expert opinion would suggest that a salbutamol nebuliser driven with oxygen is the best first treat- ment. If this is ineffective, then intravenous salbuta- mol may be required.

2. Salbutamol kills (& saves) What I know Partial β2-agonist Half-life ≈ 4 hours Use in acute asthma Tachyphylaxis ↑ Lactate PO/IV/INH/NEB What I don’t know Optimum dose Optimum delivery Why overuse kills How/when to wean When to escalate

2. Salbutamol kills Hypoxia = V/Q mismatch Delivery method will influence deposition PO = Stomach and Blood IV = Blood NEB = Blood, guts & lung INH = Lung (& guts) Andrrzejowski P. Arch Dis Child (Ed and Prac) 2016;101:194-7.

Salbutamol messages HIGH RISK GROUPS Anyone using >1 pMDI/month Anyone who needs IV treatment Anyone without a spacer Anyone with cannot take properly Anyone who cannot access

3. I don’t listen

Discuss with the person next to you for 1 minute What did you see/hear? Discuss with the person next to you for 1 minute

What did I miss?

4. People worry about steroids Patients worry about steroids In particular oral steroid courses Impact on ICS use Foster JM et al. ERJ 2017;50(3):1700765

Unresolved worry about ICS Is common (in parents) Is associated with very poor control OR 1.65 (1.23-2.23) p<0.001 Carroll WD et al. ERJ 2012;39:90-6. At: erj.ersjournals.com/content/39/1/90

Discuss with the person next to you for 1 minute Who will save the day? Discuss with the person next to you for 1 minute

Who will save the day?

Who will really save the day?

The parent in denial How can we obtain proof? Why is this important? Is there an agreed value?

Well…I am not really that convinced about ICS What now? But I am! Well…I am not really that convinced about ICS

Average Percentage Responsibility What determines adherence in young people? Average Percentage Responsibility Child Age (Years) Child Parent 20 40 60 80 100 3 5 7 9 11 13 15 17 19 PARENTS Orell-Valente JK et al. Pediatrics 2008,122:e1186-e1192

What modifies parents behaviour? Concerns about medication Perceived medication necessity Adherence Horne R, Weineman, R. J Psychosom Res 1999;47:555.

What modifies parents behaviour? ACT FEV1 FENO Concerns about medication Perceived medication necessity Adherence Horne R, Weineman, R. J Psychosom Res 1999;47:555.

What modifies parents behaviour? ACT FEV1 FENO Concerns about medication Perceived medication necessity Adherence Horne R, Weineman, R. J Psychosom Res 1999;47:555.