22/06/2011

 Asthma – an introduction (Vanessa)  Diagnosis and management of chronic asthma in line with current BTS guidelines (Dr Lowery)  3 x Case studies (Dr Lowery)  Tea break ( )  Childhood asthma (Vanessa)  Asthma & QoF  AKT questions (Adam)  Questions and feedback

 Definition of asthma  Who gets asthma and what causes it  How to diagnose and manage adult and childhood asthma in line with current BTS guidelines  Recognise signs of uncontrolled asthma  How to recognise, manage and follow up patients with an acute exacerbation  Management of Asthma during pregnancy  QoF and achieving targets

By Dr Vanessa Kerai

Asthma is a chronic inflammatory disorder of the airways characterised by:  Pulmonary symptoms  Reversible airway obstruction  Evidence of bronchial hyper-reactivity.

 The prevalence of asthma is increasing globally  More common in Western and affluent societies  The prevalence of treated asthma in the UK is approximately 7%  90% of people are diagnosed before the age of 6 years.  Asthma is more common in boys than girls, but boys are more likely to "grow out of it" and so asthma is more common in women than men  Asthma is more common in people with a personal history of atopy and in people with a family history of asthma or atopy.

 Expiratory wheeze  Shortness of breath  Chest tightness  Cough  Patients with asthma often have variable and intermittent symptoms  Their symptoms are frequently worse in the early hours of the morning  Consider other pathology in patients only complaining of a cough or cough as a main symptom.  A family history of asthma  A personal history of atopy  Think about occupational asthma in adult onset especially if symptoms worse at work

 Exercise  Respiratory infections  Environmental irritants  Allergens  Medication  Co-existent rhinitis

 Wherever possible you should do objective tests to confirm the diagnosis of asthma before starting long-term treatment.  Patients with asthma and chronic obstructive pulmonary disease both have airflow obstruction  Patients with asthma have reversible obstruction. Improvement can occur spontaneously or as a result of treatment  You should express airflow obstruction as a percentage of the patient's predicted peak flow rate or forced expiratory volume in one second (FEV 1 ) or as a percentage of their best peak flow rate.

 Patients should test their peak flow rate every morning and night for two weeks, with additional readings if they meet a trigger, or feel their symptoms. Best readings out of three attempts.  Likely to have asthma if there is a 20% variation in the peak flow recording (often with lower readings in the mornings than the evenings) on three or more days out of 14.  However a negative test does not exclude the diagnosis (it is a specific but not a sensitive test).

 You could ask your patient to do this if you suspect exercise induced asthma.  The patient should measure their PEFR and then exercise for 6 minutes. They should then repeat the peak flow every 10 mins for 30 mins.  A fall of 20% in the PEFR during the test is diagnostic of asthma, but a negative test does not exclude the diagnosis.

 Measure the PEFR or FEV 1 before and after inhalation of a short-acting beta 2 agonist  Asthma is likely if:  The PEFR increases by 20% from the baseline (and also by at least 60 l/min) or  The FEV 1 increases by 15% (and also by at least 200 ml).  A negative test does not exclude the diagnosis.

 You can do this with a six week course of inhaled steroids or a two week course of oral steroids.  Steroid reversibility trials may help to distinguish asthma from COPD.  This involves measuring the patient's PEFR (or FEV 1 ) before and after a trial of steroid either orally or inhaled.  Asthma is likely if:  The PEFR increases by 20% from the baseline (and also by at least 60 l/min) or  The FEV 1 increases by 15% (and also by at least 200 ml).  If there is no reversibility or variability in airflow obstruction, this does not exclude the diagnosis but you should consider an alternative diagnosis

 Chest xray in patients with atypical symptoms (such as unilateral chest signs, haemoptysis or excessive purulent sputum) and those who do not respond to treatment.