Adult Asthma - NHS Lothian Respiratory Managed Clinical Network

Report
Asthma
Diagnosis
Prescribing
Acute Management
Tracey Bradshaw
Respiratory Consultant
RIE
Diagnosis
• The diagnosis of asthma is a clinical one
• Based on history
• Symptoms, triggers
• Variable airflow obstruction
• FEV1 or PEF
Asthma, COPD or Both?
Asthma COPD Overlap Syndrome
(ACOS)
• ACOS is characterized by persistent airflow
limitation with several features usually associated
with asthma and several features usually
associated with COPD
• Worse outcomes compared with asthma
or COPD alone
GLOBAL INITIATIVE FOR ASTHMA, GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
ACOS diagnosis
Treat asthmatic
component with
ICS
GLOBAL INITIATIVE FOR ASTHMA, GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE
Prescribing
• Right drug
• Right dose
• Right device
A stepwise approach
Right Drug
Who needs Inhaled Steroids?
• Early Introduction of ICS
• Significant inflammation in mild asthma
• 1/3 mild asthmatics may have severe exacerbation
• Consider if any of the following:
• Using inhaled β2 agonist three times a week or more
• Symptomatic three times a week or more
• Waking one night a week
• Exacerbation of asthma in the last two years
Right dose
• In mild to moderate asthma, no benefit
starting high dose ICS and stepping down
• Start at dose appropriate to severity
• Reasonable dose 200mcg bd
*All doses in the guideline refer to beclometasone given via CFC-MDI
Right dose- Differences in ICS
• Potency Clenil : budesonide : fluticasone
1 :
• In mcgs 200 :
1
200
:
:
2
100
• At equivalent doses, efficacy is equal
Right Dose- ICS/LABA
Inhaled
corticosteroid
Equivalent
dose (mcg)
Clenil (beclom)
Fostair
Seretide Evo
Seretide Acc
Symbicort
Flutiform
200
100
100
100
200
100
UK licence
> 12 years
Yes
> 18 years
Yes
Yes
Yes*
50,125 only
* Up to 400/12 1 dose bd only
Right Dose- Stepping Down
Step 4/5
Step 3
Control ≥ 3 m
Control ≥ 3 m
Seretide 250 Evo
Seretide 125 Evo
Seretide 50 Evo
2 puffs bd (2000)
2 puffs bd (1000)
2 puffs bd (400)
Seretide 500 Acc
Seretide 250 Acc
Seretide 100 Acc
1 puff bd (2000)
2 puffs bd (1000)
1 puff bd (400)
Symbicort 400/12
Symbicort 400/12
2 puffs bd (1600)
1 puff bd (800)
Symbicort 200/6
or
1 puff bd (400)
Step 2
Control ≥ 3 m
Symbicort 200/6
Prescribe an ICS
device equivalent
to 400-500 mcg
BDP/day
• Good control 3 months
• Minimise device changes
2 puffs bd (800)
Fostair 100/6
BDP 250, 1 bd
2 puffs bd (1000)
PLUS
Formoterol 12, 1 bd
• Assess 3 monthly
• If control lost,
step back up
Right Device
• Always check inhaler technique
• Prior to starting inhalers
• Before stepping up
• Remember Accuhaler and Evohaler
are not interchangeable
• Accuhaler- salmeterol 50mcg/puff= 1 puff bd
• Evohaler- salmeterol 25mcg/puff= 2 puffs bd
Acute Management
• Recognise severity
• Immediate treatment
• Hospital referral
Severity- History
• Markers of risk of an adverse outcome in asthma
• Baseline severity
•
•
•
•
•
Recent hospital admission
Three or more regular medications
Frequent ‘‘after hours’’ GP visits
Psychosocial problems
Previous ICU admission (ever)
• Acute severity
• Heavy use of b2-agonist
• Marked (>50%) reduction or variation in peak flow
• Precipitate asthma
Severity- Examination
Speech, RR, pulse
Moderate
• Speech normal
• Respiration <25
breaths/min
• Pulse <110
beats/min
Severe
• Cannot complete
sentences
• Respiration 25
breaths/min
• Pulse 110
beats/min
Life-threatening
• Silent chest, cyanosis,
poor respiratory effort
• Bradycardia,dysrhythmia
hypotension
• Exhaustion,confusion,
coma
PEF, Pulse oximetry
50 – 80%
33- 50%
< 33%
spO2 < 92%
Goals of Immediate Treatment
• Correction of hypoxemia- high flow oxygen
• Aim for SpO2 94-98%
• Rapid reversal of airflow obstruction- bronchodilators
• MDI + spacer equivalent to nebuliser (oxygen driven)
• ↑ frequency as well as ↑ dose → greater bronchodilation
• Reduction likelihood of recurrence of severe airflow
obstruction- steroids
• 40mg for 5 days
•
Routine antibiotics not indicated
•
Inhaled corticosteroids?
Criteria for admission
• Any feature of a life-threatening or near fatal attack
• Any feature of a severe attack persisting after initial
treatment
• Other considerations
•
•
•
•
•
•
•
•
Ongoing significant symptoms
Concerns about compliance
Living alone/socially isolated
Psychological problems
Physical disability or learning difficulties
Previous near fatal or brittle asthma
Presentation at night
Pregnancy
Summary
• Prescribing
• Diagnosis
• Clinical
• History
• Airflow obstruction
• Right drug
• Right dose
• Right device
• Acute management
• Recognise severity
• Immediate treatment
• Hospital referral

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