WHAT IS ASTHMA? Lynne Powell RN, MSc., IP, PgCEd BTS/SIGN (2012) ‘Asthma is a common condition which produces a significant workload for general practice, hospital outpatient clinics and inpatient admissions. It is clear that much of this morbidity relates to poor management particularly the under use of preventative medicine.’ British Thoracic Society, Scottish Intercollegiate Guidelines Network, British Guideline on the Management of Asthma A national clinical guideline May 2008. Revised January 2012. NICE QS25 Quality standard for asthma Asthma is a long-term condition that affects the airways in the lungs in children, young people and adults. Classic symptoms include breathlessness, tightness in the chest, coughing and wheezing. The goal of management is for people to be free from symptoms and able to lead a normal, active life. This is achieved partly through treatment, tailored to the person, and partly by people getting to know what provokes their symptoms and avoiding these triggers as much as possible. The causes of asthma are not well understood, so a cure is not usually possible, although this can sometimes be achieved in occupational asthma. NICE QS25 Quality standard for asthma Occupational factors account for about 1 in 6 cases of asthma in adults of working age.’ In the UK, 5.4 million people are currently receiving treatment for asthma, 1.1 million of whom are children. Asthma is the most common long-term medical condition, and 1 in 11 children has it. There are around 1000 deaths a year from asthma, about 90% of which are associated with preventable factors. Almost 40% of these deaths are in people under 75. Asthma is responsible for large numbers of accident and emergency department attendances and hospital admissions. Most admissions are emergencies and 70% may have been preventable with appropriate early interventions.’ Diagnosis The diagnosis of asthma is a clinical one; there is no standardised definition of the type, severity or frequency of symptoms, nor of the findings on investigation. The absence of a gold standard definition means that it is not possible to make clear evidence based recommendations on how to make a diagnosis of asthma. Diagnosis Central to all definitions is the presence of symptoms (more than one of wheeze, breathlessness, chest tightness, cough) and of variable airflow obstruction. More recent descriptions of asthma in children and in adults have included airway hyper-responsiveness and airway inflammation as components of the disease. How these features relate to each other, how they are best measured and how they contribute to the clinical manifestations of asthma, remains unclear. Diagnosis Although there are many shared features in the diagnosis of asthma in children and in adults there are also important differences. The differential diagnosis, the natural history of wheezing illnesses, the ability to perform certain investigations and their diagnostic value, are all influenced by age. What causes an asthma attack? It can start at any time. Two-thirds of people get symptoms in childhood. More likely if there is a family history. It often runs in families, especially if the related allergic conditions of eczema and hay fever are present. Nasal problems such as polyps. Environmental factors, poor air quality if you already have asthma. Modern lifestyles, central heating, double glazing, carpeting and upholstered furniture. Not all asthma attacks/exacerbations are the same Some are worse than others There are 4 contributory factors to an exacerbation 4 contributory factors for an exacerbation of asthma Hypersensitivity – Once the airways have been exposed to a trigger, they become easily irritated with repeated exposure. Bronchospasm – The muscles around the airways tighten up & make the airways smaller. Inflammation – The airways become swollen & irritated. This also makes the airways smaller & makes breathing more difficult. Mucus production – Inflamed airways produce excess mucus which clogs the already narrowed openings. Symptoms of an exacerbation of asthma Cough Shortness of breath at rest or with exercise Trouble exhaling Wheezing Chest tightness Productive cough usually white & frothy Night-time waking with shortness of breath Asthma Triggers Strong emotions (laughing or crying) Hot or cold air Odors (perfume, cleansers, air freshener, etc) Exercise Exposure to animals (cats, dogs, horses, etc) Dust mites, cockroaches Smog Pollens, weeds, grasses Smoke Atopy & allergy Atopy is the predisposition of an individual to produce high quantities of IgE in response to allergens in the environment. This predisposition is inherited from your mother, father or both. Only atopic people develop sensitivity to one or more allergens. Atopy is silent; atopic people do not necessarily display symptoms of allergy. The only way to identify atopy is through allergy testing (IgE/RAST; skinprick testing). Atopy & allergy Allergy means that the person develops symptoms upon contact with an allergen to which he/she has become sensitive. You need to be atopic to become allergic but if you are atopic you will not necessarily progress to allergy. Allergen exposure Early and Late phase response Overview of allergic response Types of allergies Many asthmatics show signs of allergy such as: Eczema Allergic/perennial rhinitis Foods allergies such as dairy products Angio-oedema Anaphylaxis Allergic/non allergic If evidence of allergy is insisted upon for a diagnosis of asthma, then this will exclude non-allergic individuals who have exactly the same symptoms and signs, and who respond to anti-asthma therapy. It is therefore perfectly reasonable to classify asthma as: non-allergic ('intrinsic') allergic ('extrinsic'). Quality and Outcome Framework guidance for GMS Contract Wales 2013/14 Indicator Points Achievement thresholds Records AST001. The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months 4 Initial diagnosis AST002W. The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months or anytime after diagnosis. 15 45-80% AST003W. The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 15 months that includes an assessment of asthma control using the 3 RCP questions NICE 2011 menu ID: NM23 20 45-70% AST004W. The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 15 months 6 45-80% Ongoing management Asthma (AST) QOF Asthma (AST) QOF Quality and Outcome Framework guidance for GMS Wales 2013/14 Asthma is a common condition which responds well to appropriate management and which is principally managed in primary care. One of the main difficulties in asthma is the variability Some symptoms of asthma are shared with diseases of other systems A proportion of patients with COPD will also have asthma It is inappropriate to monitor symptom-free patients on no therapy or minimal symptoms AST indicator 003W (NICE 2011 menu ID;NM23) RCP questions In the last month: 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 (for example, housework, work/school, etc.)? Asthma Annual Review ‘If asthma appears to be uncontrolled, the following are to be managed appropriately before increasing asthma therapy:’ AST indicator 003W (NICE 2011 menu ID;NM23) RCP questions Smoking behaviour Poor inhaler technique Inadequate adherence to regular preventative asthma therapy Rhinitis Asthma Annual Review AST indicator 003W (NICE 2011 menu ID;NM23) During an asthma review the following takes place: Assess symptoms (using the 3 RCP questions) Measure peak flow Assess inhaler technique Consider a personalised asthma plan Asthma myths Asthma can be cured You can be infected with asthma by someone who has it A change in environment may help treat your asthma Patients with asthma shouldn’t exercise Asthma medications are addictive You don’t die from asthma Asthma symptoms are the same for everyone You grow out of asthma as you get older Asthma only presents in children Is asthma serious? http://www.asthma.org.uk/asthma-facts-and-statistics Imagine being paralysed by fear as you struggle to breathe, unable to speak, unable to ask for help. That’s what an asthma attack feels like. There are 5.4 million people with asthma in the UK, which means asthma affects one in five households. Asthma is not just an excuse to skip PE. For a quarter of a million people with severe asthma, even climbing the stairs can feel like a marathon, never mind going outside their home. Three people die every single day because of asthma. But most of these deaths could have been avoided. Asthma UK is the charity dedicated to changing this. Key facts 5.4 million people in the UK are currently receiving treatment for asthma: 1.1 million children (1 in 11) and 4.3 million adults (1 in 12). Asthma prevalence is thought to have plateaued since the late 1990s, although the UK still has some of the highest rates in Europe and on average 3 people a day die from asthma. There were 1,143 deaths from asthma in the UK in 2010 (16 of these were children aged 14 and under) An estimated 75% of hospital admissions for asthma are avoidable and as many as 90% of the deaths from asthma are preventable. Asthma across the UK In Northern Ireland 182,000 people are currently receiving treatment for asthma. This includes 36,000 children and 146,000 adults. In Scotland, 368,000 people are currently receiving treatment for asthma. This includes 72,000 children and 296,000 adults. In Wales 314,000 people are currently receiving treatment for asthma. This consists of 59,000 children and 256,000 adults. One in 11 children has asthma and it is the most common long-term medical condition. On average there are two children with asthma in every classroom in the UK. The UK has among the highest prevalence rates of asthma symptoms in children worldwide. Every 18 minutes a child is admitted to hospital in the UK because of their asthma. The NHS spends around £1 billion a year treating and caring for people with asthma. In 2008/09 up to 1.1 million working days were lost due to breathing or lung problems.