Allwin Mercer Dr Andrew Zurek - Berkshire West Clinical ...
Transcript of Allwin Mercer Dr Andrew Zurek - Berkshire West Clinical ...
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 www.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 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
Email 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 www.asthma.org.uk www.breatheberkshirewest.org.uk
WHATS WORKING WELL IN BERKSHIRE
EXAMPLES OF GOOD PRACTICE
INNOVATIVE IDEAS
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
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
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
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
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
A. Enquire about triggers
B. Increase BDP dose to 400 mcg BD
C. Refer to ENT
D. Rx Fostair instead of BDP
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
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 http://occupationalasthma.com/
Baker / pastry making
Spray painting
Healthcare / dentalcare
Metalwork / woodwork
Food processing
Soldering / welding
Lab animal work
Farming
Textile, plastic, rubber manufacture
Chemical processing
32 year old woman, 4 months pregnant
Asthmatic, previously well controlled with Clenil 100 2 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)
A. Rx Salbutamol inhaler QDS and arrange review in 2 days
B. Restart Clenil 100 2 puffs BD and review in 1 week
C. Rx Prednislone 40 mg OD for 5 days
D. Refer to A&E
A. Long acting β agonists
B. Theophyllines
C. Montelukast
D. Prednisolone
E. All of the above
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
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)
A. Stop Fostair and Rx Beclomethasone 400 mcg BD
B. Switch to Flutiform 125 2 puffs BD
C. Rx Montelukast
D. Rx Spiriva Respimat
Inadequate control on
low dose ICS
Add LABA
Assess control
Good response •continue ICS /
LABA
Some improvement
•↑ ICS to 800mcg
No response •stop LABA
•↑ ICS to 800mcg
Still not controlled
Montelukast
Modified release Theophylline
Spiriva Respimat
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
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
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)
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
Moderate Severe Life-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
Enquiry into all asthma deaths in UK for 1 year 2012-13
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
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 ◦ http://www.asthma.org.uk/
Implement systems to target at risk patients
QUESTIONS WELCOME