Asthma Diagnosis Prescribing Acute Management Tracey Bradshaw Respiratory Consultant RIE.

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Asthma Diagnosis Prescribing Acute Management Tracey Bradshaw Respiratory Consultant RIE

Transcript of Asthma Diagnosis Prescribing Acute Management Tracey Bradshaw Respiratory Consultant RIE.

Page 1: Asthma Diagnosis Prescribing Acute Management Tracey Bradshaw Respiratory Consultant RIE.

AsthmaDiagnosis

Prescribing

Acute Management

Tracey Bradshaw

Respiratory Consultant

RIE

Page 2: 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

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Asthma, COPD or Both?

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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

Page 5: Asthma Diagnosis Prescribing Acute Management Tracey Bradshaw Respiratory Consultant RIE.

ACOS diagnosis

GLOBAL INITIATIVE FOR ASTHMA, GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE

Treat asthmatic component with

ICS

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Prescribing

• Right drug

• Right dose

• Right device

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A stepwise approach

Page 8: Asthma Diagnosis Prescribing Acute Management Tracey Bradshaw Respiratory Consultant RIE.

Right DrugWho 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

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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

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Right dose- Differences in ICS

• Potency Clenil : budesonide : fluticasone

1 : 1 : 2

• In mcgs 200 : 200 : 100

• At equivalent doses, efficacy is equal

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Inhaled corticosteroid

Equivalent dose (mcg)

UK licence> 12 years

Clenil (beclom) 200 Yes

Fostair 100 > 18 years

Seretide Evo 100 Yes

Seretide Acc 100 Yes

Symbicort 200 Yes*

Flutiform 100 50,125 only

* Up to 400/12 1 dose bd only

Right Dose- ICS/LABA

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Step 4/5 Step 2

Seretide 250 Evo

2 puffs bd (2000)

Seretide 500 Acc

1 puff bd (2000)

Symbicort 400/12

2 puffs bd (1600)

Step 3

Seretide 125 Evo

2 puffs bd (1000)

Seretide 250 Acc

2 puffs bd (1000)

Symbicort 400/12

1 puff bd (800)

or

Symbicort 200/6

2 puffs bd (800)

Fostair 100/6

2 puffs bd (1000)

Seretide 50 Evo

2 puffs bd (400)

Seretide 100 Acc

1 puff bd (400)

Symbicort 200/6

1 puff bd (400)

BDP 250, 1 bd

PLUS

Formoterol 12, 1 bd

Prescribe an ICS

device equivalent

to 400-500 mcg

BDP/day

Control ≥ 3 mControl ≥ 3 m Control ≥ 3 m

Right Dose- Stepping Down

• Good control 3 months• Minimise device changes• Assess 3 monthly• If control lost,

step back up

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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

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Acute Management

• Recognise severity

• Immediate treatment

• Hospital referral

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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

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Moderate Severe Life-threatening

• Speech normal• Respiration <25 breaths/min• Pulse <110 beats/min

• Cannot complete sentences• Respiration 25 breaths/min• Pulse 110 beats/min

• Silent chest, cyanosis, poor respiratory effort• Bradycardia,dysrhythmia hypotension• Exhaustion,confusion, coma

Severity- Examination

Speech, RR, pulse

PEF, Pulse oximetry

50 – 80% 33- 50% < 33%

spO2 < 92%

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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?

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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

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Summary

• Diagnosis• Clinical

• History

• Airflow obstruction

• Acute management• Recognise severity• Immediate treatment• Hospital referral

• Prescribing• Right drug• Right dose• Right device