GP Reg - Asthma and Spirometry 2011 (2)

7/28/2019 GP Reg - Asthma and Spirometry 2011 (2)

1/114

Clinical update - asthma

Jo Riley

Lead for Respiratory NursingService - Oxfordshire


2/114

Asthma

Asthma is a chronic inflammatory disorder ofthe airways

In susceptible individuals, inflammatory

symptoms are usually associated withwidespread but variable airflow obstructionand an increase in airway response to avariety of stimuli.

Obstruction is often reversible, eitherspontaneously or with treatment.

International consensus report


3/114

A Lot Going On Beneath The Surface

Airway

inflammation

Airflowobstruction

Bronchial

hyperresponsiveness

Symptoms


4/114

Sensitisation to an allergen

.

Initial exposure to

allergen

Production of IgE inresponse to allergen

In atopic individual

excess of IgE attachesto mast cellsMast

cell

Allergen

IgE


5/114

Re-exposure to an allergen

.

Bronchospasm (3)

Mediator

release (2)

Allergen re-

exposure

bridges IgE (1)

Early

response


6/114

Bronchus in early asthmatic response

Goblet Cells

(with mucus) Mucosa

Nerve

Fibres

Basementmembrane

Smooth Muscle Cells

Capillary

Submucosa

Mast Cell


7/114

PeakExpiratoryFlow

Time Scale (hours)

0 hrs 3 hrs 6 hrs 9 hrs

E.A.R.

education for health


8/114

Late response to an allergen

Epithel ialshedding

Bronchospasm

Inf lammatorycells

II

IIIIIIIII

Oedema

Mucusproduct ion

Microvascu lar leakageand inf lammat ion


9/114

Bronchus in late asthmatic

response

Mast cells

Eosinophils

Mast cell

Macrophage

EosinophilLumen with

mucus, cellular

debris, plasma

exudate

Nerve fibres

partly exposed

by epithelial

damage

Basement membrane

Desquamated

epithelial cells

CapillaryMacrophage

Smooth muscle fibre


10/114

0 hrs 3 hrs 6 hrs 9 hrs

PeakExp

iratoryFlow

L.A.R.E.A.R.

Time scale (hours)education for health


11/114

Asthma

Normalbronchiole Mildasthma Severeasthma

Muscles

around airway

Airway

Narrower

airway Mucus

Tightening muscles

Inflammed

lining of

airway wall

Very

tight

muscles

Mucusblocking

airwayVery

small

airway

Inflammedswollen

airway wall


12/114

Asthma often has an atopic

component


13/114

What is atopy?

A genetic tendency to

overproduce IgE (sometimes

called hypersensitivity) in

response to commonallergens, particularly

aeroallergens.

A predisposition to develop

allergic disease


14/114

What is allergy?

Allergy is the clinical manifestation of thegenetic predisposition to atopy.

Allergic symptoms are expressed upon re-

exposure to a specific allergen. The symptoms are a result of the release of

inflammatory mediators.

66-80% of children have allergic asthma

and 15-25% of adults


15/114

Asthma triggers

Animals, house dust mite, pollens and spores,food hypersensitivity, some industrial chemicals

Exercise, smoking, drugs,stress, hormones,

respiratory infections Chronic symptoms - no identifiable trigger


16/114

The impact of asthma

1. Where do we stand? Asthma in the UK today. Available at: www.asthma.org.uk/document.rm?id=18

[AccessedJune 2008]; 2. Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s 3. Asthma UK.The Asthma Divide. http://www.asthma.org.uk/how_we_help/world_asthma_day/index.html Dateaccessed: July 2008 4.Asthma UK. Key facts and statistics.

http://www.asthma.org.uk/news_media/media_resources/for_1.html. Date accessed July 2008

An estimated 5.2 million people in the UK have asthma1

Among patients treated for their asthma, 55% are not well controlled 2

Over 67,700 people were admitted to hospital experiencing anasthma attack in England in 20043

It is estimated that 75% of all admissions for asthma areavoidable4

Somebody dies from asthma every 7 hours4

Nearly 90% of these deaths are preventable4
http://www.asthma.org.uk/document.rm?id=18http://www.asthma.org.uk/how_we_help/world_asthma_day/index.htmlhttp://www.asthma.org.uk/news_media/media_resources/for_1.htmlhttp://www.asthma.org.uk/news_media/media_resources/for_1.htmlhttp://www.asthma.org.uk/how_we_help/world_asthma_day/index.htmlhttp://www.asthma.org.uk/document.rm?id=18


17/114

1993 2004

BTS/SIGN asthma guidelines published

2003, live guidelines updated on the Web

latest update published May 2008

2008


18/114

18

ADULT with symptoms that may be due to asthma

Clinical History and examination

Spirometry (or PEF if spirometry not available)

High Probability Low ProbabilityIntermediate Probability

Yes No

Obstructive

FEV/FVC 70%

Reconsider probablediagnosis

Further investigation


19/114

19

High Probability

Patient with symptoms that may be due to asthma



1)Symptoms (cough, wheeze, SOB or chest tightness):

worse at night and in the morning

in response to exercise, allergen exposure and cold air

after taking aspirin or beta blockers

2) History of atopic disease

3) Family history of asthma or atopic disease4) Widespread wheeze

5) Evidence of airway narrowing

(NB Normal spirometry when free of symptoms does not exclude asthma)


20/114

20

Patient with symptoms that may be due to asthma



High Probability

Trial of Treatment

Response?

Asthma diagnosis confirmed

Continue Rx

Yes No

Assess compliance

and inhaler technique.

Reconsider the diagnosis

Consider further tests

or referral

Low probability equals:

1) Cough in the absence of wheeze or breathlessness

2) Prominent dizziness, light headedness, peripheral tingling3) Repeatedly normal clinical examination even when

symptomatic

4) No evidence of airway narrowing when symptomatic

5) Voice disturbance6) Symptoms with colds only

7) Chronic productive cough

8) Significant smoking history (>20 pack years)

9) Cardiac disease

Low Probability


21/114

Spirometry in asthma

Spirometry is the preferred test to confirm diagnosisof asthma Clearer identification of airflow obstruction

Less dependant on effort Useful where history and examination leave doubt about

diagnosis

Dependant on level of training of operator

If spirometry shows obstruction patient will need inhaledtreatment what? will depend on diagnosis


22/114

Differential diagnosis in adults

Without airflow obstruction

Chronic cough syndrome

Hyperventilation syndrome

Vocal cord dysfunction

Rhinitis

GORD

Heart failure

Pulmonary fibrosis

With Airflow obstruction

COPD

Bronchiectasis

Inhaled foreign body

Obliterative bronchiolitis

Large airways stenosis

Lung Cancer

Sarcoidosis


23/114

23

CHILD with symptoms that may be due to asthma

Clinical assessment

High Probability Low ProbabilityIntermediate Probability

Yes No

Continue Rx

Response?

Consider referral

Yes

Trial of Treatment

Response?

Asthma diagnosis confirmed

Continue Rx and find minimum effective dose

No

Assess compliance

and inhaler technique.

Consider furtherinvestigation and/or

referral

Consider tests of lung

function and atopy

Investigate/treat

other condition

Further

investigation

Consider

referral


24/114

Further investigations if intermediate

probability of asthma

Treatment trials and reversibility testing >400ml improvement in FEV1

Pre and post 400mcg inhaled salbutamol

Steroid trial 200mcg BD inhaled beclometasone for 6-8 weeks

30mg prednisolone for 2 weeks

Peak flow monitoring 2-4 times a day best of 3 blows (if highest within 40

l/min of each other) >20% variability if 4 times a day monitoring

Assessment of airways responsiveness E.g. methacholine challenge specialist centres only


25/114

Aims of asthma Treatment - 2008

No daytime symptoms No Night time waking due to asthma No exacerbations No need for rescue 2 agonist No activity limitation Normal lung function (FEV1 >80%) Minimal/no adverse effects for

medication


26/114

Most people with asthma should not

need to feel like asthmatics

People with asthma should expect to 1-3

Achieve and maintain control of symptoms

Prevent asthma exacerbations

Maintain normal activity levels, includingexercise

Maintain lung function as close to normal levelsas possible

1, British Thoracic Society et al, Thorax 1997

2,National heart, lung and blood institute, World Health Organisation 1998

3, BTS/SIGN guidelines. Thorax 2003


27/114

2000

1985

1980

ICS treatmentintroduced

1972

Salbutamol

introduced1968

Fixed Dose Combinationproducts introduced

1995

Progression of asthma therapy

1990Launch oflong-actingb2 -agonists

High use ofshort-actingb2 -agonists

Bronchospasm Inflammation Remodelling

1975

Increased use ofICS

AMD Combinationproducts introduced

Adults


28/114

Adults

Adults


29/114

Adults


30/114

Introducing inhaled steroids

Adults or children

using inhaled beta 2 agonist 3 times a week ormore

having symptoms 3 times a week or more Waking at night once a week or more

Consider in adults and children who havehad an exacerbation requiring oral steroidsin the last 2 years

Adults


31/114

Adults


32/114

While the use of inhaled corticosteroids

may be associated with adverse effects

(including the potential to reduced bone

mineral density) with careful inhaled steroid

dose adjustment this risk is likely to be

outweighed by their ability to reduce the

need for multiple bursts of oralcorticosteroids.771

Fear of steroids!


33/114

Stepping up treatment?

If patient not controlled, before stepping up,

consider the following:

Check compliance with existing therapies Check understanding

Check Inhaler technique

Eliminate trigger factors where possible

Adults


34/114

du s


35/114

Step 3: Initial add-on therapy

The first choice as add-on therapy to inhaled steroids in adultsand children(5-12 years) is an inhaled long-acting beta2 agonist(LABA)

Adding a LABA should be considered before going above a doseof 400 mcg BDP or equivalent and certainly before going above800mcg

Long-acting beta2 agonists are effective at providingbronchodilation over a sustained period. They increase lung

function, improve symptoms and reduce incidence ofexacerbation

LABAs are not licensed as monotherapy in the treatment ofasthma

1. British Thoracic Society, Scottish Intercollegiate Guidelines Network. BritishGuideline on the Management of Asthma: A National Clinical Guideline . Revised

Edition, 2008.


36/114

MHRA advice on LABAs

At present the benefits of long-acting 2agonists outweigh the risks, and it isimportant that patients take their asthma

medicine as prescribed to them. Patientsshould discuss any concerns regardingtheir asthma treatment with their doctor.Feb 2008

http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvice/Product-specificinformationandadvice/Asthma/index.htm


37/114

Combination inhalers

Section 4.3.3. BTS 2008

there is no difference in efficacy in giving inhaledsteroid and long-acting 2 agonist in combinationor in separate inhalers

Once a patient is on stable therapy, combinationinhalers have the advantage of guaranteeing thatthe long-acting 2 agonist is not taken withoutinhaled steroid

Supported by Oxfordshire guidance in prescribingPoints Bulletin Oxfordshire PCT Vol 17(1) 09 May2008


38/114

Adults


39/114

Adults


40/114

Children age 5-12 yrs


41/114

Children Less than 5 yrs


42/114


43/114

Stepping down

Patients who have been stable and asymptomatic

for 3 months could consider stepping down

treatment one study recommends halving ICS

dose every 3 months Some children with milder asthma and a clear

seasonal pattern to their symptoms may have a

more rapid dose reduction during their good

season

Key issues

1. regular review

2. maintain on lowest dose possible of ICS


44/114

Non-pharmacological management

Allergen avoidance

Breast feeding

Avoidance of pollutants stopsmoking/support parents to stop smoking

Family therapy in difficult childhood asthma


45/114

Allergen

Reduction

Cochrane Review: Dust Mite Contro l Measures for asthm a; Goetzsche PC;

Coch rane Syst ematic Review 2001

23 studies 6 chemical, 13 physical, 4 combined.

No evidence to support current methods of dust mite control in reducing asthma

symptoms or severity

Have we sorted Asthma?


46/114

The majority of patients accept limitations in their

lives due to asthma

Have we sorted Asthma?

- Asthma management today

% respondents

0% 10% 20% 30% 40% 50% 60% 70% 80%

Sleeping

Sport

Going up or down stairs

Walking

Socialising

Playing with children

Going to work

Sex life 27%

35%

42%

49%

50%

53%

63%

71%

Gruffydd Jones et al. Int J Clin Pract2002

(ACE survey)

f


47/114

Asthma compromises lifestyles in the UK

27% feel that asthma totally controls their life orhas a major effect on it1

44% say that at least one activity is totally or

very limited by asthma2

Only 40% usually feel well3

Two-thirds of patients who say their asthma iswell controlled use reliever twice a day4

1. National Asthma Campaign & Allen and Hanburys. The Impact of Asthma Survey, 1996. 2. National Asthma

Campaign. Asthma J2000. 3. Gruffydd Jones et al. Int J Clin Pract2002. 4. Price et al.Asthma J1999.

After being shown international guidelines,


48/114

g g ,

significantly fewer patients thought their asthma

was under control

That cant be right. My treatment doesnt do that

0% 10% 20% 30% 40% 50%

Before

After

60%

Haughney J et al. Prim Care Resp J 2004; 13: 28-35

% respondents who thought that their asthma was

under control before and after being shown

international guidelines


49/114

Asthma monitoring in primary care

Symptomatic asthma control RCP3 or ACQ (followingslides)

Lung function Spirometry or PEFR

Exacerbations, oral corticosteroid use and time off work or

school since last assessment Inhaler technique

Compliance - which can be assessed by reviewingprescription refill frequency

Bronchodilator reliance - which can be assessed by

reviewing prescription refill frequency Possession of and use of self management plan/personal

action plan


50/114

AskZERO TOLERANCE FOR SYMPTOMS

Simple questions are needed to gain an insight how patients

really are:

Have you had any asthma symptoms recently?

Have you needed your blue inhaler recently?

Do you ever wake up in the night due to your asthma?

Have you had an attack or needed an emergency visit recently?

Do you ever avoid doing things because of your asthma?

Tell them that the aim of asthma

management is zero symptoms

& Tell

Asthma Control Test (ACT)


51/114

1. In the past 4 weeks, how much of the time did your asthma keep you from

getting as much done at work, school or at home?

2. During the past 4 weeks, how often have you had shortness

of breath?

3. During the past 4 weeks, how often did your asthma symptoms

(wheezing, coughing, shortness of breath, chest tightness or pain)wake you up at night, or earlier than usual in the morning?

4. During the past 4 weeks, how often have you used your rescue

inhaler or nebulizer medication (such as salbutamol)?

5. How would you rate your asthma control during the past

4 weeks?

Score

Patient Total ScoreCopyright 2002, QualityMetric Incorporated.Asthma Control Test Is a Trademark of QualityMetric Incorporated.

Asthma Control Test (ACT)


52/114

Imperial College LondonPage 52

Assessment: Royal College of

Physicians of London three questions

Outcomes and audit. Thorax 2003; 58 (Suppl I): i1-i92

Applies to all patients with asthma aged 16 and over. Only use after diagnosis has been established.

IN THE LAST WEEK / MONTH

YES NO

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

(e.g. housework, work, school, etc)?

Date / / /


53/114

Can we control Asthma?

Asthma control is achievable in the majority

of patients

Have you got them on the correct treatment

step?

Does your patient understand what and when to

take and when to seek help?

Have you checked inhaler technique? Does your patient have a self management

plan?


54/114

Acute exacerbation

management


55/114

Living on a knife edge Asthma UK 2004

Of the 5.2 million people with asthma in the UK,2.6 million have severe symptoms.

2.1 million (of the 2.6 million) are sufferingunnecessarily because of a failure of asthma

management. 1 in 6 people with severe asthma symptoms report

weekly attacks so severe that they cannot speak(430,000 people)

20% of people with severe asthma are seriouslyconcerned that the next asthma attack will be theone that kills them (>500,000)


56/114

L f t di f A th d th


57/114

Lessons from studies of Asthma deaths

and near-fatal asthma Who is at risk?

A combination of Severeasthma :- Previous near fatal asthma

(requiring ventilation oracidotic)

Previous admission forasthma esp. in the past

year 3 or more classes of

asthma medication

Heavy use of 2 agonists

Repeated attendances forasthma to the ED

department brittle asthma

Thorax 2008 63 Su IV

AndAdverse behavioural orpsychological features:- Non compliance with treatment or

monitoring

Failure to attend appointments

Fewer GP contacts

Frequent home visits Self discharge from hospital

Psychosis, depression, other psychiatricillness or self harm

Current or recent major tranquiliser use

Denial

Alcohol or drug abuse

Obesity

Learning difficulties

Employment or income problems

Social isolation

Childhood abuse

Severe domestic, marital or legal stress


58/114

Asthma Deaths

Deaths continue to be reported following

inappropriate prescription of -blockers and

NSAIDs; all asthma patients should be

asked about past reactions to these agents

Patients with acute asthma should not be

sedated unless this is to allow anaesthetic

or intensive care procedures


59/114

Lessons learnt from

studies of asthma deaths

Management of acute asthma. Thorax 2008; 63(Suppl IV):

BHealth care professionals must be aware that patients with severeasthma and one or more adverse psychosocial factors are at risk of

death

Keep patients who have had near fatal asthma or brittle asthmaunder specialist supervision indefinitely

Respiratory specialist should follow up patients admitted withsevere asthma for at least a year after admission

Many deaths from asthma are preventable 88-92% of attacks requiring

hospitalisation develop over6 hours

Factors include:

inadequate objective monitoring failure to refer earlier for specialist advice inadequate treatment with steroids


60/114

Brittle Asthma

- Type 1: wide PEF variability (>40% diurnal

variation for >50% of the time over a period >150

days) despite intense therapy

- Type 2: sudden severe attacks on a background

of apparently well controlled asthma


61/114

Moderate asthma exacerbation

Increasing symptoms

PEF>50-75% best of predicted

No features of acute severe asthma

A t th


62/114

Acute severe asthma

Any one of:

- PEF 33-50% best or predicted

- respiratory rate 25/min

- heart rate 110/min

- inability to complete sentences in one

breath


63/114

Life threatening asthma

Any one of the following in a patient with severe

asthma:

Clinical signs Measurements Altered conscious level PEF


64/114

Near-fatal asthma

Raised PaCO2 and/or requiring mechanical

ventilation with raised inflation pressures

P ti t t


65/114

Patient assessmentClinicalfeatures

Clinical features, symptoms, respiratory and cardiovascularsigns helpful but non-specific for severity; absence does notexclude severe attack

PEF or FEV1 Measurement of severity and guide for treatment. PEF moreconvenient. (PEF as %age previous best or predicted)

Pulseoximetry

Determines adequacy of oxygen therapy and need for ABG.Aim to maintain sats >92%

Blood gasses Necessary for patients with SaO2 < 92% or if features of lifethreatening asthma

Chest

X-ray

Not routinely recommended in the absence of :-

Suspected pneumomediastinum or pneumothorax

Suspected consolidationLife threatening asthma

Failure to respond to treatment as expected

Requirement for ventilation

Systolic

paradox

Systolic paradox (pulsus paradox)is an inadequate indicator of

the severity of an attack and should not be used

Moderate Asthma


66/114

Moderate Asthma(PEF >50% pred, Speech normal, resps50%predicted continue treatment at home

Admit if Features of life threatening attack

Features of acute severe asthma after initial treatment Previous near fatal asthma

Acute severe asthma


67/114

Acute severe asthma(PEF 33-50% pred, cant complete sentence,

Resp>25, pulse>110)Consider admission High flow oxygen if available

High dose bronchodilators

Prednisolone 40 50mg (or hydrocortisone100mg)

If no response ADMIT

If admitting, stay with patient, send writtenassessment, Continue high dose bronchodilatorsvia nebuliser and oxygen in ambulance

Treatment of acute asthma in


68/114

Treatment of acute asthma in

adultsOxygen :-

Oxygen saturations should be above 92%

Give high flow oxygen to all patients with acute severeasthma

In hospital, ambulance and primary care, nebulisers shouldbe driven by high flow oxygen (minimum 6l/min flow)

Outside hospital, high dose bronchodilators can bedelivered via large volume spacers or nebulisers

The absence of supplemental oxygen should not preventnebulised therapy being given if indicated

Life threatening asthma (PEF 33%


69/114

Life threatening asthma (PEF


70/114

Special circumstances

Acute asthma in pregnancy

Give drug therapy as for the non pregnant patient

Deliver oxygen immediately to maintain

saturations above 95%

Always treat as an emergency

Asthma in children

Alter drug doses for younger children All over 12s receive adult therapy



71/114

Moderate asthma exacerbation children 2-12 years

Able to talk

No features of acute severe asthma

Pulse 5s, 50%predicted/best

Children aged >5years


72/114


Moderate exacerbation 2 agonist (salbutamol or terbutaline) 4 6 puffs via spacer

Consider soluble prednisolone 30 - 40mg

Increase dose of 2 agonist by 2 puffs every 2 minutes upto 10 puffs according to response

Arrange admission if poor responseGood response Continue 2 agonist via spacer prn but not

exceeding 4 hourly

Continue Prednisolone for 3 days

Arrange follow up in clinic

Asthma 2 5 years


73/114

Asthma 2 5 years

Moderate exacerbation 2 agonist (salbutamol or terbutaline) 4 6 puffs via

spacer

Consider soluble prednisolone 20mg

Increase dose of 2 agonist by 2 puffs every 2 minutes up

to 10 puffs according to response Arrange admission if poor response

Good response Continue 2 agonist via spacer prn butnot exceeding 4 hourly

Continue Prednisolone for 3 days Arrange follow up in clinic

Acute severe asthma children


74/114

Acute severe asthma children2-12 years

Unable to complete sentences in onebreath or too breathless to talk or feed

Use of accessory muscles

Pulse >120 in >5s, >130 in 2-5s

Resp rate >30 in >5s, >50 in 2-5s

SpO2


75/114


Acute Severe exacerbation Oxygen via face mask

2 agonist (salbutamol or terbutaline) 4 6 puffs via spacerat intervals of 10-20 mins or nebulised salbutamol 2.5-5mcg or terbutaline 5 10 mg

Soluble prednisolone 30 - 40mgAssess response to treatment 15 mins after 2 agonist

If poor response repeat 2 agonist and arrange admission

If admitting, stay with patient, send written assessment,

Continue high dose bronchodilators via neb and oxygen inambulance

Children 2 - 5years


76/114

Children 2 - 5years

Acute Severe exacerbation Oxygen via face mask

2 agonist (salbutamol or terbutaline) 4 6 puffs via spacerat intervals of 10-20 mins or nebulised salbutamol 2.5mg

Soluble prednisolone 20mg

Assess response to treatment 15 mins after 2 agonistIf poor response repeat 2 agonist and arrange admission

If admitting, stay with patient, send written assessment,Continue high dose bronchodilators via neb and oxygen inambulance

Life threatening asthma


77/114

Life threatening asthma children 2-12 years

Silent chest Cyanosis Poor respiratory effort

Hypotension Exhaustion Confusion/agitation Coma SpO2


78/114


Life threatening asthma Oxygen via face mask

High dose bronchodilators salbutamol 5mg or

terbutaline 10mg and ipratropium 0.25mg via

nebuliser driven by oxygen Soluble prednisolone 30 - 40mg or IV

hydrocortisone 100mg

Repeat 2 agonist via oxygen driven nebuliser whilst

arranging immediate admission to hospital

Children 2 - 5years


79/114

Children 2 5years

Life threatening asthma Oxygen via face mask

High dose bronchodilators salbutamol 2.5mg or

terbutaline 5mg and ipratropium 0.25mg via

nebuliser driven by oxygen Soluble prednisolone 20mg or IV hydrocortisone

50mg

Repeat 2 agonist via oxygen driven nebuliser whilst

arranging immediate admission to hospital



80/114

Moderate asthma exacerbation children under 2 years

SpO2 >92%

Audible wheezing

Using accessory muscles Still feeding

Acute severe asthma children


81/114

Acute severe asthma childrenunder 2years

SpO2


82/114

Life threatening asthma inchildren under 2 years

Apnoea

Bradicardia

Poor respiratory effort

Asthma treatment in the under


83/114

Asthma treatment in the under

2s 2-4 Puffs Salbutamol initial treatment

For mild to moderate acute asthma, a pMDI +

spacer is the optimal drug delivery device.

Consider steroid tablets in infants early in themanagement of severe episodes of acute

asthma 10mg of soluble prednisolone for 3

days

Consider inhaled ipratropium bromide in

combination with an inhaled 2 agonist for

more severe symptoms.

Lower threshold for admission for all


84/114

Lower threshold for admission for all

children if:

Attack in late afternoon or at night

Recent hospital admission or previous

severe attack

Concern over social circumstances or ability

to cope at home

NB always treat according to most severe

features

C it i f d i i


85/114

Criteria for admission

Any patient with any feature of a life threatening or near fatal attack Any patient with any feature of a severe attack persisting after initial

treatment

Any patient who after initial treatment: Still has significant symptoms

Concerns about compliance

Lives alone/socially isolated

Psychological problems

Physical disability or learning difficulties

Previous near fatal or brittle asthma

Exacerbation despite already being on oral steroids

Presentation at night Pregnancy


86/114

Overview: Managementof acute asthma

Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92

Assess and act promptly in acute asthma

Admit patients with any feature of a life threatening or nearfatal attack, or severe attack persisting after initial treatment

Measure oxygen saturation

Use steroid tablets

Primary care follow up required promptly after acute asthma


87/114

Check inhaler technique

Tailor inhaler device to the patients needs

Di h l


88/114

Discharge plan

Do your hospitals use a discharge checklist? Peak flow should be at least 75% or best or predicted with

less than 20% diurnal variation pre discharge ALL PATIENTS SHOULD HAVE A SELF MANAGEMENT

PLAN BEFORE BEING DISCHARGED Patient must be prescribed preventative therapy Inhaler technique must be checked All patients should have their own peak flow meter Advise to see GP within 2 working days can they get an

appointment? Refer for chest OPD within 4 weeks

Ed ti / itt i f ti


89/114

Education / written information

How to recognise that asthma is deteriorating

How to take medicines, how often and for how long

How to use inhaler effectively

What to do if they have another asthma attack

Are there any triggers and can they avoid them in future?

Smoking cessation

How often to make an appointment to have asthmareviewed

The importance of carrying a reliever inhaler at all times

Wh d i t ?


90/114

Why do spirometry?

More informative than peak flow To detect presence or absence of lung disease where there is a history

or pulmonary symptoms

To confirm findings of other investigations e.g.chest x-ray or bloodgasses

To establish extent of lung impairment in respiratory disease andmonitor progression e.g.COPD / Fibrosis

To investigate impact of other diseases on lung function e.g. cardiacdisease or neuromuscular disease

Occupational / environmental monitoring e.g. smokers, dust, asbestos

To determine effects of an intervention e.g.bronchodilator reversibility

tests

S i t t


91/114

Spirometry cannot -

Define the full extent of the disease e.g. In

COPD many systemic as well as pulmonary

effects

Define the response to therapy

Define the extent of disability that the patient

experiences

G id li


92/114

Guidelines

Avoid

Smoking for 24 hours

Alcohol for 4 hours

Vigorous exercise for

30 minutes

Tight clothing

Food for 2 hours Query Using Inhalers

Ch k Hi t


93/114

Check History

MI / CVA

Recent operations

Spontaneous pneumothorax

Aneurysm

Uncontrolled hypertension, angina

Ear infection Pregnancy

P ti nt p p ti n


94/114

Patient preparation

Record patients date of birth, height, ethnicorigin

Note if the patient is currently unwell or hashad a recent exacerbation

Ensure the patient is comfortable Sit the patient in a chair with arms Explain the purpose of the test

You may need to demonstrate the correcttechnique

Allow the patient practice attempts

P tient prep r ti n


95/114

Patient preparation

To withhold or not to withhold medication?

If you are doing reversibility testing: No short acting bronchodilators for 4 hours

No long acting bronchodilators for 12 hours

No sustained release oral bronchodilators for24 hours

For routine monitoring of COPD patients: Take all medication as usual

Lung volume terminology


96/114

Lung volume terminology

Tidal vol

Inspiratory

capacity

Inspiratory

reserve

vol

Expiratory

reserve vol

Vital

capacity

Residual vol

Terminology


97/114

Terminology

VC Vital capacity, the total amount of air that acn beexpelled from the lungs from full inspiration to fullexpiration

FVC Forced vital capacity, should be the same volume asVC but is sometimes reduced due to air trapping in

COPDFEV1 Forced expiratory volume in one second from full

inspirationFEV1/FVC or FEV1% or FEV1/FVC ratio The percentage of

the FVC that is produced in the first second

FEV1/VC - The percentage of the VC that is produced inthe first second

Measuring vital capacity (VC)


98/114

Measuring vital capacity (VC)

The VC is a non vorced measurement. It is often

measured at the start of a session.

Patient breathes in as deeply as is comfortable

Seals lips around mouthpiece Breathes out steadily at a comfortable pace

Continue until expiration complete

May need a nose clip Repeat

Measuring FEV and FVC


99/114

Measuring FEV1 and FVC

Ask the patient to take a deep breath in full

inspiration

Patient to blow out forcibly, as hard and fast as

possible, until there is nothing left to dispell Encourage patient to keep blowing

For some COPD patients this can take up to 15

seconds!

Spirometer may bleep to say manoeuvre complete

Repeat the procedure twice or until reproducible

results

Maintaining accuracy


100/114

Maintaining accuracy

The most common reason for inacurateresults is patient technique

Common problems include:

Inadaquate or incomplete inhalation Additional breath taken during manoeuvre Lips not sealed around mouthpiece

A slow start to the forced exhalation Some exhalation through the nose Coughing

Interpreation of results


101/114

Interpreation of results

Take the best of the 3 consistent readings of

FEV1 and of FVC

Find the predicted normals for your patient

Your machine may do this for you!

Get out your calculators!!

Predicted Normals


102/114

Predicted Normals

Depends on ;

Age

SexHeight

Race

Predicted Normal values


103/114

Predicted Normal values

Based on largepopulationsurveyse.g.ERS93,ECCS83

Predicted values arethe mean valuesobtained from thesurvey

No surveys conductedin elderly populations

Normal ventilatory function


104/114

Normal ventilatory function

FVC 80 120% of predicted

FEV1 80 120% of predicted

FEV1/FVC ratio >70%

Results clasification


105/114

Results clasification

Normal

Obstructive

Restrictive

Combined

Interpreting Spirometry


106/114

Interpreting Spirometry

Normal Obstructive Restrictive Combined

FEV1 >80% 80%


107/114

Flow volume trace


108/114

Volume (litres)

FVC

Peak expiratory flow

Flow(

l/seco

nd)

Normal Flow Volume curve


109/114

Normal Flow Volume curve

Expiratoryflow rate

L/sec

Volume (L)

FVC

Maximumexpiratory flow(PEF)

Inspiratoryflow rate

L/sec

RVTLC

Patterns of abnormality in

i t


110/114

Obstruction Restriction Mixed

Time Time Time

Vo

lume

V

olume

Vo

lume

spirometry

Slow rise, reducedvolume expired,

prolonged time to

full expiration

Fast rise to plateau

at reduced

maximum volume

Slow rise to reduced

maximum volume

Patterns of flow volume curves in


111/114

obstruction and restriction

Obstruction Severe obstruction Restriction

Volume (L)E

xpiratoryflow

rate

Expiratoryflow

rate

Expiratoryflow

rate

Volume (L) Volume (L)Steeple pattern,

reduced peak flow,

rapid fall off

Normal shape,

normal peak flow,

reduced volume

Reduced peak flow,

scooped out mid-

curve

Obstructive defects


112/114

Obstructive defects

COPD

Asthma

Bronchial carcinoma Bronchiectasis

Restrictive defects


113/114

Pulmonary causes

Fibrosing lung disease(CFA, UIP, EAA,rheumatiod)

Parenchymal tumours

Pneumoconiosis (coalworkers, asbestosis,silicosis, siderosis)

Byssinosis

Pulmonary oedema


114/114

GP Reg - Asthma and Spirometry 2011 (2)

Documents

Transcript of GP Reg - Asthma and Spirometry 2011 (2)