AsthmaDiagnosis

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

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

Treat asthmatic component with

ICS

Prescribing

• Right drug

• Right dose

• Right device

A stepwise approach

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

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 : 1 : 2

• In mcgs 200 : 200 : 100

• At equivalent doses, efficacy is equal

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

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

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

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%

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

• Diagnosis• Clinical

• History

• Airflow obstruction

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

• Prescribing• Right drug• Right dose• Right device