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 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 Treat asthmatic component with ICS GLOBAL INITIATIVE FOR ASTHMA, GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE Prescribing • Right drug • Right dose • Right device A stepwise approach Right Drug Who 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 : • In mcgs 200 : 1 200 : : 2 100 • At equivalent doses, efficacy is equal Right Dose- ICS/LABA Inhaled corticosteroid Equivalent dose (mcg) Clenil (beclom) Fostair Seretide Evo Seretide Acc Symbicort Flutiform 200 100 100 100 200 100 UK licence > 12 years Yes > 18 years Yes Yes Yes* 50,125 only * Up to 400/12 1 dose bd only Right Dose- Stepping Down Step 4/5 Step 3 Control ≥ 3 m Control ≥ 3 m Seretide 250 Evo Seretide 125 Evo Seretide 50 Evo 2 puffs bd (2000) 2 puffs bd (1000) 2 puffs bd (400) Seretide 500 Acc Seretide 250 Acc Seretide 100 Acc 1 puff bd (2000) 2 puffs bd (1000) 1 puff bd (400) Symbicort 400/12 Symbicort 400/12 2 puffs bd (1600) 1 puff bd (800) Symbicort 200/6 or 1 puff bd (400) Step 2 Control ≥ 3 m Symbicort 200/6 Prescribe an ICS device equivalent to 400-500 mcg BDP/day • Good control 3 months • Minimise device changes 2 puffs bd (800) Fostair 100/6 BDP 250, 1 bd 2 puffs bd (1000) PLUS Formoterol 12, 1 bd • 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 Severity- Examination Speech, RR, pulse Moderate • Speech normal • Respiration <25 breaths/min • Pulse <110 beats/min Severe • Cannot complete sentences • Respiration 25 breaths/min • Pulse 110 beats/min Life-threatening • Silent chest, cyanosis, poor respiratory effort • Bradycardia,dysrhythmia hypotension • Exhaustion,confusion, coma 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 • Prescribing • Diagnosis • Clinical • History • Airflow obstruction • Right drug • Right dose • Right device • Acute management • Recognise severity • Immediate treatment • Hospital referral