asthma diagnosis prescribing acute management tracey bradshaw respiratory consultant rie
TRANSCRIPT
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AsthmaDiagnosis
Prescribing
Acute Management
Tracey Bradshaw
Respiratory Consultant
RIE
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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
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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
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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