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Asthmain primarycare

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CME talk on Asthma in primary care by Dr. Zareen Mohamed, Consultant Allergist and Asthma specialist, Dr. Mehta's Hospitals, Chennai

CME talk on Asthma in primary care by Dr. Zareen Mohamed, Consultant Allergist and Asthma specialist, Dr. Mehta's Hospitals, Chennai

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  • A diagnosis of asthma should ideally be based on objective evidence of reversible airflow obstruction. Guidelines vary in their criteria for this (IPCRG spirometry at http://www.theipcrg.org/resources/resources_diagnostics.php ).
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    • 1. Asthma in PrimaryAsthma in Primary CareCare Dr. Zareen MohamedDr. Zareen Mohamed MBBS., M Med(singapore) DAA(cmcMBBS., M Med(singapore) DAA(cmc)) Consultant – Allergy and AsthmaConsultant – Allergy and Asthma Dr. Mehta’s HospitalsDr. Mehta’s Hospitals
    • 2. Burden of DiseaseBurden of Disease  WidespreadWidespread  7% prevalence and rising7% prevalence and rising  73% managed by PCPs73% managed by PCPs  Allergic vs. non-allergic asthmaAllergic vs. non-allergic asthma  60% of asthmatics have allergic asthma60% of asthmatics have allergic asthma  90% of children with asthma also have allergies90% of children with asthma also have allergies
    • 3. IntroductionIntroduction  Many patients with asthma are treated in the primaryMany patients with asthma are treated in the primary care setting. The primary care physician is therefore in acare setting. The primary care physician is therefore in a key position to recognize poorly controlled asthma andkey position to recognize poorly controlled asthma and to improve asthma management for these patients.to improve asthma management for these patients.  However, current evidence continues to show that, forHowever, current evidence continues to show that, for a substantial number of patients, asthma control isa substantial number of patients, asthma control is inadequate for a wide variety of reasons, bothinadequate for a wide variety of reasons, both physician-related and patient-relatedphysician-related and patient-related
    • 4.  Presentation provides a specialist's perspectivePresentation provides a specialist's perspective on diagnosis, appropriate therapy, diseaseon diagnosis, appropriate therapy, disease control surveillance, and appropriate referralcontrol surveillance, and appropriate referral when necessarywhen necessary
    • 5.  Many patients overestimate their level of diseaseMany patients overestimate their level of disease control, often tolerating substantial asthmacontrol, often tolerating substantial asthma symptoms and having low expectations aboutsymptoms and having low expectations about the degree of control that is possible.the degree of control that is possible.  Patients also frequently exhibit poor adherencePatients also frequently exhibit poor adherence to prescribed controller medicationsto prescribed controller medications
    • 6.  Additional patient-related factors affectingAdditional patient-related factors affecting asthma control include self-managementasthma control include self-management abilities, smoking status, inhaler technique,abilities, smoking status, inhaler technique, ability to remember doses, access toability to remember doses, access to prescriptions, and costs of medication.prescriptions, and costs of medication.
    • 7.  Physicians have a tendency to underestimate thePhysicians have a tendency to underestimate the prevalence of asthma symptoms and toprevalence of asthma symptoms and to overestimate the degree to which their patients'overestimate the degree to which their patients' asthma is controlled; therefore, they may notasthma is controlled; therefore, they may not always prescribe adequate controller medicationalways prescribe adequate controller medication therapytherapy
    • 8.  Physicians may also have an inadequatePhysicians may also have an inadequate understanding of disease etiology or may notunderstanding of disease etiology or may not communicate well with patients, and thesecommunicate well with patients, and these problems make it difficult to establish aproblems make it difficult to establish a pharmacotherapeutic regimen that the patient ispharmacotherapeutic regimen that the patient is willing and able to followwilling and able to follow
    • 9.  National Asthma Education and PreventionNational Asthma Education and Prevention Program (NAEPP) updated guidelines for theProgram (NAEPP) updated guidelines for the diagnosis and management of asthmadiagnosis and management of asthma
    • 10. Asthma DiagnosisAsthma Diagnosis  Particularly important factors that should beParticularly important factors that should be addressed as part of the medical history includeaddressed as part of the medical history include the overall pattern of symptoms (eg, perennial,the overall pattern of symptoms (eg, perennial, seasonal, or both; continual, episodic, or both;seasonal, or both; continual, episodic, or both; diurnal variations), precipitating factors (such asdiurnal variations), precipitating factors (such as the presence of allergic triggers), and a familythe presence of allergic triggers), and a family history of asthma, allergy, or other atopichistory of asthma, allergy, or other atopic disorders.disorders.
    • 11.  The guidelines recommend the use of a detailed medical history,The guidelines recommend the use of a detailed medical history, the results of a physical examination (focusing on the upperthe results of a physical examination (focusing on the upper respiratory tract, chest, and skin), and the results ofrespiratory tract, chest, and skin), and the results of spirometryspirometry (for patients aged 5 years or older) in making the diagnosis.(for patients aged 5 years or older) in making the diagnosis.  Any additional studies necessary for excluding alternativeAny additional studies necessary for excluding alternative diagnoses or identifying other potential causes of symptomsdiagnoses or identifying other potential causes of symptoms should also be performed (eg, chest radiography, specific bloodshould also be performed (eg, chest radiography, specific blood tests).tests).  primary care physicians should refer patients to a specialist forprimary care physicians should refer patients to a specialist for spirometry or allergy testing.spirometry or allergy testing.
    • 12. Role of SpirometryRole of Spirometry  Correctly diagnosing asthma is the first stepCorrectly diagnosing asthma is the first step toward attaining disease control. In general, atoward attaining disease control. In general, a diagnosis of asthma is established if episodicdiagnosis of asthma is established if episodic symptoms of airflow obstruction or airwaysymptoms of airflow obstruction or airway hyperresponsiveness are present, airflowhyperresponsiveness are present, airflow obstruction is at least partially reversible, andobstruction is at least partially reversible, and alternative diagnoses are excluded.alternative diagnoses are excluded.
    • 13.  ““All that wheezes is not asthma.”All that wheezes is not asthma.” Chevalier Jackson [1865-1958]Chevalier Jackson [1865-1958]
    • 14.  Several other conditions may coexist with asthma or complicateSeveral other conditions may coexist with asthma or complicate the diagnosis or management of asthma. Cough-variant asthma,the diagnosis or management of asthma. Cough-variant asthma, in particular, is easily overlooked because chronic cough can be ain particular, is easily overlooked because chronic cough can be a sign of a wide variety of health problems.sign of a wide variety of health problems.  Conversely, chronic cough may also be the principal (or only)Conversely, chronic cough may also be the principal (or only) manifestation of asthma, especially among young children.manifestation of asthma, especially among young children.  The diagnosis of cough-variant asthma is confirmed by a positiveThe diagnosis of cough-variant asthma is confirmed by a positive response to asthma medication, and treatment should follow theresponse to asthma medication, and treatment should follow the usual stepwise approach to asthma management.usual stepwise approach to asthma management.
    • 15. Vocal cord dysfunctionVocal cord dysfunction  Vocal cord dysfunction—characterized byVocal cord dysfunction—characterized by episodic dyspnea and wheezing caused byepisodic dyspnea and wheezing caused by intermittent paradoxical vocal cord adductionintermittent paradoxical vocal cord adduction during inspiration—often mimics asthma andduring inspiration—often mimics asthma and can be difficult to diagnose.can be difficult to diagnose.  A diagnosis is best made with indirect or directA diagnosis is best made with indirect or direct vocal cord visualization during an episode, andvocal cord visualization during an episode, and treatment generally consists of speech therapytreatment generally consists of speech therapy and relaxation techniquesand relaxation techniques
    • 16.  Other common comorbid conditions thatOther common comorbid conditions that complicate the diagnosis of asthma are chroniccomplicate the diagnosis of asthma are chronic sinusitis, gastroesophageal reflux disease,sinusitis, gastroesophageal reflux disease, obstructive sleep apnea, and respiratory tractobstructive sleep apnea, and respiratory tract infections.infections.  ABPA(Allergic bronchopulmonary aspergillosis)ABPA(Allergic bronchopulmonary aspergillosis) is often accompanied by symptoms similar tois often accompanied by symptoms similar to those of asthma and by elevated IgE levels.those of asthma and by elevated IgE levels.
    • 17.  Churg-Strauss syndromeChurg-Strauss syndrome is another comorbid conditionis another comorbid condition that should be considered in the assessment of patientsthat should be considered in the assessment of patients with difficult-to-control asthma.with difficult-to-control asthma.  It is a serious disorder characterized by eosinophilicIt is a serious disorder characterized by eosinophilic inflammation of the respiratory tract and necrotizinginflammation of the respiratory tract and necrotizing vasculitis of small and medium vessels.vasculitis of small and medium vessels.  Laboratory results demonstrate eosinophilia, andLaboratory results demonstrate eosinophilia, and symptoms include asthma, rhinosinusitis, pulmonarysymptoms include asthma, rhinosinusitis, pulmonary infiltrates, peripheral neuropathy, and skin, heart, orinfiltrates, peripheral neuropathy, and skin, heart, or gastrointestinal involvement.gastrointestinal involvement.
    • 18. MANAGING ASTHMAMANAGING ASTHMA  Once the diagnosis of asthma has beenOnce the diagnosis of asthma has been established, the focus shifts to classifying asthmaestablished, the focus shifts to classifying asthma severity so that therapy can be initiated and toseverity so that therapy can be initiated and to monitoring control over time so that therapy canmonitoring control over time so that therapy can be adjustedbe adjusted  According to the new guidelines, severity andAccording to the new guidelines, severity and control should be assessed separately, but both arecontrol should be assessed separately, but both are classified on the basis of the domains of currentclassified on the basis of the domains of current impairment and future riskimpairment and future risk
    • 19.  After disease severity has been assigned,After disease severity has been assigned, treatment can be initiated at the recommendedtreatment can be initiated at the recommended step. If the patient is already receiving asthmastep. If the patient is already receiving asthma therapy, symptom control should be periodicallytherapy, symptom control should be periodically monitoredmonitored
    • 20. Obstacles to asthma controlObstacles to asthma control  Ongoing occupational exposures, which should beOngoing occupational exposures, which should be identified and eliminated when possibleidentified and eliminated when possible  Occupational history should be considered for adultsOccupational history should be considered for adults with uncontrolled asthma, especially if symptomswith uncontrolled asthma, especially if symptoms improve on weekends and holidays.improve on weekends and holidays.  Exposure to Outdoor and Indoor AllergensExposure to Outdoor and Indoor Allergens
    • 21.  Patient related factorsPatient related factors  Physician related factorsPhysician related factors  Perhaps the environmental factor thatPerhaps the environmental factor that contributes most to the development,contributes most to the development, persistence, and severity of asthma is viralpersistence, and severity of asthma is viral respiratory infectionrespiratory infection
    • 22.  Asthma can also be exacerbated by certainAsthma can also be exacerbated by certain drugs, such as nonsteroidal anti-inflammatorydrugs, such as nonsteroidal anti-inflammatory drugs and β-blockers.drugs and β-blockers.  Aspirin-sensitive asthma is frequently associatedAspirin-sensitive asthma is frequently associated with a genetic sequence variation and is relativelywith a genetic sequence variation and is relatively common in Eastern Europe and Japancommon in Eastern Europe and Japan  Asthma may also be difficult to control in theAsthma may also be difficult to control in the presence of untreated gastroesophageal refluxpresence of untreated gastroesophageal reflux diseasedisease
    • 23. What does good asthma control lookWhat does good asthma control look like?like?  Patients should be educated so that they do notPatients should be educated so that they do not accept a certain level of ongoing symptoms,accept a certain level of ongoing symptoms, short-acting inhaler use, and reduced activity asshort-acting inhaler use, and reduced activity as “normal” for someone with asthma.“normal” for someone with asthma.
    • 24.  Any aspect of the patient's asthma control doesAny aspect of the patient's asthma control does not meet these criteria, the patient does not havenot meet these criteria, the patient does not have good asthma control, and the clinician shouldgood asthma control, and the clinician should consider changing the patient's asthmaconsider changing the patient's asthma management plan.management plan.
    • 25. Asthma Control TestAsthma Control Test  The ACT is an easy-to-use questionnaire consisting of 5The ACT is an easy-to-use questionnaire consisting of 5 questions, each scored by the patient on a scale from 1questions, each scored by the patient on a scale from 1 to 5, regarding activity levels, frequency of daytime orto 5, regarding activity levels, frequency of daytime or nighttime symptoms, rescue inhaler use, and thenighttime symptoms, rescue inhaler use, and the patient's perception of asthma control during the past 4patient's perception of asthma control during the past 4 weeks.weeks.  The result is a total numeric score ranging from 5 to 25;The result is a total numeric score ranging from 5 to 25; a cutpoint score of 20 or higher generally indicates well-a cutpoint score of 20 or higher generally indicates well- controlled asthma (in conjunction with the physician'scontrolled asthma (in conjunction with the physician's clinical assessment).clinical assessment).
    • 26. PharmacotherapyPharmacotherapy
    • 27. Step 1Step 1 Mild intermittentMild intermittent asthmaasthma Step 2Step 2 Regular PreventerRegular Preventer therapytherapy Step 3Step 3 Initial Add-On TherapyInitial Add-On Therapy Step 4Step 4 Persistent PoorPersistent Poor ControlControl Step 5Step 5 Continuous or frequentContinuous or frequent use of oral steroidsuse of oral steroids Inhaled short actingInhaled short acting BB22-agonist-agonist Prescribe inhalersPrescribe inhalers only after theonly after the patient has receivedpatient has received training in the usetraining in the use of the device andof the device and has demonstratedhas demonstrated satisfactorysatisfactory techniquetechnique Add inhaledAdd inhaled corticosteroid (ICS) 200-corticosteroid (ICS) 200- 800mcg/day (BDP or800mcg/day (BDP or equivalent)equivalent) Start dose of inhaledStart dose of inhaled corticosteroid appropriatecorticosteroid appropriate to severity of disease.to severity of disease. 400mcg/day is an400mcg/day is an appropriate dose for mostappropriate dose for most patientspatients 1.1. Add inhaled long-acting ß2-Add inhaled long-acting ß2- agonist (LABA) and 2.agonist (LABA) and 2. 2.2. Assess control of asthma:Assess control of asthma: good response to LABAgood response to LABA - continue LABA- continue LABA Combination inhalers should beCombination inhalers should be considered in those for whomconsidered in those for whom LABA are effective atLABA are effective at controlling symptoms.controlling symptoms. benefit from LABA but controlbenefit from LABA but control still inadequatestill inadequate - continue LABA and increase- continue LABA and increase inhaled steroid dose to 800inhaled steroid dose to 800 mcg/daymcg/day BDP or equivalentBDP or equivalent (if(if not already on this dose)not already on this dose) no response to LABAno response to LABA - stop LABA and increase inhaled- stop LABA and increase inhaled steroid to 800mcg/ day.steroid to 800mcg/ day. BDPBDP or equivalentor equivalent If control still inadequate,If control still inadequate, institute trial of other therapies,institute trial of other therapies, leukotriene antagonist or SRleukotriene antagonist or SR theophylline receptortheophylline receptor Consider trials of:Consider trials of: Increased dose ofIncreased dose of inhaled corticosteroidinhaled corticosteroid up to 2000mcg/dayup to 2000mcg/day BDP or equivalentBDP or equivalent Consider adding aConsider adding a fourth drug e.g.fourth drug e.g. leukotriene receptorleukotriene receptor antagonist, SRantagonist, SR theophylline ortheophylline or BB22-agonist tablet-agonist tablet Use daily steroid tablet inUse daily steroid tablet in lowest dose to providelowest dose to provide adequate controladequate control Maintain high doseMaintain high dose inhaled corticosteroids atinhaled corticosteroids at 2000mcg/day (BDP or2000mcg/day (BDP or equivalent)equivalent) Consider otherConsider other treatments to minimisetreatments to minimise the use of oral steroidsthe use of oral steroids Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009: Amended 16/06/10 http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf
    • 28. Combination inhalersCombination inhalers  Long acting beta-agonists (LABA) are the preferred first optionLong acting beta-agonists (LABA) are the preferred first option for add-on therapy, usually beyond an ICS dose of 400mcgfor add-on therapy, usually beyond an ICS dose of 400mcg Beclometasone equivalent per day in adults and 200mcg per dayBeclometasone equivalent per day in adults and 200mcg per day in children.in children.  Combination inhalers have the advantage, once a patient is onCombination inhalers have the advantage, once a patient is on stable therapy, of guaranteeing that the LABA is not takenstable therapy, of guaranteeing that the LABA is not taken without the inhaled steroidwithout the inhaled steroid Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009: http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf
    • 29. Combination of budesonide/formoterolCombination of budesonide/formoterol in a single inhalerin a single inhaler  In selected adult patients at Step 3 who are poorlyIn selected adult patients at Step 3 who are poorly controlled or in selected patients at step 2 (>400mcgcontrolled or in selected patients at step 2 (>400mcg BDP/day who are poorly controlled) the use ofBDP/day who are poorly controlled) the use of budesonide/formoterol in a single inhaler as rescuebudesonide/formoterol in a single inhaler as rescue medication instead of a short actingmedication instead of a short acting ββ2-agonist, in2-agonist, in addition to its regular use as a preventative (controller)addition to its regular use as a preventative (controller) treatment, has been shown to be effective.treatment, has been shown to be effective.  The regular daily dose of ICS may be BudesonideThe regular daily dose of ICS may be Budesonide 200mcg bd or 400mcg bd200mcg bd or 400mcg bd  Patients taking rescue budesonide/formoterol once/dayPatients taking rescue budesonide/formoterol once/day or more should have their treatment reviewedor more should have their treatment reviewed Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009: http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf
    • 30.  Regardless of the therapy step, long-termRegardless of the therapy step, long-term management of asthma always involves amanagement of asthma always involves a balance between the benefits of achieving thebalance between the benefits of achieving the best symptom control possible (hencebest symptom control possible (hence minimizing the risks of uncontrolled asthma andminimizing the risks of uncontrolled asthma and the effect of asthma on the patient's well-being)the effect of asthma on the patient's well-being) and the risks of adverse effects—a balanceand the risks of adverse effects—a balance recognized as part of the risk domain of therecognized as part of the risk domain of the updated guidelines.updated guidelines.
    • 31.  However, patients' concerns about long-termHowever, patients' concerns about long-term corticosteroid use may affect their adherence to acorticosteroid use may affect their adherence to a prescribed regimen, and the risks of systemic effectsprescribed regimen, and the risks of systemic effects (eg, reduced linear growth rate in children or lower(eg, reduced linear growth rate in children or lower bone mineral density in adults) increase with higherbone mineral density in adults) increase with higher doses.doses.  Therefore, it is just as important to step downTherefore, it is just as important to step down medication for patients with well-controlled asthma asmedication for patients with well-controlled asthma as to step up medication for those with uncontrolledto step up medication for those with uncontrolled asthma.asthma.
    • 32.  These findings concerning the risks of higher-These findings concerning the risks of higher- dose ICS therapy point toward the potentialdose ICS therapy point toward the potential advantages of adjunctive therapies for patientsadvantages of adjunctive therapies for patients with poorly controlled asthma: for example,with poorly controlled asthma: for example, adding a LABA, a leukotriene modifier, oradding a LABA, a leukotriene modifier, or theophylline to medium-dose ICS therapy attheophylline to medium-dose ICS therapy at step 4 or adding omalizumab therapy to high-step 4 or adding omalizumab therapy to high- dose ICS therapy plus a LABA at step 5.dose ICS therapy plus a LABA at step 5.
    • 33.  For patients with allergic asthma, as indicated byFor patients with allergic asthma, as indicated by positive results from a skin test or in vitro RASTpositive results from a skin test or in vitro RAST testing for individual aeroallergens, specifictesting for individual aeroallergens, specific allergen immunotherapy may be an appropriateallergen immunotherapy may be an appropriate adjunctive therapy when a clear relationshipadjunctive therapy when a clear relationship exists between asthma symptoms and allergenexists between asthma symptoms and allergen exposureexposure
    • 34.  Evidence for improved asthma control withEvidence for improved asthma control with immunotherapy is strongest when patients areimmunotherapy is strongest when patients are affected by single allergens, especially house dustaffected by single allergens, especially house dust mites, cat dander, or pollen.mites, cat dander, or pollen.  A patient with persistent asthma that may beA patient with persistent asthma that may be associated with allergy should probably beassociated with allergy should probably be referred to an allergist for skin-prick testing andreferred to an allergist for skin-prick testing and consideration of immunotherapy, omalizumabconsideration of immunotherapy, omalizumab therapy, or both.therapy, or both.
    • 35.  primary care physicians consider referral forprimary care physicians consider referral for patients who have experienced more than 2 oralpatients who have experienced more than 2 oral corticosteroid bursts per year or a recentcorticosteroid bursts per year or a recent exacerbation requiring hospitalization, thoseexacerbation requiring hospitalization, those who required therapy at step 4 or higher towho required therapy at step 4 or higher to achieve adequate asthma control, or those withachieve adequate asthma control, or those with allergiesallergies
    • 36.  Proper diagnosis and regular assessment ofProper diagnosis and regular assessment of asthma control are key components of anasthma control are key components of an effective management strategy, but improvingeffective management strategy, but improving control depends on recognition by both thecontrol depends on recognition by both the patient and the physician as to what constitutespatient and the physician as to what constitutes good asthma control.good asthma control.
    • 37. Trigger identification/control isTrigger identification/control is primary management stepprimary management step  ““For at least those patients withFor at least those patients with persistentpersistent asthma onasthma on daily medications,daily medications, the clinician should:the clinician should:  Identify allergen exposuresIdentify allergen exposures  Use the patient’s history to assess sensitivity to seasonalUse the patient’s history to assess sensitivity to seasonal allergensallergens  Use skin testingUse skin testing oror in vitroin vitro [blood] testing to assess sensitivity[blood] testing to assess sensitivity toto perennialperennial indoor allergensindoor allergens  Assess the significance of positive tests in contextAssess the significance of positive tests in context of the patient’s medical history”of the patient’s medical history”
    • 38.  ““Use skin testingUse skin testing oror in vitroin vitro testing to determine the presence oftesting to determine the presence of specific IgE antibodies to the indoor allergens to which thespecific IgE antibodies to the indoor allergens to which the patient is exposed year round.”patient is exposed year round.”  Allergy testing is the only reliable way to determine sensitivity toAllergy testing is the only reliable way to determine sensitivity to perennial indoor allergens.”perennial indoor allergens.”  For selected patients with asthma at any level of severity,For selected patients with asthma at any level of severity, detection of specific IgE sensitivity todetection of specific IgE sensitivity to seasonalseasonal or perennialor perennial allergens may be indicated as a basis for avoidance,allergens may be indicated as a basis for avoidance, or immunotherapy, or to characterize the patient’s atopic status.”or immunotherapy, or to characterize the patient’s atopic status.”
    • 39.  Allergy testing may be conducted along with pulmonaryAllergy testing may be conducted along with pulmonary function testsfunction tests and other diagnostic evaluationsand other diagnostic evaluations11  In allergic asthma:In allergic asthma:  Confirm atopy and identify specific allergic triggers forConfirm atopy and identify specific allergic triggers for avoidance counseling, symptom reduction, and control ofavoidance counseling, symptom reduction, and control of severity and comorbid ARseverity and comorbid AR
    • 40. ““Determining whether and how allergies play aDetermining whether and how allergies play a role in a patient’s asthmarole in a patient’s asthma is an important part of the clinical picture.”is an important part of the clinical picture.”
    • 41. Indication fo omalizumabIndication fo omalizumab ““Omalizumab is indicated for adults andOmalizumab is indicated for adults and adolescents (12 years of age and above) withadolescents (12 years of age and above) with moderate to severe asthma who have a positivemoderate to severe asthma who have a positive skin test orskin test or in vitroin vitro reactivity to a perennialreactivity to a perennial allergen and whose symptoms are inadequatelyallergen and whose symptoms are inadequately controlled with inhaled corticosteroidscontrolled with inhaled corticosteroids
    • 42. Lung Function Measurement inLung Function Measurement in AsthmaAsthma  Provides an assessment of severity of airflowProvides an assessment of severity of airflow limitation, its reversibility and variabilitylimitation, its reversibility and variability  Provides confirmation of the diagnosisProvides confirmation of the diagnosis  Provides complementary information aboutProvides complementary information about different aspects of asthma controldifferent aspects of asthma control
    • 43. Spirometry in AsthmaSpirometry in Asthma  Diagnosis of asthma:Diagnosis of asthma:  Degree of reversibility of FEV1 should be >12% andDegree of reversibility of FEV1 should be >12% and >200ml from pre-bronchodilator value>200ml from pre-bronchodilator value  Spirometry:Spirometry:  Reproducible but effort-dependentReproducible but effort-dependent  Pre- & post test lacks sensitivity esp. those on treatment,Pre- & post test lacks sensitivity esp. those on treatment, so repeated testing at different visits is advisedso repeated testing at different visits is advised  Proper instructions on maneuver must be givenProper instructions on maneuver must be given
    • 44. PEF measurement in AsthmaPEF measurement in Asthma  Important in both diagnosis and monitoringImportant in both diagnosis and monitoring  Peak flow meters are relatively inexpensive,Peak flow meters are relatively inexpensive, portable, plastic and ideal for use in homeportable, plastic and ideal for use in home settings for day-to-day objective measurement ofsettings for day-to-day objective measurement of airflow limitationairflow limitation  Can underestimate degree of airflow limitationCan underestimate degree of airflow limitation particularly in severe casesparticularly in severe cases
    • 45. PEF measurement in AsthmaPEF measurement in Asthma  Can be helpful to confirm the diagnosis ofCan be helpful to confirm the diagnosis of asthma:asthma:  60 L/min (or 20% or more pre-BD PEF)60 L/min (or 20% or more pre-BD PEF) improvement after inhalation of a bronchodilatorimprovement after inhalation of a bronchodilator  A diurnal variation of >20% (with twice dailyA diurnal variation of >20% (with twice daily readings >10%)readings >10%)
    • 46. PEF measurement in AsthmaPEF measurement in Asthma  Can help to improve asthma control esp. inCan help to improve asthma control esp. in those with poor perception of symptoms:those with poor perception of symptoms:  Self-monitoring using a PEF chartSelf-monitoring using a PEF chart  Can help to identifyCan help to identify environmental/occupational causes of asthmaenvironmental/occupational causes of asthma symptoms:symptoms:  PEF daily or several times a day over periods ofPEF daily or several times a day over periods of suspected exposure to risk factors (at home,suspected exposure to risk factors (at home, workplace, during exercise or other activities)workplace, during exercise or other activities)
    • 47.  Diagnostic precision leads to evidence-basedDiagnostic precision leads to evidence-based medical caremedical care  Improves patient careImproves patient care  Creates better patient satisfactionCreates better patient satisfaction  Provides more appropriate referralsProvides more appropriate referrals
    • 48. Good asthma reviewGood asthma review • Undertake structured proactive clinical reviews. Consider undertaking reviews by telephone for those patients who cannot attend regularly • Maintain register of asthma patients • Patient education and understanding of the role of medication is important to aid compliance and concordance. Use written asthma action plans Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009: http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf
    • 49. Patient education and self-Patient education and self- managementmanagement  socially disadvantaged groups, adolescents and the elderlysocially disadvantaged groups, adolescents and the elderly  Provide self-management advice focusing on individual needsProvide self-management advice focusing on individual needs  Give specific advice on recognising loss of asthma controlGive specific advice on recognising loss of asthma control  Summarise actions required if asthma control deteriorates and includeSummarise actions required if asthma control deteriorates and include information on how to seek help, the role of oral steroids and how to safelyinformation on how to seek help, the role of oral steroids and how to safely increase medicationincrease medication Adapted with permission: BTS/SIGN British Guideline on the Management of Asthma, May 2008, revised edition published June 2009: http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Asthma/Guidelines/Asthma_fullguideline_2009.pdf
    • 50.  Self-management will only achieve better healthSelf-management will only achieve better health outcomes if the prescribed asthma treatment isoutcomes if the prescribed asthma treatment is appropriate and within recommended guidanceappropriate and within recommended guidance  Difficult asthma is often associated with poorDifficult asthma is often associated with poor adherence to maintenance treatment andadherence to maintenance treatment and coexistent psychosocial morbiditycoexistent psychosocial morbidity
    • 51. Diagnosing asthma in primary careDiagnosing asthma in primary care IPCRG guidelines.IPCRG guidelines. Prim Care Respir J.Prim Care Respir J. 2006;15:202006;15:20–– 34.34. Compatible clinical historyCompatible clinical history  Episodic or persistent dyspnoea, wheeze, tightness, coughEpisodic or persistent dyspnoea, wheeze, tightness, cough  Triggers (allergic, irritant)Triggers (allergic, irritant)  Risk factors for asthma developmentRisk factors for asthma development  Consider occupational asthma for adults with recent onsetConsider occupational asthma for adults with recent onset InvestigationsInvestigations:: Spirometry or peak expiratory flowSpirometry or peak expiratory flow  Eosinophils, IgE levelEosinophils, IgE level  Allergy testingAllergy testing  Chest x-rayChest x-ray

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