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Respiratory Medicine

Respiratory Medicine. Dr Ashley Davies Airedale VTS 27.11.12. What’s today about?. Asthma BTS/SIGN guideline January 2012 Interactive and enjoyable. Why Asthma?. RCGP examiners report National Review of Asthma Deaths. Today’s Aim.

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Respiratory Medicine

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  1. Respiratory Medicine Dr Ashley Davies Airedale VTS 27.11.12

  2. What’s today about? • Asthma • BTS/SIGN guideline January 2012 • Interactive and enjoyable

  3. Why Asthma? • RCGP examiners report • National Review of Asthma Deaths

  4. Today’s Aim • Increased knowledge and confidence in dealing with everyday primary care asthma.

  5. Structure for today 1.Diagnosing asthma 2.Acute asthma 3.The annual asthma check

  6. Starting Point • What is asthma? • What are the pathological features? • What are the symptoms? • How do you make a diagnosis?

  7. Clinical Features • Symptoms (wheeze, breathlessness,chest tightness,cough) • VARIABLE airflow obstruction • Airway hyper-responsiveness • Airway inflammation

  8. “The diagnosis of asthma is a clinical one” “There is no standardised definition of the type,severity, or frequency of symptoms, nor of the findings on investigation” British Thoracic Society/SIGN

  9. BTS/SIGN making diagnosis • High probability • Low probability • “Not sure” (Intermediate probability)

  10. High or low probability? • Mum brings school age child to you

  11. Children-High probability • Start treatment • Reassess 2-3 months • Investigate if poor response

  12. Children-low probability • Consider alternative diagnosis • Investigate as appropriate • Referral?

  13. Children-”Diagnosis not sure” • Watchful waiting? • Inhaled steroid trial? • Peak flow and spirometry? • Atopy tests? • CXR? • Hospital based tests

  14. Adults • Everyone gets a spirometry • High probability: treat and review • Low probability:consider and investigate alternative diagnosis • “Not sure” and obstruction:reversibility +/- trial of treatment • “Not sure” but normal spirometry:refer*

  15. Peak Flow • Technique • What’s normal? • What happens in asthma?

  16. Normal Peak Flow • Predictive tables/personal best • Normal variability 8-20% • Diurnal variation

  17. Asthma Peak Flow • IT MAY BE NORMAL • Less than predicted/expected • Variability >20% 3 days a week over 2 weeks • “Saw tooth” pattern • Reversibility/improvement with treatment

  18. Spirometry

  19. Spirometry • Done in ALL adults with asthma (BTS) • FEV1 is reliable and needs less effort • Need to be trained • Obstructive pattern (FEV1/FVC< 0.7) varying over short time • Can be done in kids age 5+

  20. Reversibility testing • For everyone? • 400mcg salbutamol 15 minutes • Beclomethasone 200mcg BD 6-8 wks • Oral prednisolone 30mg OD 2 wks • Equivalent doses inhaled steroid for children

  21. Positive reversibility • Adults: >400ml FEV1 or >60 L/min PEF • Kids: >12% FEV1 or “significant change in PEF”

  22. The Odd One Out?

  23. What Does It Mean? • Ruttly • Chesty • Catarrhy • Phlegmy • Wheezy • Breathy

  24. “What do parents of wheezy children understand by ‘wheeze’?”RS Cane, SC Ranganathan,SA McKenzieArch Dis Child 2000 82(4) • 23% it wasn’t a sound • 11% “whistling” noise • Less than 50% agreement between doctor and parent

  25. Acute Asthma & Exacerbations

  26. Wayne • Little Wayne is 3yrs old,has an asthmatic mum, a sister with asthma and eczema, dad (big Wayne) smokes& has asthma and dog allergy but breeds Rottweillers. • Wayne has presented with widepread wheezing with 2 previous URTI, had a cough “for months”, sometimes coughs when playing,is wheezy again but not acutely unwell

  27. Wayne • Which inhaled drug? • Which inhaler device? • How often? • What explanation to be given to mum

  28. Wayne • No evidence for use of ipratropium < 5 yrs • Salbutamol has fewer side effects • PRN use is as good as 4x daily • Salbutamol MDI + spacer+ mask up to the age when can use a mouth piece • Single puffs,tidal breathing ( 5 breaths),

  29. Wayne comes back • Duty day • Wayne has been up all night difficulty breathing and wheezing • SpO2 93% • Talking and playing • HR 152 • RR 40 • Recession/accessory muscles

  30. Wayne’s mum: Michaela • 2 admissions to ICU • Most recent hospital admission 7 months ago • Oral steroids for 1 month post discharge • On salbutamol,seretide 500/50,theophylline,monteleukast

  31. Michaela • Doesn’t want admission because looking after kids • SpO2 92% • RR 28 • Can’t complete sentences • HR 124 • PEF normal best 280, today 140

  32. Lessons from asthma deaths • Most deaths BEFORE admission • Most have chronic severe,some have mild-moderate • Inadequate treatment/monitoring/follow up • Under use written plans • Heavy use salbutamol • B blockers & nsaids • Develop over 6-48 hours

  33. Severe Asthma • Previous near fatal (ventilation/acidosis) • Admission previous 12 months • 3 or more classes of drug • Heavy use b agonist • Repeat attendance A&E • Brittle asthma

  34. The Asthma Check

  35. What are you checking?

  36. Asthma Review • Symptom score/RCP 3 questions • Exacerbations, oral steroids, time off • Inhaler technique • Adherence to advice/self management plan • B agonist use • Smoking • Height and weight in kids • PEF/spirometry

  37. Back to Wayne • He’s well, destroying your room • No time off school • Growth normal • Mum confident with inhaler • Salbutamol gets used 3 or 4 times a week at home,he sometimes wakes with a cough and gets in mums bed.

  38. Inhaled Steroid Indicated • Exacerbation asthma in last 2 yrs • B agonist 3x week or more • Symptoms 3x week or more • Waking 1x week

  39. The Odd One Out?

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