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Asthma: Definition, Diagnosis, and Care | NRAD Key Findings

Learn about the definition and diagnosis of asthma, including diagnostic criteria and clinical assessment. Discover key findings from the National Review of Asthma Deaths (NRAD) and understand how to improve asthma care.

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Asthma: Definition, Diagnosis, and Care | NRAD Key Findings

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  1. Session 1 Definition and Diagnosis of Asthma

  2. Learning Outcomes 1:Theoretical demonstration at Scottish Credit Qualifications Framework (2017) Level 9/10 • Describe asthma including diagnostic criteria • Perform clinical assessment including pharmacological, non-pharmacological treatments and trigger avoidance strategies • Demonstrate correct inhaler technique (Baverstock et al 2010) • Conduct asthma annual reviews (SIGN 2016; GINA 2017; NICE 2017) • Recognise sub-optimal asthma control and appropriate referral

  3. Learning Outcomes 2: • Identify current asthma control, interpreting objective measurements e.g. peak expiratory flow rate (PEFR), Royal College of Physicians (RCP) 3 questions, asthma control test (ACT) • Adopt an inclusive team approach with appropriate referral back to the clinical lead in the surgery for asthma (NMC Code 2015) • Write a Personal Asthma Action Plan (PAAP) for self-management in collaboration with the patient to improve asthma care (NRAD 2014; SIGN 2016) • Practice person centred care: respect, holism, choice, empathy, autonomy and compassion (RCN 2015).

  4. Definition of Asthma • Inflammatory condition of airways, resulting in smooth muscle contraction, oedema of airway wall and increase in production and secretion of mucus • A response of smooth muscle in respiratory tree to external allergens and irritants resulting in muscle contraction and obstruction to normal breathing • SIGN (2016) description of asthma includes hyper-responsiveness and inflammation as elements of disease

  5. Diagnosis of Asthma • Combination of clinical signs and symptoms are more helpful and increase probability: • Wheeze • Breathlessness • Chest tightness • Cough • Confirmation hinges on demonstrating airway variability

  6. Epidemiology of Asthma(Asthma UK 2017/ NRAD 2014) • 5.4 million in the UK • Scotland 1 in 14 are currently receiving treatment for asthma: 72,000 children and 296,000 adults • Affects one in every 11 people and one in 5 households • Every 10 seconds someone having life threatening attack • Deaths in England and Wales 2016: • 1237 total • 0-14 years: 13 • 15+ years: 1224 • Deaths in Scotland 2016 • 133 total • 0 -14years: 1 • 15+ years: 132 • Asthma attacks hospitalise someone every 8 minutes • 185 people are admitted to hospital because of asthma attacks • a child is admitted to hospital every 20 minutes • 2/3 of these deaths could be prevented • Others suffer with asthma so severe current treatments don’t work • 3 people day or 1 person every 8 hours dies from asthma • In 2011-2012 average 69 emergency admissions for children in the UK per day or 1 every 21 minutes

  7. Why Asthma Still Kills The National Reviewof Asthma Deaths (NRAD) (2014)

  8. NRAD (2014) Primary Aim • To understand circumstances surrounding asthma deaths across UK between February 2012 and January 2013 • Extensive information about each death was sought from multiple sources: • primary • secondary • tertiary care • mbulance • paramedic • out-of-hours care providers • Data for analysis on 195 people

  9. NRAD Key FindingsUse of NHS services • During final attack 45% died without seeking medical assistance or before emergency medical care could be provided • 57% not recorded as being under specialist supervision during 12 months prior to death • History of previous hospital admission in 47% • 10% died within 28 days of discharge

  10. NRAD Key FindingsMedical and Professional Care • Personal asthma action plans (PAAPs) to only 23% • 43% no evidence of asthma review in last year • 39% severe asthma; 49% moderate; 9% mild: severity of asthma likely to have been underestimated; poorly controlled undertreated asthma rather than truly mild or moderate disease • Implementation of guidelines by health professionals could have avoided death in 46% • Lack of knowledge of the UK asthma guidelines 25%

  11. NRAD Key FindingsPrescribing and Medicines use • Excessive prescribing of reliever medication • 39% prescribed >12 SABA in year before they died • 4% prescribed >50 reliever inhalers • Evidence of under-prescribing of preventer • At least 5 patients were on LABA monotherapy

  12. Key RecommendationsMedical and Professional care • All should be provided with written PAAP that details: • triggers • current treatment • specifies how to prevent relapse • when and how to seek help in an emergency • Structured annual review by HCP with specialist training in asthma • People at high risk of severe attacks monitored more closely • Trigger must be elicited routinely and documented in medical records and PAAP • Assessment of recent asthma control at every asthma review • HCP must be aware of factors that increase risk of attacks and death

  13. Avoidable Risk Factors NRAD • Clinicians apparently did not recognise high risk status • Adequate asthma review not performed • Clinicians did not refer when appeared to be indicated • Patients apparently did not take prescribed medication in month before death • Patients apparently did not take prescribed medication in year before death • Patients over prescribed SABA • Poor or inadequate implementation of policy/pathway/protocol • Lack of knowledge of guidelines • Clinicians appeared to lack specific asthma expertise • Management of final attack inadequate 25% • Patients apparently did not adhere to medical advice

  14. Avoidable Factors related to Patient, Family or Environment • Poor adherence to medical advice: i.e. DNA, failure to respond to symptoms • Psychosocial factors: i.e. substance abuse • Smoker or exposed to 2nd hand smoke • Allergies: i.e. animals, food, seasonal, drug

  15. NRAD Conclusion (Prof Partridge) • Complacency must be tackled • Not just those with severe asthma who die • General failing to change systems and approaches • Is non-concordance their fault or our failure to involve them in process of shared decision making? • Are DNA’s or failure to collect repeats because our processes, methods of follow-up or their convenience was suboptimal? • Was it quality of consultation and expertise that failed to impress? • Continued failure to provide meaningful support as patients self-manage needs to be rectified

  16. Why Accurate Diagnosis is Important • Differentiating asthma from COPD and Asthma COPD Overlap (ACO) can be problematic, particularly in smokers and older adults • Differentiating is important because of marked differences in treatment, disease progression, and outcomes between the 3 conditions

  17. Asthma COPD Overlap (GINA 2017): 1 • Some patients may have clinical features of both asthma and COPD • Asthma-COPD overlap is useful to maintain awareness by clinicians of the needs of these patients • Asthma-COPD overlap does NOT describe a single disease; like asthma and COPD it likely includes different phenotypes caused by a range of underlying mechanisms.

  18. Asthma COPD Overlap (GINA 2017): 2 • Stepwise approach to diagnosis • Referral for confirmatory investigations encouraged • Initial treatment: • See GINA (2017) guidelines for management options

  19. COPD / Asthma differences • The differences in disease distribution may partly reflect distribution of main inhaled inciting agents • Asthma = allergens • COPD = tobacco smoke and environmental

  20. Different Clinical Phenotypes Asthma • Most patients are atopic • Few are non atopic • Array of severity COPD • Small airway obstruction • Emphysema • Chronic Bronchitis • “Severe Asthma”

  21. Inflammatory Expression Asthma • Inflammation mainly located in larger conducting airways • Small airways can be affected in more severe forms • Lung parenchyma not affected COPD • Inflammation predominantly affects small airways • Inflammatory changes can also be found in larger airways • Lung parenchyma affected

  22. How do I differentiate between COPD and asthma? COPD • Detailed history • Characterised by airflow obstruction • Predominately caused by smoking • Progressive, not fully reversible • Does not change markedly over several months • Insidious breathlessness Asthma • Detailed history • Variable air flow obstruction • Central to all definitions of asthma is the presence of more than 1 symptom of • Wheezes • Breathlessness • Chest Tightness • Cough NB Both conditions can exist in the same patient

  23. Diagnostic Criteria (SIGN 2016) • Presentations with respiratory symptoms: • Wheeze • Cough • Breathlessness • Chest tightness • Structured clinical assessment: history and examination, looking for:

  24. Presentation with respiratory symptoms, wheeze, cough breathlessness, chest tightness • Structured clinical assessment: from history and examination: • Recurrent episodes of symptoms • Symptoms variability • Absence of alternative diagnosis • Recorded wheeze • Personal history of atopy • Record of variable PEF/FEV1 Intermediate Probability High Probability Low Probability Test for airway obstruction Spirometry + reversibility Code as suspected asthma Options for investigations are: Initiation of treatment • Tests for eosinophilic inflammation or atopy: • FeNO • Blood eosinophils • Skin prick testing; IgE • Tests for variability: • Reversibility • PEF charting • Challenge tests Investigate/treat for other more likely diagnosis Assess response – lung function / symptom score Good response Asthma Adjust maintenance dose Provide PAAP Arrange ongoing review Suspected asthma Watchful waiting (asymptomatic) or commence treatment. Assess response objectively Other diagnosis confirmed

  25. Spirometry in Asthma • Spirometry recommended objective test to identify abnormalities in lung volumes and air flow (PCC 2013) • Use at clinic visits for diagnosis, alternatively domiciliary PEF • Spirometry with reversibility as appropriate preferred initial test • Used in conjunction with physical assessment, history taking, blood tests and x-rays, to exclude or confirm particular types of lung disease, enabling timely diagnosis and treatment • Should only be performed by people trained and assessed to ARTP or equivalent standards by recognised training bodies (PCC 2013) • All health professionals involved in the care of people with COPD should have access to spirometry and be able to interpret results (NICE 2010)

  26. Conclusion • Failure to accurately diagnose matters, prognoses for patients with the 3 disorders differ • Incorrect diagnosis can lead to inappropriate management • Patients with well-controlled asthma should have normal activity levels and life expectancy

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