Clinical update - asthma

Jo Riley Lead for Respiratory Nursing Service - Oxfordshire

Asthma
Asthma is a chronic inflammatory disorder of the airways In susceptible individuals, inflammatory symptoms are usually associated with widespread but variable airflow obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment.
International consensus report

A Lot Going On Beneath The Surface

Symptoms

Airflow obstruction
Bronchial hyperresponsiveness Airway inflammation

Sensitisation to an allergen

Initial exposure to allergen Production of IgE in . response to allergen In atopic individual excess of IgE attaches to mast cells

Allergen

IgE

Mast cell

Re-exposure to an allergen
Early . response

Mediator release (2)

Allergen reexposure bridges IgE (1)

Bronchospasm (3)

Bronchus in early asthmatic response

Goblet Cells (with mucus) Basement membrane Nerve Fibres

Mast Cell
Mucosa

Capillary

Submucosa

Smooth Muscle Cells

Peak Expiratory Flow

E.A.R.

0 hrs

3 hrs

6 hrs

9 hrs

Time Scale (hours)

education for health

Late response to an allergen

Mucus production
III II IIIIII

Microvascular leakage and inflammation

Epithelial shedding

Inflammatory cells

Oedema Bronchospasm

Bronchus in late asthmatic response

Eosinophil Lumen with mucus, cellular debris, plasma exudate Macrophage

Desquamated epithelial cells

Mast cell

Nerve fibres partly exposed by epithelial damage

Basement membrane Eosinophils

Mast cells

Macrophage

Capillary

Smooth muscle fibre

Peak Expiratory Flow

E.A.R.
0 hrs 3 hrs

L.A.R.
6 hrs 9 hrs

Time scale (hours)

education for health

Asthma
Normal bronchiole
Muscles around airway

Mild asthma
Tightening muscles

Severe asthma
Very tight muscles Mucus blocking airway

Inflammed lining of airway wall

Airway

Very small airway

Narrower airway

Mucus

Inflammed swollen airway wall

Asthma often has an atopic component

What is atopy?
A genetic tendency to overproduce IgE (sometimes called hypersensitivity) in response to common allergens, particularly aeroallergens.

A predisposition to develop allergic disease

What is allergy?
Allergy is the clinical manifestation of the genetic predisposition to atopy. Allergic symptoms are expressed upon reexposure to a specific allergen. The symptoms are a result of the release of inflammatory mediators. 66-80% of children have allergic asthma and 15-25% of adults

Asthma triggers
Animals, house dust mite, pollens and spores, food hypersensitivity, some industrial chemicals Exercise, smoking, drugs,stress, hormones, respiratory infections Chronic symptoms - no identifiable trigger

The impact of asthma

An estimated 5.2 million people in the UK have asthma1

Among patients treated for their asthma, 55% are not well controlled 2
Over 67,700 people were admitted to hospital experiencing an asthma attack in England in 20043 It is estimated that 75% of all admissions for asthma are avoidable4 Somebody dies from asthma every 7 hours4 Nearly 90% of these deaths are preventable4
1. Where do we stand? Asthma in the UK today. Available at: www.asthma.org.uk/document.rm?id=18 [AccessedJune 2008]; 2. Desfougeres JL et al. Eur Respir J 2007:30 (supple 51):249s 3. Asthma UK. The Asthma Divide. http://www.asthma.org.uk/how_we_help/world_asthma_day/index.html Date accessed: July 2008 4.Asthma UK. Key facts and statistics. http://www.asthma.org.uk/news_media/media_resources/for_1.html. Date accessed July 2008

BTS/SIGN asthma guidelines published 2003, live guidelines updated on the Web latest update published May 2008

2008

2004

1993

ADULT with symptoms that may be due to asthma

Clinical History and examination Spirometry (or PEF if spirometry not available)
High Probability Intermediate Probability Obstructive
FEV/FVC <70%

Low Probability Investigate and treat alternative diagnosis Response? No Yes

Normal
FEV/FVC >70%

Trial of Treatment
Response? Yes No
Assess compliance and inhaler technique. Reconsider the diagnosis Consider further tests or referral

Reconsider probable diagnosis Further investigation

Asthma diagnosis confirmed Continue Rx

Manage according to 18 alternative diagnosis

Patient with symptoms that may be due to asthma

Clinical History and examination Spirometry (or PEF if spirometry not available)
High Probability 1)Symptoms (cough, wheeze, SOB or chest tightness): worse at night and in the morning in response to exercise, allergen exposure and cold air after taking aspirin or beta blockers 2) History of atopic disease 3) Family history of asthma or atopic disease 4) Widespread wheeze 5) Evidence of airway narrowing
(NB Normal spirometry when free of symptoms does not exclude asthma)
19

Patient with symptoms that may be due to asthma

Clinical History and examination Spirometry (or PEF if spirometry not available)
Low Probability Highprobability Probabilityequals: Low 1) Cough in the absence of wheeze or breathlessness 2) Prominent dizziness, light headedness, peripheral tingling 3) Repeatedly normal clinical examination even when Trial of Treatment symptomatic 4) No evidence of Assess airwaycompliance narrowing when symptomatic and inhaler technique. 5) Voice disturbance Response? Reconsider the diagnosis 6) Yes Symptoms colds only No with Consider further tests or referral 7) Chronic productive cough 8) Significant smoking history (>20 pack years) Asthma diagnosis confirmed 20 9) Cardiac disease Continue Rx

Spirometry in asthma
Spirometry is the preferred test to confirm diagnosis of asthma
Clearer identification of airflow obstruction Less dependant on effort Useful where history and examination leave doubt about diagnosis Dependant on level of training of operator

If spirometry shows obstruction patient will need inhaled treatment what? will depend on diagnosis

Differential diagnosis in adults

Without airflow obstruction
Chronic cough syndrome Hyperventilation syndrome Vocal cord dysfunction Rhinitis GORD Heart failure Pulmonary fibrosis

With Airflow obstruction

COPD Bronchiectasis Inhaled foreign body Obliterative bronchiolitis Large airways stenosis Lung Cancer Sarcoidosis

CHILD with symptoms that may be due to asthma

Clinical assessment
High Probability Intermediate Probability Low Probability

Consider tests of lung function and atopy

Trial of Treatment

Consider referral
Investigate/treat other condition

Response? Yes No

Assess compliance and inhaler technique. Consider further investigation and/or referral

Asthma diagnosis confirmed Continue Rx and find minimum effective dose

Further investigation Consider referral

Response? No Yes Continue Rx

23

Further investigations if intermediate probability of asthma

Treatment trials and reversibility testing
>400ml improvement in FEV1 Pre and post 400mcg inhaled salbutamol Steroid trial
200mcg BD inhaled beclometasone for 6-8 weeks 30mg prednisolone for 2 weeks

Peak flow monitoring

2-4 times a day best of 3 blows (if highest within 40 l/min of each other) >20% variability if 4 times a day monitoring

Assessment of airways responsiveness

E.g. methacholine challenge specialist centres only

Aims of asthma Treatment - 2008

No daytime symptoms No Night time waking due to asthma No exacerbations No need for rescue 2 agonist No activity limitation Normal lung function (FEV1 >80%) Minimal/no adverse effects for medication

Most people with asthma should not need to feel like asthmatics
People with asthma should expect to 1-3
Achieve and maintain control of symptoms Prevent asthma exacerbations Maintain normal activity levels, including exercise Maintain lung function as close to normal levels as possible
1, British Thoracic Society et al, Thorax 1997 2,National heart, lung and blood institute, World Health Organisation 1998 3, BTS/SIGN guidelines. Thorax 2003

Progression of asthma therapy

ICS treatment introduced 1972
Salbutamol introduced 1968

High use of short-acting b2 -agonists

1975
1980
Increased use of ICS

AMD Combination products introduced

Fixed Dose Combination products introduced

1985 2000
1990 Launch of long-acting b2 -agonists

1995

Bronchospasm

Inflammation

Remodelling

Adults

Adults

Introducing inhaled steroids

Adults or children
using inhaled beta 2 agonist 3 times a week or more having symptoms 3 times a week or more Waking at night once a week or more

Consider in adults and children who have had an exacerbation requiring oral steroids in the last 2 years

Adults

Fear of steroids!
While the use of inhaled corticosteroids may be associated with adverse effects (including the potential to reduced bone mineral density) with careful inhaled steroid dose adjustment this risk is likely to be outweighed by their ability to reduce the need for multiple bursts of oral corticosteroids.771

Stepping up treatment?
If patient not controlled, before stepping up, consider the following: Check compliance with existing therapies Check understanding Check Inhaler technique Eliminate trigger factors where possible

Adults

Step 3: Initial add-on therapy

The first choice as add-on therapy to inhaled steroids in adults and children(5-12 years) is an inhaled long-acting beta2 agonist (LABA) Adding a LABA should be considered before going above a dose of 400 mcg BDP or equivalent and certainly before going above 800mcg Long-acting beta2 agonists are effective at providing bronchodilation over a sustained period. They increase lung function, improve symptoms and reduce incidence of exacerbation LABAs are not licensed as monotherapy in the treatment of asthma
1. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British
Guideline on the Management of Asthma: A National Clinical Guideline . Revised Edition, 2008.

MHRA advice on LABAs

At present the benefits of long-acting 2 agonists outweigh the risks, and it is important that patients take their asthma medicine as prescribed to them. Patients should discuss any concerns regarding their asthma treatment with their doctor. Feb 2008
http://www.mhra.gov.uk/Safetyinformation/Generalsafetyi nformationandadvice/Productspecificinformationandadvice/Asthma/index.htm

Combination inhalers
Section 4.3.3. BTS 2008 there is no difference in efficacy in giving inhaled steroid and long-acting 2 agonist in combination or in separate inhalers Once a patient is on stable therapy, combination inhalers have the advantage of guaranteeing that the long-acting 2 agonist is not taken without inhaled steroid Supported by Oxfordshire guidance in prescribing Points Bulletin Oxfordshire PCT Vol 17(1) 09 May 2008

Can we gain control of asthma?

Vast majority of asthmatics seen in primary care should achieve guideline level control (total control)
Appropriate dose of inhaled steroid +/- LABA AT STEP 2 OR 3 Optimal inhaler technique Compliance Understanding

Adults

Adults

Children age 5-12 yrs

Children Less than 5 yrs

Stepping down
Patients who have been stable and asymptomatic for 3 months could consider stepping down treatment one study recommends halving ICS dose every 3 months Some children with milder asthma and a clear seasonal pattern to their symptoms may have a more rapid dose reduction during their good season Key issues
1. regular review 2. maintain on lowest dose possible of ICS

Non-pharmacological management
Allergen avoidance Breast feeding Avoidance of pollutants stop smoking/support parents to stop smoking Family therapy in difficult childhood asthma

Allergen Reduction

Cochrane Review: Dust Mite Control Measures for asthma; Goetzsche PC; Cochrane Systematic Review 2001 23 studies 6 chemical, 13 physical, 4 combined. No evidence to support current methods of dust mite control in reducing asthma symptoms or severity

Have we sorted Asthma? - Asthma management today

The majority of patients accept limitations in their lives due to asthma
Sex life
Going to work Playing with children Socialising Walking Going up or down stairs Sport Sleeping 0% 10% 20% 30% 40% 50% 60% 70%

27% 35% 42% 49%

50%
53% 63% 71%
80%

% respondents

Gruffydd Jones et al. Int J Clin Pract 2002 (ACE survey)

Asthma compromises lifestyles in the UK

27% feel that asthma totally controls their life or
has a major effect on it1

44% say that at least one activity is totally or

very limited by asthma2

Only 40% usually feel well3

Two-thirds of patients who say their asthma is

well controlled use reliever twice a day4
1. National Asthma Campaign & Allen and Hanburys. The Impact of Asthma Survey, 1996. 2. National Asthma Campaign. Asthma J 2000. 3. Gruffydd Jones et al. Int J Clin Pract 2002. 4. Price et al. Asthma J 1999.

After being shown international guidelines, significantly fewer patients thought their asthma was under control
% respondents who thought that their asthma was under control before and after being shown international guidelines
Before

After

0%

10%

20%

30%

40%

50%

60%

That cant be right. My treatment doesnt do that

Haughney J et al. Prim Care Resp J 2004; 13: 28-35

Asthma monitoring in primary care

Symptomatic asthma control RCP3 or ACQ (following slides) Lung function Spirometry or PEFR Exacerbations, oral corticosteroid use and time off work or school since last assessment Inhaler technique Compliance - which can be assessed by reviewing prescription refill frequency Bronchodilator reliance - which can be assessed by reviewing prescription refill frequency Possession of and use of self management plan/personal action plan

Ask & Tell

ZERO TOLERANCE FOR SYMPTOMS Simple questions are needed to gain an insight how patients really are:
Have you had any asthma symptoms recently? Have you needed your blue inhaler recently?

Do you ever wake up in the night due to your asthma?

Have you had an attack or needed an emergency visit recently? Do you ever avoid doing things because of your asthma?

Tell them that the aim of asthma management is zero symptoms

Asthma Control Test (ACT)

1. In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?
Score

2.

During the past 4 weeks, how often have you had shortness of breath?

3.

During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) wake you up at night, or earlier than usual in the morning?

4.

During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as salbutamol)? 5. How would you rate your asthma control during the past 4 weeks?

Copyright 2002, QualityMetric Incorporated. Asthma Control Test Is a Trademark of QualityMetric Incorporated.

Patient Total Score

Assessment: Royal College of Physicians of London three questions

IN THE LAST WEEK / MONTH
YES
Have you had difficulty sleeping because of your asthma symptoms (including cough)?

NO

Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
Has your asthma interfered with your usual activities (e.g. housework, work, school, etc)? Date / / /

Page 52

Applies to all patients with asthma aged 16 and over. Only use after diagnosis has been established.
Imperial College London

Outcomes and audit. Thorax 2003; 58 (Suppl I): i1-i92

Can we control Asthma?

Asthma control is achievable in the majority of patients
Have you got them on the correct treatment step? Does your patient understand what and when to take and when to seek help? Have you checked inhaler technique? Does your patient have a self management plan?

Acute exacerbation management

Living on a knife edge Asthma UK 2004

Of the 5.2 million people with asthma in the UK, 2.6 million have severe symptoms. 2.1 million (of the 2.6 million) are suffering unnecessarily because of a failure of asthma management. 1 in 6 people with severe asthma symptoms report weekly attacks so severe that they cannot speak (430,000 people) 20% of people with severe asthma are seriously concerned that the next asthma attack will be the one that kills them (>500,000)

Lessons from studies of Asthma deaths and near-fatal asthma Who is at risk?
A combination of asthma :Severe And Adverse behavioural or psychological features: Non compliance with treatment or monitoring Failure to attend appointments Fewer GP contacts Frequent home visits Self discharge from hospital Psychosis, depression, other psychiatric illness or self harm Current or recent major tranquiliser use Denial Alcohol or drug abuse Obesity Learning difficulties Employment or income problems Social isolation Childhood abuse Severe domestic, marital or legal stress Previous near fatal asthma (requiring ventilation or acidotic) Previous admission for asthma esp. in the past year 3 or more classes of asthma medication Heavy use of 2 agonists Repeated attendances for asthma to the ED department brittle asthma

Asthma Deaths
Deaths continue to be reported following inappropriate prescription of -blockers and NSAIDs; all asthma patients should be asked about past reactions to these agents Patients with acute asthma should not be sedated unless this is to allow anaesthetic or intensive care procedures

Lessons learnt from studies of asthma deaths

Many deaths from asthma are preventable 88-92% of attacks requiring hospitalisation develop over 6 hours Factors include: inadequate objective monitoring failure to refer earlier for specialist advice inadequate treatment with steroids

Health care professionals must be aware that patients with severe asthma and one or more adverse psychosocial factors are at risk of death Keep patients who have had near fatal asthma or brittle asthma under specialist supervision indefinitely Respiratory specialist should follow up patients admitted with severe asthma for at least a year after admission
Management of acute asthma. Thorax 2008; 63(Suppl IV):

Brittle Asthma
- Type 1: wide PEF variability (>40% diurnal variation for >50% of the time over a period >150 days) despite intense therapy - Type 2: sudden severe attacks on a background of apparently well controlled asthma

Moderate asthma exacerbation

Increasing symptoms PEF>50-75% best of predicted No features of acute severe asthma

Acute severe asthma

Any one of: - PEF 33-50% best or predicted - respiratory rate 25/min - heart rate 110/min - inability to complete sentences in one breath

Life threatening asthma

Any one of the following in a patient with severe asthma:
Clinical signs Measurements Altered conscious level PEF <33% best or predicted Exhaustion SpO2 <92% Arrhythmia PaO2 <8 kPa Hypotension normal PaCO2 (4.66.0 kPa) Cyanosis Silent chest Poor respiratory effort

Near-fatal asthma
Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

Patient assessment
Clinical features PEF or FEV1 Pulse oximetry Blood gasses Chest X-ray Clinical features, symptoms, respiratory and cardiovascular signs helpful but non-specific for severity; absence does not exclude severe attack Measurement of severity and guide for treatment. PEF more convenient. (PEF as %age previous best or predicted) Determines adequacy of oxygen therapy and need for ABG. Aim to maintain sats >92% Necessary for patients with SaO2 < 92% or if features of life threatening asthma Not routinely recommended in the absence of :Suspected pneumomediastinum or pneumothorax Suspected consolidation Life threatening asthma Failure to respond to treatment as expected Requirement for ventilation Systolic paradox (pulsus paradox)is an inadequate indicator of the severity of an attack and should not be used

Systolic paradox

Moderate Asthma
(PEF >50% pred, Speech normal, resps<25, p<110)
High dose bronchodilator (Neb or inhaler) If peak flow >50 75% give 40 50mg prednisolone Continue or step up usual treatment If pulse and respiratory rate settling and peak flow >50% predicted continue treatment at home Admit if
Features of life threatening attack Features of acute severe asthma after initial treatment Previous near fatal asthma

Acute severe asthma

(PEF 33-50% pred, cant complete sentence, Resp>25, pulse>110)
Consider admission High flow oxygen if available High dose bronchodilators Prednisolone 40 50mg (or hydrocortisone 100mg) If no response ADMIT If admitting, stay with patient, send written assessment, Continue high dose bronchodilators via nebuliser and oxygen in ambulance

Treatment of acute asthma in adults

Oxygen : Oxygen saturations should be above 92% Give high flow oxygen to all patients with acute severe asthma In hospital, ambulance and primary care, nebulisers should be driven by high flow oxygen (minimum 6l/min flow) Outside hospital, high dose bronchodilators can be delivered via large volume spacers or nebulisers The absence of supplemental oxygen should not prevent nebulised therapy being given if indicated

Life threatening asthma (PEF <33%

best or predicted, sats <92%, etc)
Arrange immediate admission Whilst waiting for ambulance Oxygen 40-60% to keep sats >92% High dose bronchodilators salbutamol and ipratropium via nebuliser driven by oxygen Prednisolone 40 50mg (or hydrocortisone 100mg) Follow up after admission to hospital: GP review in 48 hours Check inhaler technique Written asthma management plan Modify treatment if underlying poor control

Special circumstances
Acute asthma in pregnancy Give drug therapy as for the non pregnant patient Deliver oxygen immediately to maintain saturations above 95% Always treat as an emergency Asthma in children Alter drug doses for younger children All over 12s receive adult therapy

Moderate asthma exacerbation children 2-12 years

Able to talk No features of acute severe asthma Pulse <120 in >5s, <130 in 2-5s Resp rate <30 in >5s, <50 in 2-5s SpO2>92% In over 5s peak flow >50% predicted/best

Children aged >5years Moderate exacerbation

2 agonist (salbutamol or terbutaline) 4 6 puffs via spacer Consider soluble prednisolone 30 - 40mg Increase dose of 2 agonist by 2 puffs every 2 minutes up to 10 puffs according to response Arrange admission if poor response Good response Continue 2 agonist via spacer prn but not exceeding 4 hourly Continue Prednisolone for 3 days Arrange follow up in clinic

Asthma 2 5 years Moderate exacerbation

2 agonist (salbutamol or terbutaline) 4 6 puffs via spacer Consider soluble prednisolone 20mg Increase dose of 2 agonist by 2 puffs every 2 minutes up to 10 puffs according to response Arrange admission if poor response Good response Continue 2 agonist via spacer prn but not exceeding 4 hourly Continue Prednisolone for 3 days Arrange follow up in clinic

Acute severe asthma children 2-12 years

Unable to complete sentences in one breath or too breathless to talk or feed Use of accessory muscles Pulse >120 in >5s, >130 in 2-5s Resp rate >30 in >5s, >50 in 2-5s SpO2 <92% In over 5s, peak flow <50% predicted/best

Children aged >5years Acute Severe exacerbation

Oxygen via face mask 2 agonist (salbutamol or terbutaline) 4 6 puffs via spacer at intervals of 10-20 mins or nebulised salbutamol 2.55mcg or terbutaline 5 10 mg Soluble prednisolone 30 - 40mg Assess response to treatment 15 mins after 2 agonist If poor response repeat 2 agonist and arrange admission If admitting, stay with patient, send written assessment, Continue high dose bronchodilators via neb and oxygen in ambulance

Children 2 - 5years Acute Severe exacerbation

Oxygen via face mask 2 agonist (salbutamol or terbutaline) 4 6 puffs via spacer at intervals of 10-20 mins or nebulised salbutamol 2.5mg Soluble prednisolone 20mg Assess response to treatment 15 mins after 2 agonist If poor response repeat 2 agonist and arrange admission If admitting, stay with patient, send written assessment, Continue high dose bronchodilators via neb and oxygen in ambulance

Life threatening asthma children 2-12 years

Silent chest Cyanosis Poor respiratory effort Hypotension Exhaustion Confusion/agitation Coma SpO2 <92% In over 5s peak flow <33% predicted/best

Children aged >5years Life threatening asthma

Oxygen via face mask High dose bronchodilators salbutamol 5mg or terbutaline 10mg and ipratropium 0.25mg via nebuliser driven by oxygen Soluble prednisolone 30 - 40mg or IV hydrocortisone 100mg Repeat 2 agonist via oxygen driven nebuliser whilst arranging immediate admission to hospital

Children 2 - 5years Life threatening asthma

Oxygen via face mask High dose bronchodilators salbutamol 2.5mg or terbutaline 5mg and ipratropium 0.25mg via nebuliser driven by oxygen Soluble prednisolone 20mg or IV hydrocortisone 50mg Repeat 2 agonist via oxygen driven nebuliser whilst arranging immediate admission to hospital

Moderate asthma exacerbation children under 2 years

SpO2 >92% Audible wheezing Using accessory muscles Still feeding

Acute severe asthma children under 2years

SpO2 <92% Cyanosis Marked respiratory distress Too breathless to feed

Life threatening asthma in children under 2 years

Apnoea Bradicardia Poor respiratory effort

Asthma treatment in the under 2s

2-4 Puffs Salbutamol initial treatment For mild to moderate acute asthma, a pMDI + spacer is the optimal drug delivery device. Consider steroid tablets in infants early in the management of severe episodes of acute asthma 10mg of soluble prednisolone for 3 days Consider inhaled ipratropium bromide in combination with an inhaled 2 agonist for more severe symptoms.

Lower threshold for admission for all children if:

Attack in late afternoon or at night Recent hospital admission or previous severe attack Concern over social circumstances or ability to cope at home NB always treat according to most severe features

Criteria for admission

Any patient with any feature of a life threatening or near fatal attack Any patient with any feature of a severe attack persisting after initial treatment Any patient who after initial treatment:
Still has significant symptoms Concerns about compliance Lives alone/socially isolated Psychological problems Physical disability or learning difficulties Previous near fatal or brittle asthma Exacerbation despite already being on oral steroids Presentation at night Pregnancy

Overview: Management of acute asthma

Assess and act promptly in acute asthma Admit patients with any feature of a life threatening or near
fatal attack, or severe attack persisting after initial treatment

Measure oxygen saturation Use steroid tablets Primary care follow up required promptly after acute asthma

Management of acute asthma. Thorax 2003; 58 (Suppl I): i1-i92

Check inhaler technique Tailor inhaler device to the patients needs

Discharge plan
Do your hospitals use a discharge checklist? Peak flow should be at least 75% or best or predicted with less than 20% diurnal variation pre discharge ALL PATIENTS SHOULD HAVE A SELF MANAGEMENT PLAN BEFORE BEING DISCHARGED Patient must be prescribed preventative therapy Inhaler technique must be checked All patients should have their own peak flow meter Advise to see GP within 2 working days can they get an Refer for chest OPD within 4 weeks

appointment?

Education / written information

How to recognise that asthma is deteriorating How to take medicines, how often and for how long How to use inhaler effectively What to do if they have another asthma attack Are there any triggers and can they avoid them in future? Smoking cessation How often to make an appointment to have asthma reviewed The importance of carrying a reliever inhaler at all times

Why do spirometry?
More informative than peak flow To detect presence or absence of lung disease where there is a history or pulmonary symptoms To confirm findings of other investigations e.g.chest x-ray or blood gasses To establish extent of lung impairment in respiratory disease and monitor progression e.g.COPD / Fibrosis To investigate impact of other diseases on lung function e.g. cardiac disease or neuromuscular disease Occupational / environmental monitoring e.g. smokers, dust, asbestos To determine effects of an intervention e.g.bronchodilator reversibility tests

Spirometry cannot Define the full extent of the disease e.g. In COPD many systemic as well as pulmonary effects Define the response to therapy Define the extent of disability that the patient experiences

Guidelines
Avoid
Smoking for 24 hours Alcohol for 4 hours Vigorous exercise for 30 minutes Tight clothing Food for 2 hours Query Using Inhalers

Check History
MI / CVA Recent operations Spontaneous pneumothorax Aneurysm Uncontrolled hypertension, angina Ear infection Pregnancy

Patient preparation
Record patients date of birth, height, ethnic origin Note if the patient is currently unwell or has had a recent exacerbation Ensure the patient is comfortable Sit the patient in a chair with arms Explain the purpose of the test You may need to demonstrate the correct technique Allow the patient practice attempts

Patient preparation
To withhold or not to withhold medication? If you are doing reversibility testing:
No short acting bronchodilators for 4 hours No long acting bronchodilators for 12 hours No sustained release oral bronchodilators for 24 hours

For routine monitoring of COPD patients:

Take all medication as usual

Lung volume terminology

Inspiratory capacity Inspiratory reserve vol

Vital capacity

Tidal vol

Expiratory reserve vol

Residual vol

Terminology
VC Vital capacity, the total amount of air that acn be expelled from the lungs from full inspiration to full expiration FVC Forced vital capacity, should be the same volume as VC but is sometimes reduced due to air trapping in COPD FEV1 Forced expiratory volume in one second from full inspiration FEV1/FVC or FEV1% or FEV1/FVC ratio The percentage of the FVC that is produced in the first second FEV1/VC - The percentage of the VC that is produced in the first second

Measuring vital capacity (VC)

The VC is a non vorced measurement. It is often measured at the start of a session. Patient breathes in as deeply as is comfortable Seals lips around mouthpiece Breathes out steadily at a comfortable pace Continue until expiration complete May need a nose clip Repeat

Measuring FEV1 and FVC

Ask the patient to take a deep breath in full inspiration Patient to blow out forcibly, as hard and fast as possible, until there is nothing left to dispell
Encourage patient to keep blowing For some COPD patients this can take up to 15 seconds! Spirometer may bleep to say manoeuvre complete

Repeat the procedure twice or until reproducible results

Maintaining accuracy
The most common reason for inacurate results is patient technique Common problems include:
Inadaquate or incomplete inhalation Additional breath taken during manoeuvre Lips not sealed around mouthpiece A slow start to the forced exhalation Some exhalation through the nose Coughing

Interpreation of results
Take the best of the 3 consistent readings of FEV1 and of FVC Find the predicted normals for your patient Your machine may do this for you! Get out your calculators!!

Predicted Normals
Depends on ; Age Sex Height Race

Predicted Normal values

Based on large population surveyse.g.ERS93, ECCS83 Predicted values are the mean values obtained from the survey No surveys conducted in elderly populations

Normal ventilatory function

FVC
FEV1

80 120% of predicted
80 120% of predicted

FEV1/FVC ratio >70%

Results clasification

Normal Obstructive Restrictive Combined

Interpreting Spirometry
Normal
FEV1 >80%

Obstructive Restrictive Combined

<80% <80%

FVC

>80%

>80%

<80%

<80%

Ratio

>70%

<70%

>70%

<70%

Normal

Flow volume trace

Peak expiratory flow Flow (l/second)

FVC Volume (litres)

Normal Flow Volume curve

Maximum expiratory flow (PEF)
Expiratory flow rate L/sec TLC Inspiratory flow rate L/sec

FVC

RV

Volume (L)

Patterns of abnormality in spirometry

Obstruction Restriction Mixed

Volume

Volume

Time

Time

Volume

Time

Slow rise, reduced volume expired, prolonged time to full expiration

Fast rise to plateau at reduced maximum volume

Slow rise to reduced maximum volume

Patterns of flow volume curves in obstruction and restriction

Obstruction
Expiratory flow rate

Severe obstruction Expiratory flow rate

Restriction

Expiratory flow rate

Volume (L) Reduced peak flow, scooped out midcurve

Volume (L) Steeple pattern, reduced peak flow, rapid fall off

Volume (L) Normal shape, normal peak flow, reduced volume

Obstructive defects
COPD Asthma Bronchial carcinoma Bronchiectasis

Restrictive defects
Pulmonary causes
Fibrosing lung disease (CFA, UIP, EAA, rheumatiod) Byssinosis Pulmonary oedema

Parenchymal tumours
Pneumoconiosis (coal workers, asbestosis, silicosis, siderosis)

Thank Thank you you