Asthma (Read Code H33) 2017

Diagnosis:

Assess probability of asthma based on history and review of previous medical record

  • Recurrent episodes of symptoms(>1 of symptoms of wheeze, breathlessness, chest tightness and cough occurring in episodes with periods of no or minimal symptoms between. Eg. symptoms triggered by allergen exposure as well as viral infections and exacerbated by exercise, cold air and emotion or laughter in children)
  • Symptom variability(symptoms worse at night or in the early morning or with exposure)
  • Absence of symptoms of alternative diagnosis(COPD, dysfunctional breathing, obesity)
  • Recorded observation of wheeze(repeatedly normal examination when symptomatic reduces probability)
  • Atopy( personalhx of eczema, allergic rhinitis or fhx of asthma +/- atopic disorder, previous eosinophilia, raised allergen specific IgE, positive skin prick test to aeroallergens)
  • Historical PEF or FEV1

High probability:

  1. code as “suspected asthma” and initiate treatment with ICS and review 6/52
  2. Assess response objectively (lung function with serial PEF or FEV1/symptoms score)

Good response -code as asthma and treat

Poor response - check inhaler technique and investigate as intermediate probability.

Intermediate probability:

Further investigation then watchful waiting if asymptomatic or commence treatment and assess response objectively as high probability

Test for airway obstruction with spirometry +bronchodilator

FEV1/FVC <0.7. FEV1 >400mls improvement post 400mcg salbutamol.

if age >5 (spirometry pre and post bronchodilator >12% improvement in FEV1).

In children who cannot perform spirometry consider watchful waiting if asymptomatic or offer careful monitored trial of ICS if symptomatic.

Options for investigations are:

Test for variability

  • PEF charting (>20% diurnal variation in recorded EU PFR (am and pm prior to any beta agonists) on 3 or more days each week for 2 weeks.Variation % = (maximum PFR-minimum PFR)/ maximum PFR x100.)
  • Methacholine challenge test looks atairwayresponsiveness. Secondary care.

Test for eosinophilic inflammation or atopy

  • FeNO
  • Blood eosinophils
  • Skinprick test, IgE

Do not add children to the asthma register unless you are confident of the diagnosis!

*Spirometry based diagnosis may be falsely negative in a patient who is well at time of assessment.

Having made the diagnosis please place them on the asthma register and put the H33 Asthma Read code in their Problem page.

Arrange a New Patient Asthma clinic appointment with the Practice Nurse.

Asthma -COPD overlap syndrome H3B.

A proportion of patients with asthma will have both asthma and COPD e.g. they have airway obstruction that does not reverse to normal but also have substantial reversibility. Use inhaled steroids and SABAs. Add other inhalers as needed, but not LABAs alone.

Don’t forget basic health promotion!

  1. Smoking status and cessation advice – Read code.
  2. Flu vaccination if on inhaled steroids
  3. Life style and exercise.
  4. Asthma self management plan.
  5. Patient information leaflets.
  6. Pre-payment certificates for script costs.

Treatment delivery options

(Patient choice is the most important factor in stable asthma)

  1. Metered Dose Inhaler and spacer – 60% of patients have the correct technique – but this can be improved to 75% with technique assessment and education.
  2. Inhaler (MDI) alone – 30 to 40% of patients have the correct technique.
  3. Dry Powder Inhaler (DPI) – as effective as MDI and spacer but costs more, not as useful during acute attacks but socially a lot more convenient. Remember the patient must have the respiratory function to be able to activate the DPI.

An MDI & spacer is the preferred option in adults and should be used in all under 12s.

Advantages of a spacer: greater delivery to the bronchioles, less oral deposition, so reduced frequency of oral thrush and it is as good as a nebuliser during acute exacerbations.

But the spacer:

Should be demonstrated and technique checked.

Should be washed monthly with detergent and allowed to air dry (NOT wiped dry).

Should be changed every twelve months.

Tidal breathing is now recommended (several normal breaths rather than one long/fast intake of breath)

Work related asthma and rhinitis:

1in 10 case or new or reappearance of childhood asthma in adult life are attributable to occupation

High risk work included

  • Baking and Pastry baking
  • Spray painting
  • Laboratory animal work
  • Healthcare and dental care
  • Food processing
  • Welding, soldering, metal work
  • Woodwork
  • Chemical processing
  • Textile, plastics and rubber manufacture
  • Farming and other jobs with exposure to dusts and fumes

Do symptoms resolve when away from work?

Arrange serial peak flow monitoring and refer to chest physician for possible work related asthma and to an allergy specialist for possible work related rhinitis

Adult asthma guidelines.

BTS/Sign 2016 and Calderdale CCG preferred inhaler choices (either MDI= 1st choice or DPI if patient prefers


Children age >5 asthmatreatment

BTS/Sign 2016 and BNF/BRS inhaler choices(either MDI + spacer = 1st choice, or DPI)

.


Children under 5 years asthma treatment.

BTS/Sign guidelines 2014 and BNF (either MDI = 1st choice or DPI if patient prefers and is able/product licensed).


Asthma review

  1. Assess control: The RCP 3 Questions. In the last month:
  1. Has your asthma interfered with your usual activities (e.g. housework, work, school, hobbies etc)?
  2. Have you had difficulties sleeping because of your asthma symptoms (including cough)?
  3. Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness?)

Asthma control test removed as an option, see below.

  1. Patient understanding of ‘preventers’ and ‘relievers’ and their appropriate usage, also ask about any side effects.
  1. Check inhaler & spacer technique.
  1. Check triggers.
  1. Compliance as per computer and patient history – number of salbutamol MDIs used in last 12 months
  1. Have they had a new spacer within the last 12 months?
  1. Check steroid use. Refer GP for FRAX or DEXA if 3-4 courses oral steroids over 12m (SIGN),high dose inhaled steroids or persistent dosing >3m).

Have they got a steroid card if long term >1000mcg BDP equiv. per day or oral steroids > 3 weeks?. See below.

  1. Smoking status and cessation advice.
  1. Any exacerbations, hospital admissions or oral steroid use since last review?
  1. Having to use a reliever more than 3 x per week?
  1. The need to step up or step down treatment

Step up if: needing salbutamol or symptomatic 3x a week or more. Or waking 1 night /wk due to asthma.

Step down if: stable for 3m. Aim to reduce inhaled steroids by 25-50%. Review 3m. Aim for lowest possible maintenance dose.

  1. Are they aware of the month of their next annual review?
  1. Variability of airways obstruction (QOF AST002) should be recorded if not done so previously. This can be done at any stage after diagnosis. This should be added for children with previous diagnosis under 8 yrs when they become old enough to fall into the target group.
  1. Check height and weight in children. GP review if growth falling off centiles(On S1 – clinical tools – child growth charts).

AND

  1. Patient asthma action plan

Strongly recommended by SIGN.

GP update suggests discussion as below.

.Two scenarios:

- ‘ your asthma has been pretty good for some months, but you wake in the middle of the night and your asthma is really bad, your chest feels really tight and you are struggling to breathe. What would you do?’

- ‘over the last 5-6 days your asthma has been getting a bit worse, you are getting breathless when you climb the stairs, but you are ok walking around. You have taken your blue and brown inhaler as you normally do, but it doesn’t seem to be improving, in fact things are getting a little bit worse. What would you do?’

Record this education on the patient’s PAAP.

Give 2 copies of the PAAP for children . Keep one at school.

Suggested actions based on peak flows:

  1. If PFR 60-80% increase inhaled steroids.
  2. If PFR 50-60% start oral steroids and see GP
  3. If PFR <50% seek urgent medical help

link to Asthma UK action plan :file:///C:/Users/GPConnect/Downloads/Written_Asthma_Action_Plan_-_updated_November_2014.pdf

Traffic light system.

For Children, use local ‘ My Asthma Action Plan’ – one for under 5s

One for 5s and over ?remove this. GP update use Asthma UK action plan above.

If more detailed assessment of control needed:

Asthma Control Test:

Adults (and children >12 yrs)

Children 4-11

-

Steroid treatment cards

The GP should issue and explain * a steroid card to patients who are:

On oral steroids for >3 weeks.

ON high dose inhaled steroids( >1000mcg BDP equiv per day or, step 4 of guideline)

On additional intranasal steroids (consider if 800-1000mcg BDP equiv per day)

On cytochrome P450 inhibitors – ritonavir, itraconazole , ketoconazole..

*Risk of adrenal suppression (or adrenal crisis or coma in children).

Consider oral corticosteroid during a period of stress eg. operation or severe illness.

Note: inhaled fluticasone diproprionate is equivalent to prednisolone 10mg od.

*Element of immune suppression/increased susceptibility to infection. See GP if contact with chickenpox if never had.

*BMD risk, see below.

*Growth.

Further advice re when to issue a steroid card :

A useful PIL to explain the steroid treatment card:

Doctors or pharmacists may obtain stocks of the steroid treatment card, free of charge, from: Department of Health PO Box 410 Wetherby LS23 7LL Fax 01937 845 381.

Pharmacists should check that appropriate patients have been issued with a steroid card and issue the patient with one, if not.

Osteoporosis risk

Treatment strategy for preventing steroid induced osteoporosis
Consider every patient for active osteoporosis prevention who has had:

  • Oral or iv steroid treatment for greater than 3 months.
  • Inhaled steroid > 1000mcg day beclomethasone.

If unable to have a DEXA then treat, 1st line = a bisphosphonate.

If steroid course likely to > 3 months then treat, 1st line = a bisphosphonate.

If able to have a DEXA and the T score above -1.5 treat with lifestyle measures +/- calcium supplementation.

NB DEXA needs repeating every 3 years

If the T score is = -1.5 or lower then treat, 1st line = a bisphosphonate.

NB DEXA needs repeating every 3 years

Another strategy for deciding who warrants a DEXA scan is to use Qfracture - (or FRAX via SystmOne) where a DEXA is indicated if risk >10%.

Indication for consultant referral

  1. Diagnosis unclear.
  2. Failure to control symptoms at Step 4.
  3. Consideration for home nebs or home oxygen.
  4. Acute severe exacerbations.
  5. Troublesome drug side effects or complications of Rx/asthma.
  6. Suspected occupational asthma

At repeat medication re-authorisation doctors must look at:

i)Beta 2 agonist over usage – arrange GP or asthma review?

ii)Spacer on repeat script? Check when last issued.

iii)Steroid card needed? Has it been issued?

iv)Oral steroid/high dose inhaled steroid usage and need for osteoporosis prophylaxis.

v)Correct Read H33 Read coding & is it in the Problem page?

vi)Annual review in date

Other News:

  1. Relvar

Combined ICS/LABA. Once daily.

Fluticasone furoate (not proprionate).High potency steroid, so only for BTS step 4 + Vilanterol.

Little experience/safety/evidence of superiority.

A not yet drug?

  1. Tiotropium.

Now licensed in adult asthma. Respimat device. Option at step 4. DTB point out limited evidence.

  1. SIT (single Inhaler Therapy) regimes are sometimes used. Idea is to use ICS/LABA combo as reliever as well as preventer. Only works with rapid onset of action of LABA eg. Formoterol( inFostair, Symbicort)
  2. From October 2014 schools have been allowed to purchase a stock of salbutamol MDIs and spacers for emergency use.
  3. Bronchial thermoplasty- 2o care treatment offered to severe adult asthmatics to reduce excessive smooth muscle.
  4. Omalizumab. An anti-IgE monoclonal antibody in a few centres. Costly.

QOF 2017/18

AST001asthma register

AST002variability at diagnosis (8 and over)

AST003annual review incl MRC 3 questions

AST00414yrs – 19yrs smoking status recorded annually

References

British Thoracic Society/Sign guidelines Sept 2016

Asthma UK

Medicines Management, Calderdale CCG

GP-Update Handbook 2016.

My Asthma Action Plans, Calderdale CCG Living Well With Asthma Project, Calderdale CCG April 2015.