See BTS/SIGN guidance on asthma, asthma prevention, asthma and obesity
National asthma guidance conflicting – NICE recommends both spirometry and Fractional exhaled nitric oxide to confirm diagnosis, has rejected “trial of treatment” and de-emphasized peak flow monitoring.
FeNO is expensive and available in only a minority of GP practices and hospital services. Requiring it means GPs can no longer make diagnosis themselves.
Spirometry results in most primary care patients with asthma are normal!
Other difference from SIGN/BTS is Leukotriene Receptor Antagonist (LRA) as first choice add on rather than Long acting Beta agonist (LABA), on basis of marginal benefit but increased cost.
Primary care respiratory society UK has produced advice on how to deal with conflicting national guidelines – reasserts prime importance of good clinical method and regular reassessment, prioritises peak flow monitoring alongside trials of treatment if necessary.
[BMJ editorial 2017]
Spacer best for everyone!
200 doses in an MDI. 2 puffs BD exhausts an MDI in 50 days. Multidosing 5 puffs 4hrly will exhaust it in 6 days.
Growth Restriction
Children who use inhaled steroids for asthma grow slower than their peers in the first year of taking the medication, by about half a centimetre per year. Metanalysis of 25 trials, various types of steroid. Seems to be most obvious in initial year of treatment. Only 1 study followed children into adulthood – budesonide, used for average of 4 years – reduction in final height of 1.2cm (Kelly, PMID 22938716).
Should therefore be prescribed at the lowest effective dose. Cochrane 2014 found significant difference between low dosing (50-100 Clenil equivalent) and medium dosing of 0.2cm per year but noted that the majority of trials did not report height data.
However, the small effect on growth needs to be weighed against the proven benefits of these drugs in controlling asthma, and ensuring children’s lungs grow to their full capacity. Undertreated asthma is much more likely to have a harmful effect on a child’s development than a small reduction in growth.
Newer Therapies
Xolair=Omalizumab, monoclonal vs IgE. Subcut, 2-4 weekly, for age 6+ where conventional therapy not working. Other criteria are total igE >30, positive tests for aeroallergens, FEV1<80%.
Airsonett is evidence based, temperature controlled laminar flow system for bedroom. Noisy!
Management
See National review of asthma deaths. Recommendations include:
- Refer specialist if >=2 courses oral steroids within 12 month period
- Follow up after every ED/OOH attendance
- Hospital follow up after every hospital attendance
- Annual inhaler technique check
- Personal asthma plan for everyone
See MyLungsMyLife.org website for self management.