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Good evening everybody. Uh Nice to see you, everyone joining us again. Um My name is Tim, uh probably a familiar face by now um hosting the middle primary care network events as much as I possibly can. Great to see everybody joining us and even greater to see the, the number of you that are catching up with our content online. Delighted to have a familiar face back with us tonight. Anyone who has been with us before is bound to know Doctor Steve Holmes. Um Have a look on me all, there are lots of past talks and recordings of talks and resources there um that he has shared with us in the past. Um We're starting a slightly new series tonight going to delve into asthma. I know we've just sort of closed a series on CO PD as is the custom, we will spend around 45 50 minutes. Um As we listen to tonight's presentation, I'd encourage you to put some questions in the chat and we'll have a bit of interactivity towards the end. Um I point you towards the app for the upcoming events. We are working on the 2025 schedule and some of them are live for registering now as well. I'll share a little bit more at the end about what's coming up soon, but without any further ado I'm going to pass over to Doctor Holmes Tim. Thanks so much and it's lovely to be back again and hello to everybody. Hope you're all having a, a good day. Um I'm gonna be covering tonight how to make a good diagnosis of asthma And I'm gonna be covering some guidance that was published about the 27th of November. About it was on the 27th of November, so about two weeks ago, but it's actually a guideline and it's quite specific and hopefully it will be interesting because I'm gonna try to compare it with some of the previous guidance we've had and I'm gonna try to put it into a perspective of just going beyond the guidelines so that at the end, hopefully you feel much more confident that when you're seeing somebody, you'll be able to make a, a confident, good diagnosis of asthma and you'll be spotting the situations where that's less likely. So what I'm gonna do, first of all is just give a few declarations of interest and do quite a lot in the respiratory world, both as a, a clinician, active clinician, but also strategically and working with a variety of groups at the national and international level. Been involved in quite a few guidelines. Um I'm also involved in a fair amount of research um work with a variety of medical education providers and have worked with quite a lot of the pharmaceutical and device companies. Again, primarily around trying to get out the message about respiratory care. Two things that are very close to the heart. One is the primary care Respiratory Society um available globally. You can get lots of information on there. Um lots of guidance that summarized into one or two pages rather than 200 plenty of up to date information and quite a few short podcasts and and other things on there if you're interested and if you're working in an international situation, then there's the International Primary Care Respiratory Group um which is a group of healthcare professionals working globally trying to provide again evidence and guidance that is suitable to use in any uh situation, no matter what sort of resource you've got available. Um and what um imaging and testing is available to you. So those are things you might want to have a look through and I might reference those as we whizz through. But what I'm gonna try to do is just talk through the definition of asthma, how to make a good diagnosis and talk about a good diagnosis, the uncertain diagnosis and the tricky diagnoses because I think any of you that are in clinical practice like myself will find it tricky at time. And then I'm gonna do a few common catches reasons why people get um present as asthma or potentially asthma and it might not be just asthma or it might not be asthma at all. So hopefully that's given us a lot. Now, the last little section is outside, the guidelines, guidelines tend to stick to the information that is present, you know, uh tends to stick to the disease they're talking about. So set, set the scene. I'm just gonna highlight Hannah, 30 year old teacher works in a local infant school cough for three months breathless. That can wake her up perhaps twice a week affects her a bit when she's exercising thinks she's had these possibly over the last year, had a horrible chest infection, sort of thinks, is it still lingering because of that? Um And on direct enquiry has a family history of asthma, that's not an uncommon presentation. Quite a few people will be younger when they're first presenting. Quite a few won't have a family history, but it's, it's not a full blown acute asthma episode. What other questions do we want to know if you were seeing Hannah in our consulting room now? And perhaps I'll, I'll answer some of those to keep us moving along. Important things are whether she has a history of hay fever, um whether she's got a history of ap eczema, always worthwhile thinking about tobacco and also other substances. There's a lot of other things that people smoke that can, um affect the lungs. Um Certainly things like crack cocaine, cannabis, smoked, heroin are notorious for causing quite significant damage at a young age to people's lungs. Often in the fixed way. More like AC O PD picture. Quite a lot of inhaled substances can trigger allergic type responses. And on top of that, the shisha pipes that you sometimes see around in towns and cities are thought to be worth somewhere around 100 to 200 cigarettes, 100 to 200 cigarettes per Shisha pipe. So worthwhile, remembering if you're seeing people who may be using Shisha pipes instead of cigarettes, cos they're more socially acceptable in that area. I'm aware that's quite common in, in the Middle East. Um ok, other things about Hannah, she's not smoking or she says she's not smoking, she's a teacher, normal body mass index. No evidence of Wheeze heard in the notes that's fairly specific and a blood eosinophil count of 0.28 0.35. Again, one of those sort of in between levels worthwhile looking at what your lab does, but we'll talk more about eosinophils in a moment. So let's think with, with Hannah in mind, what sort of things are we gonna be wondering about? First of all definition and I've taken this from Gina, there are lots of them around, they've modified slightly over time and what Gina sort of says is it's a disease that is usually characterized by some airflow limitation is not persistent all the time, but it comes and goes. So it's variable varies over time and in intensity, it often presents with shortness of breath, a feeling of chest tightness and variable cough. And often some uh something like a wheeze. Wheeze is tricky because a lot of people hearing somebody inspiring will call that a wheeze. That's an upper respiratory laryngeal voluntary maneuver that I just did. It's nothing to do with wheezing but often difficult to distinguish when you're listening to what a patient says. And one of the important triggers that makes us think asthma is much more likely is a clinician determined. Wheeze. That is, I've listened in using a stethoscope. I haven't just taken what the patient or their family have said about it. And I should point out tonight, I'm gonna concentrate primarily because a lot of this is new information on the management in adults. But we can go back at a further stage if, if people are keen to do the same sort of thing in the preschool wheezes. And in the young people remember with that definition, a lot of asthma is um t two helper, asthma sensitive. It's, and it's eosinophilic inflammation of the airways. So that's quite important, that's quite common in the younger age group as opposed to neutrophilic inflammation, which is more common in the CO PD population. And there'll be more coming in about eosinophils again and, and their importance in asthma as we go through this, this sort of talk. What else? We think about worse at night, often with, um, some conditions, they can be worse at night, heart failure, asthma, with some others, things like often CO PD patients are worse when they exert themselves. Only asthma, you would expect some exertional symptoms as well. So how do we make the diagnosis and just keep in your mind what you would do at the moment. The first thing to think about is, um, in the history, we're thinking about a history of variable respiratory symptoms. And if we can evidence of variable expiratory airflow limitation, so that's varying ways, something perhaps like a peak flow reading if you've got lots of kit around perhaps variability in proper lung function tests. So something like spirometry uh would really help to make that um more useful and gina the strategy that's produced globally by a group of uh primarily tertiary and secondary care colleagues um really suggests that at a global level spirometry before and then after a bronchodilator, they feel is the most useful in investigation, but that is guidance. They don't have the um funding and the capacity to do the detailed literature reviews that would make that guidance into a guideline. They use the evidence, they know they're very, they're very good people, they're very clever, but they don't do full blown literature searches. Um They also suggest it's important and complex to manage if the patient's already on treatment. Um and also talk about trying to optimize treatment with it. So this is the 2024 guidance that's coming out at the moment and they're talking about a spirometry first. Now, within the system, this is their pathway symptoms, history and examination if they're taking treatment, think about stopping it, if they're not keep going and do spirometry or a peak flow of that, if the spirometry is unavailable, and I'll talk about peak flow a bit as well. And if that's not positive, you go on to other sorts of tests, they also put in at that sort of stage if the test is positive thinking about um trials of treatment, this is the rather complex 2017 National Institute Clinical Excellence, the E England Wales version of the guidance, which looks very busy and difficult to understand how to follow it through. That's where they often started talking about using fractional exhaled nitric oxide more. Um and 70 years old from 2017. A lot of us still don't have easy access to that in primary and indeed secondary care. So in the UK, so that's that's important thing through. Can we get the free know to do it? The other part of the new British guidance was the BT S sign guidelines. And again, both nice do full blown literature reviews and nice also do economic evaluations, which is gonna be the most effective for us to do both cost wise and efficiency wise. And the BT S sign do very detailed guideline, literature reviews to inform their decisions. And the BT S one used to have a high probability. It sounds like asthma, give them treatment that should improve their asthma and measure their lung function if you can before and a questionnaire if they get better and they've got good response to treatment, make the diagnosis if you're not sure do testing and if it's not asthma, that's the red column, do something else. So, fairly familiar to most people are those three sets of guidelines at the moment. Um Always worthwhile saying that the last time nice produced guidance. They said be sensible if you don't have access to these tests. And this was for, for the British audience that you don't have access to these tests, do a uh do what the BT S sign and say do it on probability. And that publication where they said, please follow the BT S sign came out within a month of publication of the real um the, the nice first guidance being produced. What happened after that was with in within the UK. We said we can't really have two separate guidance which don't quite say the same thing, bang your heads together, get together and sort it out and to give them credit. They did, it took seven years, it was planned straight after 2017, 18. Um But people started to really work together. It's taken 44 years of regular meetings from some of my colleagues to try to help to distinguish what is the best way forward. And I'm gonna tell you what it is first and I'm gonna go through the background, then I'm gonna tell you again what the new recommendations are. So the first thing is, and this is taken directly from the new guidance. First thing is number one, get a good history and examination. Does it sound like asthma? If it doesn't sound like asthma, don't worry about doing the tests. If this is sounding like asthma, your test according to tonight would be blood eosinophil count, blood eosinophil count or phno level if those are positive. So the sil count is above the level, the lab reference range. So that's reasonably elevated. You'll still have some people with A to P that are less than outside that normal level. Often it's either 0.5 or 0.4 and the history and examination fit, you can make a diagnosis. They also talk about using FO and I think most people are looking at the evidence. Most people would suggest if you have fo that would be a better test because it's a slightly more specific and sensitive the and again, the level they've chosen for this to be sure at the time of diagnosis has been a level of 50 parts per billion that's relatively elevated. Um But that's our, that is the new recommendation on the BT S nice and signed guidance as to where to go across the UK. If the testing is negative, but you're still highly suspicious of asthma, then they recommend a reversibility airflow test. So that's spirometry with bronchodilation and they would expect about a 12%. Um and 200 MS or more difference when the, the patient is given a bronchodilator salbutamol, they also talk about if that isn't available. So you can't get spirometry, try to demonstrate some peak expiratory flow variation. Um And if I just say for that, it's peak expiratory flow rate, it's not just a flow rate. If someone just takes a big breath and blows out quickly, that's not peak flow. A peak flow is the biggest breath in. You possibly can and blowing out as fast as you possibly can three times hopefully within 5% reliably at the same level. A lot of the people that I see unfortunately, clinically, when I ask them to demonstrate their peak flow, it's an average big breath in and it's an average blow out that it doesn't have any reliability whatsoever. And if I ask somebody to do an average uh breath in and breathe out quickly over two weeks, that isn't going to be sensitive enough to pick up asthma, it has to be the peak flow. So useful tips to think through there. Finally, if that's not working, we need to be thinking about bronchial challenge testing. That's a test is certainly in the UK that is primarily done within the um specialist setting. But in certain codes in Europe, like for example, Germany, that that would be done out in the community as a as a standard test if the other tests were normal. So we're looking at those tests to be positive to give us that diagnosis. And if we're still unsure, that's often where we should be looking to get a specialist involved. So let's go back through that again. Make the diagnosis, blood is sinful or feno positive. You've got the answer. If not reversibility, spirometry, if that's not right, think about peak flow. But if not bronchial challenge test. The most important part on that though is the history and examination fits with asthma. So hopefully that's, that makes a bit of sense. How do they get to that, that situation that that decision as a guideline? Not just a group of people saying this is what we think is the best way forward. Well, they considered all the symptoms and their variability and likelihood and that's been done a few times and certainly clinical determined. Wheeze is one of the most specific findings that suggest an asthma diagnosis. But people who are wheezing with a cough, often symptoms worse at night, short of breath when they exert variability are the key things we should be looking for often with a family history too. Next stage on top of that is to think about. Ok. So if I do a test, how good would it be? And I've used this slide for a few years now. And I think I've looked at there's about 253 100 pages of background information on the new guide which I've looked through. I think this is probably still the easiest one to explain simply what this is, is a review of the total literature looking at people who've had bronchodilator reversibility done. These studies have been done in secondary care and the sensitivity either the test is positive. Have they really got asthma? The findings in the research trials were when the test was positive between 17 and 69% had asthma, the others didn't. And specificity is they had a normal result. Does that mean they really didn't have asthma? And as you can see from that, when they looked at that 55 to 81% with normal spirometry didn't have asthma, but a significant number did when there's only one number. So the peak flow rate there, that was only one study. But if you look at the, the peak flow where several studies were done as a diary, you find and that's because of that variability, people don't always do a peak flow when they're doing a diary that very low sensitivity. But uh you look at the far end of that people who do a peak flow for two weeks and it's flat, the likelihood is they don't have asthma. The last two are probably the ones that are the most interesting at the moment. That is the feno. And again, if your feno test is positive, then your likelihood of you having asthma with that positive test are considerably better than having positive spirometry and actually better than having a bloody Sinop count done as well. And if the test is entirely normal, again, looks to be better but only just better than bronchodilator reversibility. Finally, the bloody Sinop counter very easy for a lot of us certainly. And adults cos we've often done blood tests every time for other reasons, raised level makes it more likely to be asthma normal level helps to exclude it. But the ranges are still quite big on that. So that was part of the basic research. They did it got much more complex. They went through a series of strategies. What happens if I do bloody il first and then if it's negative, do a bronchodilator reversibility. And if that's negative to a me, the Coline bronchial reversibility challenge test and you can read through the different numbers on there, do a feno test, then do spirometry, then Mecholine et cetera, et cetera. And there's a couple of pages they looked at, they analyzed that in intense detail to see what was the likely benefits of doing each of those and came up with sensitivities and specificities for that diagnostic algorithm. Um And again, this is just to show that it's complex. This is about 300 pages of research, what they came up at the end with is probably very similar to that type. I've already shown you, which is let's concentrate on feno if we can. But if not think about eosinophils, that's a good parameter for eosinophilic inflammation. If that's normal, I'm still thinking about it. Go to bronchodilator and if that's not working peak flow rate variability or a bronchial challenge test in a more specialist environment. So there we go back to that single slide again a bit easier. Now, I think it's asthma. It sounds like asthma. I've got examination that's suspecting it. Let's do tests and let's start on treatment. Oh, I can see a question in the um chat line which sort of says about, do you do a trial of inhaled corticosteroids? Uh The answer to that is ideally not and I'm gonna be doing a session on the management of um asthma according to both Gina and the er British guidance, which is incredibly similar, which wouldn't recommend doing trials with either a Saba or an I CS on their own. But I, that's a, that's an event for another day. Quick update. For those of you who are not familiar with FENO testing is roughly about 7 to 10 lbs a test. The kit costs about 600 lbs. Um It, you have to breathe in slowly into it over about 7 to 10 seconds. You're incentivized to help a little person in a balloon, hang on and fly over a ravine or some other sort of stimulant, avoid crashing the car into a hedge at the side so that you keep your blowing accurately. And at the end of that, what it does is measure nitric oxide, nitric oxide is released when there is a significant inflammation in the airways. And although you can sit in the normal population and there's a normal range for both, um it tends to be higher in those with asthma. That's why we've put that into the guidance, why it's gone in there. Remember, it's also raised a bit in allergic rhinitis, it will go up if you've got a cough cold. Um Men who are tall, have bigger lung capacities than Children. So it will be up up a little bit but not a huge amount with that. And lots of dietary nitrates will produce more nitric acid being released in, in the airways. Things reducing it are things like um cigarette smoke, increased mucus in the lungs, caffeine will reduce it a bit and treating asthma. So if I think right, um I think this is asthma, I'll give them some inhaled corticosteroids and oral corticosteroids and get them tested in a week, 10 days. That test will be normal. So where are we with that? That's, that's your fractional exhaled nitric oxide test levels we're looking at are 50 in adults. And I also have in mind from this research, they did initially that about one in five people with a positive FENO test won't have asthma and about one in five with a negative test won't have asthma either. Uh W will have asthma but the test is negative. So it's not an absolute test. None of those on their own will help. Um So that's the, that's the plan of action is a bit different to what we're used to check. The eosinophil count check also for the um feno if you can, ideally, if those tests don't give you convincing support to your clinical diagnosis, do spirometry. And if that's not working, do um serial peak flows, if they can do a peak flow and make a decision from there, just going back to Hannah, put in the information that Hannah was uh did an arts degree. And I think whenever an adult comes in with a new diagnosis, really think about what they do both at work and in their leisure time, um oils often use uh turpentine like er irritants to dilute or, or um clean oil paint off canvases and other areas and dilute it down. Those can be very uh likely to trigger occupational asthma or a leisure asthma really cos it's part of the fun things that we do at times. So keep thinking about occupation, keep thinking about leisure because if we can pick up an occupational asthma early on and remove them from the trigger that's doing it, we can reverse the asthma process. It seems to become quiet. It, it doesn't keep going if we leave them a year or so often. Unfortunately, the asthma is persistent. So that's why we're, we're working on that. Um So, so that's the touch through on what's been recommended at the moment. Uh In the UK, people have been talking about having to do certain numbers of tests and that has been adapted if you look online, not quite clear whether it's been absolutely implemented, but the CF criteria changed on the day, the nice guidance came out because they've been planning that a need was required for that. So just check online with that and ask your local ICB if you've got any. You don't. I said that asthma is quite common in uh in this country. I've also said that the guidance covers you. I think it's asthma. It is asthma. What am I gonna do? It doesn't tell you what to do if it isn't asthma. And so I thought I'd just go through um six quick cases and then we'll have time for a chat. I'm gonna whizz through these. But these are common things that will present to us in primary care with often breathlessness, noisy breathing, um, cough. I don't think it's asthma, but it, or, and often these people, I've seen both in primary and specialist care being initiated with asthma treatment when they may not have asthma. Hopefully, the first one that's fairly commonly recognized is um deconditioning and obesity as a contributor or actually a cause of breathlessness on its own. Um, and a lot of people unfortunately get into a cycle where they say if I get breathless, it's not very nice. So I better avoid breathness, but I'm still gonna eat the same quantity and my weight goes up and that makes it even worse. And as I get deconditioned, it worsens again. Um, just so something you can apply in a clinical context. If you have a patient who's been lying at home for about a week, they lose about 12% of their muscle bulk in that week. And that's why when you think about it, very active sports, people who are put into bed rest after having a knee operation or something like that take months to get back because their muscles are getting weaker and it takes a long time to pull the muscles back, even if that's your job and you're a professional and you've gotta get back as quickly as you can really frightening. If someone's in the hospital for between three and five weeks, they often lose about 50% of their muscle strength. That's gonna take months to recover. That means when I try and walk it hurts, I can't get a decent distance. And when I'm trying to breathe, I'm gonna feel much more breathless than normal. It will get better if I keep at it. And I've just got to keep my reconditioning my rehabilitation going, but it can be one of those confusing things that patients hope you're going to be able to cure miraculously. Um, despite the rest, they've had quick reminder, if you remember things about, um, COVID, the patients who've been on intensive care, you may remember on the news being clapped out when they got out of the hospital, they were clapped out as they were pushed out in their wheelchair. They'd been on an intensive care unit for two or three weeks. They'd then been on a ward for two or three weeks. It was gonna probably take them at 18 months to get their muscle strength back, really hard work to get deconditioning back. But think about that in our patients who aren't doing a lot of exercise, weight's going up in, in asthma, more athletic people. My asthma's not getting better. I'm getting put on a higher and higher doses of treatment. Um, it's when I'm exercising, I need it. Um, I'm using lots and lots of blue inhaler quite a common story again. And one of the top TIPSS I learned from one of the national experts on this is if you can get the parent or the child or the person to get a video clip when it's happening, it doesn't have to be all the way round. But if they suddenly say I'll get breath halfway around, take a clip, then of what your breathing's like and we'll have a quick look at it cos that gives a lot of hints and perhaps a good example of that was um a young person who was winning regional sort of running competitions. Um then found out that she started to get more breathless when she was running around, went on for some specialist input, didn't get better, came to see me because they were getting a little bit desperate about the amount of uh treatment they were being given and things not improving. And the mother said, my daughter suddenly gets so breathless. I can hear her wheezing at the other side of the athletic track, what 80 100 m away, most of us who've done um emergency medicine will remember acute asthma. Um And you can't hear that 1015 yards away, let alone on the opposite side of the neck outside, um running running track. So that should immediately alert us to something else. And one of the commonest coexisting conditions or on its own conditions is exercise, inducible laryngeal obstruction. The lady there very nobly has an indirect laryngoscope going up her nose looking down onto the larynx. The image you can see at the back is the larynx. She's then put onto a treadmill and she's asked to run and as she runs the larynx, you can see on the video closes in, um showing this laryngeal obstruction secondary to muscle spasm in that area. The larynx when the muscles close in gives an audible noise that you'll hear from quite a distance away. It, it's usually inspiratory unlike the treat. Um, the asthma which tends to be um, prolonged expiratory. So, inspiratory rather than the prolonged expiratory. Few quick facts, facts about inducible laryngeal obstruction. It's transient, it's not dangerous. It settles when they stop can be triggered by exercise or inhaled irritants. It's as common in adolescents and young adults as asthma. It hasn't been studied with the prevalence in old groups, but it looks to be probably about the same prevalence When I've asked people who are adult, whether they think they get those sort of symptoms, it can mimic or it can actually be coexistent with asthma. It can be linked to the gastroesophageal reflux My literature review, which was from colleagues who published this suggests a variety of treatments. None of which have RCT level support. The two that I think most colleagues would be going for and the two that I'm I would certainly be going for would be speech and language therapist who has an interest in um upper, you know, laryngeal type problems or a, a physiotherapist. That would be a respiratory physio and they can often help with breathing patterns to settle that down. Three other quick cases, somebody who often comes in to and it's really bad. I can't get any air into my lungs. It makes it feel really tight. I get tingling around my lips. I feel dreadful with all this. I feel dizzy as well. My and you've got to do something for my asthma and again, breathing Pattern disorder is a very common condition. People used to call it dysfunctional breathing, but dysfunctional often makes people think about something you're doing bad you and, and breathing pattern disorder is not something doing something bad. It's something they learn to do. Um Breathing Pattern disorder quite commonly can't get the air in yawning a bit, get a bit, a little bit tight around the chest, um, feel dizzy if it's classic hyperventilation and getting that tingling around the lips and fingers again would be quite typical with bloating and the heart racing because things are, the respiratory rate has increased with it. A couple of quick things about breathing pattern disorder. It's common in women than men probably affects about one in 10 of us at different times. And it's a bit like driving a car. We've fallen into bad habits over time. Probably the simplest way to think of it is if I was in a car crash and hurt my ribs and they were fractured, I wouldn't take big breath in all the time. Cos that would hurt. So what I'll do is have some gentle breath in out and keep doing that for a while. 89 weeks later, when my ribs have healed, I get back to normal life, but I'm still used to cos I've been doing it for eight weeks breathing quite shallowly. And if you ask me then to exert myself, I will find that I get breathless because I'm only taking small breaths in and out. It's not me planning to do that. It's something I've learned to do to avoid the pain and that's why, um, I need a little bit of retraining to get me back into the, into good habits. Again, not deliberate, can happen in asthma after attacks when things haven't been good after pneumonias, cardiac problems, um, anxiety, depression, I think we see typical hyperventilation but you can see a variety of conditions there. Pain again, I don't want to take big breaths in because it's gonna make my pain worse. A lot of people being susceptible to an unconscious development of a breathing pattern disorder which physios can help with just to reinforce the point if you look up a CPS, uh see that's an association of respiratory physios, they will show you a variety of these um ventilation patterns um and some of the ways to manage that. But often if you can, I think just referring straight to them is a, a much better um impact in primary care. Cos we don't have that resource to take the time that they need. Quick reminder about the blue inhaler. And it's not uncommon to have people coming in with worsening asthma because they're using lots of their blue inhaler. Um And this is a reminder that back in the 19 nineties, there had been lots of trials of regular use of a short acting beta agonist, Terbutaline or Ventolin. Um Me salbutamol. And what was found in most of those trials is that most people developed bronchial hyperresponsiveness. That means if I give 100 of us salbutamol and say, use it three times a week, um at least twice on the days you use it. And then I'm gonna measure your lung function in a month's time. Probably three quarters of us will have hyper responsiveness will get twitchy airways such that when we go outside and it's cold, we get wheezy. When we try and run, we get wheezy. If we're involved in smoking environments, we feel wheezy as well. In fact, all the symptoms that we would get from asthma caused by a short acting beta agonist. Probably one of those things we've really got to be aware of as we go through because the tendency is to give people more and more short acting be agist. And if that's not working and we started them on that, we clearly need to give them asthma treatment because their symptoms are so bad. Be wary of bronchial hyperresponsiveness. This is just a study showing that if you give somebody um who's been sensitized to altol salbutamol and compare that against a placebo. When you give it to people, you, their uh respiratory function is actually worse with their salbutamol soon after taking this salbutamol than with a placebo for the same exposure to a trigger. That's quite frightening and something that we probably need to be aware of. And that's one of the reasons why this bronchial hyperresponsiveness has triggered a lot of change in the management to move away from initiating on a short acting P list. If you stop the short acting beta agonist, good explanation and they haven't got asthma and they don't need anything else. Usually settles within a week, two weeks. If they do have asthma and you give them proper asthma treatment and talk about reducing the saber, they'll often get better in about a month or so, but often good improvement within 2 to 3 weeks. So we can make decisions on that. But that's tricky because you're ending up trying to manage somebody who's potentially been made worse by their sabba potentially being made worse because of undertreated asthma, practical treatment for that. Another case just to think through quickly and again, one that if you don't get the history right, doesn't make sense. Um, somebody who does a lot of exercise and says it's really strange. I get wheezy when I'm, when I'm excited, but only at the end, never during, if I'm doing half marathon, I'll get it at the end if I'm doing a marathon. If I'm doing 10-K, 5 K, never during it. It's always at the end, it usually happens about 10 to 15 minutes afterwards and might last 10 to 15 minutes. Again, that's a fairly typical story. Although they sometimes say I get wheezy when I've been exercising the story of post exertion or exercise induced broncho constriction should make you think differently. Exercise induced broncho constriction can occur in asthma. You should control the asthma, but they'd have the symptoms during their exercise as well with that. Not just after, if they get this Trent narrowing after again, most people are absolutely fine. They recognize it. They've got to be going at a fair lake. So, if I put this up here, it's usually when they're using about 85% of their maximal ventilatory capacity, they're pushing themselves hard. It's not gonna happen. If I'm going for a gentle walk, it will last for what, 55, 10 minutes or something like that afterwards, it usually occurs quite quickly afterwards. You'll see quite a few athletes get this after they've done their event um at the Olympics and, and those sort of athletic competitions affects quite a lot of us one in five, if we're pushing ourselves to that extent. Um And again, most of these people know what it is or have realized it doesn't need any treatment. Many don't respond to short acting beta agonists. There's a little bit of evidence about using a combination inhaler for mole and I CS pre exertion to help. But that's only one study and I would probably be trying to get the story right. And then encouraging them just to allow it to settle mentally. They don't need treatment. So, wow, we've done a few different. I put some on there for some reason that's a bit mad. Um We've been through five other cases and we went through how to begin with. We've covered some really quite stretching new suggestions for making that diagnosis based on that eosinophilic inflammation. So, looking for positive blood eosinophil counts or looking for ideally, if we can a positive fractional exhaled nitric oxide, quick, easy test, primary care based in many parts of the country. Certainly, in my part, I think every practice has easy access within um a couple of days to that sort of testing. I do it in the practice and I can whizz out, pick up the machine, turn it on by the time I get back to my room and it's only what 1015 yards, uh the machine is ready to go. They explain what to do for the patient. Have an answer within about a minute and a half, two minutes, much faster than point of care testing. So definition of, as we talked about variability, symptoms changes over time due to this variable inflammation. We've talked about making a good initial diagnosis and acknowledge that it can be uncertain and difficult. And we've talked about some of the recommendations that are really based on very solid evidence compared to what we've been used to and then just gone through some of those tricky ones that are gonna fall outside the guidance. So, thank you very much for listening. Hopefully, that's helped quite a bit and I'm very happy to answer any questions that are out there. Doctor Holmes. That was fantastic. Very engaging. Once again, I love your talk because I learned something new every single time, something that I never actually picked up on before. And one of the things I actually did myself um in the interest of, of, uh, I always like to give the interest of full disclosure. I met Doctor Holmes at the R CGP conference lately just back in October and I did the FO for myself. Thankfully, it showed that I didn't have, uh have any abnormality there except for this head cold that I have at the minute. Um There were a couple of questions came through not too many this evening, but folks, we do have a little bit of time. So if there's any pressing questions, please do pop them into the chat. Um MPA has asked about in terms of diagnosis, how many episodes of wheeze. So that patient that's coming back maybe two or three times and you've maybe sort of thought. Oh, well, they've had a bit of a headquarter, a bit of a viral induced wheeze. How many times would they need to come back before you would jump into saying, could it be ok. So I think probably the first thing is, um, what do I mean by wheeze? Has it, have I listened to it? And I can hear the wheeze or is it mum said that they were wheezy last time and no one bothered to listen in or they were, were seen by an emergency service that didn't examine or record any examination and said they were very wheezy if it's a definite wheeze probably pragmatically. And I'm thinking this off the top of my head. I'm thinking number one under fives quite common. Most of those will settle down preschool, wheezing different type of issue. Younger person, more likely to be asthma occasionally can be triggered by just an infection. And if it's a worn off and they never come back again, that's fine. But if this is part of a recurring pattern with other symptoms of variability, cough breath when I cough at night, when I go upstairs and I get breathless as well and I get wheezy sometimes at night. That's making me more and more think about asthma. Merge on a little bit wheezing while I'm taking lots of crack cocaine and heroin. And other things is making me think this might not be just asthma. This might be an early onset of CO PD or something like that. The older person with Wheeze um David Price GP used to be a GP in Norwich. Um showing that most people present 6 to 8 times with a wheezy bronchitis before the diagnosis is made. So again, far, too long, I think we should be thinking about wheeze every time we hear it. What does that mean? And just to keep us all thinking clinically, if I hear a monophonic wheeze in any area or that person that has been a smoker for many years. I'm thinking a lesion in it's monophonic just or in and out. I'm thinking a lesion in the airways. Is this a lung cancer? So, um, how many episodes of we should be clear in an asthma diagnosis? It depends on the history, it depends on their age, it depends on our examination findings and it depends on things like smoking and other other things they're using. Fantastic. Fantastic. Thank you. Very comprehensive. Um Louise had asked about the patient that's maybe unable to perform spirometry accurately. Um Are they likely to be able to, you know, comply or work with the bronchial challenge test? Now of often, if, if they're not gonna be able to do um a test where we're just asking them to do a maximum breath out first and then repeat that after bronchodilators. If we're gonna do that several times with increasing concentrations of a chemical that might trigger wheezing. Um It's less likely to give us definitive answers on the spirometry. There are a number of techniques that people are starting to use in the specialist environment though. Um P um OS oscillometry, very fine breast and trying to measure the impact of those that, that has shown quite a bit of interest at the moment. There are other ways of assessing if you, if I trigger somebody who I listen to and hasn't got a wheeze at all. And then they suddenly say, I feel fine. And then when I've given them that, that challenge test and they say I'm incredibly wheezy, I can hear the wheeze that peak flow may have been dropped down. That's an easier test to do pragmatically. That may be a way to make a diagnosis. So yes, is the answer. They can't do spiry, they can't do a genuine high quality bronchial challenge test. But there may be ways around that understood. Understood. Um Carla has asked about um the ailia if that is a potential diagnostic marker, where does that fit with cough and where does that fit with, with, with that process? Um Yeah. Good, good question. Um The if it's, if they've got symptoms and features, so wheeze as well making me even more strongly thinking it is that and I can't think of another reason why they've got a higher Sinop count and all the picture fits together then nice is suggesting and BT S and sign that that is robust enough to make a good diagnosis. Ideally, I'd want to do fo um people used to say you've got to do spirometry within a certain amount of time before or after the diagnosis has been made on the day that the new guidance came out, the indi indicators were changed by nice, what I haven't been able to find out and can't see it easily written is whether they've actually said and I don't think they've sent that out to the practice. It has changed. I'm waiting for an email back from a colleague who sits on the QOF indicator group and does the determinations behind that to see if they're aware, but it's likely that the guidance would have changed and they'll be searching for a eosinophil count in the patient records or a fo level if it's recorded. Thank you. Thank you. I'm going to make a little clarification point because I'm aware our audience comes from right across right across the world. Q stands for quality and outcomes framework. And it's a process by which um general practitioners or primary care physicians here in the UK, get reimbursed for various different paths of chronic disease management, things like diabetes, reviews, asthma, reviews and things in that kind of field. So just a wee clarification point on that um Greg has asked about phenol machines. Is there anything you can recommend from your point of view on a reliable um phenol machine? Um OK. The answer to that is there's several machines that are around, some of them have pros, some of them have, you know, there's no, nothing is ever perfect. But what I would be doing is uh if you go to the accelerated access, a collaboration for NHS England on Feno, you'll find a breakdown of the different types and their costings and evaluations there that's quite useful to do. Um You normally your um local health board ICB Integrated care Board, whatever it is, your local system organizer will have a good idea of what's good value and quite often your specialists will, although they, and and again, it all depends on the funding. So like the quality outcome framework, there are the quality outcomes framework in primary care is like a lot of the bundles that come in in secondary care. They're designed to try to trigger clinicians to do certain things to get better outcomes. Uh A and that's quite common in many parts of the world in, in their uh in their funding of systems. But yeah, go to your local guys. They should be able to tell you same for spirometry. Exactly the same for spirometry. There's lots of good bits of kit out there. Some of the important parts are c the spirometry is I want a spirometer that will download all the numbers and data reliably into my computer system and code them. I don't want to do that myself. I think many of my specialist colleagues would be saying and I would love something like that too. And the number of letters where they get muddled up in translation or by dictation or whatever it is and get to me as numbers that don't make any sense at all and couldn't be interpreted. Demonstrates we probably need automatic systems that are suitable for our it system to do that. Yeah, absolutely. Streamline the process, um take the, take the error out of it. Absolutely. Um Carla has asked about in the case where we don't have that access to feno testing. Is it best to refer someone for spirometry? Is that the same with adults and Children or would there be different thoughts there? Ok. So it's slightly different for Children, for adults, eosinophil count or pheno test one. Ideally, pheno if not eosinophil, if those aren't positive test two is spirometry with reversibility. If that's not working, think about peak flow, they can do it if not bronchial challenge, test specialist referral. So I think the answer to that is if you don't have to look at a near sin full count or if you need to do a blood count, got you very, very straightforward. Uh Adam has asked about um do we start a patient on a, on a leukotriene receptor at times whilst tapering the saba and airway hyperresponsiveness? Um Not that I'm aware of. I haven't seen any evidence for that. Um What we do know now is the leukotriene receptor antagonist are not particularly advocated for viral associated wheeze, which we did use for quite a long time. Big systematic trial showed not good in young Children. And again, if they've got asthma, the fundamental treatment for asthma is an inhaled corticosteroid. Um So I would be sticking to those. There is a small subpopulation that respond very well to leukotriene receptors, but I would be normally working with the patient just to reduce their saber in their own way. Their hypersensitivity doesn't last long if they know it's only short lasting, they work their way through it. Keep on the same treatment. Perfect. Um And last two quick fire questions which I think are just little um clarification points. Um Rhea has just queried about discussed earlier in the pathway that was shown the bronchial hyperresponsiveness. Could it or could it not be identified by a bronchial challenge test? Right. So the, the hyper responsiveness can be demonstrated on bronchial challenge testing if you want to do that. And that's where quite a lot of the research was done for salbutamol, which is why it's not the easiest trial to reproduce. So if I say use salbutamol, then I wanna see if you've got bronchial hyperresponsiveness, I'll do that with a Bronchial challenge test. And that's why I'll show lots of people that twitchy, but it will also fit in with the symptoms. They tell me about um at the moment in primary care, that's not a routine test that's available. Absolutely. And the last one, hopefully a very straightforward, uh just quick question from Pluto was about the cut off point for uh using the eosinophil level, right. Yeah. And again, that's one of the debated questions. And that was one, I think they had quite a lot of debate about within the uh the nice guideline guideline group. What they came up with at the end was higher than the lab's reference range. So if your rep reference range in the lab is 0.4 that's the number, if it's 0.5 or 500 or 400 that's the number you go for things to think about with that is these are guidelines to use. When we're assessing a patient, they're not trend lines that we have to adhere to. First thing. Second thing with that is Sinop counters. Remember when we're thinking about CO PD, we're thinking about different levels of inflammation and whether they might benefit from an inhaled corticosteroid on top of their bronchodilation, different argument, often the levels are lower and what we're trying to do with asthma is say this person's come in. I've got really good evidence from the symptoms that it's like to be asthma. I've also got this eosinophil count that is telling me high eosinophilic inflammation in the body. That's asthma. If I've got fur as well even better. I've got the, I've got a really strong evidence base to say that's why I'm making the diagnosis. My trial of treatment will also help if that doesn't work. I'll come back but II can make the diagnosis on the basis of high eosinophil uh or ideally high feno count. Fantastic. Fantastic, Steve. Uh Thank you so much for that. Um Folks, I think that's us for this evening. I'm not seeing any other questions coming in the chat at the moment for anyone who joined on a little bit late. Um catch up content will be available pretty soon after tonight's talk. We'll try and get that up as soon as we possibly can. I'm going to put the feedback form into the chat. Now, as I've said before, please take a moment to complete this um, both feedback for the speaker, which is really important because they use that in their future talks. But also an idea for us on what you want to see coming up in the middle primary care network program for 2025. Um, we have one more event left this year. It is on the 17th of December. So next week um with er, Doctor Rosalind Buckland and Dr Zoe Scab in our Psychiatry series. We're going to be looking at depression covered anxiety the last time and it's now available as catch up content. I'm going to say a massive thanks to Steve again. We look forward to seeing you back in the New Year. Um Have a lovely Christmas, have a lovely time off. Uh And folks we will see you at the next event. Have a good rest of the evening. Have a good week. Ok.