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Good evening, perhaps. Good morning, perhaps. Good afternoon. Wherever you're at, er, in the world today. I know a lot of us are joining from, er, the UK. We are really excited about this event this evening. Um, it's, er, part of our primary care update series on asthma and we're really honored to have Doctor Steven Holmes, er, joining us and we're gonna be talking about how to make a good diagnosis um, of, er, asthma. Er, Doctor Holmes has been an active clinical GP for more than 30 years uh with a respiratory interest over that time and he's been chair of the Primary Care Respiratory Society, is on the British Thoracic Society Council and Research and Science Committee nationally and is involved with the International Primary Care Respiratory Group on their education committee. So we couldn't have someone better talking to us this evening. Um, about how to make a good diagnosis in asthma. We're gonna have some time at the end for questions. So please pop them into uh the chat on the right hand side. We will have a little bit of time to do that. So we'll field some questions. That's a really great opportunity to, to ask them. I've also popped a couple of links into the chat and we're really excited at Metal to have launched our mobile app on Android. And for Apple, it means that you can follow Metal primary care or other organizations on Metal and it means you'll never miss one of these events again. So if you are interested in open access, CPD me, it's a really great way to stay in the loop. So you've got both the links, it's completely free, you can download them and get a notification if another event is added or if the on demand content from this event is added as well. There's also an opportunity um in in the app in the middle primary care community to actually ask some questions as well. So if there are questions, we don't get to answer this evening, um you can actually pop some questions in the middle primary care community and you're part of a community. So we're here and we'll try to get you some answers if um if you have questions afterwards. So without further ado, I'm gonna hand over to er Doctor Holmes and we're gonna talk through asthma making a good diagnosis. Thank you, Phil. Thank you so much. Uh real privileged to be here and uh real privileged to be talking to medical primary care and all you guys who hopefully um are primarily out in primary care, doing the job. And I think the first thing I ought to say is that it's challenging, making a good diagnosis in asthma. Um It's challenging both in primary and secondary care and one of the most quoted studies is a Canadian study uh that was uh published by Sammy Souza about 12 years ago now, which showed that around about a third of the diagnoses made of asthma were incorrect when you broke that down to primary care. A third of the diagnoses were incorrect. And when you looked at our specialist colleagues, a third of the diagnoses were incorrect. So first little tip from this is if it doesn't sound like asthma, when you're seeing a, a patient in front of you, please think again now that was Canadian research. But I would think certainly looking at some of the British data and European data that is pretty much uh a, a phenomena that's occurring across the globe. So, what I'm gonna do try and do today is just talk a little bit about the definition of asthma, some principles on making that good initial diagnosis. And then I'm gonna dive a little bit into the complex world of people who are coming in with asthma and breathlessness and you're not quite sure, is it asthma or is it something else? And hopefully with that, we'll, we'll have some interesting discussions. Quick, little bits of information about me. Yes, I'm a GP, I've got a respiratory interest. I do quite a bit of medical education. I've been involved with the Royal College of General Practitioners. Quite a lot of guidelines. I've also involved in quite a lot of academic work that's ongoing at the moment, work with a variety of people to try to promote good quality respiratory care both in the UK and elsewhere. And I have spoken for pharmaceutical and device companies, although these are primarily with my own slides rather than anything that they're producing for me. Let kick straight in Hannah, a 30 year old works as a teacher. A fairly typical sort of situation coming in. Um, local infant school cough for a few weeks or months. Er, more breathless, wakes her a couple of times a week thinks it's affecting her exercise, remembers a nasty infection a few months ago and happens to mention that her sister also had asthma. Now this is not a real person, this is a fictitious patient, but it sort of combines a lot of the commoner things that are coming in if they're not presenting acutely and probably what's worthwhile thinking through there is what else do I want to know about Hannah? That's gonna help me make that diagnosis and some of those things will be about smoking, some of those things will be about what sort of job she does. Her weight is important as we'll find out later on. And one of the things that's often worthwhile doing in the notes is to try and see if you can just see if anybody has actually heard a wheeze, not a reported wheeze, but this is a clinically auscultated wheeze with a stethoscope because that's one of the main areas w which help to support a diagnosis. Other useful little tips. I'll just have a quick look at the eosinophil count and um Hanna are in that sort of borderline. Now, a lot of areas talk about a raised eosinophil count as being 0.4 or 0.5 that is in a global population. A lot of people say that a level of 0.3 or greater is more likely in the atopic individuals that we see. So let's move on and see what sort of things we can be thinking about when Hannah comes in because that's not gonna be an uncommon presentation within a primary care setting. And I guess the first thing is to, to just think through asthma as it's d defined by the global um strategy on asthma is a sort of group of diseases that are usually characterized by chronic airflow limitation, symptoms, short of breath, often worse at night, often with a cough, often with a wheeze, clinically determined, not reported. Um often with that sensation of slight tightness and one of the most important symptoms, it's variable, it's not the same severity all the time, every day, day in day out. And that's fairly typical and people can present after a week or several months without sort of thinking. But I've got to come in straight away, not all asthma that presents is like you see, in the A&E department, it can often be this grumbling symptoms and it's also more likely to show itself if the person is trying to push themselves harder. So I'm, I'm trying to play football, but I can't manage it. Now, I'm trying to do a five K run or something like that. So, what sort of things do we need to be thinking about with a diagnosis? Ideally, the first thing is it is based on that history, a good history is very important. And if I'm, if I'm making a diagnosis, I normally summarize the key points. I've picked out from the history as part of that diagnostic short paragraph that will say why I've made the diagnosis, then ideally, we should test before treating. That's both in the Gena guidelines and in the British National Institute for Clinical Excellence Guidelines. Um What we're looking for there is the variability in lung function and probably at a global level, the best treatment if we have an opportunity is spirometry before and then after a bronchodilator, the other sorts of options on that are, if we don't have full spirometry, might be to think about peak flow readings, it might be to think about looking at the eosinophil counts. It's certainly to look at the symptoms. Some, sometimes we force down the path of a trial of treatment, but let's just dive into that a little bit more and work out what the national guidelines say at the moment. Remember, guidelines are very carefully produced. Well in Britain, two guidelines, one made from the British Thoracic Society, the Specialist Group and the Scottish Intercollegiate Guideline Network really carefully produced, have produced evidence as to how do you make the diagnosis of asthma? At the same time? About four or five years ago, the National Institute for Clinical Excellence, the English guideline set produced some guidance as well. Interestingly, they both had the same review of the literature and they both quote that very carefully. Although they, they, they at the time came to quite different views as to how you should make the diagnosis. So really interesting, same evidence, different conclusions and I'll talk that through a little bit. But the first thing to note on this is that if somebody comes to me and says, oh, they've got quite a change on their peak flow or their feno is raised or their eosinophil count is raised or I've done some spirometry and it looks as though it's reversed. The first thing is that on its own w should not make the diagnosis. The diagnosis is the history, hopefully, ex examination findings as well as well as other tests supporting the diagnosis. Second thing to remember is the patient who comes in with asthma suspected her spirometry completely normal. That doesn't exclude the diagnosis either. So if you look through that little list there, bronchodilator reversibility in secondary care, 50 to 80% of people have normal tests despite the fact that they have asthma. So it's really a question of thinking through really carefully. Have I got this right? What can be useful is peak flow meter readings done twice a day at home over a two or three week period. And if that level is completely flat, that would suggest the patient doesn't have asthma. But the rest of them really use clinical context with it. There's a, a line in there that's perhaps not too familiar to a lot of us that might be the fractional exhaled nitric oxide or pheno test. And let's just talk that through a little bit. Now, fairly simple test. There are more different types of device available. Uh There's a couple that are commonly used in the UK. This is one of them, one of the important things about the test is it's a slow expiration over about 6 to 10 seconds, six in Children, slightly longer in adults where the person is just blowing consistently out. So it's not like a forced measure that we're trying to get in in spirometry. It's not the biggest breath you can and blow it out as fast as you can. What we're trying to measure in this exhalation is the amount of nitric oxide, which is common in people who have um allergic airways, eosinophilic inflammation in the airways. And a lot of people in that sort of scenario will have a positive test when they have their feno results done. And that's usually about four and five. Now, a few things that are worthwhile just thinking through, you can imagine someone breathing out, the pheno level is higher in people who've also got allergic rhinitis in their nose. So, if they had asthma, we'd expect it in the airways, allergic asthma. Yes. In asthma, we'd also expect it if they had it in their, um, upper airways. It is. It does go up quite a bit in people who've got a cold. So you shouldn't do it if someone's ill, but we shouldn't be doing lung function testing when somebody, somebody is ill with coughs, colds and that sort of thing. Last thing to remember is it's raised brackets a little bit by a big lung capacity. So men have a larger lung capacity than women by and large, taller people have a larger lung capacity than smaller people. And people who lot eat, a lot of vegetables will have a higher level. So big tall vege vegetarian men are probably gonna have a higher level than some others, but only by about 20 to 25% important. Look at the d the phenol level being decreased, smaller lung capacity will make about adults, 40 Children, 35 Children have a slightly lower feno level, but it's not a huge amount cigarette smokers because the cigarette smoke inhibits the amount of inflammation that's coming out of the airways and the nitric oxide on that will have a lower level, caffeine and alcohol are well reported. But hopefully most of our patients aren't coming in having been to the local pub. They should have been advised not to use caffeine before their outpatient appointment or clinic appointment. And then the final one, probably the most important one for us to remember as clinicians is if they've had inhaled or oral corticosteroids, the level is often coming down and may well be normal. So if we treat asthma, we'd get rid of eosinophilic inflammation in the airways and the test becomes normal. Why is that important? If I see someone tomorrow and say, well, come and see my nurse in a couple of weeks, um I'll give you some inhaled corticosteroids or a course of oral steroids. By the time they come in, they get their feno checked, it will be normal. It doesn't help me. So I've got to make decisions as to whether I'm gonna get the test done quickly or whether I'm going to manage that patient more clinically. Um A couple of other things that are worthwhile. Remembering for those of you who might be getting phenone machines in the practice at the moment. One in five people with a positive test don't have asthma. There are other reasons often allergic rhinitis and one in five people with a negative test will have asthma. So it doesn't help all and not all asthma is eosinophilic, but it will help a lot of the time in, in getting things right. So new, quick test, about a third of practices in England and Scotland have this at the moment, but it is, it's quite patchy. So some areas it's all the way round in others. It's not quite so prevalent. Um Most of our um secondary care adult teams have them. And increasingly the pediatric teams have these as well. Although that can still be a little bit patchy across the UK right there. There was always a debate in, in Britain about which guidance we should use. And in England and one of the things that came out was straight after nice produced their guidance. The two chairs of nice said, we want to tell you what to do. Don't follow our guidance, follow the BT S and sign guidance because you won't have this sort of testing available easily and to do that, it's gotta be timely, it's gotta be quick. That advice is that was published in the B MJ about a month after they'd done this testing. Uh Sorry, after they published the guidance. Now go along with that. What's happening is now we are getting to situations where people can get their spirometry and a feno test done within a week. And we're getting to an opportunity of making a very robust diagnosis in quite a few areas of the country. But if you don't have that do what the BT S sign talked about and I'll, I'll just talk through that in a little bit more detail in a second. But nice were really clear and I think we should be, you've got to use what's around, what is important is probably around the end of May. The, the pre draft is just going round in the next few days or so. But the draft consultation will be formally made available at the end of May and new guidance is expected at the end of October, which will combine the English National Institute for Clinical Excellence, the British Thoracic Society and the Scottish Inter cate guideline network information altogether. And it's like it's likely to be a mixture of what we're seeing at the moment. I don't have inside information. I wouldn't be able to tell you if I did. This is the old nice one looks quite complex. It's an algorithm. You do a test, you see what you, what the result is, then you do the next test depending on what it says. And that quite a few people have been familiar with the asthma BT S sign guidelines are probably a little bit more pragmatic, but they equally look a bit confused when you put a big page up. Basically what the BT S signs suggest is red column. If it's not asthma, look for something else, don't treat it as asthma. That's easy. Move that one out of the way high probability. So that is somebody who's got wheeze, I can hear it when they come in. They've got a low peak flow. Um, they've got all the symptoms and variability, nocturnal cough. It's affecting them when they run for that. I would normally code a suspected asthma. I would initiate treatment sometimes using a peak flow meter to take home so they can keep monitoring that over time. If I get the opportunity I could do lung function in the practice and then do it when they come back. And I'd want to try and do something like um an asthma control test, a objective test that the patient can answer twice to say whether they're feeling better when they come back. What that's gonna mean is the patient comes in? We do some basic tests, we then initiate treatment under that code of suspected asthma. They come back and say, I feel marvelous. You see their peak flow has gone up 203 100. Um You recognize that they've probably have got asthma. You make the diagnosis, you then give them the advice on maintenance treatment, perhaps give them their reliever therapy and uh think about ongoing reviews and management and personalized asthma action plans. So, fairly straightforward initiation of treatment is an inhaled corticosteroid that is treatment for asthma, not the emergency reliever of salbutamol. And that's been in the guidance since over the last five or six years in both Gina and VT S sign and nice if you're uncertain after your, you thought it was high probability but it isn't or it's not quite clear, that's where you might be pushing yourself more down the road of looking at tests to see whether you've got proof of asthma. So this is much more like the nice uh than nice guidance. And so what you're thinking about there is, can I show evidence of change in the, in the lung function? So that would be um reversibility, spirometry, a peak flow chart or sometimes certainly within the hospital setting. Only a couple of Europe er, places in Europe do challenge testing in primary care but testing a can I show reversibility when I give them salbutamol, can I show variability with the peak flow chart or can I challenge them with chemicals that will often induce wheezing to see whether that, that will show evidence of, of asthma. There, the other side might be to look for evidence of eosinophilic inflammation. And so that would be your female or blood eosinophil count occasionally skin prick testing, but that's really not too specific for asthma on its own, but more for allergic type airways and then you're making a more informed decision when you start treatment. So that's what we're probably, most of us are pretty much familiar with and that's, that's nice if it, if the patient comes in untreated and never had it before, um perhaps like um the, the case we were talking about at the beginning, but I think one of the other things to think through is it's really complex because a lot of these patients are straightforward and just to put an example in, if you remember, um we've got a school teacher who's working at a local infant school, did arts degree at university. One of the things that can often happen is in certain people with artists or hobbies is certain things can irritate airways and turpentine is well recognized at triggering airway hyperresponsiveness in quite a few people. Um Some people will even get it with some of the newer alternatives. Uh Although they are thought to be safer, key thing on that occupation and hobbies, let's have a quick look at some of the, the main triggers people who had asthma when they were young and then it, it's gone away for 10 years now. It's come back or people who develop asthma um over the age of 20 or so. So adult onset asthma think about what job they're doing really carefully and what hobbies they've got the job is really important because if it is an exposure to an allergen at work, a their work should be trying to help to prevent exposure. B it has long term implications. If we can remove them from the allergen, then often their asthma will settle down. But if not their asthma way may well persist longer term. We mentioned that art degree and painting and some of the cleansers we use there, painters and other work are gonna catch this, think about some of the cleaners that are going round in our clinical environments. Um and the sort of chemicals they're using very high for this. Actually, nurses, doctors, dental workers, lab technicians, some of the cleansing agents we're using there make people quite prone. As do people working with animals, farm industry, uh food industry and out in the forest and wood. So a huge variety of people think carefully if in doubt, refer for specialist, um, specialist assessment elsewhere. So that's your, your fairly straight forward person if the person isn't quite as straightforward. So someone like Amy here working as a solicitor diagnosed somewhere else, I'll put further south, but it could equally be further north. Um uses a lot of her blue inhaler and um, advised a few times to use the brown one but seems to only pick it up a couple of times a year. Um, comes back, comes in to see you and says I'm not doing very well with my asthma. What are you gonna do about it again? What other questions do we want to know? We do want to know about smoking, we want to know about weight, we want to know about her, her lifestyle, exercise a variety of things like that. And probably one of the key things that I do if I can get the opportunity is look to see how many blue inhalers they've had and how many brown or preventer inhalers. So blue would be a salbutamol or terbutaline. The brown wouldn't be any of the inhaled corticosteroids or sometimes a combination and be wary of the person who picks up a brown prescription every year at their annual nurse review and then doesn't get one for the next year, but has plenty of the blue. They're not taking any preventer, any proper treatment for their asthma. So, what are we gonna do in this sort of scenario? And that's where it gets much more challenging. If you want to go into a lot more detail. There's nice information in the global strategy, the Gena guidance and that talks about um a number of parameters. Let's quickly talk them through, but I'm not gonna spend a lot of time on this. I'm gonna move on to other areas with that. Uh Number one, they've got lots of respiratory symptoms and they've got variable out airflow obstruction. So I've tested them. They've got, they've, they've got on an obstructive lung picture that gets better when you give them some salbutamol that sounding like asthma treat them, get it better if they've got variable respiratory symptoms, but no evidence of airflow obstruction, despite the treatment they're that they're taking, we're now in a situation of saying, well, if they've got symptoms, but no evidence of airflow limitation, is it really asthma that are causing the s their symptoms or is it something else? Perhaps we need to be thinking about where we move with that and to do that, you might want to start thinking about reducing down um their use of a saber. You might want to think about reducing the inhaled corticosteroid rate in discussion with the patient to see whether that starts to demonstrate that there is more uh airflow limitation as it goes on really hard in a busy environment at the moment. But one of those things, if somebody's being challenged about, do they have asthma or not, do they want to go on this treatment for the next 1015 years? Um Next category, not a great number of symptoms, normal lung function, no evidence of airflow limitation. Those are people where you can, you're thinking, OK, I can safely see if we can reduce their asthma treatment down and see how it goes. And the final one on this persistent breathless, persistent airflow limitation with thinking fixed airways disease or asthma uh with a fixed airway component. So that would fit in with your asthma COPD overlap that Gina and Gold used to talk about but have recently said no longer exists. Hopefully, that's given you a rough idea of, of the outline that the specialist teams are talking about. What I was gonna do now is just spend about 15 minutes diving in a bit deeper into exertional breathlessness. So the people are coming in saying I'm getting, you know, whenever I do anything, I'm getting breathless and I've done a list of causes of breathlessness. But the ones I've put into bold are deconditioning, obesity, cer induced bronchial hyperresponsiveness, asthma, excise, induced bronchoconstriction and excise, induced for laryngeal obstruction are really important areas to think about because these are the sort of people where the diagnosis can get very challenging. Now, exertional breathlessness and asthma will have all the other symptoms as well. They'll have nocturnal symptoms. Often they'll have, often have a cough, they'll often be wheezing and they can uh move things forward with that. I've just noticed one question that says, can you explain why A CS is said to no longer exist? My very brief information on that would be um number one, gold and GNA invented it in 2015. They then said eight months later, we shouldn't call it A CS cos it's not a syndrome. It's two conditions that are overlapping asthma and CO PD uh by the end of 2015 and then by 2019, they had said we don't believe in asthma co PD overlap anymore. You treat asthma with an inhaled corticosteroid and the proper prevent treatment for asthma. And you treat CO PD with bronchodilation, they might overlap but make sure you treat both. So, II can't explain why it was invented or and then un invented by two specialist guide um guidance groups. But, but that's where we've got to the mess slightly that we're in at the moment. Asthma needs an inhaled corticosteroid. CO PD needs bronchodilation, possibly with an inhaled corticosteroid as well. So, let's dive into these other exertional causes if it's asthma and they're worse than the exertion, but they've got nocturnal cough, they've got all the other things that we're talking about, then we're into a situation where we can treat it as asthma and manage that properly. If the patient is deconditioned, they will be breathless when the eggs are a bit like me. If I'm really trying to sprint very hard, but there won't be a change in their peak flow, there won't be a wheeze, there won't be any of the other features of asthma unless they're just exerting. And quite often they will have not been doing the amount of exertion they're used to. And those people bracket a lot since lockdown where people were told to stay home, stay safe. So avoid, um, putting extra pressure on health services. They got a much less fit than they were if you're fairly fit at the moment and think, well, I could go out and walk four or five miles, um, or run four or five miles and then you didn't do anything for four months. You might find it harder when you went back to doing that again. And exactly the same here. We need to treat that by gradually increased activity. I'm gonna touch a little bit more on exercise, induced bronchoconstriction and exercise induced laryngeal obstruction in a second as I will with the um overuse of Saber cos they're slightly specific, but the deconditioning group is often associated with a larger body mass index. Um The larger body mass index does actually fit in with women with who are having more problems with asthma in a in a lot of the literature. Good article in asthma UK on why do women have worse asthma published in 2022. Um Useful thing for us in England to think through is how fit are we compared to the rest of the UK. So this fits in with the deconditioning. And if I was to ask you to just think through of these countries USA France, Netherlands, Germany, Australia, Finland, could you write down and England in this as well, who are the most fit? Who, who's gonna do 100 and 50 minutes of moderate to strenuous exercise a week might put you down in your top three, bottom three. But here are the figures. Um USA 40% Australia better Finland about the same as Australia France a bit better than Finland and Australia Germany well done. And Finland brilliant and go the other way. Uh UK 20% worse than the USA. I think that that's a really poignant point to be saying we need to be doing something to think about how we can get our, our patients fitter. And at a general principle, if you think about a patient who has been admitted to hospital, we see a lot of people admitted for a week, two weeks, within a week, they can often lose 12% of muscle strength with inactivity at home and within 3 to 5 weeks of bed rest and not, they lost nearly half of their muscle strength. That is gonna take 6789 months to get back to normal. So a lot of these people when they're getting breathless, it's because they've lost a lot of muscle strength because of other issues going on. Plenty of good evidence that promoting physical activity in hospital is of some benefit, but it's really got to be delivered at a consistent level. And I think a lot of us are seeing patients who come out much less fit than when they went in. Ok. So that's the deconditioning challenge, difficult to work out when you're seeing a patient who might have asthma and deconditioning. Right. Very specific. Now, this is exertion, the patient runs around and then after exertion, they will get a wheeze, which will often last somewhere between about five minutes and up to an hour usually settles on its own, but it occurs 3 to 5 minutes, perhaps eight minutes after high intensity exercise, that's usually getting close to their maximum voluntary er, work rate when they're doing it. So that is finish the course, win. The race come last in. The race doesn't really matter. Put in lots of effort at the end of that, about one in 20 to 1 in five of us will get a wheezy episode that occurs afterwards. It does happen in people with asthma. So it doesn't say you've got this or you can't have asthma, but it is quite a common phenomena in a lot of people who don't have asthma. And um I think probably the easiest thing to think through on that is most of these don't need any treatment at all. They tend not to respond to short acting Bagni, they get better on their own anyway. There's a little bit of evidence on, uh, laba I CS pre exertion, but that's not strong. And most people who I've spoken to, who get it, just say, well, I know what happens. I get it after I've exerted, I just potter around from a, it, it goes away, then I'm back to normal. But that's a pattern to listen out for in patients. Exercise induced bronchoconstriction might have be associated with asthma but doesn't have to be right. Another one that might be new to a lot of us in primary care is exercise induced laryngeal obstruction or, uh, it used to be called vocal cord dysfunction. But what happens here is, and this is not the sort of thing that we do in general practice and it's not the sort of thing that many hospitals are doing at the moment, but increasingly will be doing. And that is to get somebody in to the hospital, put an indirect laryngoscope up their nose to look down on the larynx, put them onto a treadmill and then get them running and what you see when you're videoing through that laryngoscope. The, er, larynx is an involuntary closure of the larynx which causes, ew, and I did that voluntarily, but an involuntary muscle spasm making their, that constriction which makes people feel breathless, gives them an order, audible inspiratory stridor and stops them from running around at full pelt. So quite often in primary care, we can pick this up. Probably one of the, the ones that I remember most was seeing a patient who came in to see me because they were a bit frustrated about going to the local hospital and just being put on escalating doses of uh inhale coric steroid for their asthma. And the mum said, and I know that I they, they get it at about 300 m when they run around a track and I can hear them at the other side of the track when they're wheezing. And that. And so I'm telling everybody this every time, remember, you're not gonna hear a wheeze around 100 m away from a patient. You can try it. If you don't believe it, go to go into an A&E department or see the next patient with asthma in your clinic and then walk 100 m away and see if you can still hear them. Any noise that you can hear in that environment is gonna be a pro production from the lung and this person now doing much better um with their inducible laryngeal obstruction, often exertional with speech therapy, speech therapist with an interest in laryngeal obstruction or physiotherapy can often help inducible laryngeal obstruction again about as common as asthma in adolescents and young people. So inducible, laryngeal obstruction, exercise, inducible as common as asthma in adolescents and young adults can coexist again. Um There are, I've put down a list of the treatments that are documented in the er European respiratory statement on this. But to be honest, most of us will only be using speech therapy or physiotherapy to help patients in that sort of zone, they can get the same symptoms if they are exposed to inhaled irritants and sometimes when they get stressed, another pattern to watch out for in that complex, distinguishing what's going on. And when you look at the difference between uh exercise, inducible laryngeal obstruction and exercise induced bronchoconstriction. The laryngeal problem will occur when they're running and will occur very quickly and it's often at peak exercise. It's not when they're finished. The excise induced occurs afterwards. Mostly the treatments that we use are ineffective, inspiratory versus expiratory. Wheeze. Um, both will make them feel very breathless, both will stop them from exerting, but at different times. Um And so it's worthwhile just thinking through when you speak to somebody about the type of symptoms they have right. Next thing on the list breathing pattern disorder. It used to be called dysfunctional breathing. Um, I don't know if you're like me, but if I was told that my Children were dysfunctional, that would mean I was a dysfunctional dad and that would all have all sorts of negative conducts. And that's why people have moved away from the term dysfunctional breathing for somebody who's having a breathing pattern disorder. Next thing you'll notice UK based and, but similar in many other countries, around 8% of the UK population will have a breathing pattern disorder which will become exposed and symptomatic at times, I think the, there's two easy ways to describe it. Number one, it's a bit like when I passed my driving test, I remember all the mirror signal maneuver. But over time, I forget quite a lot of this and I get a bit sloppy in the way in which I drive and people when they're breathing, if they're not pushing themselves or they're doing other things, their breathing pattern can become a bit sloppy too. Perhaps another good example. And you, you can think of this in two ways. One linked to a car or a, a physical contact sport injury, something like rugby. Uh The other would be with a, a nasty infection. If I injure myself playing rugby, cracked a couple of ribs, it's gonna hurt as it would in a road accident and as it might do after pneumonia for weeks afterwards, I don't like being hurt. So I'm gonna take shallow breaths over that period of time. And 6 to 8 weeks later, I've been used to doing these very shallow breaths. Once I start to get going again, I'll survive if I walk slowly. But once I start to try and get more, I'm still taking these shallow breaths and I get more breathless. I'm not wheezing. I'm just taking a shallower breath to make that happen. And again, that's one of the common causes of a breathing pattern disorder. It either becomes learned subconsciously. It's not a planned dysfunctional procedure, but it's quite common if people have had nasty episodes of asthma or COPD pneumonia and a variety of other causes that you'll be, you'll be aware of. Similarly, we know that people when they get stressed tend to breathe faster. That's not uncommon if it hurts, I'm not gonna want to push things too much. And again, that will, that will change around my breathing pattern as does if I'm frightened about things useful things to think through. When you're listening to what a patient is telling you about breathing pattern disorders. The hyperventilation that many of us will be familiar with from medical school is quite easy. That's where you're getting these sort of uh I've been getting tingling around my lips. I'm getting tingling in my fingers, I'm feeling numb, I'm feeling dizzy. I'm feeling faint. Um That sort of symptom is, is fairly typical hyperventilation, but a lot of people say I can't get the air in past here. It's just not going down far enough. I'm leaving. Sigh quite a lot. I'm sort of getting very tired a lot of the time. It's a much less specific features, but that's sort of, I can't get the air in. Remember, asthma is inflammation in the airways that makes it harder on expiration so they can get the air in all. He's trying to get the air out, that prolonged expiratory. Wheeze, that's the problem. So again, some of those patterns you can pick up when you're speaking to patients or that you can ask them, is it easier to breathe in or breathe out? I can't demonstrate these, but there are four or five different breathing patterns that are well recognized by respiratory physiotherapists. And that little logo there is the Association of Chartered Physiotherapists and Respiratory Care. They've got a good lot of resources on this. If you want to watch videos on it, if you want to give some patients some tips on how to manage it a little bit more easily. But again, very prevalent can occur with um asthma but can often occur without not the breathing pattern disorder. The inducible laryngeal obstruction, the excise induced bronchoconstriction aren't gonna get better by increasing up asthma treatment. So that's why this is starting to get important. And again, if you want a, a little bit more information in in detail on this, the BT S produced a clinical statement, uh 2022 with, um, James Hull, the lead author on that. Um And one of the key things to look for there is they've got a, a variety of in depth discussions about these separate little entities that we see very commonly in primary care, but are often ignored. So let's move on. So the last key topic of the day, which is gonna be about regular use of short acting bons. So I know that quite a few people uh have traditionally given patients a blue inhaler. So we'll see if you've got an asthma go and use this, if it works, you have, if you, if it doesn't work, you haven't. Um Now this is a, this is a, a meta analysis of trials that was published in 1999. So that's what 25 years ago. Now 19 trials. Uh Richard Beasley is a um professor now down in New Zealand and what he studied uh was the combined trials or these 19 trials of people given an inhaled short acting beon to be used twice a day, three or four times a week for a period of a month, sometimes a bit longer. But certainly most of these were over a month, some were quite a bit longer. And what he found was roughly 80% or so of patients developed hyper responsiveness if they were using salbutamol regularly, whether or not they had asthma. So regular use of so short acting beta agonist will produce airway hyperresponsiveness. In about 80% of patients who have asthma and about 80% of people who don't have asthma. What does this mean in the real world? We all go off today with our blue inhaler and within about three or four weeks, we're all finding that when we exert ourselves or when we're exposed to um, perfumes or fumes or when we get a cough cold, we're getting hyper responsiveness, which is wheezing. So, the short acting beta agonist is causing the wheeze and causing the symptoms to be worse and they're needing more and more of the blue inhaler because it's not working, is it? And I just, it must be my condition worsening, not, it is the drug that's causing it. Unfortunately, if the, if the trials were produced back in 1999 and they all are showing the same thing, you're not gonna get an ethics committee to approve another trial now, just to show it again, to create a bit of publicity. So that's something that we need to talk about in more detail. Um So this is a, so this hyperresponsiveness occurs in 2 to 3 weeks. Um, and a lot of people within four weeks. So that's within the month if they're using it three or four times a week, twice a day if they stop it. Um The original paper suggested a few days it goes back to normal. My experience has been up to two or three weeks. And Richard Beasley, when I spoke to him, said o off and up to a couple of weeks. So we're, we're all in that phase of, if they stop, they actually feel much better. Quick, little tip, quite a few patients that I've seen have come in and said, why didn't anyone tell me to stop my blue inhaler? I'm far better than I've been for years. Just not using it. It's, it's, it's mad. I'm, I'm far better. I don't know what you've done, but I'm, I'm much better. That's no change in another treatment. It's just reducing the short acting beta agonist. So hopefully, what I've done there is covered quite a few of those areas of asthma. We treat asthma deconditioning, get them to exercise more, treating excise induced bronchoconstriction. Most people just reassure it'll get better exercise induced laryngeal obstruction. There are some uh information, bits of information on the asthma and lung UK website, but uh often if you're stuck with that, it's a respiratory physiotherapist, uh breathing pat disorder. There are resources. Again, respiratory physio is really good for this and bronchial hyperresponsiveness chat with your patient, talk about reducing it quite significantly. Watch how much benefit they come back and tell you. Thank you so much. You've done really well for me. I appreciate that. So hopefully that is, that's given you quite a bit of a AAA quick run through some of the other causes. I haven't gone into uh detail of COPD overlap. I haven't gone into details of some of the other causes of breathlessness that should always be on our mind like pulmonary emboli like cardiac causes in older people like anemia. Again, I saw a lady the other day with a hemoglobin of 7.3 presenting with breathlessness, probably not surprising linked to her menorrhage and not especially due due to any respiratory because um we do need to keep our clinical acumen and our thinking going on when we evaluate these patients. But hopefully, that's given you a bit of an insight into some of those areas that in the population that we'll be seeing in real genuine general practice are having issues and then not getting better when their treatments are being changed. And sometimes these have been managed brilliantly by the our nurse colleagues. Sometimes our nurse colleagues are come to us saying I'm a bit stuck, they don't seem to be getting better anymore and that's where we need to be thinking carefully. So if I stop the slides there, I'm happy to take any questions that people have and perhaps you can have a chat about any bits that are coming through on the, on the question line. Thank you so much. Er, Doctor Holmes. That was amazing. Er, really great er, summary of um of everything we kind of need to know about making a good diagnosis in asthma. Um We've got loads of questions and we'll we'll, we'll work through. I know you've, you've tackled, er, some of them already. But, um, we'll try to work through these. Um, we've got a question from, um, ISA, um, if you don't have access, easy access to spirometry and the patient is symptomatic, do you start a trial treatment or do you still suggest doing a two week of peak expiratory flow and then follow up after that? Ok. Few, few quick pointers on that. Number one, if I see somebody who has AAA an acute asthma attack, I will try and measure their peak flow rate unless there's a acute infections going around at the time. And I'm worried about safety with that. I will measure their pulse ox, I will measure their respiratory rate. And then I would start treatment for an emergency asthma exacerbation. So I'd be giving them steroids and I'd be giving them a short acting bags and wanting to review if they're coming in with less severe symptoms that are ongoing, I often have more time to make the diagnosis. And I think one of the things in a hospital setting is most of the people who go into a hospital and in some other countries, they're only presenting when their symptoms are really bad in the UK. And many parts of Europe patients are presenting with ongoing much less severe symptoms and there what I would prefer to do given the opportunity would be to get spirometry done. And a feno done as a uh the spirometry reversibility perhaps within a week, 10 days and then see the patient back or initiate therapy having chatted to them. If I don't have access to pheno and I don't have access to spirometry, then I would be thinking more about a uh peak flow diary, but make sure the patient can use the peak flow in your surgery before sending them off to do it. If they can't do it when you're watching them, they're not gonna do it twice a day for two weeks accurately. It has to be the biggest breath in. They possibly can be as fast as they can three times within 5%. Um, from the point of view of the fo again in some areas of the country that is now routine across PCN S or across practices in others, it's still coming in. Um Q tip. I wouldn't be suggesting that practices themselves by the PA machine that, that should be part of a commissioned service and most I CBS are in the process of looking towards, um, producing that soon. So hopefully that's answered the question about and the practicalities of management. If I'm, if I'm stuck in an area where I'm not gonna get spirometry or, you know, for a period of time, it sounds like asthma, I've done a peak flow. It's low. I've given them perhaps salbutamol two plus it increased a bit. I would give them a trial of treatment as suggested by the British Thoracic Society if it fits in and then review them back uh in 4 to 8 weeks to see how they're getting on. Good. Hopefully, that's all right. Yep. Perfect. Um I'm going to move on to the next one, which is for peak flu diary. Can we give the patient a SABA so that they can perform the peak flu before using SABA? And after, so we, we can use a peak flow diary in that way. And that will sometimes demonstrate if their peak flow is low and then it goes up much more afterwards. Uh a benefit at the time from a a short acting beta agonist, but be wary of a short acting beta agonist being uh starting to produce that hyper responsiveness because then you're gonna get a peak flow diary that gets more and more variable linked to the drug that they're using, not linked to their underlying disease process, which often will settle down. Uh perfect in the sensitivity and specificity slide where it says peak expiratory flow is greater than 20% and peak expiratory flow is greater than 15%. Could you please clarify? What does this percentage mean exactly? Um Do you mean mean improvement after Saba? So, so that is variability over a 24 hour period? Um And this is part of the, the problem is that there's never been a an absolutely agreed percentage difference. Most people will say 15% or 20% some trials have gone for 15, some have gone for 20%. So because there was variation on that, that's why the guideline producers in their meta analysis as the work up for the guideline quoted them both separately. You would expect somebody to, you know, it to be more definitely to be asthma, the bigger the range you get. But unfortunately, that didn't quite show up in the results. So again, peak flow diaries be really careful in how you interpret them on their own. Remember if someone's come in and they've just made, they've just filled out the form as they're there, that can be uh quite misleading. Um So, and again, think about the hidden gains that people might get if I think I can get a lot of money by saying variability or I can get out of having to do things because I've got asthma, I might make my peak flow up and down quite a lot. If I'm worried I would lose my job, I might just make sure that that level is flat all the way along so that my employer doesn't say I've got asthma and tell me that I've got to look for employment elsewhere, world. Uh We've already tackled a couple of these, um how quickly will hyperresponsiveness present, um, trials between two and four weeks. Um The two week ones weren't quite as common. Um But those that lasted, you know, longer than that, there was much more likely. So the hyper responsiveness occurs in a lot of people with asthma. It also occurs in a lot of people without asthma. Um, you know, the normal population if you give them it. Perfect. Um, and Sarah's asking, er, we're only just getting restarted with spirometry, er, should we be purchasing a feeding machine or just going forwards with spirometry and peak expiratory flow diary to fulfill the cloth? Um, certainly worthwhile if you've got spirometry to get that going again. Um A lot of areas now are com making sure it's commissioned. Primary care was never really commissioned to do spirometry. Um Specialist care was, but then it went to block contracts and the amount they were expected to when primary care didn't have capacity uh is is difficult. Most parts of the UK are now trying to work out a way of funding it appropriately so that practices will be paid for doing these appropriate tests. Remember, quite a lot of spirometry will be normal in these patients and we might need to repeat them. And a really good question from Nina Maca er saying uh we get lots of patients sent to practice nurses who present with possible shortness of breath following viral illness. How long should we be waiting before we investigate for asthma? Right? No, no definite answer to that. Um I think a couple of things that are worthwhile remembering. Um First of all, often if you do have a significant viral or bacterial infection, something like a community acquired pneumonia and COVID, we remember not too, in the, not too distant past as well as pneumonia type viral illnesses, often patients will be breathless for three months after the infection. And with bronchitis that can often be 4 to 6 weeks or so at least. So, the first thing to get into mind is if they've had an infection, is this just part of normal recovery, are they slowly getting better? That's fine. Just keep going. We don't need to be um, give them additional diagnoses that might penalize their insurance cause them problems when they're trying to travel overseas or, or do, or join the army or all, all sorts of other things. So I guess part of that is trying to get an understanding of what's been happening to the patient. Quite a lot of us will get a cough, cold and get better within five days a week. If it's lasting three weeks, that's gonna worry quite a lot of us. And that's where we present. And that's probably where the normal understanding of uh duration for these infections comes into its own. And if you look at the BT S guidance on pneumonia, very clearly, breathlessness is usually present until about three months after their, they've started their successful treatment. They don't need antibiotics for three months. They need their antibiotics for five days, but the breathlessness will persist, although gradually improving cough, certainly 6 to 8 weeks quite significantly um as part of that normal pattern. So listen to what the patient is telling us and then try to work it out from there. Um And a couple more will squeeze them in. Um in young kids who can't do spirometry, peak exploratory flow of feno with high likelihood of asthma. Is it best to trial with I CS and continue until can do appropriate testing and then diagnose slash code the patient accordingly. Th this might be one for me to do another session on. And I think there's another one about because I noticed there were some on treatments might be one to do on what sort of treatments should we recommend. But probably a key thing about inhaled corticosteroids in Children. Number one untreated asthma from your birth weight and height. Often people will lose between 10 and 15 centimeters in, in height with untreated asthma. If you treat the asthma, the loss in height at the age of 16 to 18 isn't 10 to 15 centimeters, it's one centimeter and that's with normal dose, inhaled corticosteroids. So the first thing is looking at that your child is better being treated with an inhaled corticosteroid than not. They'll end up small and that does damage their lung function as well as they get older. We do need to make sure that if someone does have asthma, we manage that appropriately. Second thing and clinical tip I do when I'm saying this, if the patient has just a viral associated wheeze and it gets better and they're fine for weeks and weeks in between. I'm not treating that all the time if they have multiple triggers to their wheezing that is going on most of the time and they're needing time off school or from nursery, et cetera, et cetera. That's where I'm having a sensible discussion with parents and saying, OK, how about we try and nail this for a while? We're gonna, we're not gonna make a diagnosis until they're at least five or six. But we will use some of the asthma treatments which we know are safe in this age group at normal doses. So stick within that dose area if your child is better in 6 to 8 weeks and I'll just do a brief catch up then, then let's maintain it for three or four months. But then what I'm gonna be wanting to do is to try and drop down again because we know a lot of Children in their first five years. If they're having wheezing to a variety of triggers as time goes on, that gets less common and less common. We don't want to treat them forever with this treatment. We can start to step it down and let's do that as a planned uh issue together so that you've got your child at school. We're maintaining that, but we're stepping it down and we're seeing if we can get away without any treatment. We might need some, we might not, but I can't predict that. Um, I think that's us at time. Er, Doctor Holmes, uh, we've, er, filled 60 minutes with, um, how to make a good diagnosis of asthma. Just a massive. Thank you from our side. Um, a massive thank you on behalf of everyone in the audience. Um, I think this has been a really helpful session. It's been really comprehensive, really practical, um, so massive. Thank you from, from our side. Um For those of us in the audience, um you will find a feedback form in the chat. Um uh that will award you a certificate once you complete it. Um You'll also um get a notification if you have the app for the feedback form after this um uh session. So you can give um some feedback afterwards and that will then also award you a certificate and you can complete it in your own time. I'll pop the links in the chat and um and they'll be there for you to, to download and, and join. Um Thank you so much, er, Doctor Holmes. Um And thank you so much to everyone for joining us. I hope you find it helpful as well. Thanks for inviting me, Phil and thank you everyone for listening. OK.