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Good evening everyone and you are so warmly. Welcome back for this episode in Middle primary Care. Er, we are really excited to have, er, Doctor Steve Holmes, er, back with us again this evening and we're gonna be talking about uh asthma and how to make a good diagnosis. Er, er, if you didn't join us last time, er, we're really honored to have, er, Steve alongside us. He is an active clinical GP with more than 30 years of respiratory interest over his time in practice. He has been the chair of the Primary Care Respiratory Society is on the British Thoracic Society Council and Research and Science Committee nationally and is involved in an International Primary Care Respiratory Group on their education committee. So we're hearing from the very best this evening and we're really honored to have you join us, Doctor Holmes. Um, if you have questions, please pop them in the chat on the right hand side, um, we will be popping a feedback form a link into the chat at the end as well. Um, and you'll be able to get a certificate of attendance, er, afterwards and if you want to get access to the slides and on demand content. We recommend you download the app and you'll get a notification afterwards with any slides or, um, videos that, that you can watch on, on catch up. And I've just popped the links into the, into the chat for your convenience. Um, Doctor Holmes. I'm gonna hand straight over to you so we can dive into asthma making a really good diagnosis. Thank you, Phil. Thank you so much. Um, great pleasure to be here. Um, and lovely that people are tuning in in their precious evenings to listen to, to what's going on. Um, as I say, I'm, I'm Steve Homes. I'm, we covered quite a lot on the diagnosis last week. So what I'm gonna try to do is concentrate on this session a bit more about management. Um, II think Phil's nicely summarized my background. So I don't need to stick on this at all. Um, and if I move on to the next one, just so you're aware, I have received sponsorship from a number of companies. Uh, I'm not speaking on behalf or have these slide prepared by any company. I've also do a variety of academic work with different universities. Um, let's move on and get straight into the topic which is around asthma management. And I think it's really exciting times for asthma management. I wanna cover treatment options, the established ones and some of the newer ones I wanna talk about what might constitute a good review and some of the latest guidance on that. And I'm gonna talk through um thinking about severe asthma and when we possibly should be thinking about involving specialist colleagues and some of the newer biological agents that are available that can make a real life changing difference to some of our patients. Having said that probably 98% of the patients certainly in the UK are managed really well in primary care and get very good outcomes. So the severe asthma group is really quite a specific low, low grade group. Now, some of you who turned to the last uh seminar might remember, Hannah. So I thought I'd keep Hannah going. Um uh This is a fictitious character. It's not a real person, but it's based on what we see quite a lot in um clinical practice and just as a quick reminder, um what we're trying to do now with asthma, when we make the diagnosis is have a decent history that suggests this is asthma really important to get that history, right? And also to support it with your little summary of why I think it's clinically asthma with evidence of reversibility, spirometry, wean or a raised fractional exhaled nitric oxide or eosinophil count. Nice summary. We've made the diagnosis, we're pretty sure that she has asthma. What are we gonna do? Now, what's our first go to to start her on? And it might be worthwhile if you've got a pen and paper handy just thinking through what would I be doing now, in my quick consultation, I've got all the results there she says, yeah, I've been reading a little bit about it. What, what do you think I ought to be on then? Um, what are you gonna give her few seconds to think that through? And what I'm gonna do whilst that's going on is put up the British Asthma guideline, er, that was formed by the British Thoracic Society and the er Scottish Interco Guideline Network as a collaboration and it's been going around for a long time and just talk you through um the sort of strategies that are recommended there. So the first thing that you'll notice if you look at this graph is that um the, the first thing is if we think it's asthma and we're giving treatment, the treatment that is mentioned first is a low dose inhaled corticosteroid. So everyone who's done that tick that would fit in with current guidance and certainly fits in with what we know from the BT S and sign um that helps us to establish the diagnosis and evaluate and hopefully, when we've got the history, we've got our test and we've given treatment, the patient responds and then we've made that diagnosis firmly and get them onto at this stage with the BT S sign guidance, regular preventive treatment if needed, we step up usually to a combination and if still having problem with treatment, we would step up to either a slightly higher dose of inhaled corticosteroid or adding a leukotriene receptor antagonist. Now, the la last published guidance from BT S sign suggested if you were going to add in a lama on top of that, it probably should go through to somebody who is more specialized in asthma. And that was caused quite a bit of controversy. I'm aware quite a few of my colleagues actually would be very competent in primary care initiating a Lama in addition to the others. But probably the thing that I would point you to on this slide is the bit on the, the left side as you're looking at it, good practice point before initiating new drug therapy check, the patient is actually taking the old one and check that they're actually using the inhaler properly and that you've started to eliminate trigger factors. So really basic stuff, you know, with Hannah, she's new. So she won't have had that before. We need to make sure she's competent in using the inhaler. We're talking about, we need to talk to her very carefully about the sort of treatment and how we're gonna manage that. Some of you may have written down a Well, I think it's asthma. I give them a short acting b agonist and I'll probably talk today why? Even back in 2019, this wasn't being particularly favored by the BT S sign and why it's at the bottom line there it can be used as required unless they're using a maintenance reliever therapy. But a short acting beta agonist, salbutamol or something like that should only be used if the patient has infrequent short lived wheeze now, infrequent in, in the definitions is less than twice a week. Um Whether you say that short lived, um a normal inhaler has 200 actuations in it. That means that if they had infrequent but pretty persistent over one year, they would need one blue inhaler a year. Anything more than that BT S sign has recommended treat them as you would do people with asthma if they've got asthma and asthma treatment is an inhaler cortic steroid. So infrequent short lived wheeze is a very rare usage even back in the 2019 guidance. So let's move on a little bit men, maintenance and reliever therapy and a lot of you may be familiar with that and I think it's just worthwhile talking it through because it helps on the story of what sort of treatments we're thinking about. Now. Maintenance and reliever therapy is the use of an inhaled corticosteroid in combination with a long acting beta agonist regularly, the maintenance bit morning and night and if they need relief in between, as you might do at the moment with your brown inhaler and a blue inhaler maintenance and reliever. There are a lot of products that are licensed for this. The quick summary is most of the products with an inhaled corticosteroid and Formoterol as the long acting beagon are licensed for maintenance and reliever therapy. One inhaler a few, none of the ones that contain. Unfortunately, salmeterol are licensed because the pharmacodynamics of that product don't allow it to be used as a rapid reliever treatment. Some of the work around Formoterol, the one that is used in maintenance reliever therapy um has been done in A&E departments where they find that the response rate to Formoterol is equivalent to that of salbutamol. However, it persists for a lot longer. So the long acting be this but with rapid onset, hopefully that makes sense. And a lot of us are using maintenance and reliever therapy and the guidance from the BT S sign is quite direct there. It says consider maintenance and reliever therapy in adults who have history of asthma attacks on a medium dose I CS or on regular treatment. Otherwise, and that, that again often changes round the lives of our patients when they get it right. Plenty of options available for that. But we wouldn't really start somebody straight away on maintenance and reliever therapy. I guess what we've got to be starting now thinking is, well, if we're not gonna be using a short acting beta agonist, what is the rationale behind that? And if I talk that through carefully, the first thing is um we've used short acting beta agonists for 50 years as first line therapy in some areas, it does bronchodilate. And initially, we thought the problem was that of bronchoconstriction. But a lot of research over the last 40 years has demonstrated the underlying cause is eosinophilic inflammation in the airways. The bronchoconstriction relaxes the muscle but does nothing for that inflammation. So regular use of regular use of a short acting bee agonist. This is a really important point even for one or two weeks is associated with increased airways hyperresponsiveness. That means they get less effect as they keep using their short acting beta agonist. If they have got an allergy, they get increased allergic responses and increased eosinophil counts. What is airways hyperresponsiveness? That is when I exercise, my airways will go into spasm when I'm in involved with volatile substances, smoking, perfumes, uh noxious substances in the air, I'll often get spasms, exertion. I've mentioned coughs and colds will do it. And when I feel stressed now that regular use of SBA, even for 1 to 2 weeks will produce that in people with asthma and also people without asthma. So if someone comes in and gives them a blue inhaler, the likelihood is in 1 to 2 weeks of regular use, that patient will be developing airways hyperresponsiveness and that encourages them to use it more and more because it seems to work for a short period of time. But let's keep using it. And that's why some of the work by Sammy Souza and others over many years has shown that association between a short acting beta agonist use at a really high level and increased exacerbations and indeed increased mortality. So plenty of areas to be thinking about there. Number one regular use of salbutamol. No, if they are using it and by regular in this, it's often three times, uh two puffs, three times during the week on two occasions. So six goes a week will often put somebody in this situation where they're developing airways hyperresponsiveness. So, with that in mind, if I'm seeing somebody who hasn't got asthma but is using a blue inhaler and they're getting worse. I've got to try and distinguish that and encourage them to stop using their short acting beta agonist and allow things to settle down. That's quite challenging cos that's changing a lot of what we've done for 50 years and we've got very used to it and it's quick and easy. I think the other thing that, um, the saba being the initial treatment in primary care seems to do is it seems to get people trained to think that's the first line of treatment. Everything else is for worse problems. And when it's not working, that's when I need to add in other things. And actually, it's quite converse to that. And the Gena recommendations are sort of changed in 2019 after the BT S sign had produced their guidance, but has remained fairly convincing ever since. And I think that's where we probably ought to be thinking a little bit more because, and this is uh some of the experience I've heard when I've been investigating Children who've died from asthma. And I've done that on, on quite a number of occasions if you can see the three images there, the normal airway has a nice thin line, you know, space for the air to get in the lining isn't too thickened and the muscles are nice and relaxed with asthma. You often get a thickening of the uh lining of the airways and you get often a little bit more muscle spasm. But in an asthma attack, the muscles clamp down, but look at the size of the airway, the airway is mainly reduced because of that increased inflammation. And we know that that airways inflammation also creates uh increased mucus production. Now, why did I mention about investigating Children who died? One of the classic things that the paramedics and the A&E consultants and the intensivist talk about is how hard it is to ventilate. These people. They've had loads and loads of salbutamol but no steroid. And you're trying to push air into the lungs where the airways are massively inflamed and they have lots of mucus there. And that's often the, the thing that you will find on post mortem when you look is that mucus, plugging, plugging and thick in the airways. That's why inhaled corticosteroids on regular use help to prevent deaths. And that's why we use a steroid early in an acute asthma attack because even if we get it in whilst in primary care, two or three hours later, when they're having trouble, that drug will be starting to work and reducing that inflammation, salbutamol on its own is not gonna do that. So, just to reiterate that and think about some of the things we found and this is was very similar 10 years later when we did the National review of asthma tests, about a third of adults who have acute asthma episodes are defined as having mild asthma. That means they haven't had a great number of symptoms in the last few weeks or even over the last few months. And they're on low levels of treatment. Indeed, roughly one in five people with a near fatal attack again have what's termed mild asthma and a quarter of those dying don't have the most severe asthma. They're the ones with the mild end of it. Some of those are the seasonal people we see with allergic rhinitis and uh, seasonal asthma that they only need to use it once in a while. So it must be ok just to use the blue one. So please be wary. Those are really important factors to think through, um, exacerbation triggers can be unpredictable. I don't know when I'm gonna get my next cough and cold. I've got more of an idea about pollens, but unless I'm looking online regularly, I don't know when the big day where there's gonna be a lot more pollution is likely to be about due to the weather conditions. I am in control of whether I take my medications or not. Um, and that may be a conscious decision but that can leave me more prone as well at times. So what, what are the genus strategy and report suggesting and what they're suggesting primarily is using. Now, remember the maintenance reliever therapy was an I CS Formoterol. They're recommending using that as needed not regularly, like the maintenance in the morning and night and then as a reliever, just as a reliever when you get symptoms, that's on the basis of a big well conducted trial that compared it with just short acting bags and showed a roughly two third reduction in exacerbations, the flare up. So this is the background behind why gene are saying what they are. It's also compared with a low dose of inhaled corticosteroids. It compared equally well in those that were taking their medication. So this just use when you need to in mild asthma for someone with seasonal allergic rhinitis, probably a very good solution and fits in well with a lot of that evidence about while we've, we're still not doing so well with asthma deaths. Um that, that is the main trial, but there are another four other trials. So this is a review of the five trials in the literature. And again, that has shown sorry six studies, 55 being suitable that again is showing very much the same thing. This I CS for muscle combination, being effective in controlling the symptoms as well as traditional management, but reducing exacerbations quite dramatically. So, what does that mean in the real world? Well, and this comes from per personal opinion, this isn't in a guideline apart from what you see in Gina, but there is a British guideline on the way at the moment. So the new British guidelines will be nice and BT S sign and um the those three together are gonna combine to have one guideline for the whole of the UK bracket. I can hear you thinking about time too and I suspect they're gonna take very careful consideration of how to manage things, but it wouldn't surprise me if they were going along with the sort of personal opinion I put up here. But the opinion of what is going along with a lot of other colleagues, I hear you might say nice, doesn't always follow what um people with an interest recommend, but I think with Cochrane reviews and support of it and major world guidance elsewhere, supporting it and product license supporting it, um There may well be a switch and that is using I CS Laer as required in the mi when I'm initiating treatment rather than just a Subba. I think it has a good level of logic behind it. Um At the moment, there is only one license preparation which is simba called Turbohaler maximum 8 lbs per day on the license. Important to remember that the salbutamol license in acute asthma is use up to two puffs in an in an acute asthma episode. We all use more than that when we are in a crisis situation with asthma, the same is likely to be true using the four mole there until you can get more help as we do with Ventolin salbutamol. Um Other products are likely to come online over the next few months. I'm not quite sure of the timelines for that. But initially, there is only one licensed product. It is likely that the other inhaled corticosteroids with the same long acting beagon will show the the same sort of benefit. Why is it sensible to do that? Well, how many of your patients don't take their inhaled corticosteroid? They come in every year for a review and get an I CS inhaler and go back to using blue every day. It's very much likely from the evidence in the trials to reduce exacerbations and property admissions as well. That was pretty well clear in quite well controlled trials in a real world primary care setting. It also makes it easier because I make having to explain one inhaler rather than two. And as I've said, um originally, it will be considered by the British guidelines. I don't know which way that's gonna go, but there's good evidence from Gina and Cochrane to support that clinical decision no matter what the guidelines say, who would it be suitable for. So, II would think anybody who comes in newly diagnosed one inhaler makes it easier. The explanations are quite a lot easier and most of those people will do well with it. I think people with seasonal asthma where you're just worried about them, you trying to use three or four blue inhalers again, that would be a really sensible thing if you think they've got a proper asthma and they've got allergic rhinitis and other symptoms and as required antiinflammatory reliever would be a sensible solution. And people who just use a short acting beta agonist alone if it looks as though they have asthma, remember if it's hyper responsiveness, they don't need asthma treatment, they need to stop the short acting beta agonist. And for information, if you do stop the short acting bee agonist, it usually takes about three or four days before their symptoms get back to normal again, it doesn't take long, sometimes up to a week. So I would probably say, look why don't you stop it. And just even if you have to just walk when you use that short acting be drag list for seven days and then only use it following that if you really need to. Not just because you're trying to prevent things other quick things to think through. If that isn't working. I have the option, then if they're using quite a few puffs a day, say they're using four or five puffs a day to say, why don't we step up to a maintenance treatment now and then use it in between. I can go back to the traditional I CS lab and a short acting B Tragus. But it's probably easier to say, ok, just start using your p your new treatment morning and night, but keep carrying it around with you. So, unfortunately, the maintenance and reliever and the as required inhalers are a bit like a mobile phone. They probably have to be ported around with the person so that they can have treatment when, when they need it. Most people don't have six mobile phones, so they don't need one in their um bag, their sports bag, one at school, one with granny and one at home. They only need the one and II would suggest that's probably the same with the maintenance and reliever therapy. If it's not working, you've got options of leukotriene receptors. You've got options, I think in primary care of a long acting muscarinic and taking this. But having checked inhaler technique, if they still have problems, please get a specialist colleague involved to reevaluate the diagnosis and look at other treatments. So hopefully, that's given you a, a brief idea of what's going on in terms of some of the later thinking on this that's been coming through since the um old BT S signed guidance of 2019 and the nice guidance now was back in 2017, the trials were published in late 2018. So it probably didn't even get into the BT S signed methodology at that point. So Hannah goes onto her treatment. Um, she's been starting on a I CSO old fashioned treatment and within a month she's much better. That's quite common. Um, she has a blue inhaler but she had an, had an exacerbation and comes to you afterwards. Um wondering what you want to do about it and what should she do? And I guess that's quite a common thing. A few things to just think through exacerbations have a number of different symptoms. I picked up this lovely bit of research from India where colleagues had asked people with asthma attacks, what they were feeling like and what they noticed tightness in the chest, blue lips, my neck muscles feel tight. I start wheezing. I feel anxious. All those sort of symptoms that we know about as an, an an asthma attack. And what's important about that is to remember that the exacerbation doesn't strike them down from above. It takes some time. And the seminal work by Anne Tatters Field and colleagues back in the 19 nineties now showed that somebody before an exacerbation. So this followed up a lot of people to see when they exacerbated. And what she found was that these little lines are the peak flow in the morning. Their symptoms and use of rescue medication and what you're seeing before the time when they were at their most severe for the week before that there's increasing amounts of use of medication, increasing symptoms and a reduction in their peak flow readings. And then after they get their steroid treatment, you can see it dropping down quite steadily again. But that's a nice way of just remembering that asthma is building up over several days. That also is one of the components as to why an anti-inflammatory reliever when your symptoms are getting bad can help to suppress it and reduce your need for oral corticosteroids. Now, this might come as a shock to some of you thinking about the people that you see and certainly for a lot of GPS and definitely people working in emergency departments. Um, it would be unusual to think about how often do I see somebody with an asthma attack? This is from the US and the UK, it was done about six years ago on a big databases around 200,000 patients with asthma. So that's probably, you know, 5.6% of the population with asthma. And that's a big database to go through. Uh, thankfully, I'd imagine it was done automatically. But what they managed to show was your average patient would have an exacerbation every 8 to 12 years, every 10 years. That's your average exacerbation and then go to casualty about once every 50 years. Now, what I want to think with that is if I'm seeing somebody who's had two exacerbations in a year, that's very unusual. One is important. 23 or any more than that is really outside, what we would be hoping for most people with asthma and probably warrants more specialist thinking about it. So, what are we gonna do when someone's had an exacerbation? Well, this came out, I think in February, I can't remember the exact date now, but the British Thoracic Society having communicated with the primary Care Respiratory Society and a number of other colleagues have come out with this, what they call the asthma for? What should I do soon after someone's had an asthma attack to check everything's going ok. And they cut it down to four things. One check on their medication. Are they taking it again? Can they use their inhaler? Is everything stable with that? Second? Have they got an action plan that tells them what to do if things get worse, either recovering from their asthma attack or in future episodes? Three, can we help with smoking? Remember the quick way to do that is if I'm helping with smoking. Do you want, do you want referral for the most effective intervention we've got for smoking? Not the big rant about how bad it is. How can we get them into effective help? And that is around the concept of professional help along with the medications available and there's a new one coming on the market at the moment that well again will take the place of varenicline that we've lost for quite a period of time, but will help to improve those rates again and finally, action for a clinical review within about a month. And that's the time to really go back with a patient and say, why did this happen? What can we do to prevent it happening in the future? So, and they often talk about exacerbation reviews. A lovely clever person said, ex expertise starts where guidelines finish and good care starts where templates finish. You might want to debate that perhaps not here, that might be one for you to chat through with your colleagues at another time. But but actually, what we're trying to do is keep this as simple as we can so we can get the best outcomes we can and we often do have to go outside the uh guidelines and indeed guideline evidence suggests we should do because part of it is knowing the scientific guidance, the guideline, part of it is the patient's preference and part of it too is our personal practical experience of what we've come across over time. And if they're coming back for a formal review after it, so this is the four week, this isn't the ear very early. Quick review, the phone call saying uh we gave you some steroids the other day. Can I just check any questions about the medication? What are you taking at the moment I gave you a plan. Have you read any questions about that? Do you want some help with your smoking? We've got you booked in for this appointment? And that, that at the exacerbation appointment? Remember this is every decade or worse if they've been in the hospital? Certainly, if it's been in the hospital, why did it happen? What's the patient's reflection now on why they had that worsening? What happened outside and in the hospital, was it a was it a near fatal episode? Did they go into intensive care? How quickly did they get help? What did they do themselves before it happened to help, to advise them about appropriateness of seeking um medical help? Perhaps earlier at times, any things they've learned about it, any triggers they think caused it, we've spoken about smoking. But it again, it's that inhaler technique, adherence is worthwhile checking. And that's something you can't easily do over the phone. Um You can do a bit on video, but again, it's still pretty challenging, much better being seen, face to face for this. Um Don't forget occupation, somebody who comes back with asthma having not had it for a while might need help. And again, think about medica medication optimization exacerbations. Um The old BT S sign guidance, recommending step up to maintenance and reliever therapy as one of the well proven evidences for that the post exacerbation side of it suggests that it should be specialist follow up. Um But I'm aware that my colleagues and specialists can have very long waits at the moment and a lot of those patients don't get the opportunity to stay uh and get a, a specialist follow up. Um So a lot of this is falling back onto primary care at the moment as it always has done. Um this is the old guidance which will be going out. But on that again, it says early review and then a proper review after and I think that's changing round a bit. Now, the early review has to be an appropriate clinician and the spec or the more specialist review afterwards is probably best done by somebody like the practice nurse in the practice. If it's been within the practice, it might ideally be someone from a specialist setting if they needed admission. But again, a lot of our specialist nurses do really great jobs in managing this. Well, what about the standard review? And I'm sure you've all got templates. Um and there's lots of different things written on them and they can often go on to five or six pages, I guess from my side, it's, it's simple things that make a difference that I'm trying to think through. And certainly a lot of our patients, we want to know about how well they, their con how, how well is their asthma controlled? What symptoms do they have? Number one, number two. Have they had any flare ups or severe exacerbations that warrant prevention of further exacerbations. They're risky and they're also in the evidence. Um, one of the big impacts lifelong in terms of that oral corticosteroid load and risk of osteoporosis and diabetes. Standard treatment check the inhaler technique check. They're actually taking the medication, lots of patients. If you say, are you taking your inhaler twice a day will say yes, I am because you're nodding your head and telling me that's the right answer, but they won't be. And that's really worthwhile. Checking a quick bit of research in our practice. Recently, of the five people being seen in specialist care for biologics. Although the letters were coming back saying this patient is complying. None of them were picking up regular inhaled corticosteroid prescriptions. Sorry, one was out of the five, the other four weren't unfortunately, what else on a, a structured review? We should think about smoking. We should think about work their ability to exercise. We want them to be exercising and we probably do want to think at times about lung function and possibly in the new world thinking about fractional exhaled nitric oxide monitoring if they've still got symptoms because a high level of fractional exhaled nitric oxide is suggesting there is still inflammation going on in the airways. We haven't treated their asthma well enough at the moment. For whatever reason, it may be concordance, it may be inhaler technique. It may be things warrant higher levels of treatment. And remember again, one of the sad things from my investigations to people who died from asthma is many of them were unaware of the severity of that final episode. The Mark Levy who led the national review of asthma deaths. Uh Great general practitioner sort of commented that around 40% of people who do die didn't seek any medical help in their final asthma attack. The one that killed them, that's the value of the self management plan is warning them what to do with things about. Um This is another way of performing a structured review. There's lots of them on Arden's templates. Um Ems system, one that people can use if you want, it's getting something into your mind that you're quickly running into to make sure you capture what page, what people need and leave that up to you which sort of acronym you use or what system you use. But probably the sensible thing is to try and get it routinized. So you don't miss out important things and suddenly say, oh, I shouldn't have asked about whether they actually took the inhaler or not. Um Because that always makes it difficult. Now, I've spoken about the benefits of a personalized asthma action plan already. Um This is the one produced by Asthma and Lung UK. Um What I normally say about using these is um and I'll put down a little note on that peak flow rate. Um It has all sorts of things. I my present peak flow rate is and you're supposed to fill it all in. If they're not using a peak flow rate for monitoring, scribble that bit out, you don't, it's to be personalized for them, you can cross out, you don't have to do all the peak flow stuff. I normally put in what their best is. So that if they're seen in an emergency department and they can say, oh, it says here, the best one I've had in the surgery is 450. But if they use their inhalers and seeking help based on symptoms, which the majority of people can, they don't need to put flare in. This one is a standard old freshened, personalized asthma action plan. Um, if I do that for Children, I print it out from my computer in black and white and ask them to co I've got three little felt tip pens. I color in a little bit of the green, yellow and red and ask them to go back with their parents and color in the rest and make it look really pretty cos by doing that. I'm hoping that the parents will be talking to the child about it and deciding themselves and being clear about what to do when they've got it. But that personalized asthma action plan is the thing that in groups of people who've got them, they have much less admissions and from what we can tell in the literature, they're probably much less likely to, to have a fatal asthma attack. One of the things we're trying to prevent, I mentioned maintenance reliever therapy and I've talked about as required inhaled corticosteroid and um, reliever therapy in the same inhaler. What's important is if you go to the asthma and lung UK website, there are personalized asthma action plans for each of those categories. So it used to be this but within, uh, it used to be only the standard using an inhaled corticosteroid regularly. And the blue one for else for other areas. And within the last year, in fact, within the last few months, asthma and lung UK have produced very similar ones for people who are using maintenance reliever and for people who are using an as required I CS lapper. So hopefully that's of use. And again, Asthma and Lung UK are a combination of the old asthma UK and the old British Lung Foundation, the Major Respiratory Charity, lots of very good evidence on that website and lots of good resources for our patients to read up about their condition and feel more empowered. So let's go back on. Um We see Hannah her problems brewed up over several days. There wasn't a definite trigger. She went to out of hours and given a sto a course of steroids and antibiotics. No peak flow in her discharge letter wasn't done in the out of hours off work for about a week and she seems to be getting back to normal though. What are your next steps? And I've probably given you a few clues on that. I think the first things that I think through on that is OK, we haven't got a trigger. Um Most patients, in fact, all patients with pure asthma who have exacerbations will have um this caused by either virus or environment is not caused by bacteria as far as we're aware. So extremely rare to need an antibiotic. I do see quite a few people with asthma coming in saying this isn't like my normal asthma. They keep trying, keep trying to give me steroids and they've got a, a proper pneumonia. You still have to listen to these people. They'll often tell you if it's not asthma and it, that's really worthwhile. There's a clinical queue. Um thinking about if they're saying it, it isn't like the asthma I've had before. Um, nope flowing discharge letter, not done and out of hours isn't uncommon. Now, I think it probably is still a very useful investigation to know how bad things are and to have objective evidence of what that deterioration was. Similarly, I suspect in the next few years, um feno fractional exhaled nitric oxide will take that on. What about your next steps? Well, we could increase steroid, we could use a, um a lama, we could add in a theophylline, but I don't think many of us would do that. Nowadays, we could think about leukotriene receptors. What are you doing? I think again, the BT S sign guidance would have strongly recommended at this point moving towards a maintenance and reliever therapy. And that's probably one of the things just to think through. Again, people who've had a history of asthma attacks on a medium dose of inhaled corticosteroid or I CS laba. This seems to reduce that exacerbation rate even more and maintains and keeps their symptoms at least as good as they were before. So what about those who've had two episodes, three episodes, some of the ones that we see. So I gave the, the average numbers for a population of people with asthma. And that tells me most people don't exacerbate, but I know the ones that we come in contact with are often those that are more sym symptomatic. And this is a document produced by the Primary Care Respiratory Society originally in the 2019 updated in 2022. It's also been subsequently virtually adopted word for word by NHS England. Um But what it's effectively saying and the NHS England thing was a collaboration between primary and our specialist colleagues um to, to try and get some sensible guidance about who would, who should we be evaluating and thinking about referring to severe asthma clinics? Very easy. Anyone on regular oral corticosteroids for their asthma should be under specialist care, refer them back if they've been discharged if they've been discharged very recently. Refer them on to a physician who knows about biologics and asthma or look for a really, really good explanation that they've tried all the biologics or there are contraindications to that because all corticosteroids have huge long term side effects. Second group, anyone who's been admitted or been to an emergency department in the last year should be referred to the asthma clinic as part of good guidance from BT S sign and nice and the BT S. But unfortunately, it doesn't always correlate to what's happening in the real world. Um But those are people that have had severe episodes that probably warrant at least a very close look by us if not referral in two or more courses of steroids, six S that could cause a lot of problems if we sent everybody in who's had more than six S and ongoing symptoms. Despite controller. Now, the top four we can easily search for on computers. The fifth one is really something we have to concentrate on when we see patients in our outpatient clinics. Why is it important to think about those? So that group of patients, I'll just go back for a second. Why is it important to think about those, a lot of those patients um won't be taking the medication if we can get them on the medication or using it effectively and, and talk to them and understand their reasons why they don't want to, then that will often settle down their asthma really well. But I'm conscious we don't have a lot of time. So quite often we can refer to into the, our hospital colleagues. They're very busy but they have more time per patient than we do. And they'll be looking at the basics, just make sure that they are actually taking the treatment, but they have a number of um biological tricks up their sleeve. Now, the biological treatments, the first one was a luz um used in asthma monoclonal antibodies or antibodies designed specifically to target part of that inflammatory cascade. And they can really help some people and be life changing for some people who've had um significant lung inflammation. How do they treat asthma well for severe allergic? That's with your high I GS. Yeah, alium seems to be one of the, the key ones that works for your Sinop asthma. Again, there are two or three other biologics that are very handy. These are all the all injections and need regular follow up and there there's also um a further type available and there's more coming on the market. This was an update last year. Um and this is very busy but you can find this on the primary care respiratory update, uh website or primary care respiratory society update. It gives a list of the names of the drugs. It gives you uh common indications when they would be used, how often they're used who would be eligible for it. And most importantly, the common side effects, most of which are fairly innocent. And again, that's not an area that I, that I'm especially comfortable. I wouldn't be initiating this sort of treatment. I'm, I'm a primary care clinician, but it gives you an idea of what our secondary care colleagues with an interest in asthma are getting involved in at the moment. So hopefully, what I've done is left a little bit of time at the end for discussion. But hopefully, what I've done is con convince you that we have established treatments that we've known about for a long time, but we have newer ones coming through at the moment that are exciting, should make a big difference to patient outcomes. Should reduce exacerbations, admissions and probably deaths. The second area is if we can get personalized asthma, action plans ready and review patients appropriately, we again can reduce those exacerbations and deaths and for those unfortunate people who take their treatment but still have significant symptoms. There are some life changes available that our specialist care colleagues have that can make a difference to that. So what I'll do is stop there for questions and see if there are any other comments people want to make. Thank you very much. Indeed. Er, Doctor Her's amazing. Um, er, run through in er, 45 minutes of uh everything we kind of need to know about the management of asthma. Thank you so much. We've got some, er, brilliant questions. Actually, I've been, er, filtering them out as we've been, er, as we've been going through and I'm just gonna start at the top of the list. Um, if you do have other questions, please pop them in the chat and we'll try to cover as many as we can in 13 minutes. So, er, the first one is from, er, Patho and asking, um, can you advise about stepping up or switching from high dose clenil, for instance, 200 BD to foster dosage equivalent or similar in young adults? Um ie in 10 to 20 year olds when they're not controlled. Well, right. Good question. And to be generalized, I'm not, don't want to specifically target one or two brand named products. I think probably the sensible thing with that is if you're thinking about stepping up a treatment and it's a medication that you're not familiar with equivalent doses of inhaled corticosteroids go to right breathe or the Aspirin lung UK probably right breathe for. This is the appropriate one that gives you an idea of comparative doses. There is also a comparative dose chart in the British Asthma guidelines and also in the nice guidelines published a few years ago that a lot of people have a lot of um IBS have a similar comparative strength so that you can at least match the dose of inhaled corticosteroid when you ple a um inhaled corticosteroid, foster a combination at least match the uh steroid dose and add in the long acting BTRI list. If everything's going well, then I'd be looking to move it down. The second thing you put in is about young adults in 10 to 20 year olds. Again, what we're looking for, there is, um, quite a lot of evidence around young people, even the seven and eight year olds being asked by their parents to look after their own asthma and use their inhalers themselves and how many will get out of space for every time for that? Always think about inhaler technique. Always think about genuine adherence. It's easy to order an inhaler every month on your calendar and then stack it into the back of the uh back back of your kitchen cabinet and never be used. So again, we've gotta communicate accurately with patients and see what's going on with that. Hopefully, that answers the question in a slightly indirect way, but generic for all the other sort of options with it. Um Question from uh genie B, I'm relatively new to Mart. Uh when used as a reliever, what's the maximum frequency slash dose of inhaler someone can use in a flare? Right? So in a flare up, if someone has an asthma flare up and you're giving them salbutamol, your license stops on the on the second dose. But most of us, so licensed dose is two puffs. But a lot of us with a space we'd use four or five puffs or 10 puffs and do that repeatedly as it says in the BT S sign guidance for emergency asthma. So there's a license and there's what we do in an emergency. Most people are uh in, in the expert world appear to be very comfortable with. The concept of is if this is an emergency, keep using your long acting bist if you need to every few minutes until you get help from an ambulance or something like that. If it's a normal flare, there are dose limitations on all of the maintenance reliever therapies that are part of that product license. So whatever is in your integrated care board form, get familiar with two of the products there and how many puffs you can use for it in a day. The patient may go over by a couple but you should be encouraging them if they're getting close to that every day for several days to seek medical help. That's why their personalized asthma action plan is as important in maintenance reliever therapy as it is with normal. Um, the old fashioned I CS and a short acting be agonist that maintenance. Um Another quick tip for the personalized asthma action plan. Do it together, write it out together, scribble, let them scribble on it preferably rather than you. It's their plan. You're helping them to develop it and then get them to take a photo of it and keep it in there on their mobile phone. That seems to be the thing that's connected to most people most of the time nowadays. Um And so it's likely they were in having problems and they wanted to check up, they could go to that for, for additional resources. So hopefully that's, he helps there, Claire put in the comment about um how long before things settle down on stopping a short acting beta agonist. If they don't have asthma, it's usually b the evidence on a 19 trial basis were, is quoted at three or four days. In my experience, it's been up to a week, but certainly within two weeks, loads of people come in and say, I wish I hadn't been taking that blue thing. Now, I'm far better than I've been for years. Why didn't no one tell me to stop using the blue one and I can see lots of writing about stop, encouraged to reduce, encouraged to reduce, encouraged to reduce. I think it's making that story for the patient to understand. Ok, good. Hopefully that helps. Um Yeah, go ahead, Steve, what counts as low dose. Um Again, most people are talking, there's, there's a slight difference between very low, low and medium doses in um Children and adults. So again, check it through one of the things you might want to do with that is think anything more than 1000 is high dose, anything around 400 is low. The bit in between is, is that normal range. But good evidence that normal doses of inhaled corticosteroids in both Children and adults are very, very safe long term. Um, comment on exercise induced asthma. It might be worthwhile. Looking at the presentation I did on asthma diagnosis cos I touched quite a bit on exercise induced asthma. If they have exercise induced asthma, treat the asthma, don't let them use lots of blue. It's an asthma problem if they've got cough and cold during the night and they're getting, they won't run for A B and they're getting triggers all over the place. Sort out. The asthma don't let them just use a blue one for it. If they're just using blue, they only need it for exercise. It's probably either not asthma, the very vast majority of people or it's um asthma and they've got all these other symptoms if you ask them. So my advice is exercise induced, proper excise induced asthma. These a proper asthma treatment, which is an he called of a steroid, um, airways hyperresponsiveness caused by using a saber before they exercise needs to remove the Sabba. Um Really good question from Isabel Anderson and Steve of, I've seen a lot of patients can infection in the oral cavity and throat. How can we avoid that? Do all corticosteroids cause Candida? Yep. Um OK. The, the classical things on this are number one en make sure they're encouraged to keep their um inhaler in an area where they can have a drink of water afterwards by and large a bit hard if you're using an anti inflammatory reliever when you need it also a little bit harder if it's a maintenance reliever. But if they can get a drink as soon as possible after that swall their mouth out, either spit it out or swallow it, the amount of steroid in there is low, but it can increase their risk of getting a candidial infection. I'm hesitant to say always keep the inhalers in the bathroom because in most people's bathroom, when they have a lovely steamy bath or shower, there's a lot of moisture around and dry power devices are more like to clog up in that sort of environment if they've left the cap off. So there are some practicalities about that. Um Most patients, if they've got, I think their second thing to do on that is bring them in, have a look at how they use the inhaler if they're going and they're blasting all the air onto the back of their palate. It's hardly surprised they're gonna get candida. They need to. If it's a pressure meter dose inhaler, it needs a slow and steady inhalation to avoid it all just sticking on the back of the, their upper palate and uvula and that sort of area. So again, technique is very important. People talked about cycloimide, which is still available for the very low number of people who seem to get recurring candidal infections as an inhaler called a steroid. But the vast majority of patients usually find an inhaler that suits them without the need for that. Um Really great question from Claire Butler. Do eosinophil counts improve with better control or are they just used to support diagnosis? But um the eosinophil counts can improve with better control and usually do over a period of time, not, not as quickly as the FENO levels which will respond much more better. So in a primary care setting, I'd probably be suggesting we move to a much more feno based monitoring system rather than the blood test. Every time we see them to see whether they've got eosinophilic airway inflammation. Um eosinophil count can help to support the diagnosis. But again, going back to go and have a quick look at the last talk I did on diagnosis. Remember the commonest cause of raised eosinophil count globally is a chronic parasitic infection. Nothing to do with asthma or allergic rhinitis. A lot of patients with any at eczema or allergic rhinitis can have a raised eosinophil count and there are quite a lot of drugs that raise the eosinophil count as well. So um a Sinop fil counts might help to inform practice if you can see responses to treatments at other points. But probably most of the patients, I would be suggesting in a real real world context, thinking about using um a fractional exhaled nitric oxide and I hope that that will come out in the guidance soon. You'll be able to see it in the draft form in the next few weeks and I hope that will subsequently be funded. So we can really start to improve patients treatment with asthma and get them on the right stuff. Uh Sheena flower is asking mucus is often a problem for patients despite using their inhaler. Is there anything else we can do to help with that? Yeah. Um probably a few quick things trigger in my mind when that's going on. I think the first thing is, is the mucus associated with infections and how are they getting recurring infections? Is this actually asthma that's been under treated for a long time, go back to the diagnosis section and then now developing a fixed airways problem or is it um bronchiectasis or is it um a habit forming thing that they've had for a long time? Is the mucus coming from the chest or is it coming from the nose? Do you need to treat their allergic rhinitis? Um So for, for certain patients, it's worthwhile trying to distinguish where, where is this mucopurulent or mu mucoid discharge coming from? Other thing to think through again is smokers, a lot of smokers, if you think about going into a big bonfire area on bonfire night, um you get lots of smoke going into your lungs, the lungs will feel very dry afterwards and sore. If I have a bonfire every day, I start to develop something called mucociliary hyperplasia. That means that the wavy things that produce uh mucus in my airwaves. Think I don't want all this stuff drying out my airwaves making me feel bad. Let's produce more and that hyperplasia produces more and more mucus. If someone suddenly stops smoking or is ill and reduces their smoking, they're probably producing more mucus because the body is expecting that toxin, that toxic smoke to be coming back into the lungs. So there's a number of things to think through. Some of our patients might benefit from a mucolytic a lot. It's not particularly well used in this sort of group and it doesn't fit into the guidelines in asthma. And I haven't seen any good reviews in asthma. It's much more used in things like CO PD and bronchiectasis. But again, try to establish why are they producing, producing more mucus than you'd expect um, bit of time just to squeeze perhaps one more in from, er, Lorraine, which was, what is the maximum number of puffs that you can, er, take off Brycon in an emergency of brycon. Correct. Yep. Um, Brycon, I haven't actually looked that one up. It might be something to have a quick look at, but most of them, most of the older products are probably gonna say one or two puffs in an acute situation. I might be wrong on that. I haven't looked it up. So I really don't know. But I'll be ii that's something I'll do after this meeting. We always have to have a little bit of homework to do. I think people are saying I mentioned during this, that Symbicort was licensed for um the as needed I CS Laba. So that's just when you need to in mild asthma in people over 12 for people with a maintenance and reliever therapy. There are quite a lot of inhaled corticosteroid laba combinations that are licensed. You need to look them up, they should be on your local formulary as to which ones are available. But at the moment, Symbicort, only for um, antiinflammatory reliever they as needed over the next month, year, a lot of others will have a similar license. It's a matter of time. Um Steven, if you can let us know what the answer is, what we'll do is, uh, we'll pop that in a thread. So Lorian, you'll get a notification afterwards. We, we'll pop the answer in the primary care, er community on metal. So that, so that you have an answer afterwards if you, if you keep talking for, if you keep talking for about half a minute. Ok. Ok. Perfect. So perfect segue. I'm just going to, I'm going to put a QR code on the screen. Um, if you've enjoyed this session, I hope you have. Um, I certainly have, I think it's been amazing and massive. Thank you to Doctor Holmes for putting it together. Um Give us a follow at the top of the screen hit. Follow me primary care um and then download the app with the QR code here. It means you'll get invitations to other similar sessions. And uh we do this because we want to make medical education radically accessible. And uh and we believe in doing that, not just for colleagues in the UK, Ireland and, and beyond, but also for colleagues around the world in lower middle income settings. Um We do a completely open access and we're really proud that you've joined us this evening. So um you can uh get invites to the next sessions, you can get your feedback form, you can get your certificate, you can get access to the catch up content um in the app and you'll get, er, you'll be the first one to know about our next events. Um I'm gonna pop a feedback form into the chat and if you give us some feedback, you'll get a certificate at the end. Hopefully, that's given you enough time, Steve it has. I've got the answer. The answer is with Terbutaline, the license is one puff in the exacerbation up to four in a 24 hour period. So again, not enough to, to, to the sort of extent we would be routinely using it in an acute emergency type environment. That's with a, that's with a pressure beer, sorry, a dry powder device um at 500 M er micrograms. Amazing. Um And we just had a question of like, can we watch your first session on the app. Yes, you can. So the first session is there and you'll be able to watch it on demand. Um I'm gonna call it a day. Uh There we rattled through loads of um great education and also some amazing questions. So thank you to everyone in the audience for um for joining us keeping this interactive and lots of, lots of really great conversation. Uh We hope to see you at our next session. Um Just scan the QR codes and follow us um at all primary care. Uh You'll be the first one to know about it. Um uh Just leave to say thank you to Doctor Holmes to um to everyone who's joined us for a really great collaborative session. Uh We're, we're really grateful. Um And, and I hope you find it useful. Have a really wonderful evening everyone and thank you for joining us. Thank you very much.