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Asthma

Managing acute asthma in children

25 Jun 2018

The BTS/SIGN guideline specifies that the accurate measurement of oxygen saturation is essential in the assessment of all children with acute wheezing. It recommends that oxygen saturation probes and monitors should be available for use by all healthcare professionals assessing acute asthma in primary care. It is important to use the appropriate size paediatric probe to ensure accuracy. Any patient who presents to the GP practice with any features of a moderate exacerbation should be referred to an emergency department for further assessment and monitoring. 

Regular review pivotal in chronic asthma in children

23 Nov 2017Paid-up subscribers

The aim of asthma treatment is complete control of symptoms as soon as possible while minimising side effects and inconvenience to the patient. All parents and older children should be offered a written action plan. This should include details of the patient’s regular medicines, how to recognise deterioration and what to do in the event of an attack. Children should be referred to secondary care if: the diagnosis is unclear; control remains poor despite monitored treatment; they have suffered a life-threatening attack or red flag features are present.

GPs have key role in improving outcomes in acute asthma

24 Nov 2016Paid-up subscribers

Features which indicate a high risk of severe attacks include: previous admission to intensive care, particularly if requiring mechanical ventilation; previous admission with asthma especially in the past year or repeated emergency admissions; history of worsening asthma in January or February; use of three or more classes of asthma medication; heavy use of beta-2 agonists; anxiety traits; and marital stress. 

Optimising the management of patients with difficult asthma

25 Nov 2015Registered users

Between 5 and 10% of asthma (depending on the definition used) is categorised as difficult asthma, a term which generally refers to patients who continue to experience symptoms and frequent exacerbations despite the prescription of high-dose asthma therapy. Difficult asthma is an indication for specialist review by an appropriate respiratory physician, but close liaison between primary, secondary and tertiary care is critical.

Improving the management of asthma in adults in primary care

24 Nov 2014Registered users

Studies in adult patients have suggested that 30% of those diagnosed with asthma do not have the condition and it is likely that the diagnosis is missed in many others. The BTS/SIGN guideline advocates spirometry after taking the history. If airflow obstruction is present, a trial of treatment can commence, but a firm diagnosis also requires a symptomatic response and an improvement in the measured airflow obstruction. The FeNO level correlates well with airway inflammation, and is therefore a good indicator of asthma and in particular of the likely response to inhaled corticosteroids. The test is especially useful for patients with suggestive symptoms but normal spirometry.

Occupational asthma often goes unrecognised

12 Dec 2012Paid-up subscribers

Occupational asthma is induced de novo by an airborne agent encountered in the workplace. The risk of occupational asthma is greater in those with a prior atopic history. Work-exacerbated asthma is the provocation of pre-existing, or coincidental, disease by one or more irritant exposures at work. Distinguishing occupational from work-exacerbated asthma can be difficult but it is important since the two have very different clinical, occupational and legal implications. 

 

Other respiratory diseases

Assessment and management of active and latent TB

24 Nov 2016Paid-up subscribers

Clinically significant disease occurs through progression of primary infection or through later reactivation of latent TB infection (LTBI); this is most likely to occur in the first few years following infection, although late reactivation can occur several decades later, particularly in individuals who become immunosuppressed. Risk of TB acquisition is increased in people who have come to the UK from high incidence countries or who are born in the UK but come from high-risk ethnic minority groups. Other risk groups include those who are homeless, in prison or who misuse drugs or alcohol.

Early diagnosis pivotal to survival in lung cancer

24 Nov 2014Paid-up subscribers

Lung cancer is the most common cause of cancer death, both in the UK and worldwide. There has been little change in survival over the past 20 years, with increasing evidence that there are disparities in outcomes between the UK and other comparable healthcare systems. It has been postulated that this is due to an excess of early deaths, delays in diagnosis are thought to contribute to this problem. A recent study showed that 30% of patients with lung cancer die within the first 90 days and they have seen their GP on average five times in the four months before diagnosis, suggesting there may be opportunities to diagnose these patients earlier in the disease process. The challenge GPs face is to identify and refer those at risk as early as possible and to maintain a high index of suspicion if symptoms persist.  [With external links to current evidence base]

Diagnosing and managing pulmonary hypertension

12 Dec 2012Paid-up subscribers

Pulmonary hypertension (PH) is defined as an increase in mean pulmonary arterial pressure ≥ 25 mmHg at rest as assessed invasively by right heart catheterisation. It can affect patients at any age and presents with non-specific symptoms. Accurate diagnosis is important as while PH is a potentially lethal disease it is treatable. Identification of the cause of PH is crucial to ensure that the patient receives appropriate management.

Improving outcomes in lung cancer patients

23 Nov 2011Registered users

Lung cancer is the leading cause of cancer mortality in the UK resulting in more than 33,500 deaths in 2008, 4,000 more than for bowel and breast cancer combined. Five-year survival figures are poor but have recently improved from around 5% to 7.5% in men and 8.5% in women.There is evidence of marked variation in the standard of care in England.  It has recently been shown that if patients are first referred to a thoracic surgical centre, rather than a hospital that does not have thoracic surgeons on site, they are 51% more likely to have a resection. There are similar findings for other active treatments. By reducing this variation there is scope for marked improvement in outcomes, possibly to levels seen in other countries such as Australia, Canada, Sweden and Norway where five-year survival rates are approximately double. Thus there is a need to encourage lung cancer teams to select patients correctly so that the best treatment can be offered. Improving diagnosis, staging and fitness assessment was a major focus in the recently updated NICE guideline on diagnosis and treatment of lung cancer, published in April 2011.  [With external links to current evidence and summaries]

Improving outcomes in patients with cystic fibrosis

08 Aug 2011Paid-up subscribers

Cystic fibrosis (CF) is the most common fatal inherited disease in Caucasian people. Recent data indicate that there are more than 9,000 patients with CF in the UK. This would equate to around one or two patients for an average GP practice. Recognising the symptoms and signs that may point to a diagnosis of CF is important so that appropriate referral and investigations can be organised. Symptoms suggestive of CF in the first two years of life include failure to thrive, steatorrhoea, recurrent chest infections, meconium ileus, rectal prolapse and prolonged neonatal jaundice. In older children, additional suggestive symptoms include ‘asthma'-like symptoms, clubbing and idiopathic bronchiectasis, nasal polyps and sinusitis, and heat exhaustion with hyponatraemia. Suggestive symptoms in patients who present in adulthood, who are more likely to have atypical CF, include azoospermia, bronchiectasis, chronic sinusitis, acute or chronic pancreatitis, allergic bronchopulmonary aspergillosis, focal biliary cirrhosis, abnormal glucose tolerance, portal hypertension and cholestasis/gallstones. [With external links to the evidence base]

Tackling upper respiratory tract infections

22 Nov 2010Paid-up subscribers

Upper respiratory tract infection (URTI) refers to a wide range of acute illnesses that affect the upper respiratory tract. URTIs are the most common reason for general practice consultations. On average adults suffer two to three such infections per year. Most URTIs are self-managed. A UK study of 516 women aged 20-44 years found that only one in 18 episodes of sore throat led to a general practice consultation. Patients who do seek consultations often benefit from reassurance, education and instructions for symptomatic home treatment. A large proportion of antibiotic prescribing in primary care is for respiratory tract infections. There was a 44% reduction in antibiotic prescribing for respiratory tract infections between 1994 and 2000. The larger part of this reduction was due to lower consultation rates rather than a decrease in prescribing by GPs. Antibiotics are frequently prescribed for resolving symptoms and to prevent complications. Patients' expectations have a significant influence on prescribing, even when their doctor judges that antibiotics are not indicated.There are certain at-risk groups who require immediate antibiotics or further evaluation.

Obstructive sleep apnoea increases risk of CVD

15 Nov 2009Paid-up subscribers

In OSA, the patient suffers repeated episodes of apnoea caused by narrowing or closure of the pharyngeal airway during sleep. About 2-4% of the middle-aged population have OSA. Although understanding of the condition has improved considerably, it is estimated that 85-90% of sufferers still remain undiagnosed.

 

Asthma - research reviews

Temporary quadrupling of inhaled steroids can reduce severe asthma exacerbations

23 Apr 2018Registered users

A temporary four-fold increase in inhaled steroids for deteriorating asthma control reduced the incidence of severe exacerbations, in a UK study.

Breathing self-management programme improves quality of life in asthma

23 Jan 2018

A breathing retraining exercise programme, incorporating a training DVD and accompanying booklet, achieved similar improvements in quality of life scores as conventional face to face training in patients with asthma, in a UK study.

 

COPD related articles

Smoking duration the best indicator of COPD progression

22 May 2018Registered users

The number of years that an individual has been smoking is closely linked to the degree of structural lung disease, airflow obstruction and functional outcomes in chronic obstructive pulmonary disease (COPD). It is a better measure than pack-years or the number of cigarettes smoked per day, a large study from the USA has shown.

Pulmonary rehabilitation improves exercise capacity and quality of life

23 Jan 2018Registered users

Pulmonary rehabilitation is a multifaceted programme of exercise and education that aims to improve breathlessness, exercise capacity, and quality of life, and aid self-management. Patients with chronic respiratory failure, those on long-term or ambulatory oxygen and patients with anxiety and depression can all benefit from rehabilitation. It is one of the most beneficial and cost-effective treatments for COPD and should be considered a fundamental component of disease management rather than an option.

Improving outcomes in COPD

23 Nov 2017Paid-up subscribers

Cigarette smoking is overwhelmingly the most important risk factor for COPD. In some cases, other factors such as occupation, passive exposure to inhalants and fetal nutrition/low birthweight are also important. The diagnosis should be suspected in symptomatic patients with risk factors, usually cigarette smoking, aged 40 years or above, albeit a majority of people with COPD present when considerably older. The 2017 GOLD guideline recommends that management should be focused on two objectives. First, to relieve symptoms of breathlessness (assessed using the MRC dyspnoea scale) and improve quality of life (assessed by the COPD Assessment Test). Second, to reduce risk assessed by the number of exacerbations and hospitalisations in the previous year.

 

Allergy and anaphylaxis

History taking the key to diagnosing food allergy in children

25 Jul 2018

Allergy to milk and egg are the two most prevalent food allergies in children. They are typically diagnosed in infancy and carry a good prognosis with the majority of cases resolving before the child reaches school age. Other allergies may present later in childhood and are more likely to persist. There is evidence of a causal link between early onset severe and widespread eczema that is unresponsive to moderate topical steroids and development of IgE mediated food allergy, in particular peanut allergy. The EAT study showed that infants who were weaned early and exposed to egg and peanut had a significant reduction in allergy to both foods.



Peanut allergy – is it time to change infant feeding practice?

23 Mar 2015Registered users

Early introduction of peanut into the diet of high-risk babies significantly decreases the frequency of peanut allergy at five years of age, a UK open label single-centre study has found. The present study was well designed and showed a strong effect in its primary outcome. The question many will ask is can these findings now be translated into advice for our patients? The answer is no.

Diagnosing and managing peanut allergy in children

23 Jun 2014Registered users

The prevalence of peanut allergy is thought to be rising with 1 in 70 children affected in the UK. Accidental exposures are frequent and nut allergies are the leading cause of fatal food allergic reactions. Peanut allergy most commonly presents in the first five years of life. More than 90% of nut allergic children will have a history of eczema, asthma, rhinitis or another food allergy. The clinical diagnosis of peanut allergy is made from a typical history in combination with clinical evidence of sensitisation i.e. the presence of peanut-specific IgE or positive skin prick tests. [With external links to the evidence base]

Optimising treatment of allergic rhinitis in children

24 Jun 2013Paid-up subscribers

Acute and chronic symptoms of allergic rhinitis can disrupt school and leisure activities, significantly reducing quality of life. Temporal patterns of exacerbation give clues as to the most important aeroallergens implicated.  Where continuing deterioration presents a challenge and allergic symptoms remain uncontrolled, patients should be referred to a specialist allergy service to be considered for immunotherapy. [With external links to the evidence base]

Identifying the culprit allergen in seasonal allergic rhinitis

30 May 2011Paid-up subscribers

Seasonal allergic rhinitis (SAR) is a global health problem and affects 20% of the UK population. It is the main form of rhinitis in children whereas in adults it accounts for about a third of cases. SAR can have  a significant impact on patients' quality of life. It can lead to non-attendance and underperformance at school and work and results in substantial NHS costs. In children, it may affect GCSE results as the grass pollen season coincides with exams. SAR is a risk factor for the development of asthma and chronic rhinosinusitis which may be difficult to treat. As the major burden of allergic rhinitis is on primary care, GPs play a key role in the management of these patients.