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Symposium: Respiratory medicine

Improving the management of chronic asthma in children

21 Dec 2020Paid-up subscribers

There is no gold standard test to diagnose asthma. As a result, overdiagnosis and underdiagnosis are common especially when relying on history and clinical examination alone. Spirometry and bronchodilator reversibility testing are particularly useful when a child aged 5 years or older is brought to the practice with symptoms. The validated Asthma Control Test for children aged 12 years and over and the Children’s Asthma Control Test for children aged 4-11 years should be used to assess current asthma control based on four-week recall. Asthma control test scores correlate poorly with lung function and measures of airway inflammation such as FeNO in children and should not be used in isolation.

Diagnosis and management of malignant pleural mesothelioma

21 Dec 2020

Mesothelioma accounts for less than 1% of all cancers in England, Wales and Northern Ireland. There are almost 2,500 new diagnoses a year, of which 96% are pleural. The median age at diagnosis for malignant pleural mesothelioma (MPM) is 76 years. The majority of cases occur in men, most commonly following occupational exposure to asbestos. There is a latent period, usually 30-40 years, between exposure and disease development. A chest X-ray is usually the first-line investigation; 94% of patients with MPM have a unilateral pleural effusion, although the chest X-ray may be normal or show another asbestos-related lung disease. 

 

COPD related articles

Improving COPD outcomes in primary care

24 Oct 2019Paid-up subscribers

Diagnosis of COPD is based on the presence of airflow obstruction after the administration of a bronchodilator i.e. post-bronchodilator spirometry. However, the National COPD Audit report for 2017-18 found that 59.5% of people hospitalised with a COPD exacerbation in England and Wales had no spirometry result available and in 12% of those who had undergone spirometry the test showed no airflow obstruction. Patients with COPD should be reviewed annually. It is advisable to repeat spirometry if there is a significant change in symptoms. It is important to determine objective measures of breathlessness (MRC dyspnoea score), quality of life (CAT questionnaire) and exacerbations (annual exacerbation and hospitalisation rate) as part of this review.

Optimising the management of patients with COPD

25 Mar 2019Paid-up subscribers

COPD should be suspected in an older adult (at least 35 years old but typically more than 45 years old) who presents with symptoms such as breathlessness, wheeze, cough and sputum production and has one or more risk factors, typically current, or a past history of, cigarette smoking. A diagnosis should also be suspected when an individual with a risk factor develops a lower respiratory tract infection requiring treatment. COPD is far more common in smokers of heroin and crack cocaine, in whom it occurs at a younger age.

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 2017Registered users

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.

 

Asthma in adults

Managing mild to moderate asthma in adults

22 Nov 2018Registered users

The National Review of Asthma Deaths found that most patients who died were actually considered to have mild to moderate asthma, with 57% of fatal cases not under specialist care at the time of their death. In cases of fatal asthma there was widespread underuse of inhaled corticosteroids and an overreliance on short-acting beta-agonists. Referral to secondary care should take place when there is diagnostic uncertainty or atypical features, the possibility of hypersensitivity to inhaled material or concerns over treatment or exacerbations. Patients who have suffered even a single life-threatening asthma attack should be under specialist supervision. 

GPs have key role in improving outcomes in acute asthma

24 Nov 2016Registered users

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. 

 

Other respiratory diseases

Detecting and managing pulmonary hypertension

20 Dec 2019Registered users

Pulmonary hypertension (PH) is a haemodynamic state where the mean pulmonary artery pressure measured at cardiac catheterisation is 25 mmHg or more. Precapillary PH arises from increased resistance to blood flow in the pulmonary arterioles and postcapillary PH from elevated left atrial pressure. In postcapillary PH the cause is left heart disease whereas precapillary PH may be caused by any other form of PH. Patients develop symptoms only when the disease is advanced. Symptoms at presentation are non specific. Adults almost always present with breathlessness and may also complain of exercise-induced dizziness or syncope and angina. An echocardiogram is the best investigation to ascertain the probability of PH.

Time to diagnosis key in improving lung cancer outcomes

25 Nov 2019

NICE recommends urgent referral via a suspected cancer referral pathway to the two week wait service if: chest X-ray findings suggest lung cancer or if patients aged 40 and over have unexplained haemoptysis. However, studies have indicated that around 20-25% of patients with confirmed lung cancer may have a chest X-ray reported as normal and this figure may be higher for early stage lung cancers. Therefore, the National Optimal Lung Cancer Pathway recommends that where there is a high suspicion of underlying malignancy (but the chest X-ray is normal), GPs should refer patients directly for a CT scan.

 

Allergy and anaphylaxis

Improving outcomes in allergic rhinitis in children

24 Jun 2019Paid-up subscribers

Allergic rhinitis can affect a child’s physical health, reduce their quality of life, sleep and concentration, and impact on school performance. Children with allergic rhinitis are at increased risk of developing asthma. Around 85% of those with asthma have allergic rhinitis, which can complicate diagnosis and management and also increase the risk of hospitalisation for asthma exacerbations. However, appropriate management of allergic rhinitis can improve asthma control. The diagnosis of allergic rhinitis can usually be made on the basis of the patient’s history and examination alone. 

History taking the key to diagnosing food allergy in children

25 Jul 2018Registered users

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.



 

Asthma in children

Improving the management of chronic asthma in children

21 Dec 2020Paid-up subscribers

There is no gold standard test to diagnose asthma. As a result, overdiagnosis and underdiagnosis are common especially when relying on history and clinical examination alone. Spirometry and bronchodilator reversibility testing are particularly useful when a child aged 5 years or older is brought to the practice with symptoms. The validated Asthma Control Test for children aged 12 years and over and the Children’s Asthma Control Test for children aged 4-11 years should be used to assess current asthma control based on four-week recall. Asthma control test scores correlate poorly with lung function and measures of airway inflammation such as FeNO in children and should not be used in isolation.

Managing acute asthma in children

25 Jun 2018Paid-up subscribers

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. 

 

Research reviews

Asthma admissions in under 5s fall following smoking ban in vehicles

24 Sep 2021Registered users

Hospitalisation rates for asthma in preschool children have significantly declined since the ban on smoking in vehicles carrying children in Scotland, a study has found.

Corticosteroid therapy for asthma raises risk of osteoporosis and fragility fractures

27 Oct 2020Registered users

Use of oral or inhaled corticosteroids appears to be an independent risk factor for osteoporosis and fragility fractures in patients with asthma, a UK population-based study has found.

Is air pollution associated with onset of asthma in childhood?

24 Sep 2020Registered users

A nationwide case-control study from Denmark has strengthened the evidence that parental asthma and smoking in pregnancy are risk factors for onset of asthma and persistent wheezing in children. The results also suggest that exposure to ambient small particles < 2.5 µm (PM2.5) may be a potential risk factor. However, this finding needs to be substantiated in future studies, the authors say.

Asthma persisting from childhood to adulthood presents a distinct phenotype

24 Jul 2020Registered users

Asthma that starts in childhood and persists throughout adult life tends to be more severe and is associated with poorer lung function compared with adult-onset asthma, a study from Japan has concluded. The difference in clinical characteristics points to a distinct phenotype.

Weight gain associated with accelerated lung function decline

24 Mar 2020Paid-up subscribers

Adults who put on weight over a 20-year period had a more rapid decline in FVC and FEV1, a large international population-based study has shown. However, weight loss was found to attenuate the decline.

Overweight adolescents consult more frequently for respiratory symptoms

23 Jan 2020Paid-up subscribers

Overweight teenagers are more likely to consult their GP for asthma, and other respiratory symptoms, than those of normal weight, a study from the Netherlands has found. A total of 617 children, aged 2 to 18 years, were recruited to a prospective cohort study from 71 GP practices across the country. Height and weight were measured at recruitment and other health and social data collated from questionnaires sent to patients/parents. Children with disabilities or conditions affecting their weight were excluded. Details of subsequent consultations were obtained from the medical records.

Automated cough sound analysis shows promise as a diagnostic tool

20 Dec 2019Paid-up subscribers

Analysis of cough sounds captured on a smartphone can potentially be used to help diagnose common respiratory conditions in children, a study from Western Australia has shown. The study authors conclude: ‘We have demonstrated that automated cough analysis delivers good diagnostic accuracy in detecting common childhood respiratory diseases including pneumonia, RAD, croup, bronchiolitis, upper and lower respiratory tract disorders. It can be used as a diagnostic aid for childhood respiratory disorders.’

Symptoms based approach to asthma may miss children at risk

25 Nov 2019Registered users

Abnormal spirometry and FeNO results are common in children with asthma managed in primary care and relate poorly to symptom scores, a UK study has shown.

Breathlessness independently associated with obesity and weight gain in adult life

24 Oct 2019Paid-up subscribers

Middle-aged individuals with a high body mass index (BMI) and those whose BMI had significantly increased since the age of 20 had an increased prevalence of breathlessness, a population-based study has found.

High levels of cardiorespiratory fitness associated with reduced risk of COPD

07 Aug 2019Paid-up subscribers

Good cardiorespiratory fitness in midlife may lower the risk of developing and dying from COPD, a prospective cohort study from Denmark has found.

 

Asthma - research reviews

Temporary quadrupling of inhaled steroids can reduce severe asthma exacerbations

23 Apr 2018

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.

 

Wheeze in children

Risk factors for wheezing in early childhood across Europe

22 Nov 2018Registered users

Lower respiratory tract infections (LRTIs), maternal smoking, day care attendance and male gender are important risk factors for wheezing in infants, a panEuropean study has confirmed. Food allergy and infant feeding practices were not associated with wheeze. The prevalence of wheezing varied widely between different European countries.

Optimising the management of wheeze in preschool children

23 Jun 2016Paid-up subscribers

One third of all preschool children will have an episode of wheeze and many of these present to primary care. Most will fall within a spectrum of diagnosis ranging from episodic viral wheeze to multiple trigger wheeze or early onset asthma. The child should be referred to hospital immediately if you suspect an inhaled foreign body or anaphylaxis (after administering IM adrenaline). NICE recommends immediate referral for children with wheeze and high-risk features and also those with intermediate-risk features failing to respond to bronchodilator therapy.