How do you diagnose asthma?
Diagnose asthma in adults (aged 17 and over) if they have symptoms suggestive of asthma and:
- a FeNO (fractional exhaled nitric oxide) level of 40 ppb or more with either positive bronchodilator reversibility or positive peak flow variability or bronchial hyperreactivity, or
- a FeNO level between 25 and 39 ppb and a positive bronchial challenge test, or
- positive bronchodilator reversibility and positive peak flow variability irrespective of FeNO level.
What are the different tests to diagnose asthma and when would you use them?
Fractional exhaled nitric oxide
- Offer a FeNO test to adults (aged 17 and over) if a diagnosis of asthma is being considered. Regard a FeNO level of 40 parts per billion (ppb) or more as a positive test.
- Consider a FeNO test in children and young people (aged 5 to 16)[2] if there is diagnostic uncertainty after initial assessment and they have either:
- normal spirometry or
- obstructive spirometry with a negative bronchodilator reversibility (BDR) test.
- Regard a FeNO level of 35 ppb or more as a positive test.
- Be aware that a person’s current smoking status can lower FeNO levels both acutely and cumulatively. However, a high level remains useful in supporting a diagnosis of asthma.
Spirometry
- Offer spirometry to adults, young people and children aged 5 and over if a diagnosis of asthma is being considered. Regard a forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio of less than 70% (or below the lower limit of normal if this value is available) as a positive test for obstructive airway disease (obstructive spirometry).
Bronchodilator reversibility
- Offer a BDR test to adults (aged 17 and over) with obstructive spirometry (FEV1/FVC ratio less than 70%). Regard an improvement in FEV1 of 12% or more, together with an increase in volume of 200 ml or more, as a positive test.
- Consider a BDR test in children and young people (aged 5 to 16) with obstructive spirometry (FEV1/FVC ratio less than 70%). Regard an improvement in FEV1 of 12% or more as a positive test.
Peak expiratory flow variability
- Monitor peak flow variability for 2 to 4 weeks in adults (aged 17 and over) if there is diagnostic uncertainty after initial assessment and a FeNO test and they have either:
- normal spirometry or
- obstructive spirometry, reversible airways obstruction (positive BDR) but a FeNO level of 39 ppb or less.
- Regard a value of more than 20% variability as a positive test.
Consider monitoring peak flow variability for 2 to 4 weeks in adults (aged 17 and over) if there is diagnostic uncertainty after initial assessment and they have:
- obstructive spirometry and
- irreversible airways obstruction (negative BDR) and
- a FeNO level between 25 and 39 ppb.
- Regard a value of more than 20% variability as a positive test.
Direct bronchial challenge test with histamine or methacholine
- Offer a direct bronchial challenge test with histamine or methacholine[3] to adults (aged 17 and over) if there is diagnostic uncertainty after a normal spirometry and either a:
- FeNO level of 40 ppb or more and no variability in peak flow readings or
- FeNO level of 39 ppb or less with variability in peak flow readings.
- Regard a PC20 value of 8 mg/ml or less as a positive test.
What should you do before starting or adjusting medicine in asthma?
Take into account the possible reasons for uncontrolled asthma, before starting or adjusting medicines for asthma in adults, young people and children. These may include:
- alternative diagnoses
- lack of adherence
- suboptimal inhaler technique
- smoking (active or passive)
- occupational exposures
- psychosocial factors
seasonal or environmental factors.
What pharmalogical treatment is available to adults (17 and older)?
- 6.1 Offer a short-acting beta2 agonist (SABA) as reliever therapy to adults (aged 17 and over) with newly diagnosed asthma.
- 6.2 For adults (aged 17 and over) with asthma who have infrequent, short-lived wheeze and normal lung function, consider treatment with SABA reliever therapy alone.
- 6.3 Offer a low dose of an ICS as the first-line maintenance therapy to adults (aged 17 and over) with:
symptoms at presentation that clearly indicate the need for maintenance therapy (for example, asthma-related symptoms 3 times a week or more, or causing waking at night) or
asthma that is uncontrolled with a SABA alone.
- 6.4 If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS as maintenance therapy, offer a leukotriene receptor antagonist (LTRA) in addition to the ICS and review the response to treatment in 4 to 8 weeks.
- 6.5 If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and an LTRA as maintenance therapy, offer a long-acting beta2 agonist (LABA) in combination with the ICS, and review LTRA treatment as follows:
discuss with the person whether or not to continue LTRA treatment
take into account the degree of response to LTRA treatment.
- 6.6 If asthma is uncontrolled in adults (aged 17 and over) on a low dose of ICS and a LABA, with or without an LTRA, as maintenance therapy, offer to change the person’s ICS and LABA maintenance therapy to a MART regimen with a low maintenance ICS dose.
- 6.7 If asthma is uncontrolled in adults (aged 17 and over) on a MART regimen with a low maintenance ICS dose, with or without an LTRA, consider increasing the ICS to a moderate maintenance dose (either continuing on a MART regimen or changing to a fixed-dose of an ICS and a LABA, with a SABA as a reliever therapy).
- 6.8 If asthma is uncontrolled in adults (aged 17 and over) on a moderate maintenance ICS dose with a LABA (either as MART or a fixed-dose regimen), with or without an LTRA, consider:
increasing the ICS to a high maintenance dose (this should only be offered as part of a fixed-dose regimen, with a SABA used as a reliever therapy) or
a trial of an additional drug (for example, a long-acting muscarinic receptor antagonist or theophylline) or
seeking advice from a healthcare professional with expertise in asthma.
What is classed as a low, moderate and high dose for ICS?
less than or equal to 400 micrograms budesonide or equivalent would be considered a low dose
more than 400 micrograms to 800 micrograms budesonide or equivalent would be considered a moderate dose
more than 800 micrograms budesonide or equivalent would be considered a high dose.
What is MART?
Maintenance and reliever therapy (MART) is a form of combined ICS and LABA treatment in which a single inhaler, containing both ICS and a fast-acting LABA, is used for both daily maintenance therapy and the relief of symptoms as required. MART is only available for ICS and LABA combinations in which the LABA has a fast-acting component (for example, formoterol).
What is uncontrolled asthma?
Uncontrolled asthma describes asthma that has an impact on a person’s lifestyle or restricts their normal activities. Symptoms such as coughing, wheezing, shortness of breath and chest tightness associated with uncontrolled asthma can significantly decrease a person’s quality of life and may lead to a medical emergency. Questionnaires are available that can be quantify this.
This guideline uses the following pragmatic thresholds to define uncontrolled asthma:
3 or more days a week with symptoms or
3 or more days a week with required use of a SABA for symptomatic relief or
1 or more nights a week with awakening due to asthma.
In what order should you do asthma tests?
Measure:
- FeNO (Fractional exhaled nitric oxide) then spirometry
- Carry out a BDR (Bronchodilator reversibility) test if spirometry shows obstruction
- If uncertain monitor peak flow variability for 2-4 weeks
- Refer for a direct bronchial challenge test with histamine or methacholine
Which factors make a diagnosis of asthma more likely?
- More than one of the following symptoms: wheeze, breathlessness, chest tightness and cough, particularly if:
symptoms worse at night and in the early morning
symptoms in response to exercise, allergen exposure and cold air
symptoms after taking aspirin or beta blockers
frequent, recurrent, occur apart from colds/with emotion (children) - History of atopic disorder
- Family history of asthma and/or atopic disorder
- Widespread wheeze heard on auscultation of the chest
- Otherwise unexplained low FEV1 or PEF (historical or serial readings)
- Otherwise unexplained peripheral blood eosinophilia
- Symptoms/lung function improve with treatment (children)
What is included as part of an asthma review?
Control Lung function (spirometry or PEFR). Exacerbations, ICS use, time off work/school. Inhaler technique. Concordance (compliance). Frequency of B2 agonist prescriptions. Possession and use of personal action plan. Flu jab! Children: exposure to smoke, growth Personal asthma action plan
When would you suspect inflammatory back pain?
Suspect if:
- pain and stiffness lasting more than 30mins after waking
- pain that is relieved by mobilizing
- insidious onset and a chronic course
- age<45
What are the signs and symptoms of sciatica?
- unilateral leg pain that radiates below the knee to the foot or toes
- back pain when present is less severe than the leg pain
What are the signs and symptoms of nerve root compression?
(numbness, tingling, weakness, or loss of tendon reflexes) all in the distribution of a nerve root
What are the time limits for acute and chronic mechanical lower back pain?
acute if <6 weeks, chronic if >6 weeks
What are the red flags for lower back pain?
- Cauda Equina Syndrome
- Significant trauma (r/o #)
- Weight Loss
- Hx of cancer
- Constitutional symptoms eg fever, chill, unexplained weight loss
- IV drug use
- Steroid Use / immunosuppression
- <20 or >55
- Severe unremitting night-time pain
- Pain that gets worse lying down
- Vertebral pain
What are the yellow flags of back pain?
- Belief that pain and activity are harmful
- Sickness behaviours, such as extended rest
- Social withdrawal
- Emotional problems such as low or negative mood, depression, anxiety and stress
- Problems and/or dissatisfaction at work
- Problems with claims or compensation, or time off work
- Overprotective family; lack of support
- Inappropriate expectations of treatment, including low expectations of active participation in treatment.
What investigations are done if serious spinal pathology is suspected?
MRI
Bloods
- Incl fbc, U+E, lft, crp, Ca, phos,
- If abnormal bloods then further screening tests incl PSA, Serum electrophoresis/Bence Jones proteins etc
Which medications can cause dyspepsia?
- bisphosphonates
- corticosteroids
- NSAIDs (including otc ie not prescribed)
What are causes of dyspepsia?
- medication
- obesity
- smoking
- alcohol
- diet
- stress
When should you refer someone with dyspepsia?
Urgent OGD if dyspepsia +1 or more alarm symptoms at any age:
- Chronic GI bleeding
- Unintentional weight loss
- Dysphagia
- Persistent vomiting
- Iron deficiency anaemia
- Epigastric mass
OGD in any patient any age with unexplained or unresponsive symptoms
Patients considering surgery as alternative to long term medication
HP unresponsive to 2nd line eradication therapy
How do you manage dyspepsia/
- Review medications, lifestyle and triggers and advise
- Offer empirical full dose PPI for 4/52 and/or test and treat H pylori
- Note: Step down to lowest effective dose of PPI, and stop if symptoms resolve. If inadequate response to PPI consider H2 receptor antagonist.
H pylori testing
- Commonly in GP serology is being used.
- Use breath test, stool antigen, but need 2 week wash out from PPI if using breath test or stool antigen test
- If positive 1/52 1st line eradication (Amox, Clarithro, PPI)
- If ongoing symptoms + pos breath/stool test then 2nd line eradication
When is cardiovascular risk assessed?
Health Check Programme:
- Everyone aged 40-74 (not already diagnosed with CVD, DM or CKD) invited every 5 years
- Includes CVD risk assessment, alcohol consumption, physical activity, screening for DM and CKD
When is QRISK2 not suitable?
- People who already have CVD
- People with type 1 diabetes.
- People with CKD
- People with familial hypercholesterolaemia
- People aged 85 years or older
Which drugs can be used to help stop smoking?
- Nicotine replacement therapy
- Buproprion: Dopamine/Noradrenalin reuptake inhibitor
- Varenicline (Champix)
Targets the α4-β2 nicotinic acetylcholine receptor, stimulant that reduces cravings
