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Brittle asthma

Four key questions

answered

Dr Sophie Farooque and Professor Tak Lee answer four questions frequently asked by GPs about this life-threatening condition

1. What role can allergen avoidance play in the management of brittle asthma?

Patients with severe food allergy will often present with severe bronchospasm within minutes of eating the offending food, even before cutaneous symptoms manifest.

If the patient describes attacks consist-ently occurring within minutes of eating,

refer to an allergy clinic for further assessment. Around 10 per cent of all asthmatics are aspirin-sensitive.

All patients with brittle asthma should undergo skin-prick or RAST testing to determine inhalent allergen sensitisation.

2. What is the role of the GP in the management of brittle asthma?

Multiple small interventions, both pharmacological and non-pharmacological, may lead to modest improvements in control and even small successes can be psychologically beneficial to the patient.

Important elements for the prevention of exacerbations and for early asthma treatment, in type 1 brittle asthma (more common in women, wide swings in PEF despite maximal therapy), include:

·a written home treatment plan

·a daily peak flow and symptom diary to recognise early signs of an asthma attack

·emergency steroids and antibiotics should be kept at home, along with clear instructions for use in case of deterioration

·encouraging the patient to promptly report any serious deterioration of asthma control to their GP

·checking inhaler technique regularly and giving patients a spacer; a combined preparation, containing both a long-acting ?2 agonist and an inhaled steroid, can improve compliance

·treatment of concurrent conditions known to aggravate asthma.

Managing type 2 brittle asthma (very sudden attacks with no warning) is less complex. Patients should wear a Medicalert bracelet. It is crucial to identify inhaled or ingested allergens.

3. What action should a GP take when presented with an acute brittle asthmatic?

In the brittle asthmatic, presenting acutely, intramuscular or nebulised adrenaline (1:1000 concentration, 0.3ml) should be considered if there is an inadequate response to treatment with nebulised salbutamol and oxygen.

In particular, if there is a history of acute asphyxic asthma and the patient is drowsy, disoriented or unable to co-operate, adrenaline should be promptly given.

4. How can the GP approach the psychological aspects of brittle asthma?

There is a high incidence of depression and frequent evidence of broken relationships and physical or sexual abuse with type 1 brittle asthma patients. They often cope badly with worsening symptoms, part of which may be due to a panic reaction.

In addition, patients, their families and their physicians frequently underestimate the severity of brittle asthma. It is important for all those involved in the care of the patient with brittle asthma to be aware of any psychosocial factors contributing to the patient's condition.

Sophie Farooque is specialist registrar in allergy at King's College London School of Medicine, and Tak Lee is professor of allergy and respiratory medicine, King's College London school of medicine, and Director of the MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, Guy's Hospital, London

Find the full version of this article in The Practitioner, free with your copy of Pulse next week

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